Abstract
Dear Sir, We read with interest the paper by Cuvellier et al. in a recent issue of Cephalalgia on premonitory symptoms (PS) in pediatric migraine (1). They retrospectively found a prevalence of 67% of PS in 103 children/adolescents with migraine attending their clinic. To our surprise, they comment on other retrospective studies analysing PS in adults, but they do not mention our study, published in the same journal in 2006, in which we prospectively investigated the nosology of PS (and also of resolution symptoms) in 100 unselected adult migraineurs consulting their general physician (2). Two key methodological aspects of our study were that, to be considered as having a true PS, we discounted, intrapatient, the symptoms experienced by these subjects when they were headache-free, and also that, we analysed the consistency of PS in three attacks. True PS were reported by 84% of migraine patients in our series. The higher percentage of PS found in our work has at least two potential explanations: either PS are more frequent in adults or, more probably, this difference is due to our prospective assessment. Regarding the profile of PS, face changes, fatigue and irritability were the most frequent PS in the French study, but anxiety, phonophobia and irritability showed the highest frequency on our study. Assuming that PS are an integral part of a migraine attack, the PS profile suggests that migraine attack probably begins primarily as a rather diffuse cerebral disturbance, which then may spread to discrete areas, such as the hypothalamus or to the brainstem dopaminergic nuclei. Face changes, probably difficult to interpret, have not been described in adults as PS and, in our study, asthenia was the most frequent resolution symptom, but was not among the most frequent PS, thus highlighting the potential differences between children/adolescents and/or the difficulties of the retrospective assessment especially in children. In any case, the two studies confirm the high prevalence of PS in migraine at all ages, which should be taken into account in future studies both for an accurate diagnosis and for planning future preemptive clinical trials.