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The trochlear region is a source of distinct pain that may give rise to specific primary pain disorders (primary trochlear headache), but also modulate other pre-existing headache disorders such as migraine. The sensory innervation of this region, by a branch of the ophthalmic division of the trigeminal nerve, may explain the modulatory influence of the nociceptive afferents of this region over migraine headache. We propose the term "trochlear migraine" to refer to the coexistence of strictly unilateral migraine and ipsilateral trochleodynia, with the improvement of migraine being dependent on the resolution of the trochleodynia. Trochleitis is an inflammatory trochleodynia, being frequently idiopathic and rarely secondary to usually immunologic and rheumatologic disorders. We postulate that nociceptive afferents from the inner part of the orbit may sustain the activation of trigeminal neurons, thus sensitizing or exacerbating migraine. Decreasing the possible wind-up induced from this nociceptive afferent stimulation may be effective in controlling headache. [ABSTRACT FROM AUTHOR]

Background: The brain of migraineurs is hyperexcitable, particularly the occipital cortex, which is probably hypersensitive to light. Photophobia or hypersensitivity to light may be accounted for by an increased excitability of trigeminal, the visual pathways, and the occipital cortex., Objective: To study light sensitivity and photophobia by assessing the response to light stimuli with functional magnetic resonance imaging-blood oxygenation level dependent (fMRI-BOLD) of the occipital cortex in migraineurs and in controls. Also, to try to decipher the contribution of the occipital cortex to photophobia and whether the cortical reactivity of migraineurs may be part of a constitutional (defensive) mechanism or represents an acquired (sensitization) phenomenon., Methods: Nineteen patients with migraine (7 with aura and 12 without aura) and 19 controls were studied with fMRI-BOLD during 4 increasing light intensities. Eight axial image sections of 0.5 cm that covered the occipital cortex were acquired for each intensity. We measured the extension and the intensity of activation for every light stimuli. Photophobia was estimated according to a 0 to 3 semiquantitative scale of light discomfort., Results: Migraineurs had a significantly higher number of fMRI-activated voxels at low (320.4 for migraineurs [SD = 253.9] and 164.3 for controls [SD = 102.7], P = .027) and medium-low luminance levels (501.2 for migraineurs [SD = 279.5] and 331.1 for controls [SD = 194.3], P = .034) but not at medium-high (579.5 for migraineurs [SD = 201.4] and 510.2 for controls [SD = 239.5], P = .410) and high light stimuli (496.2 for migraineurs [SD = 216.2] and 394.7 for controls [SD = 240], P = .210). No differences were found with respect to the voxel activation intensity (amplitude of the BOLD wave) between migraineurs and controls (8.98 [SD = 2.58] vs 7.99 [SD = 2.57], P = .25; 10.82 [SD = 3.27] vs 9.81 [SD = 3.19], P = .31; 11.90 [SD = 3.18] vs 11.06 [SD = 2.56], P = .62; 11.45 [SD = 2.65] vs 10.25 [SD = 2.22], P = .16). Light discomfort was higher in the group of migraineurs at all the intensities tested, but there was no correlation with the number of activated voxels in the occipital cortex and photophobia. Repetitive light stimuli failed to demonstrate a lack of habituation in migraineurs., Conclusions: Migraineurs during interictal periods showed hyperxcitability of the visual cortex with a wider photoresponsive area, the underlying mechanism probably being dual: constitutional-defensive and acquired-sensitizating., (© 2011 American Headache Society.)

Introduction: Data on the reality of chronic migraine in our clinics are scarce. AIM. To know the frequency of consultation and attitude of the neurologist regarding chronic migraine, and the opinion of patients with this condition., Subjects and Methods: A total of 145 neurologists consulted electronically two questionnaires. The first tested the impact of chronic migraine and their approach in the daily practice. The second was filled in by the consecutive patients., Results: A total of 4.1% of patients consulted due to chronic migraine, mostly women in their forties. The average time for diagnosis was 28.7 months. All neurologists recommended preventive treatment from the beginning. More than a quarter kept this treatment for more than a year and used drug combinations. Only half thought that overuse was the reason for chronic migraine and the majority allowed non-steroidal anti-inflammatories and triptans at restricted doses. Only half of the patients knew they had chronic migraine. In their opinion, heredity and the absence of an early and serious treatment could contribute for chronic migraine development., Conclusions: Almost one patient per day consults due to chronic migraine, which gives an idea of its impact. A better feed-back with primary care level is necessary, if we consider that the delay in the diagnosis is longer than two years. The majority of neurologists follows the current recommendations of the Headache Group of the Spanish Society of Neurology.

Introduction: Migraine is the most common neurological consultation in our country. AIM. To analyse the satisfaction level of the patient with migraine attending our clinics., Patients and Methods: A total of 160 neurologists asked 10 consecutive migraine patients to fill in a satisfaction questionnaire., Results: The questionnaire was answered by 1330 patients. The most important factors they considered for their neurologists were professional experience and kindness. Patients thought neurologist should improve in time to explain treatment and accessibility. Almost 90% of patients considered that treatments for migraine had improved, but almost half of them were not satisfied with the management in primary care setting. Patients were more satisfied with symptomatic treatment (69.1%) than with preventatives (50.4%). More than half had a neuroimaging study due to their headaches. Only half thought that such an study would improve their satisfaction., Conclusions: The level of satisfaction of the migraine patient attending our clinics has improved in the last years. In patients' opinion the aspects which should be improved are the time to explain migraine and its treatment, accessibility and preventive treatment.

Introduction: Headache is the most frequent neurological reason for consultation in our country., Aim: To obtain descriptive data on the approach and satisfaction of the neurologist regarding the diagnosis, burden and management of headaches, and migraine in particular, together with the relationship with primary care physicians (PCP)., Subjects and Methods: A total of 160 neurologists participated and answered electronically five questionnaires during one year. The results for patients were obtained in a standard clinic day and for the first 10 patients., Results: The mean number of patients/day was 20.7. Thirty-six percent consulted due to headache, most under 50 and women. Half had migraine; in 70% daily activities were moderate-severely affected. Almost half had missed at least one work day due to migraine in the previous month. Neurologist considered that headache background of PCP should improve, mainly regarding preventive treatment. Complementary studies were asked in a rather low proportion of patients; CT (35%) being the most frequent. The majority indicated triptans, and in the mild phase of pain, and neuromodulators or beta-blockers for the preventive treatment., Conclusions: Migraine is the first reason for consultation in the Neurology Services of our country and impacts negatively in the quality of life of our patients, usually women below 50. Its management should be improved with a better feedback with PCP and the use of the most efficacious treatments.

Background: Use of preventive therapy for migraine is often recommended for only 6-9 months, but no randomised, placebo-controlled trials have investigated migraine frequency after the end of prophylaxis. We assessed the effects of discontinuation of topiramate after a treatment period of 6 months., Methods: 818 patients who have migraines were enrolled from 88 clinics in 21 countries. After a 4-8-week lead-in period, patients received topiramate in a 26-week open-label phase. Daily dose was increased from 25 mg to 100 mg in steps of 25 mg every week; the dose could be adjusted further in the range 50-200 mg/day, but was stable for the final 4 weeks. Patients were randomly assigned to continue this dose or switch to placebo for a 26-week double-blind phase. The primary endpoint was the difference in number of days with migraine during the last 4 weeks of the double-blind phase compared with the last 4 weeks of the open-label phase. Analysis was by intention to treat. This trial is registered with EudraCT, number 2005-000321-29., Findings: 559 patients (68.3%) completed the open-label phase; 514 entered the double-blind phase and were assigned to topiramate (n=255) or placebo (n=259). The mean increase in number of migraine days was greater in the placebo group (1.19 days in 4 weeks, 95% CI 0.71 to 1.66; p<0.0001) than in the topiramate group (0.10, -0.36 to 0.56; p=0.5756; mean difference between groups -1.09, -1.75 to -0.43; p=0.0011) [corrected] Patients in the placebo group had a greater number of days on acute medication than did those in the topiramate group (mean difference between groups -0.95, -1.49 to -0.41; p=0.0007). Quality of life, as assessed by the MIDAS questionnaire, fell in the placebo group but remained stable in the topiramate group. Patients were more satisfied with the efficacy of topiramate than with that of placebo, whereas satisfaction with tolerability was similar in both treatment groups., Interpretation: Sustained benefit was reported after discontinuation of topiramate, although number of migraine days did increase. These findings suggest that patients should be treated for 6 months, with the option to continue to 12 months in some patients.

Clinical features of different headache syndromes have been described in great detail; however, its pathophysiology remains poorly understood. We review the latest findings in both human imaging studies and experimental animals to explain the possible mechanisms involved in the genesis of headache syndromes.