Background: Time in headache disorders is crucial for diagnosis and gives insight into headache pathophysiology. Objective: To summarize published studies which describe timing processes in both attack presentation (onset, duration) and disease characterization (age of onset, evolution over time) in primary headache disorders and link to pathophysiology. Methods: A comprehensive search was conducted through Ovid MEDLINE(R) and PubMed, focusing on English-language articles from 1946 to 2023 to write the review. The International Classification of Headache Disorders, 3rd edition provided the framework for the review of primary headache disorders (migraine, tension-type headache and cluster headache). Results: Attack presentation: Migraine attacks exhibit significant circadian and infradian rhythms, influenced by hormonal levels, light sensitivity, and hypothalamic activation. Tension-type headache lacks clear chronobiological patterns, with limited understanding of its underlying mechanisms. Cluster headache displays a distinct circannual pattern, with attacks often occurring at night and relevant involvement of the hypothalamus. Disease characterization: Age of onset exhibits the earliest peak in migraine; frequency and typical features of primary headache disorders decrease over time. Conclusion: This comprehensive analysis of time patterns in primary headache disorders underscores their role in phenotyping, understanding and treating primary headache disorders, offering promising avenues for advancing and tailoring headache management.

Aim: To evaluate the effectiveness and tolerability of non-invasive vagus nerve stimulation (nVNS) as acute or preventive treatment, or both, in a cohort of trigeminal autonomic cephalalgia (TAC) patients. Methods: A service evaluation retrospectively included patients with TACs between January 2014 and February 2025 who had used, or currently use, nVNS. Data were collected from clinical letters. Data are presented as descriptive statistics analysis and non-parametric tests were performed. Results: In total, 108 patients were included, 74 patients with cluster headache (CH), 10 with paroxysmal hemicrania, 15 with hemicrania continua, four with short-lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT), three with short-lasting unilateral neuralgiform with cranial autonomic symptoms (SUNA) and two with an undifferentiated TAC. Overall, 70 patients considered nVNS useful over a median time using nVNS of 47 (interquartile range = 18–66) months. The median time of use in patients who did not find nVNS useful was 7 (interquartile range = 4–12) months. Twenty-three patients reported an adverse event (AE), while no serious treatment-related AEs occurred. Fifty-nine patients withdrew from using the device, including 11 patients that initially reported nVNS as useful. All groups considered nVNS more useful as preventive, while cluster headache and SUNCT/SUNA patients also considered it useful as acute treatment. Conclusions: Our findings complement previous evidence of the effectiveness and tolerability of nVNS in CH in addition to other forms of TACs. Interestingly, nVNS seems to be more effective as preventive rather than as acute treatment in our cohort.

Aim: To quantify delays in migraine diagnosis and treatment in an Australian tertiary hospital headache clinic. Methods: Data were collected from patients attending a tertiary headache clinic from February 2024 to November 2024 and entered into a secure REDCAP database. Patients fulfilling International Classification of Headache Disorders-3 (ICHD-3) diagnostic criteria for migraine were included in the study. Patients were asked the earliest age they could recall having migraine symptoms, when they first received a diagnosis of migraine from a clinician, and what preventive treatments they had tried for migraine. Statistical analysis with the Mann-Whitney U test for numerical data and Fisher's exact test for binomial data was then performed on SPSS. Results: The median delay between migraine symptom onset and formal diagnosis of migraine was 6 years. 39% of patients (39/100) had not trialled a preventive prior to attendance at the clinic, including 27% (20/73) with 8 or more migraine days per month. There was a median delay of 11 years between reported symptom onset and commencement of prophylactic therapy. Conclusion: There remain significant delays in migraine diagnosis and commencement of prophylactic therapy in Australian patients with migraine.

Background: The hypothalamus has been posited to play a role in premonitory symptomatology in migraine. Many patients also report particular triggers for their migraine attacks. Identifying the relationship between these may provide insights into the potential role of hypothalamic dysfunction in migraine pathophysiology. Methods: A single centre cross-sectional study was performed. Data was collected on the presence of premonitory symptoms and triggers from patients who attended a tertiary headache clinic from February 2024 to December 2024 and entered into a Headache Database. Statistical analysis with multivariate binomial logistic regression was performed to identify relationships between premonitory symptoms and triggers. Results: Of the100 patients who were identified as fulfilling a diagnosis of migraine as per ICHD-3 criteria, 96% reported at least one premonitory symptom. Women reported a greater number of premonitory symptoms (6 [IQR 4–9] vs 4 [IQR2–7], P = 0.005) and triggers (4 [IQR 3–7] vs 3 [IQR 2–5], P = 0.046) compared to men. Linear regression showed that patients with more triggers were likely to report more premonitory symptoms (R ² = 0.466). Statistically significant correlations were found between certain triggers and premonitory symptoms such as poor sleep and photophobia ( P = 0.001) and overcast weather and drowsiness ( P = 0.003). Independent correlations were also found between certain premonitory symptoms, allowing for groupings of certain symptoms with each other. Conclusions: The study demonstrated that patients who reported more triggers were likely to report more premonitory symptoms, and that women reported more premonitory symptoms compared to men. Certain triggers were also associated with the presence of certain premonitory symptoms, for example poor sleep and photophobia as well as overcast weather and drowsiness. The presence of independent associations between certain triggers and premonitory symptoms may suggest specific network dysfunctions in different networks that may account for interindividual variability in migraine triggers and symptomatology.