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Introduction: Tension-type headache (TTH) is a common neurological disorder characterized by bilateral head pain and muscle tension, affecting up to 78% of the population. Despite its prevalence, TTH has historically received less attention than migraines. However, recent years have seen increased interest in understanding its pathophysiology and treatment options. This review comprehensively analyzes TTH management, covering non-pharmacological and pharmacological approaches to guide clinical practice and future research effectively. State of Knowledge: TTHs manifest as bilateral, pressing, encircling head pain, profoundly affecting individuals' quality of life. Recent years have witnessed increased interest in TTH understanding and treatment. Non-pharmacological interventions, including behavioral modifications, exercise, dietary adjustments, sleep hygiene, physical therapy, psychotherapy, and pharmacological treatments like over-the-counter medications, prophylactic drugs, psychedelics, and botulinum toxin A, have shown promise in alleviating symptoms. Conclusion: This review highlights the multifaceted management of TTH. Non-pharmacological interventions, including behavioral modifications and psychotherapy, offer symptom relief. Body awareness therapy, exercise, and psychotherapy benefit TTH symptoms and quality of life. Paracetamol, ibuprofen, and amitriptyline are standard treatments, with emerging options like psychedelics and botulinum toxin A. Personalizing treatment and understanding TTH mechanisms pose challenges. A multidisciplinary approach is essential for enhancing management and outcomes. More research is required to identify optimal treatments and long-term efficacy. Despite challenges, progress in TTH management brings hope for better patient care.

Resumen: Introducción: La trombosis venosa cerebral (TVC) es una causa poco común de ictus que afecta principalmente a adultos jóvenes. Un diagnóstico precoz y preciso puede reducir la tasa y gravedad de las complicaciones. Objetivo: Analizar las características clínicas, manejo y tratamiento de la TVC en diferentes centros de nuestro país. Métodos: Estudio descriptivo retrospectivo multicéntrico de pacientes hospitalizados por TVC entre 2008 y 2017 en 11 centros sanitarios en nuestro país. Resultados: Se incluyeron 256 pacientes, edad media 49,8 ± 18,7 años y el 51% fueron mujeres. Los síntomas más frecuentes fueron: cefalea (73%), déficits focales (50%), crisis epilépticas (33%) y encefalopatía (21%). Las localizaciones más frecuentes fueron: seno longitudinal superior (12,5%), transverso (10,9%) y afectación de dos o más senos o venas (66,4%). La etiología conocida más frecuente fue la trombofilia (24%), siendo la mutación de la protrombina G20210A la más común (19%). El 46% fue tratado con antitrombóticos durante 3-6 meses, el 21% durante un año y un 22,6% de los pacientes requirieron anticoagulación indefinida. En un 5% de los sujetos fue preciso terapia endovascular y un 33% requirió neurocirugía. En relación al pronóstico, el 75% fueron independientes a los 3 meses con una puntuación en la escala de Rankin modificada (mRS) ≤ 2 y la presencia de papiledema (p = 0,03), déficit focal (p = 0,001) y encefalopatía (p 3). La tasa de mortalidad intrahospitalaria fue del 4,3% y el 6,3% de los pacientes fallecieron a los 3 meses. Conclusión: La diversidad de factores de riesgo y la presentación variable suponen un desafío en el diagnóstico y tratamiento de la TVC. Para mejorar el pronóstico y reducir la mortalidad es fundamental la instauración de protocolos en el manejo de esta patología. Abstract: Introduction: Cerebral venous thrombosis (CVT) is an uncommon cause of stroke that mainly affects young adults. Early, accurate diagnosis can reduce the rate and severity of complications. Objective: The aim of this study was to analyse the clinical characteristics, management, and treatment of CVT in different centres in Spain. Methods: We conducted a multicentre, retrospective, descriptive study of patients hospitalised due to CVT between 2008 and 2017 at 11 Spanish centres. Results: We included 256 patients, with a mean age (SD) of 49.8 (18.7) years; 51% of patients were women. The most frequent symptoms were headache (73%), focal deficits (50%), epileptic seizures (33%), and encephalopathy (21%). The most frequent localisations were the superior sagittal sinus (12.5%), the transverse sinus (10.9%), and 2 or more sinuses or veins (66.4%). Thrombophilia was the most frequent known aetiology (24%), and was most commonly associated with the prothrombin G20210A mutation (19%). Forty-six percent of patients were treated with antithrombotics for 3-6 months, 21% for one year, and 22.6% required indefinite anticoagulation. Endovascular therapy was performed in 5% of cases, and 33% required neurosurgery. Regarding outcomes, 75% of patients were independent at 3 months (modified Rankin Scale [mRS] score ≤ 2), with papilloedema (P = .03), focal deficits (P = .001), and encephalopathy (P 3). The in-hospital mortality rate was 4.3%, with a 3-month mortality rate of 6.3%. Conclusion: The diverse risk factors and variable presentation of CVT represent a challenge in the diagnosis and treatment of this condition. To improve prognosis and reduce mortality, it is essential to establish management protocols for this entity.

Introduction Tension-type headaches (TTH) are a significant health concern that demands precise diagnostic approaches and effective management strategies. A nuanced understanding of their pathophysiology and diagnostic challenges is not just pivotal, but a responsibility we share, for enhancing patient care. Aim This article aims to explore the complex realm of TTH diagnosis and management, underlining the need for precision in diagnostics and the intricate balance of cost-effectiveness. It also delves into the diverse therapeutic options available for treating TTH, presenting a stimulating challenge for healthcare professionals, researchers, and medical students. State of Knowledge Initial diagnosis involves excluding secondary headaches by identifying red flags indicative of serious underlying conditions. A detailed medical history, complemented by patient-recorded pain diaries, enhances diagnostic accuracy. Ancillary procedures like neuroimaging, despite cost-effectiveness debates, are often preferred by clinicians to mitigate diagnostic risks. Validated tools such as the MIDAS and HIT-6 questionnaires provide valuable insights into headache-related disability. Differential diagnosis among headache types relies on recognizing distinctive clinical features. Summary (Conclusions) Effectively managing TTH necessitates a multifaceted approach, incorporating pharmacological, non-pharmacological, and lifestyle interventions tailored to individual patient needs. Collaborative efforts spanning legal, technological, and research domains are crucial for advancing headache diagnostics and therapeutics. While technological advancements offer promise, interdisciplinary collaboration remains fundamental in optimizing patient care outcomes.

Objective: To develop and validate the content of an auricular acupuncture point protocol for the treatment of headaches. Method: A methodological study, carried out in June 2023 in Montes Claros, Minas Gerais, Brazil. It was structured in three stages: Planning (bibliographic survey and identification of the study variables); Construction of the instruments (characterization of the experts, point protocol and treatment regime); and Content validation in charge of 15 experts. In the data analysis, an absolute agreement percentage equal to or greater than 80% was used. Results: The auricular acupuncture protocol for the treatment of headaches that was validated by experts consisted of the following points: “Door of the Mind” (93.3%), Kidney (86.7%), Sympathetic (86.7%), Anxiety (86.7%), Subcortex (86.7%), Brainstem (86.7%), Frontal (86.7%), Occipital (86.7%), Temporal (86.7%) and Liver (80%). Conclusion: the auricular acupuncture protocol for the treatment of headaches was considered valid, which will allow its use in the clinical practice and research studies.

Introduction: Migraine remains one of the most prevalent chronic neurological conditions that significantly impacts the quality of life. The treatment aims to help with the symptoms and prevent further attacks. There are several pharmacological methods, but because of their side effects, sometimes lower-than-expected effectiveness, costs, and long-term dependency, non-pharmacological approaches have gained popularity. Review methods: We conducted our study as a literature review, with data gathered via PubMed and Embase. The state of knowledge: Managing migraine is hard to achieve based only on pharmacological therapy. Recently, the development of alternative approaches, such as cognitive behavioral therapy, acupuncture, or butterbur, has been observed. Many studies try to assess its effectiveness. Biofeedback is a promising treatment method, however, it is expensive and requires special equipment. Aerobic training is essential in the prevention and therapy of many illnesses and proper intensity can be helpful with migraines, while yoga is a great lower-intensity option. Conclusions: Alternative methods may be a great alternative or support in migraine management. However, there is still a need for standardized investigations to evaluate effectiveness and safety.

El síndrome de vasoconstricción cerebral reversible es poco frecuente y su fisiopatología aún no está bien dilucidada. Su presentación clínica se caracteriza por manifestaciones neurológicas como cefalea “en trueno”, déficit focal, vómito, fotofobia y, en casos graves, puede tener complicaciones como eventos cerebrovasculares isquémicos o hemorrágicos. El diagnóstico se realiza mediante angiografía cerebral, angiotomografía o angioresonancia, las cuales documentan vasoconstricción de las arterias cerebrales con resolución espontánea, que en la mayoría de los casos es consistente con un buen pronóstico clínico. A continuación, se expone el caso de una paciente con vasoconstricción cerebral reversible y lesión miocárdica asociada, en donde se logra un diagnóstico mediante imágenes y tratamiento oportuno. La importancia del caso radica en informar sobre el reconocimiento temprano de una complicación miocárdica poco común del síndrome de vasoconstricción cerebral, pero con riesgo de morbimortalidad dentro del espectro de los cuadros cerebrovasculares.

Resumen: Introducción: La fotofobia es un síntoma de intolerancia anómala a la luz sin sensación de dolor que requiere de una anamnesis y una exploración para el diagnóstico de una etiología subyacente. Procedimiento básico: El presente artículo se centra en 30 casos clínicos con fotofobia intensa aislada y su revisión de la bibliografía. Objetivo: El objetivo consiste en establecer unos criterios diagnósticos de la fotofobia. Resultados: La etiología de la fotofobia parece encontrarse a nivel de las células ganglionares de la retina intrínsecamente fotosensibles, conocidas como las células de la melanopsina, y a un nivel neuroquímico mediado por el péptido relacionado con la calcitonina y el péptido pituitario activador de la ciclasa. Conclusión: El tratamiento de la fotofobia podría consistir en anticuerpos monoclonales contra los péptidos relacionados con la calcitonina y/o el péptido pituitario activador de la ciclasa. Abstract: Introduction: Photophobia is a symptom of abnormal light intolerance without pain sensation that requires an anamnesis and an examination to diagnose an underlying etiology. Basic procedure: This article focuses on 30 clinical cases with isolated intense photophobia and on the review of the literature. Objective: The purpose of this article is to establish diagnostic criteria for photophobia. Results: The etiology of photophobia appears to be at the level of the intrinsically photosensitive retinal ganglion cells known as melanopsin cells and at a neurochemical level mediated by calcitonin-related peptide and the pituitary activating peptide cyclase. Conclusion: The treatment of photophobia could consist of monoclonal antibodies against calcitonin-related peptide and/or pituitary activating peptide cyclase.

Introduction: In today's fast-paced life, an increasing number of people are experiencing chronic stress, which negatively impacts our mental and physical health, leading to troublesome conditions such as primary headaches. Faced with this challenge, more individuals are turning their attention to mindfulness techniques as an effective tool for stress management. In light of this, mindfulness, focusing on the awareness of the present moment, emerges as a promising method for preventing and alleviating stress-induced headaches and the resulting aftermath. Purpose: Offer a comprehensive overview of the current understanding of the efficacy of mindfulness training, particularly Mindfulness-Based Stress Reduction (MBSR), in the prevention and relief of primary headaches and their associated consequences. Description of the state of knowledge: MBSR demonstrates the potential for effectively coping with stress-induced headaches and their subsequent effects, including disability related to headaches. This category of pain includes conditions like migraine and tension-type headaches. In the clinical trials conducted thus far participants in the MBSR program show noticeable improvement in headache-related disability, self-efficacy, quality of life, catastrophic pain, and depression scores. Summary: Studies suggest that integrating mindfulness training could present a promising strategy for preventing and reducing the severity of primary headaches and their consequences, by mitigating stress, a crucial factor influencing the onset of these headaches. To validate these promising findings, further randomized, large-scale, placebo-controlled studies are required.

Chronic migraine is a disease that significantly reduces the quality of life of patients. It affects millions of people around the world, and is common particularly among young women. Family physicians often encounter the problem of migraine headaches in their daily practice. The diagnostic problem results from absence of tests or imaging studies that can clearly indicate the cause of the headache. In order to establish a diagnosis and exclude secondary sources of pain, doctors focus on a detailed medical history and analysis of symptoms presented over time. Preventive treatment of migraine requires appropriate drug selection after weighing the benefits and risks for each patient. This review paper presents and briefly discusses selected pharmacological and non-pharmacological methods used in migraine prevention. They were selected by searching the PubMed Internet database. The presented non-pharmacological methods include the use of nutraceutics, acupuncture and behavioral therapy. The discussed pharmacological methods include treatment with beta-blockers, topimarate, flunarizine or one of the latest methods - the use of monoclonal antibodies against CGRP. In addition, the use of botulinum toxin type A in the treatment of chronic migraine has also been demonstrated. It should be remembered that the type of therapy chosen should be individualized: according to the patient's preferences, treatment effectiveness, possible side effects or accompanying diseases. Proper management of chronic migraine prophylaxis can significantly improve the quality of life of patients and reduce the frequency of headache attacks.

Introduction. Brain tumours constitute approximately 1% of all newly diagnosed cancers. Their manifestation typically involves headache, neurological impairment, focal onset seizures and syndromes related to tumour location. Severe headache presents as a prevailing symptom and occurs in over 50% of patients. Brain tumour associated headache exerts significant effect on quality of life in cancer patients. The following article aims to provide a comprehensive overview of most common and promising brain tumour related headache treatment strategies. State of knowledge. Headache in brain tumour patients arises from traction or displacement of intracranial pain-sensitive structures, such as vascular tissue, dura mater or periosteum. This can be caused by tumour’s mass itself, by tumour associated oedema or as a sequela of anti-tumour treatment. Most common therapeutic modalities include tumour surgical resection, cerebral oedema management, radiotherapeutic interventions and administration of analgesic agents. Complete removal of the tumour stands as the most effective approach, often bringing substantial alleviation in majority of cases. Conclusion. Headache affects the majority of individuals afflicted by brain tumours. Not all patients are suitable candidates for the resection of the underlying neoplasm. In such instances, the application of alternative approaches might be beneficial. Ongoing and future investigations may enhance the development of novel treatment strategies, possibly influencing the well-being of cancer patients, especially within palliative care area.

Migraine is one of the leading causes of disability in humans. It causes significant deterioration in patients' lives and prevents daily functioning. Its main symptoms include photophobia, an enormous stabbing headache, nausea and vomiting. In addition, it can be accompanied by tinnitus, visual disturbances or dizziness. Before diagnosing migraine, serious intracranial pathology or other neurological conditions should be ruled out. Treatment of acute migraine is difficult due to significant rates of nonresponse to medications and the difficulty in predicting individual response to a particular agent or dose. A new class of drugs, calcitonin gene-related peptide (CGRP) antagonists, has been approved for the prevention of migraine in adults. In contrast, effective first-line therapies for mild to moderate migraine are over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) and combination analgesics containing paracetamol, aspirin and caffeine.

Resumen: Introducción: La cefalea es muy frecuente entre la población general y un motivo habitual de consulta médica. Objetivos: Describir las características clínicas de los pacientes que acuden a urgencias por cefalea. Métodos: Estudio descriptivo con recogida prospectiva de pacientes consecutivos mayores de 15 años que acuden al Servicio de Urgencias del Hospital Universitario Marqués de Valdecilla por cefalea como motivo principal de consulta. Resultados: Se recogieron 100 pacientes. La cefalea como motivo de consulta supuso el 1,4% de las urgencias atendidas. El grupo mayoritario fue el de edades comprendidas entre los 31 y 45 años, con predominio de mujeres (61%). Se diagnosticaron 67 cefaleas primarias y 33 secundarias. El diagnóstico más frecuente fue el de migraña, con un 36% del total de cefaleas. Uno de cada 3 pacientes tenía antecedentes de cefalea y 4 de cada 5 acudieron a urgencias por decisión propia. Solo un pequeño porcentaje de los pacientes atendidos en urgencias llegaron a ingresar (12%), y 3 de cada 5 fueron derivados a atención primaria. Se realizaron pruebas complementarias al 84% de los pacientes atendidos. Se realizó un TAC craneal por cada 3 pacientes. Un 80% de los pacientes fueron correctamente diagnosticados por los médicos de urgencias. Conclusiones: La cefalea es un motivo frecuente de consulta en los servicios de urgencias, siendo más habituales las cefaleas primarias, y dentro de estas, la migraña. En nuestro medio se realiza un buen cribado y diagnóstico de las cefaleas, así como un adecuado uso de los recursos disponibles en urgencias para su diagnóstico y manejo. Abstract: Introduction: Headache is common in the general population and a frequent reason for medical consultation. Objectives: To describe the characteristics of patients attending the Emergency Department (ED) for headache. Methods: A descriptive study with prospective collection of 100 consecutive patients over 15 years old who attended our ED due to headache as the main complaint. Results: Headache accounted for 1,4% of ED visits. The most common age range is between 31 and 45 years and the majority of the patients are females (61%). We diagnosed 67 primary and 33 secondary headaches. The most frequent diagnosis was migraine, with 36% of cases. One out of 3 patients had a history of headache and 4 out of 5 consulted by their own decision. Only a small percentage of patients were admitted as inpatients (12%), and 3 out of 5 were referred to Primary Care. Complementary tests were performed on 84% of the patients. One CT scan was performed for every 3 patients. A total of 80% patients was correctly diagnosed by the ED physicians. Conclusions: Headache is a frequent complaint in the ED, where primary headaches are the most common with migraine being the most frequent reason for consultation. In our setting, there is a good screening and diagnosis of headaches, as well as an adequate use of the available resources in the ED for their diagnosis and management.

Resumen: Introducción y objetivo: La cefalea representa un motivo de consulta frecuente entre los médicos de atención primaria, urgencias y especialistas en Neurología, que no siempre es bien manejada. El Grupo de Cefaleas de la Sociedad Andaluza de Neurología (SANCE) se plantea conocer su manejo entre los distintos niveles asistenciales. Material y métodos: Estudio descriptivo transversal realizado mediante una encuesta retrospectiva en julio de 2019. Los participantes completaron una serie de cuestionarios estructurados recogiéndose distintas variables socio-laborales en cuatro grupos sanitarios distintos (Atención Primaria, Servicios de Urgencias, Neurología General, Unidades de Cefalea). Resultados: Se llevaron a cabo un total de 204 entrevistas repartidas entre los distintos grupos profesionales: 35 médicos de urgencias, 113 de atención primaria, 37 neurólogos generales y 19 neurólogos especialistas en cefaleas. El 85% de los médicos de AP prescribe fármacos preventivos, que mantiene durante al menos seis meses (59%), siendo flunarizina y amitriptilina los más utilizados. La atención primaria representa la vía principal de llegada a las consultas de Neurología General (65%), siendo los cambios en el patrón de la cefalea el principal motivo de derivación (74%). Todos los niveles asistenciales incluidos en el trabajo muestran gran interés en la cefalea y en la posibilidad de asistir a cursos de formación (97% AP, 100% médicos de urgencias, 100% neurólogos generales). Conclusiones: El presente trabajo ha observado escasez de recursos reflejado por prolongadas listas de esperas, así como gran interés en las cefaleas por parte de los participantes. Es necesario buscar otras formas de comunicación bilateral entre los distintos ámbitos asistenciales, como por ejemplo el correo electrónico. Abstract: Introduction and objective: Headache is a frequent reason for consultation between primary care physicians, emergency services physicians, and neurology specialists; however, it is not always well managed. The Andalusian Society of Neurology's Headache Study Group (SANCE) aimed to analyse headache management at different levels of care. Material and methods: We conducted a descriptive cross-sectional study with data gathered through a retrospective survey in July 2019. Participants completed a series of structured questionnaires on different social and work-related variables from 4 different groups of healthcare professionals (primary care [PC], emergency departments, neurology departments, headache units). Results: A total of 204 healthcare professionals completed the survey: 35 emergency department physicians, 113 PC physicians, 37 general neurologists, and 19 neurologists specialising in headache. Eighty-five percent of PC physicians reported prescribing preventive drugs, which were maintained for at least 6 months (59%), with flunarizine and amitriptyline being the most commonly used. Most patients attended at neurology consultations (65%) are referred by PC physicians, with changes in the headache pattern being the main reason for referral (74%). Healthcare professionals across all levels of care showed great interest in headache and in receiving training in headache management (97% of PC physicians, 100% of emergency services physicians, 100% of general neurologists). Conclusions: Migraine sparks great interest among healthcare professionals from different levels of care. Our results also reveal a lack of resources for headache management, which is reflected in the long waiting times. Other means of bilateral communication between different levels of care should be explored (e.g., e-mail).

Resumen: Introducción: La migraña afecta a más de 4,5 millones de personas en España con el consiguiente impacto socioeconómico. A pesar de la existencia de guías nacionales e internacionales, el manejo del paciente migrañoso, especialmente con migraña crónica, es inadecuado. Sujetos y métodos: Se llevó a cabo una encuesta a 40 médicos de Atención Primaria (AP) de España dentro de un proyecto europeo que involucraba a 201 médicos de 5 países. Resultados: La mayoría de los participantes diagnostican migraña episódica y migraña crónica (93% vs. 65%). El 82,5% indicó que no derivaba a los pacientes al especialista y en el 100% de casos los médicos de AP declararon ser los encargados del seguimiento del paciente. Las principales herramientas usadas en AP para el diagnóstico y seguimiento son la entrevista clínica, la guía de anamnesis y el diario del paciente. Se observó que los tratamientos prescritos no están en concordancia con las guías nacionales ni internacionales. Los participantes que no derivan al paciente estiman que solo el 48% recibe tratamiento preventivo y que la valoración de la eficacia se hace mediante la percepción del paciente. El 70% indica una necesidad de formación en migraña. Finalmente, el 100% de los participantes consideran que una guía para la anamnesis y la derivación sería imprescindible o de utilidad para el manejo de la migraña en AP. Conclusiones: Los resultados de la encuesta muestran que hay una necesidad de formación y guía en AP para mejorar el diagnóstico y manejo del paciente con migraña, especialmente con migraña crónica. Abstract: Introduction: Migraine affects more than 4.5 million people in Spain, resulting in a considerable socioeconomic impact. Although national and international guidelines have been published, the management of patients with migraine, especially those with chronic migraine, is inadequate. Subjects and methods: We conducted a survey among 40 primary care (PC) physicians in Spain as part of a European project involving 201 physicians from 5 countries. Results: Most participants issued diagnoses of episodic migraine and chronic migraine (93% vs 65%); 82.5% indicated that they did not refer these patients to specialists, and 100% of PC physicians stated that they were responsible for patient follow-up. The main tools used in PC for diagnosis and follow-up were clinical interviews, medical histories, and the patient diaries. Our data revealed that the treatments prescribed were not in accordance with the national and international guidelines. Participants who did not refer patients estimated that only 48% of patients received preventive treatment, and that the assessment of efficacy was based on patient perception. Seventy percent of respondents indicated a need for migraine training. Finally, 100% of participants considered that a guide for medical history taking and referral would be essential or useful for the management of migraine in PC. Conclusions: The survey results revealed a need for training and guidance in PC to improve the diagnosis and management of patients with migraine, particularly chronic migraine.

Resumen: Introducción: La neurofibromatosis tipo 1 (NF1) es un desorden progresivo multisistémico de herencia autosómica dominante que presenta numerosas manifestaciones neurológicas. Métodos: Revisión de historias clínicas de pacientes afectos de NF1 controlados en una Unidad de Neuropediatría de mayo de 1990 a 31 de diciembre de 2018 y sus manifestaciones neurológicas asociadas. Resultados: Se revisaron 128 pacientes afectos de NF1. Edad media al diagnóstico de NF1, 4,43 años ± 3,38 SDS (rango 6 meses-14,5 años) con discreto predominio femenino (53,1%). Se asocia macrocefalia (PC> 2SDS) en el 37,5% de los casos. TDAH en el 28,9% de los casos (37), subtipo combinado 20, inatento 15 casos y predominantemente hiperactivo 2 casos. Otras manifestaciones incluyen; cefalea (18,7%), déficit cognitivo (7,8%), afectación motora (6,2%) y epilepsia (4,68%). Se realizó RM cerebral a 85 pacientes, mostrando 60 (70,5%) hiperseñales en T2 en ganglios basales y/o cerebelo, junto con otras alteraciones como Chiari I (4 casos) y quistes aracnoideos (3 casos). Se identificaron gliomas de nervio óptico en 22 casos (25,8%). Otros hallazgos diagnosticados por RM incluyen neurofibromas plexiformes (9,3%) y otros gliomas localizados en sistema nervioso central (3,1%). Conclusiones: Las manifestaciones neurológicas encontradas concuerdan con lo recogido en la literatura. El seguimiento de estos pacientes se pierde en la edad adulta, siendo necesario establecer adecuadas estrategias de transferencia y posterior seguimiento de pacientes a los servicios de adultos. Abstract: Introduction: Neurofibromatosis type 1 (NF1) is a progressive multisystem disorder following an autosomal dominant inheritance pattern that presents with multiple neurological manifestations. Methods: We reviewed medical histories of patients with NF1 followed up at our hospital's paediatric neurology department from May 1990 to 31 December 2018. We collected data on neurological symptoms. Results: A total of 128 patients with NF1 were identified. Mean age (SD) at NF1 diagnosis was 4.43 (3.38) years (range, 0.5-14.5 years). There was a slight female predominance (53.1%). Macrocephaly (head circumference over 2 SDs above average for age) was present in 37.5% of cases. Attention-deficit/hyperactivity disorder was recorded in 28.9% of patients (37): combined type in 20 patients, predominantly inattentive in 15, and predominantly impulsive/hyperactive in 2. Other manifestations included headache (18.6%), cognitive impairment (7.8%), motor deficit (6.2%), and epilepsy (4.68%). Brain MRI was performed in 85 patients, revealing T2-weighted hyperintensities in the basal ganglia and/or cerebellum in 60 patients (70.5%), Chiari malformation type 1 in 4 cases, and arachnoid cysts in 3. Optic nerve gliomas were identified by MRI in 22 patients (25.8%). Other MRI findings included plexiform neurofibromas (9.3%) and central nervous system gliomas (3.1%). Conclusions: The neurological manifestations identified in our sample are consistent with those reported in the literature. Effective transfer strategies from paediatric neurology departments and subsequent clinical follow-up by adult neurology departments are needed to prevent loss to follow-up in adulthood.

Resumen: Introducción: La cefalea es un motivo de consulta frecuente en atención primaria (AP), sin embargo, se trata de una patología infradiagnosticada e infratratada. Uno de los posibles factores es la falta de formación de los profesionales de AP en cefaleas. Métodos: Estudio descriptivo transversal mediante encuesta autoadministrada a los médicos de AP de nuestro sector sanitario. Se recogieron variables sociodemográficas, variables relacionadas con la formación previa en neurología y cefaleas y variables en relación con sus necesidades formativas. Resultados: Completaron la encuesta 104 médicos de AP, de los cuales el 53% fueron mujeres y la edad media fue 49 años. La mayoría de los encuestados trabajan en un centro de salud urbano (42,3%) y se han formado vía MIR (77,9%). El 65,4% dedica más tiempo a una consulta de cefaleas que a otras consultas y solo un 32,7% utiliza la Clasificación Internacional de Cefaleas. El 68,3% declara tener un interés alto o muy alto en cefaleas y al 75,9% le gustaría mejorar su formación, eligiendo cursos teórico-prácticos y ponencias de actualización como la herramienta más útil. Un 90% utiliza triptanes en su práctica clínica diaria y el 78% emplea tratamientos preventivos. El fármaco más utilizado es amitriptilina y solo un 22,1% elige topiramato. Conclusiones: Los profesionales de AP están en contacto constante con pacientes con cefaleas y muestran interés en la formación en esta patología, lo que podría ayudarnos a diseñar programas docentes dirigidos a mejorar la calidad asistencial en este ámbito. Abstract: Introduction: Headache is a frequent reason for consultation with primary care (PC) physicians. However, the condition is underdiagnosed and undertreated. One reason for this may be the lack of specific training on headache in PC. Methods: We conducted a descriptive cross-sectional study of data gathered with a self-administered survey that was completed by PC physicians from our health district. We collected sociodemographic data and information on previous training in neurology and headache, and training needs. Results: The survey was completed by 104 PC physicians, 53% of whom were women; mean age was 49 years. Most respondents worked in urban settings (42.3%) and had been trained via residency (77.9%). Although 65.4% spent more time with patients with headache than with other patients, only 32.7% used the International Classification of Headache Disorders. In our sample, 68.3% of respondents reported a high or very high interest in headache, and 75.9% wished to receive further training on the condition; theoretical and practical courses and update lectures were regarded as the most useful tools. In clinical practice, 90% used triptans and 78% used preventive treatments. The most frequently used drug was amitriptyline; only 22.1% choose topiramate. Conclusions: PC physicians are in frequent contact with patients with headache and show interest in receiving training on this condition. This could be helpful in designing training programmes aimed at improving quality of care in this area.

Antiphospholipid syndrome (APS) is an entity defined for the presence of antiphospholipid antibodies and events such as recurrent fetal loss and arterial or ve-nous thrombosis. APS diagnosis is made through clas-sification criteria, including laboratory criteria and clinical manifestations (most of them being throm-botic manifestations). Nonetheless, there is a wide variety of non-thrombotic manifestations of APS, which are not included in classification criteria. These “non-criteria” manifestations are important for decision making, based on their frequency or clinical relevan-ce. Among them, some domains stand out: the hematologic domain, being thrombocytopenia the main manifestation; and the neurological domain with different manifestations such as migraine, epilepsy, dementia and severe manifestations, such as chorea and myelitis. Therefore, in the present article, information concerning two of the most common “noncriteria” domains (neurological and hematological) of APS is reviewed.

Se describe el caso de un paciente de 70 años que consultó por cefalea súbita, tipo trueno, sin alteración del estado de consciencia, acompañada de dolor torácico de una hora de evolución y de baja intensidad. A su ingreso fue enfocado como cefalea en trueno, que es clasificada, en cuanto a la atención, como bandera roja. La medición de troponina fue negativa y una tomografía de cráneo fue leída como normal. Desde el ingreso presentaba signos vitales normales, cuando iba a ser dado de alta se torna hipotenso (completamente asintomático) y por su síntoma cardinal (cefalea), que se asoció a dolor torácico leve y no anginoso, se solicitó angiotomografía toracoabdominal, con la que se demostró aneurisma disecante de la aorta. Con la presentación de este caso, se busca resaltar la importancia en el servicio de urgencias de la asociación de la cefalea tipo trueno, con condiciones vasculares como la disección aórtica.

Introduction Nowadays it is pointed out how important it is to take care of both mental and physical health. It is also undeniable that one affects the other and vice versa. That is why it is so important to nurture your body. Yoga as one of the physical activities has a proven effect on psychosomatic symptoms. Yoga is increasingly recommended mainly to relieve anxiety or stress. It brings great solace and even greater attentiveness. Lifestyle activities are increasingly considered an important component of treatment. State of knowledge Medical conditions such as dementia, Parkinson's disease, headaches, PTSD, depression are mainly treated with drugs. Yoga, as a non-pharmacological treatment, alleviates psychological conditions, as it reduces stress, anxiety, depressive symptoms, and enhances attentiveness to one's self, self-control and a different perspective on traumatic situations. Conclusions A review of the following works has shown the effects of yoga on mental health and common neurological conditions. With regular practice, it is possible to develop cognitive function, reduce the intensity and frequency of headaches. In Parkinson's disease, mindfulness exercises lead to an increase in muscle strength, a decrease in muscle tremors, and therefore improved rehabilitation. Most of the examples below mention a decrease in anxiety, stress, depressive symptoms and an increase in mindfulness, greater emotional and physical flexibility. The works cited point out that more in-depth research is needed to delve deeper into the effects of yoga on health.

Cerebral venous sinus thrombosis is infrequent in the pediatric population and its clinical manifestations may vary depending on the anatomical location and the extent of the lesion, etiology or age group(1). The association of this pathology with viruses is uncommon, however, cases in adults with SARS-Cov2 have been reported triggered by procoagulant mechanisms due to endothelial injury and inflammatory response.The following article is the first reported case in Colombia of cerebral venous thrombosis in a previously healthy child, who debuted with gastrointestinal infectious disease and a week later with headache and sixth right cranial nerve palsy . The diagnosis of sagittal venous sinus thrombosis with extension to transverse sinuses was documented in a computed tomography angiography; laboratories for systemic diseases were negative and antibodies for coronavirus were positive.

Resumen: En el presente artículo, en base a una revisión de la literatura y su experiencia personal, un equipo multidisciplinar de 14 profesionales sanitarios (incluyendo dermatólogos, reumatólogos, neurólogos, gastroenterólogos, farmacéuticos y enfermeras) ha elaborado una serie de recomendaciones generales y específicas (basadas en la fisiopatología) para el manejo de los efectos adversos secundarios a apremilast que con mayor frecuencia conducen a la suspensión del tratamiento (diarrea, náuseas y cefalea). Se aportan algoritmos sencillos de manejo que incluyen aspectos clínicos de evaluación y sugerencias de tratamiento farmacológico.Los efectos adversos de apremilast pueden ser abordados desde un punto de vista multidisciplinar y la optimización en su manejo pretende proporcionar un beneficio clínico a los pacientes que los sufren. Abstract: We present a series of general and specific recommendations based on pathophysiologic considerations for managing the most common adverse effects of apremilast that lead to treatment discontinuation: diarrhea, nausea, and headache. The recommendations are based on a review of the literature and the experience of a multidisciplinary team of 14 experts including dermatologists, rheumatologists, neurologists, gastroenterologists, pharmacists, and nurses. We propose a series of simple algorithms that include clinical actions and suggestions for pharmacologic treatment.The adverse effects of apremilast can be managed from a multidisciplinary approach. The purpose of optimizing management is to bring clinical benefits to patients.

Resumen: Introducción: En los últimos años han surgido numerosos dispositivos de neuromodulación, invasivos y no invasivos, que se han aplicado en pacientes con cefaleas y neuralgias sin que exista una revisión actualizada de su eficacia y seguridad, ni recomendaciones de ninguna institución sanitaria sobre su uso específico en cada entidad nosológica. Métodos: Neurólogos del Grupo de Cefaleas de la Sociedad Española de Neurología (SEN) y neurocirujanos expertos en neurocirugía funcional seleccionados por la Sociedad Española de Neurocirugía (SENEC), hemos realizado una revisión exhaustiva en el sistema Medline sobre neuromodulación en cefaleas y neuralgias. Resultados: Presentamos una revisión actualizada y establecemos por primera vez unas recomendaciones consensuadas entre la SEN y la SENEC sobre el uso de la neuromodulación en cefaleas y neuralgias, adjudicando niveles de evidencia sobre su eficacia actual, específicamente en cada entidad nosológica. Conclusiones: Los resultados actuales de los estudios proporcionan evidencias para la indicación de técnicas de neuromodulación en casos refractarios de cefaleas y neuralgias (sobre todo en migraña, cefalea en racimos y neuralgia del trigémino), seleccionados por neurólogos expertos en cefaleas, tras comprobar el agotamiento de las opciones farmacológicas. Adicionalmente, en el caso de la neuromodulación invasiva, se recomienda que los casos sean debatidos en comités multidisciplinarios y la cirugía sea realizada por equipos de neurocirujanos expertos en neurocirugía funcional y con una morbimortalidad aceptable. Abstract: Introduction: Numerous invasive and non-invasive neuromodulation devices have been developed and applied to patients with headache and neuralgia in recent years. However, no updated review addresses their safety and efficacy, and no healthcare institution has issued specific recommendations on their use for these 2 conditions. Methods: Neurologists from the Spanish Society of Neurology's (SEN) Headache Study Group and neurosurgeons specialising in functional neurosurgery, selected by the Spanish Society of Neurosurgery (SENEC), performed a comprehensive review of articles on the MEDLINE database addressing the use of the technique in patients with headache and neuralgia. Results: We present an updated review and establish the first set of consensus recommendations of the SEN and SENC on the use of neuromodulation to treat headache and neuralgia, analysing the current levels of evidence on its effectiveness for each specific condition. Conclusions: Current evidence supports the indication of neuromodulation techniques for patients with refractory headache and neuralgia (especially migraine, cluster headache, and trigeminal neuralgia) selected by neurologists and headache specialists, after pharmacological treatment options are exhausted. Furthermore, we recommend that invasive neuromodulation be debated by multidisciplinary committees, and that the procedure be performed by teams of neurosurgeons specialising in functional neurosurgery, with acceptable rates of morbidity and mortality.

ABSTRACT We report an unusual case of brucellosis presented with headache, diminished vision, papillitis and multiple peripapillary hemorrhages accompanied by subretinal fluid extending up to macula. Diagnosis of brucellosis was made based on positive polymerase chain reaction of cerebrospinal fluid sample for Brucella species DNA, accompanied by a raised titer of anti-brucella antibodies. Patient showed remarkable improvement on triple drug therapy in form of doxycycline, rifampicin and ceftriaxone.

Resumen: Introducción: En los últimos meses han surgido dudas por parte de pacientes, médicos de familia y neurólogos sobre la posibilidad de que algunos de los fármacos que habitualmente se utilizan en cefaleas y neuralgias puedan facilitar o complicar la infección por el SARS-CoV-2. Material y métodos: Hemos recabado información sobre el posicionamiento de sociedades científicas, así como de las distintas Agencias de Medicamentos (americana, europea y española) para poder esclarecer dudas respecto al uso de fármacos como lisinopril, candesartán, ibuprofeno, corticoides, carbamazepina, anticuerpos monoclonales contra el péptido relacionado con el gen de la calcitonina (CGRP) durante la pandemia por COVID-19. Resultados: Planteamos recomendaciones acerca del uso de fármacos habituales en el tratamiento de las cefaleas en el contexto de la pandemia por COVID-19, basándonos en las evidencias de las que disponemos en el momento actual. Conclusiones: Actualmente no existe ningún argumento científico robusto para contraindicar formalmente ninguno de los tratamientos que se emplean en cefaleas y neuralgias. Abstract: Introduction: In recent months, doubts have arisen among patients, general practitioners, and neurologists as to whether some drugs commonly used in patients with headaches and neuralgia may favour or complicate the disease caused by SARS-CoV-2. Material and methods: We collected information on the opinions of scientific societies and medicines agencies (American, European, and Spanish) to clarify doubts regarding the use of drugs such as lisinopril, candesartan, ibuprofen, corticosteroids, carbamazepine, and monoclonal antibodies targeting the calcitonin gene–related peptide in the context of the COVID-19 pandemic. Results: We make recommendations about the use of standard headache treatments in the context of the COVID-19 pandemic, based on the current scientific evidence. Conclusions: At present, there is no robust scientific argument to formally contraindicate any of the standard treatments employed for headaches and neuralgias.

Resumen: Introducción: La infección por SARS-CoV-2 ha tenido un enorme impacto en los sistemas sanitarios. España, donde la cefalea constituye el motivo principal de consulta ambulatoria en Neurología, es uno de los países con más casos notificados. Objetivo: Conocer el impacto de la pandemia COVID-19 en las Unidades de Cefaleas en España y evaluar cómo imaginan el futuro de estas estructuras los neurólogos responsables. Métodos: Estudio transversal mediante encuesta online distribuida a los responsables de las Unidades, realizada durante la sexta semana del estado de alarma. Resultados: La tasa de respuesta fue del 74%, con participación de centros de diferentes características y de todas las Comunidades Autónomas. El 95,8% describió limitaciones en la actividad presencial, un 60,4% mantuvo la consulta presencial preferente y el 45,8% los procedimientos urgentes. En el 91,7% de los centros la actividad presencial cancelada se sustituyó por consulta telefónica. El 95,8% de los encuestados afirmó que empleará material de protección personal en el futuro y el 86% pretende incorporar en mayor medida la telemedicina. La mayoría prevé un incremento en las listas de espera (93,8% en primeras visitas, 89,6% en revisiones y 89,4% en procedimientos) y una peor situación clínica de los pacientes, pero solo un 15% cree que su estructura asistencial se verá debilitada. Conclusiones: Como consecuencia de la pandemia, la actividad asistencial e investigadora en cefaleas se ha reducido de manera notable. Esto pone de manifiesto la necesidad de un incremento de la oferta de telemedicina en nuestros centros en un futuro cercano. Abstract: Introduction: The COVID-19 pandemic has had a great impact on healthcare systems. Spain, where headache is the main reason for outpatient neurology consultation, is one of the countries with the most reported cases of the disease. Objective: This study aimed to analyse the impact of the COVID-19 pandemic on headache units in Spain and to evaluate how neurologists see the future of these units. Methods: We conducted a cross-sectional online survey of headache units during the sixth week of the state of alarm declared in Spain in response to the pandemic. Results: The response rate was 74%, with the participation of centres with different characteristics and from all Autonomous Communities of Spain. Limitations in face-to-face activity were reported by 95.8% of centres, with preferential face-to-face consultation being maintained in 60.4%, and urgent procedures in 45.8%. In 91.7% of centres, the cancelled face-to-face activity was replaced by telephone consultation. 95.8% of respondents stated that they would use personal protection equipment in the future, and 86% intended to increase the use of telemedicine. The majority foresaw an increase in waiting lists (93.8% for initial consultations, 89.6% for follow-up, and 89.4% for procedures) and a worse clinical situation for patients, but only 15% believed that their healthcare structures would be negatively affected in the future. Conclusions: As a consequence of the pandemic, headache care and research activity has reduced considerably. This demonstrates the need for an increase in the availability of telemedicine in our centres in the near future.

Resumen: Introducción: . Cuando se sospecha que estamos ante una cefalea secundaria y se deriva un paciente a Urgencias o a la consulta de Neurología es importante saber qué exploraciones complementarias son oportunas hacer en cada caso, además de saber posteriormente cuál es el circuito adecuado que ha de seguir el paciente.Por este motivo, el Grupo de Estudio de Cefaleas de la Sociedad Española de Neurología (GECSEN) ha decidido crear unas recomendaciones consensuadas que establezcan un protocolo de derivación de pacientes con cefalea y/o neuralgias craneofaciales. Desarrollo: Se ha contactado con neurólogos jóvenes con interés y experiencia en cefalea y con la Junta Directiva del GECSEN han desarrollado este documento que, por razones prácticas, se ha dividido en 2 artículos. El primero centrado en las cefaleas primarias y neuralgias craneofaciales, y este centrado en las cefaleas secundarias y otros dolores craneofaciales. El enfoque es práctico, con tablas que resumen los criterios de derivación con exploraciones complementarias y otros especialistas a los que derivar, para que sea útil y facilite su uso en nuestra práctica asistencial diaria. Conclusiones: Esperamos ofrecer una guía y herramientas para mejorar la toma de decisiones ante un paciente con cefalea valorando exploraciones a priorizar y que circuitos seguir para así evitarla duplicación de consultas y retrasos en el diagnóstico y en el tratamiento. Abstract: Introduction: When secondary headache is suspected and the patient is referred to the emergency department or to the outpatient neurology clinic, it is important to know which are the appropriate complementary examinations to perform and the suitable referral pathway for patients to follow.In order to establish recommendations on this matter, the Spanish Society of Neurology's Headache Study Group (GECSEN) has decided to issue a series of agreed recommendations constituting a referral protocol for patients with headache and/or craniofacial neuralgias. Development: Young neurologists with an interest and experience in headache were invited to draft a series of practical guidelines in collaboration with GECSEN's Executive Committee. For practical reasons, the document was divided into 2 articles: the first focuses on primary headaches and craniofacial neuralgias and this second article on secondary headaches and other craniofacial pain. In order for the recommendations to be helpful for daily practice, they follow a practical approach, with tables summarising referral criteria, examinations to be performed, and referral to other specialists. Conclusions: We hope to offer a guide and tools to improve decision-making regarding patients with headache, identifying complementary tests to prioritise and referral pathways to be followed, in order to avoid duplicated consultations and delayed diagnosis and treatment.