Drug-resistant chronic cluster headache successfully treated with supraorbital plus occipital nerve stimulation. A rare case report

Chronic cluster headache (CCH) is a rare and extremely disabling headache syndrome with a recent clinical systematization of its clinical frame from the European Headache Federation [1]. We present a case of a young man affected by drug-resistant chronic CH (rCCH) who showed improvement after a two-time combined supraorbital and occipital nerve stimulation (S-ONS). The clinical improvement was still present at 6-month follow-up

Low-dose buprenorphine infusion to prevent postoperative hyperalgesia in patients undergoing major lung surgery and remifentanil infusion: a double-blind, randomized, active-controlled trial

Abstract Background Postoperative secondary hyperalgesia arises from central sensitization due to pain pathways facilitation and/or acute opioid exposure. The latter is also known as opioid-induced hyperalgesia (OIH). Remifentanil, a potent μ-opioid agonist, reportedly induces postoperative hyperalgesia and increases postoperative pain scores and opioid consumption. The pathophysiology underlying secondary hyperalgesia involves N-methyl-D-aspartate (NMDA)-mediated pain pathways. In this study, we investigated whether perioperatively infusing low-dose buprenorphine, an opioid with anti-NMDA activity, in patients receiving remifentanil infusion prevents postoperative secondary hyperalgesia. Methods Sixty-four patients, undergoing remifentanil infusion during general anaesthesia and major lung surgery, were randomly assigned to receive either buprenorphine i.v. infusion (25 μg h −1 for 24 h) or morphine (equianalgesic dose) perioperatively. The presence and extent of punctuate hyperalgesia were assessed one day postoperatively. Secondary outcome variables included postoperative pain scores, opioid consumption and postoperative neuropathic pain assessed one and three months postoperatively. Results A distinct area of hyperalgesia or allodynia around the surgical incision was found in more patients in the control group than in the treated group. Mean time from extubation to first morphine rescue dose was twice as long in the buprenorphine-treated group than in the morphine-treated group: 18 vs 9 min ( P =0.002). At 30 min postoperatively, patients receiving morphine had a higher hazard ratio for the first analgesic rescue dose than those treated with buprenorphine ( P =0.009). At three months, no differences between groups were noted. Conclusions Low-dose buprenorphine infusion prevents the development of secondary hyperalgesia around the surgical incision but shows no long-term efficacy at three months follow-up

2009, Il villaggio protostorico di Viale dei Cipressi e la facies Capo Graziano

Rapporto di scavo del villaggio dell'età del bronzo di V.le dei Cipressi a Milazzo. Edizione dei materiali e tipologia per la facies Capo Graziano, cui appartengono le principali capanne; sintesi delle successive facies Milazzese e Ausonio

Milazzo (ME), distribuzione della ceramica e uso degli spazi nella capanna 1 di v.le dei Cipressi (facies di Capo Graziano)

Ricostruzione delle zone di uso dello spazio interno della grande capanna della facies di Capo Graziano sulla base della distribuzione puntuale dei reperti rinvenuti sul pavimento

Invasive neurostimulation

Chronic migraine afflicts 1-5% of the global population and poses a substantial burden on subjects’ quality of life and on health services utilization [1]. Although most patients benefit from abortive and preventive drugs, a subgroup of patients remains refractory to treatment. Refractory chronic migraine is one of the greatest chal- lenges in headache medicine and, in these patients, inva- sive techniques should be considered. In the past 20 years neuromodulatory approaches, already proved effective in other chronic pain syndromes, have been increasingly used for refractory primary headaches. Neuromodulation, a reversible and adjustable manipula- tion of pain pathways is an evidence-based invasive treat- ment for chronic pain conditions and it may be applied to any neural structure: spinal cord, deep brain, and periph- eral nerves. Recently, three 12-week follow-up prospective, rando- mised trials have been conducted to validate occipital nerve stimulation in chronic migraine and intractable chronic migraine associated to occipital localization of pain. Considering the primary outcomes (50% reduction in pain intensity, 50% decrease of headache days) all the three trials have failed. In one of these studies [2], although the second follow-up at 52 weeks has shown important effects on pain severity, headache days, HIT-6 and MIDAS scores (60% of patients achieved 30% reduction in headache days and/or pain, 50% achieved 50% reduction in headache days and/or pain, 70% reported excellent or good headache relief and improved QoL, 70% would undergo the procedure again), it has also shown high incidence of adverse events related to the procedure (70% of patients experienced at least one * Correspondence: [email protected] 1Department of Medical-Surgical Sciences and Traslational Medicine, Sapienza University of Rome, Sant’Andrea Hospital, Rome, Italy Full list of author information is available at the end of the article AE, 41% of AEs required supplemental surgery, 8.6% of AEs required hospitalization). A more recent prospective, open-label, exploratory study [3] assessing the long-term (6-months) safety, tolerability and efficacy of cervical high frequency (10 kHz), paresthe- sia-free, spinal cord stimulation in a cohort of 14 refrac- tory chronic migraine patients (refractory also to Onabotulinumtoxin-A) has shown good results on reduc- tion of headache days, medication intake, HIT-6 and MIDAS scores. The patients were carefully selected, for refractory chronic migraine, not considering topographic criteria for localization of pain, and were assessed by two different psychologists before eligibility. A significant reduction in headache days was observed at 24 weeks (average 7.0 days). Seven (50%) subjects recorded a >30% decrease in headache days, while 5 (36%) subjects reported a reduction in headache days greater than 50%. Eight sub- jects (57%) reverted to an episodic pattern of headache (<15 days a month). Medication intake reduced signifi- cantly, and four subjects discontinued triptans. Few adverse events have been reported. HF10-SCS deserves further clinical investigations to evaluate its possible role in the management of rCM

L\u2019ET\uc0 DEL BRONZO A STROMBOLI: IL VILLAGGIO TERRAZZATO DI SAN VINCENZO COME AVAMPOSTO NORD-ORIENTALE DELL\u2019ARCIPELAGO EOLIANO

The chronological and cultural sequence and the material culture of the early Bronze age village of S. Vincenzo at Stromboli (Aeolian Islands