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Objective: To describe transcranial Doppler (TCD) findings in a population with clinical probable RCVS. Exploratory objectives included the study of clinical characteristics of probable RCVS patients with and without spasm detected by TCD., Methods: Cross-sectional cohort study of patients with thunderclap headache (TCH) without subarachnoid hemorrhage (SAH) of our neurology and headache center between 2010 and 2019, selecting patients with clinical diagnosis of probable RCVS (negative angiography study) by ICHD-3 criteria and with at least two TCD studies., Results: From 114 TCH patients, 36/114 had probable RCVS by ICHD-3 criteria and had at least two TCD studies available. The mean age at RCVS onset was 42.9years (21-72years); 29/36 (80.6%) were female, 7/28 (25%) had cardiovascular risk factors and 20/36 (55.6%) had history of migraine. Most common triggers were stressful emotion, drugs, valsalva maneuvers and sexual activity. Five/36 (13.9%) had complications and 3/36 (8.3%) had late recurrence. Initial TCD was performed on average of 16 (6-26) days after headache onset. Twenty-nine had vasospasm on TCD, presenting mean flow velocity of MCA (VMCA) of 135.7±17.0cm/s and mean maximum VMCA of 138.3±17.2. Vasospasm was mild in 21/29 patients (72.4%) and moderate in 8/29 (27.6%). Complete VMCA normalization occurred on average 41 (30-70) days after headache onset and 24 (11-47) days after initial TCD. The group of patients with vasospasm detected by TCD had more female patients (26/29, 89.7% vs. 3/7, 42.8%, P=0.016), and more TCH attacks (mean of 3.6 vs. 2.14, P=0.049)., Conclusion: TCD may be a useful tool in the identification of vasospasm in patients with probable RCVS, supporting the diagnosis of RCVS in patients presenting with recurrent TCH without SAH., (Copyright © 2021 Elsevier Masson SAS. All rights reserved.)

Background: The economic burden of headache in European countries is substantial, mostly related to indirect work-productivity loss costs, yet data for Portugal is scarce., Methods: An anonymous web-based survey of headache was distributed to a convenience sample of Portuguese companies' workforces, to assess last-year headache and "yesterday"-point prevalence. Preexisting headaches were classified into migraine and non-migraine headache and work impact (absenteeism and presenteeism) was evaluated in relation to point prevalence. If no significant selection biases were detected, projected work-loss costs for the whole country were to be calculated., Results: Eleven (17%) of 65 invited companies participated, around 15,000 active workers were exposed to the survey and 3624 (24.3%) responded, 73% females, 84.3% with previous ("last-year") headaches, 53% with migraine. Due to participation and gender bias, national cost-projections were not calculated. Workday point-prevalence was 21% (migraine) and 9% (non-migraine headache), resulting in 14 employees with migraine losing, on average, 4 h and 32 min of work time. Presenteeism occurred in 29% of migraine and 15% of NMH employees. Yearly cost of each employee with a headache disorder was €664.88., Discussion: Headache has a significant economic burden, as measured by work loss costs, in Portugal. Company-based interventions should aim to support employees' access to headache diagnosis and treatment, including non-pharmacological coping strategies, in order to reduce headache related economic costs.

Background: In 2013, one of the authors described a 36-year-old female with orthostatic headache without documented intracranial hypotension or evidence of cerebrospinal fluid leak, despite extensive workup. Headache was unresponsive to conservative treatment since 2010, showed only transient benefit after repeated epidural blood patches while vitamin A supplementation resulted in progressive improvement., Case: Since 2013, the patient followed a relapsing and remitting course yet relapse control became difficult after a drug induced liver injury required vitamin A discontinuation in 2017, when her headache became chronic. Greater occipital nerve blocks provided pain relief as alternative but were stopped due to the pandemic and her latest severe relapse, in late 2020, required not only restarting anaesthetic blocks and aggressive medication management, but also reassessing and treating comorbidities (obstructive sleep apnoea and major depressive disorder) with modest benefit., Conclusion: Orthostatic headache without intracranial hypotension is rare, with only 28 cases reported so far, all treated empirically and all treatment options revealing to be mostly ineffective. Vitamin A anecdotally appeared to be useful in our case but had to be stopped for severe side effects, so unfavourable long-term prognosis, in ours and 2/3 of the reported cases, seems to be the rule in this intriguing entity.

The paper from Steiner et al. suggests that an outcome measure expressed in time units may be an adequate method to assess the impact of headache disorders, regardless of diagnosis or health care setting, proving useful for cost-benefit analysis and health policy definition. Using time lost to each attack - weighted by disability - may prove to be a reliable measure to establish the effectiveness of acute treatment, but if considering also the attack frequency it could evaluate the effects of preventive strategies. A measure such as the Headache Gauge, which translates the proportion of time lost to headache -related disability, has proven to be applicable also in routine clinical practice as well, and can be tested in clinical trials and populational analysis. There are practical limitations, such as disability assessment and the need for prospective data collection to avoid recall bias but it seems consensual that impairment related to primary headache disorders is primarily driven by the TIME stolen from the perfect health status., (© 2022. The Author(s).)

Background: Several patient-reported outcome measures are available to monitor headache impact, but are those reliable in real-life clinical practice?, Methods: Two identical patient-reported outcome measures (HALT-90 and MIDAS) were applied simultaneously in each clinical visit to a series of patients treated with monoclonal antibodies for migraine and intra-individual agreement was evaluated using the intraclass correlation coefficients., Results: Our sample included 92 patients, 92.4% females, 45 years old on average. Moderate (0.50 to 0.75) and even poor (<0.50) ICC were observed in all but the first item of these patient-reported outcome measures in at least one evaluation. Over time, missing data were more frequent and no learning effect was detected., Discussion: We observed intra-personal variation in reliability when answering patient-reported outcome measures, persisting in repeated applications, and a decrease in the motivation to respond, which should alert clinicians for these additional challenges in real-life clinical practice.

Background:  Elucidating mechanisms of brain damage in cerebral venous thrombosis (CVT) would be instrumental to develop targeted therapies and improve prognosis prediction. Matrix metalloproteinase-9 (MMP-9), a gelatinase that degrades major components of the basal lamina, has been associated to blood-brain barrier disruption. We aimed to assess, in patients with CVT, the temporal change in serum concentrations of MMP-9 and its association with key imaging and clinical outcomes., Methods:  Pathophysiology of Venous Infarction-PRediction of InfarctiOn and RecanalIzaTion in CVT (PRIORITy-CVT) was a multicenter prospective cohort study of patients with newly diagnosed CVT. Serial collection of peripheral blood samples performed on day 1, 3, and 8, and standardized magnetic resonance imaging on day 1, 8, and 90. MMP-9 was quantified using enzyme-linked immunosorbent assay in 59 patients and 22 healthy controls. Primary outcomes were parenchymal brain lesion, early evolution of brain lesion, early recanalization, and functional outcome on day 90., Results:  CVT patients with parenchymal brain lesion had higher baseline concentrations of MMP-9 compared with controls (adjusted p  = 0.001). The area under receiver operating characteristic curve value for MMP-9 for predicting brain lesion was 0.71 (95% confidence interval [CI]: 0.57-0.85, p  = 0.009). Patients with venous recanalization showed early decline of circulating MMP-9 and significantly lower levels on day 8 ( p  = 0.021). Higher MMP-9 on day 8 was associated with persistent venous occlusion (odds ratio: 1.20 [per 20 ng/mL], 95% CI: 1.02-1.43, p  = 0.030)., Conclusion:  We report a novel relationship among MMP-9, parenchymal brain damage, and early venous recanalization, suggesting that circulating MMP-9 is a dynamic marker of brain tissue damage in patients with CVT., Competing Interests: Dr. Aguiar de Sousa reports nonfinancial support from Boehringer Ingelheim, outside the submitted work. Dr. Ferro reports personal fees and grants from Boehringer Ingelheim outside of the submitted work and a grant from Bayer outside of the submitted work. Dr. Aguiar de Sousa reports nonfinancial support from Boehringer Ingelheim outside of the submitted work. The other authors report no conflicts of interest., (Thieme. All rights reserved.)

Background: Clinical guidelines agree that preventive treatment should be considered in patients with uncontrolled migraine despite acute medications or patients with ≥4 migraine days per month. However, the criteria to define the effectiveness of treatment and the factors that inform the decision to (dis)continue it are not clearly defined in clinical practice., Methods: Overall, 148 healthcare practitioners from five European countries completed a two-wave questionnaire. The Steering Committee defined a simulated set of 108 migraine patient profiles based on the combination of five factors (frequency of the attacks, intensity of the attacks, use of acute migraine medications, patient perception and presence/absence of tolerable side effects). These profiles were used in a Delphi survey among European neurologists to identify the criteria that should be used to decide treatment response and continuation using a conjoint analysis approach., Results: Consensus was reached for 82/108 (76%) of profiles regarding treatment response, and for 86/108 (80%) regarding treatment continuation. Multivariable logistic regression analysis showed that a ≥50% reduction in the use of acute migraine medications and positive patient's perception of treatment were the most important factors that lead to the decision of continuing (combined factors, OR = 18.3, 95% CI 13.4-25.05)., Conclusions: This survey identifies two relevant outcome measures: one objective (use of acute migraine treatment medications) and one subjective (positive patient perception) that guide the clinician decision to continue preventive treatment in migraine patients., Significance: In clinical practice, criteria to define the effectiveness of migraine preventive treatment and factors that guide treatment stop or continuation are not clearly defined. In this simulated clinical setting study, a reduction in the use of acute migraine medications was the factor associated with preventive treatment effectiveness definition. This study also revealed that factors strongly associated with the decision of treatment continuation in real life are the acute migraine medications use and a positive patient's perception of treatment effectiveness., (© 2021 The Authors. European Journal of Pain published by John Wiley & Sons Ltd on behalf of European Pain Federation - EFIC ®.)

Background: This study aimed to validate a semi-quantitative composite score tool, "Headache Gauge" (HG), to monitor the treatment effect in primary headaches in everyday clinic practice, adjustable to any chosen timeframe., Method: A cohort validation study of HG was performed in primary headache patients, recovering their clinical data and patient-related outcome measures (PROMs) for headache (HIT-6, MIDAS, HURT), work impact (WPAIQ), quality-of-life (SF-12), and mood (STAI, ZUNG). HG score distribution, its relation to clinical variables, its internal consistency, and its convergent validity were determined., Results: HG was plotted in 233 patients: 90.1% females, age average 37 years, 86% with migraine, 27% with chronic headaches, and 28% with medication overuse. HG ranged from 0.21 to 58.3 in this sample, higher in chronic headaches (HG 16) and medication overuse (HG 15). HG presented good concurrent validity, significantly correlating with HIT-6 (p < 0.0001), SF-12 (p = 0.001), WPAIQ (p < 0.0001), MIDAS (p < 0.0001), and HURT (p < 0.0001). Good sensitivity to change (p < 0.001) and moderate test-retest reliability (p = 0.001) were calculated after reassessment of 147 patients (63.1% of the initial sample)., Conclusions: Headache Gauge is a clinical data-based outcome measure that conceptually translates the percentage of lost time to headache in any given timeframe. It relates to headache impact, therefore bearing the potential to be relevant in real-life clinical monitoring., (© 2021. Fondazione Società Italiana di Neurologia.)

In countries where headache services exist at all, their focus is usually on specialist (tertiary) care. This is clinically and economically inappropriate: most headache disorders can effectively and more efficiently (and at lower cost) be treated in educationally supported primary care. At the same time, compartmentalizing divisions between primary, secondary and tertiary care in many health-care systems create multiple inefficiencies, confronting patients attempting to navigate these levels (the "patient journey") with perplexing obstacles.High demand for headache care, estimated here in a needs-assessment exercise, is the biggest of the challenges to reform. It is also the principal reason why reform is necessary.The structured headache services model presented here by experts from all world regions on behalf of the Global Campaign against Headache is the suggested health-care solution to headache. It develops and refines previous proposals, responding to the challenge of high demand by basing headache services in primary care, with two supporting arguments. First, only primary care can deliver headache services equitably to the large numbers of people needing it. Second, with educational supports, they can do so effectively to most of these people. The model calls for vertical integration between care levels (primary, secondary and tertiary), and protection of the more advanced levels for the minority of patients who need them. At the same time, it is amenable to horizontal integration with other care services. It is adaptable according to the broader national or regional health services in which headache services should be embedded.It is, according to evidence and argument presented, an efficient and cost-effective model, but these are claims to be tested in formal economic analyses., (© 2021. The Author(s).)

Objectives and Background: The effect of headache on cognitive performance is controversial, due to conflicting results obtained from studies in clinical or population settings. We aimed to understand if migraine and other headaches modify the rates of decline on different cognitive measures, during a 5-year interval., Design and Method: A cohort of community dwelling adults (> 50 years) with migraine (MH), non-migraine headaches (NMH) and controls without headache (WoH), was assessed by a comprehensive neuropsychological battery with tests of memory, language and executive functions, repeated 5 years apart. Change in performance between baseline and reevaluation was compared between groups, and controlled for age, gender, literacy and depressive symptoms., Results: A total of 275 participants (78.5% WoH, 12.7% MH, 8.7% NMH) were reevaluated (average age 70.40 + 8.34 years, 64% females). Cognitive decline or dementia occurred in 11.4%, with a similar proportion among the three groups. Although MH participants had significantly more subjective cognitive complaints (p = 0.030, 95%CI:]-3.929,-0.014[), both MH and NMH subjects showed an age-associated decline identical to controls. Furthermore, migraine features (disease and attack duration, frequency and aura) were unrelated with cognitive performance., Conclusion: Migraine and non-migraine headache are not associated with increasing risk of dementia or cognitive decline at an older age although subjects with migraine have more cognitive complaints. Longer longitudinal studies are necessary to understand if this pattern persists for more than 5 years.

Background and Purpose- The hypothesis that venous recanalization prevents progression of venous infarction is not established in patients with cerebral venous thrombosis (CVT). Evidence is also scarce on the association between residual symptoms, particularly headache, and the recanalization grade. We aimed to assess, in patients with CVT treated with standard anticoagulation, (1) the rate of early venous recanalization, (2) whether lack of early recanalization was predictor of parenchymal brain lesion progression, and (3) the prevalence and features of persistent headache according to the recanalization grade achieved. Methods- PRIORITy-CVT (Pathophysiology of Venous Infarction - Prediction of Infarction and Recanalization in CVT) was a multicenter, prospective, cohort study including patients with newly diagnosed CVT. Standardized magnetic resonance imaging was performed at inclusion (≤24 hours of therapeutic anticoagulation), days 8 and 90. Potential imaging predictors of recanalization were predefined and analyzed at each anatomical segment. Primary outcomes were rate of early recanalization and brain lesion progression at day 8. Secondary outcomes were headache (days 8 and 90) and functional outcome (modified Rankin Scale at days 8 and 90). Results- Sixty eight patients with CVT were included, of whom 30 (44%) had parenchymal lesions. At the early follow-up (n=63; 8±2 days), 68% (n=43) of patients had partial recanalization and 6% (n=4) full recanalization. Early recanalization was associated both with early regression ( P =0.03) and lower risk of enlargement of nonhemorrhagic lesions ( P =0.02). Lesions showing diffusion restriction (n=12) were fully reversible in 66% of cases, particularly in patients showing early venous recanalization. Evidence of new or enlarged hemorrhagic lesions, headache at days 8 and 90, and unfavorable functional outcome at days 8 and 90 were not significantly different in patients achieving recanalization. Conclusions- Venous recanalization started within the first 8 days of therapeutic anticoagulation in most patients with CVT and was associated with early regression of nonhemorrhagic lesions, including venous infarction. There was an association between persistent venous occlusion at day 8 and enlargement of nonhemorrhagic lesions.

Susac syndrome is a rare, probably immune-mediated endotheliopathy presenting with encephalopathy, sensorineural hearing loss and retinal arterial occlusions. A 33-year-old female with Susac syndrome was worsening despite high-dose steroids so a brain biopsy was performed which suggested a possible fungal infection. Treatment with amphotericin B resulted in prompt reversal of symptoms and radiological findings, and no further symptoms occurred during 8 years of follow-up. A diagnosis of fungal infection was not confirmed. The etiology of Susac syndrome is unknown and this anecdotal observation suggests that an infectious agent susceptible to amphotericin might have caused or triggered Susac syndrome in this patient.

Background: Migraine is a complex neurological disorder that affects a significant percentage of the human species, from all geographic areas and cultures. Cognitive symptoms and dysfunctions are interim and disabling components of this disorder and may be related to the brain processes underlying the pathophysiology. Yet they are often undervalued by clinicians. In this review, we present the different types of cognitive dysfunctions associated with migraine and the mechanisms that are potentially causing them., Findings: While reversible attack-related cognitive dysfunction seems extremely consistent and likely related to functional cortical and subcortical brain changes occurring during attacks, interictal cognitive dysfunction is less consistent and might become more relevant as attack frequency and disease complexity increase. Migraine traits do not seem a predisposition to long-term cognitive decline. Cognitive dysfunction is a frequent manifestation of migraine attacks and may be specific to this disorder; it is important to understand if it could be useful in migraine diagnosis. Attack-related cognitive dysfunction is clinically relevant and contributes to disability, so it should be perceived as a therapeutic target. While there is no evidence to support that migraine increases the risk of long-term or persistent cognitive dysfunction, the fact that it occurs during the attacks and may persist in subjects with frequent or complicated attacks should prompt the understanding of the mechanisms related to its pathophysiology for it may also clarify the processes underlying migraine.

Brucellosis, an endemic zoonosis in Portugal, is a multisystem disease, presenting with neurological manifestations in up to 25% of cases. Neurobrucellosis diagnostic criteria include evidence of central nervous system invasion, either by documenting increased blood-brain barrier permeability that normalizes after treatment or by Brucella isolation. We report 2 patients with systemic brucellosis presenting with neurological symptoms: A 28-year-old female with progressive hemiparesis associated with severe refractory thoracic and lumbar pain, whose spinal magnetic resonance imaging identified longitudinally extensive myelitis. Brucella agglutination test was positive in blood; however, cerebrospinal fluid cytochemical, serological testing, and cultures were negative. A 58-year-old male with intermittent fever in the evening, associated with severe refractory cervical and lumbar spinal and radicular pain. Blood workup identified leukocytosis, elevated inflammatory markers and positive Brucella agglutination test. Cerebrospinal fluid presented mild protein increase and negative serological testing and cultures. Electromyogram revealed demyelinating polyradiculoneuropathy. In both cases, antibiotic therapy induced symptom resolution. Despite the neurological presentation, no evidence of direct nervous system infection was found. An indirect mechanism appears to be involved, such as a parainfectious syndrome or circulating endotoxins release by the bacteria. Brucellosis should be considered in patients presenting with inflammatory neurological symptoms in endemic regions. Prompt diagnosis and treatment are important as chronic infection has significant morbidity.

Introduction Cognitive symptoms have been described during migraine attacks since the Roman era; while being neglected throughout the centuries, they are relevant contributors to migraine-related disability. Objective To determine whether cognitive symptoms are included in clinical series describing migraine attack phenomenology, and which symptoms occur in each attack phase. Method Systematic review of existing data on clinical descriptions of migraine attacks, focusing on cognitive symptomatology. Data were organized and analyzed qualitatively, due to methodological differences between studies. Results Twenty-four articles were reviewed, with a total sample of 7007 patients, including 82.9% females with an average age of 39.2 years. Twenty one (75%) studies analyzed one phase of the attack (eight prodromes, five auras, one between aura and pain, three headaches and three postdromes), the remaining studied more than one phase. Cognitive complaints were the most frequent symptom of the prodromic (30%) and headache (38%) phases, while fatigue (70%) dominated the resolution phase. Not enough data is available to estimate the frequency of cognitive symptoms during the aura. Discussion Cognitive symptoms are described in all phases of the migraine attack phenomenology in published clinical series of migraine. Their characteristics appear to be different in each attack phase, although methodological limitations prevent generalization of this finding.

Background: Studies of brain perfusion during migraine without aura attacks have inconsistent results., Methods: Arterial spin labeling MRI, a non-invasive quantitative perfusion technique, was used to prospectively study a spontaneous untreated migraine without aura attack and a headache-free period. Image analysis used FSL and MATLAB software; Group analysis used permutation methods for perfusion differences between sessions., Results: Thirteen women (age 35.7) were scanned during an attack of an average intensity of 6.8 (on 0-10 Visual Analog Scale) and 16 h duration. No global or regional perfusion differences were identified when comparing migraine and migraine-free sessions., Discussion: Our findings suggest that the painful phase of migraine without aura attacks is not associated with brain perfusion abnormalities.

Background: Mig-SCog is a 9-item questionnaire developed to quantify attack-related cognitive complaints in migraine (M). The items relate to executive function and language, and the total Mig-SCog score is the sum of those scales., Objective: To evaluate the Mig-SCog scores regarding cognitive symptoms during a variety of conditions., Methods: We conducted a prospective comparative study of the Mig-SCog scores (1) between migraine and tension-type headache (TTH) patients during a headache; (2) in migraine patients between migraine attacks, non-headache pain and pain-free status; (3) in migraine patients during and outside a migraine attack., Results: One hundred forty-nine patients (98 M and 51 TTHA). Total Mig-SCog score was higher in migraine patients than TTH (8.0 ± 4.1 vs 3.4 ± 3.2, P < .0001). Sixty-three patients took part in the next part of the study. Migraine patients rated the Mig-SCog higher for migraine (7.9 ± 4.6) than for non-headache pain (2.3 ± 2.9, P < .0006) or pain-free (1.6 ± 2.4, P < .0006). In the final phase of the study, 38 patients Mig-SCog scores were not significantly different whether obtained during or outside an M attack (P = .26)., Conclusions: Attack-related subjective cognitive symptoms, assessed by Mig-SCog scores, differed between migraine and TTH patients. The Mig-SCog scores from migraine patients were found to be higher during migraine than during non-headache pain or pain-free conditions. Patient scoring from memory for usual attacks was not significantly different to scoring within attacks, We believe this demonstrates negligible recall bias., (© 2016 American Headache Society.)

Background: The socio-economic impact of migraine is mostly related to work loss either by absenteeism or decreased work performance. Migraine-associated cognitive dysfunction during an attack may contribute to these difficulties., Objective: The objective of this article is to analyze the presence and relevance of cognitive symptoms during migraine attacks and to relate their intensity and symptom-related disability with other migraine-defining symptoms., Methods: Consecutive migraine patients of a headache clinic completed diaries scoring each migraine symptom (including cognitive symptoms) intensity and symptom-related disability., Results: Of 100 consecutive patients included in this study, 34 (all females, age average 31.8 ± 8.8 years) returned information on 229 attacks, on average 6.7 per participant. Every symptom's intensity was always rated slightly higher than the disability it caused. Pain was the symptom scored with the highest intensity and disability, followed by cognitive symptoms (difficulty in thinking and worsening with mental effort) and photo- and phonophobia. Scoring was independent of any of the clinical variables. Attack intensity and disability scores correlated with intensity and disability from pain and from worsening with mental effort., Conclusions: Attack-related cognitive symptoms are intense and disabling. Some attack-related cognitive symptoms correlate to intensity and disability subjectively attributed to the migraine attack. Cognitive performance should be addressed as a valuable secondary endpoint in trials of acute migraine treatment., (© International Headache Society 2015.)

Background: A migraine attack aggregates a range of different symptoms, besides pain, that contribute to attack-related disability. Cognitive dysfunction is an unacknowledged part of the migraine attack., Objective: To provide a profile of the frequency and character of migraine attack-related cognitive symptoms occurring during the headache phase of the attack., Study Design: Cross-sectional survey., Setting: Clinical-based sample of episodic migraine patients., Methods: Sequential patients were screened about the occurrence of cognitive symptoms during migraine attacks using an open-ended question followed by a self-fulfilled symptom checklist., Results: Of 165 migraine patients (15 men, age average 37.3 ± 10.7 years), 89.7% described cognitive symptoms during the headache phase of the migraine attack. On average 2.5 ± 1.6 symptoms were reported per patient, uninfluenced by demographic or disease-related variables. The most common spontaneous symptoms related to executive functions, such as poor ability to concentrate (37%), difficulty in reasoning (25%), and thinking (23%). The pattern of responses on the symptoms checklist corroborated with those reported spontaneously and quantitative scores of the checklist were higher in patients with spontaneous symptoms., Limitations: Open-ended questions tend to overestimate frequency; data accuracy may be influenced by the population chosen (clinical-based, some using prophylactic treatment)., Conclusions: This study detailed the frequency and characteristics of migraine attack-related subjective cognitive symptoms and found its frequency to be similar to reports of other migraine defining symptoms (ex. nausea, photophobia) in recent clinical series. Patients' reports were consistent and dominated by complaints of attention difficulties, diminished cognitive efficiency, and processing speed impairment.

Background: Cognitive difficulties contribute to patients' disability during migraine attacks and have been overlooked in migraine research. Neuropsychological studies performed during attacks have produced inconsistent findings due to design differences and limitations., Objective: Our objective is to document changes in cognitive performance of migraine patients during migraine attacks with a comprehensive battery of cognitive/behavioral tests, while controlling for potential confounders., Method: A prospective two-period, randomized, cross-over study compared within-subject neuropsychological evaluation in two conditions-during a naturally occurring untreated migraine attack and a headache-free period., Results: Thirty-nine patients with episodic migraine (37 females, average 38 years old) were included and 24 completed the study. Participants performed worse during the attack in the majority of cognitive tests, compared to the headache-free status, and significantly so in word reading speed (p = 0.013), verbal learning (p = 0.01), short-term verbal recall with (p = 0.01) and without (p = 0.013) semantic cueing and delayed recall with (p = 0.003) and without (p = 0.05) semantic cues. Differences found were unrelated to age, gender, literacy, condition order, interval between evaluations, anxiety, pain intensity or duration of the attack., Discussion: Cognitive performance decreases during migraine attacks, especially in reading and processing speed, verbal memory and learning, supporting patients' subjective complaints. These findings suggest the existence of a reversible brain dysfunction during attacks of migraine without aura, which can relate specifically to migraine or be a consequence of acute pain processing by the brain., (© International Headache Society 2014.)

Patients consistently report cognitive impairment during migraine attacks, yet the documentation of such dysfunction by neuropsychological evaluation has lacked similar consistency. This incongruence may be due to discrepant study designs, assessment tools and small samples sizes. To search for evidence of decline in cognitive functions during a migraine attack, compared to headache-free performance. The secondary objective was to determine if the eventual decline had a consistent neuropsychological pattern. Systematic review of the medical literature using PubMed and Cochrane library databases without limitations or restrictions from inception to March 2014, using the search terms "migraine", "cognition", "neuropsychological". We included studies in episodic migraine that had a neuropsychological evaluation performed during an attack. From 1,023 titles screened, a total of 10 articles met criteria for inclusion and were fully reviewed. Only five of these studies, comprising a total of 163 individuals, had enough data to allow an appraisal of the study question. All five studies were positive in documenting some type of reversible cognitive impairment during the migraine attack. The pattern of cognitive impairment most often documented was of executive dysfunction, but the presence of bias induced by the choice of tests and of small samples prevents this finding from being conclusive. This review supports the existence of reversible cognitive dysfunction during the migraine attack, corroborating patients' subjective descriptions. Further work is needed to establish the pattern of cognitive dysfunction, their underling pathophysiological mechanisms and the impact of these symptoms in migraine-associated disability.

Background: General practitioners (GPs) and neurologists are involved in treating headache patients in Portugal. Having migraine themselves might influence the way they perceive and treat migraine patients., Objective: To identify clinicians' perceptions about migraine, their own headache status and management of their own migraine., Methods: An observational cross-sectional survey of GPs and neurologists using anonymous questionnaires including demographic data, headache and migraine status and migraine perception questions., Results: Of 348 respondent physicians, 20% were neurologists and 53% were females with an average age of 48 years. The majority had an interest in migraine and considered it disabling (93%), although 65-85% reported management difficulties, GPs more often than neurologists. Satisfaction with current treatment options was high (69-79%). 63 physicians suffered from migraine and 81% felt it influenced their perception of the disease. Portuguese physicians preferentially treat their own migraines with NSAIDs (33%), analgesics (29%) and triptans (20%)., Conclusion: Portuguese physicians treating migraine patients have realistic perceptions about the disease and those with migraine feel their perception is influenced by their experience. Although reporting management difficulties, the majority of physicians are satisfied with current treatment options for migraine., (© 2014 S. Karger AG, Basel.)

Background: Symptomatic cluster-like headache has been described with some ophthalmological disorders such as glaucoma, orbital myositis, posterior scleritis, enucleation, herpes zoster ophthalmicus, and cataract surgery., Case Report: We report a new case of a 79-year-old nonsmoker woman who developed cluster-like symptoms 2 days after a cataract surgery and review the 2 previously reported cases., Discussion: The surgical technique of cataract removal involves corneal incision, which can trigger the trigeminal-autonomic reflex, a pathophysiological mechanism potentially implicated in idiopathic cluster headache. Differential diagnosis in these cases includes surgical and anesthetic complications.

Introduction: Orthostatic headache is very suggestive of intracranial hypotension. It has a good prognosis as it usually responds to conservative treatment or epidural blood patches., Case Report: A 36-year-old female presented with severe and prolonged orthostatic headache starting after a seizure. No stigma of intracranial hypotension was detected on brain MRI, and intracranial pressure was within normal range. No imaging evidence of a fistula was found. She was refractory to symptomatic treatment including five epidural blood patches. Progressive improvement occurred simultaneously to the introduction of vitamin A supplementation., Discussion: A series of six similar patients is discussed, in which five patients remained severely symptomatic and workdisabled at an average follow-up of four years. It is proposed that the pathophysiological mechanism producing orthostatic headache might not be dependent on intracranial hypotension and could respond to vitamin A.

Objectives and Background: The possible effects of migraine on executive abilities remain controversial; hence, we studied inter-ictal cognitive performance of individuals with migraine and non migraine headaches (NMH) compared with headache free controls., Design and Method: In a cross-sectional observational study, taking place in primary care, adults aged 50 or above were evaluated by a neurobehavioral battery including several executive measures. Present history of headache was sought, and migraine was diagnosed by the ID-Migraine questionnaire. The effect of headache type on cognitive measures was analyzed with multiple regression with adjustment by diagnosis, age, gender, education, and depressive symptoms., Results: Among 478 participants, 23.2% reported current headache, of whom 50 were NMH, and 61 were migraine headaches. No group differences were found in the majority of cognitive measures. Compared with controls, migraine subjects performed worse on a test of attention, while NMH participants presented more intrusions and worse discriminability in memory recognition plus a lower performance on semantic memory tests., Conclusion: The presence of headaches in late adulthood was related to a worse performance on few measures of executive functioning, suggesting that cognitive impact is not specific to migraine but might be associated to headache., (© 2012 American Headache Society.)

The objective of this study was to define "quality" of headache care, and develop indicators that are applicable in different settings and cultures and to all types of headache. No definition of quality of headache care has been formulated. Two sets of quality indicators, proposed in the US and UK, are limited to their localities and/or specific to migraine and their development received no input from people with headache. We first undertook a literature review. Then we conducted a series of focus-group consultations with key stakeholders (doctors, nurses and patients) in headache care. From the findings we proposed a large number of putative quality indicators, and refined these and reduced their number in consultations with larger international groups of stakeholder representatives. We formulated a definition of quality from the quality indicators. Five main themes were identified: (1) headache services; (2) health professionals; (3) patients; (4) financial resources; (5) political agenda and legislation. An initial list of 160 putative quality indicators in 14 domains was reduced to 30 indicators in 9 domains. These gave rise to the following multidimensional definition of quality of headache care: "Good-quality headache care achieves accurate diagnosis and individualized management, has appropriate referral pathways, educates patients about their headaches and their management, is convenient and comfortable, satisfies patients, is efficient and equitable, assesses outcomes and is safe." Quality in headache care is multidimensional and resides in nine essential domains that are of equal importance. The indicators are currently being tested for feasibility of use in clinical settings.

Widely accepted quality indicators for headache care would provide a basis not only for assessment of care but also, and more importantly, for its improvement. The objective of the study was to identify and summarize existing information on such indicators: specifically, did indicators exist, how had they been developed, what aspects of headache care did they relate to and how and with what utility were they being used? A systematic review of the medical literature was performed. A total of 32 articles met criteria for inclusion. We identified 55 existing headache quality indicators of which 37 evaluated processes of headache care. Most were relevant only to specific populations of patients and to care delivered in high-resource settings. Indicators had been used to describe overall quality of headache care at a national level, but not systematically applied to the evaluation and improvement of headache services in other settings. Some studies had evaluated the use of existing disability and quality of life instruments, but their findings had not been incorporated into quality indicators. Existing headache care quality indicators are incomplete and inadequate for purpose. They emphasize processes of care rather than structure or outcomes, and are not widely applicable to different levels and locations of headache care. Furthermore, they do not fully incorporate accepted evidence regarding optimal methods of care. There is a clear need for consensus-based indicators that fully reflect patients' and public-health priorities. Ideally, these will be valid across cultures and health-care settings.

Background: The burden of migraine is determined by impairment during attacks due to pain or non-painful symptoms such as cognitive symptoms., Objective: Development of a questionnaire to measure self-reported subjective cognitive symptoms during migraine attacks., Methods: Item generation was accomplished through structured patient interviews analysed by a panel of experts. A set of 43 candidate items was applied to consecutive migraine patients. Test construction with factor analysis retained nine items. Internal consistency was assessed with Cronbach's alpha and Spearman's rho, and convergent and construct validity by correlation to spontaneous cognitive complaints, and the 43-item and the Cognitive Failures Questionnaires., Results: The nine-item Mig-SCog covers two domains, executive functions and language. Cronbach's alpha was 0.82. It correlates with spontaneous cognitive complaints (p < 0.001), the 43-item (rho = 0.69) and the Cognitive Failures Questionnaires (rho = 0.61). Test-retest reliability (Cohen's kappa) was 0.55., Conclusions: Mig-SCog is a valid, reliable, consistent working instrument of fast self-administration that quantifies subjective cognitive symptoms during migraine attacks.

Arachnoid cysts represent a common, innocent, finding in routine neuroimaging of headache patients. We present the first report of symptomatic migraine with aura caused by the spontaneous rupture of a middle fossa arachnoid cyst into the subdural space. Brain imaging enabled an accurate diagnosis and, subsequently, adequate surgical management.

Background: The occurrence of headaches during cerebral angiography or endovascular procedures is an ill-defined issue, as limited information is available to define its frequency, risk factors, pathogenesis and implications for future pain management., Purpose: To determine the frequency of headaches during endovascular procedures (HdEVP) and to define their characteristics and risk factors for their occurrence., Methods: Prospective cross-sectional observational study of adult patients undertaking cerebral angiography or endovascular procedures, recording HdEVP clinical features, previous headache history and procedural variables., Results: One hundred and twenty two procedures were evaluated. HdEVP occurred in 13 patients, both in diagnostic and therapeutic procedures. Pain was described as brief, stabbing or localized pressure of mild to moderate intensity, felt ipsilaterally to the manipulated vessel. Its occurrence was associated with therapeutic interventions (p = 0.007), female gender (p = 0.015) and previous history of more than 4 headache episodes per month (p = 0.018)., Conclusion: HdEVP is an uncommon brief headache that should be further evaluated in the future. Its pathogenesis is probably related to mechanical vessel distension, which activates the trigeminovascular nociceptive system in susceptible individuals.

Hypnic headache is a rare form of primary headache with attacks occurring exclusively with sleep. As it is typical of the elderly, a wide range of alternative diagnosis must be considered. We present a case report of a 54-year-old woman with unsuspected secondary hypnic headache that was relieved by anti-hypertensive therapy. We reviewed the literature to evaluate the usual diagnostic workup performed in hypnic headache patients. We suggest that 24 h ambulatory blood pressure monitoring may be included in the evaluation of nocturnal headache complaints especially in the elderly, in whom essential hypertension is a very frequent comorbidity.