Living with chronic migraine: a qualitative study on female patients' perspectives from a specialised headache clinic in Spain

OBJECTIVES

The aim of this study was to explore the views and experiences of a group of Spanish women suffering from chronic migraine (CM).

SETTING

Headache clinic at a university hospital in Madrid (Spain).

PARTICIPANTS

Purposeful sampling of patients that attended a specialised headache clinic for the first time between June 2016 and February 2017 was performed. The patients included were females aged 18-65 and with positive diagnoses of CM according to the International Classification of Headache disorders (third edition, beta version), with or without medication overuse. Accordingly, 20 patients participated in the study with a mean age of 38.65 years (SD 13.85).

DESIGN

Qualitative phenomenological study.

METHODS

Data were collected through in-depth interviews, researchers' field notes and patients' drawings. A thematic analysis was performed following appropriate guidelines for qualitative research.

RESULTS

Five main themes describing the significance of suffering emerged: (a) the shame of suffering from an invisible condition; (b) treatment: between need, scepticism and fear; (c) looking for physicians' support and sincerity and fighting misconceptions; (d) limiting the impact on daily life through self-control; and (e) family and work: between understanding and disbelief. The disease is experienced as an invisible process, and the journey to diagnosis can be a long and tortuous one. Drug prescription by the physician is greeted with distrust and scepticism. Patients expect sincerity, support and the involvement of their doctors in relation to their disease. Pain becomes the main focus of the patient's life, and it requires considerable self-control. The disease has a strong impact in the work and family environment, where the patient may feel misunderstood.

CONCLUSIONS

Qualitative research offers insight into the way patients with CM experience their disease and it may be helpful in establishing a more fruitful relationship with these patients.

Infratrochlear neuralgia: A prospective series of seven patients treated with infratrochlear nerve blocks

Background Infratrochlear neuralgia is a recently described painful cranial neuropathy that causes pain in the internal angle of the orbit and the medial upper eyelid, the upper bridge of the nose and/or the lacrimal caruncle. We aim to present seven new cases of infratrochlear neuralgia treated with anaesthetic nerve blocks. Methods Over an 18-month period, we prospectively identified seven cases of infratrochlear neuralgia among the patients attending the Headache Unit in a tertiary hospital. Anaesthetic blocks were performed by injecting 0.5 cc of bupivacaine 0.5% at the emergence of the nerve above the internal canthus. Results All patients were women, and the mean age was 49.1 years (standard deviation, 17.9). The pain appeared at the internal angle of the orbit and/or the medial upper eyelid in six cases, and the whole territory of the infratrochlear nerve in one case. Six patients had continuous pain and one had episodes lasting 8-24 hours. All patients showed sensory disturbances within the painful area and tenderness upon palpation of the infratrochlear nerve. Nerve blocks resulted in complete and long-lasting relief in four patients and short-lasting relief in the other three patients. Conclusions Infratrochlear neuralgia should be considered among the neuralgic causes of orbital and periorbital pain. Anaesthetic blocks may assist clinicians in the diagnosis and may also be an effective therapy.

Lacrimal Nerve Blocks for Three New Cases of Lacrimal Neuralgia

OBJECTIVE

Our aim was to report three new cases of lacrimal neuralgia and their response to superficial nerve blocks.

BACKGROUND

Lacrimal neuralgia has been recently described as a pain in the territory supplied by the lacrimal nerve, at the lateral upper eyelid and/or the adjacent area of the temple. The pain is typically accompanied by tenderness on palpation of the lacrimal nerve at the superoexternal angle of the orbit.

METHODS

Between January 2015 and June 2016, we prospective identified three cases of lacrimal neuralgia among the patients attending the Headache Unit in a tertiary hospital. Anesthetic blocks were performed in all cases by inserting a 30-G needle on the emergence of the nerve and injecting 0.5 cc of bupivacaine 0.5% subcutaneously.

RESULTS

Three women aged 44, 49, and 51 presented with pain in the territory supplied by the lacrimal nerve. Two of them localized their pain in a small area of the right temple, while the remaining patient had pain in the right upper lateral eyelid and a small area of the lower lateral eyelid. The pain was continuous in two patients and episodic with attacks lasting 48 hours in one patient. All patients had tenderness on palpation of the lacrimal nerve. Anesthetic blocks confirmed the diagnosis of lacrimal neuralgia and provided the patients with long-lasting pain relief.

CONCLUSIONS

Lacrimal neuralgia should be considered among the neuralgic causes of orbital and periorbital pain. Superficial nerve blocks may assist clinicians in the diagnosis and may also be a therapeutic option.

Facial epicrania fugax: A prospective series of eight new cases

Introduction

Epicrania fugax (EF) is a primary headache whose main feature is the dynamic character of the pain. EF pain typically moves across different dermatomes in a linear or zigzag trajectory. Recently, a facial variant of EF has been described, with the pain starting in the lower face and radiating upwards.

Aim

We report eight patients with an EF-type of pain of facial location and either upward or downward radiation.

Methods

For each patient, we recorded relevant demographic and clinical data. Magnetic resonance imaging (MRI) with fast imaging employing steady state acquisition (FIESTA) was obtained in all cases for the assessment of neurovascular compression of the trigeminal nerve.

Results

There were seven women and one man, and the mean age was 76.1 years (standard deviation, 11.3). Six patients had a paroxysmal pain starting at the lower face and moving upwards, while two patients had downward radiation. The pain always followed a fixed linear trajectory across different dermatomes. All cases had triggers, and pain intensity was consistently severe. Half of the patients had accompanying autonomic features. Neurovascular compression with imprinting over the trigeminal root on the symptomatic side was identified in three patients. All cases responded to antiepileptic drugs, and three had spontaneous remissions.

Conclusions

This series reinforces the facial variant of EF and extends the phenotype with cases of downward radiation. It also contributes to enriching the differential diagnosis of facial pain. Neurovascular compression of the trigeminal nerve may be found in some cases, although a possible pathogenic link needs further research.

Possible Involvement of the Inhibition of NF-κB Factor in Anti-Inflammatory Actions That Melatonin Exerts on Mast Cells

Melatonin is a molecule endogenously produced in a wide variety of immune cells, including mast cells (RBL-2H3). It exhibits immunomodulatory, anti-inflammatory and anti-apoptotic properties. The physiologic mechanisms underlying these activities of melatonin have not been clarified in mast cells. This work is designed to determine the anti-inflammatory effect and mechanism of action of melatonin on activated mast cells. RBL-2H3 were pre-treated with exogenous melatonin (MELx) at physiological (100nM) and pharmacological (1 mM) doses for 30 min, washed and activated with PMACI (phorbol 12-myristate 13-acetate plus calcium ionophore A23187) for 2 h and 12 h. The data shows that pre-treatment of MELx in stimulated mast cells, significantly reduced the levels of endogenous melatonin production (MELn), TNF-α and IL-6. These effects are directly related with the MELx concentration used. MELx also inhibited IKK/NF-κB signal transduction pathway in stimulated mast cells. These results indicate a molecular basis for the ability of melatonin to prevent inflammation and for the treatment of allergic inflammatory diseases through the down-regulation of mast cell activation. J. Cell. Biochem. 117: 1926-1933, 2016. © 2016 Wiley Periodicals, Inc.

External Nasal Neuralgia: A Neuropathic Pain Within the Territory of the External Nasal Nerve

BACKGROUND

Nasal pain is a challenging diagnosis and very little has been reported in the neurological literature. The nose is a sophisticated structure regarding its innervation, which is supplied by the first and second divisions of the trigeminal nerve. Painful cranial neuropathies are an important group in the differential diagnosis, although they have been described only scarcely. Here, we report a case that can conform a non-traumatic external nasal nerve neuralgia.

CASE

A 76-year-old woman was referred to our office due to pain in her left nose. She was suffering from daily excruciating attacks, which were strictly limited to the territory supplied by her left external nasal nerve (left ala nasi and apex nasi). She denied previous traumatisms and the ancillary tests did not yield any underlying pathology. An anesthetic blockade of her left external nasal nerve achieved a marked reduction of the number of episodes as well as their intensity.

CONCLUSION

External nasal neuralgia seems a specific neuralgia causing nasal pain. Anesthetic blockades of the external nasal nerve may be a valid treatment for this condition.