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In children with certain brain disorders, headache can be associated with focal neurologic signs or symptoms; these children represent a true diagnostic challenge to physicians, owing to the possibility of severe underlying disease. The differential diagnosis in children with headache and focal neurologic signs includes primary etiologies, such as migraine with aura, and secondary etiologies, such as trauma, infection, and vascular, neoplastic, and epileptic disorders.
Achieving a diagnosis in children can be challenging at times; important reasons for this include poor description of pain by children and several childhood periodic syndromes that can be common precursors of migraine.
Migraine is a multiphasic disorder and understanding of its pathophysiology starts with the acknowledgment that migraine is not simply a disease of intermittently occurring pain, but that it involves processes that affect the brain over time.
If one wants to interpret the most recent findings in migraine pathophysiology it is important to again discuss the clinical presentation of all phases of a migraine attack.
There are three clinical features of migraine which point towards the limbic system and hypothalamus as attack generating brain structures. The first one is that almost all symptoms of the premonitory phase including yawning, tiredness and mood changes already point towards hypothalamic involvement. Secondly, the circadian rhythmicity of attacks and thirdly the association of attacks with hormonal status and the menstrual cycle.
The hypothalamus has various neuroanatomical connections to pain modulating systems and also to the spinal trigeminal nuclei. The orexinergic system, which is known to regulate arousal and nociceptive processing as well as thermoregulation and autonomic functions, has only recently become a site of interest in migraine research.
Another neurotransmitter system involving the hypothalamus is the central dopaminergic system. Recent neuroimaging studies in migraine patients undermine hypothalamic involvement in the premonitory and acute pain phase of migraine. Most recently one migraine patient went into the scanner daily over a whole month which included 3 spontaneous untreated headache attacks.
Increased hypothalamic activation was seen in the prodromal phase within the last 24 h before migraine headache onset as compared to the interictal state. More importantly, the pain-related hypothalamic functional connectivity between the hypothalamus and the spinal trigeminal nuclei was significantly increased during the preictal phase as compared to the interictal phase.
These data strongly suggest that the hypothalamus plays a crucial role in generating premonitory symptoms but also the migraine attack itself. Moreover, using a recently developed protocol for high resolution brainstem imaging of standardized trigeminal nociceptive stimulation, the anterior right hypothalamus HT was significantly stronger activated in CM as compared to healthy controls. These data corroborate a crucial role of the HT for migraine chronification but also as for the sustainment of acute migraine pain.
NeuroImage ; — The hypothalamus as a mediator of chronic migraine: Evidence from high resolution fMRI. Neurology — May A. Understanding migraine as a cycling brain syndrome: reviewing the evidence from functional imaging. Neurol Sci ; — Cluster headache, hypothalamus, and orexin. Curr Pain Headache Rep ; — Alstadhaug KB. Migraine and the hypothalamus. Cephalalgia ; — Immunohistological studies show widespread distribution of CGRP within the CNS, but the role and function of this neuropeptides in the brain and spinal cord are largely unknown.
There is also increasing interest whether CGRP antagonists penetrate the blood brain barrier and abort migraine headaches in part via central mechanisms. As migraine is a CNS disorder a central abortive or preventative mechanisms is suspected for several years. Finally, we will illustrate the contribution of CGRP in an animal model of photophobia. The classification of headache disorders has improved over the years, but further work is needed to develop and improve headache diagnosis within headache subtypes.
Calcitonin gene-related peptide CGRP is considered to be one of the main molecules in the pathophysiology of migraine. Currently, several drugs that target either the CGRP peptide or its receptor are in clinical studies for the prophylactic as well as the acute treatment of migraine.
While CGRP is expressed abundantly in the central nervous system, it also plays an important role in the peripheral nervous system. Most antimigraine drugs that are currently in clinical development and target CGRP or its receptor for example, the monoclonal antibodies are not able to cross the blood brain barrier and thus do not reach the central nervous system, highlighting the importance of CGRP and its receptors at sites not protected by the blood brain barrier.
These sites include the trigeminal ganglion, but also perivascular sensory afferents that may be involved in the pathophysiology of migraine as well as in the development of potential side effects. During the lecture, models and mechanisms important for the understanding of the role of CGRP in the peripheral nervous system will be discussed. Migraine is the most common cause of neurological disability worldwide [1]; it is a disorder of the brain with pan-sensory dysfunction [2]. Migraine has, in essence, three phases, prior to the canonical attack- the premonitory or prodromal phase, the attack itself, headache with or without aura, and the period after canonical attack, the postdrome.
The premonitory phase can occur from hours to days before the canonical attack. The symptoms can be seen in children, as they are in adults [4]. Moreover, there is evidence from functional imaging of activation in the region of the hypothalamus during the premonitory phase [5]. The postdrome phase occurs after the headache phase of the canonical attack is settling; it is typically settled in about half of patients in six hours. Remarkably there is widespread reduction in brain blood flow in the postdrome [7], which reflects the phenotype well.
Understanding the non-pain phases of migraine will lead to be a better formulation of the pathophysiology of migraine and eventually to better treatment.
Global, regional, and national incidence, prevalence, and years lived with disability for diseases and injuries, a systematic analysis for the Global Burden of Disease Study Pathophysiology of Migraine- A disorder of sensory processing.
Physiological Reviews. Premonitory symptoms in migraine: an electronic diary study. Premonitory symptoms of migraine in childhood and adolescence. Current Pain and Headache Reports. Brain activations in the premonitory phase of nitroglycerin triggered migraine attacks. The migraine postdrome. An electronic diary study. Neurology Minneap. The project took the form of surveys by structured questionnaire, conducted from November to August Unadjusted lifetime prevalence of any headache was Gender-adjusted 1-year prevalences were Personal impact was high, and included ictal symptom burden, interictal burden, cumulative burden and impact on others partners and children.
We confirmed that depression and especially anxiety are comorbid more than by chance with migraine. The level of this impact and its pervasiveness taken together with estimates of huge financial cost, have important implications for health policy in Europe. Eurolight should proceed with focusing on cluster headache and headache in the elderly.
Background : Despite the very high prevalence of headaches, multidisciplinary headache clinics are still few and better documentation of their content and efficacy is needed.
Objective : To describe the structure of a multidisciplinary approach and to characterize the patients and treatment results from existing centres. Further to describe the proposed organization of headache care in Europe. At this level headache specialists and a multidisciplinary team should conduct more complex treatment, initiate research and education.
The composition of the multidisciplinary team may vary, however and here there is no international consensus. Most centres include nurses, psychologists and in some countries also sports-therapists or physiotherapists. A systematic review of patients from the tertiary Danish Headache Centre revealed that patients had a mean age of In recent years more evidence from other centres has been provided and the positive outcome was confirmed, also in so called refractory patients.
Conclusion : Treatments strategies to the complicated headache patients need individualization but the present evidence provide hope for the patients and a strong support for a multidisciplinary approach in a tertiary headache centre.
The existing treatment strategies will be presented. Further discussion and evaluation of the elements and the outcome predictors are important for future planning. Migraine is a common debilitating brain disorder characterized by severe headache attacks with various associated neurological symptoms. About one-third of migraine patients experience an aura preceding the headache phase: hence migraine with and without aura.
Many migraine patients also suffer from comorbid neurological disorders, such as epilepsy, depression and stroke. Migraine is a genetic disease with both environmental and genetic factors determining the susceptibility to attacks. Recent technological advances in genetic analysis, which allowed simultaneous testing of hundreds of thousands of single nucleotide polymorphisms SNPs in tens of thousands of migraine patients in genome-wide association studies GWAS , made it feasible to identify robust gene variants for the common forms of migraine.
Whereas GWAS performed in various migraine subtypes yielded different top hits for the different subtypes, additional analyses seem to point to a shared genetic underpinning in migraine. Identified gene variants point towards various molecular pathways, e. GWAS data sets, to some extent, can also been used to identify the type of brain cell involved in pathology. GWAS also enable the identification of shared genetic factors for diseases comorbid with migraine.
Unlike gene mutations in monogenic migraine subtypes, the effect size of gene variants in common migraine is small, thus complicating direct translation to diagnostic tests, pathogenetic mechanisms, and treatment targets. In fact, strategies to properly address the biological role of these variants are still being developed. The coming years will show the true impact of these combined genetic approaches on the identification of genes, pathological mechanisms, and diagnosis of patients in migraine.
Research has devised various techniques for investigating nociceptive and non-nociceptive somatosensory pathways in patients with neuropathic pain. The most widely agreed tools in use today include neurophysiological techniques and skin biopsy. Laser Evoked Potentials LEPs are the easiest and most reliable neurophysiological technique for assessing nociceptive pathway function. In diseases associated with nociceptive-pathway damage, LEPs can be absent, reduced in amplitude or delayed in latency.
Skin biopsy is a reliable and minimally invasive tool for investigation of nociceptive fibres in human epidermis and dermis. Researchers have used this technique for assessing epidermal nerve fibres qualitatively and quantitatively. Skin biopsy can be done at any site of the body, with a disposable punch, using a sterile technique, and under local anaesthesia. Many investigators have used skin biopsy to investigate epidermal nerve fibres in various peripheral nerve diseases, such as diabetic neuropathy, infectious and inflammatory neuropathies and neuropathies associated with systemic diseases.
In all studies, epidermal nerve fibre density was significantly lower in patients with neuropathy than in controls. Patients suffering from chronic headaches challange health care systems. A proportion of chronic headache patients does not properly respond to prophylactic treatments or shows low tolerability profile and remains in need for alternative therapeutic strategies and options. The improved understanding of head pain pathophysiology has focused attention on the role of neural structures both at peripheral and central nervous system level.
Thus in the attempt to improve chronic intractable neurovascular headache migraine and cluster headache patients a number of neuromodulation procedures targeting peripheral and central nervous system structures have been tried. So far, efficacy and safety of various non-invasive and invasive stimulation procedures and devices have been investigated.
Vagus nerve stimulation, supraorbital stimulation and single-pulse transcranial magnetic stimulation are considered non invasive neurostimulation options.
While invasive procedures are occipital nerve stimulation, sphenopalatine ganglion stimulation and hypothalamic deep brain stimulation. Years after their introduction there is still debate about their use and place in clinical practice.
Results from open label series and few controlled trials suggest the need of further investigations. Criteria employed to define intractable headaches were given more than ten years ago 1. An ad hoc European Headache Federation expert board has reviewed these aspects 2.
A still unsolved issue is the lack of adequate placebo to properly design randomized controlled trials in neurostimulation studies. In patients with chronic pain conditions interpretation of placebo effect is a challange particularly for headache specialists. In chronic migraine and chronic cluster headache patients occurrence of psychiatric comorbidities is frequently encountered.
Also, occurrence of medication overuse headache — seen as an addiction behavior - is frequently observed both in chronic migraine and chronic cluster headache.
These factors are often a barrier when selecting patients for neurostimulation procedures. Long term experience with deep brain stimulation of the posterior hypothalamic area in chronic cluster headache has suggested that the generator of the attacks is not there 3. Similarly other neurostimulation procedures tried in migraine and cluster headache have shown poor, unsatisfactory ability to stop ongoing attacks. Towards a definition of intractable headache for use in clinical practice and trials.
Neuromodulation of chronic headaches: position statement from the European Headache Federation. J Headache Pain. Success, failure and putative mechanisms in hypothalamic stimulation for drug resistant chronic cluster headache. Pain ; 1 : An underlying concept in the new ICHD-3 classification of trigeminal neuralgia is the postulation that clinical presentations matter because they reflect distinct pathophysiological mechanisms.
Previous attempts to establish the connection between the two have yielded uncertain results as the authors have paid limited attention to individual clinical symptoms and signs.
Yet, the relatively strict criteria for trigeminal neuralgia and its subgroups yield homogenous populations that allow advantage to be taken of the advances in neurophysiological and imaging methods. It is now possible to conduct subgroup-specific pathophysiological studies aimed at biomarkers that pave the way for precision diagnosis of TN and individualised therapy. An example of how this might be done comes from recent studies based on sensory profiling of peripheral neuropathic pain.
In a large group of patients with three different diagnoses, cluster analysis of detailed sensory testing revealed three main sensory phenotypes [1], with the potential to allocate individual patients to these sensory groups [2].
In my presentation I will suggest a pathway as to how to accomplish this. I will start by arguing that the existing data are sufficient to recommend preferred treatment in selected cases. I will then highlight a number of clinically relevant research questions that can be answered by large-population multi-centre studies applying established methods ranging from QST and evoked potentials to structural and functional neuroimaging of the trigeminal system and linking them with clinical signs and symptoms.
Alongside this, I will discuss the challenges of phenotype profiling that could guide pharmacotherapy with, e. Peripheral neuropathic pain: a mechanism-related organizing principle based on sensory profiles. Pain ; Stratifying patients with peripheral neuropathic pain based on sensory profiles: algorithm and sample size recommendations. Mild head injury is associated with good recovery in most patients, but with a small risk of poor outcomes.
Headache is the most common complication that occurs as an isolated symptom or can be a part of the post-concussion syndrome which can also include dizziness, fatigue, reduced ability to concentrate, psychomotor slowing, mild memory problems, insomnia, anxiety, personality changes and irritability Following head injuries, children may develop headache for the first time or have their previously experienced headache getting worse in severity or frequency.
Post head injury headache is referred to as acute posttraumatic headache if it evolves within one week of the injury and resolves within 3 months and it is called chronic posttraumatic headache CPTH if it persisted for over 3 months.
The pathophysiology of posttraumatic headache is not well understood, but likely to involve several mechanisms and factors. It is suggested that even minor head injury may cause a widespread stretching or shearing injuries to the axonal network. Psychosocial factors may also play a role in the pathogenesis of CPTH. The clinical features of CPTH are similar to primary headache disorders phenotypes with the majority of children presenting with migraine-like headache and probable tension-type headache.
Some children may have mixed or unclassified headache disorders. In the majority of children no investigations are necessary. However, neuroimaging and other investigations may be necessary in children with red flags or abnormal findings on neurological examination. The management of children with CPTH should include reassurances, adequate pain relief and preventative treatment as appropriate. Multidisciplinary approach is necessary and should include support from clinical psychology and education to help the child achieve normal school attendance and education.
The prognosis of CPTH is generally good, but long term data are needed. The interaction between enzyme inductive antiepileptics EiAED like carbamazepine, phenytoin, primidone, phenobarbitone, rufinamide, lamotrigine, topiramate and COCs is well-known. Therefore, while taking this medication, the risk of contraceptive failure is quite high.
The mechanism of action of enzyme-inductors is to modify the metabolism of the sexual steroids in the liver. Moreover, ethinylestradiol EE might modify the metabolism of certain antiepileptic drugs glucuronization of lamotrigine. Therefore, the gynaecologist has to be careful when prescribing the pill or administering other types of hormonal contraceptives for WWE.
Knowing the interaction between antiepileptics and contraceptives is important to find the most effective medication with fewer side effects. Nowadays, women with epilepsy do not always get the right information; thus, it is necessary to improve the cooperation and consultation between the epileptologist and the gynaecologist. The information is also needed even if the patient is sexually inactive.
Migraine is a complex neuronal disorder where the cortex has a key importance and characteristic headache attack is associated with multiple sensorial disturbances. A cerebral cortical phenomenon known as cortical spreading depression CSD was linked to lateralized headache. CSD is an intrinsic brain phenomenon to a noxious stimulus such as high potassium or trauma, and manifests as an extreme excitability state of the gray matter with massive depolarization of neuronal and glial membranes and redistribution of ions.
Propagating depolarization in the brain parenchyma leads to a release of various vasoactive and nociceptive ions and molecules.
Vascular compartment reacts with initial hyperemia followed by long-term oligemia. It occurs in many species from rodents to primates, though it is hard to initiate and sustain its propagation in gyrencephalic brains. Spreading depression wave involves neuronal, glial and vascular cells, and leads remarkable effects on those compartments and overlying meningeal membranes with capability of triggering peripheral trigeminal fibers and second order trigeminal neurons in the brainstem nucleus, though its effect on subcortical structures are less known.
CSD is implicated in the development of inflammatory response and releasing CGRP and nitric oxide from trigeminal nerve endings. Animal studies investigating the mechanisms of migraine and CSD are usually conducted under anesthesia, despite the fact that pain is a conscious experience.
Anesthesia have profound effects on the mechanisms by which CSD is initiated and propagated, and clearly prevents observation of any associated behavioral response. Therefore CSD studies in awake animals are crucial for translational migraine research. Cerebral cortex and thalamus are inseparable in sensory processing and thalamic reticular nucleus TRN is the gatekeeper of sensory outflow to the cortex.
Electrocorticographic recordings demonstrated the direct propagation of CSD waves in to thalamic reticular nucleus.
It was dependent on full conscious experience and highly vulnerable to anesthetics. MK did not exert any effect on CSD induced amygdala activation and anxiety behavior. TRN is also involved in discrimination of sensory stimulus and transient disruption of sensorial perception during migraine headache attacks was reported Boran et al, Involvement of a strategic subcortical thalamic structure by a cortical event is important to explain several clinical features of migraine such as 1 Dysfunction of the GABAergic neurons in TRN would result in enhanced transmission of sensory information to the cortex and disruption of sensory discrimination 2 Photophobia and visual hallucinations of aura may reflect dysregulation of visual stimuli by the TRN, 3 TRN could play a role in either termination or initiation of an attack as sleep is closely related with migraine, attacks are often associated with the circadian cycle and are typically relieved by sleep, 4 Thalamo-cortical gating could be a novel target in migraine as valproate, triptans and CGRP antagonists MK suppressed CSD induced TRN activation.
Common misdiagnoses for TN include dental pathology, other regional neuralgias, short-lasting neuralgiform headaches with autonomic signs SUNHA , cluster headache and theoretically an atypical shorter cluster-tic syndrome CTS. More rarely there may be more sinister underlying disorders tumors, multiple sclerosis that induce TN-like syndromes.
We will outline and highlight the salient features across disorders that will ensure correct diagnosis. Trigeminal neuralgia TN is a neurological disease which is peculiar under several respects. The diagnosis of TN, in its typical presentation, in unmistakable on clinical grounds alone.
Pain manifests with intense bursts that occur and end abruptly and usually last few seconds only. This type of pain is paradigmatic of what pain scholars call paroxysmal pain. The most common verbal descriptors are electric-shock like or stabbing. Unique to TN is the trigger mechanism. The attacks are evoked by innocuous stimuli in tiny zones of the extra- or intraoral trigeminal territories. The most frequent trigger maneuvers include activities of the daily life such as washing, cleaning, brushing the teeth or talking.
Although the trigger zones shared by most patients are confined between the nostril and the lateral perioral region, any area innervated by the trigeminal nerve may do. One aspect of pathophysiology is supported by established neurophysiologic, neuroimaging, and histologic evidence: the primary mechanism is focal demyelination of primary afferents near the entry extra- or intra-axial of the trigeminal root into the pons.
A second pathophysiologic theory, admittedly more debatable, is that hyperexcitable primary afferents, in the area of focal demyelination, become a source of ectopic generation of impulses and ephaptic transmission cross talk from close, healthy nerve fibers. More supported by evidence from animal models is the generation of high-frequency discharges. A third potential step, with so far almost no sound evidence at all, is that the hyperactivity of primary afferents secondarily induces central sensitization of wide dynamic range neurons in the spinal trigeminal nucleus or even more central changes.
Finally, TN is unique also for its pharmacological and surgical treatment. TN is highly sensitive to voltage-gated, frequency-dependent sodium-channels blockers and almost nothing else , and is the neuropathic pain condition that respond best to surgical lesions of the postganglionic primary sensory afferents. The speaker will present an overview of the methodological potentials and challenges of the HUNT survey. Results will be displayed regarding prevalences of the common headache disorders and their trends over time.
Most importantly, the HUNT-survey enables risk factor analyses. Findings will be reviewed for factors of life such as physical activity, substance use, head traumas, insomnia, and mortality. Finally, associations between intracranial abnormalities and headache disorders are now beginning to be published from a neuroimaging sub-study HUNT MRI. SD is widely accepted as the pathophysiological event underlying migraine aura, and may play a role in headache pathogenesis in secondary headache disorders such as ischemic stroke, subarachnoid or intracerebral hemorrhage, traumatic brain injury, and epilepsy.
Here, we provide an overview of the pathogenic mechanisms and propose plausible hypotheses on the involvement of SD in primary and secondary headache disorders. SD can activate downstream trigeminovascular nociceptive pathways to explain the cephalgia in migraine, and possibly in secondary headache disorders as well.
In healthy, well-nourished tissue such as migraine , the intense transmembrane ionic shifts, the cell swelling, and the metabolic and hemodynamic responses associated with SD do not cause tissue injury; however, when SD occurs in metabolically compromised tissue e. Recent non-invasive technologies to detect SDs in human brain injury may aid in the investigation of SD in headache disorders in which invasive recordings are not possible.
SD explains migraine aura and progression of neurological deficits associated with other neurological disorders. Studying the nature of SD in headache disorders might provide pathophysiological insights for disease and lead to targeted therapies in the era of precision medicine.
The proportion of adult patients reporting non-traumatic headache as their major complaint at ER access ranges from 0. The main objective is to identify the patients who require urgent investigations besause of a suspected serious secondary cause. The crucial step in the diagnosis is the initial interview. Most patients presenting with headache as the chief complaint have a primary headache disorder, such as migraine or tension-type headache, the diagnosis of which relies on strict diagnostic criteria in the absence of any objective marker.
Secondary headache disorders manifest as new-onset headaches that arise in close temporal association with the underlying cause. Secondary headache should be suspected in any patient without a history of primary headache who reports a new onset headache and in any patient with a new unusual headache that is clearly distinct from their usual primary headache attacks.
Since many serious disorders, such as subarachnoid haemorrhage, can present with isolated headache and a normal clinical examination, diagnosis is reliant on clinical investigation. Subarachnoid hemorrhage should be suspected in anyone with a sudden or a thunderclap headache. Diagnosis is based on plain brain computed tomography and, if tomogram is normal, on lumbar puncture. Reversible cerebral vasoconstriction syndrome should be suspected in anyone with recurrent thunderclap headaches over a few days.
Cervical artery dissection, cerebral venous thrombosis, reversible cerebral vasoconstriction syndrome and pituitary apoplexy may present with isolated headache and normal physical examination, normal cerebral computed tomography and normal cerebrospinal fluid.
When computed tomography and lumbar puncture are normal, other investigations are needed, including cervical and cerebral vascular imaging and brain magnetic resonance imaging.
Treatment of headaches in the ER should be based on the etiology. The treatment of secondary headaches requires the treatment of the underlying cause and a symptomatic treatment based on intravenous acetaminophen or on opiates depending on the pain intensity. In women migraine prevalence peaks during reproductive years. Menstruation is a significant risk factor for migraine with attacks most likely to occur between 2 days before the onset of menstruation and the first three days of bleeding.
The pathophysiology of menstrual attacks involves estrogen withdrawal and potentially abnormal release of prostaglandins triggered by the end-cycle drop in estrogen level. Reproductive year are the life span during which many women require effective contraception. Migraine with aura MA and to a lesser extent migraine without aura MO increase the risk for cardiovascular events, especially for stroke.
There is a substantial elevation of these risks in migraineurs using combined contraceptive pills COC. Several clinical trials report improvements in migraine frequency and intensity in users of the progestin-only pill POP with desogestrel 75microgram. Both, inhibition of ovulation and ist continous use contribute to reduce hormone flucutations during ist use. The positive impact of this pill has been shown in MA and MO patients. In women with chronic migraine, the reduction in pain medications used contributes to prevent medication overuse headaches.
The existing nosology of cranial-nerve pains does not fully portray the subtle differences between various conditions. However, rather than abandoning many long-established diagnostic terms, this classification retains them, providing detailed definitions for differential diagnoses and their types, subtypes and subforms. There are several axes of classification: a syndomology neuralgia vs.
The authors of the classification tried to incorporate the existing literature into the IHS classification system. The current version defines the trigeminal neuralgia and trigeminal neuropathy.
Trigeminal neuralgia is subdivided into classical due to nerve-vascular compression, not purely a nerve vascular contact , idiopathic unknown cause or nerve vascular contact, because the value of a nerve vascualr contact is unclear and secondary due to other disease. Base don the clinical presentation it is further characterised as TN with and without concomitant facial pain indicating pure response to treatment.
The cut-line for distinguishing between an acute and persistent headache is defined to be 3 months: resolution of headache within this period complies with an acute, persistence for the longer time — with a persistent headache. Headache attributed to the injury to the head is further subclassified based on the severity of preceding trauma.
Probably one of the most debated diagnostic criterions of this chapter is the time of onset of headache after a traumatic event.
For the main classification it is agreed that causative relation between trauma and development of headache should be within 7 days after the trauma.
However based on a data derived from reports of everyday clinical practice alternative criteria published under the Appendix allow the delayed onset of headache, reaching up to 30 days following the injury. Clinical phenotypes of post-traumatic headache are varying from mild tension-type-like to severe migrainous.
Pathophysiological mechanisms of post-traumatic headaches remain largely unclear as a reason to the epidemiological data suggesting, that mild injury to the head represents a greater risk of developing persistent headache. The latter one causes a considerable reduction of health related quality of life and frequently is challenging in terms of treatment, requiring pharmacological preventative medications and non-pharmacological cognitive behavioural treatment, physical therapy, counselling etc approaches.
For treatment resistant cases interventional procedures, usage of onabotulinum toxin A and neurostimulation have been reported to be potentially effective.
To determine persistence of and transitions between episodic migraine EM and chronic migraine CM and to describe and model the natural variability of self-reported frequency of headache days. Relatively little is known about the stability of headache days per month in persons with EM or CM over time.
Within person variability in headache day frequency has implications for the diagnosis of CM, assessing treatment in clinical practice and for the design and interpretation of clinical trials. We modelled longitudinal transitions between EM and CM and, separately, headache day frequency per month using negative binomial repeated measures regression models NBRMR.
Among the 5, respondents with EM at baseline providing 4 or 5 waves of data, 5, Among respondents with CM at baseline providing 4 or 5 waves of data, had CM in every wave Individual plots revealed striking within-person variations in headache days per month.
Follow-up at 3 month intervals reveals a high level of short-term variability in headache days per month. Nearly three forths of persons with CM at baseline drop below this diagnostic boundary at least once over the course of a year. These findings my influence case definitions of migraine subtypes, the design and interpretation of epidemiologic studies and clinical trials as well as the interpretation of change in headache days in clinical practice.
Impairment of brain solute clearance through the recently described glymphatic system has been linked with traumatic brain injury, sleep deprivation, and aging. This lecture will summarize new data showing that cortical spreading depression CSD , the neural correlate of migraine aura, closes the paravascular space and impairs glymphatic flow. This closure holds the potential to define a novel mechanism for regulation of glymphatic flow.
It also implicates the glymphatic system in altered cortical and endothelial functioning of the migraine brain, which can explain the increased risk of stroke among migraine aura patients. Many patients report that their need to avoid light is driven mainly by how unpleasant it makes them feel. This lecture will attempt to explain why is light unpleasant.
The data presented will show that during migraine, light can trigger the perception of a hypothalamic-mediated autonomic responses such as chest tightness, throat tightness, shortness of breath, fast breathing, faster than usual heart rate, light-headedness, dizziness, nausea, vomiting, dry mouth, salivation, rhinorrhea, stuffy sinuses and lacrimation; b hypothalamic mediated non-autonomic responses such as thirst, hunger drowsiness, tiredness, sleepiness, fatigue, and yawning; c negative emotions such as intense, irritable, angry, nervous, hopeless, needy, agitated, sad, scared, cranky, upset, depressed, disappointed, jittery, worried, stressed, anxious, panic and fear; and d positive emotions such as happy, relaxing, soothing, and calming.
By defining better the aversive nature of light, the findings suggest that the retina and hypothalamus play a critical role in migraine-type photophobia and that photophobia may not depend on hyperexcitable visual cortex, as traditionally thought.
We have recently described a macroscopic pathway in the central nervous system — the glymphatic system that facilitates the clearance of interstitial waste products from neuronal metabolism. Glymphatic clearance of macromolecules is driven by cerebrospinal fluid CSF that flows in along para-arterial spaces and through the brain parenchyma via support from astroglial aquaporin-4 water channels.
The glymphatic circulation constitutes a complete anatomical pathway; para-arterial CSF exchanges with the interstitial fluid, solutes collect along para-venous spaces, then drain into the vessels of the lymphatic system for ultimate excretion from the kidney or degradation in the liver.
As such, this may after circulation represent a novel and unexplored target for prevention and treatment of neurodegenerative diseases. We aimed to investigate the prevalence of headache in General Population adults years old in Greece.
A quantitative study, using the form of computer-assisted telephone interviews C. A draft questionnaire consisting of 37 questions was delivered in headache sufferers in a pre-study work to evaluate the diagnosis of the primary headache disorder according to ICH-3beta diagnostic criteria. After the analysis of this questionnaire the specific item questionnaire was decided.
The one-year prevalence of Migraine that reduces activity was 8. Females tend to suffer more from migraines and TTH as well as ages The average patients has been suffering from headaches for 12 years. Headaches typically occur once a month or more frequently, 8 days per month on average. Although patients rarely misss work due to headaches, they do report headache-induced reductions in performance around 3 days per month. About one fifth of patients seek professional treatment for headaches, most of them in the private sector.
The most popular specialty for headache treatment is neurologist, followed by internist. Regarding both prophylactic and acute treatment, patients prefer oral medication to injection, even if the former is administered more frequently. The stimulation device seems to be more attractive to males. Painkillers also are by far the most common acute treatment for headaches and the vast majority of patients have never taken prophylaxis for headaches.
Only a small fraction have stopped taking a prophylactic treatment due to adverse effects. Calcitonin gene-related peptide CGRP , a neuropeptide previously known only by specialists interested in neurogenic inflammation, is now discussed throughout the communities of migraine researchers, headache therapists and even migraine patients.
The reason for this surprising career of CGRP awareness is evident. CGRP is the main neuropeptide of a major part of nociceptive trigeminal afferents and is released upon their activation. Thus CGRP release is characteristic, though in no way specific, for the trigeminovascular system, which is regarded as the structural basis for headache generation.
In fact, CGRP has been found at elevated concentrations in the cranial outflow during attacks of migraine and some trigemino-autonomic headaches; infusion of CGRP into patients suffering from primary headaches can cause head pain mimicking their spontaneous headache attacks; inhibiting CGRP or its receptors or its release can be preventive or therapeutic in those types of primary headaches.
However, looking behind the curtain of impressive significance of this biomarker, broad gaps in our knowledge are visible concerning the sites of CGRP release, its flow through the meningeal compartments, the sites and mechanisms of actions and its elimination. With preclinical experiments we are only at the beginning to study these issues, which are increasingly important in the light of new pharmacological developments targeting CGRP and its receptors by antagonists or monoclonal antibodies, and keeping in mind possible risks of a long-term treatment with these substances.
Trigeminal activity controlled by CGRP receptor activation could indeed be a pivot point in headache generation and therapy. However, measurable circulating concentrations of CGRP are far too low to explain any receptor effects, while it is difficult to assess its real concentrations near the likely release sites, namely the meningeal terminals of trigeminal afferents, the trigeminal ganglion and the central terminals in the trigemino-cervical brainstem complex.
The central effects of CGRP as a synaptic neuromodulator could explain neuronal CGRP effects to some extent but big molecules like monoclonal antibodies are unlikely to pass the blood-brain barrier and may not be able to act there. Peripheral effects of CGRP are largely confined to its well-known vascular functions, while fast neuronal effects are not established so far in the trigeminal system.
The trigeminal ganglion is a possible point of CGRP action but only few experiments have shown an impact on the signalling or metabolic changes of ganglion neurons. Therefore new experimental approaches are needed to uncover the secrets of the nociceptive CGRP signalling system and its therapeutic control.
Medical management of headache disorders, for the vast majority of people affected by them, can and should be carried out in primary care. It does not require specialist skills. Nonetheless, it is recognised that non-specialists throughout Europe may have received limited training in the diagnosis and treatment of headache.
This publication, in the Journal of Headache and Pain , provides a combination of educational materials and practical management aids. It is a product of the Global Campaign against Headache, a programme of action for the benefit of people with headache conducted by the UK-registered non-governmental organization Lifting The Burden LTB in official relations with the World Health Organization.
It updates the first edition [1], published 10 years ago. It has undergone review by a wider consultation group of headache experts, including representatives of the member national societies of EHF, primary-care physicians from eight countries of Europe, and lay advocates from the European Headache Alliance.
While the focus is Europe, the inclusion in the consultation group of members from all six world regions has aimed for cross-cultural relevance of all content so that it is useful to a much wider population. The European principles of management of headache disorders in primary care , laid out in 11 sections, are the core of the content.
Each of these is more-or-less stand-alone, in order to act as practical management aids as well as educational resources. There is a set of additional practical management aids. An abbreviated version of the International Classification of Headache Disorders, 3rd edition ICHD-3 , provides diagnostic criteria for the few headache disorders relevant to primary care. A headache diary further assists diagnosis and a headache calendar assists follow-up. A measure of headache impact the HALT index can be employed in pre-treatment assessment of illness severity, and an outcome measure the HURT questionnaire is a guide to follow-up and need for treatment-review.
Five patient information leaflets are included, which may be offered to patients to improve their understanding of their headache disorders and their management. We hope for benefits for both physicians and patients. Several data indicate that migraine, especially migraine with aura, is associated with an increased risk of ischemic stroke and other vascular events. Of concern is whether the risk of ischemic stroke in migraineurs is magnified by the use of hormonal contraceptives HCs.
As migraine prevalence is high in women of reproductive age, it is common to face the issue of migraine and HC use in clinical practice. The document pointed out that evidence addressing the risk of ischemic stroke associated with the use of HCs is generally poor.
All information relies on observational data, which may carry the risk of potential bias. Available studies had different settings and used different groups for comparing risks, limiting reliable comparison of studies as a pooled analysis of data.
Most of the available studies were published several years ago and used compounds which are different from those available today. Additionally, in most studies not enough information is available regarding the type of HC considered and in most cases results are not provided according to migraine type.
Despite those limitations, available data pointed toward an increased risk of ischemic stroke associated with the use of HCs in women with migraine. Literature indicated that, whereas combined HCs carry a certain risk of arterial ischemic events this does not happen for progestogens-only HCs which are considered safe in terms of cardiovascular risk even in the presence of associated risk factors. Considering those data, and unless studies will prove safety of the use of combined HCs in women with migraine, the recommendations from the Consensus Group gave priority to safety and suggested several limitations in the use of combined HCs in women with migraine.
There are alternative methods to combined HCs which provide similar contraceptive benefits but that are much safer in terms of risks. Further research is need to address safety of newer compounds in women with migraine. J Headache Pain ;in press.
Neuropathic pain is pain caused by a lesion or disease of the somatosensory nervous system. The term lesion is refers to nervous system damage demonstrated by imaging, neurophysiology, biopsies or surgical evidence. The term disease is used when the nervous system damage is due to a neurological disorder such as stroke or peripheral diabetes neuropathy.
In peripheral neuropathic pain there is usually a mixture of damaged and undamaged axons within the peripheral nerve, leading to the clinical presentation with ongoing pain, sensory loss and sensory gain hyperalgesia, allodynia. The clinical presentation in central neuropathic pain is similar, but the mechanisms are less well understood. Mechanisms of peripheral neuropathic pain include ectopic impulse generation, peripheral sensitization of undamaged nerve fibers, and central sensitization; the latter includes altered signal processing in the CNS due to changes in descending pain modulation.
For this reason the exact prevalence of neuropathic pain is not yet known, but is expected to be high due to the high prevalence of the underlying neurological disorders. A range of clinical neurophysiological and functional imaging studies have suggested that migraine might be associated with cerebellar dysfunction.
These studies all had methodological short-comings to a greater or lesser extent. Therefore, it is still uncertain whether migraine is associated with cerebellar dysfunction, and, if so, to what extent and why. Recent anatomical studies demonstrated that the output of the cerebellum targets multiple non-motor areas in the prefrontal and posterior parietal cortex. Neuro-anatomy and functions of the cerebellum will be reviewed as well as the evidence of cerebellar infarcts in migraineurs.
During the last decades, the methods of neurophysiology proved to be very effective in disclosing subtle functional abnormalities of the brain of patients affected by primary headache disorders. These methods received several refinements during the last years, further improving our understanding of headaches pathophysiology.
Abnormal increased responsivity was several times revealed with almost all the sensory modalities of stimulation in migraine between attacks, with its normalization during the attacks. Recently, authors observed that the degree of some neurophysiological abnormalities might depends on the distance from the last attack, i.
Somatosensory cortex lateral inhibition, gating, and interhemispheric inhibition were altered in migraine, and may contribute to cortical hyperresponsivity and clinical features.
Cluster headache patients are characterized by a deficient habituation of the brainstem blink reflex during the bout, outside of attacks, on the affected side. Evidence for sensitization of pain processing was disclosed by studying temporal summation threshold of the nociceptive withdrawal reflex, which was less modulated by supraspinal descending inhibitory controls. In conclusion, much has been discovered and much more needs to be investigated to better understand what causes, how it triggers, keeps and runs out recurrent primary headaches.
Clarifying some of these mechanisms might help in the identification of new therapeutic targets. Within the brain, neuropeptides can modulate the strength of synaptic signaling even at a relatively large distance from their site of release. Given the evidence for CGRP in migraine and potential roles for other hypothalamic peptides, it seems likely that altered neuropeptide actions may be a general theme underlying the heightened sensory state of migraine.
Towards this point, I will briefly discuss our preclinical CGRP and optogenetic studies using light aversive behavior in mouse models as a surrogate for migraine-associated photophobia.
I will describe how both the brain and the periphery are susceptible to elevated CGRP and how CGRP appears to act by distinct mechanisms in these sites. These ideas will be tied together in a speculative model that integrates peripheral and central CGRP actions in photophobia. Classical trigeminal neuralgia TN is a unique neuropathic facial pain disorder.
As there are no diagnostic tests to confirm the diagnosis, it relies on a thorough history and exam. MRI is used to exclude symptomatic trigeminal neuralgia, not to confirm the diagnosis of TN. Knowing how to interpret MRI findings is of importance with respect to surgical treatment options and their expected chance of a successful outcome.
TN is characterized by paroxysms of unilateral intense pain usually in the 2 nd and 3 rd trigeminal branch. The pain quality is stabbing and the pain is typically evoked by sensory stimuli like light touch, brushing teeth, cold wind or eating. Up to half of the patients also have concomitant persistent pain. A smaller proportion of patients may have sporadic autonomic symptoms.
The average age of disease onset is in the early fifties and TN is slightly more prevalent in women than in men. As a general rule, the neurological exam is normal in TN patients. As objective signs of TN, patients may wince at pain paroxysms and may avoid shaving or brushing their teeth on the affected side.
Some studies argue that a proportion of TN patients have subtle sensory abnormalities at bedside exam, primarily hypoesthesia. Studies using quantitative sensory testing also documented sensory changes in TN. Rather than indicating nerve damage, the findings may be explained by functional changes of the nervous system in response to severe pain. There is widespread consensus that TN is associated to a neurovascular contact between the trigeminal nerve and a blood vessel in the prepontine course of the nerve.
Emerging advanced imaging studies confirms that at the site of a neurovascular contact on the ipsilateral side of pain, there is of demyelination — a process that seems to be reversible in some patients after successful surgery. Imaging studies also consistently show that TN is strongly associated to a neurovascular contact with morphological changes of the trigeminal nerve, i.
Meanwhile, only half of TN patients have morphological changes of the trigeminal nerve and there may be other unknown etiological factors causing TN. The pearls and pitfalls of TN diagnosis and neuroimaging is discussed from both a clinical and a scientific perspective.
The first evidence for potential role of PACAP in pathomechanism of migraine was the intravenous administration of PACAP caused headache and vasodilatation in healthy subjects as well as in migraineurs, and lead to delayed-type migraine-like attacks [2].
Preclinical experiments revealed that both PACAP and PACAP were found elevated in the trigeminal nucleus caudalis of rats following electrical stimulation of the trigeminal ganglion or chemical stimulation by nitroglycerin of the trigeminovascular system [3]. A magnetic resonance imaging MRI angiographic study demonstrated that PACAPinduced headache was associated with prolonged dilatation of the middle meningeal arteries, but not of the middle cerebral arteries in healthy volunteers [4].
The recent functional imaging study pointed that intravenous PACAPinduced migraine attacks was associated with alterations in brain network connectivity [6]. Clinical investigation provided evidence of a clear association between migraine phases during a spontaneous migraine attack versus pain-free period and the alteration of plasma PACAP level [7].
The activation and sensitization of the trigeminovascular system by vasoactive neuropeptides might be crucial factors of the migraine pathogenesis [8]. The recent preclinical and clinical studies suggest the importance of PACAP as a future biomarker of migraine headache.
Schytz, H. PACAP38 induces migraine-like attacks in patients with migraine without aura. Tuka, B. Peripheral and central alterations of pituitary adenylate cyclase activating polypeptide-like immunoreactivity in the rat in response to activation of the trigeminovascular system. Peptides ; CoreNLP is your one stop shop for natural language processing in Java!
CoreNLP enables users to derive linguistic annotations for text, including token and sentence boundaries, parts of speech, named entities, numeric and time values, dependency and constituency parses, coreference, sentiment, quote attributions, and relations. Polyglot is a natural language pipeline that supports massive multilingual applications such as tokenization, language detection, part of speech tagging and sentiment analysis.
Gensim is a free open-source Python library for representing documents as semantic vectors, as efficiently computer-wise and painlessly human-wise as possible. It is designed to process raw, unstructured digital texts "plain text" using unsupervised machine learning algorithms.
By running nltk. We can get their specific location and we'll find these files in our computers anytime. Text processing is an essential part of performing data analytics or modeling on string data.
Unlike numerical and even categorical variables, text data can't be easily structured in a table format and has its own very unique and rather complex set of rules that it follows. Engaging in text processing allows us to move onto more difficult tasks which are unique to dealing with text.
Text processing is the practice of manipulating text data in order to make it more amenable to analysis and modeling. There are a whole host of powerful libraries dedicated to this, including:. Cleaning the tweets before going though any other text manipulation is helpful.
For these first steps we will use some of the methods that the module String has. To learn more about the String methods click here. Python string method find determines if string str occurs in string, or in a substring of string if starting index beg and ending index end are given. We will search for all the tweets that contain "http". Once we've identified them, we will remove the URL's. Given that we are aiming to perform a Sentiment Analysis, we don't want to remove the negative stopwords because it could impact our detection of any negative sentiment.
Before removing the stop words from our tweets, let's review what is Tokenization. We read each word, interpret its meaning, and read the next word until we find an end point. This is the reason why tokenization exists. If we want to create a model, the model might need all the words that make up the sentence separately. If instead on a sentence we have a paragraph, then we need to get all the sentences and out of all these sentences, we need to get the words.
At that point we can move forward to perform any kind of prediction. What is Tokenization? String tokenization is a process where a string is broken into several parts or tokens. NLTK has different tokenize methods that can be applied to strings according to the desire output. To serve our purpose, we would like to keep some combination of characters as they can reference emojis and therefore, they can reference emotions.
The Collections module implements high-performance container datatypes beyond the built-in types list, dict and tuple and contains many useful data structures that you can use to store information in memory.
Stemming is the process of removing prefixes and suffixes from words so that they are reduced to simpler forms which are called stems. In lemmatization, the speech part of a word must be determined first and the normalization rules will be different for different parts of the speech, whereas, the stemmer operates on a single word without knowledge of the context, and therefore cannot discriminate between words that have different meanings depending on part of the speech.
A "tag" is a case-sensitive string that specifies some property of a token, such as its part of speech. Tagged tokens are encoded as tuples tag, token. This model allows us to extract features from the text by converting the text into a matrix of occurrence of words.
We will take our tweets that have been already processed, and the sentiment 1: Positive, 0: Negative. Then, we will proceed to create a list with the tweets and finally we will be able to use Countvectorizer. Countvectorizer is a method to convert text to numerical data: It converts a collection of text documents to a matrix of token counts. TF-IDF allows for a simple mathematical way of defining word "importance". This allows for a smarter document vector.
Term frequency—inverse document frequency, is a numerical statistic that is intended to reflect how important a word is to a document in a collection or corpus.
Inverse document frequency: This downscales words that appear a lot across documents in a given corpus and that are hence empirically less informative than features that occur in a small fraction of the training corpus.
Human language is astoundingly perplexing and diverse. NLP is an approach that helps us improve our communication and influence skills at a time these are becoming even more important. Even though computing systems enable fast and highly accurate communication channels, machines have never been good at understanding how and why we communicate in the first place.
What is NLP? NLP is a branch of artificial intelligence that allows computers to interpret, analyze and manipulate human language. NLP is about developing applications and services that can understand human languages. Alan Turing was part of this team.
Part-of-speech tagging Named Entity Recognition NER Question answering Speech recognition Text-to-speech and speech-to-text Topic modeling Sentiment classification Language modeling Translation Information retrieval: Web searching algorithms that use keyword matching. Any examples? Maybe Google? Target Ads: Recommendations based on key words from social media. Have you search for shoes, laptops, flowers? Later you'll see some adds based on all those searchs.
Text Summarization: Algorithms that allow getting a summary out of a text. Sentiment Analysis: Analysis done to reviews or posts from apps like Twitter, Yelp, Airbnb, Google reviews, etc, to understand human's feelings and emotions.
Which libraries can we use? It provides easy-to-use interfaces to over 50 corpora and lexical resources such as WordNet, along with a suite of text processing libraries for classification, tokenization, stemming, tagging, parsing, and semantic reasoning, wrappers for industrial-strength NLP libraries, and an active discussion forum. NLTK has been called "a wonderful tool for teaching, and working in, computational linguistics using Python," and "an amazing library to play with natural language.
Getting the data we're going to use ready. In [1]:. Libraries to help with reading and manipulating data import numpy as np import pandas as pd libraries for visualizations import seaborn as sns import matplotlib. In [2]:. You'll need to install NLTK if you don't have it already!
In [3]:. Let's use the NLTK library import nltk from nltk. Where are the files that we're downloading? In [4]:. In [5]:. In [6]:. In [7]:. We can divide apply the string to both files with the objective of converting them into a lists. In [8]:. In [9]:. Checking tweets in the position 6 from both lists. In [10]:. In [11]:. Since we've checked that we have now two lists, we can get the amount of positive and negative tweets that we have available for our analysis. In [12]:.
Positive tweets: Negative tweets: In [13]:. In [14]:. We will merge the positive and negative tweets into one dataset to handle the data in a better and simpler way. We'll add tags for each kind of tweet.
Positive tweets: pos and negative tweets: neg. Steps: Create a new column to identify both, positive and negative tweets. Call this new column sentiment. Do this for both DataFrames. In [15]:. How do the positive tweets look like? In [16]:. How do the negative tweets look like? In [17]:. Merging the DataFrames to have both, positive and negative tweets in one DataFrame. In [18]:.
In [19]:. Adding the negative tweets to our new DataFrame "tweets". In [20]:. In [21]:. Let's visualize and verify that our data is consistent. In [22]:. Engaging in text processing allows us to move onto more difficult tasks which are unique to dealing with text What is text processing? There are a whole host of powerful libraries dedicated to this, including: string and str. For an easier text manipulation we will convert any string to lowercase.
We will remove special characters and any strings that are not going to be needed for further analysis. String module Cleaning the tweets before going though any other text manipulation is helpful. In [23]:. Before we start, let's create a copy of our data so we can compare all the changes later.
Converting any uppercase string to lowercase. In [24]:. In [25]:. In [26]:. Reviewing the tweets that include URL's. In [27]:. Looking at the datapoint with index 0 to confirm that it has an URL.
Removing URL's from tweets. In [28]:. In [29]:.
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