Abstract Background Red Ear Syndrome is a burning sensation and erythema of the ear, associated with a various number of disorders including migraine, trigeminal neuralgia, autoimmune disorders etc. Theories for RES pathophysiology have developed from current understandings of comorbid conditions. Characterizing the underlying mechanism of RES is crucial for defining effective treatments. Case presentation Three caucasian patients, ages 15, 47, and 67 years, with migraine, one with erythromelalgia are reported in this manuscript. RES pathophysiology is not fully understood due to its variable clinical presentation and numerous comorbid conditions, making it difficult to identify effective treatments. Conclusion RES seems to be largely treatment-resistant, and most options involve treating the associated disorders and minimizing pain. Further investigation of future cases should lead to a more comprehensive understanding of the fundamental cause of RES and, hopefully, successful treatments.

The standard of care paradigm for migraine treatment has been based almost exclusively on approaches that grew out of the happenstance use of market pharmaceuticals. Only methysergide, which has long since been removed from use for safety concerns, the ergotamine family of drugs, and the triptans were explicitly developed with migraine and other vascular headaches in mind. While the forward and innovative thinking to utilize the broad array of agents to treat migraine served millions well, their therapeutic efficacy was often low, and adverse event profiles were troublesome in the least. Advances in biochemical and molecular biology and the application of advanced "designing drugs" methods have brought about a potentially significant shift in treatment. The gepants have efficacies similar to the triptans but without vascular safety or medication overuse concerns. Preventative gepants offer innovative approaches to prevention and efficacy that exceed even the CGRP monoclonal antibodies. Those monoclonal antibodies brought rapid and highly effective outcomes across the spectrum of migraine. They outpaced older oral medication efficacy and eliminated most adverse events while potentially improving compliance with monthly or quarterly dosing. Other serotonin receptors beyond the 5HT1B and1D receptors have been targeted for decades. They now lead us to better formulations of dihydroergotamine for efficacy, convenience, and tolerability, and a 5HT1F-specific acute treatment like the gepants opens new options for acute management. Neuromodulation goes back to the mid-1800's. Our improved understanding of applied biomedical engineering has brought forward several tantalizing devices, including the application of currents distant from the target and patient regulated. Whether these advances change the paradigm of migraine treatment and standards of care remains to be seen, and issues such as cost and patient acceptance will help mold it.

SPECIALTY GRAND CHALLENGE article Front. Pain Res., 09 August 2021Sec. Headache https://doi.org/10.3389/fpain.2021.690683

OBJECTIVE: To report the first case of hyalinizing clear cell carcinoma (HCCC) with headaches as the presenting complaint and to emphasize importance of early diagnosis and treatment of this rare tumor which we believe is not as indolent as reported previously. BACKGROUND: HCCC is a rare, low-grade, malignant tumor of minor salivary glands which commonly involves the mucosa of oral cavity. This distinct clinico-pathological entity accounts for less than 1[percnt] of all salivary gland tumors. A rare location of this tumor is base of tongue, and only 12 cases (22[percnt]) have been reported at this site. It is commonly reported in females and the most common clinical presentation is a painless swelling. DESIGN: We report case of a 60 year old male with 2 year history of headaches and new onset dysphagia and dysarthria. RESULTS: CT-neck demonstrated a new hypodense, cystic lesion at left-base of tongue with another smaller cystic nodule in left level-III region, absent on comparison CT-neck in 2013. Initial cytomorphology and immunoprofile were consistent with poorly-differentiated salivary gland carcinoma with concerns for metastasis (pT2N1M0). Transcervical-resection of base of tongue was performed with limited left neck dissection. Pathology results came back for HCCC of minor salivary glands. Patient underwent post-op radiotherapy. He was seen in clinic four months later with no new complaints. He denied any headaches or neck pain, had passed swallow test and slurring of speech also improved. CONCLUSION: After reviewing the 55 cases of HCCC reported so far, we present first case of HCCC with headaches as the chief complaint. This case is unique not only by its clinical presentation but is also rare in terms of patient's sex, site of tumor and presence of nodal metastasis. Additional cases need to be reported to further define the behavior and clinical presentation of this rare tumor.

Only in recent years has there been a mandate, if you would, to study newer pharmaceutical agents in children and adolescents. As such, there is a paucity of well controlled clinical trials, let alone drugs that have been through registration trials in these age groups. Migraine, while less common especially in children than adults however still requires treatment. This has led healthcare providers to utilize treatments from the ?adult? world in these younger patients. Even in the adult population there are relatively few agents that are approved by the Food and Drug Administration (FDA) or other regulatory bodies compared to the many treatments that are given for the treatment of migraine. These treatments have varying levels of evidence for efficacy and tolerability. Multiple guidelines and recommendations have been published in recent years examining the evidence based medicine of migraine treatment offering guidance oriented towards primary care clinicians and neurologists whose primary focus is not headache medicine.

Introduction: There are multiple choices of agents for the acute management of migraine available. Patient-specific factors such as associated symptoms including nausea, vomiting, and gastroparesis are important considerations. Oral administration may often be the patient-preferred route of delivery because of comfort or convenience but when it is important to bypass gut absorption then either parenteral or intranasal administration may be appropriate delivery approaches. A new formulation of a low-dose sumatriptan intranasal powder administered via a novel breath-powered delivery device may be a viable option Areas covered: Our search of the available literature pertaining to the topic of intranasal sumatriptan powder yielded pharmacokinetic studies and randomized, double-blind, placebo-controlled trials (including The TARGET Study, The COMPASS study) published between 2010 and 2015. Expert commentary: A new formulation of a low-dose sumatriptan intranasal powder administered via a novel breath-powered delivery device appears to be a safe and efficacious option for the acute management of a migraine ideally suited for this situation. It appears to have superior efficacy to sumatriptan 100 mg oral tablets with superior pain freedom by 15 minutes and pain relief over the initial 30 minutes post-dose.

OBJECTIVE: To evaluate the incidence of adverse events (AEs) after administration of 1, 2, or 蠅3 MAP0004 doses/month over 1 year. BACKGROUND: The efficacy and safety of MAP0004, a dihydroergotamine (DHE) delivered through the lung via a breath-synchronized, metered-dose inhaler (TEMPO®), have been demonstrated for acutely treating migraine in placebo-controlled, double-blind trials. DHE has a long half-life and prolonged binding to 5-HT1B and 5-HT1D receptors. This post hoc analysis assessed whether an increase in AEs would occur after repeated DHE administration, because of these pharmacokinetic and pharmacodynamic properties. DESIGN/METHODS: This analysis used AE data from an open-label study to evaluate the safety and tolerability of MAP0004. Subject-reported AEs were recorded and mapped to organ systems and preferred terms using the Medical Dictionary for Regulatory Activities; this analysis counted only the population AE incidence by dose group, and did not track AE changes over time in individual patients. The incidence of AEs in subjects who administered 1 MAP0004 dose/month were compared with those who received 2 or 蠅3 MAP0004 doses/month. RESULTS: 288 subjects received 蠅1 MAP0004 doses/month for 12 months. 77 subjects received 1 dose/month, 121 received 2 doses/month, and 90 received 3-6 doses/month of MAP0004. The incidence of AEs was similar across the 3 groups. The most common AEs were upper respiratory infections, with similar incidence across the 3 groups. Potential DHE-related AEs (eg, nausea, gastrointestinal symptoms, fatigue, chest symptoms) were comparable across all 3 groups. Incidence of individual AEs showed that most were comparable across groups, and none of the AEs were observed in clinically significant higher frequency with repeated use of MAP0004. CONCLUSIONS: In this post-hoc analysis, repeated administration of up to 6 MAP0004 doses/month resulted in no increased incidence of drug-related AEs versus administration of 1 or 2 doses/month. Study Supported by: Allergan, Inc.

There are only a handful of drugs that have been submitted for and received an indication for the preventative treatment of migraine by the US Food and Drug Administration, as well as international governmental regulatory agencies. However, there are a wide variety of agents that are used for this indication with different levels of evidence for efficacy and tolerability. Several guidelines have been published in recent years examining the evidence-based medicine of migraine preventative therapy and these provide guidance especially for the primary care clinician, but also for neurologists whose primary focus is not headache medicine. Some of the therapies are used in children and adolescents while others are used more commonly in adults. In the adult population, an evolutive state of migraine is more commonly seen than in young persons, that is chronic migraine. There is a paucity of evidence for medications for this stage of migraine but there is a single agent that is approved for this use but not for use in the treatment of episodic migraine. There have been few advances in the field of migraine-preventative medications in recent years but potential novel approaches are in development.

We review the therapies for primary headache disorders: migraine, chronic migraine , tension-type headache, and cluster headache . Recommendations follow the evidence-based treatments so far as is possible with expert opinion to give clinical guidance. Headache has 2 levels of care: acute treatments designed to stop a headache from progressing and alleviate all symptoms associated with the headache and preventive therapies for patients whose headache frequency is such that by itself produces significant disability and impact on quality of life , or where the frequency of use of acute medications, regardless of efficacy, poses risks in terms of overuse or adverse events.

Headache is among the most common disabling pain complaints. While many patients are managed in primary care or referral neurology practices, some patients have refractive situations that necessitate referral to a tertiary headache center. Increasing frequency of headache is strongly associated with increasing disability and workplace absenteeism as well as increased healthcare utilization. Previous studies have demonstrated that headache care in a dedicated tertiary center is associated with a decrease in headache frequency and improvement in other characteristics that persist over extended periods of time. Previous studies have not examined the impact of this treatment on subsequent healthcare utilization and associated expenditures. In this study we examined the changes in healthcare utilization and expenditures as well as the impact on disability and workplace productivity with treatment in a tertiary headache care center that used initial treatment settings of inpatient and outpatient care and considered the difference between those with episodic migraine and those with chronic migraine and its complications. Tertiary care was found to produce positive reductions in disability, healthcare utilization, and expenditures. These results suggest that earlier tertiary-level intervention may avoid the complications of migraine that occur in some patients and the increasing costs and utilization of care associated with higher disability.

The treatment of migraine was transformed in 1992 with the introduction of the first triptan-based therapy, subcutaneous (SC) sumatriptan. SC sumatriptan has high efficacy and a rapid onset of action compared with other available triptans and formulations presumably because of its short T-max, high C-max, and avoidance of enteral absorption. Because of these characteristics, SC sumatriptan is still considered the most reliably and rapidly effective self-administered medication available for acute migraine. Even so, it is relatively little used possibly in part because of patient "needle-phobia." The needle-free sumatriptan injection system (Sumavel DosePro) was developed to address this concern. Clinical trials have shown that the needle-free system is bioequivalent to needle-based injection systems, easy to use, and capable of providing rapid and effective symptom relief for many migraine episodes. Sumavel DosePro is an effective treatment for migraine and should be part of the therapeutic armamentarium, particularly in cases where a rapid onset of action is critical or where oral administration is problematic.

Although tension-type headache is ubiquitous, only a relatively small percentage of the population has these headaches occurring with sufficient frequency and severity to cause them to seek out medical attention. This small group, however, may have substantial impact from their disease on productivity and quality of life. Assessment of the headaches includes assessment for other headache disorders that may overlap it, such as a chronic migraine. Additionally, coexisting diseases that may contribute to the process, such as mood disorders and mechanical disorders of the spine and neck, require investigation. Treatment is optimized by appropriate use of acute medications and preventive treatments that may include drugs in the antidepressant classes along with nonpharmacologic modalities and other alternative treatments ranging from biofeedback to manual therapy to the use of botulinum toxin type A injections.