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See detailNeurophysiological tests and neuroimaging procedures in non-acute headache (2nd edition).
Sandrini, G.; Friberg, L.; Coppola, G. et al

in European Journal of Neurology (2011), 18

Background and purpose: A large number of instrumental investigations are used in patients with non-acute headache in both research and clinical fields. Although the literature has shown that most of ... [more ▼]

Background and purpose: A large number of instrumental investigations are used in patients with non-acute headache in both research and clinical fields. Although the literature has shown that most of these tools contributed greatly to increasing understanding of the pathogenesis of primary headache, they are of little or no value in the clinical setting. Methods: This paper provides an update of the 2004 EFNS guidelines and recommendations for the use of neurophysiological tools and neuroimaging procedures in non-acute headache (first edition). Even though the period since the publication of the first edition has seen an increase in the number of published papers dealing with this topic, the updated guidelines contain only minimal changes in the levels of evidence and grades of recommendation. Results: (i) Interictal EEG is not routinely indicated in the diagnostic evaluation of patients with headache. Interictal EEG is, however, indicated if the clinical history suggests a possible diagnosis of epilepsy (differential diagnosis). Ictal EEG could be useful in certain patients suffering from hemiplegic or basilar migraine. (ii) Recording evoked potentials is not recommended for the diagnosis of headache disorders. (iii) There is no evidence warranting recommendation of reflex responses or autonomic tests for the routine clinical examination of patients with headache. (iv) Manual palpation of pericranial muscles, with standardized palpation pressure, can be recommended for subdividing patient groups but not for diagnosis. Pain threshold measurements and EMG are not recommended as clinical diagnostic tests. (v) In adult and pediatric patients with migraine, with no recent change in attack pattern, no history of seizures, and no other focal neurological symptoms or signs, the routine use of neuroimaging is not warranted. In patients with trigeminal autonomic cephalalgia, neuroimaging should be carefully considered and may necessitate additional scanning of intracranial/cervical vasculature and/or the sellar/orbital/(para)nasal region. In patients with atypical headache patterns, a history of seizures and/or focal neurological symptoms or signs, MRI may be indicated. (vi) If attacks can be fully accounted for by the standard headache classification (IHS), a PET or SPECT scan will normally be of no further diagnostic value. Nuclear medical examinations of the cerebral circulation and metabolism can be carried out in subgroups of patients with headache for the diagnosis and evaluation of complications, when patients experience unusually severe attacks or when the quality or severity of attacks has changed. (vii) Transcranial Doppler examination is not helpful in headache diagnosis. Conclusion: Although many of the examinations described in the present guidelines are of little or no value in the clinical setting, most of the tools, including thermal pain thresholds and transcranial magnetic stimulation, have considerable potential for differential diagnostic evaluation as well as for the further exploration of headache pathophysiology and the effects of pharmacological treatment. [less ▲]

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See detailEFNS guideline on the treatment of tension-type headache - Report of an EFNS task force.
Bendtsen, L.; Evers, S.; Linde, M. et al

in European Journal of Neurology (2010)

Background: Tension-type headache (TTH) is the most prevalent headache type and is causing a high degree of disability. Treatment of frequent TTH is often difficult. Objectives: To give evidence-based or ... [more ▼]

Background: Tension-type headache (TTH) is the most prevalent headache type and is causing a high degree of disability. Treatment of frequent TTH is often difficult. Objectives: To give evidence-based or expert recommendations for the different treatment procedures in TTH based on a literature search and the consensus of an expert panel. Methods: All available medical reference systems were screened for the range of clinical studies on TTH. The findings in these studies were evaluated according to the recommendations of the EFNS resulting in level A, B or C recommendations and good practice points. Recommendations: Non-drug management should always be considered although the scientific basis is limited. Information, reassurance and identification of trigger factors may be rewarding. Electromyography (EMG) biofeedback has a documented effect in TTH, whilst cognitive-behavioural therapy and relaxation training most likely are effective. Physical therapy and acupuncture may be valuable options for patients with frequent TTH, but there is no robust scientific evidence for efficacy. Simple analgesics and non-steroidal anti-inflammatory drugs are recommended for the treatment of episodic TTH. Combination analgesics containing caffeine are drugs of second choice. Triptans, muscle relaxants and opioids should not be used. It is crucial to avoid frequent and excessive use of analgesics to prevent the development of medication-overuse headache. The tricyclic antidepressant amitriptyline is drug of first choice for the prophylactic treatment of chronic TTH. Mirtazapine and venlafaxine are drugs of second choice. The efficacy of the prophylactic drugs is often limited, and treatment may be hampered by side effects. [less ▲]

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See detailImplementation and evaluation of existing guidelines on the use of neurophysiological tests in non-acute migraine patients: a questionnaire survey of neurologists and primary care physicians.
Rossi, P.; Schoenen, Jean ULg; Bolla, M. et al

in European Journal of Neurology (2009), 16(8), 937-42

BACKGROUND AND PURPOSE: The main aims of this study were to evaluate: the diffusion, use and perception of the usefulness of the 2004 EFNS guidelines on neurophysiological testing in non-acute headache ... [more ▼]

BACKGROUND AND PURPOSE: The main aims of this study were to evaluate: the diffusion, use and perception of the usefulness of the 2004 EFNS guidelines on neurophysiological testing in non-acute headache patients; the frequency with which the different neurophysiological tests were recommended in non-acute migraine patients by physicians aware or unaware of the guidelines; and the appropriateness of the reasons given for recommending neurophysiological tests. METHODS: One hundred and fifty physicians selected amongst the members of the Italian societies of general practitioner (GPs), neurologists and headache specialists were contacted via e-mail and invited to fill in a questionnaire specially created for the study. RESULTS: Ninety-two percent of the headache specialists, 8.6% of the neurologists and 0% of the GPs were already aware of the EFNS guidelines. A significantly higher proportion of headache specialists had not recommended any neurophysiological tests to the migraine patients they had seen in the previous 3 months, whereas these tests had frequently been prescribed by the GPs and neurologists. Overall, 80%, 42% and 42.6% of the reasons given by headache specialists, neurologists and GPs, respectively, for recommending neurophysiological testing in their migraine patients were appropriate (P < 0.01). CONCLUSIONS: The diffusion of the EFNS guidelines on neurophysiological tests and neuroimaging procedures was found to be very limited amongst neurologists and GPs. The physicians aware of the EFNS guidelines recommended neurophysiological tests to migraine patients less frequently and more appropriately than physicians who were not aware of them. The most frequent misconceptions regarding neurophysiological tests concerned their perceived capacity to discriminate between migraine and secondary headaches or between migraine and other primary headaches. [less ▲]

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See detailEvaluation and proposal for optimization of neurophysiological tests in migraine: Part 2 - neuroimaging and the nitroglycerin test
Magis, Delphine ULg; Bendtsen, L.; Goadsby, P. J. et al

in Cephalalgia : An International Journal of Headache (2007), 27(12), 1339-1359

Neuroimaging methods have been widely used in headache and migraine research. They have provided invaluable information on brain perfusion, metabolism and structure during and outside of migraine attacks ... [more ▼]

Neuroimaging methods have been widely used in headache and migraine research. They have provided invaluable information on brain perfusion, metabolism and structure during and outside of migraine attacks, contributing to an improved understanding of the pathophysiology of the disorder. Human models of migraine attacks are indispensable tools in pathophysiological and therapeutic research. This review of neuroimaging methods and the attack-provoking nitroglycerin test is part an initiative by a task force within the EUROHEAD project (EU Strep LSHM-CT-2004-5044837-Workpackage 9) with the objective of critically evaluating neurophysiological tests used in migraine. The first part, presented in a companion paper, is devoted to electrophysiological methods, this second part to neuroimaging methods such as functional magnetic resonance imaging, positron emission tomography and voxel-based morphometry, as well as the nitroglycerin test. For each of these methods, we summarize the results, analyse the methodological limitations and propose recommendations for improved methodology and standardization of research protocols. [less ▲]

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See detailNeurophysiological tests and neuroimaging procedures in non-acute headache: guidelines and recommendations
Sandrini, G.; Friberg, L.; Janig, W. et al

in European Journal of Neurology (2004), 11(4), 217-224

The use of instrumental examinations in headache patients varies widely. In order to evaluate their usefulness, the most common instrumental procedures were evaluated, on the basis of evidence from the ... [more ▼]

The use of instrumental examinations in headache patients varies widely. In order to evaluate their usefulness, the most common instrumental procedures were evaluated, on the basis of evidence from the literature, by an EFNS Task Force (TF) on neurophysiological tests and imaging procedures in non-acute headache patients. The conclusions of the TF regarding each technique are expressed in the following guidelines for clinical use. 1 Interictal electroencephalography (EEG) is not routinely indicated in the diagnostic evaluation of headache patients. Interictal EEG is. however, indicated if the clinical history suggests a possible diagnosis of epilepsy (differential diagnosis). Ictal EEG could be useful in certain patients suffering from hemiplegic and basilar migraine. 2 Recording of evoked potentials is not recommended for the diagnosis of headache disorders. 3 There is no evidence to justify the recommendation of autonomic tests for the routine clinical examination of headache patients. 4 Manual palpation of pericranial muscles, with standardized palpation pressure, can be recommended for subdividing patient groups but not for diagnosis. Pressure algometry and electromyography (EMG) cannot be recommended as clinical diagnostic tests. 5 In adult and paediatric patients with migraine, with no recent change in attack pattern, no history of seizures, and no other Focal neurological signs or symptoms, the routine use of neuroimaging is not warranted. In patients with atypical headache patterns, a history Of seizures and/or focal neurological signs or symptoms, magnetic resonance imaging (MRI) may be indicated. 6 If attacks can be fully accounted for by the standard headache classification [International Headache Society (IHS)], a positron emission tomography (PET) or single-photon emission computerized tomography (SPECT) and scan will generally be of no further diagnostic value. 7 Nuclear medicine examinations of the cerebral circulation and metabolism can be carried out in Subgroups of headache patients for diagnosis and evaluation of complications, when patients experience unusually severe attacks, or when the quality or severity of attacks has changed. 8 Transcranial Doppler examination is not helpful in headache diagnosis. Although many of the examinations described are of little or no value in the clinical setting, most of the tools have a vast potential for further exploring the pathophysiology of headaches and the effects of pharmacological treatment. [less ▲]

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See detailInstrumental investigations in primary headache. An updated review and new perspectives
Friberg, L.; Sandrini, G.; Janig, W. et al

in Functional Neurology (2003), 18(3, JUL-SEP), 127-144

While some instrumental techniques are clearly useful for differentiating symptomatic forms from primary headache, the usefulness of certain other techniques, neurophysiological investigations in ... [more ▼]

While some instrumental techniques are clearly useful for differentiating symptomatic forms from primary headache, the usefulness of certain other techniques, neurophysiological investigations in particular, in clinical practice is still debated. A Task Force of the European Federation of Neurological Societies has recently proposed guidelines and recommendations on the use of neurophysiological tests and neuroimaging procedures in non-acute headache. This article reviews many of the most important literature references relevant to this topic and looks at the prospects for future research. [less ▲]

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See detailClinical and para-clinical tests in the routine examination of headache patients.
Friberg, L.; Sandrini, G.; Janig, W. et al

in Functional Neurology (2000), 15 Suppl 3

Para-clinical examinations in the diagnosis and treatment control of headache patients vary considerably between clinics and headache centers. Among the neurological societies in Europe there has been a ... [more ▼]

Para-clinical examinations in the diagnosis and treatment control of headache patients vary considerably between clinics and headache centers. Among the neurological societies in Europe there has been a consensus that some common procedures and recommendations should be created. In the Fall of 1998, the European Federation of Neurological Societies (EFNS) commissioned a Task Force on Neurophysiological Tests and Imaging Procedures in Headache Patients. Members of the Task Force are the present authors and we have reviewed the literature on 1) neurophysiological tests (EEG and evoked potentials), 2) autonomic nervous system and clinical tests and 3) imaging and cerebrovascular tests (X-ray, CT, MR, fMRI, PET, SPECT and transcranial Doppler). The literature was carefully evaluated with respect to validity and strength of the data. The task was to reach conclusions about each technique in the form of guidelines for clinical use. Finally, selected areas for future research will be outlined. The extensive review and the guidelines will be published by the EFNS during 2000. [less ▲]

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See detailInvestigations of migraine
Nappi, G.; Sandrini, G.; Schoenen, Jean ULg

in Ekbom, K. (Ed.) Migraine in General Practice: basic concepts (1993)

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