BackgroundChronic migraine is a prevalent disabling disease, with major health-related burden and poor quality of life. Long-term use of preventive medications carries risk of side effects.ObjectivesThe aim of this study was to compare repetitive transcranial magnetic stimulation (rTMS) to botulinum toxin-A (BTX-A) injection as preventive therapies for chronic migraine.MethodsA pilot, randomized study was conducted on a small-scale sample of 29 Egyptian patients with chronic migraine, recruited from Kasr Al-Aini teaching hospital outpatient clinic and diagnosed according to ICHD-III (beta version). Patients were randomly assigned into two groups; 15 patients received BTX-A injection following the Phase III Research Evaluating Migraine Prophylaxis Therapy injection paradigm and 14 patients were subjected to 12 rTMS sessions delivered at high frequency (10 Hz) over the left motor cortex (MC, M1). All the patients were requested to have their 1-month headache calendar, and they were subjected to a baseline 25-item (beta version) Henry Ford Hospital Headache Disability Inventory (HDI), Headache Impact Test (HIT-6), and visual analogue scale assessment of headache intensity. The primary efficacy measures were headache frequency and severity; secondary measures were 25-item HDI, HIT-6, and number of acute medications. Follow-up visits were scheduled at weeks 4, 6, 8, 10, and 12 after baseline visit.ResultsA reduction in all outcome measures was achieved in both the groups. However, this improvement was more sustained in the BTX-A group, and both the therapies were well tolerated.ConclusionBTX-A injection and rTMS have favorable efficacy and safety profiles in chronic migraineurs. rTMS is of comparable efficacy to BTX-A injection in chronic migraine therapy, but with less sustained effect.

BackgroundMultiple sclerosis (MS) is a complex autoimmune disease with a heterogeneous presentation and diverse disease course. Recent studies indicate a rising prevalence of MS in the Middle East.ObjectiveTo characterize the demographics and disease features of Egyptian patients attending four tertiary referral MS centers in Cairo.Materials and methodsThis was a retrospective, observational study on 1,581 patients between 2001 and 2015. Medical records were reviewed and data were identified and extracted in a standardized electronic registry.ResultsThe mean age of disease onset was 26.6±7.8 years, with the majority being female (2.11:1). Relapsing–remitting MS was the most common type (75.1%). The main presenting symptom was motor weakness (43.9%), which was also the most frequent symptom during the disease course. Family history of MS was found in 2.28%. Higher initial Expanded Disability Status Scale score, black holes, and infratentorial lesions on initial magnetic resonance imaging were independent factors for disease progression by univariate analysis (OR 3.87 [95% CI 1.84–6.51], 4.14 [95% CI 3.08–5.58], 4.07 [95% CI 3.21–4.99], respectively); however, in multivariate analysis, only infratentorial lesions were an independent risk for disease progression (OR 6, 95% CI 2.99–12.02; P=0.0005).ConclusionThe results from this registry – the largest for MS in the Arab region to date – are comparable to other registries with slight differences.

BackgroundThe reported prevalence of headache disorders in Arab regions varies considerably between countries. This may be due to a lack of standardized survey instruments that capture the prevalence.Purpose of the studyOur goal was to construct and validate a structured headache questionnaire for Arabic-speaking headache patients to be used as an epidemiological survey instrument.MethodsWe developed a culturally adapted interviewer-administered questionnaire in Arabic language comprising two sets of questions. The first set included personal and sociodemographic data together with a screening question regarding the presence of headaches over the last year. The second set was designed to define the type and pattern of headaches according to the International Classification of Headache Disorders criteria (for subjects with “yes” answers on the screening question). Validation process took place in two phases through probability random sampling selected from 1,221 headache subjects collected in an epidemiological survey 3 (n=70) and 6 months (n=232) later. A detailed assessment of patients’ headaches was performed by neurologists (blinded from the questionnaire diagnosis) who clinically assessed the patients’ headache.ResultsThe validity of the questionnaire was tested in 232 subjects with a mean age of 41.2±10.9 years, 72.8% of whom were females. The mean time to complete the questionnaire was 8.4±1.7 minutes. The intraclass correlation coefficient was 0.903 (95% confidence interval: 0.875–0.925), the Cronbach κ coefficient was 0.775 (95% confidence interval: 0.682–0.837), and the percentage of agreement was 84.5%.ConclusionOur results support the use of this comprehensive questionnaire as a valid tool for headache assessment among Arabic-speaking patients.

Single-nucleotide polymorphisms (SNPs) in microRNA-146a (miRNA-146a) can be associated with the development of immune-system dysfunctions.The aim of this work is to correlate SNPs of miRNA-146a and its target gene, IRAK1, with susceptibility, clinical manifestations, and diseases progression in patients with systemic lupus erythematous (SLE) and multiple sclerosis (MS). Genotyping for miRNA-146a (rs2910164) and its target gene IRAK1 (rs3027898) was performed using real-time polymerase chain reaction (RT-PCR) in 80 patients with SLE and 70 patients with MS, as well as 120 healthy control individuals. A statistically significant difference was found between the frequencies of the genotypes and alleles of miRNA-146a (rs2910164) and IRAK1 (rs3027898), compared with the control group. Also, whereas the mutant allele G of miRNA-146a may be a factor in the pathogenesis of lupus nephritis, the mutant allele C of IRAK1 may play a role in lupus arthritis. Both genes may contribute to the susceptibility of patients to SLE and MS.

The emergence of the novel coronavirus disease 2019 (COVID-19) pandemic has become a major public health challenge of global concern since December 2019, when the virus was recognized in Wuhan, the capital city of Hubei province in China and epicenter of the COVID-19 epidemic. Given the novelty of COVID-19 and the lack of specific anti-virus therapies, the current management is essentially supportive. There is an absence of consensus on guidelines or treatment strategies for complex disorders such as multiple sclerosis (MS), in which the risk of infections is higher than in the general population. This is due to the overall impairment of the immune system typical of autoimmune diseases, in addition to accumulation of disabilities, and the iatrogenic effect generated by corticosteroids and the recommended disease-modifying therapies (DMTs). DMTs have different modes of action, but all modulate and interfere with the patient's immune response, thereby raising concerns about adverse effects, such as an increased susceptibility to infections. In this review, we analyze the evidence for use of DMTs during the current critical period and ratify an algorithmic approach for management to optimize care between keeping DMTs, with their infection hazards, or coming off them, with the risk of disease activation. We also provide an algorithmic approach to the management of breakthrough activity during the COVID-19 pandemic.