Veronica Hackenthal, MD

Women often experience perimenopausal changes in headache frequency, when migraines may worsen or new types of headaches begin. The following case series describes a possible 

 that appears to develop in overweight/obese women around the time of 

The case series concerns eight women who were seen by a single neurologist at the 

 over the course of one year. All the women described recent onset (within the last year) bilateral daily head pain. Pain was worse in the morning just before rising from bed, with reported intensity ranging up to 10/10. Only one out of the eight women described co-occurring migraine features. None were able to identify triggers.

The average age of onset was 57 years (two women were perimenopausal, the remainder were menopausal). Six out of the eight had a history of 

, which was either well controlled or in remission when the new headache symptoms started. Six out of the eight were either overweight or obese.

All patients had normal ophthalmic exams, with no evidence of disc edema. Trendelenburg in the 10 degree head-down tilt position precipitated immediate worsening of symptoms in all patients. MRI with or without contrast and MR venography were normal, except for small incidental venous anomalies in three patients. Lumbar puncture (LP) was performed on two patients and showed normal to low opening pressure. Both developed 

LP was not deemed curative. All women showed rapid response (within 2 to7 days) with near complete resolution of symptoms when treated with acetazolamide (7 patients) or spironolactone (one patient). All experienced headache recurrence when tapering off medication, and none were able to completely taper off medication.

The case series appears to identify a new subtype of chronic daily headache in overweight/obese women in their fifties and sixties. The Trendelenburg position, an indication of increased intracranial pressure, appears to be diagnostic. While the etiology remains unknown, it could be related to cerebrospinal fluid (CSF) pressure high enough above baseline to cause headaches, but not severe enough to cause disc edema.

Why these women developed increased CSF pressure is unknown but multiple causes may have worked together to cause the condition.

Increased BMI has been linked to elevated intracranial pressure. But weight alone may not be to blame, because not all women in this series were overweight or obese. Other contributing factors can include cerebral venous congestion, venous anomaly, and decreased estrogen levels causing cerebral venous insufficiency.

Other causes of increased CSF pressure were ruled out but include: intracranial mass lesions, venous thrombosis, vessel stenosis, jugular vein compression, decreased CSF absorption (eg, from past meningitis or intracranial hemorrhage), or increased CSF production (eg, from a choroid plexus lesion or malignant systemic hypertension).

• This case series describes a possible 

 of daily headache in middle-aged overweight or obese women
• Trendelenburg position appeared diagnostic, and indicated increased intracranial pressure
• All women responded well to CSF-pressure lowering medication
• The cause of increased CSF pressure was unknown; contributing factors could be increased BMI, hormonal factors, venous anomaly, and/or venous congestion

A new subtype of chronic daily headache presenting in older women

Articles

This case series appears to identify a new subtype of chronic daily headache in overweight/obese women in their fifties and sixties.

New Type of Chronic Daily Headache in Older Women?

People admitted to the hospital for migraine with aura have over two times 

 for later readmission for transient ischemic attack (TIA).

 Sometimes called “mini-stroke,” a TIA occurs when blood flow to the brain is briefly interrupted without causing permanent neurological damage. TIAs can increase the risk for later stroke.

 also found that people admitted with severe migraine that does not respond to medication (status migrainosus) may have almost five times increased risk of later readmission for subarachnoid hemorrhage (SAH), or bleeding into the space around the brain.

 that about 9% of cerebrovascular events are missed upon initial ED evaluation, and that over 80% of cases initially misdiagnosed as headache were actually SAH.

 That study highlighted how misdiagnosis can delay accurate diagnosis of SAH, an often fatal condition.

“Given the high likelihood of misdiagnosis of TIA and SAH, this should raise awareness for physicians evaluating aura-positive patients for TIA symptoms to avoid misclassification. In addition, physicians evaluating patients for status migrainosus may need to 

 and evaluate more often for a sentinel bleed of SAH,” wrote first author Lili Velickovic Ostojic, MD,

 of Mount Sinai Downtown, New York, and colleagues.

To get a better idea of the risk of later cerebrovascular events associated with a hospital admission for migraine, researchers accessed 2013 admissions data housed in the Nationwide Readmissions Database, which includes all payers and uninsured individuals in the US. They used ICD-9 codes to identify 12,448 adult migraine admissions, of which 80.1% were women with a mean age 45.56 years.

About 24% of included individuals had migraine with aura and 14% had status migrainosus. Then they evaluated readmission for acute ischemic stroke, TIA, SAH, and intracerebral hemorrhage 30, 60, and 90 days after the migraine admission. Results were adjusted for age and vascular risk factors.

• 30-day readmission rate per 100,000 migraine admissions:

• Migraine with aura significantly linked to two times increased risk for readmission for TIA (HR 2.13, p <0.01)

• Status migrainosus significantly linked to almost 5 times increased risk for readmission for SAH (HR 4.83, p=0.04)

The authors mentioned that the study can only reveal associations and cannot prove cause and effect. For example, based on these results it is unclear whether migraine with aura actually causes TIA, or whether migraine with aura is being misdiagnosed as TIA in some cases. They noted that more research is needed to clarify causality.

• Nationwide administrative claims-based study found admission for migraine with aura was linked over two times increased risk for later readmission for TIA

• Status migrainosus was linked to almost four times increased risk for SAH

• Results cannot prove causality, but may suggest misdiagnosis in some cases

1. Velickovic Ostojic L, Liang JW, Sheikh HU, Dhamoon MS. 

Impact of Aura and Status Migrainosus on Readmissions for Vascular Events After Migraine Admission

2. Tarnutzer AA, Lee SH, Robinson KA, et al. 

ED misdiagnosis of cerebrovascular events in the era of modern neuroimaging: A meta-analysis

Researchers sought to find whether the risk of later cerebrovascular events was associated with a hospital admission for migraine.

Migraine: Putting TIA and Acute Ischemic Stroke in Perspective

Studies have found that children who take antiepileptic drugs (AEDs) have lower bone mineral density and increased fracture risk, compared with those who do not take AEDs.

 of children with epilepsy treated with AEDS matched to twins, siblings, or cousins not on AEDs found increased prevalence of bone fractures and decreased bone volume in AED users.

Some researchers have postulated that impaired vitamin D synthesis related to AEDs may explain the association, but vitamin D status was not statistically significant between cases and controls in this study.

Impaired bone and muscle development in young people treated with antiepileptic drugs

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 (ART) during the earliest phase of HIV infection may not be enough to prevent formation of viral reservoirs and enable cure or long-term ART-free HIV remission, according to a case study of 2 patients 

 “HIV relapsed despite initiation of ART at one of the earliest stages of acute HIV infection possible. Near complete loss of detectable HIV in blood and tissues did not lead to indefinite ART-free HIV remission,” wrote first author Timothy Henrich, MD, of University of California San Francisco, and colleagues.

One of the patients is the first documented case of an adult started on ART at one of the earliest opportunities after seroconversion. Other cases have been followed to see if some people can achieve functional “cure” for HIV. The Mississippi baby, a well-known example, tested positive for HIV at birth, was started on ART, and had undetectable HIV levels after a 5-month treatment interruption. Yet, at about age 4, HIV re-emerged. Other examples include 2 adult patients, one of which may harbor a genetic mutation associated with 

; the other underwent stem cell transplantation from a donor with a genetic mutation that prevents HIV entry into cells. In both patients, HIV levels have remained undetectable or extremely low off ART.

The problem with achieving cure or remission is the persistence of viral reservoirs in memory 

 in the blood or in tissues, which form a source of viral rebound upon ART discontinuation. To see whether very early initiation of ART can decrease viral reservoirs and prevent establishment of lifelong infection, doctors studied 2 individuals recruited from a pre-exposure prophylaxis (PrEP) program at the University of California San Francisco. Both patients initially tested negative for HIV, were started on 2-drug PrEP regimens, and then converted to standard 4-drug ART regimens after confirmed HIV infection.

Patient A was a 54-year-old man who was started on ART 10 days after HIV seroconversion, with peak plasma HIV RNA of 220 copies/mL. Viremia was fully suppressed on ART, with no detectable HIV from the ileum, rectum, lymph nodes, bone marrow, CSF, circulating CD4+ T cells, and plasma.

As part of the study, Patient A underwent treatment interruption after 32 weeks of being on ART. After stopping therapy, he remained without viremia for 7.4 months, after which he rebounded with HIV RNA of 36 copies/mL. Within 6 days, his viral load increased to 59,805 copies/mL, and ART was re-started. Rebound plasma HIV sequences were the same as those during acute infection. Mathematical modeling revealed that the latent reservoir size in Patient A was about 200 cells before treatment interruption. Researchers estimated that about 1% of people with a similar HIV burden might be able to achieve lifelong ART-free remission.

Patient B was a 31-year-old man who was started on ART about 12 days after seroconversion, with peak plasma HIV RNA of 3343 copies/mL. No HIV was detected in tissue samples. However, low-level HIV RNA or DNA were intermittently found in his blood and CD4+ Tcells, and he did not undergo treatment interruption.

Experiments in mice showed that 1 out of 10 mice that received CD4+ cells from patient A developed very low level HIV viremia (201 copies/mL). Three out of 8 mice that received CD4+ cells from Patient B developed HIV viremia (1000, 5000, and 11,000 copies/mL).

The researchers hypothesized that if a true “curative window” of opportunity exists, it may be very small. For example, 

 who are started on ART within 2 days of receiving SIV infection can prevent infection, while those started 3 days after receiving SIV experience viral rebound after 

 Henrich and colleagues concluded “. . . , although HIV persisted indefinitely in both of these PrEP cases, a continuum may exist across PrEP, postexposure prophylaxis, and early ART strategies. Further investigation in larger cohorts of individuals treated extremely early following HIV infection is warranted.” A limitation of the study was the very small sample size because of the rarity of individuals who present with very early HIV infection.


• ART started at the earliest stage of acute HIV infection did not prevent formation of latent viral reservoirs, nor did it prevent HIV rebound upon treatment discontinuation
• Viremia was fully suppressed for 2 years in Patient A but rebounded 7.4 months after treatment discontinuation
• Low-levels of HIV RNA or DNA were intermittently found in Patient B’s blood and CD4+ Tcells, and he did not undergo treatment interruption
• Mathematical modeling suggests that the latent reservoir size in Patient A was about 200 cells before treatment interruption; it is surmised that about 1% of people with a similar HIV burden may be able to achieve lifelong ART-free remission
• Larger studies are needed to determine whether a “curative window” exists during which extremely early ART initiation can prevent lifelong infection

1. Henrich TJ, Hatano H, Bacon O, et al. 

HIV-1 persistence following extremely early initiation of antiretroviral therapy (ART) during acute HIV-1 infection: an observational study

. PLoS Med. 2017;14:e1002417.
2. Lifson JD, Piatak M Jr, Cline An, et al. 

Transient early post-inoculation anti-retroviral treatment facilitates controlled infection with sparing of CA4+ T cells in gut-associated lymphoid tissues in SIVmas239-infected rhesus macaques, but not resistance to rechallenge

. J Med Primatol. 2003;32:201-210.
3. Whitney JB, Hill AL, Barouch DH. 

Rapid seeding of the viral reservoir prior to SIV viraemia in rhesus monkeys

Starting antiretroviral therapy during the earliest phase of HIV infection may not be enough to prevent formation of viral reservoirs and enable cure or long-term ART-free HIV remission.

Early Antiretroviral Therapy Initiation Does Not Lead to HIV Functional Cure

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A study conducted in Baltimore has suggested that African Americans under age 50 have a 61% higher likelihood of having a lacunar stroke than European Americans, and that hypertension represents a modifiable risk factor that may be involved. 

“While ethnicity, age, and sex are major non-modifiable risk factors for stroke, the modifiable risk factors remain a critical intervention point for physicians working to reduce future stroke risk,” wrote lead author John Cole, MD, and colleagues at the University of Maryland.

Young onset stroke before age 50 accounts for 10-15% of all strokes, and its incidence may be increasing, according to background information in the article. The effects of young onset stroke can be devastating, resulting in more years of life affected by disability, decreased productivity, and increased family burden. 

Studies have suggested higher frequencies of ischemic stroke and differences in age-related stroke mortality among young African Americans compared to European Americans. Reasons for these differences include higher prevalence and severity of stroke risk factors, lower socioeconomic status, and biological differences between African Americans and European Americans.

In the population-based study, researchers used discharge surveillance data drawn from 59 hospitals in the Baltimore-Washington area to identify cases of first ischemic stroke in individuals aged 15-49 (n=950; 441 female, 509 male, mean age 40 years). Researchers also identified cases via direct referral from neurologists. Cases came from three different studies: the Stroke Prevention in Young Women-1 study (1992-1996), the Stroke Prevention in Young Women-2 study (2001-2003), and the Stroke Prevention in Young Men study (2003-2007).

Researchers collected data on age, sex, and ethnicity using standardized interviews. Patients or proxies self-reported stroke risk factors (hypertension and smoking). Two vascular neurologists evaluated stroke subtypes using the Trial of Org 10172 in Acute Stroke Treatment (TOAST) criteria: lacunar (small vessel), large vessel (atherosclerotic), cardioembolic, other determined etiology, and unknown etiology.

Key results for individual TOAST subtypes vs. all other subtypes combined:

• African Americans had 61% higher likelihood of lacunar stroke compared to European Americans (OR = 1.61; 95 % CI = 1.12–2.32; P = 0.011) (analyses controlled for age and sex).

• Hypertension (analyses controlled for sex, ethnicity, and age):

♦ Double the likelihood of lacunar stroke (OR = 2.03; 95 % CI = 1.38–2.98; P = 0.0003)

♦ 1.7 times higher likelihood of larger artery stroke (OR = 1.70; 95 % CI = 1.01–2.88; P = 0.048)

♦ Hypertension may have mediated the increased risk for lacunar stroke in African Americans.

• People <40 years vs. those >40 (analyses controlled for sex and ethnicity):

♦ 1.62 times higher likelihood of cardioembolic stroke (OR = 1.62; 95 % CI = 1.15–2.27; P = 0.006)

• People >40 years vs. those <40 (analyses controlled for sex and ethnicity):

♦ 2.97 times higher likelihood of lacunar stroke (OR = 2.97; 95 % CI = 1.82–4.86; P <0.0001)

♦ 2.77 times higher likelihood of large artery stroke (OR = 2.77; 95 % CI = 1.39–5.55; P = 0.004)

• Current smokers had 79% higher likelihood of large artery stroke, compared to non-smokers (OR = 1.79; 95 % CI = 1.08–2.98; P = 0.024).

Small sample size in several TOAST subgroups may have limited the analysis because other traditional stroke risk factors like diabetes and past MI could not be explored. In addition, data on hyperlipidemia was inadequate, so the study did not include this variable. Finally, the study could not analyze other stroke etiologies like dissection and hypercoagulable states, as well as other risk factors seen in younger populations, like drug abuse and complications of pregnancy.

Nevertheless, the authors emphasized the critical importance of smoking cessation, and pointed out that hypertension may increase the risk for young onset ischemic stroke in ethnically specific ways.

“These findings may help clarify mechanisms of stroke in young adults, which may be partially driven by ethnic differences in the onset of early traditional stroke risk factors,” they concluded, “Awareness of these associations may improve a physician’s ability to recognize predisposing risk factors for a specific subtype of ischemic stroke within an individual, thereby indicating a differing emphasis on primary and secondary stroke prevention and infer on the workup after a stroke has occurred.”

• A Baltimore study found African Americans are at increased risk for young onset lacunar stroke, and that hypertension may play a role.

• Hypertension increases the likelihood of lacunar and large artery stroke.

• People under age 40 have a higher likelihood of cardioembolic stroke, while those age 40 and over have a higher likelihood of lacunar and large artery stroke.

• Smoking increases the risk of large artery stroke.

Ethnic differences in ischemic stroke subtypes in young-onset stroke: the Stroke Prevention in Young Adults Study

In ischemic stroke subtypes in young-onset stroke, researchers identify a modifiable risk factor in a high-risk group.

Ethnic Differences in Ischemic Stroke Risk

A new study may add pharmacoresistant epilepsy to the list of comorbidities associated with type 1 diabetes (T1DM). The UK study found that the prevalence of T1DM was twice as high among patients with pharmacoresistant epilepsy compared to the general population. The findings could shed new light on the underlying pathophysiology of these disorders, and have therapeutic implications.

The study is also important because it reports on the largest group of individuals with comorbid epilepsy and T1DM identified to date. Past studies looking at this issue have suffered from failure to differentiate between T1DM and T2DM.

In the study, researchers did a retrospective review of people with pharmacoresistant epilepsy who had been admitted to a tertiary care institution in the UK between January 2001 and January 2011. Researchers defined pharmacoresistant epilepsy as lack of seizure control during the past 12 months, despite trials of at least two different antiepileptic medications. They diagnosed epilepsy using clinical history, EEG, and MRI. T1DM was self-reported.

• The analysis included 2016 people with pharmacoresistant epilepsy, of which 20 had T1DM (point prevalence: 9.9 cases per 100 individuals).

• Estimates of the prevalence of T1DM in the general population range from 3.4-4.4 per 1000.

• In 80% of patients, T1DM preceded the development of epilepsy by a median of 1.5 years.

• Cryptogenic/unknown epilepsy was significantly more likely with T1DM, compared to T2DM or no diabetes (85% vs 35% and 40%, P=0.045).

• All patients with T1DM and epilepsy had focal epilepsy, of which 45% was temporal lobe epilepsy.

The increased prevalence of epilepsy among those with T1DM may have to do with anti-glutamic acid decarboxylase (GAD-A) antibodies, which could be the potential target of new therapies, the authors conjectured.

“A particular association between T1DM and cryptogenic/unknown epilepsy would be in keeping with the proposed pathophysiological link between T1DM and epilepsy, an autoimmune process associated with antibodies to glutamic acid decarboxylase [GAD-A],” wrote first author Mark Keezer of University College, London, UK, and colleagues in Switzerland and The Netherlands.

About 80% of people with T1DM have GAD-A, which may also be elevated in about 6% of people with epilepsy, according to background information in the article. Past studies have suggested that GAD-A may be more common in people with temporal lobe and pharmacoresistant focal epilepsy than generalized epilepsy. High GAD-A serum levels have also been linked to more severe epilepsy.

Potential therapeutic implications could include immunosuppressive therapy and antiepileptic drugs directed towards GABA, which may be more effective in patients with GAD-A, according to the authors.

“The prevalence of T1DM appears to be increased in people with pharmacoresistant epilepsy and is associated with cryptogenic/unknown epilepsy,” the authors concluded, “…Our findings may have pathophysiological as well as therapeutic implications, especially in the context of previous evidence regarding GAD-A.”

• A retrospective cohort study in the UK found that the prevalence of pharmacoresistant epilepsy is two times higher among patients with T1DM compared to estimates for the general population.

• In 80% of patients, T1DM preceded the development of epilepsy, and the vast majority had cryptogenic/unknown epilepsy.

• Many people with T1DM have anti-glutamic acid decarboxylase antibodies (GAD-A), which are also found in people with epilepsy.

• GAD-A may be involved in the underlying pathophysiology of T1DM and epilepsy, which could have therapeutic implications.

Type 1 diabetes mellitus in people with pharmacoresistant epilepsy: Prevalence and clinical characteristics

Recent findings could explain underlying pathophysiology of these disorders and have therapeutic implications.

Are Epilepsy and Type 1 Diabetes Linked?

A recent study may have given new meaning to the phrase “working yourself into an early grave.” The systematic review and meta-analysis included data from over 600,000 people, and suggested that long work hours can increase the risk of stroke by 33%. The risk of coronary heart disease (CHD) was also increased, but to a lesser extent than stroke.

Studies have suggested that long work hours could contribute to the development of cardiovascular disease, but most of the evidence comes from studies about CHD. Though both stress and sitting for long hours can increase the risk for stroke, not many studies have looked at long work hours and the risk for stroke. Other issues associated with long work hours, such as heavy drinking, may also increase the risk for stroke.

“Sudden death from overwork is often caused by stroke and is believed to result from a repetitive triggering of the stress response,” wrote first author Mika KivimÃ¤ki of University College in London, UK and colleagues with the Individual-Participant-Data Meta-analysis in Working Populations (IPD-Work) Consortium.

In the study, researchers conducted a search for prospective cohort studies published in English in PubMed and Embase from inception until August 20, 2014. They also did manual reviews of reference lists in selected publications, and did a citation search in Web of Science. Researchers addressed the possibility of publication bias by including unpublished data from 20 cohort studies housed in open access archives and from the IPD-Work Consortium.

The analysis included 25 studies from Europe, the USA, Israel, and Australia. The meta-analysis of CHD included 603,838 people, and the meta-analysis of stroke included 528,908 people. Standard work hours were considered 35-40 hours/week, while long work hours were considered ≥55 hours/week. Additional analyses were adjusted for age, sex, socioeconomic status, reverse causation (the possibility that employees with underlying CVD reduced their work hours in the period before a CV event), and different research methods for identifying stroke.

♦ 33% increased risk of stroke (relative risk [RR] 1.33, 95% CI 1.11-1.61, p=0.002)

♦ 13% increased risk of CHD (RR 1.13, 1.02-1.26, p=0.02)

• After adjustment, the link between long work hours and increased risk for stroke remained (range of RR estimates 1.30-1.42).

• A dose-response relationship between long work hours and increased risk for stroke (p

♦ 41-48 hours: 10% increased stroke risk (RR 1.10, 0.94-1.28, p=0.24)

♦ 49-54 hours: 27% increased stroke risk (RR 1.27, 1.03-1.56, p=0.03)

♦ ≥55 hours: 33% increased stroke risk (RR 1.33, 1.11-1.61, p=0.002)

“[O]ur meta-analysis shows that employees who work long hours have a higher risk of stroke than those working standard hours. However, the evidence for coronary heart disease is less persuasive,” the authors concluded. “Our findings suggest that more attention should be paid to the management of vascular risk factors in individuals who work long hours.”

Working ≥55 per week may increase the risk of stroke by 33%.

Working ≥55 per week may increase the risk of CHD by 13%.

Vascular risk factors in employees who work long hours should receive greater attention.

Long working hours and risk of coronary heart disease and stroke: a systematic review and meta-analysis of published and unpublished data for 603â838 individuals

We know working long hours is bad for our health, but which risk is greater, coronary heart disease or stroke?

Stroke Risk with Long Work Hours

Self-management training can improve the quality of life of patients with epilepsy, according to a small case-control study published in September. 

Epilepsy treatment has traditionally focused on medical therapy, sometimes to the exclusion of psychosocial and quality of life issues. Yet epilepsy can affect many factors that influence patients’ quality of life. Coping with chronic illness, medication issues and side effects, as well as cognitive and behavioral issues related to epilepsy can all have detrimental effects on quality of life. Stigma, especially in Asian countries, can impact epilepsy patients’ self-esteem and social functioning. Epilepsy can also negatively affect family stability, as well as financial, educational, and employment opportunities, according to background information in the article.

The case-control study included 60 patients being treated for epilepsy at the Zanjan Neurology Clinic, which is affiliated with a teaching hospital in Zanjan, Iran. Almost 62% of patients were 18-25 years old, 51.7% were male, and 95% had generalized seizures. Researchers randomized 30 patients to receive pamphlets and four training sessions about the medical aspects of epilepsy and self-management, including lifestyle and stress management. Controls (n=30) received routine clinical care. Patients completed self-reported, standardized quality of life questionnaires before and one month after the intervention. 

♦ Total quality of life: No statistical difference between the intervention and control groups (p=0.444).

♦ Total quality of life: Statistically different between the intervention and control groups (p<0.001).

♦ The intervention group had statistically better overall quality of life (p=0.004), social functioning (p=0.039), medication effects (p<0.001), cognitive functioning (p=0.014), energy/fatigue (p<0.001), mental health (p<0.001), and worry about seizures (p<0.001), compared to the control group.

• Patients had statistically significant differences in total quality of life before and after the study in the intervention group (p<0.001), but not in controls (p=0.620).

 “After the intervention, quality of life and its dimensions in the case group improved significantly, and the difference between case and control groups was statistically significant…” concluded first author Mohammed Ali Yadegary, MD, of Tehran University, and colleagues the Zajan University of Medical Sciences. “[T]raining patients and their families about epilepsy plays an important role in coping with the disease and increases patients’ self-confidence and self-management skills that make[s] patients aware of their needs and [how] to access specific resources [for] these needs.”

Epilepsy self-management programs should be started immediately after an epilepsy diagnosis, the authors recommended, because studies have suggested that starting these programs early can maximize their effect.

• Epilepsy can affect multiple variables that impact patients’ quality of life.

• A small case control study in Iran has found that patients who participated in an epilepsy self-management program had improved quality of life.

• Patients should start epilepsy self-management programs as soon as possible after receiving a diagnosis of epilepsy.

The effect of self-management training on health-related quality of life in patients with epilepsy

A group of doctors looked at the effect of incorporating quality of life management with traditional medical therapy for epilepsy treatment.

Improving Quality of Life in Epilepsy

Migraines affect about 43% of women and 18% of men over the course of their lifetimes.

In the US, medical costs due to migraine are estimated at $1 billion, with $16 billion lost in productivity per year.

Medical management is often ineffective. Botox is FDA approved for treating migraines but usually offers only temporary relief.

• Surgical treatment is based on the premise that peripheral sensory branches of the trigeminal and cervical spinal nerves become compressed and irritated, causing migraine.

• Surgery focuses on decompression of four main trigger points: frontal, temporal, nasoseptal, and occipital.

• As of October 2014, 17 clinical studies, including 2 RCTs, supported the efficacy of surgical decompression for migraines, with the overall success rate approaching 90%.

• Most common adverse events: transient numbness at the surgical site, incisional hair loss, intraoperative bleeding, transient uneven brow movement.

Study 2: Migraine Trigger Site Deactivation

• A migraine trigger site, where the migraine begins, is defined by anatomical areas innervated by branches of the trigeminal or occipital nerves.

• Compression of the nerve at these sites and irritation of surrounding structures can lead to inflammation and migraine.

• A recent study looked at 20 adult patients with bilateral temporal migraines.

♦ Patients received unilateral surgical decompression and unilateral neurectomy (on the opposite side) of the zygotemporal branch of the trigeminal nerve between January 2011 and August 2012.

♦ 19 patients completed the study at 12 months followup.

♦ 34/38 (89%) operative sites showed >50% improvement in migraine frequency, days, severity, and duration.

♦ 21/38 (55%) operative sites showed complete resolution of symptoms.

♦ No statistically significant difference was found between decompression vs neurectomy for decreased migraine frequency, days, severity, and duration.

• Conclusion: “Both avulsion neurectomy and decompression of the zygotemporal branch of the trigeminal nerve are equally effective methods for the treatment of temporal migraine headache… Performing decompression as the first option leaves avulsion neurectomy as another option if decompression fails to provide the intended relief.  It is our recommendation that whenever feasible, decompression should be attempted first.”

Migraine Symptoms for Decompression vs. Neurectomy

1. Migraine Headache index score = migraine frequency x duration x intensity

• Migraine among adolescents is common, often not adequately controlled, and has been linked to psychosocial problems like anxiety and depression.

• Topiramate is the only FDA approved drug for migraine prevention in adolescents, approved for ages 12-17.

• A recent retrospective review looked at the surgical outcomes for one surgeon, Bhaman Guruyon, who pioneered migraine surgery.

• The study included all adolescent patients ≤18 years with a family history of migraine into adulthood, and neurologist confirmed refractory migraine.

• Legal guardians completed a migraine headache questionnaire preoperatively and at each postoperative visit.

• Analysis included 14 patients and 15 operations (11 girls, 3 boys, average age 16 years, average followup 38.2 months).

♦ Migraine frequency and migraine days per month both decreased from 25 to 5 (P < 0.0001).

♦ Migraine index decreased from 148.1 to 12.4 (p < 0.001).

♦ Duration (number of hours/24 hours) decreased from 0.71 to 0.25 (p = 0.002).

♦ Migraine severity decreased from 8.2 to 4.3 (p = 0.0004).

♦ Five patients reported complete resolution of all migraine symptoms.

♦ One patient showed no improvement in frequency of migraine, but severity and duration did improve.

♦ No surgical complications were noted.

• Conclusion:  “In the adolescent population with migraine headaches refractory to traditional medical management, migraine surgery may offer symptomatic improvement of migraine headache frequency, duration, and severity in patients with identifiable anatomical trigger sites.”

• Migraine is a common problem, especially in women; medications and botox may not treat the underlying disorder.

• Studies suggest that surgical decompression for migraine may have an overall success rate approaching 90%.

• Neurectomy and decompression of the zygotemporal branch of the trigeminal nerve may be equally effective for treating temporal migraines.

• Surgical decompression may be effective for treating certain adolescents with migraine.

When medications no longer offer relief to your patients with migraines, surgical treatment may be the answer.