SC101. Migraine with aura in the population of Buenos Aires, Argentina: association analysis of 6 SNPs
González R1, Giglio JA2, Miranda S3, Nowik M1 and Catanesi CI1,4
1Instituto Multidisciplinario de Biología Celular IMBICE (CONICET-UNLP-CIC), La Plata, Buenos Aires, Argentina
2Hospital Interzonal General de Agudos “Prof. Dr. Rodolfo Rossi”, La Plata, Buenos Aires, Argentina
3Instituto Central de Medicina, La Plata, Buenos Aires, Argentina
4Facultad de Cs. Naturales y Museo (UNLP), La Plata, Buenos Aires, Argentina
Introduction: Migraine with aura is a complex disabling neurological disorder that manifests with episodic and recurrent attacks. It has a high prevalence and socioeconomic impact. Its causes are both environmental and genetic. Although genetic factors are relevant for prevention and treatment, they have not been analyzed in depth in the population of Argentina.
Objectives: The objective of this study is to characterize migraine with aura in the population of Buenos Aires, through the analysis of genetic variants previously reported for other populations in association to this disorder.
Materials and methods: DNA from 203 donors (105 migraineurs and 98 controls) was obtained from saliva samples and genotyped for the SNPs rs12134493 (TSPAN2), rs10166942 (TRPM8), rs10456100 (KCNK5), rs4910165 (MRVI1), rs11031122 (MPPED2) and rs6081613 (SLC24A3) through allele-specific PCR amplification. The study was previously approved by the Ethics Committee of IMBICE, and all donors gave written consent for participation in it.
Results: The cases fitted the HWE (Hardy-Weinberg Equilibrium, p > 0.05) for all the SNPs and in the control group they fitted with the exception of rs12134493 and rs4910165. Non-significant differences were found between cases and controls (FST). A model of logistic regression was performed using all genotypes of the analyzed markers. For rs10456100, association was significant (Χ2 = 4.15; p = 0.0416) in TT genotype taking as reference CC, giving an OR (odds ratio) of 0.11 (confidence interval 0.01-0.92) while the other SNPs did not show significant association.
Conclusions: We found that the T allele of rs10456100, which has been reported as a risk allele in other populations of the world, probably acts as protective when it is present in homozygous genotype in our population. These preliminary results need confirmation in a larger sample size, nevertheless they suggest a particular genetic basis of migraine with aura in the studied population. Moreover, as additional genetic markers will be included in this study, the information might be of help for defining a better treatment of local migraine patients.
SC102. Mnemonic method in Portuguese for headaches in ER
Hilton Mariano da Silva Júnior1 and Larissa Volpini Cardoso2
1Pontificial Catholic University of Campinas, Faculty of Medicine, Department of Semiology, Campinas, SP, Brazil
2Pontificial Catholic University of Campinas, Faculty of Medicine, Campinas, SP, Brazil
Introduction: It is of crucial importance to quickly stratify the risk of patients with headaches in the emergency setting, especially considering how secondary headaches are associated with high morbidity and mortality. Mnemonics are a useful tool to remember the alarm criteria in those cases. Such mnemonics were written in English and Spanish, but none in Portuguese.
Objectives: To present the first mnemonic method in Portuguese for alarm criteria in emergency headaches in order to facilitate their identification and diagnosis.
Materials and Methods: A search was made through different databases for a mnemonic method regarding alarm criteria in emergency headaches that was written in Portuguese. None were found. Thus, the emergency criteria were gathered and turned into a mnemonic in Portuguese.
Results: We present the mnemonic method “RISADA PEGA” (“laughter spreads”, in English): R – Repentina/(Sudden onset) I – Início depois dos 50 anos/(onset in a patient older than 50) S – Sinais e/ou sintomas de doenças sistêmicas ou neurológicas/(Signs and/or symptoms of systemic or neurologic diseases) A – Anormalidades no exame neurológico/(abnormalities upon neurologic examination) D – Depressão da imunidade (AIDS, Câncer)/Depressed immunity (HIV or cancer) A – Antecedentes: doenças que podem acometer o SNC; número de vindas ao PS, história familiar de cefaleia)/(prior conditions: diseases affecting the central nervous system; number of visits to the health center, history of headache in the family) P – Padrão alterado (mudança no padrão anterior da cefaleia)/(change in headache pattern) E – Esforço/(exertion; effort, headaches with Valsalva’s maneuver or headache associated with sexual activity) G – Gravidez/(pregnancy) A – Autonomia (sinais autonômicos)/(autonomic signs).
Conclusions: Secondary headaches are challenging complaints in the emergency department, especially considering the time constraints for diagnosis and initial treatment in this department. This shows the usefulness of a method to quickly identify the alarm criteria and, through that, correctly stratify the patient’s risk and initiate treatment. As far as we know, this is the first mnemonics in Portuguese for the alarm criteria in emergency headaches and we believe this tool can be very useful in teaching and clinical settings.
SC103. Patterns of Libido, Sexual Activity and Sexual Function in Female Migraineurs
John F. Rothrock and Alison Koutsandreas
Inova Health/University of Virginia School of Medicine
Background: Although migraine traditionally has been assumed to convey a relative decrease in libido, sexual activity and sexual performance, recent data have suggested that the female migraine population is far from homogenous in this regard.
Objective: We sought to determine the levels of libido, sexual activity and sexual performance in the female migraine patient population both generally and according to clinical phenotype.
Methods: In this single-blind study, a consecutive series of sexually active new female patients ages 25-55 initially presenting to a university-based headache clinic and having a >1-year history of migraine were asked to complete anonymously a survey assessing their sexual histories generally and as they related to their headache disorder and the 19-item Female Sexual Function Index (FSFI). To serve as 2 separate control groups, 100 sexually active females with no history of migraine and 100 female migraineurs from the general (non-clinic) population but matched for age, marital status, educational background and socioeconomic status completed a similar survey.
Results: Over a period of 3 months, 188 consecutive migraine patients were invited to participate. Twenty declined, and 28 of the remaining 160 potential subjects failed to meet the inclusion criterion utilized for “sexually active” (ie, heterosexual intercourse at a frequency of >once per month in each of the preceding 6 months). In all groups younger age (p < .005), higher educational level attained (p < .05) and higher socioeconomic status (p < .025) correlated with a higher monthly frequency of intercourse and a higher likelihood of intercourse resulting in orgasm. Relative to the 100 control subjects with no history of migraine, the two migraine groups (total n = 232) reported a lower monthly frequency of intercourse and recorded a lower FSFI score (both p < .025), but the contribution to this difference came primarily from the chronic migraine (CM) subgroup (n = 92). Patients with low frequency episodic migraine (LFEM) and mid frequency episodic migraine (MFEM) reported a higher FSFI score, higher monthly frequency of intercourse, higher likelihood of intercourse resulting in orgasm and higher likelihood of multiple active sex partners than controls. All migraine subgroups reported a decreased likelihood of engaging in intercourse during an active migraine attack, but relative to the CM subgroup (8/92 = 9%), a higher proportion of patients in the LFEM (12/49 = 25%), MFEM (14/67 = 21%) and high frequency episodic migraine (HFEM: 6/14 = 43%) subgroups reported utilizing intercourse – and orgasm specifically – as a means of potentially terminating a migraine attack.In the clinic vs no-clinic groups there were no significant differences in the dependent variables assessed.
Conclusions: Research subjects with LFEM and MFEM may report a level of libido, frequency of intercourse and likelihood of orgasm-associated intercourse that exceeds what is reported by age-matched controls free of migraine. Many patients with LFEM, MFEM and HFEM appear to utilize intercourse/orgasm as a means to potentially terminate an acute migraine attack.
SC104. Algorithm in the preventive treatment of cluster headache in Mexican patients
Maria-Karina Velez Jimenez1, Silvia García1, Manuel Gudiño Castelazo2, Adriana Martínez1 and Ildefonso Rodríguez Leyva3
1Hospital Ángeles, Ciudad de México, México
2Hospital Star Médica Lomas Verdes, Ciudad de México, México
3Universidad Autónoma de San Luis Potosí, México
Introduction: Simplifying the preventive treatment of cluster headache patients will help the physician unfamiliar with this pathology to give the most adequate and specific treatment to patients suffering from this disease. Cluster headache is classified within the group of Primary Autonomic Trigeminal Headaches that affects 0.1% of the population. Although it is not very frequent, its management is always a challenge due to the characteristics of the pain: its severe and disabling intensity, its association with the cranial autonomic symptoms that characterize it, the duration and frequency of the episodes, as well as the pattern associated with the circadian rhythm and annual circadian rhythm. The preventive treatment of cluster headache with most drugs used was not specifically designed for this disease; however, controlled clinical studies compared with placebo have demonstrated its effectiveness. Currently, in Mexico, we have a monoclonal antibody approved for this type of headache by the FDA and EMA. Although we do not have this approbation in Mexico by COFEPRIS (our regulatory agency), its use off-label using a lower dose, we have found a good answer with our patients suffering pathology.
Cluster headache preventive treatment algorithm.
SC105. Monoclonal antibodies in patients with migraine. Experience in a headache service
Headache Service. Department of Neurology. Fleni. CABA, Argentina
Introduction: Calcitonin gene-related peptide (CGRP) plays an important role in the pathophysiology of migraine through nociceptive mechanisms in the trigeminovascular system. Several studies demonstrate the safety and effectiveness of monoclonal antibodies (mAbs) against CGRP or its receptor as preventive treatment for episodic migraine (EM) and chronic migraine (CM).
Objectives: To evaluated the experience of treatment with mAbs against CRGP pathway in patients with EM and CM evaluated at a headache service in Argentina.
Materials and Methods: Retrospective, descriptive study. We reviewed electronic medical records of patients evaluated in our headache service with EM or CM who received Erenumab (70 or 140 mg) or Fremanezumab (225 mg) in monthly subcutaneous injections as preventive treatment of migraine between 07/2019 and 03/2022. The following information was obtained: age, sex, headache days/month (HDM), medication overuse headache, migraine preventive medication (in the previous month and at 3, 6, 12 months after starting treatment), type and dose of mAbs, adverse effects (AE) and response at 3, 6 and 12 months after starting treatment (reduction less than 30%, between 30 to 50%, greater thant 50% or no reduction in HDM).
Results: mAbs were indicated in 69 patients (86% women). 51 years average. 77% CM. 83% Erenumab and 17% Fremanezumab. 80% had failed to more than 3 oral preventive drugs. Topiramate and amitriptyline were the most used preventive medications. 72% used botulinum toxin previously. 5 patients did not return to control (1 EM, 4 CM).15 patients with EM received treatment (14 Erenumab,1 Fremanezumab). At 3 months 40% of EM had a reduction greater than 50% in HDM while 27% had no reduction. At 6 months 33% maintained a reduction greater than 50%. 13 patients completed 12-months follow-up: 8% had no reduction, 23% a reduction between 30 to 50% and 38% greater than 50% (of whom 60% was greater than 75%) while 31% discontinued treatment. 49 CM started treatment (41 Erenumab, 8 Fremanezumab). At 3 months 35% has a decrease greater than 50%, while 41% had no reduction. At 6 months 46% maintained a reduction greater than 50%. 30 patients completed 12-months follow-up: 13% had no reduction, 34% had a decrease between 30 to 50% and 50% of at least 50% (of whom 40% was greater than 75%). At 12 months 16 patients (53%) reverted from CM to EM.14 discontinued: 9 because no response, 4 because costs, while 1 because fertility treatment.12 presented AE, constipation was the most frequent. All received Erenumab and no one had to stop treatment. 32 patients (50%) had MOH before treatment: 17 completed 12-months follow-up, 16 of them without MOH.
Conclusion: In real world Erenumab and Fremanezumab are effective as preventive treatment for patients with EM and CM, even in those who failed with other treatments, including botulinum toxin. A reduction in the overuse of analgesic medication was registered. Good adherence and tolerance were observed, without discontinue treatment due to AE. It is necessary to consider mAbs treatment in patients with EM or CM who have not responded to previous treatments.
SC106. Analysing cortical expression patterns of migraine-associated genes: a new perspective on migraine genetics
Marco Lisicki1, Mariela Carpinella1, Marcelo Filipchuk1, Tatiana Castro Zamparella1,2 and Diego Conci Magris1
1Neuroscience Unit, Conci-Carpinella Institute, Córdoba, Argentina
2Psychological Research Institute, Faculty of Psychology, National University of Córdoba (UNC) – National Council for Scientific and Technical Research (CONICET)
Introduction: Migraine is a complex multifactorial neurological disorder with a major genetic component. During the past few decades significant progress has been made in our understanding of both the rare monogenic forms of this condition and the more common polygenic migraine types. Most genetic-pathophysiological studies have focused on gene function, leaving anatomical information at an organ level at best. Nonetheless, it is well established that gene expression in the brain is not homogeneous, resulting in different concentrations of DNA products throughout the different regions. Therefore, in this study, we evaluated cortical expression patterns of migraine-associated genes to determine whether this approach could provide additional information in the investigation of migraine genetics.
Objectives: To explore cortical expression patterns of migraine-associated genes using digital maps.
Materials and methods: Three-dimensional digital maps of familial hemiplegic migraine and common migraine-associated genes were mined from an open-source database. These models were constructed using information from the Allen Brain Atlas (500 samples per hemisphere extracted from the brain of six different donors with no known history of neurologic or neuropsychiatric disorders) and subsequently validated in positron emission tomography experiments. Gene expression models of the 38 genes where susceptibility loci for migraine have been mapped in seminal genome-wide association studies were grouped based on their similarity using neural networks clustering implemented in MATLAB®.
Results: Gene expression showed marked contrasts in key regions previously implicated in migraine pathophysiology in most cases. Numerous genes exhibited similar expression patterns.
Conclusion: Gain or loss of function of migraine-associated genes could produce focal functional alterations in specific regions associated with migraine pathophysiology. A new paradigm including both gene function and topographical expression might be superior to currently disseminated approaches. Translational studies are warranted.
Familial hemiplegic migraine genes and larger clusters of common migraine-associated genes.
SC107. Impact of COVID-19 pandemic lockdown on migraine patients in Latin America
Reyes María Teresa1, Bancalari Ernesto2,3, Santana-Vargas Angel Daniel4, Velez Karina5, Rodríguez Idelfonso6, Marfil Alejandro7, Miranda Silvina8 and Zegarra-Valdivia Jonathan Adrián9
1SANNA/Clínica Sanchez Ferrer, Trujillo-Peru
2Universidad Católica Santo Toribio de Mogrovejo. Chiclayo-Peru
3Clínica Anglo Americana, Lima Peru
4General Hospital of Mexico “Dr. Eduardo Liceaga” Research Department. Mexico City-Mexico
5Hospital Ángeles Interlomas. Mexico City-México
6Hospital Central, Facultad de Medicina UASLP, SLP-México
7Neurology Service. University Hospital Dr. J. E. González, Autonomous University of Nuevo León, Monterrey, México
8Instituto Central de Medicina. La Plata. Buenos Aires-Argentina
9Universidad Señor de Sipán, Faculty of Health Sciences, Chiclayo, Perú
Introduction: The coronavirus (COVID-19) pandemic, home confinement, fear of COVID, lifestyle changes, and worldwide health care impacted almost all diseases. Reports from countries outside Latin America found differences in their migraine patients. The present study describes and compares the immediate changes in migraine symptoms associated with COVID-19 quarantine in patients from three Latin American countries with different restrictions (Argentina, Mexico, and Peru).
Objectives: Identify and analyze similarities and differences of Pandemic Confinement in three Latin American countries.
Methods: An online survey was conducted from May to July 2020. The survey was answered by 243 migraine patients (85.2% women), with questions related to sociodemographic data, quarantine conditions, changes in working conditions, physical activity and coffee intake, changes in healthcare access and acute migraine medication use, and symptoms of anxiety and depression and fear of COVID-19.
Results: The results showed that 48.6% of migraine patients worsened their symptoms, 15.6% improved their symptoms, and 35.8% remained unchanged. Worsening migraine symptoms were associated with staying at home during the lockdown. Intake of analgesics was associated with an 18 times increase for worsening migraine symptoms than those that did not increase their intake. Migraine improved when sleep hours increased, and we found an improvement when patients decreased analgesic intake. Questions regarding COVID-19 news and social media, symptoms caused by COVID-19, and the uncertainty about when the pandemic will stop, were the three items that contributed to the worsening of migraine in the patients in the three countries.
Conclusions: Confinement during the first pandemic wave in Latin America harmed migraine patients who stayed at home during lockdown and increased symptoms if overused medication. On the other hand, a good sleep hygiene and less drug intake, improved migraine symptoms. Negative impact of Social Media, awareness of COVID symptoms and uncertainty of when the pandemic will stop, negatively impacted migraine symptoms.
SC108. Long-term effectiveness of combined unilateral Sphenopalatine and Occipital nerve stimulation in patients with refractory chronic cluster headache
1Fundación Cenit para la Investigación en Neurociencias
2Sociedad Argentina de Neuromodulación
3Programa Provincial de Neuromodulación de la Pcia de Buenos Aires
4Jefe del Área de Cefaleas y Dolor Fundación Ineba (Instituto Neurociencias de Buenos Aires)
5Consultor en Cefaleas del Instituto de Neurología y Neurociugía Fundación Favaloro
6Unidad de Neurociencias – Instituto Conci Carpinella
Introduction: Chronic Cluster Headache (CCH) is an extremely debilitating disorder characterized by recurrent attacks of excruciating pain associated with cranial autonomic symptoms. Contrary to its episodic form, there are no periods of remission in this condition, or they last very shortly. Treatment of Chronic Cluster Headache is always challenging. Several peripheral and central invasive neuromodulation techniques and ablative procedures have been attempted in the past with so far inconclusive results. Isolated Occipital Nerve (ON) stimulation has proven beneficial for CCH, but it can take up to several months before benefits are observed. Sphenopalatine (SPG) ganglion stimulation becomes effective in a shorter term and can be used both as preventive and as abortive on demand, yet results from previous studies overall suggest that there is still room for improvement. Of note, according to the literature, each of these two techniques has reached no more than level B of recommendation. Therefore, developing new strategies that provide rapid and sustained amelioration becomes crucial. In this study we present the results of a prolonged follow-up of refractory chronic cluster headache patients receiving combined invasive occipital and sphenopalatine ganglion neuromodulation.
Materials and methods: Seven patients suffering from refractory CCH (3f/4m), underwent implantation of electrodes for sphenopalatine ganglion (SPG) and greater occipital nerve (GON) stimulation ipsilateral to the side of the pain. Patients were evaluated preoperatively and then every three months after surgery. The visual analogue scale (VAS) and HIT-6 scale were used to monitor treatment response.
Results: Mean follow-up was 8,13 ± 1,9 years at the moment of submission of this abstract. Six out of the seven patients (86%) experienced good-to-excellent initial pain relief, and achieved an almost complete remission of symptoms later on. One patient stopped requiring stimulation 15 months after the procedure and remained stable for up to 23 months when the device had to be restarted. Regarding HIT-6 results, mean values decreased to the ‘Little or no impact’ severity level (Fig 1) already during the first control after surgery, and persisted similarly low during subsequent visits. Alike results were observed in the VAS. The total number of attacks also decreased significantly from 44,7 ± 19,6 to 13,2 ± 7,4 per month. Electrode migration requiring a re-intervention was observed in two patients at 12 days and at 3 months after surgery, regaining the initial benefit in one case. One patient passed away during follow-up due to an unrelated cause.
Discussion: Our results show that combined invasive SPG and GON neuromodulation significantly and enduringly improve CCH symptoms in a group of refractory patients. If corroborated in larger cohorts, findings from our study suggest that this combined approach might be superior to each of the two techniques it comprises alone. Patients should be closely followed during the first months after surgery because of the risk of lead migration.
Conclusions: Synergic SPG- GON stimulation is a promising alternative for long-lasting CCH control.
Left: Anteroposterior X-ray of a patient who underwent infrazygomatic percutaneous lead implantation for SPG stimulation (red arrow) and a paddle lead for GON stimulation (green arrow). Right: Mean (and SD) HIT-6 values during follow-up (last observation carried forward). The asterisks denote statistically significant (*p < 0.05; **p < 0.01) differences with respect to baseline. The red line at y = 49 depicts the ‘little or no impact’ threshold for this scale.
SC109. A neuropsychological profile-based classification outperforms ICHD-3 in terms of disability: exploratory analysis with anatomical correlates
Tatiana Castro Zamparella1,2, Mariela Carpinella1, Marcelo Filipchuk1, Verónica Balaszczuk2, Carolina Maldonado3, Diego Conci Magris1 and Marco Lisicki1
1Neuroscience Unit, Conci-Carpinella Institute, Córdoba, Argentina
2Psychological Research Institute, Faculty of Psychology, National University of Córdoba (UNC) – National Council for Scientific and Technical Research (CONICET)
3Faculty of Exact, Physical and Natural Sciences, National University of Córdoba (UNC), Argentina
Introduction: Migraine patients are not all equally affected by the condition. Recognizing the degree of impairment is fundamental to personalize treatment. The International Classification of Headache disorders recognizes two types of migraine with regards to severity (i.e. episodic and chronic), separated according to the frequency and characteristics of headache attacks. Although cumulative evidence supports the usefulness of this classification, it is well established that migraine is more than a headache. Therefore, it remains to be determined whether novel strategies could provide better outcomes. In this study, we compared migraine-related disability between patients classified according to the ICHD-3 or classified using a neuropsychological profile-based classification system, and performed a supplementary gray matter (GM) volume analysis to better understand our findings.
Materials and Methods: Neuropsychological evaluations of 135 migraine patients were included. The evaluation protocol included Wechsler Word Pair memory, Wais forward and reverse Digits attention, and Wais processing speed Digit-Symbol subtests, and Trail Making Test A and B. Episodic or chronic migraine ICHD-3 diagnoses were performed by neurologists based on paper diaries filled by patients. For neuropsychological profile-based classification, results from the evaluation protocol were introduced in an automated k-means clustering algorithm. Headache Impact Test (HIT-6) and Migraine Disability Assessment (MIDAS) results were compared between groups. Voxel-based Morphometry (VBM) supplementary analysis included a subgroup of 48 patients. Differences in GM (p < 0.001 unc) are presented.
Results: Seventy-five patients were diagnosed as episodic and 60 were diagnosed as chronic. Non-supervised clustering allocated 49 participants to cluster 1 and 86 to cluster 2. Age and gender proportions were similar between groups (overall mean age 39 ± 12, 92% female). Statistically significant differences in HIT-6 results were observed between neuropsychological-driven groups (cluster1 65 ± 9 vs cluster2 62 ± 8; p = 0.006) but not between ICHD-3 episodic and chronic patients (episodic 64 ± 8 vs chronic 63 ± 10; p = 0.73). Differences in MIDAS results were also more pronounced between neuropsychological-driven groups (cluster 1 81 ± 70 vs cluster 2 60 ± 61; p = 0.034) compared to the ICHD-3 (episodic 64 ± 67 vs chronic 72 ± 64; p = 0.27). VBM analyses showed greater GM volume in the left superior temporal, left parahippocampal, right inferior temporal, and right superior frontal gyri of chronic patients compared to episodic, and increased GM in the right precuneus and left superior parietal lobe of patients in cluster1.
Conclusions: Our results suggest that a neuropsychological profile-based classification system that could be readily implemented in the clinic would provide a better insight into migraine severity. Differences in gray matter volume between episodic and chronic patients were found in regions involved in nociception and analgesic dependence. In contrast, neuropsychological profile-based clustering segregated patients with different gray matter volume close to a region recently determined to be the hub of a common migraine network. If corroborated in larger cohorts, these findings have implications not only at the single patient level, but also for epidemiological, pharmacological and pathophysiological studies.
SC110. Strategic planning for the headache committee of the Colombian Association of Neurology-ACN – Proposal
Joe Muñoz-Ceron1, Mauricio Rueda-Sánchez2, Natalia Hernández3 and Kelly Vergara4
1Hospital Universitario Mayor, CIMED – Universidad del Rosario, Clínica Universitaria Colombia, Bogotá, Colombia
2Práctica privada, Bucaramanga, Colombia
3Promedan, Neuroclínica, Neuromédica, Medellín, Colombia. Mail
4Uni-Empresarial Cámara de Comercio – Bogotá, Colombia
Introduction: Strategic planning refers to the transformational process whereby an organization establishes management objectives and determines indicators to evaluate its evolution. Strategic plans for specific public health programs and some specific clinical care areas have been published.
Objectives: To design a strategic planning model within the ACN’s headache committee.
Materials and methods: A coordinator group was set up to structure the project. Gender inclusion, regional participation, senior and junior members of the committee were considered to be part of the taskforce. The process was carried out through the execution of philosophical, analytical and operational phases, virtual meetings were held over a period of 6 months.
Results: 1. Philosophical phase: The mission, vision, values, policies and objectives were obtained after this stage.
2. Analytical phase: In this section, the SWOT analysis and strategies for obtaining objectives were carried out. Figure 1.
3. Operational phase: Management indicators were determined for the objectives considered.
Conclusions: Strategic planning is an organizational tool that can be implemented by the ACN headache committee to generate collaborative work to rise up the generation of value products and guarantees the quality of academic processes.
Results of the execution phases.
SC111. The best friend of a migraine sufferer
Tatiana Castro Zamparella1,2, Diego Conci1 and Marco Lisicki1
1Unidad de Neurociencias, Instituto Conci·Carpinella, Córdoba, Argentina
2Instituto de Investigaciones Psicológicas, Facultad de Psicología, Universidad Nacional de Córdoba (UNC) – Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET)
Introduction: Migraine is a disabling neurological disorder that affects a large part of the world population. In addition to intense headache, those who suffer from it have a great social impact, absenteeism from work, disruption of daily life and high symptoms compatible with depression and mood disorders.
Objective: To analyse the severity of depression symptoms in people with migraine who have or do not have dogs as pets.
Materials and Methods: 49 patients attending a private health centre in the city of Córdoba were studied. The ICHD-3 criteria were used to establish the diagnosis of migraine and the Beck Depression Scale (BDI) to determine the presence and severity of depressive symptoms. The HIT-6 and MIDAS scales were also used, which measure impact indexes of headache and disability, respectively.
Results: Nearly sixty percent (57.14%, n = 28) of the participants were dog owners. There were no statistically significant differences between dog-owning and non-dog-owning patients in terms of age, gender, percentage of medication, HIT score, or MIDAS score. 44.9% of patients with migraine evaluated suffer from depression according to the results of the BDI-II. Dog owners were significantly less likely to be depressed compared to their counterparts (32.14% vs. 61.9%, respectively. X = 4.296.1; p = 0.038).
Conclusions: The data show that a large percentage of patients with chronic migraine also present symptoms of depression. However, dog ownership seems to have a positive influence on the mood of patients, presenting fewer symptoms of depression and less negative impact of suffering from headache.
SC112. Botulinum Toxin A in the preventive treatment of chronic migraine; experience in Argentine headache centre
Larripa N, Grandinetti M, Calvo D, Nagel V and Goicochea MT
Headache Service, Department of Neurology, Fleni, Argentina
Introduction: Chronic migraine (CM), defined as at least 15 headache days per month, with a minimum of 8 of them with migraine features, during the last three months (ICHD). In 2010, the use of a Botulinum Toxin type A (BoNTA), was approved as a preventive treatment for this neurologic disease. Its use has spread and, currently, it corresponds to a pharmacological tool in patients with CM. Its main mechanism of action is by blocking the exocytosis of algogenic peptides and excitatory substances such as substance P, CGPR and glutamate, in the synaptic gap of nociceptive afferents. In our country there is scarce information published about the response to this treatment.
Objective: The objective of this study is to describe our experience in the headache service in Argentina, with the administration of BoNTA as a preventive treatment for CM.
Materials and methods: A retrospective analysis was performed by reviewing the digital medical records of all patients from the Headache Service, treated with BoNTA between January and December 2021. Patients ≥18 years old were included, with at least 1 application of BoNTA according to the dose and points included in the PREEMPT protocol. Epidemiological data, coexistence of acute headache medication overuse, duration of treatment (year of initiation, number of application), number of previous oral preventives received, evolution during treatment, number of headaches days per month, days of analgesics per month, were evaluated. We consider non responder patients if they had less than 30% reduction of headache days per month, after 3 treatment cycles. The review of adverse events and patient reported wearing off effect of the therapeutic benefit of BoNTA was registered. For data analysis, the STATA/14.0 program was used.
Results: The records of 394 patients were analysed. 91% were female, mean age 46 (range: 18-85). 66% (n 241) had coexisting analgesic overuse. All patients had received at least one previous oral preventive treatment, with a median number of preventives of 3. 42% of the patients analysed were carrying out applications two years ago, 20% more than two years ago and 37% were starting treatment (1–3 applications). 82% (n 317) had already received 3 or more applications.162 patients kept a headache diary, 65% of which responded with a ≥50% reduction in headache days/month and 15% had a ≥30% decrease in the frequency of headache days per month. 34% reversed the overuse of analgesics. 40% (n160) reported deterioration at the end of the dose, 4% (n15) reported some adverse effect associated with the application, without being a reason for discontinuation of treatment.
Conclusions: In local clinical practice BoNTA has an important role in the treatment of CM, high percentage of patients reduce the headache days per month and days of acute headache medication. It is an effective and well tolerated treatment for CM.
SC113. Brain activity in interictal, ictal, and chronic migraine
Marcelo Filipchuk1, Mariela Carpinella1, Tatiana Castro Zamparella1,2, Diego Conci Magris1 and Marco Lisicki1
1Neuroscience Unit, Conci-Carpinella Institute, Córdoba, Argentina
2Psychological Research Institute, Faculty of Psychology, National University of Córdoba (UNC) – National Council for Scientific and Technical Research (CONICET)
Introduction: Migraine is a fluctuating disorder. Analyzing changes in cerebral activity throughout migraine variations has greatly contributed to our understanding of the pathophysiology of this condition in the past. Yet, most neuroimaging methods of analysis evaluate indirect markers of neural activation such as regional metabolism or blood flow. In contrast, electrophysiological assessment provides explicit information about the underlying synaptic processes. In this study we evaluated brain activity in different forms of migraine using an electrophysiological-based neuroimaging approach (Low Resolution Brain Electromagnetic Tomography, LORETA).
Objective: To compare cortical activity between interictal, ictal, and chronic migraine patients and healthy controls.
Materials and methods: One hundred participants (25 healthy controls and 75 migraine patients: 25 ictal, 25 inter-ictal, and 25 chronic) were included. A sixty-second artifact-free resting-state 22-channel electroencephalogram segment from each individual was analyzed using eLORETA. Mean subject-normalized Delta (1–3 Hz), Theta (4–7 Hz), Alpha (8–12 Hz), Beta (13–30 Hz), and Gamma (31–45 Hz) band activity from each group was compared (whole brain, voxel-wise) with that of controls. Brain areas that systematically exhibited differences in neural activation were selected for data-driven post-hoc region of interest (ROI) analyses.
Results: Significant contrasts in brain activity with respect to healthy controls were observed in multiple regions across groups (Fig. 1). Consistent differences mostly comprised six specific brain areas: bilateral subgenual gyrus (BA25), left extrastriate visual cortex (L-BA7), right dorsal entorhinal gyrus (R-BA34), bilateral dorsal posterior cingulate cortex (BA31), and bilateral supramarginal gyrus (BA40). The subgenual and right dorsal entorhinal gyrus presented significantly lesser activity in ictal migraine patients compared to the other groups. In the left extrastriate visual cortex higher alpha activity was observed in the interictal group, while the ictal and chronic groups exhibited more low and high frequency activity respectively.
Conclusions: Brain activity tends to vary in relation to migraine phase and severity. Key regions exhibiting variations include the subgenual gyrus, a cortical region tightly connected to the hypothalamus and brainstem, and a portion of the extrastriate visual cortex (BA7) that harbors V3a, known for its implications in migraine aura. Our finding of reduced neural activity in the subgenual gyrus in ictal migraine patients suggests that the increased blood flow observed in this region during spontaneous migraine attacks in seminal studies might in fact reflect increased inhibitory neuron activity. Similarly, the phase and severity-dependent band-specific alterations in the visual cortex that we found expand our knowledge about migraine electrophysiology, particularly the thalamocortical dysrhythmia commonly described.
SC114. General Neurologists’ prescription practices for migraine attacks with emphasis on opioids
Bancalari B Ernesto1 and Wicht S Astrid2
1Universidad Católica Santo Toribio de Mogrovejo, Chiclayo, Perú
2Clínica Anglo Americana, Lima Perú
Left, comparisons of cortical activity between migraine groups and healthy controls. Right, region of interest analyses.
Introduction: Opioids have been widely indicated for headaches in the past. Today, it is recognized as a Public Health problem worldwide. Physicians, specially neurologists, should avoid prescribing them for migraine headaches, since it’s abuse is one of the causes of Medication Overuse Headache (MOH).
Objectives: To understand migraine prescription practices between Neurologists attending the 2018 Peruvian National Neurology Congress.
Material and Methods: We performed a 13 question survey between Neurologists attending the bi annual meeting in 2018 in order to understand their prescription practices. We also wanted to know if they considered opioids drugs were indicated for the treatment of migraine, and if so, if they indeed prescribed them. Out of 150 attendees, 56 of them answered the survey.
Results: Around 27% of neurologists that answered the survey prescribed NSAIDs for a migraine attack, 23% Triptans as monotherapy, 14% Triptans and other analgesic, 14% ergotamine and 7% opioids. When asked if Opioids were indicated for Migraine Headaches, 43% of them answered they were. When asked those that answered that opioids were indicated, if they in fact prescribed them, 88% did use opioids for migraine headaches. There was no difference in Neurologists’ age and opioid indication believe. Those that were aware that opioids should not be indicated for migraine, did not use them at all. There was a statistical difference between those two groups (p < 0.000).
Discussion: Medication overuse headache is a frequent cause of consultation at headache specialists’ practice. A recent paper published in Headache Medicine found that neurologist, more than general practitioners, were causing medication overuse headache in migraineur patients. Understanding what neurologists prescribe for migraine headaches can give us a view on why MOH could be a problem generated by them. Although our survey is not intended to look for MOH, neurologist prescription practices could be a good indicative of the problem. Our finding points out two interesting results. NSAIDs and Triptans are mostly used for Migraine attacks by neurologists, although there is a 7% of them that do use opioids. Ergotamine is no longer the main drug used for migraine headaches. Ergotamine used to be the most frequently prescribed drug in the past and a well-known cause of MOH. Prescription practices have changed during the years. The second finding is that neurologist are not aware that the use of opioids for migraine headache is not a good practice. Since there was no statistical difference in prescribers age in the group of those that thought opioid should be used for migraine headaches, we can conclude that knowledge of this indication has been passed from teachers to residents.
Conclusion: Efforts should be made to educate neurologists on migraine prescription practices specially on the use of Opioid therapy.
SC115. Migrainous Infarction: Case series in a neurological center of Buenos Aires
Wainberg FN1, Castiglione JI1, Rodríguez Pérez MS2 and Goicochea MT3
1Neurology department, FLENI, Argentina
2Vascular Neurology, Neurology department, FLENI, Argentina
3Headaches service, Neurology department, FLENI, Argentina
Objectives: To describe our experience related to patients with migrainous infarction (MI).
Background: MI is a rare complication of migraine with aura (MwA) that must be considered in patients that present with aura episodes lasting more than 60 minutes. According to ICHDIII criteria, one or more migraine aura symptoms associated with an ischaemic brain lesion in the appropriate territory demonstrated by neuroimaging, confirm the diagnosis.
Materials and methods: Clinical records of adult patients with MI diagnosed at our institution from June/2006 to June/2020 were retrospectively reviewed. Demographic data, neuroimages findings, treatment and long-term evolution were analyzed.
Results: Ten patients were included according to ICHD 3 criteria for MI (women = 7, median age: 28.5 years). All described MwA of at least 5 years of evolution, with a low frequency of episodes (5 reported less than 12 episodes/year), and all referred habitual visual aura (average duration of 40 minutes). Only 2 reported additional sensorial symptoms, 1 motor and 1 aphasia. Ergotamine derivatives or triptans were declared by 4 patients and only one reported use of oral contraceptives. All presented with a longer-than- habitual aura (average 9.4 hours) and 3 patients persisted symptomatic at evaluation (NIHSS range: 0–2). Magnetic resonance imaging (MRI) evidenced diffusion-restrictive images on all patients (median volume 0.575 cm3), 50% on posterior circulation territory, 3 on the anterior and 2 border zone infarcts. All patients were discharged asymptomatic (NIHSS 0), with migraine preventive treatment and aspirin; no recurrence of MI was reported on follow-up.
Conclusion: We observed MI in young patients without other stroke risk factors. Unlike previous reports that showed higher incidence of MI during the first year of MwA, all of our patients declared an evolution of 5 years or longer at diagnosis. After discharge, all patients initiated preventive migraine treatment, with no neurological deficit and no recurrence of MI.
SC116. Spontaneous Intracranial Hypotension: clinical characteristics and treatment in 23 patients
Nagel Vanesa, Bonamico Lucas, Perez Adriana and Goicochea Maria Teresa
Headache Service. Department of Neurology. Fleni. CABA, Argentina
Introduction: Spontaneous Intracranial Hypotension is caused by cerebrospinal fluid (CSF) leakage without traumatic cause in the previous month. Orthostatic headache is the most common symptom. Brain Magnetic Resonance Image (MRI) usually shows suggestive signs. The initial treatment is based on conservative measures: rest at 0 degrees, hydration and caffeine. Sometimes it is necessary to perform blood patches or surgery.
Objectives: To analyze clinical characteristics, complementary studies and treatments performed on patients diagnosed with spontaneous intracranial hypotension in a headache service in Argentina.
Materials and Methods: Descriptive, retrospective study. We reviewed the electronic medical records of patients diagnosed with Spontaneous Intracranial Hypotension evaluated between 01/2012 and 03/2021 in our headache service. Conservative measures and rest at 0 degrees for at least 48 hours were indicated in all cases. Sex, age, type of headache, time to diagnosis, other symptoms, complementary studies, treatment and response at first and sixth month of treatment were considered.
Results: 23 patients (56% women) were evaluated. Mean age was 59 years. Time to diagnosis 51 days. 83% of the patients manifested orthostatic headache. 91% has at least other symptom: nausea and vomiting (52%), photophobia and/or phonophobia (52%) and neck pain (30%). 86% of brain MRI showed indirect signs, with pachymeningeal enhancement being the most frequent (95%), followed by tonsillar descent (30%), reduction of pretroncal cistern (30%), subdural hematomas (30%) and hygromas (30%). In 4 cases the site of CSF leak was detected (2 in MRI and 2 in myeloTC). 6 patients were treated only with conservative measures. Of these 4 were pain-free after a month of treatment (1 of whom recurred after 6 months). 17 required at least 1 blood patch. Of these 12 evolved without headache at one month (5 of whom recurred at 6 months). 1 patient required surgery to close the fistula.
Conclusions: In this cohort orthostatic headache was the most frequent symptom in Spontaneous Intracranial Hypotension, although a percentage of patients may lack it. In most this cases brain MRI showed indirect signs, although a normal study does not exclude the diagnosis. Treatment can be challenging, as a significant proportion of patients remain symptomatic at 6 months, even after blood patching.The delay in diagnosis decreases the chances of a successful treatment. Identifying the CSF leakage is important, since targeted treatment could be more effective.
SC117. Pillars of diagnosis and treatment of migraine: Information from primary care physicians in Colombia
Joe Munoz Cerón1,2 and Loren Gallo1
1Hospital MEDERI – Universidad del Rosario, Colombia
Introduction: Migraine is highly prevalent and disabling condition and most of the patients are faced at the primary care level. To the best of our knowledge in Colombia there is no information with respect to the knowledge of migraine at this level of attention. The group of work considered that using the ICHD criteria, being familiar with respect to the guidelines to start preventive treatment, restrict analgesics and not to use opioids along with taking into account comorbidities represent the basic pillars to approach to migraine sufferers.
Objective: To determine the proportion of primary care (PCs) physicians who use these pillars of diagnosis and treatment for the clinical practice of migraine in Colombia.
Materials and methods: Cross sectional study. By means of an online semi-structured questionnaire labor active PCs from all over the Colombian territory were interviewed. The group included general practitioners, pediatricians, gynecologists, internists and family medicine specialists.
Results: 347 PCs were interviewed from all the regions in Colombia, 65,5% women, the range of 20–30 years was the most frequent representing 55,8% of the sample, Andina region was the most representative accounting for 90,9% of the participants, 19 participants were excluded. 22,5% of the subjects use ICHD 3 criteria always or most of the times, 36,9% and 75,0% are familiar with the Colombian recommendations guidelines to start preventive therapy and limit the excessive use of analgesics respectively, 62,2% always recommends no to use opioids for acute attacks and 69,2% take into account comorbidities as part of the clinical approach. 80.9% of the subjects consider using red flags as part of the tools to differentiate primary vs non-primary etiologies. We did not find significant differences when specialties, time of exercise, age and area of work were compared.
Conclusion: This study suggests limited knowledge of migraine at the primary care in Colombia, these results are comparable with similar studies around the world.
SC118. Translation and Validation of the Child and Adolescent HARDSHIP (Headache-Attributed Restriction, Disability, Social Handicap and Impaired Participation) Questionnaire into the Brazilian Portuguese Language
Arruda R1,2, Arruda MA2, Steiner TJ3 and Jensen RH4
1Ribeirão Preto Medical School, University of São Paulo, Brazil
2Glia Institute, Brazil
3Division of Brain Sciences, Imperial College London, UK
4Danish Headache Centre, Glostrup Hospital, University of Copenhagen, Copenhagen, Denmark
Background: Headache disorders are among the most prevalent and disabling conditions worldwide, affecting many people throughout their lifetimes. Data regarding headache in children and adolescents are relatively scarce, and published studies have important methodological differences, compromising comparability and hindering informed health policies. The present study is part of the Global Campaign Against Headache, Lifting The Burden (LTB), which aims to map the headache problem worldwide using a standardized methodology.
Objectives: Translate the Child and Adolescent HARDSHIP (Headache-Attributed Restriction, Disability, Social Handicap, and Impaired Participation) Questionnaire into Brazilian Portuguese language, and validate it through a pilot study.
Methods: The translation process was conducted in consonance with LTB’s guidelines, and the pilot survey followed the generic protocol for the global study. A cross-sectional schools-based pilot study was conducted in two public schools of the city of Brodowski, Brazil. Children and adolescents between 7–17 years answered the self-reported questionnaire. Headache diagnoses were based on ICHD-3 criteria. A 24-hour-interval retest was performed to assess diagnosis concordance, which used the Cohen’s Kappa test. Internal consistency was assessed using Cronbach’s Alpha. An exploratory factor analysis of the quality-of-life (QoL) domain was performed to assess interrelations among its items. To assess construct validity, QoL summed score was compared using Kruskal-Wallis Rank Sum test in 5 separate analyses, according to headache a) intensity; b) duration; c) frequency; d) between participants with and without headache; and e) among specific headache diagnosis.
Results: No important concerns were raised along the translation process. Of 340 eligible participants for the pilot survey, 279 had analyzable data (48% female; 44% children aged 7–12 years; 56% adolescents aged 13–17 years). Participation rate was 82.1%, with no discernable bias from non-participation. The Cronbach’s alpha for internal consistency found for the whole questionnaire was 0.82 (CI: 0.78–0.85). 48 students performed the 24-hour-interval retest. Test-retest reliability yielded a Kappa of 0.603 (p < 0.001). Exploratory factor analysis of the QoL scale identified two significantly different dimensions (spearman correlation = −0.35). Within each dimension, items were significantly correlated (correlation coefficients all above 0.50). QoL analyses showed significant worse scores for children and adolescents with higher frequencies (p < 0.001), duration (p = 0.004) and worse intensities (p < 0.001) of headache. Furthermore, participants with any headache diagnosis had worse QoL summed score than those without headache (p < 0.001).
Conclusions: The Brazilian Portuguese version of the ChildAd-HARDSHIP is a reliable instrument, yielding notable parameters of internal consistency, concordance analysis and stability. Furthermore, the instrument had a remarkable performance in distinguishing QoL between no headache participants and headache sufferers.
SC119. Trends in Physiopathology Research of Primary Headaches over the last 50 years
Arruda R1,2 and Bordini CA3,4
1Ribeirão Preto Medical School, University of São Paulo, Brazil
2Glia Institute, Brazil
3Professor of Neurology, Municipal University Center of Franca, Brazil
4Neurologic Clinic of Batatais, Brazil
Introduction: The headache field, mainly migraine, is passing through a transformative era of new treatments. These breakthroughs would not be possible without the evolving knowledge on mechanisms of headaches. However, there are still unmet needs for headaches’ understanding and treatments.
Objectives: Assess whether there is a trend in the number of publications regarding physiopathology of each primary headache disorders (PHD) in the past 50 years. Secondarily, we aimed to evaluate how the SARS-CoV-2 pandemics impacted on physiopathology researches of PHD.
Methods: PHD were divided hierarchically in first- and second-digit, according to ICHD-3 criteria. PubMed database was searched using both the name of the PHD and MeSH terms related to physiopathology. Each search yielded the number of publications for a determined PHD along the period selected (1971–2021). Data were retrieved and separated in two groups: a) per decades (1971–2020); and b) per year (2011–2021). Ratios between every two timepoints in each group were calculated, as well as a total ratio for the whole interval.
Results: Either divided per decades, or divided annually for the last 10 years, migraine had the highest absolute number of pathophysiology publications, significantly above the other PHD. Divided per decades, with exception of tension-type headache (TTH), all the other PHD groups have increased their number of publications over time. Meanwhile, TTH in the last decade decreased the total number of mechanisms research. The number of papers published in 2020 was lower than in 2019 for TTH, trigeminal autonomic cephalalgias (TACs) and group 4 “other PHD” (4.OPHD), migraine kept practically the same number.
Conclusions: There is a clear disparity in the number of publications on mechanisms of each PHD, being migraine well above TTH, TACs and 4.OPHD. As expected, the recent COVID pandemics has clearly impaired pathophysiologic research in the headache field.
SC120. Chronic migraine and prophylaxis with botulinum toxin, epidemiological characterization of patients treated at DIPRECA Hospital and evolutionary profile of the disease
Raúl Juliet Perez1, Vánili Gómez Godoy1, Jessica Miranda Mora2 and Francisco Bustos Espinoza2
Introduction: Chronic migraine (CM) is a pathology with an estimated prevalence of 2 to 3% in the world population. It is a disabling headache, with a significant impact in life and high economic costs, since it generally occurs in the most productive years of patients. The goal of treatment is to improve the quality of life, reducing the frequency, intensity and duration of the crisis, being prophylaxis is one of the principal focus in the management of this pathology; Within the treatment options, the efficacy of onabotulinumtoxin-A in CM associated with detoxification and discontinuation of the drug in overuse has been reported.
Objectives: The purpose of this study was to establish the evolutionary profile and epidemiological characteristics of patients admitted at DIPRECA Hospital with a diagnosis of CM and treated with botulinum toxin, associated or not with overuse headache. At the same time, values from MIDAS and HIT-6 scales were recorded, in the same observation period.
Materials and methods: Observational retrospective study, review of databases in the internal system of DIPRECA Hospital, with the approval of the Scientific Ethics Committee. The inclusion criteria was “chronic migraine”; from these only those who had been treated with botulinum toxin for at least 1 year were included. Through the review of clinical records, it was possible to carry out the epidemiological characterization and record the behavior of the MIDAS and HIT-6 scales.
Results: From the database search, 44 subjects who met the study inclusion criteria were selected After statistical analysis, it was found that 84.09% were women, with a mean age of 43.43 years (SD ± 10.98 years). Overuse headache was present in 76.92%. The most prevalent associated comorbidity was psychiatric pathologies (9.85%). Regarding the average values of the HIT and MIDAS scales, at the beginning 81.60 points (SD ± 40.40 points) and the final figure obtained after 4 interventions was 52.73 points (SD ± 9.70 points). The initial MIDAS values were 37.53 points (SD ± 32.46 points), the final figure obtained after 4 interventions was 11.87 points (SD ± 12.36 points). Higher starting value were recorded on the HIT-6 scale in patients with drug overuse, with a more pronounced drop after the first intervention.
Conclusion: Among patients with CM, we found a prevalence of overuse headache similar to international studies. CM is associated with various comorbidities, the main prevalence of psychiatric disorders. The usefulness of scales, such as those used in the study (HIT-6 and MIDAS), in patients with CM and overuse headache shows a better response in the latter subpopulation.
SC121. Cephalalgia heterotopica: a case series of lower half face migraine
Carlos Alberto Bordini1 and Hilton Mariano da Silva Junior2
1Pontifical Catholic University of Campinas, Faculty of Medicine, Medical Sciences College, Campinas, SP, Brazil
2Municipal University Center, Faculty of Medicine, Franca, SP, Brazil
Introduction: Migraine is a common and very disabling neurological disease. It typically causes severe throbbing pain or a pulsing sensation, usually on one side of the head. It’s often accompanied by nausea, vomiting, and extreme sensitivity to light and sound. According to the definition of headache, the pain should be located in the head or in the face above the orbitomeatal line. Beyond this classical view, recent evidence has shown that it could be an arbitrary boundary, and other clinical features can prevail during the diagnosis process.
Objective: This consecutive case series study aimed to report clinical features, treatment, and outcome of 5 patients with a lower-half facial presentation of migraine.
Materials and Methods: Case series of our Headache Clinic. Data disclosure was authorized by the patients through an informed consent form.
Results: Of the 5 patients, 3 were women and 2 were men. Mean age was 34, 6 (13–56 years). The mean age of symptoms onset was 15,2 (11–29 years). All patients described a throbbing, moderate to severe pain in the malar area. Four patients reported frequent phonophobia and photophobia accompanying pain attacks. One patient reported great relief of pain with rizatriptan and another with sumatriptan. Preventive treatment with pizotifen, propranolol, flunarizine, amitriptyline, divalproex sodium, and pregabalin was useful. All patients underwent extensive dental and otolaryngological evaluation and treatment, which were worthless.
Conclusions: Migraine orofacial presentation is a diagnostic challenge. Proper recognition of these cases not only prevents unnecessary examination and treatment trials but directly benefits the patients since effective treatment is already available. A proper case definition of this rare clinical presentation may provide new insight into our understanding of the migraine mechanisms.
Clinical Cases
CC 101. Glossopharyngeal neuralgia due to lacunar infarction of PICA: an unusual case
María E. Novoa M. and María Alfaro-Olivera
Instituto Nacional de Ciencias Neurológicas, Lima-Perú
Introduction: Glossopharyngeal neuralgia (GPN) is of sudden onset, lasting seconds, usually caused by cold stimuli when chewing, swallowing, talking, coughing, yawning, and sneezing. Painful paroxysms are characteristic, located mostly in the oropharynx and irradiated to the middle ear or vice versa, due to involvement of the pharyngeal branch or auricular branch of the glossopharyngeal nerve (GN). According to the ICHD-3 (International Classification of Headache Disorders-3) classic GPN occurs due to vascular compression. Secondary GPN, due to underlying disease; while idiopathic GPN has no causal evidence. Incidence of 0.7/100,000/year, 9:5 males over females, average age 64 years, left location, 12:9. Infarcts of the posterior inferior cerebellar artery (PICA), an unusual cause of GPN, involving small vessels, associated with risk factors, would explain the ischemic etiology. They represent 40% of cerebellar infarcts, compared to the anterior inferior cerebellar artery (AICA) and the superior cerebellar artery (SUCA). The PICA is divided into 5 segments; anterior medullary (p1), lateral medullary (p2), tonsillomedullary (p3), telovelotonsillar (p4) and cortical (p5). Being the lateral spinal cord segment (p2) the most involved. Represented by Wallenberg syndrome. T2-weighted imaging (T2WI) is more sensitive than fluid-attenuated inversion recovery (FLAIR) in identifying posterior fossa infarcts.
Objective: We present an unusual case of GPN, secondary to a lacunar infarct in the p2-segment of the PICA.
Case description: 65-year-old male, with no apparent pathological history. He reports sudden oropharyngeal pain, radiating to the mandibular angle and left ear, as bursts of electric shocks between 7 and 10 seconds, 2 times a day, when chewing, swallowing and speaking. Concomitantly, dizziness and vertigo are limited to the week of onset of pain. Oropharyngeal tactile stimulation causes a burst of pain that paralyzes the patient for a few seconds. The T2 sequence (T2W1) of the MR showed a small hyperintensity in the lateral medullary segment of the left posterior inferior cerebellar artery (PICA). Uncontrolled arterial hypertension, cardiac arrhythmia and hypothyroidism were the risk factors found in the patient. Indicating pregabalin (75 mg/1 time/day) and the management of heart attack risk factors. The case presented did not characterize Wallenberg syndrome. However, it compromised the prominence of the bulbar olive, up to the origin of the rootlets of the GN, where the pharyngeal branch of the left GN could be injured and cause GPN. Meanwhile, the scant surrounding edema in the small ischemia would promptly explain the limited dizziness and vertigo. The theory of mechanisms of hyperexcitability and ephaptic transmission in central neurons, activating N-methyl-D-aspartic acid receptors in the GN. They would explain the efficacy of antiepileptic drugs in neuralgia. Pregabalin at minimal doses controlled the patient’s outbursts of pain.
Conclusion: GPN of small infarct in the PICA territory is an unusual condition. In our case, the lateral anteromedullary segment of the left PICA compromised the ipsilateral GN. The T2W1 of the MR sequence revealed hyperintensity in PICA-p2. Management with pregabalin was effective.
MRI T2W1 sequence showed small hyperintensity in left PICA-p2.
CC102. Paroxysmal facial pain in a patient with Parry Romberg Syndrome
Yasmín Bravo1, Celeste Esliman Julieta Arena2 and María Teresa Goicochea1
1Headache Service, Fleni, Argentina
2Movement Disorders Service, Fleni, Argentina
Objective: Parry Romberg Syndrome (PRS) is a rare disease, characterized by hemiatrophy of the skin and facial soft tissues, it can affect muscles, cartilage and bones. The cause has not been clarified. It may be due to traumas, vascular malformations, infections, immune-mediated processes and alterations of the sympathetic nervous system. Neurological clinical manifestations occur in approximately 20% of cases, headaches and facial pain are some of them. The objective is to describe the clinical characteristics of facial pain in a patient, report its association with PRS and response to treatment.
Case Description: A 27-year-old woman with a diagnosis of PRS and a history of bruxism and episodic migraine without aura, controlled with ibuprofen, referred stabbing and paroxysmal pain of 7 years of evolution. Pain was in the left temporal and maxillary region, lasting from seconds to 1 minute, moderate intensity and some episodes associated with homolateral temporal and masseter muscle spasm. Frequency of 5 times a day. She referred another sharp and severe left eye pain, lasting 2 hours with ipsilateral congestion and rhinorrhea lasting 24 hours, up to 2 crises in a day and 10 crises per month, with response to indomethacin. Physical examination revealed left facial hemiatrophy and homolateral temporal and masseter muscle spasm and preserved sensitivity in the trigeminal territory. Brain magnetic resonance imaging (MRI): isolated nonspecific punctiform images. Magnetic resonance angiography of intracranial arteries was normal. Magnetic resonance neurography of the cranial nerves showed hypertrophy of the left muscles of mastication, volume asymmetry of the masseter muscles with less volume on the left side, decreased volume of the submandibular gland and decreased thickness of the soft tissues. Left hemifacial: thinning of the hemifacial and hemicranial bone structures as well as of the left soft tissues was observed. The cranial nerves evaluated present normal caliber, course and signal. Temporomandibular joint (TMJ) MRI: dysfunction of both TMJs. Electromyogram of the left masseter and temporal muscles: when presenting the masticatory spasm, contraction of the temporal muscle was observed, follow sequentially by the masseter before ending. Gabapentin treatment was performed without improvement. Treatment with botulinum toxin, under EMG guidance of the left masseter and temporal muscles, was indicated with 80% improvement in pain and spasm.
Conclusion: The association between PRS and hemimasticatory spasm is rare and is associated with compromise of the trigeminal nerve. It is described that the sympathetic hyperactivity produced by an inflammatory process affects the blood vessels and the cranial nerves and this would cause tissue damage. Due to the atrophy of the soft tissues, mainly of the masseter and temporalis muscles, there is a focal demyelination of the peripheral branches of the trigeminal nerve, which causes an abnormal excitation of the fiber and consequently facial pain. This patient had two different pains, paroxystic facial pain and a longer lasting ocular pain with autonomic signs probably as a consequence of trigeminal involvement. More studies are needed to elucidate the cause.
CC103. Case report: a paroxysmal hemicrania responsive to verapamil
Pablo Guarisco Ferreira1, Ângelo Afonso Fabris1, Paola Bernardi da Silva1 and Alcântara Ramos de Assis Cesar2
1Member of Nucleus of Studies on Headache and Cranial Pain in Western Paraná; Professor of Neurology at the Federal University of Paraná, Toledo campus, Brazil
2Coordinator of the Nucleus of Studies on Headache and Cranial Pain in Western Paraná; Professor of Neurology at the Federal University of Paraná, Toledo campus, Brazil
Objective: Paroxysmal hemicrania is a rare type of trigeminal autonomic headache, whose diagnostic criteria include responsiveness to indomethacin. In this report, we present a case of a patient with a partial response to the first-line drug therapy and good responsiveness to verapamil.
Case Description: A 56-year-old woman presented with a 1-year history of throbbing pain in the left hemiface, and retro-orbital and temporal ipsilateral pain, which lasted for about 30 minutes with a frequency of 5–6 episodes per day, and a maximum remission period of 3 months. The headache attacks were associated with nasal congestion and allodynia and had worsened recently. Her past medical history was positive for major depressive disorder and hypertension. At the time she presented, she was taking carbamazepine 900 mg per day, which resulted in partial relief of the pain. Clinical examination revealed pain on palpation of the trigeminal nerve branches on the left side, bilateral temporomandibular pain, and pain on palpation of the right greater occipital nerve. Magnetic resonance angiography of the head did not show any abnormality. To manage the headache attacks, treatment was started with indomethacin 300 mg in the occurrence of the pain episodes, along with chlorpromazine 6 mg per day and carbamazepine 200 mg per day, which decreased the intensity of the pain but did not influence the frequency of the attacks. Therefore, verapamil 80 mg per day was started, continuing the use of previously prescribed medications. Given the normal ECG result, the dose of verapamil was increased to 240 mg per day, and carbamazepine was discontinued. The patient progressed with only two mild episodes of pain per month.
Conclusion: Responsiveness to indomethacin is an important diagnostic criterion for paroxysmal hemicrania, yet some patients have an incomplete response to this therapy. The use of alternative therapies is limited by the lack of research and evidence supporting treatment with other drugs. Nevertheless, it is worth noting that indomethacin should not be neglected as the first therapeutic choice, and non-responsiveness to the first-line drug should increase the possibility of alternative diagnoses. Verapamil was effective in this case, corroborating with case reports that obtained this same result. However, further studies are needed to evaluate alternative treatments to indomethacin, especially regarding verapamil and other calcium channel blockers.
CC104. Dermatologic finding during Migraine headache attack
Bancalari B. Ernesto1,2 and Wicht S Astrid3
1Centro para el Estudio y Tratamiento de las Cefaleas, Lima, Perú
2Escuela de Medicina, Universidad Católica Santo Toribio de Mogrovejo, Chiclayo, Perú
3Clínica Angloamericana, Lima, Perú
Objective: To report a patient with migraine and ecchymotic lesions in relation with migraine attacks probably due to trigeminovascular activation associated to autonomic vascular dysfunction.
Case description: A 21-year-old woman diagnosed with episodic migraine with aura since the age of 14, who described her headaches as hemicraneal, throbbing pain associated to sensitivity to light and sound, with a frequency of five to six severe episodes per month, some of them accompanied by visual aura. She recently noticed that at the time of her migraine attacks, eyelid ecchymosis ipsilateral to the side, pain developed. It appeared on both, right or left side and upper or lower eyelids depending of the pain side during the attack (figure 1). The ecchymosis usually lasted a couple of days and was not associated with oedema or vegetative manifestations. Neurologic examination and brain MRI were normal, blood workup revealed no evidence for vasculitis or coagulation disorders. She started topiramate 25 mg bid with improvement of headache frequency and resolution of periorbital ecchymosis. On a follow up call 6 months later, she told us that today, during a migraine attack, she develops baggy eyes, but no ecchymosis. Previous reports have described red forehead dot syndrome, red ear syndrome and periorbital ecchymosis in migraine patients. It has been hypothesized that activation of the trigeminovascular system leading to extracerebral vasodilatation with extravasation of red blood cells in the V1 distribution of the trigeminal nerve via the release of vasoactive peptides could cause these phenomena. Another factor may be coagulation changes with heparin release from mast cells and basophilic leukocytes, previously documented during migraine attacks.
Conclusion: Our case describes an unusual finding during migraine attacks, such as periorbital ecchymosis with a possible pathogenic mechanism of autonomic vascular dysfunction following trigeminovascular activation during migraine attacks.
Upper eyelid ecchymosis in the right eye (right) and lower eyelid ecchymosis in the left eye (left) observed during different attacks.
CC105. Abnormal CT perfusion in a patient during a migraine with aura episode: Case report
Wainberg FN1, Ricciardi M1, Chaves Hernán2 and Goicochea MT3
1General neurology department, FLENI, Argentina
2Diagnostic Imaging department, FLENI, Argentina
3Headaches service, neurology department. FLENI, Argentina
Objective: To describe a case with relevant radiologic findings in the acute aura phase of migraine.
Clinical case: A 30-year-old male patient, without cardiovascular risk factors or migraine history, presented to the emergency department with a 90 minutes negative visual defect compatible with right homonymous hemianopia with progressive improvement and bifrontal headache. At admission, no other neurological deficits were found. He was immediately studied with a non-enhanced computed tomography (NECT) and CT angiography (CTA) with no pathological findings. CT perfusion (CTP) showed a prolonged Time-to-Maximum (Tmax) in both posterior cerebral arteries territory as a sign of hypoperfusion. As symptoms were potentially disabling and ischaemic stroke was suspected, treatment with alteplase was administered. Patient persisted with residual deficit for at least 24 hours. A magnetic resonance imaging scan was performed at that point, with no evidence of acute ischemic images. Diagnosis of transient ischemic attack versus debut of probable migraine with prolonged aura (MA) was initially made. At 10-month follow-up, he presented a new episode of visual aura with positive symptoms, confirming the diagnosis of MA.
Conclusion: Reduced cerebral blood flow (CBF) and cerebral blood volume are the most commonly reported findings on perfusion studies in the aura phase of migraine. These perfusion alterations are followed in frequency by prolonged mean transit time (MTT), time to peak (TTP) or Tmax; encompassing more than one vascular territory with an occipital predominance as seen in our patient, even with normal CBF and CBV. Perfusion imaging studies in stroke patients show a more severe increase of MTT, TTP or Tmax, reaching values that are atypical in MA; these findings should raise a suspicion of critical hypoperfusion, as seen in acute ischaemic stroke.
Relevance to the field: This data is promising and encourages further investigation to facilitate differentiation between stroke and migraine with aura attack debut in emergency departments using perfusion imaging studies with the purpose of avoiding unnecessary treatments that are not exempt from adverse effects and elevated costs.
CTP showed no alterations on CBF (A) and prolonged max (B) in both occipital lobes, not reaching the critical hypoperfusion threshold (Tmax > 6 seconds).
CC106. Cough headache secondary to spontaneous occult fistula
Luis Cortez-Salazar
Edgardo Rebagliati Martins National Hospital, Lima, Perú
Objective: To describe the case of a patient who developed cough headache secondary to an occult thoracolumbar fistula, with an excellent response after the blood patch.
Case description: Patient male 56-year-old. Without relevant medical history, denies recent trauma or surgery. Onset four months ago with throbbing headache, bilateral, with moderate intensity (7/10), which is triggered after coughing, sneezing or with postural changes, not accompanied by nausea, vomiting, photophobia or sonophobia, it is of daily frequency, each episode lasts approximately 1 to 3 minutes. He received therapeutic trials with NSAIDs and triptans for 2 months without improvement, being subsequently medicated with acetazolamide and indomethacin for 1 month due to probable primary cough headache, without obtaining headache relief. He was hospitalized, on admission the neurological examination was normal. Brain magnetic resonance imaging (MRI) with angioresonance showed no alterations. Lumbar puncture revealed an opening pressure of 12 cmH2O with normal cytochemical and negative microbiological tests. An extensive study with radioisotope cisternography by intrathecal administration of Tc99m-DTPA showed slow ascent of the tracer through the lumbar and lower dorsal subarachnoid space without visualization of basal cisterns, with signs of paraspinal extravasation of cerebrospinal fluid (CSF) at the lumbar and dorsal levels (Fig. 1), findings suggestive of CSF leakage at the thoracolumbar level, not being possible to identify the fistulous tract by MRI of the dorsolumbar spine. Epidural administration of autologous venous blood was performed, without complications. After the procedure, the patient presented a favorable evolution with cessation of headache, without recurrence in the 9-month follow-up.
Conclusions: Cough headache is a widely described, rare condition. It is characteristically triggered by a rapid rise in intra-abdominal pressure that occurs with coughing, sneezing, or straining. Secondary cough headache comprises about 40% of cough headaches and is associated with a wide variety of aetiologies, including spontaneous intracranial hypotension due to CSF leak. Neuroimaging is important to identify intracranial lesions, in doubtful cases radioisotopic cisternography plays an important role in identifying CSF leak. Treatment is usually conservative, in disabling conditions epidural injection of autologous blood (blood patch) has a high response rate.
Radioisotopic cisternography. (A, B) Anterior and posterior projection image taken 2 hours after tracer injection, showing several foci of paraspinal activity, absence of visualization of basal cisterns. Early urinary activity. C) Image in anterior, posterior and lateral projection made at 24 hours, showing very low cranial activity, suggestive of CSF leak.
CC107. Painful unilateral facial swelling due to superficial temporal artery thrombosis: a rare presentation of Antiphospholipid Syndrome
Helena da Cunha Lopes de Lima1, Carmen Caroline Orru2, Ana Clara Dias Pereira1, Naiara Cunha de Moura1, Vivian Langue Rodrigues Silva1 and Hilton Mariano da Silva Junior1,2
1Pontifical Catholic University of Campinas, Faculty of Medicine, Medical Sciences College, Campinas, SP, Brazil
2Department of Neurology and Neurosurgery of Dr. Mario Gatti Hospital Campinas, SP, Brazil
Introduction: Persistent painful unilateral temporal swelling is rarely seen in clinical practice. Antiphospholipid syndrome (APS) is an autoimmune and systemic disorder that causes changes in blood clotting homeostasis, marked by arterial or venous thrombosis, gestational morbidity, and high and persistently positive serum levels of antiphospholipid antibodies (aPL). APS is more common in young women and middle-aged adults, with no preference for race. Among its clinical features, temporal artery thrombosis, associated with headache and temporal and hemifacial edema is extremely rare, with few publications worldwide on this topic.
Objectives: This report aims to present the case of a unilateral painful facial edema due to thrombosis of the superficial temporal artery as an unprecedented manifestation of Antiphospholipid Syndrome. Thus, the only record in the English-language literature surveyed in the Pubmed database in July 2022 highlights the rarity of this APS presentation and the consequent challenge in suspecting the correct diagnosis for adequate treatment.
Case description: A 32-year-old woman was presented with pain in the right temporal region of her face. The pain was intense, daily and continuous, pulsating, without irradiation, which worsened with physical activity and presented partial relief with common analgesics. After 20 days, she developed a right pale temporal edema (Figure 1) associated with a significant worsening of pain and intense right unilateral headache attacks triggered by chewing and speaking. She has a history of deep vein thrombosis in the left lower limb. Physical examination and imaging tests showed significant cold edema of the right temporal region with asymmetry of the temporal muscles, which was extremely painful on palpation and made it difficult to open the mouth. There were no other changes in the general physical or neurological examination. During evolution, hypertrophy of the masseter muscles on the right was also noted. She presented erythrocyte sedimentation velocity (ESR) tests with high values, subcutaneous edema in the right temporal region on magnetic resonance imaging (MRI) of the brain, and a biopsy of the right temporal artery revealed a residual histological picture of the previous thrombosis. In the case of suspected hematological disease, serial investigations were performed for aPL markers, which were positive, and for systemic lupus erythematosus, which was negative. Evolved with improvement of edema and pain with the use of indomethacin and low molecular weight heparin. Data disclosure was authorized by the patient through an informed consent form.
Conclusions: This report demonstrates a persistent painful unilateral temporal swelling due to a temporal artery thrombosis resulting from APS. This is a very rare presentation of this condition, highlighting the importance of a high level of clinical suspicion for directing laboratory investigation and appropriate treatment.
Right pale temporal edema.
CC108. Psilocybin for the treatment of cluster headache, case report
1Neurology Department, Hospital Maciel, School of Medicine, University of the Republic, Montevideo, Uruguay
2Internal Medicine 1 (Medical Clinic 1) Hospital Maciel, School of Medicine. University of the Republic, Montevideo, Uruguay
Objectives: To describe the clinical case of a patient who used psilocybin for the treatment of cluster headache. To describe the modality, dose, efficacy and adverse effects of psilocybin in the patient. To carry out a review of the available evidence about this treatment.
Case description: Male, 60 years old. Smoker. History of 19 years of evolution of right periorbitary headache, intensity 10/10, throbbing, lasting up to two hours with tearing, conjunctival congestion and rhinorrhea ipsilateral to the pain and psychomotor agitation. Presents up to 3 episodes in 24 hours, reporting at least one at night in the first half of it. The evolution has been with asymptomatic periods between one to three months. MRI of normal skull. With episodic cluster headache raised, crisis and preventive treatment is started. For crises oxygen-therapy MFL 7 to 10 liters per min with improvement. He has received multiple preventive treatments: prednisone 60 mg a day for a week, verapamil up to 480 mg a day, topiramate 100 mg a day, lithium up to 900 mg a day, sometimes in association with melatonin with poor response to them. In the last 6 years he self-indicates psilocybin, with which he becomes aware from the online forum “Clusterbusters”. It is used in the form of an infusion from Psilocybe cubensis on a monthly basis, at doses of 0.5 to 1.0 g of the active ingredient associated with caffeine. From the start of treatment, he reports a decrease of more than 50% in the frequency and intensity of the crises, with remission periods of up to 1 year and a half. As an adverse effect with a higher dose than usual, he refers to autoscopic-type hallucinations, on one occasion.
Conclusions – Relevance to the field: Cluster headache is considered one of the most intense headaches, with suicidal ideas in many patients. The treatment indicated is that of crises and prevention. Although there are numerous drugs, none have universal efficacy. It is to prioritize that psilocybin (hallucinogen) is being used by patients with cluster headache who seek advice in international forums. Although the patient had a significant reduction in the frequency and intensity of the crises, the precise dose for the treatment of this entity is not known, so its use may be risky (hypertension, secondary headache and hallucinations). Two phase 1 randomized controlled clinical trials of the use of psilocybin for the treatment of cluster headaches are currently underway and are expected to provide further evidence of its efficacy. This case report provides empirical evidence in favor of the trend towards the use of psilocybin as preventive therapy for cluster headache, given the limited effectiveness of conventional therapy in many of these patients. There is a growing interest regarding the above, which has generated the appearance of new research, which today has provided little quality evidence due to the illegality of the substance and the absence of completed clinical trials that objectively compare the efficacy and safety of psilocybin compared to current best treatments.
CC109. Mimic migraine as a presentation of neurocysticercosis of the 4th ventricle
1Neurology Working Group, Dr. José M. Penna General Acute Hospital, CABA, Argentina
2Ineba – Institute of Neurosciences of Buenos Aires. CABA, Argentina
Introduction and objectives: Neurocysticercosis (NCC) is the most common helminthic disease of the nervous system. It can present with epileptic seizures, focal deficit, cognitive impairment and headaches. The latter usually occur in the context of intracranial hypertension associated with multiple cystic lesions of the brain parenchyma or giant cysts. We present a clinical case of NCC that debuts as mimic migraine.
Case description: A 22-year-old puerperal patient, a native of Bolivia. She presents with throbbing hemicranean headache, with progressive intensity, persistent for a month of evolution. She adds photophobia, sonophobia, nausea and vomiting associated with dizziness and tinnitus. She was refractory to symptomatic treatment. Hydrocephalus is observed in the computed tomography of the brain. Lumbar puncture is performed: cerebrospinal fluid with physicochemical and negative cultures. Serology for cysticercosis: positive. Magnetic resonance imaging of the brain: cystic image with nodular formation inside in topography of the 4th ventricle. It is interpreted as compatible with NCC. Treatment with intravenous corticosteroids and oral albendazole was started, with a favourable clinical response and imaging resolution.
Conclusion: A case with secondary to a NCC headache is presented, mimicking a migraine, fulfilling the IHS criteria for this entity.
CC 110. Fighter pilot with incapacitating headache attacks: Dramatic response to galcanezumab on intensity/frequency of migraine attacks, but without affecting prodromal manifestations
Samuel Nucci Perez1, Juliana Ramos de Andrade2, Marcelo Moraes Valença2 and Carlos Alberto Bordini1
1Centro Universitário Municipal de Franca, Franca São Paulo, Brazil
2Instituto Keizo Asami, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil
Objective: In a migraine attack, we can highlight two phases: (1) the prodromal phase that precedes the pain by hours, and (2) the phase of the classic manifestations of migraine with aura and headache, associated with pathognomonic nausea/vomiting, photo/phonophobia. We wish to present a case of a patient with incapacitating migraine attacks (two to three times a week), which are always preceded by marked prodromal manifestations. With treatment using monoclonal antibody anti-CGRP (galcanezumab), there was a drastic improvement in migraine pain crises without affecting prodromal symptoms of hypertonia and cervical-nuchal pain. Thus, there is an apparent dichotomy between the action of galcanezumab on the prodromal phase and the classic painful phase of migraine.
Case description: Caucasian 38-year-old man, airplane pilot, with refractory migraine, with incapacitating migraine attacks (two to three times a week, 5 to 7 sumatriptan tablets a week), reported that his migraines crises started at age 14. One and 6 hours prior to the crises, the patient reported prodromal manifestations, such as pain and hypertonia in the right nuchal region, soreness in the outer corner of the right eye, and a vague feeling of discomfort. On examination: pain in the supraorbital and greater occipital nerves on the right. Because of his profession, he did not tolerate divalproex, amitriptyline, propranolol, and topiramate. Divalproate could not be tolerated due to difficulty in delicate movements and he felt drowsy. Topiramate was not tolerated due to drowsiness and cognitive difficulty. The therapeutic proposal was nerve block and anti-CGRP monoclonal antibody. The patient received as preventive treatment galcanezumab (120 mg/month). Sixty days after the first dose of galcanezumab, he improved substantially, reporting only two less intense crises associated with alcohol consumption and using three sumatriptan tablets in the period. Furthermore, 150 days later, he used only three tablets of sumatriptan in a 90-day interval. Stressful situations no longer trigger seizures. On the third return to the outpatient clinic after 270 days, he mentioned almost no headache crises. He reports that triggering situations such as stress or intense light sometimes cause pain and stiffness in the cervical muscles and a feeling of discomfort, but the crisis does not develop beyond that.
Conclusion: We describe the action of an anti-CGRP antibody in a patient who works as a fighter pilot, a profession that demands great cognitive activity and motor skills. This class of drugs has a preventive action on migraine without altering cognitive functions, including attention and motor performance. The treatment showed a dichotomized action on the phases of migraine – acting essentially on headache attacks without affecting prodromal manifestations.
