Aids to management of headache disorders in primary care (2nd edition) : on behalf of the European Headache Federation and Lifting The Burden: the Global Campaign against Headache

The Aids to Management are a product of the Global Campaign against Headache, a worldwide programme of action conducted in official relations with the World Health Organization. Developed in partnership with the European Headache Federation, they update the first edition published 11 years ago.The common headache disorders (migraine, tension-type headache and medication-overuse headache) are major causes of ill health. They should be managed in primary care, firstly because their management is generally not difficult, and secondly because they are so common. These Aids to Management, with the European principles of management of headache disorders in primary care as the core of their content, combine educational materials with practical management aids. They are supplemented by translation protocols, to ensure that translations are unchanged in meaning from the English-language originals.The Aids to Management may be individually downloaded and, as is the case for all products of the Global Campaign against Headache, are available without restriction for non-commercial use.

The headache under-response to treatment (HURT) questionnaire, an outcome measure to guide follow-up in primary care: development, psychometric evaluation and assessment of utility

Background

Headache disorders are both common and burdensome but, given the many people affected, provision of health care to all is challenging. Structured headache services based in primary care are the most efficient, equitable and cost-effective solution but place responsibility for managing most patients on health-care providers with limited training in headache care. The development of practical management aids for primary care is therefore a purpose of the Global Campaign against Headache. This manuscript presents an outcome measure, the Headache Under-Response to Treatment (HURT) questionnaire, describing its purpose, development, psychometric evaluation and assessment for clinical utility. The objective was a simple-to-use instrument that would both assess outcome and provide guidance to improving outcome, having utility across the range of headache disorders, across clinical settings and across countries and cultures.

Methods

After literature review, an expert consensus group drawn from all six world regions formulated HURT through item development and item reduction using item-response theory. Using the American Migraine Prevalence and Prevention Study’s general-population respondent panel, two mailed surveys assessed the psychometric properties of HURT, comparing it with other instruments as external validators. Reliability was assessed in patients in two culturally-contrasting clinical settings: headache specialist centres in Europe (n = 159) and primary-care centres in Saudi Arabia (n = 40). Clinical utility was assessed in similar settings (Europe n = 201; Saudi Arabia n = 342).

Results

The final instrument, an 8-item self-administered questionnaire, addressed headache frequency, disability, medication use and effect, patients’ perceptions of headache “control” and their understanding of their diagnoses. Psychometric evaluation revealed a two-factor model (headache frequency, disability and medication use; and medication efficacy and headache control), with scale properties apparently stable across disorders and correlating well and in the expected directions with external validators. The literature review found few instruments linking assessment to clinical advice or suggested actions: HURT appeared to fill this gap. In European specialist care, it showed utility as an outcome measure across headache disorders. In Saudi Arabian primary care, HURT (translated into Arabic) was reliable and responsive to clinical change.

Conclusions

With demonstrated validity and clinical utility across disorders, cultures and settings, HURT is available for clinical and research purposes.

Electronic supplementary material

The online version of this article (10.1186/s10194-018-0842-6) contains supplementary material, which is available to authorized users.

Comparative Efficacy of Eletriptan vs. Naratriptan in the Acute Treatment of Migraine

This was a randomized, double-blind study designed to evaluate the comparative efficacy and tolerability of the 40-mg dose of eletriptan and the 2.5-mg dose of naratriptan. Patients ( n = 548) meeting International Headache Society (IHS) criteria for migraine were randomized to treat a single migraine attack with either eletriptan 40 mg, naratriptan 2.5 mg, or placebo. Headache response rates at 2 h and 4 h, respectively, were 56% and 80% for eletriptan, 42% and 67% for naratriptan ( P < 0.01 for both time-points vs. eletriptan), and 31% and 44% for placebo ( P < 0.0001 vs. both active drugs at both time-points). Eletriptan also showed a significantly greater pain-free response at 2 h (35% vs. 18%; P < 0.001) as well as lower use of rescue medication (15% vs. 27%; P < 0.01) and higher sustained headache response at 24 h (38%) compared with naratriptan (27%; P < 0.05) and placebo (19%; P < 0.01). Both eletriptan and naratriptan were well tolerated. The results confirm previous meta-analyses that have suggested the superiority of eletriptan vs. naratriptan in the acute treatment of migraine.

Short-term frovatriptan for the prevention of difficult-to-treat menstrual migraine attacks

The efficacy of a 6-day regimen of frovatriptan for menstrual migraine (MM; attacks starting on day -2 to +3 of menses) prevention in women with difficult-to-treat MM was assessed. Women with a documented inadequate response to triptans for acute MM treatment were included in this placebo-controlled, parallel-group trial. Women were randomized to double-blind treatment for three perimenstrual periods (PMPs) with either frovatriptan 2.5 mg (q.d. or b.i.d.) or placebo initiated 2 days before anticipated MM. The efficacy analysis included 410 women with 85% completing three double-blind PMPs. The mean number of headache-free PMPs was 0.92 with frovatriptan b.i.d., 0.69 with frovatriptan q.d. and 0.42 with placebo [P < 0.001 (b.i.d.) and P < 0.02 (q.d.) vs. placebo]. When migraine occurred, severity was reduced with frovatriptan q.d. (P < 0.001) and b.i.d. (P < 0.001) vs. placebo. Both frovatriptan regimens were well tolerated. In women with difficult-to-treat MM, a 6-day regimen of frovatriptan significantly reduced MM incidence and severity.

Incidence of migraine relative to menstrual cycle phases of rising and falling estrogen

OBJECTIVE

To investigate the association between urinary hormone levels and migraine, with particular reference to rising and falling levels of estrogen across the menstrual cycle in women with menstrual and menstrually related migraine.

METHODS

Women with regular menstrual cycles, who were not using hormonal contraception or treatments and who experienced between one and four migraine attacks per month, one of which regularly occurred on or between days 1 +/- 2 of menstruation, were studied for three cycles. Women used a fertility monitor to identify ovulation, conducting a test each day as requested by the monitor, using a sample of early morning urine. Urine samples were collected daily for assay of estrone-3-glucuronide, pregnanediol 3-glucuronide, follicle-stimulating hormone, and luteinizing hormone. All women kept a daily migraine diary and continued their usual treatment for migraine.

RESULTS

Of 40 women recruited, data from 38 women were available for analysis. Compared with the expected number of attacks, there was a significantly higher number of migraine attacks during the late luteal/early follicular phase of falling estrogen and lower number of attacks during rising phases of estrogen.

CONCLUSION

These findings confirm a relationship between migraine and changing levels of estrogen, supporting the hypothesis of perimenstrual but not postovulatory estrogen "withdrawal" migraine. In addition, rising levels of estrogen appear to offer some protection against migraine.

Prevention of menstrual attacks of migraine: A double-blind placebo-controlled crossover study

OBJECTIVE

To assess the effect of perimenstrual estradiol supplements on menstrual attacks of migraine associated with estrogen withdrawal.

METHODS

Women with regular menstrual cycles and menstrual migraine or menstrually related migraine completed an initial three-cycle assessment confirming eligibility for a six-cycle crossover study using estradiol or placebo to prevent menstrual attacks of migraine. Women collected early morning samples of urine daily for laboratory assay and used a fertility monitor to identify peak fertility associated with ovulation. Estradiol gel or placebo was first applied on the tenth day following the first day of peak fertility and continued daily until, and including, the second full day of menstruation. Women kept a daily migraine diary and continued their usual treatment for migraine. The main outcome was the number of days during gel use on which a migraine occurred.

RESULTS

Data from 35 women were available for a paired analysis. Percutaneous estradiol was associated with a 22% reduction in migraine days (RR 0.78, 95% CI 0.62 to 0.99, p = 0.04); these migraines were less severe and less likely to be associated with nausea. This was, however, followed by a 40% increase in migraine in the 5 days following estradiol vs placebo (RR 1.40, 95% CI 1.03 to 1.92, p = 0.03).

CONCLUSION

Although perimenstrual percutaneous estradiol showed benefit during treatment, this was offset by deferred estrogen withdrawal, triggering post-dosing migraine immediately after the gel was stopped. Further work could assess if this could be avoided by extending the duration of treatment with estradiol.

Female sex hormones and migraine

During the reproductive years migraine is three times more common in women than in men. Although it is often assumed that this female preponderance is associated with the additional trigger of fluctuating sex hormones of the menstrual cycle, few studies have been undertaken to confirm or refute this. There is increasing evidence confirming an association between estrogen 'withdrawal' and attacks of migraine without aura, as well as evidence for an association between high estrogen states and attacks of migraine with aura.

Impact of migraine on patients and their families: the Migraine And Zolmitriptan Evaluation (MAZE) survey--Phase III

OBJECTIVE

To investigate the impact of migraine on migraineurs and their families and evaluate migraineurs' preference for different treatment formulations. This study also assessed the prevalence and impact of migraine with menstruation.

METHODS

Participants (n = 1028) from around the world (USA [39%], Canada [20%], Europe [37%] and other countries [4%]) completed an online questionnaire. Of these, 866 were migraineurs and 162 were non-migraineurs living with/related to migraineurs. Migraineurs were identified based on responses to a modified Kiel questionnaire and/or diagnosis of migraine by a doctor. Disability was quantified using the Migraine Disability Assessment Scale (MIDAS).

RESULTS

Migraineurs missed more days from family/leisure activities than from work/school (mean 4.2 vs 2.4 days) in the previous 3 months. On an additional 6.2 days within the 3-month period, productivity at work/school was reduced by at least half. Inability and reduced ability (by at least half) to perform household work were reported on 6.0 and 6.5 days, respectively. Of the women surveyed, 51% identified menstruation as a trigger for attacks and 6% reported attacks solely with menstruation (i. e. attacks occurred during menstruation on at least 9 out of 10 occasions), the latter associated with a higher pain score than other attacks. Living with or being related to a migraineur decreased nonmigraineurs' ability to participate in home/family life (moderate/great impact 49%) and social/leisure activities (moderate/great impact 47%). In a tradeoff analysis, 60% of treatment choice was driven by formulation type and 40% was driven by speed of onset. As migraine disability increased, speed of onset became more important.

CONCLUSIONS

This study confirms the significant burden of migraine on patients and families/cohabitants, highlighting not only reduced productivity and absences from work/school, but also time missed from family/social occasions. Many women identify menstruation to be associated with more painful attacks. Overall, in terms of treatment choice, formulation type was a more important driver than speed of onset; however, as migrainerelated disability escalates, speed of onset becomes more important. To optimise migraine management, treatment choice should be based on individual patients' needs and preferences.

Comparative efficacy of eletriptan and zolmitriptan in the acute treatment of migraine

Eletriptan 40 mg and 80 mg have shown greater efficacy in acute migraine than oral sumatriptan 100 mg and naratriptan 2.5 mg. This study continues the systematic series of active comparator trials in the eletriptan clinical development programme. In a multicentre double-blind, double-dummy, parallel-groups trial, 1587 outpatients with migraine by IHS criteria were randomised in a 3: 3 : 3: 1 ratio to eletriptan 80 mg, eletriptan 40 mg, zolmitriptan 2.5 mg or placebo. Of these, 1312 treated a single migraine attack and recorded baseline and outcome data to be included in the intention-to-treat population. The primary analysis was between eletriptan 80 mg and zolmitriptan. For the primary efficacy end-point of 2-h headache response, rates were 74% on eletriptan 80 mg, 64% on eletriptan 40 mg, 60% on zolmitriptan (P < 0.0001 vs. eletriptan 80 mg) and 22% on placebo (P < 0.0001 vs. all active treatments). Eletriptan 80 mg was superior to zolmitriptan on all secondary end-points at 1, 2 and 24 h, in most cases with statistical significance. Eletriptan 40 mg had similar efficacy to zolmitriptan 2.5 mg in earlier end-points, and significantly (P < 0.05) lower recurrence rate and need for rescue medication over 24 h. All treatments were well tolerated; 30-42% of patients on active treatments and 40% on placebo reported all-causality adverse events that were mostly mild and transient. On patients' global ratings of treatment, both eletriptan doses scored significantly better than zolmitriptan.

North Staffordshire Headache Survey: development, reliability and validity of a questionnaire for use in a general population survey

The North Staffordshire Headache Survey aims to measure the effect and impact of headaches, medicine use and healthcare utilization in a general population sample. A self-reporting questionnaire was piloted in a general population sample, with reliability being tested in a sample of pilot responders after one month and validity by comparing pilot responders with primary and secondary care headache consulters. One hundred and twenty-two (61%) responded to the pilot survey, with 56% of items having completion rates of 90% or more, and tests showed good internal consistency (>90%). One-month test-retest data showed good agreement, though questions relating to specific time periods (with partial or no overlap between survey periods) showed expected lower agreement. The headache consulters reported greater frequency, duration and severity of headaches than the population sample suggesting good construct validity. Results from these studies indicate that the questionnaire is a reliable and valid instrument to collect data about headaches in the general population.

Zolmitriptan orally disintegrating tablet is effective in the acute treatment of migraine

A new formulation of zolmitriptan has been developed that dissolves on the tongue without the need for additional fluid intake. In this double-blind, parallel study, 471 patients were randomized to receive the zolmitriptan orally disintegrating tablet 2.5 mg (n=231) or matching placebo (n=240) to treat a single moderate or severe migraine. Headache relief following zolmitriptan 2.5 mg (63%) was significantly greater than with placebo (22%) at 2 h post-dose (primary endpoint; P < 0.0001). The zolmitriptan orally disintegrating tablet was also significantly more effective than placebo for 1-, 2- and 4-h pain-free response (8% vs. 3%, P=0.0207, 27% vs. 7%, P < 0.0001, and 37% vs. 11%, P < 0.0001, respectively). Of those patients stating a preference, 70% of patients preferred the orally disintegrating tablet to a conventional tablet. Zolmitriptan orally disintegrating tablets are an effective and convenient alternative to a conventional tablet, allowing migraine attacks to be treated anytime a migraine strikes, which can facilitate earlier treatment.

Migraine-related disability: impact and implications for sufferers' lives and clinical issues

Migraine is a common, debilitating disorder that imposes a large personal burden on sufferers and high economic costs on society. Sufferers have a significant level of migraine-related disability in all aspects of their daily lives, including employment, household work, and non-work activities. Despite this burden of illness, physicians often do not diagnose or treat the illness effectively. Physicians consider that specific treatment is necessary when disability information is known but, until recently, no criteria have been available for assessment of migraine severity. Two studies indicate that information on disability is an important criterion in assessing migraine severity and influences physicians in their judgments of illness severity and treatment needs. However, physicians and patients often do not seek or share migraine-associated disability, which may contribute to suboptimal management. Efforts to improve knowledge of headache-related disability in the consultation have the potential to improve migraine management. An assessment tool that could reliably quantify headache-related disability has the potential for grading migraine severity and improving care.

Information about migraine disability influences physicians' perceptions of illness severity and treatment needs

OBJECTIVE

To assess physician-patient communication about headache-related disability and to evaluate the influence of information about disability on physicians' perceptions of illness severity and the treatment needs of migraineurs.

BACKGROUND

Evidence suggests that migraine is suboptimally treated in clinical practice, partly due to poor communication between physicians and their patients.

METHODS

One hundred five neurologists and primary care physicians with an interest in headache participated in two interactive surveys, one in North America (n=42) and one in Europe (n=63). Each survey focused on the evaluation of four videotaped migraine cases. The first case was evaluated twice, initially after a typical symptom history that centered on diagnosis and then following a fuller history of migraine disability. Additional questions assessed the extent of the collection of migraine disability information in clinical practice.

RESULTS

Physicians reported that they recorded symptoms relating to diagnosis (eg, pain location/intensity, associated symptoms) rather than information on headache-related disability. Only about one third of patients volunteered disability information. When made available to them, physicians rated information on disability as one of the most important factors in assessing treatment needs. In particular, when physicians knew the patient's disability history: (1) the proportion of physicians who rated the patient's illness as "severe" increased by 128% in North America, 27% in Europe; (2) the proportion of physicians who recommended immediate treatment increased by 63% in North America, 37% in Europe; and (3) the proportion of patients recommended for a follow-up visit increased by 15% in North America, 18% in Europe.

CONCLUSIONS

Physicians and patients often fail to discuss headache-related disability during consultation. This information has a powerful influence on physicians' perceptions of illness severity, treatment choice, and the need for follow-up. Tools to improve communication about headache-related disability, such as the Migraine Disability Assessment questionnaire, may favorably improve migraine management.

Relationship of sequence and structure to specificity in the alpha-amylase family of enzymes

The hydrolases and transferases that constitute the alpha-amylase family are multidomain proteins, but each has a catalytic domain in the form of a (beta/alpha)(8)-barrel, with the active site being at the C-terminal end of the barrel beta-strands. Although the enzymes are believed to share the same catalytic acids and a common mechanism of action, they have been assigned to three separate families - 13, 70 and 77 - in the classification scheme for glycoside hydrolases and transferases that is based on amino acid sequence similarities. Each enzyme has one glutamic acid and two aspartic acid residues necessary for activity, while most enzymes of the family also contain two histidine residues critical for transition state stabilisation. These five residues occur in four short sequences conserved throughout the family, and within such sequences some key amino acid residues are related to enzyme specificity. A table is given showing motifs distinctive for each specificity as extracted from 316 sequences, which should aid in identifying the enzyme from primary structure information. Where appropriate, existing problems with identification of some enzymes of the family are pointed out. For enzymes of known three-dimensional structure, action is discussed in terms of molecular architecture. The sequence-specificity and structure-specificity relationships described may provide useful pointers for rational protein engineering.

Anti-emetics

Nausea and vomiting are common symptoms of migraine, which can be controlled with a variety of anti-emetics including phenothiazines and antihistamines. Metoclopramide and domperidone have an additional prokinetic effect which may be important in migraine to overcome gastric stasis and enhance absorption of oral medication.

Contraception

The supremacy of combined oral contraceptives (OCs) is being challenged. For too long combined OCs have been seen as synonymous with contraception, helping to maintain ignorance of alternative methods. Further, the efficacy of these OCs and condoms is often compromised by incorrect or inconsistent use. We particularly welcome developments in male systemic methods, that allow men to share not only in conception but also in contraception, and methods that are completely forgettable once instituted, especially if usable by adolescents.

Risks and benefits of hormone replacement therapy

Menopause, the permanent cessation of menstruation, is due to ovarian failure, which may lead to oestrogen deficiency diseases, particularly osteoporosis, cardiovascular disease and cerebrovascular disease. Mortality and morbidity caused by these conditions can be modified by using hormone replacement therapy, but the benefits of this therapy must be weighed against the increased risk of breast cancer and the symptomatic side-effects the treatment may cause. The combination of transdermal oestrogen and natural progesterone offers the most favourable risk-to-benefit profile.

Migraine in a specialist menopause clinic

OBJECTIVES

Epidemiological studies suggest that migraine and headache worsen during the climacteric. The authors noted that women attending a specialist hospital-based menopause clinic frequently reported vasomotor and other common climacteric symptoms but few spontaneously reported headache or migraine. The aim of this study was to assess the prevalence of migraine and headache in women attending this clinic.

METHODS

Seventy-four women consecutively attending the menopause clinic at St. Bartholomew's Hospital were questioned about headache. Those with a positive response were further interviewed to obtain a headache diagnosis.

RESULTS

Headache was found to be a common symptom affecting 57% of women in the 3 months before attending a specialist menopause clinic. Migraine affected 29% of patients in the preceding 3 months. This condition was associated with significant disability: 80% of women reported that attacks were more frequent than once a month; 75% reported that the attacks were severe; 50% reported that the duration of treated attacks was longer than 1 day.

DISCUSSION

The high prevalence of headache and migraine in this group suggests that perimenopausal women should routinely be asked about headache and offered appropriate advice. This should include optimal attack therapy and strategies for preventing attacks, which may include hormone replacement therapy (HRT). Further studies are warranted to evaluate the relationship between climacteric symptoms, headaches, migraine and HRT.

Combined oral contraceptives, migraine and ischaemic stroke. Clinical and Scientific Committee of the Faculty of Family Planning and Reproductive Health Care and the Family Planning Association

The incidence of ischaemic stroke is low in women of reproductive age but increased in women with migraine, particularly if they also take combined oral contraceptives (COCs). Since there is limited evidence that this risk may be further focused on some groups of women with migraine, this paper presents current recommendations for COC use by a confirmed migraineur, pending further data.

S-fluoxetine in the prophylaxis of migraine: a phase II double-blind randomized placebo-controlled study

S-fluoxetine is the long-acting enantiomer of the racemic antidepressant serotonin reuptake inhibitor. Sixty-five patients needing migraine prophylaxis were recruited into a phase II, double-blind, placebo-controlled trial. After a 1-month placebo run-in, 53 patients met entry criteria with regard to attack frequency and were randomized, 27 to S-fluoxetine and 26 to matching placebo. Three failed to start treatment and there were 17 early discontinuations, 9 from S-fluoxetine, 8 from placebo, at similar times and for similar reasons. The primary efficacy variable was attack frequency and analysis compared decline-from-baseline in the two groups. This was earlier and greater (1.7 attacks/28 days, or 52%) on active therapy than on placebo (1.1 attacks/28 days, or 27%), and statistically significant in month 2 (F = 4.93; p = 0.033) and month 4 (F = 4.55; p = 0.041). As secondary measures of efficacy, migraine-days per month and Patient's Global Impression of Disease Severity coherently reflected the changes in attack frequency. Mean attack severity and acute medication use (doses per attack) were unaltered by either treatment. There were no serious adverse events. Withdrawals for adverse events were four from each group but none was considered causally related. The finding of greater efficacy of S-fluoxetine than of placebo should be interpreted conservatively, since the analysis in the final month was made on only half of the entered patients. It supports progression to phase III evaluation, which was the purpose of the study.

Substrate binding and catalytic mechanism of a barley beta-D-Glucosidase/(1,4)-beta-D-glucan exohydrolase

A beta-glucosidase, designated isoenzyme betaII, from germinated barley (Hordeum vulgare L.) hydrolyzes aryl-beta-glucosides and shares a high level of amino acid sequence similarity with beta-glucosidases of diverse origin. It releases glucose from the non-reducing termini of cellodextrins with catalytic efficiency factors, kcat/Km, that increase approximately 9-fold as the degree of polymerization of these substrates increases from 2 to 6. Thus, the enzyme has a specificity and action pattern characteristic of both beta-glucosidases (EC 3.2.1.21) and the polysaccharide exohydrolase, (1,4)-beta-glucan glucohydrolase (EC 3.2.1.74). At high concentrations (100 mM) of 4-nitrophenyl beta-glucoside, beta-glucosidase isoenzyme betaII catalyzes glycosyl transfer reactions, which generate 4-nitrophenyl-beta-laminaribioside, -cellobioside, and -gentiobioside. Subsite mapping with cellooligosaccharides indicates that the barley beta-glucosidase isoenzyme betaII has six substrate-binding subsites, each of which binds an individual beta-glucosyl residue. Amino acid residues Glu181 and Glu391 are identified as the probable catalytic acid and catalytic nucleophile, respectively. The enzyme is a family 1 glycoside hydrolase that is likely to adopt a (beta/alpha)8 barrel fold and in which the catalytic amino acid residues appear to be located at the bottom of a funnel-shaped pocket in the enzyme.

Zolmitriptan clinical studies

Zolmitriptan, a selective 5-HT(1B/D) agonist was developed for the acute treatment of migraine. Dose-finding studies show a clearly defined dose response curve for the oral formulation with onset of efficacy demonstrated within 45 min of dosing. Clinical trials support its efficacy in all types of migraine, with excellent safety and tolerability in those patients for whom zolmitriptan is not contraindicated. Future developments, including new formulations, will provide patients with a greater choice of treatment.

The doctor and the migraine patient: improving compliance

Migraine is an underdiagnosed and undertreated disorder. This can be attributed to the low consultation rate for migraine, for which many reasons have been proposed. These include the fact that many migraineurs self-treat and, historically, the lack of available effective treatments. Some migraineurs are referred to specialist centers for advice. These patients do not merely need effective pain relief. They also need an explanation of the cause of the migraine and reassurance that their headache pain does not have a more sinister cause. By spending time with patients and taking a full history of their migraine condition, the physician can propose a management strategy that is appropriate to each individual patient, thus providing a tailored-care approach. Thorough exploration of possible trigger factors for migraine and advice on avoidance may help to reduce attack frequency. Simple techniques can also be used to improve compliance with prescribed therapies. For example, it is important for the physician to establish that the patient understands any instructions given and to reinforce this advice at follow-up visits. Regular follow-up is important because it enables management strategies to be evaluated and helps the patients to feel involved in the management of their migraine. A correct understanding of the way a drug works and the nature of the condition, together with an explanation of any potential side effects, is likely to maximize clinical benefit.

Menstruation, sex hormones, and migraine

All women with migraine are susceptible to the effects of hormonal changes. For a minority with menstrual migraine, fluctuating hormones of the normal ovarian cycle are a specific trigger, particularly during perimenopause. The author proposes that the term menstrual migraine should be restricted to migraine attacks occurring on day 1 +/- 2 days of the menstrual cycle with freedom from migraine during the rest of the cycle. This definition is compatible with the mechanism of estrogen withdrawal. Other mechanisms such as prostaglandin release also may be important for some women. The changing hormonal environment at various stages of life provides further evidence of the role of estrogen in migraine. Treatments that stabilize hormone levels in the form of estrogen supplementation for menstrual migraine, elimination of the pill-free week, and adequate, stable levels of estrogen for HRT, all are associated with an improvement in migraine. The control of the menstrual cycle, however, is extremely complex, and until further studies are undertaken using strict criteria, the mechanism of migraine triggered by hormonal events remains uncertain.

"Menstrual" migraine: towards a definition

"Menstrual" migraine, a term misused by both patients and doctors, lacks precise definition. This dissertation critically reviews papers on the subject and examines the problem from a clinical perspective. A definition is proposed that the term "menstrual" migraine should be restricted to attacks exclusively starting on or between day 1 +/- 2 days of the menstrual cycle; the woman should be free from attacks at all other times of the cycle. This definition, unlike many used previously, links to a specific mechanism; the timing is consistent with oestrogen withdrawal. If this is correct, "oestrogen withdrawal" migraine may be a better term. Future studies, necessary to support or refute these proposals, are suggested.

A circularly permuted alpha-amylase-type alpha/beta-barrel structure in glucan-synthesizing glucosyltransferases

A motif of amino acid residues, located at the active site and specific beta-strands in alpha-amylases, is recognized in alpha-1,3- and alpha-1,6-glucan-synthesizing glucosyltransferases, leading to the conclusion that these enzymes contain an alpha/beta-barrel closely related to the (beta/alpha)8-fold of the alpha-amylase superfamily. The secondary structure elements of the transferase barrel, however, are circularly permuted to start with an alpha-helix equivalent to helix 3 in the alpha-amylases. Thus, the transferase counterpart of the long third beta-->alpha connection--constituting a domain in the alpha-amylases--is divided to precede and succeed the barrel. This architectural arrangement may be coupled to sucrose scission and glucosyl transfer. The involvement in the mechanism in glucosyltransferases of active site residues recurring in amylolytic enzymes is discussed.

Is abdominal pain a feature of adult migraine?

Recurrent abdominal pain in children, frequently diagnosed as "abdominal migraine," is thought to evolve into more typical migraine headache during the teens and twenties. If this transformation occurred, we would expect some adult migraineurs to retain abdominal pain; but we could not recall this symptom being mentioned by patients. However, without direct questioning the absence cannot be assumed. We, therefore, asked 100 migraineurs about abdominal symptoms during migraine attacks: only one experienced unexplained abdominal pain. We conclude that abdominal pain is not a feature in adult migraineurs, leading us to support the notions that: (1) recurrent abdominal pain of childhood has a number of causes; (2) abdominal migraine may be an incorrect attribution and is liable to be over diagnosed; (3) abdominal migraine requires more precise definition; (4) the transition from childhood abdominal migraine to adult migraine needs precise prospective study.

Migraine consultations: a triangle of viewpoints

Several studies have examined patients' attitudes to a consultation for migraine and other headaches. However, a patient's assessment of the problem for which they seek treatment may differ from that of the referring primary physician which may, in turn, differ from the specialist's. This study set out to examine this triangle. The commonest reason for referral was failure of treatment response. This contrasted with the patient's different perception--an increase in the frequency of attacks which we saw as headaches additional to migraine, accounting for failed treatment. Similarly, our view of the patient wanting reassurance paralleled their request for further information. These findings confirmed the hypothesis that recognizing and understanding a patient's fears were important factors towards a favorable outcome of a consultation.

Models for the action of barley alpha-amylase isozymes on linear substrates

The formation of maltodextrins, G1 to G12, during the hydrolysis of amylose by alpha-amylases 1 and 2 from barley malt was followed by HPLC. Similar, but not identical, distributions of products were obtained with the two alpha-amylase components. Maltose, G6, and G7 were major products, but G7 was degraded as hydrolysis proceeded. alpha-Amylase 1 produced more G1 and G3 than did alpha-amylase 2 at all stages of hydrolysis. Products formed during the hydrolysis of G9, G10, G11, and G12 by the two alpha-amylases were also determined. A different spectrum of products was observed with each substrate and small differences were observed in the action pattern of the two alpha-amylases, e.g., G3 and G7 were the major products formed during the hydrolysis of G10 by alpha-amylase 1, whereas G2 and G8 were the major products formed by alpha-amylase 2 on the same substrate. These results were used to develop a model of the active site of barley malt alpha-amylases. This site contains ten contiguous subsites with the catalytic site situated between subsites 7 and 8. The model can be used to predict hydrolysis patterns of amylose and maltodextrins by cereal alpha-amylases.

Migraine and the neck

Fifty patients with migraine were asked about the occurrence of neck symptoms during different phases of their attacks, and if they felt the neck could act as a precipitant. Of the 32 reporting neck pain or stiffness, 10 noted symptoms during the premonitory phase, 30 during the headache phase, and 10 postdromally. In 7 cases the pain radiated into the shoulder and in 1 case into the lumbar region. These findings indicate extracerebral involvement of the migraine process and an overlap between the trigeminal and cervical distribution.

Starch- and glycogen-debranching and branching enzymes: prediction of structural features of the catalytic (beta/alpha)8-barrel domain and evolutionary relationship to other amylolytic enzymes

Sequence alignment and structure prediction are used to locate catalytic alpha-amylase-type (beta/alpha)8-barrel domains and the positions of their beta-strands and alpha-helices in isoamylase, pullulanase, neopullulanase, alpha-amylase-pullulanase, dextran glucosidase, branching enzyme, and glycogen branching enzymes--all enzymes involved in hydrolysis or synthesis of alpha-1,6-glucosidic linkages in starch and related polysaccharides. This has allowed identification of the transferase active site of the glycogen debranching enzyme and the locations of beta-->alpha loops making up the active sites of all enzymes studied. Activity and specificity of the enzymes are discussed in terms of conserved amino acid residues and loop variations. An evolutionary distance tree of 47 amylolytic and related enzymes is built on 37 residues representing the four best conserved beta-strands of the barrel. It exhibits clusters of enzymes close in specificity, with the branching and glycogen debranching enzymes being the most distantly related.

Domperidone plus paracetamol in the treatment of migraine

This study was designed to evaluate the safety and efficacy of domperidone in combination with paracetamol in the treatment of migraine. Severity of headache, duration of migraine attack and overall efficacy of treatment were amongst the variables assessed in a randomized, double-blind, three-way cross-over comparison of 1 g paracetamol plus either domperidone 30 mg, domperidone 20 mg or placebo, taken at onset of headache. Forty-six patients attending the City of London Migraine Clinic completed the study. A significant difference was observed in the duration of the migraine attack: a median of 17.5 h with paracetamol alone was reduced to 12.0 h with the addition of domperidone 20 mg, and to 12.0 h with domperidone 30 mg. No significant adverse events were reported. A reduction in pain intensity and nausea was noted but this was not statistically significant. It was concluded that domperidone shortens the duration of a migraine attack and may help reduce headache and associated symptoms.

How many different headaches do you have?

Patients with migraine attending a specialist clinic often have more than one type of headache. One hundred and two patients attending the City of London Migraine Clinic for the first time were asked: "What type(s) of headache do you think you have?" A separate diagnosis was made by the doctor, who was blinded to the self-diagnosis. On clinic diagnosis, 27 (26.5%) patients were found to have migraine plus an additional non-migraine headache. When compared with the self-diagnosis, 15 (56%) of these had correctly self-diagnosed two types of headache. Many migraineurs can distinguish migraine from non-migraine headaches when they have both.

Migraine: an informative method of communication

The Keypad Audience Response System can be used to obtain simultaneous information from a large number of people in an audience. Answers to specific questions are transmitted from a keypad (pressed by each participant) to a computer. The results are displayed on a screen within 20 seconds, expressed as percentages of total responses to each question and presented as bar diagrams or pie charts. At a meeting of the British Migraine Association, over 100 migraineurs learned how their attacks differed from, or resembled those of others. The speakers were able to clarify and discuss both questions and answers which confirmed previous findings about attack duration, prodromes, postdromes, effect of pregnancy, oral contraceptives and the menopause. Three new points emerged which merit further study: 1. Hormone replacement therapy aggravated migraine in 42% of women, 27% noted an improvement, and 31% observed no alteration. 2. Twenty-five percent prefer to sit up during an attack. 3. Seven percent reported prolonged attacks (3-7 days). The use of keypads at seminars or lectures is valuable in promoting enthusiastic audience participation, and the understanding of the diverse symptoms and manifestations of a condition. Although observations cannot be extrapolated to a wider population because all audiences are a selected group, new points requiring research may be highlighted.

Handling of 5-hydroxytryptamine by platelets in migraine

There is little dispute that a link exists between 5-hydroxytryptamine (5HT) and migraine but the exact mechanism of an attack has yet to be established. The handling of 5HT by the platelet is regarded as a simple model of the handling of 5HT by nerve terminals. If differences are seen in how the platelets from migraineurs handle 5HT compared to those from a control population, it is possible that a similar difference exists in the nerve terminal. The Haemostatometer allows the rapid and simultaneous in vitro assessment of platelet function (shear-induced haemostasis), coagulation and thrombolysis from non anticoagulated blood samples. In this study, a baseline comparison of haemostasis was made on 20 migraineurs between attacks and 20 controls. No differences were found in the results from each of the two groups. 5 microM of 5HT was then added to blood taken from 10 migraineurs and 10 controls and the recordings were repeated. Again, no differences were found between the results from the two groups. In blood taken from both migraineurs and controls, the effect of 5HT was to significantly enhance clotting time and clot lysis. No effect was seen on primary aggregation. The possible reasons for and significance of these findings is discussed.

Ice cream headache--site, duration, and relationship to migraine

OBJECTIVE

To examine the characteristics of cold-induced headaches in a group of migraine patients, to compare these with their usual migraine headaches and with cold-induced headaches in a control population.

DESIGN

Subjects completed a structured questionnaire recording previous headache history along with the characteristics of any headache produced during supervised palatal and pharyngeal application of ice cream.

SUBJECTS

70 consecutive patients attending the City of London Migraine Clinic, and 50 pre-clinical medical and dental student volunteers from Queen Mary and Westfield College.

RESULTS

27% of the migraine patients and 40% of the students reported previous ice cream headaches. 17% of the migraine patients and 46% of the students developed headache following palatal application or a swallow of ice cream. Typically the headache was of early onset (x = 12.5s) and short duration (x = 21s), with a tendency for anterior headache on the same side as a palatal stimulus, and bilateral headache following an ice cream swallow. However, a significant minority experienced a previously unreported headache of late onset (x = 102s) and long duration (x = 236s) which tended to occur particularly after swallowing ice cream and to be less well localised to the side of the cold stimulus. Ice cream appeared not to be a common trigger for migraine, and there was no significant correlation between site of ice cream headache and usual site of migraine.

CONCLUSIONS

These findings confirm that cold stimulation of the palate or pharynx commonly produces a headache. In contrast to previous studies, our results suggest that the 'ice cream headache' is less common in migraine patients than the general population. A similar pattern of headache was produced in both migraine patients and controls, and apart from the few for whom an ice cream headache may trigger a migraine, the ice cream headache seems not to have any special significance for migraine patients.