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I trattamenti di profilassi per l'emicrania comprendono farmaci beta-bloccanti, antiepilettici, antidepressivi, antagonisti dei canali del calcio, antagonisti della serotonina, inibitori dell'angiotensina e neurotossina botulinica. L'introduzione degli anticorpi monoclonali (mAbs) che bloccano il peptide correlato al gene della calcitonina (CGRP) od il suo recettore (mAbs anti-CGRP) ha posto l'esigenza di ricorrere ad opportuni strumenti per la valutazione dell'appropriatezza prescrittiva al fine di garantire l'accesso a tali terapie nel rispetto dei criteri di rimborsabilità da Piano Terapeutico (almeno otto episodi di emicrania al mese e precedente terapia fallimentare con 3 diverse classi terapeutiche somministrate per un periodo di almeno 6 settimane ciascuna). Nel presente elaborato, sono stati individuati due indicatori di appropriatezza prescrittiva per il trattamento di profilassi dell'emicrania, quali la percentuale di pazienti affetti da emicrania avviati al trattamento con mAbs anti-CGRP senza i criteri di eleggibilità (sovra-uso) e la percentuale di pazienti affetti da emicrania con i criteri di eleggibilità non in trattamento con mAbs anti-CGRP (sotto-uso). Tali indicatori sono stati progettati per essere calcolati mediante i dati contenuti nei flussi amministrativi comunemente disponibili presso le Aziende Sanitarie Locali. L'utilizzo di tali database amministrativi consente di identificare sia l'avvio al trattamento con mAbs anti-CGRP (prescrizione), sia la presenza dei criteri di eleggibilità (rimborsabilità) e, quindi, di valutare l'appropriatezza prescrittiva (in eccesso o in difetto), avviare azioni correttive per razionalizzare l'uso delle terapie vecchie e nuove e programmare le risorse necessarie, finanziarie ed organizzative, mediante la quantificazione dei pazienti effettivamente eleggibili ai nuovi farmaci. [ABSTRACT FROM AUTHOR]

Objectives: Understanding migraine management using data from a sample of patients representative of the Italian general adult population.Methods: Retrospective analysis on IQVIA Italian Longitudinal Patient Database. Two cohorts were created. (a) The triptan user cohort included patients with triptan prescriptions between November 2015 and October 2016. Migraine days were estimated counting triptan and indometacin/caffeine/prochlorperazine (ICP) pills prescribed during the 6 months following first triptan prescription. Patients were categorized as having episodic (EM) or chronic (CM) migraine based on the number of migraine days following International Classification of Headache Disorders criteria. (b) The migraine preventive treatment (MPT) user cohort included patients with MPT prescriptions during the period June 2016-May 2017. MPTs considered included beta-blockers, calcium-channel blockers, antiepileptics, antidepressants and antiserotoninergics. Migraine days experienced by MPTs users were estimated counting triptan and ICP pills prescribed during the 6 months following the most recent MPT prescription, while the number of MPT switches was estimated based on MPT prescriptions during the previous two years.Results: There were 9461 patients with triptan prescriptions to treat migraine acute attacks, which accounted yearly for 0.8% of general adult population. CM patients accounted for 3% of triptan users. There were 2004 patients prescribed with MPTs, which accounted for 0.16% of general adult population. Overall, among MPT users, 291 (15%) were still experiencing at least four migraine days/month, with this proportion increasing with the increase in the number of MPT switches.Conclusions: Results from this study suggest an unmet need in the management of migraine: too many patients did not receive MPTs, with this potentially due to several reasons requiring further investigations. Furthermore, even among patients receiving MPTs, disease control level with now available drugs seems to be sub-optimal. [ABSTRACT FROM AUTHOR]

The International Classification of Headache Disorders (ICHD-3 beta) includes headache attributed to intracranial endovascular procedures (EVPs). The aim of this review is to describe the clinical and pathophysiological aspects of headache related to vascular lesions and EVPs. Current studies regarding this issue are contradictory, although generally favouring headache improvement after EVPs. Further large studies are needed to adequately assess the effect of EVPs on headache. [ABSTRACT FROM AUTHOR]

Hemiplegic migraine (HM) is a rare migraine with aura; it can be familiar or sporadic. A 46-years-old man presented left migraine followed by right hemiparesis with bilateral plantar flexion of cutaneous plantar reflex (CPR). Brain CT and CT-angiography were normal. The next day patient got worse. The EEG showed left fronto-temporal cuspidate delta waves and brain MRI showed a minimal hyperintensity at T2-sequences in the left frontal cortex with a minor representation of the cortical veins at susceptibility weighted imaging sequences. After 3 days, he had a progressive neurological improvement. After 2 weeks, EEG and brain MRI were normal. He was discharged with diagnosis of probably first attack of sporadic HM and after 8 months he was asymptomatic. The normal CPR on the hemiplegic side might be a clinical marker of functional hemiplegia. For the international classification of headache disorder (ICHD-3) two attacks are necessary for HM diagnosis. We propose for the first attack of HM to make diagnosis of "probable" HM as expected to the same ICHD-3 for migraine. Further studies are necessary to support our hypotheses. [ABSTRACT FROM AUTHOR]

We describe 2 patients with cluster headache attacks associated with a dissection of the ipsilateral internal carotid artery at the extra–intracranial passage. These cases highlight the need for extensive neuroradiological investigation in cluster headache patients when atypical features are present. We also performed a PubMed search to review the current literature data about this association. [ABSTRACT FROM AUTHOR]

The interest of the medical community has recently focused on the relationship between gender and cardiocerebrovascular risk. In this paper, we will first review gender differences in cardiocerebrovascular disorders, then we will discuss the existing evidence on the links between migraine and stroke and cardiovascular disease in women, and speculate on the possible physiopathological interpretations of this emerging epidemiological link. In the third part of this work, we will address the issue of the effect of sex hormones on vascular risk, and consider the evidence concerning the safety of oral contraceptives and hormone-replacement therapy. Finally, we will outline the main trends of future research and its possible clinical and therapeutic implications. [ABSTRACT FROM AUTHOR]

Abstract Headache is a critical problem in the emergency department (ED). The main aim for the ED doctor is to distinguish primary forms of headache from secondary forms. In this paper we will briefly review epidemiological data regarding headache in ED, consider the role of diagnostic alarms and “warning symptoms” in differential diagnosis and describe some “dangerous headaches”. [ABSTRACT FROM AUTHOR]

Background: Chronic migraine is a disabling condition that is currently underdiagnosed and undertreated. In this narrative review, we discuss the future of chronic migraine management in relation to recent progress in evidence-based pharmacological treatment. Findings: Patients with chronic migraine require prophylactic therapy to reduce the frequency of migraine attacks, but the only currently available evidence-based prophylactic treatment options for chronic migraine are topiramate and onabotulinumtoxinA. Improved prophylactic therapy is needed to reduce the high burden of chronic migraine in Italy. Monoclonal antibodies that target the calcitonin gene-related peptide (CGRP) pathway of migraine pathogenesis have been specifically developed for the prophylactic treatment of chronic migraine. These anti-CGRP/R monoclonal antibodies have demonstrated good efficacy and excellent tolerability in phase II and III clinical trials, and offer new hope to patients who are currently not taking any prophylactic therapy or not benefitting from their current treatment. Conclusions: Treatment of chronic migraine is a dynamic and rapidly advancing area of research. New developments in this field have the potential to improve the diagnosis and provide more individualised treatments for this condition. Establishing a culture of prevention is essential for reducing the personal, social and economic burden of chronic migraine. [ABSTRACT FROM AUTHOR]