Prophylactic treatment of migraine; the patient's view, a qualitative study

Contains fulltext : 109202.pdf (publisher's version ) (Open Access)BACKGROUND: Prophylactic treatment is an important but under-utilised option for the management of migraine. Patients and physicians appear to have reservations about initiating this treatment option. This paper explores the opinions, motives and expectations of patients regarding prophylactic migraine therapy. METHODS: A qualitative focus group study in general practice in the Netherlands with twenty patients recruited from urban and rural general practices. Three focus group meetings were held with 6-7 migraine patients per group (2 female and 1 male group). All participants were migraine patients according to the IHS (International Headache Society); 9 had experience with prophylactic medication. The focus group meetings were analysed using a general thematic analysis. RESULTS: For patients several distinguished factors count when making a decision on prophylactic treatment. The decision of a patient on prophylactic medication is depending on experience and perspectives, grouped into five categories, namely the context of being active or passive in taking the initiative to start prophylaxis; assessing the advantages and disadvantages of prophylaxis; satisfaction with current migraine treatment; the relationship with the physician and the feeling to be heard; and previous steps taken to prevent migraine. CONCLUSION: In addition to the functional impact of migraine, the decision to start prophylaxis is based on a complex of considerations from the patient's perspective (e.g. perceived burden of migraine, expected benefits or disadvantages, interaction with relatives, colleagues and physician). Therefore, when advising migraine patients about prophylaxis, their opinions should be taken into account. Patients need to be open to advice and information and intervention have to be offered at an appropriate moment in the course of migraine

Beta-blocker migraine prophylaxis affects the excitability of the visual cortex as revealed by transcranial magnetic stimulation

The objective of this study is to assess effects of beta-blocker migraine prophylaxis on cortical excitability determined by transcranial magnetic stimulation (TMS). Phosphene and motor thresholds (PT, MT) were investigated in 29 patients with migraine, in 15 of them prior to and following preventive medication with metoprolol and in 14 patients without prophylaxis. Following prophylaxis headache frequency significantly decreased (p = 0.005) and mean PT were significantly increased (51.5 ± 7.5 vs. 63.6 ± 8.4%) compared to patients without preventive treatment (53.7 ± 5.3 vs. 52.3 ± 6.3%; p = 0.040). Mean MT did not significantly differ either between groups or due to treatment. In the group of all patients, a significant inverse correlation between headache frequency and the level of PT was found (R = −0.629; p < 0.01). There was, however, no significant correlation in the subgroups of patients. We conclude that (a) clinical efficacy of beta-blocker treatment in migraine could be (at least partly) linked to its ability to modulate the excitability of the visual cortex and (b) the PT determined by TMS appears suitable to assess the effects of prophylaxis on cortical excitability in the individual patient. This may be useful in clinical trials investigating migraine preventive drugs

Italian guidelines for primary headaches: 2012 revised version

The first edition of the Italian diagnostic and therapeutic guidelines for primary headaches in adults was published in J Headache Pain 2(Suppl. 1):105–190 (2001). Ten years later, the guideline committee of the Italian Society for the Study of Headaches (SISC) decided it was time to update therapeutic guidelines. A literature search was carried out on Medline database, and all articles on primary headache treatments in English, German, French and Italian published from February 2001 to December 2011 were taken into account. Only randomized controlled trials (RCT) and meta-analyses were analysed for each drug. If RCT were lacking, open studies and case series were also examined. According to the previous edition, four levels of recommendation were defined on the basis of levels of evidence, scientific strength of evidence and clinical effectiveness. Recommendations for symptomatic and prophylactic treatment of migraine and cluster headache were therefore revised with respect to previous 2001 guidelines and a section was dedicated to non-pharmacological treatment. This article reports a summary of the revised version published in extenso in an Italian version

Lateral inhibition in visual cortex of migraine patients between attacks

BACKGROUND: The interictal deficit of habituation to repetitive visual stimuli in migraine patients could be due to deficient intracortical inhibition and/or to low cortical pre-activation levels. Which of these abnormalities contributes more to the habituation deficit cannot be determined with the common methods used to record transient visual responses. We investigated lateral inhibition in the visual cortex during the migraine cycle and in healthy subjects by using differential temporal modulations of radial windmill-dartboard (WD) or partial-windmill (PW) visual patterns. METHODS: Transient (TR-VEP) and steady-state visual-evoked potentials (SS-VEP) were recorded in 65 migraine patients (21 without and 22 with aura between attacks; 22 patients during an attack) and in 21 healthy volunteers (HV). Three stimulations were used in each subject: classic checkerboard pattern (contrast-reversion 3.1Hz), WD and PW (contrast-reversion ~4Hz). For each randomly presented stimulation protocol, 600 sweeps were acquired and off-line partitioned in 6 blocks of 100. Fourier analysis allowed data to extract in SS-VEP the fundamental (1H) and the second harmonic (2H) components that reflect respectively short-(WD) and long- range lateral inhibition (attenuation of 2H in WD compared to PW). RESULTS: Compared to HV, migraineurs recorded interictally had significantly less habituation of the N1-P1 TR-VEP component over subsequent blocks and they tended to have a smaller 1(st) block amplitude. 1H amplitude in the 1(st) block of WD SS-VEP was significantly greater than in HV and habituated in successive blocks, contrasting with an amplitude increase in HV. Both the interictal TR-VEP and SS-VEP abnormalities normalized during an attack. There was no significant between group difference in the PW 2H amplitude and its attenuation. When data of HV and migraine patients were combined, the habituation slope of WD-VEP 1H was negatively correlated with that of TR-VEP N1-P1 and with number of days since the last migraine attack. CONCLUSION: These results are in favour of a migraine cycle-dependent imbalance between excitation and inhibition in the visual cortex. We hypothesize that an interictal hypoactivity of monaminergic pathways may cause a functional disconnection of the thalamus in migraine leading to an abnormal intracortical short-range lateral inhibition that could contribute to the habituation deficit observed during stimulus repetition

Effects of light deprivation on visual evoked potentials in migraine without aura.

BACKGROUND: The mechanisms underlying the interictal habituation deficit of cortical visual evoked potentials (VEP) in migraine are not well understood. Abnormal long-term functional plasticity of the visual cortex may play a role and it can be assessed experimentally by light deprivation (LD). METHODS: We have compared the effects of LD on VEP in migraine patients without aura between attacks (MO, n = 17) and in healthy volunteers (HV, n = 17). Six sequential blocks of 100 averaged VEP at 3.1 Hz were recorded before and after 1 hour of LD. We measured VEP P100 amplitude of the 1st block of 100 sweeps and its change over 5 sequential blocks of 100 responses. RESULTS: In HV, the consequence of LD was a reduction of 1st block VEP amplitude and of the normal habituation pattern. By contrast, in MO patients, the interictal habituation deficit was not significantly modified, although 1st block VEP amplitude, already lower than in HV before LD, further decreased after LD. CONCLUSIONS: Light deprivation is thought to decrease both excitatory and subsequent inhibitory processes in visual cortex, which is in line with our findings in healthy volunteers. The VEP results in migraine patients suggest that early excitation was adequately suppressed, but not the inhibitory mechanisms occurring during long term stimulation and habituation. Accordingly, deficient intracortical inhibition is unlikely to be a primary factor in migraine pathophysiology and the habituation deficit