"Status trigeminal neuralgia": Analysis of 39 cases and proposal for diagnostic criteria

OBJECTIVE

The aim of this descriptive study was to propose diagnostic criteria for acute exacerbation of trigeminal neuralgia (TN) based on the analysis of retrospective cases.

BACKGROUND

TN is a rare and extremely painful condition whose evolution can be punctuated by major exacerbations, leading to significant functional impairment. Several denominations are used for these exacerbations: "acute exacerbation", "status of trigeminal neuralgia", and "status trigeminus". There is currently no clinical definition of this state. In this manuscript, we used the term "status trigeminal neuralgia" (STN).

METHODS

We conducted a retrospective study, in a tertiary care specialist headache center, in France. Patients were selected from January 2015 to October 2022, with the French translation of the keyword "STN", in the medical records (outpatients) or the codage for trigeminal neuralgia (inpatients). Additional cases of STN were prospectively recruited from October 2022 to February 2023. We analyzed the clinical and paraclinical data of these patients.

RESULTS

Thirty-nine patients presenting with STN were included. There was a preponderance of women (64%) with 24 cases of classic TN (62%) and 15 cases of secondary TN (38%). Concerning STN, 39 episodes were described. Pain was very severe in all patients. Cranial autonomic signs were present in 23% of cases. Pain extended beyond the usual territory in 44% of cases. A continuous pain background was present in 35% of cases. With regard to triggering factors, paroxysms of facial pain were triggered by eating (97% of patients), speaking (90%) or drinking (62% of patients). Repercussions on weight, hydration, or mood disorders were observed in 67%, 56% and 59% of the cases, respectively.

CONCLUSION

STN is a rare clinical presentation of TN. We proposed criteria and a new denomination for this condition.

Real-life study of the use of oto-acoustic emissions in the diagnosis of intracranial hypotension

BACKGROUND

The diagnosis of spontaneous or post-traumatic intracranial hypotension (IH) mainly relies on clinical features and neuro-imaging. However, the results of brain and spine magnetic resonance imaging are not always contributive. There is an interest for other non-invasive procedures, able to confirm or refute the diagnosis. The use of oto-acoustic emissions (OAE) was previously reported on isolated cases of IH associated with endolymphatic hydrops (ELH). The aim of this study was to assess the real-life utilization of this electrophysiological method in a larger population of suspected IH.

METHODS

A retro-prospective cohort study was conducted from November 2013 to July 2022 in patients with a suspected or doubtful diagnosis of IH. They were assessed for ELH by recording bilateral distortion product of oto-acoustic emissions (DPOAE) in sitting then in supine position.

RESULTS

Among the 32 patients assessed, the diagnostic of IH was confirmed in 18 patients. An ELH was shown in 15 of them (83%), but also in seven other patients. They had several differential diagnoses: chronic migraine, Chiari malformation, rebound intracranial hypertension and perilymph fistula.

CONCLUSIONS

This procedure seems to be insufficient to exclude differential diagnosis when intracranial hypotension is suspected.

Study of severe migraine in general medicine

OBJECTIVE

To evaluate the criteria of severe migraine in a general population consulting a general practitioner (GP) and to evaluate assessment of migraine severity in the migraine patient as well as treating physicians' knowledge of their patient's migraine and its severity.

METHODS

We questioned voluntary headache patients who had an appointment with a GP about the severity of their migraine using recognized scores - HIT-6 and MIDAS - as well as with a specific questionnaire created for the study. We compared the criteria for severe migraine with the patient's description of their symptoms, their HIT-6 score, their MIDAS score, and the GP's opinion, analyzing collected data using means and standard deviations.

RESULTS

We found that 152 out of 942 headache patients questioned in the general medicine setting met the criteria of "strict migraine", corresponding to 10.3% prevalence. Seventy-one out of 100 patients (71%) with migraine who filled out in the questionnaire completely had what is characterized as "severe migraine". Forty-one (57%) of the 71 severe migraine patients presented the strict criteria. Additionally, 21 of the 29 (72%) patients with a non-severe diagnosis agreed that their headache was non-severe. When the HIT-6 score was stratified above 65, correspondence between the questionnaire-derived diagnosis and patient perception of severity was observed in 36 of the 58 (62%) with severe migraine. Finally, participating GPs were aware of their patient's migraine for 60% of patients with migraine. GPs correctly classified the severity of their patient's migraine for 55 (36%) patients.

CONCLUSION

GP education and training about migraine remain a public health issue. The diagnosis of severe migraine is necessary for proper patient management. Current criteria for severe migraine are not robust enough; we propose a modification of the criteria.

Cyclic vomiting syndrome, a common language? A 20-year bibliometric study

BACKGROUND

Cyclic vomiting syndrome (CVS) is recognized as an episodic syndrome associated with migraine in the last version of the International Classification of Headache Disorders (ICHD-3). It manifests as stereotypical episodes of intense nausea and vomiting, occurring preferentially in childhood. Over the last 2 decades, the knowledge of this disorder has increased. The diagnostic criteria have been modified, through the evolution of several successive classifications. Actually, two classifications are prominent in the literature: the ICHD-3 and the Rome IV classification. The predictable periodicity of episodes is only recognized in the ICHD-3.

OBJECTIVE

We aimed to analyze the evolution of CVS literature in the last 2 decades, with a focus on CVS criteria used in these papers.

METHODS

We conducted a bibliometric study. We searched in the Web of Science database all papers in English literature with the term CVS in the abstract or title, in the category "article" or "review", published from 2001 to 2020. We searched within the paper which classification was used or mentioned.

RESULTS

In total, 213 papers were analyzed. 116 papers exclusively concerned childhood and adolescence CVS, or were written by pediatric practitioners. For most of the papers, the corresponding author was specialized in the field of gastroenterology. The Rome III classification was the main classification used or mentioned. The ICHD-3 and its beta version were mostly used or mentioned by the authors affiliated to the neurologic field.

CONCLUSION

This study shows the growth in the number of publications on CVS. It highlights the lack of reference to the ICHD, in particular by practitioners in the field of gastroduodenal disorders. This should encourage the achievement of a common classification with the different scientific societies.

The teaching of headache medicine in France: A questionnaire-based study

BACKGROUND

The treatment of patients with headache represents an important part of a neurologist's activity. It requires sufficient training for neurology residents. In France, residents in neurology can complete this training by attending specialized consultations or by participating in a postgraduate training program called "Diplôme Inter-Universitaire Migraine et Céphalées" (DIUMC).

OBJECTIVE

The objective of this cross-sectional study was to investigate the French residents' knowledge in headache medicine and the impact of different types of training in headache medicine that are available in France.

METHODS

An anonymous survey was carried out among 548 French residents in neurology.

RESULTS

The questionnaires of 121 residents (22.1%) were analyzed. Among them, 54.5% (66/121) had no complementary training apart from the internship (Group 1), 21.5% (26/121) had attended only specialized consultations (Group 2), and 24% (29/121) had participated in the DIUMC (Group 3). There was no difference between all groups regarding the knowledge of the prevalence of primary or chronic headaches. There was almost no difference between the groups in the management of episodic migraine. In contrast, the management of tension-type headache and chronic headache was better known by residents of Group 3 than residents of Group 1. In these two diseases, residents of Group 3 offered prophylactic treatment more often. Almost 29% of the residents (35/121) had read the French guidelines for the diagnosis and management of migraine. In Group 3, residents had read them significantly more often (1.6% in Group 1, 38.5% in Group 2 and 62.1% in Group 3, p < 0.001).

CONCLUSION

This study shows the lack of knowledge among French neurology residents regarding headache medicine. It highlights the interest of specific training programs that could improve the practical and theoretical knowledge of future neurologists.

Hemiplegic Migraine Associated With PRRT2 Mutations: A Clinical and Genetic Study

BACKGROUND AND OBJECTIVE

PRRT2 variants have been reported in a few cases of patients with hemiplegic migraine. To clarify the role of PRRT2 in familial hemiplegic migraine, we studied this gene in a large cohort of affected probands.

METHODS

PRRT2 was analyzed in 860 probands with hemiplegic migraine and PRRT2 mutations were identified in 30 probands. Genotyping of relatives identified a total of 49 persons with mutations whose clinical manifestations were detailed.

RESULTS

PRRT2 mutations were found in 12 of 163 probands previously tested negative for CACNA1A, ATP1A2 and SCN1A mutations, and in 18 of 697 consecutive probands screened simultaneously on the four genes. In this second group, pathogenic variants were found in 105 subjects, mostly in ATP1A2 (42%), followed by CACNA1A (26%), PRRT2 (17%) and SCN1A (15%). The PRRT2 mutations included seven distinct variants, five of which already described in persons with paroxysmal kinesigenic dyskinesia, and two new variants. Eight probands had a deletion of the whole PRRT2 gene.Among the 49 PRRT2 mutated patients, 26 had pure hemiplegic migraine, 16 had hemiplegic migraine associated with another manifestation: epilepsy (8), learning disabilities (5), hypersomnia (4) or abnormal movement (3). Three patients had epilepsy without migraine, two had paroxysmal kinesigenic dyskinesia without migraine, and one was asymptomatic.

CONCLUSION

PRRT2 should be regarded as the fourth autosomal dominant gene for hemiplegic migraine, and screened in any affected patient, together with the three other main genes. Further studies are needed to understand how the same loss of function PRRT2 mutations can lead to a wide range of neurologic phenotypes including paroxysmal movement disorder, epilepsy, learning disabilities, sleep disorder and hemiplegic migraine.

Episodic syndromes that may be associated with migraine: What adult neurologists need to know

Four episodic syndromes are recognized in the current version of the International Classification of Headache Disorders (ICHD): cyclic vomiting syndrome (CVS); abdominal migraine; benign paroxysmal vertigo; benign paroxysmal torticollis. Previously called childhood periodic syndromes, they are thought to be early expressions of a migrainous spectrum. They usually occur in childhood or adolescence and some of these patients will develop migraine later in childhood or in adulthood. More rarely, some of these disorders, in particular CVS and abdominal migraine, can persist or even begin at adulthood. The concept of episodic syndromes associated with migraine in adults is relatively recent, recognized for the first time in the version III-beta of the ICHD (2013). It is important for the adult neurologist to recognize the clinical pattern of these disorders. Lack of knowledge of these disorders often leads to delayed diagnosis, and a large number of complementary tests. Treatments are often borrowed from migraine abortive and preventive treatments. This review summarizes the characteristics of episodic syndromes and is particularly focused on data in adults.

The neurologist and the hydrops

The presence of endolymphatic hydrops has been studied in many neurological disorders. The pathophysiological mechanisms may involve CSF pressure variations, transmitted to the innear ear. This hydrops could play a role in vestibular or cochlear symptoms. For the ENT specialist, the etiological diagnosis of endolymphatic hydrops is a challenge, and neurological etiologies must be known. The treatment of these neurological causes could be effective on cochleo-vestibular symptoms. The knowledge of endolymphatic hydrops could also be a target for noninvasive tests, able to estimate CSF pressure variations. For the neurologist, this could represent a useful tool for the diagnosis and follow-up, in some of these neurological disorders, related to a CSF pressure imbalance. The purpose of this paper is to summarize literature data on endolymphatic hydrops in neurological disorders. We define some neurological conditions, for which there is a particular interest in noninvasive investigations of endolymphatic hydrops.

Genetic counselling difficulties and ethical implications of incidental findings from array-CGH: a 7-year national survey

Microarray-based comparative genomic hybridization (aCGH) is commonly used in diagnosing patients with intellectual disability (ID) with or without congenital malformation. Because aCGH interrogates with the whole genome, there is a risk of being confronted with incidental findings (IF). In order to anticipate the ethical issues of IF with the generalization of new genome-wide analysis technologies, we questioned French clinicians and cytogeneticists about the situations they have faced regarding IF from aCGH. Sixty-five IF were reported. Forty corresponded to autosomal dominant diseases with incomplete penetrance, 7 to autosomal dominant diseases with complete penetrance, 14 to X-linked diseases, and 4 were heterozygotes for autosomal recessive diseases with a high prevalence of heterozygotes in the population. Therapeutic/preventive measures or genetic counselling could be argued for all cases except four. These four IF were intentionally not returned to the patients. Clinicians reported difficulties in returning the results in 29% of the cases, mainly when the question of IF had not been anticipated. Indeed, at the time of the investigation, only 48% of the clinicians used consents mentioning the risk of IF. With the emergence of new technologies, there is a need to report such national experiences; they show the importance of pre-test information on IF.

Platination of the (T2G4)4 telomeric sequence: a structural and cross-linking study

The telomeric sequence (T(2)G(4))(4) was platinated in aqueous solutions containing 50 mM LiClO(4), NaClO(4), or KClO(4). The identification of the guanines which reacted with [Pt(NH(3))(3)(H(2)O)](2+) revealed that the same type of folding exists in the presence of the three cations and that the latter determine the relative stabilities of the G-quadruplex structures in the order K(+) > Na(+) >> Li(+). The tri-ammine complex yielded ca. 40--90% of adducts, mono- and poly-platinated, bound to 4 guanines out of the 16 guanines in the sequence, in the decreasing amounts G9 > G15 >> G3 > G21. The formation of these adducts was interpreted with a G-quadruplex structure obtained by restrained molecular dynamics (rMD) simulations which confirms the schematic model proposed by Williamson et al. [(1989) Cell 59, 871--880]. The bifunctional complexes cis- and trans-[Pt(NH(3))(2)(H(2)O)(2)](2+) also first reacted with G9 and G15 and gave cross-linked adducts between two guanines, which did not exceed 5% each of the products formed. Both the cis and trans isomers formed a G3-G15 platinum chelate, and the second also formed bis-chelates at both ends of the G-quadruplex structure: G3-G15/G9-G21 and G3-G15/G9-G24. The rMD simulations showed that the cross-linking reactions by the trans complex can occur without disturbing the stacking of the three G-quartets.

Respiratory history during infancy and childhood, and respiratory conditions in adulthood

The aim of this paper was to study respiratory disorders in infancy and childhood as a risk factor for respiratory conditions in adulthood. During the first part of the survey 15,247 adolescents in the Bordeaux area (average age: 16.5 years, boys = 46.6%) filled in a self-administered questionnaire concerning their respiratory history during infancy and childhood, their present symptoms and their smoking habits. Each subject with chronic cough (n = 538) was then matched with two controls (n = 1094) and the parents of these subjects and of their controls were sent a complementary questionnaire. During the second part, 1807 adults (average age: 39.3 years; men = 49.7%) working at Bordeaux University filled in a self-administered questionnaire about their present respiratory symptoms, smoking habits and respiratory symptoms during adolescence. Spirometry was performed in 172 adolescents and 1665 adults. The results of the first part showed a very significant relationship in adolescents between respiratory history during infancy and childhood and current chronic cough even in non-smokers, non-wheezers and non-asthmatics. The second part showed a very significant relationship in adults between respiratory symptoms during adolescence and present respiratory symptoms on the one hand, and a lower pulmonary function on the other, taking wheezing, smoking and asthma into account. In common with many similar studies, we conclude that respiratory disorders in young children may predispose to later disease, and that consequently it might be important to determine appropriate measures to prevent respiratory illness in childhood.

Respiratory function in flour-mill workers

The frequency of bronchial symptoms and the alteration of respiratory function parameters were studied in a group of 63 workers of an industrial flour-mill, and in a control group matched according to age, social class, and tobacco intake. In the exposed group the answers to a questionnaire indicated a greater incidence of cough (p less than 0.01) and chronic expectoration (p less than 0.01) as well as clinical airway hyperreactivity (p less than 0.01). No differences were noted for either asthma or allergy. The respiratory function parameters did not differ between the two groups studied. These results suggest that workers exposed to the vegetable dust found in fluor-mills are subject to develop chronic bronchial irritation.

[Respiratory history of children and chronic cough in adolescents]

The purpose of this work was to study the relation between respiratory history during childhood and teenagers' chronic cough and possible abnormalities of pulmonary function. This etiological survey was carried out among 538 pupils with a chronic cough and 1,094 controls (boys and girls), teenagers attending school in Bordeaux and its surroundings (average age, 16.7 years). The data were collected by means of self-administered questionnaires among the teenagers and their parents. Spirometry was performed in a randomised sample of 172 pupils. A significant relation was found between chronic cough and both respiratory history and a decrease of F.E.V.1 (in boys and girls) and F.E.F. 25-75 (in girls only). Moreover this relation was present also among the subjects with incomplete answers and in the group of non-asthmatics.