The careful monitoring of the trigger factors of headache could be an important step in treatment, because their avoidance may lessen the frequency and severity of attacks. Furthermore, they may provide a clue to the aetiology of headache. The aim of the present study was to estimate the prevalence of tension-type headache (TTH) and to establish the frequency of precipitating factors in subjects with migraine and TTH in the adult population of Bakar, County of the Coast and Gorski Kotar, Croatia. Another important purpose of the study was to examine the relationship of the precipitating factors with migraine and TTH, and with migraine subtypes: migraine with aura (MA) and migraine without aura (MO). We performed a population-based survey using a 'face-to-face door-to-door' interview method. The surveyed population consisted of 5173 residents aged between 15 and 65 years. The 3794 participants (73.3%) were screened for headache history according to the International Headache Society (IHS) criteria. Headache screen-positive responders, 2475 (65.2%), were interviewed by trained medical students with a structured detailed interview focused on the precipitating factors. The following precipitating factors in lifetime migraineurs and tension-type headachers have been assessed: stress, sleep disturbances, eating habits, menstrual cycle, oral contraceptives, food items, afferent stimulation, changes in weather conditions and temperature, frequent travelling and physical activity. A total of 720 lifetime migraineurs and 1319 tension-type headachers have been identified. The most common precipitants for both migraine and TTH were stress and frequent travelling. Stress (odds ratio (OR) 1.4, 95% confidence interval (CI) 1.17, 1.69) was associated with migraine, whereas physical activity (OR 0.72, 95% CI 0.59, 0.87) was related to TTH. Considering MA and MO, frequent travelling (OR 2.2, 95% CI 1.59, 2.99), food items (OR 2.2, 95% CI 1.35, 3.51) and changes in weather conditions and temperature (OR 1.75, 95% CI 1.27, 2.41) exhibited a significant positive association with MA. The present study demonstrated that precipitant-dependent attacks are frequent among both migraineurs and tension-type headachers. Lifetime migraineurs experienced headache attacks preceded by triggering factors more frequently than tension-type headachers. MA was more frequently associated with precipitating factors than MO. We suggest that some triggering factors may contribute to the higher occurrence of precipitant-dependent headache attacks in susceptible individuals.

To the best of our knowledge, persistent visual symptoms, lasting months or years without evidence of infarction, a rare complication of migraine with aura, has been reported in only 20 patients. We report the case of a 43-year-old woman with a 31-year history of migraine with typical visual aura. At presentation, she experienced a visual aura in her right hemifield followed by a pulsating headache. The visual symptoms persisted. There were no abnormal findings on neurological and ophthalmological examinations, EEG, visual evoked potentials (VEPs), brain computed tomography and magnetic resonance imaging (MRI). Both brain single photon emission computed tomography (SPECT) and brain perfusion MRI revealed decreased left fronto-parieto-occipital and right occipital blood perfusion. A perfusion MRI, performed 7 months after symptom onset and almost complete extinction of symptoms, was normal. As previously reported, we demonstrated a cortical hypoperfusion by SPECT in a case of persistent visual aura. For the first time this finding was confirmed by perfusion MRI.

One hundred and one patients suffering from chronic daily headache (CDH) and medication overuse were treated, in an in-patient setting, with abrupt discontinuation of the medication overused, intravenous hydrating, and intravenous administration of benzodiazepines and ademetionine. The mean time to CDH resolution was 8.8 days. The in-patient withdrawal protocol used was effective, safe and well tolerated. There was a trend for a shorter time to CDH resolution in patients who overused triptans ( P = 0.062). There was no correlation between time to CDH resolution and either the type of initial primary headache or duration of medication abuse, whereas time to CDH resolution was related to daily drug intake ( P = 0.01). In multiple regression analysis, daily drug intake, age and type of medication overused were independent predictors of time to CDH resolution. At 3-months' follow-up, no patient had relapsed and was again overusing symptomatic medications. ᮀ Chronic daily headache, medication overuse headache, shortterm follow-up, withdrawal therapy

IntroductionIt is a matter of clinical experience that psychological factors, in particular stress, can exert notable effects on primary headaches. Several studies have shown that stress is one of the most common trigger factors for headache, both in migraine and in tension-type headache [1][2][3][4][5]. It is reasonable, therefore, that stress may exert effects on the clinical evolution of these headaches. For example, stressful events may increase headache frequency or promote transformation of an episodic headache into a chronic form. A chronic headache is one present on average more than 15 days per month [6]. A transformed headache is an originally episodic headache that developed into a chronic one.A stressful event is an environmental situation or psychological trauma that compromises or threatens wellbeing. Several models have been proposed to explain how stress can influence headache. More recent theories do not consider stress as a purely exogenous factor but recognise that stressful events can induce objective biological and psychological changes.Stress acts on the body via the endocrine system, autonomic nervous system and immune system [7][8][9]. These systems act as biological integrators in the body, functioning to maintain homeostasis. In turn they are influenced by such factors as genetic makeup or constitution, psychobiological imprinting and the external environment (the sum of physical, emotional and social stimuli). Stressful events affect the brain through inputs from the cortex, subcortical regions, and sensory organs, and from the endocrine system, provoking reactions mediated, principally, by the hypothalamo-hypophyseal-adrenal axis (CRH) and by the locus coeruleus (norepinephrine). The effects of these multifarious hormonal and neurotransmitter changes vary with the duration of the stressful stimulus. Prolonged and repeated exposure to stressful stimuli may lead to permanent functional changes and even to anatomical damage, and can thus assume the role of a pathogenetic agent or illness precursor. Abstract The aims of this study were to assess how stress affects chronic headaches, and in particular to determine whether events play a role in the transformation of an episodic headache into a chronic form. A population of 267 Italian patients with chronic headache (headache present on average more than 15 days per month) was studied. Our results confirm a triggering role of stress on headache. We also found that episodic headache (migraine in most patients, 74.1%) preceded the development of a chronic form in about 90% cases. Among these patients, in 44.8% a stressful event correlated with the transformation. Analysis of these events revealed that minor events played a greater role than major life events, suggesting that patients with transformed headache are characterised by a different way of reacting to stress.

Nontraumatic headache (NTH) is a common complaint and one of the most frequent presenting symptoms to the Emergency Department (ED). It accounts for 1.2%-4.5% of all visits and 10%-21% of all neurological consulting visits to the ED [1-5]. Furthermore, it is one of the main reasons for the request of an urgent neurological visit to establish a correct aetiological diagnosis of headache. High frequency in the general population and vagueness of the symptoms make headache a very worrying symptom with a need to exclude a situation of immediate danger. At the same time, this must not lead to an indiscriminate use of diagnostic investigations, such as computerised tomography, which, even though not invasive, represents a biological and economic burden for the whole population. Epidemiological studies on headache presenting to EDs allow us to know how frequently we will come across and what are the risk factors for types of secondary headaches