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Those that have good Voices may be taught to sing the newest Opera-Airs, and, if requir'd, to speak either Italian or French, paying something extraordinary above the common Rates. They whose Friends are not able to pay the full Prices may be taken as Half-boarders.
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She is also well-skilled in the Drapery-part, and puts on Hoods and mixes Ribbons so as to suit the Colours of the Face with great Art and Success. This Day is publish'd An Essay on Criticism. Printed for W. Osborn, in Gray's Inn near the Walks; T. Graves, in St. James's Street; and T. Shubertrtenemi 26 czerwca Carlosgub 27 czerwca Carlosgub 28 czerwca EdwardGepsy 23 lipca Robertplume 23 lipca Robertplume 24 lipca EdwardGepsy 24 lipca EdwardGepsy 25 lipca Robertplume 25 lipca Robertplume 26 lipca Robertplume 27 lipca Robertplume 28 lipca Robertplume 29 lipca Robertplume 30 lipca Robertplume 31 lipca Robertplume 1 sierpnia Robertplume 2 sierpnia Robertplume 3 sierpnia Robertplume 4 sierpnia Robertplume 5 sierpnia Robertplume 6 sierpnia Robertplume 7 sierpnia Robertplume 8 sierpnia Robertplume 9 sierpnia EdwardGepsy 14 sierpnia ForexPidly 23 stycznia BrandonDeeri 21 marca ForexPidly 29 marca ForexPidly 15 kwietnia PkudLanknuri 9 czerwca DoiiLanknuri 10 czerwca DraiLanknuri 11 czerwca GregLanknuri 21 czerwca SregLanknuri 21 czerwca SobiLanknuri 27 czerwca DacLanknuri 4 lipca HusajnLanknuri 15 lipca Josephadorp 25 sierpnia K0tflgLanknuri 1 listopada G4zy4gLanknuri 1 listopada Chwo8oLanknuri 1 listopada Alkr5eLanknuri 1 listopada An1b4qLanknuri 1 listopada Cephalalgia ; Chronic Migraine in Children and Adolescents.
Headache and comorbidities in childhood and adolescence. Springer, Whether medication-overuse headache MOH represents a distinct biological entity within the concept of chronic daily headache with specific neurobiological and genetic background is still a matter of debate. A great deal of interest has been directed at understanding the neurophysiological mechanisms that underlie MOH pathogenesis.
Currently, two main, non-mutually exclusive hypotheses have been proposed. The first, stems from the apparent compulsive use of headache medications by MOH patients, and considers this disorder a sort of addiction to symptomatic remedies.
The second shifts the focus from drug addiction to neural sensitization, claiming that triptan overuse triggers adaptations of the trigeminovascular system, thereby facilitating pain transmission and leading to a state of latent sensitization. Answering these questions might be relevant to better understand the neurochemical mechanisms prompted by acute headache medications that underlie the pathophysiology of MOH and of chronic headache in general.
In this presentation, preclinical data will be presented showing that chronic exposure to eletriptan or indomethacin alter trigeminal ganglion gene expression patterns broadly and to a similar extend.
Remarkably, qualitative transcriptomic analysis reveals that prolonged exposure to the two different symptomatic drugs triggers almost identical, increased expression of various genes coding for proteins involved in headache pathogenesis such as neuropeptides, their cognate receptors, TRP channels, prostanoid and NO synthesizing enzymes.
These findings will be correlated with the clinical aspects of MOH. The dramatic caloric restriction promotes the fat metabolism, mimicking the starvation, even if meals replacements ad hoc developed accounts for essential nutrients, avoiding the malnutrition.
Because of the extreme caloric restriction, this type of diet is very effective in weight loss, however, that characteristic also is the main limit of VLCD, since it is possible to follow this kind of dietetic regimen for a very limited period usually weeks. Salads are allowed ad libitum dressed with a spoonful of olive oil. Also in this kind of diet, there are meals per day, mainly consisting in meal replacement products. There is a growing interest in the ketogenic form of the VLCD because several studies have shown a higher compliance of patients with this diet.
The reason of this higher adherence to the diet is still under scrutiny but several reasons are called in cause: an appetite suppression induced by proteins and maybe by ketone bodies KBs , or a modification in hormone secretion insulin, glucagon, ghrelin, adipokines.
The real impact of ketogenic diets in weight loss is still disputed; in fact, on the long period there are not differences between low-carb and low-fat diets in terms of weight reduction and regain of lost weight after the diet. However, thanks to the higher compliance and the drastic caloric restriction, the VLCKDs seem to be a promising approach in the early management of obesity and in the preparation phase for patients that must undergo to bariatric or other types of surgical procedures.
Temporomandibular disorders TMD represent the main cause of orofacial pain of non-dental origin and comprehend several disturbances of the masticatory system characterized by myofascial pain of masticatory muscles or articular pain localized in the pre-auricular area. Moreover, TMD patients show temporomandibular joint sounds and deviation or limitation of the opening of the mouth.
Myofascial pain is a probable consequence of central nervous system mechanisms of convergence and activation of second order neurons with enlargement of the receptive field, reduced pain threshold and allodinia. Often there are accompanying symptoms like facial pain and headaches.
Headache is the most prevalent neurologic disorder, third most diffused health disturbance and the seventh cause of disability in the world. It can be primary, without apparent organic cause, or secondary to other pathologies.
Some epidemiological studies indicates that headache is more prevalent in TMD patients and TMD is more prevalent in subjects affected by headache. A stronger association exists between TMD and chronic migraine in comparison with other types of headache. Nevertheless the methodological quality of the available studies is not optimal and many of them classify patients with anamnestic questionnaire that tend to overestimate the values of prevalence. A growing body of literature suggests that the association between headache and TMD may be a manifestation of a central sensitization mechanism.
Temporomandibular joint and muscles receive the sensitive innervation of the trigeminal nerve that supply also the cranial vascular structures likely involved in the etiology of the headache. The sensitization of the trigeminal caudate nucleus by the TMD symptoms can favor the triggering of migraine episode.
Beside the epidemiological studies and the neurophysiologic hypothesis, there are some initial clinical evidence that show how severity of TMD symptoms parallels an increase of frequency and intensity of migraine and the simultaneous treatment of both conditions results in better outcomes. From a clinical perspective, a comprehensive assessment based on a biopsychosocial approach can provide relevant information to plan a contemporaneous treatment of TMD and headache, together with an intervention targeted to the reduction of psychosocial conditions that can elicit and maintain mechanisms of central sensitization likely responsible of the comorbidity of TMD and headache.
The exact pathophysiology is still unknown, but evidence supporting both peripheral and central mechanisms i. In fact, the frequency of headache attacks has found to be related to the level of central sensitization [4]. However, not all TTH patients present with the same level of central sensitization and clinical presentation, but subgroups need to be identified in order to offer specific therapeutic programs [5]. Prolonged peripheral nociceptive input from the pericranial, neck, and shoulder regions e.
In fact, it has been found that sustained stimulation of TrPs may induce central sensitization in healthy participants [7]. The number of TrPs seems to be associated with the degree of widespread pressure pain hypersensitivity in TTH patients, supporting the role of TrPs on central sensitization: however the cross-sectional nature of the study does not allow to establish a cause and effect relationship between TrPs and central sensitization, as other variables may influence this association [9].
Physical therapy may be helpful for the management of TTH patients [10,11], as it may decrese the peripheral nociceptive input. The global burden of headache: a documentation of headache prevalence and disability worldwide. Cephalalgia ;— Tension type headache. Curr Rheumatol Rev ; — Pressure pain thresholds assessed over temporalis, masseter, and frontalis muscles in healthy individuals, patients with tension- type headache, and those with migraine: A systematic review.
Pain ; — Frequency of headache is related to sensitization: a population study. Pain ; Identification of subgroups of patients with tension type headache with higher widespread pressure pain hyperalgesia. J Headache Pain ; 18 1 The role of muscles in tension-type headache. Curr Pain Headache Rep. Sustained nociceptive mechanical stimulation of latent myofascial trigger point induces central sensitization in healthy subjects. J Pain.
Myofascial trigger points and sensitization: An updated pain model for tension-type headache. Trigger Points are associated with widespread pressure pain sensitivity in people with tension-type headache.
Cephalalgia [Epub ahead of print]. Muscle trigger point therapy in tension-type headache. Expert Rev Neurother ; 12 3 Effectiveneess of physical therapy in patients with tension-type headache: literature review.
J Jpn Phys Ther Assoc ; 17 1 Migraine is related to the highest disability among headaches. Great efforts are faced to improve the outcome of forthcoming treatments. However, still now, many patients regard as unsatisfactory the low responder rate about the half of patients and adverse effects that current treatments account.
Therefore, waiting for innovative, more tolerated and effective treatments, there is a large request for non-pharmacological approaches that in many cases have specific pathophysiological targets. Among these treatments, nutraceuticals has a leading role.
Several nutraceutical products are proposed for migraine and sold around the world, but researchers adequately study only few compounds. Among studied nutraceuticals compounds, only few of them have studies of good quality in support. Moreover, also interactions among different molecules are not studied. We have reviewed literature data in order to find researches that support the use of nutraceutical molecules in migraine management.
Available good quality data support the use of certain nutraceuticals, in particular riboflavin, coenzyme Q10, magnesium, butterbur, feverfew, and omega-3 polyunsaturated fatty acids.
Even if not supported by double blind studies, recently some prospective observational studies about fixed combination of nutraceuticals were performed. For instance, it is the case of a combination of coenzyme Q10, feverfew and magnesium for migraine prophylaxis: a prospective observational study. A double blind versus placebo study about the effect of a fixed combination of riboflavin, coenzyme Q10, feverfew, andrographis and magnesium for migraine prophylaxis is currently in progress.
Usually patients appreciate nutraceuticals more than traditional drugs, since they are regarded as safe and of efficacy not inferior to other pharmacological products. Available data seem to support this widespread belief, but some concerns about the regulation of nutraceuticals and quality of some products, still remain.
Contrary to what is generally thought of, headaches and algology pain therapy share many aspects. Headaches and chronic non-oncological pain are two paradigms of chronic illness capable of generating enormous individual and social impact by disabling the sick person not only in the biological, but also in the psychological, professional, social and relational spheres. Both cause alterations in psychological equilibrium, secondary depression, loss of social and professional roles, which, in the most serious cases, can cause loss of work.
Literature documents in both cases, headaches and chronic pain, a rise in direct costs but above all of the indirect ones with a huge burden of disease. Both are capable of generating a marked drop in the quality of life associated with a serious bio-psycho-social disability.
Headaches and chronic pain, although distinct according to a topographical criterion, share many mechanisms and physiopathogenetic steps. One of the most current fields in which neurologists and pain therapists converge is the focus on neuroinflammation [3] and central sensitization[4], two key mechanism for triggering, maintaining, and subsequent perpetuation of pain: the pain as a symptom, filogenetically responsible for maintaining homeostasis of the organism against actual or potential damage, becomes unnecessary illness without any protective meaning.
Another important shared pathogenetic passage is that of neuroimmune mechanisms, which interlink the immune system with the central nervous system[4].
Furthermore, numerous contribution to the scientific international literature highlight the need to modify the therapeutic approach, directing it towards a semeiotic criterion pain phenothype: specific sign and symptoms of a certain type of pain in a specific moment , which is an epiphenomenon of underlyng pathogenetic mechanism, instead of basing it on a etiologic criterion[5]. This would enable a more appropriate prescription and greater efficiency, taking into primary consideration the possibility of getting back to everyday life rather than obtaining complete analgesia.
All the above mentioned aspects are equally important but one of them can prevail over the others depending on patient characteristics and background.
In conclusion it can be stated that the aspects of sharing between headaches and chronic non-oncological pain are significantly greater than those that clearly divide them. World Health Organization. International classification of functioning, disability and health ICF.
Geneva, World Health Organization, Steiner T. J Lifting the burden: The global campaign against headache. Ru-Rong Ji Emerging targets in neuroinflammation-driven chronic pain. Nat Rev Drug Discov. Baron R Neuropathic pain: diagnosis, pathophysiological mechanisms, and treatment. Lancet Neurol. Headache is a common clinical feature in neurological patients. Usually, neuroimaging is unnecessary in patients with episodic migraine or tension type headache with typical headache features and with a normal neurological examination.
These patients do not have a higher probability of a relevant brain pathology compared to the general population. A recent study, however, reported that neuroimaging is routinely ordered in outpatient headache even if guidelines specifically recommend against their use. Brain MRI with detailed study of the pituitary area and cavernous sinus, is recommended for all trigeminal autonomic cephalalgias TACs.
Neuroimaging should be considered in patients presenting with atypical headache features, a new onset headache, change in previously headache pattern, headache abruptly reaching the peak level, headache changing with posture, headache awakening the patient, or precipitated by physical activity or Valsalva manoeuvre and abnormal neurological examination.
A recent consensus recommends brain MRI for the case of migraine with aura that persists on one side or in brainstem aura. According the same consensus, fFor primary cough headache, exercise headache, headache associated with sexual activity, thunderclap headache and hypnic headache apart from brain MRI additional tests may be required [3].
Particularly in emergency room it is mandatory to exclude a secondary headache that requires special attention and further diagnostic workup. CT scan is the first line neuroimaging examination. MRI offers a greater resolution and discrimination and might therefore be the preferred method of choice in non acute headache.
In addition, radiation due to CT scanning may be avoided. Neuroimaging non conventional techniques are of little or no value in the clinical setting. Headache neuroimaging: Routine testing when guidelines recommend against them. European Headache Federation consensus on technical investigation for primary headachedisorders. Migraine frequency fluctuates over time. In the literature, the most important recognized factors associated to chronic migraine are overuse of acute migraine medication, ineffective acute treatment, obesity, depression, presence of allodynia and stressful life events.
Other factors reported in studies are age, female sex and low educational status. Very recently, a large population study suggested that the presence of additional noncephalic pain site is a risk factor for migraine chronification. For many of these factors the relationship with migraine chronification may however be bi-directional. For instance, in the case of depression, it is possible that depression may negatively affect the response of migraine to acute and prophylactic treatments, but it is also true the opposite: i.
In the case of obesity, the association with chronic migraine may simply be ascribed to the effect of fat tissue in drug distribution.
Beside and beyond the putative biological factors that may cause a worsening of disease, several lines of evidence suggest that the progression from episodic to chronic migraine is associated to a progressive increase and stabilization of functional and anatomical changes associated to chronic sensitization.
In this frame, it appears obvious that an additional cause for chronic migraine is quite likely represented by the low rate of prescription of preventive medications. The underutilization of preventive drugs has several explanations ranging from drug-associated issues limited efficacy, poor tolerability profile to education of practitioners, pharmacists and patients, and it also involve the limited access to qualified care.
Underutilization of preventative drugs also translate into a higher recourse to acute drugs, thus feeding on a vicious cycle that leads to negative consequences. CT has participated in advisory boards for Allergan and electroCore; she has lectured at symposia sponsored by Allergan; she is PI or collaborator in clinical trials sponsored by Alder, electroCore, Eli-Lilly and Teva.
Prevalence of migraine sufferers who are candidates for preventive therapy: results from the American migraine study AMPP study. Headache ; — The added value of an electronic monitoring and alerting system in the management of medication-overuse headache: A controlled multicentre study.
To date, the majority of clinical studies concerning primary headaches and their comorbidities are focused on migraine. Comorbidities of migraine may include neurological and psychiatric conditions, as mood disorders depression, mania, anxiety, panic attacks , epilepsy, essential tremor, stroke, and the presence of white matter abnormalities [2].
Particularly, a complex and bidirectional relation between migraine and stroke has been described, including migraine as a risk factor for cerebral ischemia, migraine caused by cerebral ischemia, migraine mimicking cerebral ischemia, migraine and cerebral ischemia sharing a common cause, and migraine associated with subclinical vascular brain lesions [2]. A recent meta-analysis pointed out that migraine is associated with increased ischemic stroke risk [3], and according to a systematic review and meta-analysis [4] the risk of hemorrhagic stroke in migraineurs is increased with respect to non-migraineurs.
Besides, the risk of transient ischemic attack seems to be increased in migraineurs, although this issue has not been extensively investigated [5]. A recent systematic review and meta-analysis also describes an increased risk of myocardial infarction and angina in migraineurs compared to non-migraineurs [6]. Concerning the association between migraine and vascular risk factors arterial hypertension, diabetes mellitus, dyslipidemia, obesity, alcohol consumption, family history of cardiovascular disease , a recent review [7] showed no solid evidence of an increased burden of conventional vascular risk factors in migraineurs, with the only exceptions of dyslipidemia and cigarette smoking, while a systematic review and meta-analysis regarding migraine and body mass index categories [8] found an increased risk of having migraine in underweight subjects and in obese women as compared with normal-weight subjects.
Few studies investigated the comorbidities of tension-type headache TTH , despite the fact that tension-type headache TTH is highly prevalent, and may be as debilitating as migraine [9]. It is noteworthy that, according to a review, TTH is associated with increased rate of affective distress [9]. Furthermore, some medical disorders may worsen a preexisting TTH, and it has been described the comorbidity of TTH with psychiatric disorders and fibromyalgia [10].
The International Classification of Headache Disorders, 3 rd edition beta version. Comorbid neuropathologies in migraine. Migraine headache and ischemic stroke risk: an updated meta-analysis. Am J Med. Migraine and hemorrhagic stroke: a meta-analysis. Sacco S, Kurth T. Migraine and the risk for stroke and cardiovascular disease. Curr Cardiol Rep. Migraine and risk of ischaemic heart disease: a systematic review and meta-analysis of observational studies.
Conventional vascular risk factors: Their role in the association between migraine and cardiovascular diseases. Migraine and body mass index categories: a systematic review and meta-analysis of observational studies. Tension-type headache and psychiatric comorbidity. Tension-type headache and systemic medical disorders. Differentiating patients with life-threatening headaches from the overwhelming majority with primary headaches eg migraine, tension or cluster headache is an important issue in emergency department ED.
Patients with non-traumatic headaches are up to 4. These numbers seem to remain constant in Western countries Ramirez-Lassepas, ; Kowalski, ; Cvetkovic, ; Gaughran, Primary headaches still pose an open challenge in the ED because the failure to recognize a secondary headache could cause potentially fatal consequences.
Unfortunately, to date, there is still no a standard diagnostic procedure for headache in emergency conditions; although according to the diagnostic guidelines there are red flags that could help in the process, the positive predictive value of each severity indicator is not yet determined. The problem of poor diagnostic sensitivity was attributed to IHCD-3 criteria rigidity in relation to primary headache diagnosis in emergency setting Dutto, , Swadron, Alternatively, a different standardized work-up has been proposed for the most frequent headache scenarios in ED Cortelli, ; Dutto, A careful history and physical examination remain the most important part of the assessment of the headache patient; they enable the clinician to determine whether the patient is at significant risk for a dangerous cause of their symptoms and what additional workup is necessary.
This presentation will discuss how to approach adults with headache in ED with an emphasis on those features that characterize high-risk headaches. Thus, the muscolokeletal contribution in Primary Headaches is still debate in the literature [5]. Moreover, recent knowledge suggests that different clinical headache phenotypes arising from a common pathophysiology rather than an independent disorder [6].
That is, in the most prevalent headaches disorders i. In this presentation, the role of the musculoskeletal inputs in primary headaches it will be provided. Moreover, evidences of the effectiveness of a manual therapy management provided by a physiotherapist and its integration in a multidisciplinary team it will be discussed.
Migraine prophylaxis with drugs influencing the renin-angiotensin system. The impact of headache in Europe: principal results of the Eurolight project. Pietrobon D, Striessnig J. Neurobiology of migraine. Nat Rev Neurosci. Cady RK. The convergence hypothesis. Noseda R, Burstein R. Migraine pathophysiology: anatomy of the trigeminovascular pathway and associated neurological symptoms, CSD, sensitization and modulation of pain.
Migraine pathophysiology: anatomy of the trigeminovascular pathway and associated neurological symptoms, cortical spreading depression, sensitization, and modulation of pain. The European Headache Federation recognized the value of OnabotulinumtoxinA suggesting that, before labeling a patient as affected by refractory CM, a proper treatment with this drug needs to be completed [1]. In the last years several real-life prospective studies provided further evidence in clinical setting of OnabotulinumtoxinA U efficacy for the headache prophylaxis in CM complicated by medication overuse headache MOH [2].
Recently we published the results of a prospective study on the long-term 2 years efficacy and safety of a single dose of OnabotulinumtoxinA or U in patients with CM plus MOH had failed previous preventative drugs and detoxification attempts [3].
Both the doses were effective and equally safe, but U was more effective than U in reducing headache days, migraine days, pain medication intake days and Headache Impact Test HIT -6 score. Even more, the U dose superior efficacy was evident since the first injection and maintained over all the study period of 24 months. Interestingly we observed a progressive improvement in all the efficacy measures during the 2 years of follow-up with both the doses and significantly more with U.
Sometime a response appears only after the second or third injections. For this reason in selected cases can be useful to temporarily continue an oral preventative agent. The NICE guidelines recommend OnabotulinumtoxinA only for patients who have already tried at least three different preventative drug treatments that have not worked. The chance to use it as first-line preventative treatment may shorten the period of chronicity and eventually prevent the developing of MOH.
Several studies conducted before OnabotulinumtoxinA approval shown that it is ineffective in patients with episodic migraine [4]. Those studies had important limitations as range doses and injection paradigm.
Furthermore, the population enrolled was represented in the majority by patients with low frequency episodic migraine an average of attacks per month. Refractory chronic migraine: a consensus statement on clinical definition from the European headache federation. J Headache Pain ;28; A critical evaluation on MOH current treatments. Curr Treat Options Neurol. A two years open-label prospective study of OnabotulinumtoxinA U in medication overuse headache: a real-world experience.
J Headache Pain ; Efficacy of botulinum toxin type A for the prophylaxis of episodic migraine headaches: a meta-analysis of randomized, double-blind, placebo-controlled trials. Pharmacotherapy ;— Trigeminal autonomic cephalalgias TACs are a group of primary headaches comprehending the following syndromes: episodic and chronic cluster headache CH , episodic and chronic paroxysmal hemicrania PH , short-lasting unilateral neuralgiform headache attacks, and hemicrania continua HC [1].
Their phenotypes are similar and attack duration is the main feature distinguishing the first three TACs. An accurate diagnosis is important because of their different response to treatments. CH typically occurs at the same time of the day, from once to eight times per day, and in the same period of the year. Trigger factors can include alcohol, volatile chemicals or a warm environment 3.
Controlled trials have investigated the efficacy of subcutaneous sumatriptan, nasal sumatriptan, and nasal zolmitriptan. When a preventive medication is required, verapamil is the reference treatment. PH attack features are characterized by unilateral, often stabbing, headaches, shorter and more frequent than in cluster headaches. PH is responsive to treatment with indomethacin.
Indomethacin dosages ranges from 25 to 75 mg, three times a day. SUNCT-SUNA attacks are very short in duration seconds to minutes , triggered by touching the face or chewing, with associated autonomic features and occur up to hundreds of times per day.
In HC, clinical attack features have been reported as unilateral, side-locked continuous pain although interrupted by frequent severe exacerbations , associated with autonomic symptoms and responsive to indomethacin. Therapeutic options in TACs are limited. In many patients the preventive treatment does not help to control attack frequency, or the acute drugs are not well tolerated or are contraindicated.
For these reasons, after the discovery of the central role of the hypothalamus in TACs pathogenesis, neuromodulation techniques started. After the results obtained with hypothalamic deep brain stimulation in CH, other peripheral neuromodulation targets occipital nerves, spinal cord, sphenopalatine ganglion, vagus nerve were tried in the management of refractory CH and other TACs.
Headache Classification Committee of the International Headache Society: The international classification of headache disorders: 3th edition beta version.
Cephalalgia , Headache ; Chronic headaches are a relevant health problem characterized by significant disability, poor quality of life and high economic burden 1. The most common forms include chronic migraine CM and medication overuse headache MOH , which are frequently associated, given that the majority of CM sufferers do overuse acute medications CM with MO.
Chronic headaches represent a challenge for physicians, given their frequent resistance to therapies, risk of relapse and associated comorbidities. Their management includes several steps aimed to: 1 make a proper diagnosis excluding secondary forms; 2 identify exacerbating factors; 3 treat comorbidities; 4 identify and address medication overuse; 5 establish a therapeutic agreement with patient; 6 define an integrated care approach.
Patient-history collection is crucial for defining headache onset and its life-long course, chronicization factors, and outcomes of previous therapies acute and prophylactic.
Overused drug discontinuation is the first approach for MOH and it can be achieved via multiple modalities - in-patient or out-patient withdrawal procedures, advice alone — depending on several headache-associated or patient-associated factors. During withdrawal, adequate care is required to help the patient to go through the treatment phases, given the frequent occurrence of headache recrudescence. Headache diaries represent useful tools in monitoring attacks frequency, detecting medication overuse, checking therapies outcomes, and assessing disability improvements.
A relevant problem in MOH is the risk of relapse into overuse after successful withdrawal. There are only few controlled pharmacological trials on the management of MO in CM, which does not allow to derive precise figures on the risk of relapse into MO associated to specific therapies. Furthermore, the relapse risk is also influenced by psychological and clinical comorbidities.
For instance, mood and personality disorders e. Psychological factors indeed seem to play a crucial role in predicting the outcome e.
The presence of other pain-syndrome comorbidities e. Such a management is not limited to the earliest stages of treatment diagnosis, therapies, detoxification , being very important also when the patients resume their everyday life 4.
It is important to prevent unrealistic expectations e. The cost of headache disorders in Europe: the Eurolight project. Changes in anxiety and depression symptoms associated to the outcome of MOH: A post-hoc analysis of the Comoestas Project. Psychological factors associated to failure of detoxification treatment in chronic headache associated with medication overuse.
A consensus protocol for the management of medication-overuse headache: Evaluation in a multicentric, multinational study. Headache prevalence is age-dependent and decreases progressively over time, especially starting from the age of The incidence of primary headaches declines, whereas secondary headaches tend to occur more frequently with increasing age [1].
Although the prevalence of headache in the elderly is relevant, few studies have been conducted in patients over 65 so far. The clinical records of consecutive outpatients aged over 18 referred to our Headache Centre from to were reviewed. Patients were diagnosed based on The International Classification of Headache Disorders, 3rd edition beta version criteria [2]. Out of patients, a total of 5. Primary headaches were diagnosed in patients In the primary headache group the most common disorders were migraine without aura As for patients with migraine and chronic tension-type headache, the onset of headache occurred in most cases before 45, in particular in chronic migraine Secondary headaches were represented above all by cervicogenic headache, frequently associated with tension-type headache.
Among cranial neuropathies, trigeminal neuralgia was by far the most commonly diagnosed headache. In our population of elderly headache patients, migraine without aura, chronic tension-type headache and chronic migraine accounted for There was a large majority of females in all the subgroups of headaches.
In cluster headache, considered as a typical disorder of young men, we found indeed a slight preponderance of females. Migraine with aura not infrequently occurs in the elderly; this headache, as well as cluster headache, can even start, even rarely, over 65 and in such cases a differential diagnosis with a possible secondary disorder is mandatory.
Among patients with chronic headaches, a medication overuse was found more frequently in chronic migraine
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