16th European Headache Congress

Chair

Characterization of adult patients with status migrainosus in a tertiary hospital in Colombia, 2019-2021

Abstract text (incl. figure legends and references) Objective: To describe demographic and clinical characteristics, treatment strategies, use of diagnostic tests, evolution in hospitalization and readmissions of patients with status migrainosus (SM) who required inpatient management. Methods: Retrospective and observational study analysing patients who presented SM between 2019 and 2021 at a tertiary hospital in Colombia. Results: We identified 170 SM in 135 subjects. 91% were women with a median age of 34 years. 79,9% had migraine without aura. 79,9% had episodic migraine. 22,9% were taken prophylactic medication. The median duration of headache before admission to emergency department (ED) was 120 hours. 96,5% with level pain ≥7/10. Pulsatile headache (86,5%), worsening of pain with physical activity (87,1%), photophobia (94,7%) and nausea (90%) were the most common symptoms. Pregnancy was present in 8,9%. It was more probable that pregnant women received opioids for their treatment (p=0,0002). 18,2% had prior medication overuse; subjects with medication overuse were less probable to improve with the first line of treatment at ED (p=0.02). Only 34,1% of SM improved with treatment at ED. 81% of SM who improved at ED required at least three medications. Improvement with treatment at ED was less probable if subjects had received opioids before admission (p=0,002). All participants treated by neurologists received a combination of drugs. 52% of them required at least 2 lines of treatment. The most used medications by neurology were magnesium sulfate, ketorolac and triptans. 68,2% received at least one diagnostic test and 94,8% of them were normal. Median length of hospital stay was 1,96 days. 69,4% were discharged pain-free. 12,3% were readmitted to ED due to headache within the next week. Conclusion: SM is a disabling condition. SM requires to be treated with drug combinations with synergic mechanisms of action, which can lead to freedom of pain in most patients. Opioids should be avoided in the treatment of SM.

Epidemiology

Migraine

ePoster

Implementing a digital treatment solution for headache patients – a pilot study.

Abstract text (incl. figure legends and references) Background. Migraine is the leading cause of disability worldwide, affecting primarily working-age population. Poor availability of non-pharma cological treatment options and shortage of specialists is a major problem on a global scale. The goal of this pilot study was to create a model that would allow for comparisons between conventional and digitally mediated care while evaluating the cost-effectiveness of digitally mediated care. Question. Is it possible to conduct manual-based digitally mediated non-pharmacological treatment in a way that is comparable to conventional treatment? Methods. The pilot study was approved by the Research Ethics Committee of the University of Tartu. Two groups of patients (n=10 for conventional treatment and n=10 for digitally mediated treatment) participated in an intense 8-week non-pharmacological interdisciplinary treatment program. The patient received nurse counselling, cognitive-behavioural therapy, and physical therapy as part of their treatment. The number of headache days, headache's influence on everyday life, changes in quality of life, anxiety and depression levels were measured. The level of patient satisfaction with the intervention and the amount of work time required by experts were examined. Results. There was no change in the number of days with headaches. In both groups, satisfaction with the intervention was extremely high. Indicators of quality of life improved in both groups. Ten times less time was spent on digitally mediated treatment by specialists. Conclusions. The developed non-pharmacological intervention program and manual-based intervention are appropriate for a wider scale trial. Digitally mediated treatment is just as effective as conventional treatment but permits 10 times as many individuals to be treated without sacrificing quality. There is a need for larger-scale research to demonstrate with greater precision the influence on patients' lives and the cost-effectiveness of the intervention strategy.

PACAP signaling is not involved in GTN- and levcromakalim-induced hypersensitivity in mouse models of migraine

Abstract text (incl. figure legends and references) Question: Calcitonin gene-related peptide (CGRP) antagonizing drugs represents the most important advance in migraine therapy for decades. However, these new drugs are only effective in 50-60% of patients. Recent studies have shown that the pituitary adenylate cyclase-activating peptide (PACAP38) pathway is independent from the CGRP signaling pathway. Here, we investigate PACAP38 signaling pathways in relation to glyceryl trinitrate (GTN), levcromakalim and sumatriptan. Methods: In vivo mouse models of PACAP38-, GTN-, and levcromakalim-induced migraine were applied using tactile sensitivity to von Frey filaments as measuring readout. Signaling pathways involved in the three models were dissected using PACAP-inhibiting antibodies (mAbs) and sumatriptan. Results: We showed that PACAP mAbs block PACAP38 induced hypersensitivity, but not via signaling pathways involved in GTN and levcromakalim. Also, sumatriptan has no effect on PACAP38-induced hypersensitivity relevant to migraine. This is the first study testing the effect of a PACAP-inhibiting drug on GTN- and levcromakalim-induced hypersensitivity. Conclusions: Based on the findings in our mouse model of migraine using migraine-inducing compounds and anti-migraine drugs, we suggest that PACAP acts via a distinct pathway. Using PACAP38 antagonism may be a novel therapeutic target of interest in a subgroup of migraine patients who do not respond to existing therapies.

Prof.

Effect of Topical Clonazepam on the Burning Mouth Syndrome Patients' Functional Connectivity

Abstract text (incl. figure legends and references) Objectives: Burning mouth syndrome (BMS) is an idiopathic and debilitating burning sensation of the oral mucosa. BMS treatment remains a challenge due to its uncertain aetiopathophysiology, but reports have implied that BMS is a central neuropathic pain disorder. We hypothesised that BMS patients' functional connectivity (FC) was modulated by pain intensity following clonazepam mouthwash (MW) and the difference between treatment responders and non-responders. Methods: 26 BMS patients underwent two sessions. In session 1, they received clinical and neuropsychological assessments. In session 2, pain scores (NRS, 0-10) and resting-state functional MRI scans were acquired before and after mouthwash. Seed-based FC analysis of the right anterior insula (RAI) cortex was performed (pFWE corrected &lt;0.05), given reports of perturbed functioning in this region in chronic pain. Treatment responders were defined as reporting 50% or greater pain reduction from baseline following clonazepam administration. Results: After clonazepam, BMS patients experienced a mean NRS reduction of 2.67 (SD ±2.23), and 15 patients responded to treatment. We observed a decrease of post-MW FC across BMS patients, between the RAI and anterior cerebellum and inferior parietal lobe. At baseline, responders showed lower FC than non-responder between RAI, lateral occipital cortex and parietal lobe. After mouthwash responder showed greater FC network changes (∆FC) than the non-responder between RAI and frontal orbital cortex, frontal medial cortex and paracingulate gyrus but a lesser ∆FC between RAI and prefrontal cortex (Figure 1). Conclusion: This study provides a preliminary insight into the anti-nociceptive mechanism of action of topical clonazepam on brain networks. We demonstrated FC changes between RAI and brain regions involved in pain modulation, which may reflect BMS's ongoing pain symptoms and a valuable marker of treatment response.

Oro-facial and temporomandibular disorders

Pathophysiology others than migraine and cluster

Prevalence of temporomandibular disorders with comorbid migraine: A retrospective study in a 5-year period 

Abstract text (incl. figure legends and references) Introduction: Temporomandibular disorders (TMD) is complex and associated with the burden of chronic pain pathologies. Migraine has become one of those constantly found among TMD patients. An association between TMD and migraine has been published. However, no study has reported TMD prevalence according to migraine pain distribution of the somatosensory of the trigeminal nerve (V1, V2, V3). Aim: To investigate the prevalence of TMD with comorbid migraine in Orofacial Pain Clinic, Dental Institute, King's College London Hospital during 2016-2021. Method: The dataset was reviewed for patients diagnosed with TMD during consultation at the OFP Clinic at KCH between January 2016 and December 2021. Data were described by simple statistics, including numbers and percentages. Result: Over five years, we collected data from 1,345 OFP patients. Among 421 TMD patients, 28.26% (n=119) of them presented with comorbid migraine. The majority (94%) had chronic TMD symptoms (duration &gt; 3 months). Myofascial pain was the most prevalent (54.62%), followed by TMD pain due to arthrogenous origin (26.89%). Among TMD patients with comorbid migraine, 60.50% were diagnosed with chronic migraine. Of the TMD patients with migraine, 66.39% suffered from migraine headache (V1 area only), 26.89% suffered from migraine with facial involvement (V1 with V2 and/or V3 area), and 6.72% suffered from orofacial migraine (V2 and/or V3 area). The sole migraine patients were also included in our dataset. Among 242 migraine patients, TMD was found in 57.24% of patients with migraine headache (V1 area only), in 49.23% of patients with migraine with facial involvement (V1 with V2 and/or V3 area), and in 20.51% of patients with orofacial migraine (V2 and/or V3 area). Conclusion: TMD and migraines might commonly occur, especially in individuals with muscle-related chronic TMD and chronic migraine. Although TMD is mostly related to migraine pain in the V1 area, the proportion of TMD with migraine patients reporting pain in the facial region (V2 and/or V3) was not relatively small. Therefore, clinicians should be aware of the presence of migraine headache and orofacial migraine in TMD patients.

Autonomic Nervous System Disorders in Patients with Burning Mouth Syndrome

Abstract text (incl. figure legends and references) Objectives: Burning mouth syndrome (BMS) is a chronic idiopathic orofacial pain with poorly understood aetiopathogenesis, making treatment challenging. Studies have highlighted central and autonomic nervous system (ANS) dysregulations in BMS, yet studies investigating the interaction between ANS and brain are lacking. The periaqueductal grey area (PAG) has a crucial role in mediating the relationship between ANS and pain, and changes in PAG have been described in other chronic pain conditions. We combined Heart Rate Variability (HRV) as a measure reflective of ANS function, resting-state functional MRI and voxel-based morphometric analysis of brain structure to explore the interaction between ANS and brain mechanisms underpinning BMS pain experiences, focusing on the role of PAG. Methods: 26 BMS patients were assessed in two sessions. In session 1, resting heart rate (HR) was measured for 5 minutes. In session 2, structural and functional MRI scans were acquired. The root mean square of successive differences (a measure of vagal-mediated HRV; RMSSD) was extracted from HR inter-beat. Associations between seed-based PAG functional connectivity (FC) and the interaction between RMSSD and pain scores were investigated (pFWE corrected &lt;0.05). Patients were divided into low and high RMSSD groups for further analysis. Results: The mean pain score (NRS 0-10) was 5.5 (SD ±1.42). Patients with lower RMSSD had higher pain scores in session 1 (p=0.009). RMSSD was positively associated with FC between the PAG and insula and negatively associated with insula grey matter volume. The association between RMSSD and pain was positively mediated by the strength of FC between PAG and thalamus. (Figure 1). Conclusion: BMS brain structure and function changes are associated with parasympathetic tone and perceived pain intensity. These complex relationships provide indications of linkages between the brain and ANS, which may be insightful for developing future therapeutic interventions.

Two physiotherapy programs in headache attributed to temporomandibular disorder

Abstract text (incl. figure legends and references) Objective: Assess the effects of two 8-week physiotherapy programs on frequency, intensity, and impact of headaches attributed to temporomandibular disorder (TMD). Methods: Twenty-four patients diagnosed with headache attributed to TMD were divided into two groups of 12 participants: a therapeutic exercise program (G1, mean age: 26.3±5.6years) and an aerobic and therapeutic exercise program (G2, mean age:26.0±4.6years). Headache frequency and intensity were evaluated using a headache diary, intensity was reported using a numerical pain rating scale (NRS), and headache impact was evaluated using a Headache Impact Test (HIT-6). These parameters were evaluated twice at baseline (A01/A02), at the end of the 8-week intervention period (A1), and 8–12 weeks after the end of the intervention (A2). The study protocol was approved by the ethical committee of the Egas Moniz University Institute on February 13, 2019 (reference number: 675). All individuals provided informed consent in accordance with the Helsinki Declaration and understood that they were free to withdraw from the study at any time. Results: None of G2 participants reported having headaches, and in G1, only two participants reported headache, at A1. Scores for headache intensity (0.3 [95%CI: -0,401, 1.068]), (0.0 [95%CI: -0.734,0.734]), significantly decreased in G1/G2 at A1. Score of HIT-6 (50.7 [95%CI:38.008,63.459]), (49.5 [95%CI:36.808,62.259]), significantly decreased in G1 and G2 at A1. Effects obtained immediately after programs completion were maintained until the final follow-up in both groups. Conclusion: The programs conducted by G1 (therapeutic exercises) and G2 (therapeutic and aerobic exercise) had significant results at A1 and A2. The physiotherapy programs are important to reduce headache attributed to TMD.

Orofacial Pain- An Emerging Speciality Bridging the Gap between Medicine and Dentistry

Abstract text (incl. figure legends and references) Orofacial Pain refers to pain associated with the hard and soft tissues of the head, face, and neck. These tissues, whether skin, blood vessels, teeth, glands or muscles send impulses through the trigeminal nerve to be interpreted as pain by the brain. A vast variety of disorders fall under the umbrella of orofacial pain disorders. There is a bidirectional association between orofacial pain and sleep. Orofacial pain is a relatively common complaint in general medicine and dental practice. Diagnosis and treatment of pain originating from the head, face, oropharynx, ears, sinonasal area and neck is a complex process compounded by the density of anatomical structures and the prominent psychologic significance attributed to this region. Management of orofacial pain thus demands the service of clinicians from various specializations such as dentistry, otolaryngology, ophthalmology, neurology, neurosurgery, psychiatry and psychology. The quest to better manage pain problems involving the head and neck area has led to the establishment of Orofacial pain as a discipline in the field of dentistry. Orofacial pain remains a prevalent and debilitating condition with significant social and economic impacts. Clearly the task required is integration of knowledge in this anatomically dense region, traditionally divided between many medical disciplines. Management of orofacial pain requires a professional collaboration between dentists and medical doctors Based on extensive clinical experience with patients suffering from facial pain and headache, an Orofacial pain clinician is well equipped to fulfill this task of giving adequate relief to an orofacial pain patient and improving his/her quality of life. REFERENCES OroFacial Pain – Guidelines for Assessment, Diagnosis and Management ,The American Academy of OroFacial Pain - Reny de Leeuw, Gary D. Klasser. Bell&quot;s Oral and Facial Pain - Jeffrey P. Okeson The face of Dental Sleep Medicine in 21st century J Oral Rehab Dec 2020

Association of pain intensity and psychological factors among patients with symptomatic temporomandibular disorders: a cross-sectional study

Abstract text (incl. figure legends and references) Question: Are pain intensity and psychological variables associated in patients with symptomatic temporomandibular joint disorders? Method: A cross-sectional study was carried out with convenience sampling between February 1, 2022, and May 30, 2022, at the Universidad Europea de Canarias (Spain). Adults with TMJ pain with more than 12 weeks of evolution and who would not be undergone pharmacological or physiotherapeutic treatment were selected. An assessment of pain intensity (VAS) as well as anxiety (STAI), catastrophizing (PCS), perceived stress scale (PSS), and sleep quality (PSQI) was performed. Moreover, the statistical analysis was carried out using the Jamovi 2.3.12 software, performing the descriptive analysis, the Shapiro Wilks normality test (p&lt;0.05), and the strength of correlational association through the calculation of the Pearson Correlation Coefficient (Pearson's r). Results: We recruited 21 subjects (F:17; M:4) aged mean of 41.47 (SD=10.28) suffering from symtomatic TMJ dirsorder with a pain intensity of 4.84 (SD=1.70), anxiety 26.11 (SD=5.22), catastrophism 17.05 (SD=13.05), perceived stress 25.58 (SD= 8.60) and sleep quality 8.26 (SD=4.17). After checking the normality of the data, a weak linear correlation was found between the pain intensity and anxiety (Pearson's r = 0.141; r2=0.019; p=0.564), pain intensity and catastrophism (Pearson's r= 0.180,r2=0.032;p=0.462) and pain intensity and perceived stress (Pearson's r=0.358;r2=0.128;p=0.132). In contrast, moderate and negative strength of association between pain intensity and sleep quality was detected (Pearson's r= 0.403,r2=0.163;p=0.087). Conclusions: Psychological variables were not associated with pain intensity among TMJ patients. However, sleep quality was the only variable that maintains a moderate linear association with pain intensity.

Neurovascular Orofacial Pain – A Diagnostic Dilemma

Abstract text (incl. figure legends and references) The sites of the migraine headache are predominantly temporal, supraorbital, frontal, parietal, and occipital. However, they may occur in the orofacial region also. Referral of pain to maxillary teeth is not uncommon. In view of the uncommon pain location, a high number of these patients are misdiagnosed with dental or sinus-related conditions, frequently resulting in inappropriate surgical and medical treatments. If the oro-facial area is the focus of the pain, the newly developed International Classification of orofacial pain refers to &quot;Orofacial Migraine&quot; and &quot;Trigeminal autonomic orofacial pain&quot;. Benoliel et al introduced the term Neurovascular oro-facial pain (NVOP), previously also described as lower facial migraine. Migraine can be localized in the face resembling facial or dental pain, indicating the influence of the trigeminovascular system in the structures innervated by the maxillary and mandibular branches of the trigeminal nerve. The clinical features of NVOP contains a distinctive combination of signs and symptoms common to both migraine and trigeminal autonomic cephalalgias. In contrast to migraine, patients are older at the time of onset and even more predominantly female. Frequently, there is cold allodynia of several teeth. This finding needs to be investigated properly, since it would be an important test and might link this entity to migraine, in which mechanical allodynia is seen during attacks. NVOP is becoming increasingly recognized in medical and dental clinics. It is important for clinicians evaluating patients with facial pain to show their diligence and identify the associated symptoms of migraine, so as to avoid unnecessary treatments and surgical procedures and deliver appropriate medical therapy. The collaboration between neurologists and facial pain specialists is key to increasing awareness and education on this rare but treatable manifestation of an otherwise very frequent headache disorder. References Interplay of Oral, Mandibular, and Facial Disorders and Migraine Curr Pain Headache Rep 2022 May Migraine presenting as isolated facial pain:Cephlalgia 2020 International Classification of Orofacial Pain. Cephalalgia 2020

Role of Orofacial Pain Specialists in Diagnosis and Management of Oropharyngeal, Head and Neck Cancer

Abstract text (incl. figure legends and references) Patients with oropharyngeal, head and neck cancer often experience pain and suffering that reduces quality of life, increases anxiety and depression, affects well being and even compliance with treatment. Also, oral manifestations of hematologic cancers and metastasis to oral tissues may cause pain with similar effects. Orofacial pain can be due to cancer itself, due to cancer therapy or due to noncancerous etiology in cancer patients. Even cancer therapy is well known to frequently induce painful oral complications. Pathogenesis of oral cancer is not fully understood and various mediators like endothelin-1, proteases and nerve growth factor have been implicated. Effective management of orofacial pain in patients with cancer requires comprehensive assessment of multifactorial etiologies and treatment directed at these causative factors. Orofacial pain in cancer patients remains a prevalent and debilitating condition with significant social and economic impacts. Clearly the task required is integration of knowledge in this anatomically dense region, traditionally divided between many medical disciplines. Management of orofacial pain requires a professional collaboration between dentists and medical doctors. Dentists, Orofacial pain specialists in particular, play an important role in screening oropharyngeal, head and neck cancer patients, helping in the diagnosis and management by making appropriate referrals. Based on extensive clinical experience with patients suffering from facial pain and headache, an Orofacial pain clinician, being part of the multidisciplinary team, is well equipped to fulfill the task of giving adequate relief to orofacial pain in cancer patients and thereby improving quality of life. Orofacial pain in patients with cancer can be managed by using topical therapy, non-opioid and strong opioid analgesics, adjuvant and centrally acting analgesics as well as adjunctive or complementary management strategies.

Poster session 4

Appointment

Chair

Programme