Objectives-Chronic migraine (CM), previously called transformed migraine, is a frequent headache disorder that aVects 2%-3% of the general population. Analgesic overuse, insomnia, depression, and anxiety are disorders that are often comorbid with CM. Hypothalamic dysfunction has been implicated in its pathogenesis, but it has never been studied in patients with CM. The aim was to analyze hypothalamic involvement in CM by measurement of melatonin, prolactin, growth hormone, and cortisol nocturnal secretion. Methods-A total of 338 blood samples (13/patient) from 17 patients with CM and nine age and sex matched healthy volunteers were taken. Melatonin, prolactin, growth hormone, and cortisol concentrations were determined every hour for 12 hours. The presence of comorbid disorders was also evaluated. Results-An abnormal pattern of hypothalamic hormonal secretion was found in CM. This included: (1) a decreased nocturnal prolactin peak, (2) increased cortisol concentrations, (3) a delayed nocturnal melatonin peak in patients with CM, and (4) lower melatonin concentrations in patients with CM with insomnia. Growth hormone secretion did not diVer from controls. Conclusion-These results support hypothalamic involvement in CM, shown by a chronobiologic dysregulation, and a possible hyperdopaminergic state in patients with CM. Insomnia might be an important variable in the study findings. (J Neurol Neurosurg Psychiatry 2001;71:747-751)

Cluster headache is perhaps the most painful of the primary headache disorders. Its treatment includes acute, transitional, and preventive therapy. Despite the availability of many treatments, cluster headache patients can still be difficult to treat. We treated 14 cluster headache patients with greater occipital nerve block as transitional therapy (treatment initiated at the same time as preventive therapy). The mean number of headache-free days was 13.1+23.6. Four patients (28.5%) had a good response, five (35.7%) a moderate, and five (35.7%) no response. The greater occipital nerve block was well tolerated with no adverse events. Headache intensity, frequency and duration were significantly decreased comparing the week before with the week after the nerve block (P<0.003, P=0.003, P<0.005, respectively). Greater occipital nerve blockade is a therapeutic option for the transitional treatment of cluster headache. u Cluster headache, nerve block, occipital nerve

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Both preclinical and clinical data link glutamate to the migraine pathophisiology. Altered plasma, platelets and cerebrospinal (CSF) glutamate levels have been reported in migraine patients. Chronic migraine is comorbid with several conditions. It has been recently shown chronic migraine comorbidity with fibromyalgia. The objective of this study was to study cerebrospinal fluid glutamate levels in chronic migraine patients with and without fibromyalgia. We studied 20 chronic migraine patients, with and without fibromyalgia, compared to age-sex matched controls. CSF glutamate levels were measured by HPLC. CSF glutamate demonstrated significantly higher levels in patients with fibromyalgia compared to those without fibromyalgia. Patients overall had higher CSF glutamate levels than controls. Mean pain score correlated with glutamate levels in chronic migraine patients. Tender points, the hallmark of fibromyalgia, can be considered as pressure allodynia, and is probably mediated by central sensitization, with increase in CSF glutamate levels. We postulate chronic migraine patients with fibromyalgia, in addition to have more disabling headaches, suffer from a more severe central sensitization process. This subtype of patients may respond to medications modulating glutamate receptors. Headache intensity correlate with glutamate levels in chronic migraine patients.

There is now evidence that melatonin may have a role in the biological regulation of circadian rhythms, sleep, mood, and ageing. Altered melatonin levels in cluster headache and migraine have been documented. Melatonin mechanisms are related to headache pathophysiology in many ways, including its anti-inflammatory effect, toxic free radical scavenging, reduction of proinflammatory cytokine up-regulation, nitric oxide synthase activity and dopamine release inhibition, membrane stabilization, GABA and opioid analgesia potentiation, glutamate neurotoxicity protection, neurovascular regulation, serotonin modulation, and the similarity of chemical structure to that of indomethacin. Treatment of headache disorders with melatonin and other chronobiotic agents is promising. A double-blind, placebo-controlled trial shows melatonin is effective in cluster headache prevention, other studies also show benefit in other disorders. Melatonin plays an important role in headache disorders, offering new avenues for studying their pathophysiology and treatment.

Positive results of M1 stimulation in other studies, and the absence of significant benefits of active high-frequency rTMS of the DLPFC in the present study, point to M1 as a more promising target than the DLPFC, for larger trials of noninvasive brain stimulation in patients with chronic migraine.

Odorants, isolated or in association, especially perfume, may trigger migraine attacks after a few minutes of exposure.

The objectives of this study were to estimate the 1-year prevalence of chronic daily headache (CDH) and the degree of the association of CDH with some sociodemographic characteristics of the adult population of Brazil. This was a cross-sectional, population-based study. We conducted telephone interviews with 3848 people, aged 18-79 years, randomly selected from the 27 States of Brazil. The degree of the association was calculated through prevalence ratios, adjusted with Poisson regression by gender, age and some sociodemographic factors. The estimated 1-year gender- and age-adjusted prevalence of CDH was 6.9%. CDH was 2.4 times more prevalent in women, 1.72 times more in unemployed, 1.63 times more in subjects with high household income and two times greater in those who did not exercise. The overall prevalence of CDH in Brazil is high. CDH is significantly more prevalent in women, the unemployed, subjects with higher income, and in those who do not exercise.