16th European Headache Congress

Chair

Prevalence of migraine according to Migraine Screening-Questionnaire (MS-Q) and headache characteristics in patients with inflammatory bowel disease (IBD)

Headache, hormones and dietary

Migraine

Abstract text (incl. figure legends and references) Objective: The gut-brain axis describes a complex bidirectional association between neurological and gastrointestinal (GI) disorders. In patients with migraine, GI comorbidities are common. We aimed to evaluate the prevalence of migraine according to Migraine Screening Questionnaire (MS-Q) among patients with inflammatory bowel disease (IBD) and describe the headache characteristics compared to a control group. Additionally, we explored the relationship between migraine and IBD activity. Methods: We performed a cross-sectional study through an online survey including patients with IBD from the IBD Unit at our tertiary hospital. Clinical and demographic variables were collected. MS-Q was used for migraine prevalence evaluation. Scale scores from HIT-6, HADS, ISI, Harvey-Bradshaw and Mayo were also included. Results: We evaluated 66 patients with IBD and 47 controls. Among patients with IBD, 28/66 (42%) were women, mean age 42 years and 23/66 (64%) had ulcerative colitis and 43/66 (65.15%) Crohn"s disease. MS-Q was positive in 13/66 (23%) of IBD patients and 4 (13%) controls. Among patients with IBD, headache was unilateral in 5/13 (38%) and throbbing in 10/13 (77%). We found that a female sex (p= 0.006), weight (p=0.002), height (p=0.003) and anti-TNF use (0.0035) were associated with MS-Q positive diagnosis. We did not find any association between HIT-6 and IBD activity scales scores. Conclusions: Migraine prevalence according to MS-Q is higher in patients with IBD than in the control group, which might be explained by the relationship between these entities through the gut-brain axis. Some sociodemographic characteristics of patients with IBD could predict the presence of migraine. These results highlight the importance of migraine detection among patients with IBD which could improve management of this condition and the quality of life of these patients.

ePoster

Prof. Dr.

Influence of migraine and migraine aura on the prescription of hormonal contraception in German outpatient gynecological clinics

Abstract text (incl. figure legends and references) Objective: Hormonal fluctuations during the menstrual cycle affect migraine frequency, duration and intensity. Use of combined oral contraception (COC) containing new generation of estrogen, COC with extended cycle as well as gestagen monotherapy (GM) can reduce the burden of disease. Access to hormonal contraception (HC) to women with migraine especially with aura (MA), has often been denied due to an increased risk of ischemic stroke. However, the absolute risk of ischemic stroke with the use of HC in migrane is minor and the prescription after informed consent is possible. We assessed the influence of migraine without aura (MO) and MA on the prescribing behavior of HC among German gynecologists and investigated potential factors influencing gynecologist"s decision-making process. Method: In this descriptive observational study of practicing German gynecologists, prescription of HC in migraine was investigated using a self-administered online-based survey with up to 29 items from October 2021 to March 2022. The survey was distributed via mail and e-mail. Results: A total of n=851 gynecologists responded to the questionnaire. Gynecologists regularly ask for MO (94.5%) and MA (91.8%) prior to prescribing HC. In the presence of MO, 75% of participants reported to prescribe COC only under certain conditions, with cardiovascular risk factors and other comorbidities particularly influencing the decision. In contrast, GM is prescribed in MO by 82% of participating gynecologists without restrictions. In MA, 90% of gynecologists do not prescribe COC at all and 47% of gynecologists stated to not prescribe GM or do so only under certain conditions. Almost all gynecologist reported to have initiated (80%), discontinued (95.8%) or changed (99.2%) a HC due to migraine. Conclusion: Although HC is not generally contraindicated in migraine patients, presence of MA but also MO hinder German gynecologists to prescribe HC.

Prof.

Sex differences in migraine attack characteristics: a longitudinal E-diary study

Abstract text (incl. figure legends and references) Background Women retrospectively report longer migraine attacks and more accompanying symptoms than men, but this has not been confirmed in longitudinal studies (1). Supposed differences could result from more refractory perimenstrual migraine attacks, or migraine attacks in women in general could be associated with different characteristics. Methods We assessed differences in migraine attack characteristics between men and women, who were prospectively followed with previously validated E-diaries at the Leiden Headache Center. The primary outcome was attack duration. Secondary outcomes comprised recurrence risk and prevalence of accompanying symptoms. Differences between men and women were assessed with linear and logistic models using GEE, corrected for chronic migraine, medication-overuse headache and age dichotomized at 50 as a proxy for menopause. Results A total of 1,347 women and 284 men were included. Both perimenstrual (62% (47-79%), p&lt;0.001) and non-perimenstrual (15% (5-25%), p=0.03) migraine attacks had longer duration than migraine attacks in men. Recurrence risk was greater for perimenstrual (OR (95%CI): 2.39 (1.93-2.95), p&lt;0.001), but not for non-perimenstrual (1.18 (0.97-1.45), p=0.06) attacks. Migraine attacks in women in general were more often accompanied by photophobia, phonophobia and nausea, but less often by aura symptoms. Conclusion Not only perimenstrual, but also non-perimenstrual migraine attacks have longer duration than migraine attacks in men, although to a lesser extent. In general, women more often experience accompanying symptoms than men. These results highlight the need for sex-specific approaches in migraine treatment and research. Buse DC, Loder EW, Gorman JA, et al. Sex differences in the prevalence, symptoms, and associated features of migraine, probable migraine and other severe headache: results of the American Migraine Prevalence and Prevention (AMPP) Study. Headache 2013;53:1278-1299.

Ketogenic diet for migraine prevention: an effective option beyond weight loss

Abstract text (incl. figure legends and references) Question: ketogenic diet (KD) is gaining attention as a possible non pharmacological approach for migraine prevention, supported by many pre-clinical and clinical observations. KD is also used for weight loss purposes, and there is a well defined relationship between migraine and weight excess. However, it is not known if the effect of KD on migraine is only due to weight reduction or if it depends on mechanisms which are specific for the ketogenic nature of the intervention. Methods: we conducted a retrospective observational study on patients suffering from migraine who received a KD as a preventive treatment. All the patients were evaluated both from a neurological and a nutritional point of view, including bioimpedance analysis. Results: 23 migraine patients were considered in the analysis, 10 (43.5%) were affected by chronic migraine and 6 (26.1%) were suffering from medication overuse headache. The number of previously failed preventive treatments was 1.78±2.21. After KD, we observed a reduction in monthly headache days (12.5±0.5 v.s. 6.7±8.6; p&lt;0.001) and in days of acute medication intake (11.06±9.37 v.s. 4.93±7.99; p=0.008). We also observed a reduction of patients" weight (73.8±15.2 v.s. 68.4±14.6; p&lt;0.001) and BMI (26.9±6.2 v.s. 23.7±8.1; p&lt;0.001), with decrement of the fat mass (28.6±12.5 v.s. 20.6±9.8; p&lt;0.001). Responders and non-respondersto KD did not differ for weight loss (5.6±2.7 v.s. 6.2±5.1; p=0.299) or fat mass loss (6.1±2.1 v.s. 5.0±4.1; p=0.120). In addition, we observed no significant difference in the reduction of headache days between patients who had normal BMI or who were overweight or obese at baseline (9.2±11.5 v.s. 3.7±3.2; p=0.545). Conclusions: these data corroborate the use of KD as a preventive treatment for migraine. Moreover, since KD improved migraine independently from weight or fat mass loss, its action is probably mediated by mechanisms specific for this kind of nutritional intervention.

Professor

The association between Alternative Healthy Eating Index and odds of migraine headaches: a case-control study

Epidemiology

Abstract text (incl. figure legends and references) Background: Migraine is the most common disabling primary headache globally. Although the pathogenesis of migraine headache is not fully understood, the possible role of inflammation and disturbed immune system has been proposed; thus, adherence to a dietary pattern that follows the Alternative Healthy Eating Index (AHEI) might reduce the risk of migraine. The current study aimed to investigate the association between the AHEI and odds of migraine headaches. Methods: This case-control research was conducted on a total of 501 patients with migraine headaches (94.2% were women) and 576 sex-matched healthy controls (94.4% were women). A valid and reliable semi-quantitative food frequency questionnaire was used to record participants' dietary intakes. AHEI-2010 score was measured based on the dietary records, and regression models were used to determine the association between AHEI and migraine headaches odds. Results: In the multivariable-adjusted model, the odds of migraine headaches was 76% lower for the patients in the last tertile of the AHEI score (aOR: 0.24, 95%CI: 0.16, 0.35, P for trend &lt; 0.001). In the both base and adjusted models, odds of migraine headaches was significantly lower in patients in the last tertile of Whole grains (aOR: 0.60, 95%CI: 0.43, 0.82, P for trend: 0.001), Legumes (aOR: 0.30, 95%CI: 0.25, 0.48, P for trend &lt; 0.001) and PUFA (aOR: 0.12, 95%CI: 0.08, 0.18, P for trend &lt; 0.001). Patients in the last tertile of Fruits (aOR: 1.77, 95%CI: 1.27, 2.45, P for trend &lt; 0.001), and sodium (aOR: 2.57, 95%CI: 1.82, 3.64, P for trend &lt; 0.001), had a higher odds of migraine headaches in the both base and adjusted models Conclusion: Following a dietary pattern, which is in adherence to the healthy eating index, may be protective against migraine headaches.

The association between Mediterranean diet adherence and odds of migraine headaches: a case-control study

Abstract text (incl. figure legends and references) Background: Migraine is a chronic neurological disorder characterized by attacks of moderate or severe headache and reversible neurological and systemic symptoms. Individuals with migraines may benefit from a nutritional approach incorporating a Mediterranean pattern. The current study aimed to investigate the association between the Mediterranean diet and odds of migraine headaches. Methods: This case-control research was conducted on a total of 501 patients with migraine headaches (94.2% were women) and 576 sex-matched healthy controls (94.4% were women). A valid and reliable semi-quantitative food frequency questionnaire was used to record participants' dietary intakes. Adherence to the Mediterranean diet was assessed using MEDI-LITE (literature-derived Mediterranean diet) score to determine the association between the Mediterranean diet and migraine headaches odds. Results: In the multivariable-adjusted model, the odds of migraine headaches was 38% lower for the patients in the last tertile of the MEDI_LITE score (aOR: 0.62, 95%CI: 0.45, 0.86, P for trend: 0.003). In both base and adjusted models, odds of migraine headaches were significantly lower in patients in the last tertile of Whole grains (aOR: 0.60, 95%CI: 0.43, 0.82, P for trend: 0.001), and Legumes (aOR: 0.30, 95%CI: 0.22, 0.42, P for trend &lt; 0.001). Patients in the last tertile of Fruits and nuts (aOR: 1.84, 95%CI: 1.32, 2.56, P for trend &lt; 0.001), Mono-unsaturated/saturated fatty acids ratio (aOR: 1.54, 95%CI: 1.13, 2.11, P for trend: 0.006), and dairy (aOR: 2.06, 95%CI: 1.45, 2.91, P for trend &lt; 0.001), had a higher odds of migraine headaches in the both base and adjusted models. Conclusions: A higher MEDI_LITE score, indicating greater adherence to the Mediterranean diet, is associated with a lower odds of migraine headaches. Therefore, adherence to the Mediterranean diet pattern is associated with reducing the odds of migraine headaches.

Evaluation of Serum Leptin Level in a Sample of Egyptian Patients with Migraine

Abstract text (incl. figure legends and references) Background : Obesity is a risk factor for multiple neurological disorders including stroke , dementia and migraine . In addition , several cytokines and adipocytokines associated with migraine are modulated by body mass , which also act in the neurogenic inflammation in migraine . The aim of the study : was to throw light and asses leptin levels , one of the adipcytokines , in headache – free period of migraine patients and investigate its relation to vascular risk factors . Material and methods : Sixty – three patients with episodic migraine and 33 control subjects were enrolled in the study . All participants were subjected to full history taking and clinical examination , anthropometric measurements , Body mass index and fat mass values were calculated ,fasting blood glucose , lipid profiles and serum leptin assay by ELISA technique ,CT brain to exclude any brain lesions. Results : Leptin levels were found significantly lower in migraineurs than controls ( 21.16 ± 2.4 ng/ml , 35.48 ± 8.1 ng/ml ; p &lt; 0.001 ) . Body mass index and fat mass were not differ between 2 groups . Conclusion : Migraine patients have lower leptin levels , which may be related to the pathogenesis of migraine . The importance of these findings on the prevalence , pathogenesis and treatment of migraine needs to be investigated in further detailed studies . Table (1) : The Associations Between Leptin and Anthropometric Measurements in Migraine Patients <table> <tr> <td colspan="3"> Leptin </td> </tr> <tr> <td> </td> <td> r </td> <td> P </td> </tr> <tr> <td> Age </td> <td> 0.485 </td> <td> &lt;0.001 </td> </tr> <tr> <td> BMI </td> <td> 0.087 </td> <td> &gt;0.05 </td> </tr> <tr> <td> WC </td> <td> 0.260 </td> <td> &lt;0.05 </td> </tr> <tr> <td> Fat mass </td> <td> 0.145 </td> <td> &gt;0.05 </td> </tr> </table> Leptin levels of migraineurs were correlated with age and WC Graph 1 S LEPTIN Relation between leptin level in migraine patient and duration of headache. Graph 2 FBG Relation between fasting blood glucose level in migraine patient and duration of headache

nVNS treatment instead of microvascular decompression

Neuromodulation and nerve blocks

Trigeminal neuralgia

Abstract text (incl. figure legends and references) Question: Non-invasive Vagal nerve stimulation (nVNS) with the GammaCore device is a safe and well tolerated treatment. Randomised sham-controlled trials have shown nVNS is efficacious for the treatment of cluster headache. There is also some evidence of the efficacy of nVNS for other trigeminal autonomic cephalalgias, namely hemicrania continua and paroxysmal hemicrania. On the other hand, patients who fail standard treatment for SUNCT/SUNA and are found to have trigeminal neurovascular conflict may be considered for microvascular decompression. Methods: We report the case of a 58-year old woman who had a history of chronic SUNA. She had initially responded to pregabalin and then added lamotrigine, which was not sufficiently efficacious. She also failed gabapentin. Following funding the patient was started on nVNS. A previous MRI 10 years ago did not include trigeminal views. A recent brain MRI with 3D-CISS sequence showed neurovascular conflict and thinning of the of the trigeminal nerve compared to the contralateral, to the pain, side. Results: The patient, who had been referred to neurosurgery given the new MRI findings, became attack-free after 2 months on nVNS, which she was taking at 4 treatments TDS. After 1 year of follow-up the benefit persisted and a procedure is no longer being contemplated. Conclusions: The utility of nVNS as a treatment for refractory SUNCT/ SUNA, even in the presence of neurovascular conflict, could open the doors for its use before considering surgery, given the well-recognised risks of a procedure.

Effectiveness and safety of pulsed radiofrequency in patients with chronic and refractory trigeminal neuralgia and cluster headache

Abstract text (incl. figure legends and references) Objective: Pulsed radiofrequency (PRF) is a neuromodulation technique used in chronic pain conditions which does not cause irreversible nerve damage. We aimed to evaluate the effectiveness and safety of Gasser and sphenopalatine ganglion PRF in patients with chronic and refractory trigeminal neuralgia (TN) and cluster headache (CH), respectively. Methods: We performed a retrospective study including patients with TN and CH according to the International Classification of Headache Disorders-ICHD-3, attended at the national reference Pain Unit for refractory pain of our tertiary hospital. We evaluated clinical and demographic variables. The primary endpoint was the reduction in the number of attacks. Secondary objectives were 50% response rate, change in Numerical Rating Scale (NRS), Patient Global Impression (PGI) at 3 months, percentage of recurrence and major adverse events. Results: Among 293 patients who received radiofrequency in our center, 19 had a headache diagnosis of chronic and refractory TN and 6 CH according to the ICDH-3, therefore a total of 25 patients were analyzed. A reduction in the number of attacks was observed in 14/19(73.68%) of patients with NT and in 5/6(83.3%) of patients with CH. A 50% response rate was observed in 11/19(58%) of patients with TN and there were differences between the NRS at baseline and at 3 months, statistically significant in NT(p&lt;0.05). Among patients with CCH, 4/6 (66.6%) showed a 50% response rate. Pain recurrence occurred in 13/14(92,86%) patients with TN and 5/5(100%) patients with CH, half of them more than one year after RFP. Conclusions: According to our study, PRF of Gasser and sphenopalatine ganglion is an effective and safe choice for patients with NT and CCH, even considering recurrence, especially in fragile patients not candidates for aggressive procedures.

Ultrasound Guided Percutaneous Electrical Nerve Stimulation for the Third Occipital Nerve inPatients with Suboccipital Headache Pain. Treatment Proposal

Secondary headaches

Abstract text (incl. figure legends and references) Background Suboccipital headache is one of the main symptoms in various pathologies such as cervicogenic headache, acute and chronic whiplash. Sensitization of the third occipital nerve has been identified as one of the main causes of pain specific to the suboccipital region. Classically transcutaneous stimulation (TENS) has been used to treat the symptoms, however, the inclusion of ultrasound in the physiotherapeutic field allows a more specific invasive treatment, guaranteeing the safety of the intervention. Objective To perform a specific, safe and effective percutaneous approach to the third occipital nerve (TON). Methods Treatment Parameters with Asymmetrical Biphasic Current: 15 minutes Low Frecuencies: 2-4Hz Pulse Amplitude: 150-300 useg Materials: Ultrasound Disinfection and Asectic Material Dry Needle (0,30/0,40x0,25) Electrotherapy equitment with clamp connectors. Results Approximately 1-2 mm superficial to the CII-CIII facet joint in longitudinal view with the probe perpendicular to all planes and about 2-3 cm posterior to the mastoid process and 0.5 cm posterior and inferior to the vertebral artery. A linear probe in longitudinal view is used for this purpose. The out-of-plane or in-plane access will depend on the ergonomics offered by the patient. Doppler mode should be used to locate vascular structures such as the inferior branch of the occipital artery. Sonographically, the TON appears hypoechoic with an internal architecture with a hyperechoic outer rim. Conclusion Ultrasound-guided intervention allows a safe physiotherapeutic approach.Percutaneous intervention with electrotherapy allows a physiotherapeutic specific approach.The implementation of electrotherapy is a non-pharmacological alternative, less expensive and more accessible.

Poster session 10

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