Headache Forum

Latest posts from our headache forum are listed below and updated every time a new post is accepted

Headache forum therapy archive 2008

Use of botulinum toxin a in adult neurological disorders : efficacy, tolerability and safety.

CNS Drugs. 2008;22(9):725-38

Authors: Schulte-Mattler WJ

The protein botulinum neurotoxin A (BoNT/A) is one of seven distinct neurotoxins produced by Clostridium botulinum. BoNT/A blocks cholinergic synapses with an extremely high specificity and potency. Appropriately purified and diluted, BoNT/A serves as a reliable and well tolerated drug that is applied by local injection.The efficacy of BoNT/A is evident in the symptomatic therapy of disorders in which muscular hyperactivity plays a prominent role, such as focal dystonias and hemifacial spasm; in these disorders, BoNT/A is considered first-line therapy. BoNT/A is also beneficial in the treatment of both adults and children with spasticity of various causes. The pain that frequently accompanies these conditions is effectively reduced by BoNT/A. A genuine analgesic effect for BoNT/A unrelated to skeletal muscle spasmolysis has been suggested on the basis of in vitro and in vivo (animal) data. However, studies in humans designed to detect such an effect were negative, as were controlled studies of BoNT/A in patients with primary headache disorders.BoNT/A also acts on cholinergic synapses of the autonomic nervous system, and injection of BoNT/A into salivary glands significantly decreases the production of saliva. This may be beneficial for patients with Parkinson's disease, in whom the excessive production of saliva may be problematic.Overall, BoNT/A has been confirmed as an efficacious, predictable and well tolerated drug in an ever-increasing number of neurological disorders.

Headache Forum PMID: 18698873 [PubMed - in process][Tsutsugamushi disease during the last seven years in the past in Hamamatsu City, Shizuoka Prefecture--including evaluation of the hyponatremia in scrub typhus] Headache Forum Related Articles

[Tsutsugamushi disease during the last seven years in the past in Hamamatsu City, Shizuoka Prefecture--including evaluation of the hyponatremia in scrub typhus]

Kansenshogaku Zasshi. 2008 Jul;82(4):335-40

Authors: Shichi D, Tanizawa T, Honda K

Six cases of scrub typhus (tsutsugamushi disease) were reported to the Shizuoka Prefecture Hamamatsu City public health center during the seven years from 2001 to 2007. The content of the clinical record of the five cases were investigated. High serum titers of antibody to Gilliam-type Orientia tsutsugamushi were detected by immunofluorescense assay in most of these patients. Fever, rash, headache and relative bradycardia seen at a high frequency. On peripheral blood smear examination, atypical lymphocytes were detected in 3 cases. Serum electrolyte examination revealed hyponatremia in 4 (80%) patients; SIADH was suspected in one of these cases. All the patients improved promptly following start of therapy with intravenous or oral minocycline.

Headache Forum PMID: 18697486 [PubMed - in process]Reversal of Inflammatory and Noninflammatory Visceral Pain by Central or Peripheral Actions of Sumatriptan. Headache Forum Related Articles

Reversal of Inflammatory and Noninflammatory Visceral Pain by Central or Peripheral Actions of Sumatriptan.

Gastroenterology. 2008 Jul 3;

Authors: Vera-Portocarrero LP, Ossipov MH, King T, Porreca F

BACKGROUND & AIMS: Sumatriptan is used specifically to relieve headache pain. The possible efficacy of sumatriptan was investigated in 2 models of visceral pain. METHODS: Pancreatic inflammation was induced by intravenous injection of dibutyltin dichloride. Noninflammatory irritable bowel syndrome was induced by intracolonic instillation of sodium butyrate. The effects of systemic sumatriptan on referred hypersensitivity were tested in both models. Effects of sumatriptan within the rostral ventromedial medulla (RVM), a site of descending modulation of visceral pain, was determined by (1) testing the effects of RVM administration of 5HT1(B/D) antagonists on systemic sumatriptan action and (2) determining whether RVM application of sumatriptan reproduced the actions of systemic drug administration. RESULTS: Systemic sumatriptan elicited a dose- and time-related blockade of referred hypersensitivity in both models that was blocked by systemic administration of either 5HT1(B) or 5HT1(D) antagonists. Sumatriptan administered into the RVM similarly produced dose- and time-related blockade of referred hypersensitivity in both visceral pain models. This was blocked by local microinjection of the 5HT1(B) antagonist but not the 5HT1(D) antagonist. Microinjection of 5HT1(B) or 5HT1(D) antagonists into the RVM did not block the effects of systemic sumatriptan. CONCLUSIONS: Our findings suggest that sumatriptan suppresses either inflammatory or noninflammatory visceral pain, most likely through peripheral 5HT1(B)/1(D) receptors. Actions at 5HT1(B) receptors within the RVM offer an additional potential site of action for the modulation of visceral pain by triptans. These studies offer new insights into the development of strategies that may improve therapy of visceral pain conditions using already available medications.

Headache Forum PMID: 18694754 [PubMed - as supplied by publisher]Acetylsalicylic acid + extended-release dipyridamole combination therapy for secondary stroke prevention. Headache Forum Related Articles

Acetylsalicylic acid + extended-release dipyridamole combination therapy for secondary stroke prevention.

Clin Ther. 2008 Jul;30(7):1196-205

Authors: Chaturvedi S

Background: Approximately 25% of strokes are recurrent. Antiplatelet therapy is indicated for the prevention of recurrent stroke in patients with a history of noncardioembolic minor stroke or transient ischemic attack (TIA). Although clinicians may choose acetylsalicylic acid (ASA) as first-line therapy for secondary prevention, clinical guidelines and evidence from trials suggest that ASA may not be the most effective strategy. Objective: The purpose of this review was to discuss results from clinical trials that have compared the efficacy of ASA monotherapy versus ASA + extendedrelease dipyridamole in secondary stroke prevention. Methods: Relevant randomized experimental and clinical studies in patients with a history of minor stroke or TIA of noncardioembolic etiology were identified using a search of the US National Library of Medicine database, with no limits on publication dates. The primary search terms used were secondary stroke prevention, antiplatelet therapy, acetylsalicylic acid, ASA, aspirin, aspirin + extended-release dipyridamole, and combination therapy. Results: Early trials of dipyridamole monotherapy or ASA + dipyridamole involved small numbers of patients and found no significant treatment differences. Two major trials that compared ASA monotherapy, dipyridamole monotherapy, and ASA + dipyridamole were identified: the Second European Stroke Prevention Study (ESPS-2) and the European/Australasian Stroke Prevention in Reversible Ischaemia Trial (ESPRIT). Efficacy measurements in ESPS-2 found that stroke relative risk reductions were 18% (P = 0.013), 16% (P = 0.039), and 37% (P < 0.001), respectively, compared with placebo for a relative risk reduction of 23.1% (P = 0.006) favoring the combination over ASA monotherapy. In ESPRIT, patients who received ASA + dipyridamole had a 20% relative risk reduction versus ASA monotherapy for the composite end point of death from all vascular causes, nonfatal stroke, nonfatal myocardial infarction, or major bleeding complications. In ESPS-2, headache was 5% more common with dual therapy compared with ASA monotherapy. ESPRIT found that combination treatment was not associated with a higher complication rate than ASA monotherapy, but that the rate of withdrawal due to adverse events was higher in the group that received the combination. Conclusion: Based on the results from these 2 large, randomized trials, ASA + dipyridamole was more effective than ASA monotherapy as first-line therapy for secondary stroke prevention in these patients with a history of minor stroke or TIA of noncardioembolic etiology.

Headache Forum PMID: 18691981 [PubMed - in process]Topiramate monotherapy in the treatment of newly or recently diagnosed epilepsy. Headache Forum Related Articles

Topiramate monotherapy in the treatment of newly or recently diagnosed epilepsy.

Clin Ther. 2008 Jul;30(7):1180-95

Authors: Ben-Menachem E, Sander JW, Stefan H, Schwalen S, Schäuble B

Background: The efficacy of topiramate (TPM) as an adjunctive treatment for epilepsy has been established in placebo-controlled clinical trials. Clinical trials of antiepileptic monotherapy usually evaluate low and high doses of study drug or compare study drug with another active agent. Objective: This article reviews available evidence for the use of TPM as monotherapy in patients with newly or recently diagnosed epilepsy. Methods: A search of MEDLINE, EMBASE, BIOSIS, SCISEARCH, and the Cochrane Database of Systematic Reviews (all years) for reports of controlled trials of TPM monotherapy in patients with recently diagnosed (within the previous 3 years) epilepsy was conducted in January 2008 using the terms topiramate, epilepsy, newly diagnosed, recently diagnosed, and monotherapy. Identified trials were included in the review if they were published in peer-reviewed journals and enrolled >/=20 patients. Results: Three randomized, double-blind, controlled trials met the criteria for inclusion in the review. In a comparison of TPM 50 and 500 mg/d, the higher dose was associated with significantly greater freedom from seizures at 6 months compared with the lower dose (54% vs 39%, respectively; P = 0.02). The time to first seizure was significantly associated with mean plasma TPM concentrations (P = 0.015). In a comparison of TPM 50 and 400 mg/d, the time to first seizure was significantly longer with the higher dose compared with the lower dose (P<0.001, Kaplan-Meier analysis), and the probability of 12-month seizure freedom was significantly higher (76% vs 59%, respectively; P = 0.001). Again, the time to first seizure was significantly associated with mean plasma TPM concentrations (P = 0.029). In a comparative study of TPM 100 and 200 mg/d, carbamazepine 600 mg/d, and valproate 1250 mg/d, there was no significant difference in rates of 6-month seizure freedom with TPM 100 and 200 mg/d (49% and 44%, respectively), carbamazepine (44%), and valproate (44%). Adverse events in the 3 studies were similar between TPM dose groups, although the incidence generally increased with increasing doses, occurred early in treatment, and decreased with prolonged therapy. In a pooled analysis of the 3 trials, the most commonly occurring adverse events during dose titration were paresthesia (25%), fatigue (16%), dizziness (13%), somnolence (13%), and nausea (10%); the most frequent adverse events during maintenance therapy were headache (20%), decreased appetite (11%), and weight loss (11%). Conclusion: In the 3 studies reviewed, TPM monotherapy was effective and generally well tolerated in patients with newly diagnosed epilepsy.

Headache Forum PMID: 18691980 [PubMed - in process]Rapidly progressing purpuric lesions to massive hemorrhagic bullae, with rapid improvement by Prednisolon as a coetaneous manifestation of Systemic Lupus Erythematosus: a case report. Headache Forum Related Articles

Rapidly progressing purpuric lesions to massive hemorrhagic bullae, with rapid improvement by Prednisolon as a coetaneous manifestation of Systemic Lupus Erythematosus: a case report.

Cases J. 2008 Aug 8;1(1):79

Authors: Khorvash FF, Emami Naeini AA, Behjati MM, Karimifar MM, Khorvash FF, Dialami KK

ABSTRACT: BACKGROUND: Systemic lupus Erythematosus is a chronic autodestructive disease, with loss of immune tolerance to nucleic acid and other cross reactive antigens. Despite of the numerous studies, the presence of some new manifestations indicates the greater proportion of unknown data. CASE PRESENTATION: Our case, is a 26-year-old female, by the chief complaint of headache, vomiting, fever and arthralgia. Some hemorrhagic ulcers in her mouth with fulminant pethechia/purpura on her limbs and buttocks were prominent. On admission, she was in hypotensive state. By the clinical suspicion to meningococcal septicemia, lumbar puncture was performed, and antibiotic therapy was started. Cerebrospinal fluid was normal. Suddenly, on the 3rd day of admission, hemorrhagic bullae were evolved from those purpuric lesions. Leukocytosis, immune hemolytic anemia, thrombocytopenia and high antinuclear antibody/double stranded DNA level and hypocomplemania were present simultaneously. In skin biopsy, immune complex deposition in dermoepidermal junction was seen. The diagnosis of Systemic lupus Erythematosus was made. The patient responded well to corticosteroid therapy. CONCLUSION: Coetaneous manifestations are very common in Systemic lupus Erythematosus, and help the physician making differential diagnoses and proper diagnosis. The rapidly evolving hemorrhagic bulla from primary purpuric lesions, with rapid response to Prednisolon, is a rare manifestation of Systemic lupus Erythematosus, which should be considered in such a disease setting.

Headache Forum PMID: 18691404 [PubMed - as supplied by publisher]Aspergillus sellar abscess: Case report and review of the literature. Headache Forum Related Articles

Aspergillus sellar abscess: Case report and review of the literature.

Neurol India. 2008 Apr-Jun;56(2):186-8

Authors: Hao L, Jing C, Bowen C, Min H, Chao Y

Aspergillus sellar abscess is a very rare form of fungal infections of the central nervous system (CNS). In this report, we describe the successful treatment of a patient with aspergillus sellar abscess. A 65-year-old woman presented with headache, nasal discharge and decreased visual acuity. The diagnosis of sellar mass was made on the basis of magnetic resonance imaging (MRI) examination. The computed tomography (CT) scan revealed sellar enlargement and sellar floor bony destruction. After hospitalization the patient underwent transsphenoidal surgery. Histopathological examination of the sellar mass revealed aspergillosis. Postoperatively, amphotericine-B and itraconazole therapy was started. During a six-month follow-up, the patient's headache and inertia disappeared, visual acuity improved. Aspergillus sellar abscess must be considered in the differential diagnosis of a sellar mass. The correct diagnosis of pituitary aspergillosis can only be achieved by histopathological examination. Surgical intervention and antifungal therapy should be considered the optimal treatment.

Headache Forum PMID: 18688146 [PubMed - in process]Direct renin inhibition: an evaluation of the safety and tolerability of aliskiren. Headache Forum Related Articles

Direct renin inhibition: an evaluation of the safety and tolerability of aliskiren.

Curr Med Res Opin. 2008 Aug 6;

Authors: Rashid H

BACKGROUND: Aliskiren, an antihypertensive drug approved in the United States and Europe, is the first in a new class known as direct renin inhibitors. Aliskiren has been evaluated for safety and tolerability in more than 6400 patients. It has demonstrated a favorable safety and tolerability profile alone or in combination with other drugs.OBJECTIVE: This article reviews the currently available safety and tolerability data for aliskiren.METHODOLOGY: Using the search term aliskiren, MEDLINE (no timeframe set) and major cardiovascular congresses (2005-2008) were searched. Articles and abstracts with safety and drug interaction data were included.FINDINGS: Aliskiren may share common adverse effects observed with angiotensin-converting enzyme (ACE)-inhibitor and angiotensin receptor blocker (ARB) therapy. In placebo-controlled trials, those commonly reported for aliskiren at the approved dosage were headache, diarrhea, and fatigue, with incidences similar to those of placebo. Aliskiren has been well tolerated in black, geriatric, diabetic, or obese patients and patients with renal or hepatic impairment. Aliskiren neither inhibits nor induces the cytochrome P450 system; it does not inhibit P-glycoprotein, but is a substrate for this drug transporter. Adding a direct renin inhibitor to another renin-angiotensin-aldosterone system (RAAS) inhibitor may further improve cardiovascular outcomes, renal outcomes, or both, without increasing the incidence of adverse effects.CONCLUSIONS: Aliskiren is well tolerated, has an adverse effect profile comparable to that of placebo, and has a low potential for drug interactions. Data from ongoing trials evaluating the effects of aliskiren on surrogate markers, morbidity, and mortality will further define the role of direct renin inhibition in the antihypertensive armamentarium.

Headache Forum PMID: 18687166 [PubMed - as supplied by publisher][Treatment guidelines for preventive treatment of migraine] Headache Forum Related Articles

[Treatment guidelines for preventive treatment of migraine]

Acta Neurol Taiwan. 2008 Jun;17(2):132-48

Authors:

The Treatment Guideline Subcommittee of the Taiwan Headache Society evaluated the medications currently used for preventive therapy of migraine in Taiwan according to the principles of evidence-based medicine. We assessed the quality of clinical trials, levels of evidence, and referred to other treatment guidelines proposed by Western countries. Throughout several panel discussions, we merged opinions from the subcommittee members in order to propose a Taiwan consensus about the major roles, recommended levels, clinical efficacy, adverse events and cautions of clinical practice for these medications in preventive treatment of migraine. Migraine preventive medications currently available in Taiwan can be categorized into s-blockers, antidepressants, calcium channel blockers, anticonvulsants, nonsteroid anti-inflammatory drugs, botulinum toxin type A and miscellaneous medications. Propranolol has the best level of evidence, and is recommended as the first-line medication for migraine prevention. Valproic acid, topiramate, flunarizine and amitriptyline are suggested as the second-line medications. The rest medications are used when the above medications fail. Botulinum toxin type A did not differ from placebo for episodic migraine prevention but its efficacy in chronic migraine is not determined yet. It is not recommended to use migraine preventive medication during pregnancy. For those women with menstrual migraine, nonsteroid anti-inflammatory drug and triptans can be used for prevention during the menstrual period. The levels of evidence for migraine preventive medications in children/adolescents and elderly population are low. The preventive medications should follow the "start low and go slow" doctrine to reach an effective dosage. This can prevent adverse events and increase tolerance. The efficacy of preventive medications can not be evaluated until 3 to 4 weeks after treatment. If the improvement of migraine maintains for 4 to 6 months, physicians can gradually taper down or off the medications. Physicians should notify the patients not to overuse acute medications during migraine prevention treatment.

Headache Forum PMID: 18686655 [PubMed - in process]Simultaneous thrombosis of cerebral artery and venous sinus. Headache Forum Related Articles

Simultaneous thrombosis of cerebral artery and venous sinus.

Acta Neurol Taiwan. 2008 Jun;17(2):112-6

Authors: Ho BL, Huang P, Khor GT, Lin RT

Cerebral venous thrombosis (CVT) is infrequent among cerebrovascular diseases. The simultaneous thrombosis involving both cerebral artery and venous sinus is even extremely rare. We reported a 41-year-old woman who presented with acute headache and left hemiparesis due to concomitant arterial ischemic stroke and recurrent CVT. Extensive investigation disclosed acquired protein C and protein S deficiency, iron deficiency anemia (IDA) and cryoglobulinemia. She was treated with intravenous injection of heparin followed by oral anticoagulant therapy. The headache rapidly subsided; however, left hemiparesis persisted over five months. The rare condition of simultaneous thrombosis of cerebral artery and venous sinus may be caused by the synergistic effect of coagulation disorders, IDA and cryoglobulinemia.

Headache Forum PMID: 18686652 [PubMed - in process]Side-effect and vital sign profile of nifedipine as a tocolytic for preterm labour. Headache Forum Related Articles

Side-effect and vital sign profile of nifedipine as a tocolytic for preterm labour.

Hong Kong Med J. 2008 Aug;14(4):267-72

Authors: Chan LW, Sahota DS, Yeung SY, Leung TY, Fung TY, Lau TK, Leung TN

OBJECTIVE. To examine the side-effect and vital sign profile of nifedipine used as a tocolytic. DESIGN. Retrospective audit. SETTING. Tertiary care university hospital, Hong Kong. PATIENTS. Women presenting with preterm labour (before 34 weeks of gestation) between March 2001 and September 2004. MAIN OUTCOME MEASURES. Maternal heart rate, blood pressure, and foetal heart rate were monitored regularly. A four-point Likert scale multiple-choice questionnaire was used to assess the perceived degree of flushing, headache, nausea, dizziness, and shortness of breath. All assessments were performed at predefined intervals from the onset of treatment. Repeated measures analysis of variance was performed to identify any time-dependent association with nifedipine treatment. RESULTS. In all, 212 episodes of preterm labour were treated with nifedipine in 203 women. In 120 episodes, preterm labour was suppressed for more than 48 hours. Treatment was discontinued in three women because of profound hypotension (<90/60 mm Hg), and in one because of severe flushing. Only one patient developed maternal tachycardia (>=140 beats per minute), and in two foetal tachycardia (>=180 beats per minute) was encountered. Moderate headache was experienced in nine women, flushing in nine, dizziness in four, nausea in three, and shortness of breath in one. Repeated measures analysis of variance with time of measurement revealed a significant reduction in maternal blood pressure and increase in maternal heart rate that plateaued after 1 hour of therapy. The foetal heart rate returned to baseline values 3 hours after commencing therapy. CONCLUSION. In general, use of nifedipine as the first-line tocolytic was safe. However, severe maternal hypotension can occur and close monitoring of vital signs is warranted.

Headache Forum PMID: 18685158 [PubMed - in process]Vardenafil demonstrates first-dose success and reliability of penetration and maintenance of erection in men with erectile dysfunction - RELY-II. Headache Forum Related Articles

Vardenafil demonstrates first-dose success and reliability of penetration and maintenance of erection in men with erectile dysfunction - RELY-II.

Can Urol Assoc J. 2008 Jun;2(3):187-95

Authors: Valiquette L, Montorsi F, Auerbach S

OBJECTIVE: Vardenafil has been shown to be efficacious in patients with erectile dysfunction (ED). We evaluated first-dose and repeat-dose response to vardenafil 20 mg. METHODS: This randomized, placebo-controlled study consisted of a 4-week, treatment-free run-in phase; a 1-week, open-label challenge phase; and a 12-week, double-blind treatment phase. Primary efficacy was assessed in terms of reliability of insertion based on dose as measured by the Sexual Encounter Profile question 2 (SEP2). We assessed safety by evaluating adverse events (AEs). RESULTS: Baseline patient characteristics in the 2 treatment groups were similar. The most common comorbidities were hypertension (41%), dyslipidemia (28%) and diabetes mellitus (24%). Of the 573 patients receiving the 20-mg vardenafil challenge dose, 464 (81%) achieved first-time successful penetration (SEP2), and 401 (70%) reported successful erection maintenance (SEP3). Patients receiving vardenafil 20 mg had statistically (p < 0.001) and clinically superior SEP2 rates (85%) through weeks 0-12, compared with patients receiving placebo (45%). The increase in reliability of insertion was seen within the first 4 weeks of treatment. Vardenafil therapy was statistically (p < 0.001) and clinically superior to placebo for all secondary efficacy end points as well. Most AEs associated with vardenafil were mild to moderate, with headache, flushing and nasal congestion most frequently reported. CONCLUSION: Vardenafil 20 mg had a high first-dose success rate for both SEP2 (81%) and SEP3 (70%); this was maintained through to the study end point (85% for SEP2 and 78% for SEP3). These findings were achieved in men with frequently associated comorbidities including hypertension, dyslipidemia and diabetes.

Headache Forum PMID: 18682779 [PubMed - in process]Upper cervical ligament testing in a patient with os odontoideum presenting with headaches. Headache Forum Related Articles

Upper cervical ligament testing in a patient with os odontoideum presenting with headaches.

J Orthop Sports Phys Ther. 2008 Aug;38(8):465-75

Authors: Mintken PE, Metrick L, Flynn TW

STUDY DESIGN: Resident's case problem. BACKGROUND: The role of premanipulative testing of the cervical spine is an area of controversy, and there are very few data to inform and guide practitioners on the use of ligamentous stability tests when assessing the upper cervical spine. DIAGNOSIS: A 23-year-old female was referred to physical therapy by a neurologist for the management of intractable headaches of possible musculoskeletal origin. Her Neck Disability Index score was 54% and she rated her headache pain from 3/10 to 9/10 on a Numerical Pain Rating Scale. She reported a 2-year history of intermittent lower extremity paresthesias without a known mechanism or current symptoms. She was treated in physical therapy for 11 visits with improvements in cervical range of motion, strength, and intensity of her headaches, but noted no change in the frequency of headaches. She was subsequently referred to the primary author for a second opinion and potential manual therapy interventions. Initial neurological screening examination for upper and lower motor neuron lesions was unremarkable. Assessment of the transverse ligament, using the anterior shear test in supine, brought on paresthesias in both feet and her toes. The paresthesias continued after the cessation of the test. The Sharp-Purser test performed in sitting, immediately after the transverse ligament test, abolished the paresthesias. She was then referred back to her primary care physician for further evaluation. Subsequent radiographs and magnetic resonance imaging revealed that the patient had a C2-C3 Klippel-Feil congenital fusion and os odontoideum. The patient was examined by a neurosurgeon who concluded that she was not a surgical candidate. Her neurological symptoms completely resolved, but she continued to have headaches. DISCUSSION: Os odontoideum is a clinically important condition, given that the mobile dens may render the transverse ligament incompetent, leading to atlantoaxial instability. Both the role and sequencing of upper cervical ligamentous testing is controversial. The results of this case report suggest that physical therapists should be cognizant of this condition and consider screening the upper cervical ligaments prior to manual or mechanical interventions to this region. LEVEL OF EVIDENCE: Differential diagnosis, level 4. J Orthop Sports Phys Ther. 2008;38(8):465-475, published online 27 June 2008. doi:10.2519/jospt.2008.2747.

Headache Forum PMID: 18678962 [PubMed - in process]Unusual primary manifestations of multiple sclerosis. Headache Forum Related Articles

Unusual primary manifestations of multiple sclerosis.

N Z Med J. 2008 Jul 4;121(1277):47-59

Authors: Yetimalar Y, Seçil Y, Inceoglu AK, Eren S, Başoğlu M

OBJECTIVES: The aim of this study is to describe patients with unusual symptoms that were primary manifestations of multiple sclerosis (MS). PATIENTS AND METHODS: We report 21 multiple sclerosis patients who presented unusual initial pictures (acute brachial pain n=4, headache n=6, ptosis n=1, oculomotor nerve palsy n=1, peripheral facial palsy n=1, throat pain n=1, hypoglossal nerve palsy n=1, visual field defect n=2, epilepsia n=2, and coma n=2) as the first manifestations in the absence of other obvious symptoms or signs. RESULTS: Investigations demonstrated changes highly suggestive of multiple sclerosis on magnetic resonance imaging, cerebrospinal fluid analysis and electrophysiological tests. All cases completely or partially recovered after high-dose corticosteroid therapy. These patients have been followed up for 5 years. CONCLUSION: In this study, we discuss possible correlations between clinical disturbances and neuroradiological abnormalities and show some rare or previously undescribed manifestations in multiple sclerosis.

Headache Forum PMID: 18677330 [PubMed - indexed for MEDLINE]Sirolimus therapy in liver transplant patients: an initial experience at a single center. Headache Forum Related Articles

Sirolimus therapy in liver transplant patients: an initial experience at a single center.

Transplant Proc. 2008 Jul-Aug;40(6):1950-2

Authors: Nocera A, Andorno E, Tagliamacco A, Morelli N, Bottino G, Ravazzoni F, Casaccia M, Barocci S, Alice S, Santori G, Ghirelli R, Valente U

Sirolimus (SRL) is an mTOR inhibitor that has been shown, in contrast to calcineurin inhibitors (CNI), to inhibit cancers in experimental models. Since February 2005, we introduced SRL in liver transplant patients in group a, in whom the primary disease was hepatocellular carcinoma (HCC) associated with hepatitis B virus (HBV), hepatitis C virus (HCV), alcoholic or autoimmune liver cirrhosis, and group b, HCC-negative patients who developed posttransplantation cancers de novo. Of 18 patients in group a, 11 received SRL ab initio (subgroup a1), starting for 10 patients at 66.1 +/- 29.2 days after surgical healing and after 10 days in 1 case; the remaining 7 patients (subgroup a2) received SRL at 31.2 +/- 24.2 months. Three patients in group b, included 1 with Kaposi's sarcoma, 1 with bladder cancer, and 1 with thyroid cancer. In this group, SRL was introduced at 80.8 +/- 40.4 months. In all patients but one, who received a single 5 mg loading dose, SRL was started at 2 mg/d and adjusted to 6 to 8 ng/mL blood levels. CNI drugs, present as primary therapy, were gradually tapered to low levels and eventually stopped. The following observations were drawn from this initial experience: (1) 4/21 (19.0%) patients had to discontinue SRL because of early and late side effects: thrombocytopenia (n = 2) and headache with leukopenia and leg edema associated with knee joint arthralgia (n = 2); (2) 14 patients (11 in group a and 3 in group b) are still on SRL monotherapy; (3) 1 HCC recurrence and 1 de novo pancreatic adenocarcinoma were observed at 14 and 16 months, respectively (at the time of transplantation, both patients were beyond the MIlan HCC criteria), and (4) 1 patient, from subgroup a1, died after 99 days due to pneumonitis and possible relation to SRL lung toxicity. In conclusion, SRL appeared to be an effective immunosuppressant that could be used as monotherapy in liver transplant patients. Any conclusion on SRL anticancer effects can only come from randomized large studies after long follow-up.

Headache Forum PMID: 18675098 [PubMed - in process][Giant cell arteritis--case report] Headache Forum Related Articles

[Giant cell arteritis--case report]

Klin Oczna. 2008;110(1-3):78-81

Authors: Napora KJ, Obuchowska I, Mariak Z

Giant cell arteritis is a systemic disease of unknown origin. Vasculitis involves large and medium-sized vessels. Frequent clinical manifestations include characteristic headache in the temporal area, jaw or tongue claudication, apathy, fatigue, weight loss. The incidence of ocular involvement is reported in up to 70% patients. The most common and serious ophthalmic presentation is arteritic anterior ischemic optic neuropathy, which can lead to irreversible visual loss. Only early and aggressive steroid therapy may prevent this dangerous complication. The authors presented a case of a 68-years-old woman with giant cell arteritis. The main visual manifestation of this disease was anterior ischemic optic neuropathy.

Headache Forum PMID: 18669091 [PubMed - in process]Effect of Treatment With Efavirenz on Neuropsychiatric Adverse Events of Interferon in HIV/HCV-Coinfected Patients. Headache Forum Related Articles

Effect of Treatment With Efavirenz on Neuropsychiatric Adverse Events of Interferon in HIV/HCV-Coinfected Patients.

J Acquir Immune Defic Syndr. 2008 Jul 23;

Authors: Quereda C, Corral I, Moreno A, Pérez-Elías MJ, Casado JL, Dronda F, Rodríguez-Sagrado MA, Hernández B, Moreno S

BACKGROUND:: Mood disorders and other neuropsychiatric disorders are common adverse events limiting tolerability of alpha-interferon (IFN) therapy for hepatitis C virus (HCV). Because efavirenz (EFV) frequently produces neuropsychiatric side effects, we studied the effect of EFV in the incidence of these side effects in HIV/HCV patients receiving IFN. METHODS:: Prospective cohort of HIV/HCV patients receiving IFN and ribavirin. Adverse events and concomitant medications were systematically recorded once monthly. RESULTS:: Among 266 HIV/HCV patients starting a course of IFN (91% pegylated IFN) plus ribavirin, 53 (20%) received concomitant EFV and 213 (80%) did not. Most EFV patients (92%) were already on EFV before starting IFN (mean 26 months). Neuropsychiatric side effects were frequent, without significant differences between both groups (79% vs 65%, P = 0.051), and only 10 patients discontinued IFN. Mood disorders were reported more frequently in EFV patients (36% vs 23%, P = 0.046), but antidepressant therapy use was similar in both groups. The incidence of anxiety, insomnia, irritability, headache or prescription of anxiolytics or hypnotics was similar. CONCLUSIONS:: Neuropsychiatric adverse events are common in HIV/HCV patients receiving IFN, usually mild or moderate. EFV may favor symptoms of mood disorders, although it was not related to an increased risk of significant depression requiring specific treatment.

Headache Forum PMID: 18667933 [PubMed - as supplied by publisher]The NTI-tss device for the therapy of bruxism, temporomandibular disorders, and headache: where do we stand? A qualitative systematic review of the literature. Headache Forum Related Articles

The NTI-tss device for the therapy of bruxism, temporomandibular disorders, and headache: where do we stand? A qualitative systematic review of the literature.

BMC Oral Health. 2008 Jul 29;8(1):22

Authors: Stapelmann H, Turp JC

ABSTRACT: BACKGROUND: The NTI-tss device is an anterior bite stop, which, according to the manufacturer, is indicated for the prevention and treatment of bruxism, temporomandibular disorders (TMDs), tension-type headaches, and migraine. The aim of this systematic review was to appraise the currently available evidence regarding the efficacy and safety of the NTI-tss splint. METHODS: We performed a systematic search in nine electronic databases and in NTI-tss-associated websites (last update: December 31, 2007). The reference lists of all relevant articles were perused. Five levels of scientific quality were distinguished. Reporting quality of articles about randomized controlled trials (RCTs) was evaluated using the Jadad score. To identify adverse events, we searched in the identified publications and in the MAUDE database. RESULTS: Nine of 68 relevant publications reported about the results of five different RCTs. Two RCTs concentrated on electromyographic (EMG) investigations in patients with TMDs and concomitant bruxism (Baad-Hansen et al 2007, Jadad score: 4) or with bruxism alone (Kavakli 2006, Jadad score: 2); in both studies, compared to an occlusal stabilization splint the NTI-tss device showed significant reduction of EMG activity. Two RCTs focused exclusively on TMD patients; in one trial (Magnusson et al 2004, Jadad score: 3), a stabilization appliance led to greater improvement than a NTI-tss device, while in the other study (Jokstad et al 2005, Jadad score: 5) no difference was found. In one RCT (Shankland 2002, Jadad score: 1), patients with tension-type headache or migraine responded more favorably to the NTI-tss splint than to a bleaching tray. NTI-tss-induced complications related predominantly to single teeth or to the occlusion. CONCLUSIONS: Evidence from RCTs suggests that the NTI-tss device may be successfully used for the management of bruxism and TMDs. However, to avoid potential unwanted effects, it should be chosen only if certain a patient will be compliant with follow-up appointments. The NTI-tss bite splint may be justified when a reduction of jaw closer muscle activity (e.g., jaw clenching or tooth grinding) is desired, or as an emergency device in patients with acute temporomandibular pain and, possibly, restricted jaw opening.

Headache Forum PMID: 18662411 [PubMed - as supplied by publisher][Medically unexplained symptoms in older adults: a combination of physical, psychiatric and psychological factors] Headache Forum Related Articles

[Medically unexplained symptoms in older adults: a combination of physical, psychiatric and psychological factors]

Ned Tijdschr Geneeskd. 2008 Jun 7;152(23):1305-8

Authors: Hilderink PH, Benraad CE, van Driel TJ, Olde Rikkert MG

3 women aged 75, 75 and 65 years, respectively, were referred to an outpatient clinic for medically unexplained symptoms (MUS). These cases illustrate the heterogeneity and complexity of MUS in elderly patients, which requires broad, multidisciplinary clinical examination by a geriatrician, psychiatrist and psychologist. The first patient presented with persistent pain in the lower back and legs. Examination revealed a spinal stenosis, which was treated surgically; symptoms subsequently resolved. The second patient had chronic abdominal pain and constipation in combination with depression. She was diagnosed with a severe depressive disorder. After adequate drug treatment, her mood improved and the somatic symptoms disappeared. The third patient complained of headache and feared that she may have a brain tumour. There was no somatic diagnosis. She underwent cognitive behavioural group therapy, which substantially improved her functioning. These cases illustrate the diversity and complexity of MUS in elderly patients and underscore the diagnostic appropriateness of the biopsychosocial paradigm. A specialised multidisciplinary examination ensures accurate diagnosis and cognitive behavioural therapy.

Headache Forum PMID: 18661854 [PubMed - in process]Prophylaxis of central nervous system leukemia: a case of chronic myeloid leukemia with lymphoid blast crisis treated with imatinib mesylate. Headache Forum Related Articles

Prophylaxis of central nervous system leukemia: a case of chronic myeloid leukemia with lymphoid blast crisis treated with imatinib mesylate.

World J Pediatr. 2008 May;4(2):145-7

Authors: Thavaraj V, Seth R

BACKGROUND: Chronic myeloid leukemia (CML) in blast crisis has a dismal prognosis. Imatinib mesylate (IM) is a new drug which has been shown to induce complete hematological remission in 55% and complete cytogenetic response in 22% of the patients with CML in blast crisis. METHODS: A child with CML in lymphoid blast crisis was diagnosed by complete hematological and bone marrow examination. There was no central nervous system (CNS) leukemia at presentation. The child was treated with IM at a daily dose of 400 mg. RESULTS: The child showed remission after IM administration for 28 days and remained in remission till 59 days. On day 59 she experienced headache and vomiting. Results of cerebrospinal fluid taken for cytopathology showed CNS leukemia. MCP 841 protocol for ALL and weekly intrathecal triple therapy (ITT) was given. CONCLUSIONS: Along with IM treatment in patients with CML in blast crisis, weekly ITT with hydrocortisone, cytosine arabinoside and methotrexate should be recommended to prevent CNS involvement.

Headache Forum PMID: 18661773 [PubMed - in process][Eclampsia and total bilateral amaurosis in a woman subsequently diagnosed with reversible posterior leukoencephalopathy syndrome] Headache Forum Related Articles

[Eclampsia and total bilateral amaurosis in a woman subsequently diagnosed with reversible posterior leukoencephalopathy syndrome]

Rev Esp Anestesiol Reanim. 2008 May;55(5):304-7

Authors: Andrés MA, Ortiz-Gómez JR, Mansob AM, Martí IP, García SH, Ortigosa FS

Eclampsia is a complication of preeclampsia and is characterized by the appearance of grand mal seizures and/or coma, in the absence of any other neurological abnormalities. Neither focal neurological deficit nor prolonged coma tends to develop following a crisis. Eclampsia should therefore lead us to consider other clinical entities that may require special treatment. We report the case of a pregnant woman who presented total bilateral loss of vision following a grand mal seizure. The patient was subsequently diagnosed with reversible posterior leukoencephalopathy syndrome, which has clinical and radiologic manifestations linked to several causes, such as hypertensive encephalopathy, eclampsia, kidney failure, and immunosuppressant therapy. The syndrome involves headache, altered states of consciousness, changes in vision (including blindness), and seizures; these symptoms generally coincide with a rapid increase in blood pressure. Diagnosis requires neuroimaging, and the typical finding is edema in the posterior zones of the brain hemispheres. The most widely accepted hypothesis concerning the pathophysiologic mechanism underlying this syndrome is failure of cerebral autoregulation with development of vasogenic edema. The prognosis is good and the alterations usually resolve completely with appropriate treatment, which is the same as for the management of eclampsia, with strict monitoring of blood pressure.

Headache Forum PMID: 18661690 [PubMed - in process]Recent advances in the pharmacotherapy of chronic anal fissure: an update. Headache Forum Related Articles

Recent advances in the pharmacotherapy of chronic anal fissure: an update.

Asian J Surg. 2008 Jul;31(3):154-63

Authors: Medhi B, Rao RS, Prakash A, Prakash O, Kaman L, Pandhi P

Surgical sphincterotomy reduces anal tone and sphincter spasm and promotes ulcer healing. Because the surgery is associated with the side effect of faecal incontinence, pharmacological agents to treat chronic anal fissure have been explored recently. Glyceryl trinitrate (GTN) ointment (0.2%) has an efficacy of up to 68% in healing chronic anal fissure, but it is associated with headache as the major and most common side effect. Though botulinum toxin injected into the anal sphincter healed over 80% of chronic anal fissures, it is more invasive and expensive than GTN therapy. Diltiazem ointment achieved healing of chronic anal fissure comparable to 0.2% GTN ointment but was associated with fewer side effects. Other drugs that have been tried are lidocaine, the alpha-adrenergic antagonist indoramin, and the potassium channel opener minoxidil.

Headache Forum PMID: 18658016 [PubMed - in process]ORIGINAL RESEARCH: A Randomized, Double-Blind, Parallel-Group, Multicenter, Placebo-Controlled Study of the Safety and Efficacy of Extended-Release Guaifenesin/Pseudoephedrine Hydrochloride for Symptom Relief as an Adjunctive Therapy to Antibiotic Treatment of Acute Respiratory Infections. Headache Forum Related Articles

ORIGINAL RESEARCH: A Randomized, Double-Blind, Parallel-Group, Multicenter, Placebo-Controlled Study of the Safety and Efficacy of Extended-Release Guaifenesin/Pseudoephedrine Hydrochloride for Symptom Relief as an Adjunctive Therapy to Antibiotic Treatment of Acute Respiratory Infections.

Postgrad Med. 2008 Jul;120(2):53-59

Authors: Skoner DP, Laforce C, Gentile DA

Purpose: This study assessed the effi cacy and safety of guaifenesin 600 mg and pseudoephedrine hydrochloride 60 mg extended-release bilayer tablets in providing relief of acute respiratory symptoms when used as an adjunct to antibiotics in patients with an acute respiratory infection (ARI). Methods: Adult patients experiencing symptoms of ARI and meeting the physician's usual diagnostic criteria for oral antibiotic treatment were prescribed an antibiotic and randomized to adjunctive guaifenesin/pseudoephedrine hydrochloride or matching placebo twice daily for 7 days. Patients completed symptom diaries and treatment assessments twice daily and attended offi ce visits on Days 4 and 8. Results: The safety/intent-to-treat (ITT) population analysis included 601 patients (guaifenesin/ pseudoephedrine, n = 303; placebo, n = 298). Mean symptom scores were lower with guaifenesin/ pseudoephedrine from Day 3 for every symptom assessed, with statistically significant improvements in total symptom score from Day 3 (P = 0.026). The greatest effects of treatment with guaifenesin/pseudoephedrine were observed for nasal congestion and sinus headache. Time to overall relief was shorter with guaifenesin/pseudoephedrine (P = 0.038). Signifi cantly more patients reported "the medication was helping during the day" on Day 2 with guaifenesin/ pseudoephedrine (P = 0.002). Patient assessments of symptom relief showed a signifi cant preference for guaifenesin/pseudoephedrine versus placebo (P = 0.021). Treatment with guaifenesin/ pseudoephedrine was well tolerated. Insomnia (2.6%), nausea (2.3%), and headache (1.3%) were the most common treatment-related adverse effects. Conclusions: As adjunctive therapy for symptom relief for patients taking antibiotics for ARIs, guaifenesin/pseudoephedrine shortened time to relief and improved bothersome respiratory symptoms better than placebo, with greatest effects seen for nasal congestion and sinus headache.

Headache Forum PMID: 18654069 [PubMed - as supplied by publisher]Normothermic treatment in acute clinical encephalitis: a case report. Headache Forum Related Articles

Normothermic treatment in acute clinical encephalitis: a case report.

J Med Case Reports. 2008;2:246

Authors: Terashima M, Kataoka H, Hirai K, Ueno S

ABSTRACT: INTRODUCTION: Encephalitis is a common infection of the brain, associated with a high risk of mortality and morbidity despite intensive supportive therapy. This report describes a patient with acute clinical meningoencephalitis who responded dramatically when her body temperature was decreased to normothermia (36 to 37 degrees C) in combination with barbiturate therapy. CASE PRESENTATION: A 15-year-old, previously healthy girl presented with a 2-day history of headache and meningeal stiffness and pyrexia. Cranial magnetic resonance imaging showed high-intensity signals in the splenium of the corpus callosum on T2-weighted and diffusion-weighted images. On day 4 of admission, the level of consciousness decreased and ataxic respiration and apnea appeared. After that, fever (body temperature >40 degrees C) developed with remarkable tachycardia. The body temperature was decreased with the use of a forced-air-cooling blanket and head cooling. The core temperature, measured in the bladder, was maintained at between 36 and 37 degrees C for 5 days. During the period of normothermia, thiopental sodium was given continuously for 3 days. After normothermia, the level of consciousness increased without the development of fever, and ventilatory support was withdrawn. CONCLUSION: Our experience suggests that normothermic treatment in combination with barbiturate therapy may be an effective option for the management of brain swelling associated with acute meningoencephalitis, particularly when accompanied by a persistent high fever.

Headache Forum PMID: 18652703 [PubMed - in process]Prevention of Visual Stress and Migraine With Precision Spectral Filters. Headache Forum Related Articles

Prevention of Visual Stress and Migraine With Precision Spectral Filters.

Drug Dev Res. 2007;68(7):469-475

Authors: Wilkins A, Huang J, Cao Y

Strategy, Management and Health Policy Enabling Technology, Genomics, ProteomicsPreclinical ResearchPreclinical Development Toxicology, Formulation Drug Delivery, PharmacokineticsClinical Development Phases I-III Regulatory, Quality, ManufacturingPostmarketing Phase IVIndividuals who suffer migraine, particularly migraine with visual aura (MwA), are susceptible to physiologically strong visual stimuli and find them aversive. Strong stimuli including bright light and certain visual patterns produce discomfort and perceptual illusions and can trigger migraine attacks. Perceptual illusions and visual discomfort are reported by most migraine sufferers and those with frequent headaches. These phenomena suggest that visual stimulation and consequent visual cortical activity contribute to the triggering of some migraine attacks. Perceptual illusions in MwA patients were found to be associated with hyper-activation in visual cortex. This excessive cortical activity is called visual stress. The cortex is generally hypothesized to be hyperexcitable in migraine, and this hyperexcitability could be the underlying mechanism of visual stress. It is hypothesized that visual stress results from too great a neural (hyperneural) activity in response to strong physiological sensory stimulation, particularly, but not exclusively, visual. A strong physiological visual input may cause a spread of excitation through hyperexcitable cortex, leading to neurons firing inappropriately and thereby resulting in perceptual illusions and distortions, and possibly promoting a migraine attack. Over the last 10 years, the use of colored filters to treat perceptual distortion of text has become common in many schools in Britain. The efficacy of precision spectral filters (PSF) in preventing migraine headache has been reported in several studies. One preliminary study revealed the suppressing effect of the PSF on visual cortical activity in a MwA patient, suggesting that it might be this reduction in cortical activation that is responsible for the reduction of the frequency of migraine attacks in those who benefited from the PSF. PSF offer a possible new prophylactic therapy for migraine. They are safe, free of side effects, and inexpensive.

Headache Forum PMID: 18648581 [PubMed - as supplied by publisher]Diagnosis and treatment of pituitary microadenoma: report of 80 cases. Headache Forum Related Articles

Diagnosis and treatment of pituitary microadenoma: report of 80 cases.

Neurol Res. 2008 Sep;30(6):587-93

Authors: Zhang HW, Sun W, Yang J, Yan CX, Yu CJ

OBJECTIVE: To analyse and discuss the diagnosis and treatment of pituitary microadenoma. SUBJECTS AND METHODS: Eighty cases of pituitary microadenoma treated with transsphenoidal approach in our department were analysed retrospectively during the last 2 years. RESULTS: During following-up of 13.0 +/- 3.2 months, neither remained tumor was found except one patients with microprolactinoma, nor recurrence. Diabetes insipidus occurred in 19 patients, among which 15 patients recovered in 1 week, three in 1 month and one in 7 months. The adrenocorticotrophic hormone deficiency was found in nine of 63 patients with PRL-, GH- and non-functioning microadenoma (12%), but hypoadrenalemia recovered in all patients. Among these nine patients, seven recovered in 3 months and two in 6 months. Dysosphesia occurred in 32 cases: 30 recovered in 1 month and two in 4 months. Thirteen of 15 patients (86.7%) with ACTH-secreting microadenoma achieved chemical remission judged by plasma cortisol levels

Headache Forum PMID: 18647498 [PubMed - in process]Normobaric and hyperbaric oxygen therapy for migraine and cluster headache. Headache Forum Related Articles

Normobaric and hyperbaric oxygen therapy for migraine and cluster headache.

Cochrane Database Syst Rev. 2008;(3):CD005219

Authors: Bennett MH, French C, Schnabel A, Wasiak J, Kranke P

BACKGROUND: Migraine and cluster headaches are severe and disabling. Migraine affects up to 18% of women, while cluster headaches are much less common (0.2% of the population). A number of acute and prophylactic therapies are available. Hyperbaric oxygen therapy (HBOT) is the therapeutic administration of 100% oxygen at environmental pressures greater than one atmosphere, while normobaric oxygen therapy (NBOT) is oxygen administered at one atmosphere. OBJECTIVES: To assess the safety and effectiveness of HBOT and NBOT for treating and preventing migraine and cluster headaches. SEARCH STRATEGY: We searched the following in May 2008: CENTRAL, MEDLINE, EMBASE, CINAHL, DORCTIHM and reference lists from relevant articles. Relevant journals were hand searched and researchers contacted. SELECTION CRITERIA: Randomised trials comparing HBOT or NBOT with one another, other active therapies, placebo (sham) interventions or no treatment in patients with migraine or cluster headache. DATA COLLECTION AND ANALYSIS: Three reviewers independently evaluated study quality and extracted data. MAIN RESULTS: Nine small trials involving 201 participants were included. Five trials compared HBOT versus sham therapy for acute migraine, two compared HBOT to sham therapy for cluster headache and two evaluated NBOT for cluster headache.Pooling of data from three trials suggested that HBOT was effective in relieving migraine headaches compared to sham therapy (relative risk (RR) 5.97, 95% confidence interval (CI) 1.46 to 24.38, P = 0.01). There was no evidence that HBOT could prevent migraine episodes, reduce the incidence of nausea and vomiting or reduce the requirement for rescue medication. There was a trend to better outcome in a single trial evaluating HBOT for the termination of cluster headache (RR 11.38, 95% CI 0.77 to 167.85, P = 0.08), but this trial had low power.NBOT was effective in terminating cluster headache compared to sham in a single small study (RR 7.88, 95% CI 1.13 to 54.66, P = 0.04), but not superior to ergotamine administration in another small trial (RR 1.17, 95% CI 0.94 to 1.46, P = 0.16). Seventy-six per cent of patients responded to NBOT in these two trials.No serious adverse effects of HBOT or NBOT were reported. AUTHORS' CONCLUSIONS: There was some evidence that HBOT was effective for the termination of acute migraine in an unselected population, and weak evidence that NBOT was similarly effective in cluster headache. Given the cost and poor availability of HBOT, more research should be done on patients unresponsive to standard therapy. NBOT is cheap, safe and easy to apply, so will probably continue to be used despite the limited evidence in this review.

Headache Forum PMID: 18646121 [PubMed - in process]Efficacy and safety of oral SK3530 for the treatment of erectile dysfunction in Korean men: a multicenter, randomized, double-blind, placebo-controlled, fixed dose, parallel group clinical trial. Headache Forum Related Articles

Efficacy and safety of oral SK3530 for the treatment of erectile dysfunction in Korean men: a multicenter, randomized, double-blind, placebo-controlled, fixed dose, parallel group clinical trial.

Asian J Androl. 2008 Sep;10(5):791-8

Authors: Paick JS, Choi HK, Kim SC, Ahn TY, Kim JJ, Park JK, Park KS, Lee SW, Kim SW, Park K, Jung H, Park NC

Aim: To evaluate the efficacy and safety of SK3530, a newly developed type 5 phosphodiesterase inhibitor (PDE5I), in Korean men with erectile dysfunction (ED). Methods: A total of 119 patients were randomized at 10 centers in Korea to receive either SK3530 (50, 100, or 150 mg; n = 89) or placebo (n = 30) taken l h before anticipated sexual activity for an 8-week period. The patients were evaluated at baseline and 4 and 8 weeks after beginning therapy. Efficacy was assessed using the International Index of Erectile Function (IIEF), Sexual Encounter Profile (SEP), and the Global Assessment Question (GAQ). Safety was analyzed by adverse events, laboratory values and vital signs. Results: At the end of the study, all the primary and secondary efficacy end-points were statistically significantly improved by SK3530 compared with placebo (P<0.05). Of the 89 patients in the treatment arm, 36 (42.3%) achieved normal erectile function after treatment, including six patients with severe ED. Treatment-related adverse events occurred in 32 patients. The most common adverse events were flushing, headache, dizziness and eye redness (10.9%, 7.6%, 2.5% and 2.5%, respectively), and most were mild. Only two patients discontinued treatment during the study period because of adverse events. Conclusion: The results of our phase II study have confirmed the efficacy and safety of SK3530 in a broad population of men with ED of various etiologies and severity. The optimal doses in terms of efficacy and safety were determined to be 50 mg and 100 mg, respectively.

Headache Forum PMID: 18645683 [PubMed - in process]Predictors of Pneumocystosis or Tuberculosis in HIV-Infected Asian Patients With AFB Smear-Negative Sputum Pneumonia. Headache Forum Related Articles

Predictors of Pneumocystosis or Tuberculosis in HIV-Infected Asian Patients With AFB Smear-Negative Sputum Pneumonia.

J Acquir Immune Defic Syndr. 2008 Aug 15;48(5):620-627

Authors: Minor OL, Germani Y, Chartier L, Lan NH, Lan NT, Duc NH, Laureillard D, Fontanet A, Sar B, Saman M, Chan S, Lʼher P, Mayaud C, Vray M

OBJECTIVES:: To identify predictors of Pneumocystis jiroveci pneumonia (PCP) or pulmonary tuberculosis (TB) in acid-fast bacillus smear-negative HIV-infected patients and to develop clinical prediction rules. DESIGN:: A cohort study conducted in consecutive hospitalized Asian patients. METHODS:: Multivariate analyses were performed on the Cambodian sample to determine clinical, radiological, and biological predictors of PCP or TB at hospital admission. The Vietnamese sample was kept for independent validation. RESULTS:: In Cambodia, the gold standard technique for TB and PCP were fulfilled in 172 (27 cases) and 160 (84 cases) patients, respectively. For TB, independent predictors included the following: headache [odds ratio (OR) 3.0; 95% confidence interval (CI) 1.04 to 8.6], localized radiological opacity (OR 5.8; 95% CI 1.9-17.9), and mediastinal adenopathy (OR 10.1; 95% CI 3.5 to 29.0); and for PCP: resting oxygen saturation <90% (OR 3.3; 95% CI 1.3 to 8.5 for resting arterial oxygen saturation >/=80%; and OR 9.1; 95% CI 1.8 to 44.5 for resting arterial oxygen saturation <80%), trimethoprim-sulphamethoxazole prophylaxis (OR 0.1; 95% CI 0.04 to 0.6), and diffuse radiological shadowing (OR 7.0; 95% CI 2.7 to 18.6). PCP risk predicted by a score based on these 3 factors ranged from 3% to 92% (Cambodia). When tested on Vietnamese patients (n = 69, 38 with PCP), the score maintained correct predictive ability (c-index = 0.72) but with poor calibration. CONCLUSIONS:: The PCP score could provide a useful clinical tool to identify PCP among acid-fast bacillus smear-negative pneumonia and start specific therapy.

Headache Forum PMID: 18645508 [PubMed - as supplied by publisher]Prednisone in withdrawal therapy following medication overuse headache. Headache Forum Related Articles

Prednisone in withdrawal therapy following medication overuse headache.

Cephalalgia. 2008 Jul 15;

Authors: Ribeiro R

Headache Forum PMID: 18644032 [PubMed - as supplied by publisher]Cat scratch disease complicated with aseptic meningitis and neuroretinitis. Headache Forum Related Articles

Cat scratch disease complicated with aseptic meningitis and neuroretinitis.

Braz J Infect Dis. 2008 Apr;12(2):158-60

Authors: Pinto VL, Curi AL, Pinto Ada S, Nunes EP, Teixeira Mde L, Rozental T, Favacho AR, Castro EL, Bóia MN

Cat scratch disease (CSD) is a self limited condition characterized by fever, lymph node enlargement and less often eye involvement. Central nervous system involvement by Bartonella henselae infection is possibly an important cause of morbidity; its role as an agent of aseptic meningitis is unknown. We report a case of a 40 years-old man with CSD accompanied by aseptic meningitis and neuroretinitis. Serum indirect immmunofluorescence (IFI) assays for B. henselae were positive and the cerebrospinal fluid (CSF) analysis showed mononuclear pleocytosis and increased level of protein. Serological tests for other etiologies were negative. The patient responded well to antibiotic therapy with oral doxycicline plus rifampin and in the 12th day of hospitalization evolved to total regression of the headache and partial regression of the visual loss. Clinicians should consider CSD as a differential diagnosis when assessing previously healthy patients with aseptic meningitis associated with regional lymphadenopathy and epidemiological history of feline contact.

Headache Forum PMID: 18641856 [PubMed - in process]Polymyalgia rheumatica and giant-cell arteritis. Headache Forum Related Articles

Polymyalgia rheumatica and giant-cell arteritis.

Lancet. 2008 Jul 19;372(9634):234-45

Authors: Salvarani C, Cantini F, Hunder GG

Polymyalgia rheumatica and giant-cell arteritis are closely related disorders that affect people of middle age and older. They frequently occur together. Both are syndromes of unknown cause, but genetic and environmental factors might have a role in their pathogenesis. The symptoms of polymyalgia rheumatica seem to be related to synovitis of proximal joints and extra-articular synovial structures. Giant-cell arteritis primarily affects the aorta and its extracranial branches. The clinical findings in giant-cell arteritis are broad, but commonly include visual loss, headache, scalp tenderness, jaw claudication, cerebrovascular accidents, aortic arch syndrome, thoracic aorta aneurysm, and dissection. Glucocorticosteroids are the cornerstone of treatment of both polymyalgia rheumatica and giant-cell arteritis. Some patients have a chronic course and might need glucocorticosteroids for several years. Adverse events of glucocorticosteroids affect more than 50% of patients. Trials of steroid-sparing drugs have yielded conflicting results. A greater understanding of the molecular mechanisms involved in the pathogenesis should provide new targets for therapy.

Headache Forum PMID: 18640460 [PubMed - indexed for MEDLINE]Use of complementary and alternative medicine by patients with cluster headache: Results of a multi-centre headache clinic survey. Headache Forum Related Articles

Use of complementary and alternative medicine by patients with cluster headache: Results of a multi-centre headache clinic survey.

Complement Ther Med. 2008 Aug;16(4):220-7

Authors: Rossi P, Torelli P, Di Lorenzo C, Sances G, Manzoni GC, Tassorelli C, Nappi G

OBJECTIVES: To evaluate the rates, pattern, satisfaction with, and presence of predictors of complementary and alternative medicine (CAM) use in a clinical population of patients with cluster headache (CH). DESIGN AND SETTING: One hundred CH patients attending one of three headache clinics were asked to undergo a physician-administered structured interview designed to gather information on CAM use. RESULTS: Past use of CAM therapies was reported by 29% of the patients surveyed, with 10% having used CAM in the previous year. Only 8% of the therapies used were perceived as effective, while a partial effectiveness was reported in 28% of CAM treatments. The most common source of recommendation of CAM was a friend or relative (54%). Approximately 62% of CAM users had not informed their medical doctors of their CAM use. The most common reason for deciding to try a CAM therapy was that it offered a "potential improvement of headache" (44.8%). Univariate analysis showed that CAM users had a higher income, had a higher lifetime number of conventional medical doctor visits, had consulted more headache specialists, had a higher number of CH attacks per year, and had a significantly higher proportion of chronic CH versus episodic CH. A binary logistic regression analysis was performed and two variables remained as significant predictors of CAM use: income level (OR=5.7, CI=1.6-9.1, p=0.01), and number of attacks per year (OR=3.08, CI=1.64-6.7, p<0.0001). CONCLUSION: Our findings suggest that CH patients, in their need of and quest for care, seek and explore both conventional and CAM approaches, even though only a very small minority finds them very satisfactory.

Headache Forum PMID: 18638713 [PubMed - in process]Single-day, patient-initiated famciclovir therapy versus 3-day valacyclovir regimen for recurrent genital herpes: a randomized, double-blind, comparative trial. Headache Forum Related Articles

Single-day, patient-initiated famciclovir therapy versus 3-day valacyclovir regimen for recurrent genital herpes: a randomized, double-blind, comparative trial.

Clin Infect Dis. 2008 Sep 1;47(5):651-8

Authors: Abudalu M, Tyring S, Koltun W, Bodsworth N, Hamed K

BACKGROUND: Recurrent genital herpes is a major problem for patients worldwide. Early episodic treatment with short-course therapy is effective, often stopping progression of outbreaks. This study is the first head-to-head comparison of single-day famciclovir (1000 mg administered twice daily) versus 3-day valacyclovir (500 mg administered twice daily) for episodic therapy in immunocompetent patients. METHODS: In this multicenter, multinational, double-blind, parallel-group study, 1179 adults with a history of recurrent genital herpes were randomized 1:1 to receive either famciclovir or valacyclovir. Patients initiated treatment within 6 h after a recurrence. The primary objective was to establish noninferiority of single-day famciclovir, compared with a 3-day course of valacyclovir, in time to healing of all nonaborted lesions in a modified intent-to-treat population. RESULTS: This study established that single-day famciclovir therapy was noninferior to 3-day valacyclovir therapy in reducing time to healing of all nonaborted genital herpes lesions (median time to healing, 4.25 days vs. 4.08 days). Approximately one-third of patients in each treatment group had aborted genital herpes episodes, suggesting that both treatments have similar efficacy in preventing outbreaks or progression of lesions beyond the papule stage. There was no significant difference in time to resolution of symptoms associated with recurrence. The overall incidence of adverse events was similar (23.2% for the famciclovir group vs. 22.3% for the valacyclovir group), with headache, nausea, diarrhea, vomiting, and abdominal pain reported most often. CONCLUSIONS: Single-day famciclovir (1000 mg administered twice daily) was similar to 3-day valacyclovir (500 mg administered twice daily) in both efficacy and safety, representing a more convenient treatment for immunocompetent adults with recurrent genital herpes.

Headache Forum PMID: 18637755 [PubMed - in process]Cerebral Venous Thrombosis. A Descriptive Multicenter Study of Patients in Pakistan and Middle East. Headache Forum Related Articles

Cerebral Venous Thrombosis. A Descriptive Multicenter Study of Patients in Pakistan and Middle East.

Stroke. 2008 Jul 17;

Authors: Khealani BA, Wasay M, Saadah M, Sultana E, Mustafa S, Shohab Khan F, Kamal AK

BACKGROUND AND PURPOSE: The natural history, causative factors, and outcomes of patients with cerebral venous thrombosis from Asia and Middle East have not been well described. This descriptive multicenter study describes the results for cerebral venous thrombosis patients in South Asia and the Middle East. METHODS: The retrospective and prospective data of patients with radiologically confirmed cerebral venous thrombosis were collected from 4 centers located in Pakistan and United Arab Emirates. The demographic, clinical, radiological, and outcome data were recorded and analyzed. Primary outcome was death or dependency (modified Rankin score >2) at the time of hospital discharge. RESULTS: This study included 109 patients with cerebral venous thrombosis; the presenting features most commonly being observed were headache (81%), focal motor deficits (45%), seizures (39%), and mental status changes (37%). Important predisposing factors included systemic and central nervous system infection (18%), postpartum state (17%), hyperhomocystinemia (9%), genetic thrombophilia (5%), and oral contraceptive pill use (3%). Ninety-six (67%) patients received therapeutic anticoagulation. Seven patients died and 43 had poor outcome at discharge. Focal motor deficits (OR, 2.93; 95% CI, 1.2-7.5; P=0.018) and hemorrhagic infarctions (OR, 2.81; 95% CI, 1.04-7.85; P=0.041) were independent predictors of unfavorable outcome at discharge. Hemorrhagic infarction was the most significant factor of long-term unfavorable outcome (OR, 5.87; 95% CI, 1.49-23.02; P=0.011). CONCLUSIONS: Infections and postpartum state were the most common predisposing factors for cerebral venous thrombosis in this cohort. Most patients (67%) were treated with anticoagulation therapy. Almost 50% of patients were dead or disabled at discharge.

Headache Forum PMID: 18635853 [PubMed - as supplied by publisher][Spontaneous improvement of idiopathic intracranial carotid artery dissection: a case report] Headache Forum Related Articles

[Spontaneous improvement of idiopathic intracranial carotid artery dissection: a case report]

No Shinkei Geka. 2008 Jul;36(7):625-31

Authors: Iwamuro Y, Nakahara I, Higashi T, Watanabe Y, Matsumoto S, Takahashi K, Kikuchi T, Ando M, Takezawa M

We report a rare case of spontaneous intracranial carotid artery dissection presenting with multiple infarctions. A 65-year-old man became aware of transient visual disturbance in the right eye and headache. Magnetic resonance imaging (MRI) at a local neurosurgical clinic depicted fresh multiple infarctions of the right cerebral hemisphere along with severe right carotid artery stenosis and delayed cerebral blood flow on the right side. The patient was transferred to our hospital. Three-dimensional computed tomography (3D-CT) showed an intimal flap in the righ petrous internal carotid artery and we diagnosed spontaneous intracranial carotid artery dissection of the petrous portion. We started conservative therapy including anti-coagulant and antiplatelet drug and blood pressure control. Two weeks after admission, angiography, 3D-CT, MR angiography demonstrated that the dissection had improved and the patient was discharged without neurological deficit. In this case, 3D-CT was effective for the diagnosis of intracranial carotid artery dissection. We report this rare case along with a literature review of the clinical profile and related neuroimaging findings.

Headache Forum PMID: 18634405 [PubMed - in process]Doripenem (Doribax): the newest addition to the carbapenems. Headache Forum Related Articles

Doripenem (Doribax): the newest addition to the carbapenems.

Proc (Bayl Univ Med Cent). 2008 Jul;21(3):337-41

Authors: Greer ND

Carbapenems are a class of antimicrobials structurally related to penicillin. Doripenem, the newest agent in this class, was recently approved by the Food and Drug Administration for the treatment of complicated intra-abdominal infections and complicated urinary tract infections. Its spectrum of activity is similar to that of meropenem and imipenem/cilastatin. Some studies indicate that approximately 29% of carbapenem-resistant Pseudomonas aeruginosa isolates may remain sensitive to doripenem, although the clinical relevance of that finding has not been determined. Clinical studies, which have been published only in abstract form to date, have found doripenem to be similar to comparator agents. The most common adverse effects related to doripenem therapy were headache, nausea, diarrhea, rash, and phlebitis. Doripenem, like the other carbapenems, may also cause seizures. Because of the lack of published data, the lack of clear advantages over meropenem, and the increased cost compared with meropenem, doripenem will not be available for use at Baylor University Medical Center except by infectious diseases specialists.

Headache Forum PMID: 18628935 [PubMed - in process]Unique aspects of supportive care using monoclonal antibodies in cancer treatment. Headache Forum Related Articles

Unique aspects of supportive care using monoclonal antibodies in cancer treatment.

Support Cancer Ther. 2003 Oct 1;1(1):38-48

Authors: Dillman RO, Hendrix CS

The "magic bullet" era of targeted cancer therapy began with the United States Food and Drug Administration approval of rituximab for the treatment of B-cell lymphoma in the late fall of 1997. Since then, several additional anticancer antibody products have received regulatory approval, including the monoclonal antibodies (MoAbs) trastuzumab for breast cancer and alemtuzumab for chronic lymphocytic leukemia, and the MoAb immunoconjugates gemtuzumab ozogamicin for acute myelogenous leukemia and yttrium 90 ibritumomab tiuxetan for B-cell lymphoma. These products are associated with adverse events that are quite different than those seen with chemotherapy. Adverse events associated with MoAb products typically have 1 of 3 etiologies: direct and indirect effects of antibody-antigen interaction, effects of toxins or radioisotopes that have been conjugated to antibodies, and allergic and hypersensitivity reactions to foreign protein. The infusion-related symptom complex is the most common and predictable side effect associated with all MoAbs that react with circulating blood cells. This pattern of various systemic effects includes flu-like symptoms such as headache, shortness of breath, fever, skin rash, hypotension, nausea, and asthenia, but usually occurs only in association with the first of any series of weekly infusions. The severity of these reactions is influenced by the rate of infusion, and the syndrome is the consequence of cytokines released from immune cells. Severe hypotension, bronchospasm, hypoxia, and even death have occurred. A true tumor lysis syndrome may occur if there are large numbers of proliferating antigen-positive cells in the blood. Symptoms related to the infusion reaction are ameliorated by slowing or stopping the infusion and administering antiinflammatory agents and antihistamines.

Headache Forum PMID: 18628130 [PubMed - in process]Reduction in the impact of chronic migraine with medication overuse after day-hospital withdrawal therapy. Headache Forum Related Articles

Reduction in the impact of chronic migraine with medication overuse after day-hospital withdrawal therapy.

Neurol Sci. 2008 May;29 Suppl 1:S176-8

Authors: Usai S, Grazzi L, D'Amico D, Andrasik F, Bussone G

The 6-item Headache Impact Test questionnaire (HIT-6) is a simple and reliable tool to measure the impact headaches have on patients' lives. Patients with chronic migraine (CM) and medication overuse are markedly impaired in their functional activity. The aim of this study was to investigate the responsiveness of the HIT-6 tool to clinical changes induced by treatment in patients with CM and medication overuse. A sample of 160 patients underwent a day-hospital withdrawal treatment followed by prophylaxis. Sixty-two of them completed the 12-month follow up. Patients improved significantly after treatment intervention, as days of headache per month and medications/month decreased from baseline to follow up. Also HIT-6 scores improved, with mean score decreasing from 65+/-5.4 (median 65) to 59.4+/-8.5 (median 62) (Student's t-test p<0.00001) and with a reduction in the percentage of patients with very severe headache-related impact one year after withdrawal therapy.

Headache Forum PMID: 18545928 [PubMed - in process]Primary headache and multiple sclerosis: preliminary results of a prospective study. Headache Forum Related Articles

Primary headache and multiple sclerosis: preliminary results of a prospective study.

Neurol Sci. 2008 May;29 Suppl 1:S146-8

Authors: Villani V, Prosperini L, Ciuffoli A, Pizzolato R, Salvetti M, Pozzilli C, Sette G

The aim of this study was to explore the association between different types of headache (HA) and the clinical features of multiple sclerosis (MS). The relationship between HA and MS-specific therapies was also analysed. A total of 102 MS patients were recruited at the MS Centre of S. Andrea Hospital in Rome. According to International Headache Society criteria, the lifetime prevalence of primary HA was 61.8%. Migraine was observed more often in young relapsing-remitting MS patients, whilst tension-type HA was associated with older age, male gender and a secondary progressive course. Sixty-four patients had a history of ongoing or past interferon beta (IFNb) exposure. Of these, 17 subjects did not have a history of HA, while 24 complained of an increase in frequency of migraine attacks and 7 reported an IFNb-induced HA. Investigating and treating HA in MS patients starting IFNb therapy may improve MS-specific medication compliance.

Headache Forum PMID: 18545918 [PubMed - in process]A functional MRI study of language disturbances in subjects with migraine headache during treatment with topiramate. Headache Forum Related Articles

A functional MRI study of language disturbances in subjects with migraine headache during treatment with topiramate.

Neurol Sci. 2008 May;29 Suppl 1:S141-3

Authors: De Ciantis A, Muti M, Piccolini C, Principi M, Di Renzo A, De Ciantis R, Frondizi D, Iannone G, Ottaviano P, Piccirilli M

Topiramate (TPM) is a new antiepileptic drug approved for the prevention of migraine headache. However its use is limited by treatment-emergent adverse events; in particular, therapy can exert profound impact on language function. In this investigation, we used functional magnetic resonance imaging (fMRI) to study the anatomofunctional correlates of language disturbances in TPM patients experiencing subjective cognitive impairment. Ten right-handed individuals receiving therapy (five with and five without language disfluency) and five matched healthy control subjects took part in this study. During fMRI subjects alternately rested and performed a word-generating task. The task comprised the silent generation of words beginning with a different input letter visually presented. The activation paradigm consisted of six activation blocks alternating with six baseline rest blocks. The main fMRI measure was the pattern activation of the prefrontal regions (Brodmann's areas 44, 45, and 46) in both left and right hemispheres. Patients receiving TPM (50-100 mg/day) significantly reduced mean monthly migraine frequency. However several differences in fMRI activation were evident in the subject group comparison. Notably, changes in brain activity were observed during the phonemic task in patients with language disturbances. It is likely that TPM therapy is associated with a "remapping" of the language cerebral network.

Headache Forum PMID: 18545916 [PubMed - in process]Headache therapy with neuronal stabilising drugs. Headache Forum Related Articles

Headache therapy with neuronal stabilising drugs.

Neurol Sci. 2008 May;29 Suppl 1:S131-6

Authors: Colombo B, Dalla Libera D, Annovazzi PO, Comi G

Migraine is a frequent episodic condition that often requires prophylaxis treatment to reduce the severity, frequency and duration of attacks and to ameliorate disability. Migraine can be interpreted as a disorder of pain modulation, which involves the trigeminovascular system and central nervous system modulation of pain-controlling structures. Antiepileptic drugs (neuronal stabilising drugs, NSD) have been increasingly recommended for migraine prophylaxis because of several well conducted studies confirming their efficacy. Valproate, Topiramate and Gabapentin are indicated as useful drugs for migraine preventive therapy according to the results of randomised double-blind, placebo-controlled trials. Due to these positive results, neuronal stabilisation may be considered as a pivotal approach for headache therapy.

Headache Forum PMID: 18545914 [PubMed - in process]A case of systemic polyarteritis nodosa with spermatic cord involvement. Headache Forum Related Articles

A case of systemic polyarteritis nodosa with spermatic cord involvement.

Nat Clin Pract Urol. 2008 Aug;5(8):462-6

Authors: Bush NC, Maxwell KM, Hamoui N, Colegrove P

BACKGROUND: A 50-year-old man with a history of hyperlipidemia and hypertension presented to an emergency department after 10 days of fevers (temperature 40 degrees C), headache, malaise, myalgia, poor appetite, diarrhea, and weight loss of 6.35 kg. He would subsequently develop bilateral scrotal swelling and pain during his evaluation. INVESTIGATIONS: Physical examination, CBC, blood chemistry panel, measurement of erythrocyte sedimentation rate and C-reactive protein level, liver function profile, urinalysis, lumbar puncture, blood cultures, urine cultures, cerebrospinal fluid culture, stool analysis and cultures, multiple viral studies including hepatitis serologies, measurement of antineutrophil cytoplasmic autoantibody levels, urine protein electrophoresis, serum protein electrophoresis, CT of the head, chest, abdomen and pelvis, MRI of the brain, temporal artery biopsy and pathologic analysis, scrotal ultrasonography, right spermatic cord biopsy and pathologic analysis. DIAGNOSIS: Polyarteritis nodosa with involvement of both spermatic cords. MANAGEMENT: Prednisone 60 mg daily was started for presumed temporal arteritis, but was discontinued when no evidence of arteritis was found in the temporal artery biopsy specimen. When pathologic analysis of the spermatic cord biopsy tissue confirmed polyarteritis nodosa, prednisone 40 mg twice daily was administered and the patient's scrotal pain and swelling resolved quickly. Steroids were slowly tapered and discontinued over the next 18 months. He remained free of systemic symptoms, with normal results on physical examination and laboratory evaluation, including urinalysis, CBC, erythrocyte sedimentation rate and C-reactive protein level, 5.5 months after discontinuation of glucocorticoid therapy.

Headache Forum PMID: 18626512 [PubMed - in process]IL-6 Receptor inhibition with tocilizumab improves treatment outcomes in patients with rheumatoid arthritis refractory to anti-TNF biologics: results from a 24-week multicentre Randomised Placebo Controlled Trial. Headache Forum Related Articles

IL-6 Receptor inhibition with tocilizumab improves treatment outcomes in patients with rheumatoid arthritis refractory to anti-TNF biologics: results from a 24-week multicentre Randomised Placebo Controlled Trial.

Ann Rheum Dis. 2008 Jul 14;

Authors: Emery P, Keystone E, Tony HP, Cantagrel A, van Vollenhoven R, Sanchez A, Alecock E, Lee J, Kremer J

OBJECTIVES: The Phase III RADIATE study examined efficacy and safety of tocilizumab, an anti-interleukin-6 receptor monoclonal antibody in patients with rheumatoid arthritis (RA) refractory to TNF-antagonist therapy. METHODS: 499 patients with inadequate response to >1 TNF-antagonist were randomised to receive 8 mg/kg or 4 mg/kg tocilizumab or placebo (control) intravenously every 4 weeks with stable methotrexate for 24 weeks. ACR20 responses, secondary efficacy and safety endpoints were assessed. RESULTS: ACR20 was achieved at 24 weeks by 50.0%, 30.4% and 10.1% of patients in the 8 mg/kg, 4 mg/kg and control groups, respectively (p<0.0001 both tocilizumab groups vs. control). At Week 4 more patients achieved ACR20 in 8 mg/kg tocilizumab vs. controls (p=0.0008). Patients responded regardless of most-recently failed anti-TNF or the number of failed treatments. DAS28 remission (DAS28 <2.6) rates at Week 24 were clearly dose-related, being achieved by 30.1%, 7.6% and 1.6% of 8 mg/kg, 4 mg/kg and control groups (p=0.0001 for 8 mg/kg and p=0.053 for 4 mg/kg vs. control). Most adverse events (AEs) were mild or moderate with overall incidences of 84.0%, 87.1% and 80.6%, respectively. The most common AEs with higher incidence in tocilizumab groups were infections, GI symptoms, rash, and headache. Serious AE incidence was higher in controls (11.3%) than 8 mg/kg (6.3%) and 4 mg/kg (7.4%) groups. CONCLUSION: Tocilizumab + MTX is effective in achieving rapid and sustained improvements in signs and symptoms of RA in patients with inadequate response to TNF antagonists and has a manageable safety profile. ClinicalTrials.gov identifier: NCT00106522.

Headache Forum PMID: 18625622 [PubMed - as supplied by publisher]Oxygen Therapy Influences Episodic Cluster Headache and Related Cutaneous Brush and Cold Allodynia. Headache Forum Related Articles

Oxygen Therapy Influences Episodic Cluster Headache and Related Cutaneous Brush and Cold Allodynia.

Headache. 2008 Jul 1;

Authors: Huber G, Lampl C

Cluster headache (CH) is characterized by a series of sudden attacks of short-lasting severe headache pain with ipsilateral autonomic features, including lacrimation, rhinorrhea, localized sweating, eyelid edema, and partial or complete Horner's syndrome. Just like in migraine, brush allodynia has been described for CH and for short lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT) syndrome. Administration of normobaric oxygen is part of the standard therapy for CH attacks. Here, we describe a young male with a first CH attack and the influence of oxygen on pain and concomitant cutaneous allodynia.

Headache Forum PMID: 18624708 [PubMed - as supplied by publisher]Prescribing patterns in hypertension: the emerging role of fixed-dose combinations for attaining BP goals in hypertensive patients. Headache Forum Related Articles

Prescribing patterns in hypertension: the emerging role of fixed-dose combinations for attaining BP goals in hypertensive patients.

Curr Med Res Opin. 2008 Jul 9;

Authors: Neutel JM

BACKGROUND: The attainment of clinical blood pressure (BP) goals can markedly reduce cardiovascular morbidity and mortality, yet approximately two-thirds of treated hypertensive patients in the United States have uncontrolled BP. Consequently, more aggressive management of hypertension, frequently involving combination therapy (e.g., fixed-dose combination [FDC] therapy), is needed to achieve the recommended BP goals of <140/90 mmHg for most patients, and <130/80 mmHg for high-risk patients.SCOPE: This article, based on data from an extensive Medline search ('hypertension' AND 'prescribe', 'prescribing' OR 'prescription', date range: 1995-2007), focuses on prescribing patterns for antihypertensive medication, and on the emerging role of combination therapy, specifically FDC therapy, in treating hypertensive patients to target BP levels.FINDINGS: Although the use of antihypertensive combination therapy has increased substantially in US adults over the last 20 years, such therapy remains considerably underutilized. Numerous studies have shown that combination therapies, including FDCs, can markedly reduce BP and adverse events relative to monotherapies, and this paper overviews data for various combination therapies: angiotensin-receptor blocker (ARB) + diuretic; angiotensin-converting enzyme (ACE) inhibitor + diuretic; calcium-channel blocker (CCB) + ACE inhibitor; and CCB + ARB. Specifically, fixed-dose CCB/ARB combinations of amlodipine with losartan, valsartan, or olmesartan medoxomil have recently been developed, and combination therapy schedules of amlodipine plus one of these ARBs have shown greater BP-lowering efficacy compared with the constituent monotherapies. Furthermore, in two large studies in a total of >3000 patients, CCB + ARB combination therapy was associated with significantly lower incidences of headache and peripheral edema than CCB monotherapy.CONCLUSION: Guidelines for hypertension management clearly support the greater use of multidrug therapy, especially in high-risk patients. FDCs (e.g., various emerging CCB/ARB combinations) are a valuable option for such high-risk patients, as these combinations offer the potential to reduce adverse events, increase compliance, lower treatment costs, and improve BP goal-attainment rates.

Headache Forum PMID: 18616863 [PubMed - as supplied by publisher]Efficacy and safety of antidepressant augmentation with lamotrigine in patients with treatment-resistant depression: a randomized, placebo-controlled, double-blind study. Headache Forum Related Articles

Efficacy and safety of antidepressant augmentation with lamotrigine in patients with treatment-resistant depression: a randomized, placebo-controlled, double-blind study.

Prim Care Companion J Clin Psychiatry. 2008;10(3):187-90

Authors: Santos MA, Rocha FL, Hara C

Objective: This study reports a clinical trial evaluating lamotrigine safety and efficacy as an antidepressant augmentation agent in treatment-resistant depression, therefore adding more empirical evidence to the limited number of studies on the use of lamotrigine.Method: A double-blind pilot study was conducted between March 2004 and January 2006 with 34 nonbi-polar, nonpsychotic patients who had DSM-IV major depressive disorder and were resistant to at least 2 anti-depressants. The subjects were taking antidepressant therapy and were randomly assigned to receive placebo or lamotrigine as an adjunct therapy for 8 weeks. They were evaluated on a biweekly basis in order to assess the efficacy and the safety of the drug. Efficacy was measured with the Montgomery-Asberg Depression Rating Scale (MADRS) and the Clinical Global Impressions (CGI) scale. Response was defined as a decrease of at least 50% from baseline on the MADRS and a final score

Headache Forum PMID: 18615166 [PubMed - in process]LIPODYSTROPHY IN PATIENTS WITH ACROMEGALY RECEIVING PEGVISOMANT. Headache Forum Related Articles

LIPODYSTROPHY IN PATIENTS WITH ACROMEGALY RECEIVING PEGVISOMANT.

J Clin Endocrinol Metab. 2008 Jul 8;

Authors: Bonert VS, Kennedy L, Petersenn S, Barkan A, Carmichael J, Melmed S

Context: Pegvisomant, GH receptor antagonist suppresses serum IGF-1 levels into the normal range in >95% of patients with acromegaly. Documented side effects in the initial registration studies included headache, injection-site reactions, flu-like syndrome and reversible elevation of hepatic enzymes. Objective: We report seven patients with acromegaly treated with pegvisomant who developed lipodystrophy at the site of injection (anterior abdominal wall, thigh, buttock, upper arm). This side-effect resulted in discontinuation of pegvisomant in 4 patients, with subsequent regression of lipohypertrophy. Subjects: Six female and one male patient with acromegaly, aged 24-59 years, are reported. All patients had undergone prior transsphenoidal surgery and four received subsequent radiotherapy. Four patients had been treated with maximal doses of somatostatin analogs with partial suppression of IGF-1 levels prior to initiation of pegvisomant therapy. Pegvisomant suppressed IGF-1 levels into the normal range in five of seven subjects, prior to discontinuation of the drug. Two of seven patients received pegvisomant as first-line medical therapy, without prior somatostatin analog treatment and one received combination therapy with a longacting somatostatin analog and weekly pegvisomant injections. One patient experienced an erythematous superficial injection-site reaction which responded to application of steroid cream, prior to the onset of lipohypertrophy. Conclusions: We report seven patients with acromegaly who developed lipohypertrophy at the pegvisomant injection-site. Pegvisomant was discontinued due to dissatisfaction with lipohypertrophy by four patients. Lipohypertrophy regressed in all patients when the medication was discontinued. Lipohypertrophy recurred when two patients were re-challenged with pegvisomant. Patients receiving pegvisomant should undergo frequent examination of injection sites for lipohypertrophy.

Headache Forum PMID: 18611977 [PubMed - as supplied by publisher]Late-onset adrenal hypoplasia congenita caused by a novel mutation of the DAX-1 gene. Headache Forum Related Articles

Late-onset adrenal hypoplasia congenita caused by a novel mutation of the DAX-1 gene.

Eur J Pediatr. 2008 Jul 8;

Authors: Yang F, Hanaki K, Kinoshita T, Kawashima Y, Nagaishi JI, Kanzaki S

Mutation in the orphan nuclear receptor DAX-1 gene causes X-linked adrenal hypoplasia congenita (AHC). Affected male children classically suffer a salt-losing crisis and adrenal insufficiency in their early infancy or, in some rare exceptions, with late-onset subtype. We report here a patient manifesting late-onset adrenal hypoplasia congenita caused by the premature truncation of the C-terminus of the DAX-1 molecule, which is essential for its function as a transcriptional repressor. A 12-year-old boy was referred to us after being afflicted with generalized skin pigmentation for about 3 years, fatigue and headache. Primary adrenal insufficiency was determined on the basis of a low plasma cortisol level (3.9 mug/dl) despite an extremely high ACTH level (1200 pg/ml). Replacement therapy with hydrocortisone and fludorocortisone acetate was initiated soon thereafter. Hypogonadotropic hypogonadism was confirmed at the age of 18 years, at which time sexual infantilism had become apparent. Direct sequencing of the peripheral lymphocyte-derived DNA revealed a novel 1033del13 mutation on the ligand-binding domain of the NR0B1 (DAX-1) gene, which generated a premature stop codon truncating the C-terminus. This mutation was considered de novo since we could not find it in his mother. This case demonstrates that even a truncated protein lacking the major functional domain of DAX-1 can present late-onset and latent adrenal failure.

Headache Forum PMID: 18607630 [PubMed - as supplied by publisher]Varenicline and its role in smoking cessation. Headache Forum Related Articles

Varenicline and its role in smoking cessation.

Prev Cardiol. 2008;11(3):168-71

Authors: Kapoor S

Varenicline is a partial agonist of alpha4beta2 nicotinic receptors. It was recently approved for smoking cessation in the United States. It is administered at a dosage of 0.5 mg once a day for an initial period of 3 days followed by 0.5 mg twice a day for the next 4 days. Following this, the drug is administered at a dosage of 1.0 mg twice a day. The total duration of therapy is 12 weeks. Common adverse effects include nausea, headache, and insomnia. Recent studies show that varenicline is almost twice as effective as bupropion SR in smoking cessation. Given the increased risk of cardiovascular morbidity secondary to smoking, especially in the elderly, varenicline is a major therapeutic tool in the fight against smoking. prev cardiol. 2008;11:168-171.

Headache Forum PMID: 18607153 [PubMed - in process]Multimechanistic (sumatriptan-naproxen) early intervention for the acute treatment of migraine. Headache Forum Related Articles

Multimechanistic (sumatriptan-naproxen) early intervention for the acute treatment of migraine.

Neurology. 2008 Jul 8;71(2):114-21

Authors: Silberstein SD, Mannix LK, Goldstein J, Couch JR, Byrd SC, Ames MH, McDonald SA, Lener SE

BACKGROUND: Research suggests treating a migraine at the first sign of pain increases the likelihood of the best clinical outcome. OBJECTIVE: To investigate the efficacy and tolerability of a fixed-dose, single-tablet formulation of sumatriptan 85 mg, formulated with RT Technology, and naproxen sodium 500 mg (sumatriptan/naproxen) as early intervention acute therapy for migraine. METHODS: Patients (aged 18 to 65 years) with International Headache Society-defined migraine with or without aura were enrolled in one of two identically designed, randomized, double-blind, parallel group, placebo-controlled studies. Patients treated a single migraine within 1 hour of onset of migraine head pain and while the pain was mild with either sumatriptan/naproxen or placebo. The primary efficacy measure was the percentage of patients who became pain-free 2 hours postdose. RESULTS: Intent-to-treat analyses consisted of 576 and 535 migraineurs. At 2 hours, 52% and 51% of sumatriptan/naproxen-treated patients were pain free, as compared to 17% and 15% of placebo-treated patients (p < 0.001). Significant pain-free responses in favor of sumatriptan/naproxen were demonstrated as early as 30 minutes, maintained at 1 hour, and sustained from 2 to 24 hours. At 2 and 4 hours, sumatriptan/naproxen provided significantly lower rates of traditional migraine-associated symptoms (nausea, photophobia, and phonophobia) and nontraditional migraine-associated symptoms (neck pain/discomfort and sinus pain/pressure). The most commonly reported adverse events were nausea (< or =4%) and dizziness (< or =2%). CONCLUSION: The fixed-dose single-tablet formulation of sumatriptan/naproxen was effective and well tolerated in an early intervention paradigm for the acute treatment of migraine, including traditional and nontraditional symptoms.

Headache Forum PMID: 18606965 [PubMed - indexed for MEDLINE]Surveillance for adverse drug reactions to combination antimalarial therapy with sulfadoxine-pyrimethamine plus artesunate in Peru. Headache Forum Related Articles

Surveillance for adverse drug reactions to combination antimalarial therapy with sulfadoxine-pyrimethamine plus artesunate in Peru.

Am J Trop Med Hyg. 2008 Jul;79(1):42-4

Authors: Cairo J, Durand S, Marquiño W, Cabezas C, Lachira A, Quintana F, Vegas W, Ruebush TK, Utz G, Bacon DJ

In 2001, Peru changed its treatment policy for uncomplicated Plasmodium falciparum malaria on the northern Pacific Coast to sulfadoxine-pyrimethamine with atresunate (SP-AS). Because Peru was the first country in the Americas to adopt this combination therapy, we established a surveillance system in the region to assess the frequency of new or worsening symptoms after starting therapy. Over a period of two years, 1,552, or approximately two-thirds of all patients with uncomplicated P. falciparum malaria who had received SP-AS on the northern coast were followed up. Of these, 8.8% reported at least one adverse effect, with the most common being vomiting, nausea, headache, abdominal pain, dizziness, and fever; no severe adverse effects related to SP-AS therapy were identified. Treatment of uncomplicated malaria with SP-AS was associated with a low frequency of mild adverse effects in Peru, and therefore should be considered as a first-line therapy in areas of the Americas where SP efficacy is still high.

Headache Forum PMID: 18606762 [PubMed - indexed for MEDLINE]Pott's Puffy tumor after minor head trauma. Headache Forum Related Articles

Pott's Puffy tumor after minor head trauma.

Am J Emerg Med. 2008 Jul;26(6):739.e1-3

Authors: Martinez-Diaz GJ, Hsia R

Posttraumatic osteomyelitis may occur as a direct result of bony injury after trauma or arise as a nosocomial infection after the treatment of trauma. Most cases arise after an open fracture, but bony infection can also arise from spread of infection from contiguous soft tissues or by puncture wounds. Motor vehicle accidents, sport injuries, and the use of orthopedic hardware to manage trauma have contributed to the apparent increase in prevalence of posttraumatic osteomyelitis. We report on a case of Pott's Puffy tumor in a previously healthy woman who had an episode of minor forehead trauma 1 month before presentation to the emergency department (ED), complaining of persistent headache and swelling of her forehead. Results of computed tomography (CT) revealed features characteristic of this condition. After postobliteration of the left frontal sinus via a bicoronal approach with an iliac crest bone graft and some dental extractions and 2 weeks of antibiotic therapy, the patient achieved a complete recovery.

Headache Forum PMID: 18606352 [PubMed - in process][Deep brain stimulation in the context of addiction--a literature-based systematic evaluation] Headache Forum Related Articles

[Deep brain stimulation in the context of addiction--a literature-based systematic evaluation]

Fortschr Neurol Psychiatr. 2008 Jul;76(7):396-401

Authors: Bauer R, Pohl S, Klosterkötter J, Kuhn J

BACKGROUND: Deep Brain Stimulation (DBS) is established as option to treat Parkinson's Disease and essential tremor by now. Successful treatments of small samples suffering from dystonia, cluster headache or Tourette's Syndrome or from obessive-compulsive disorders and depression make a future extension of indication seem probable. In this context the efficiency of DBS for the treatment of addiction is being discussed. AIM AND METHODS: To assess the potential effects of DBS of different target areas on addiction a keyword-related research in Pubmed (National Library of Medicine, Washington) was undertaken and own research was integrated. FINDINGS: Only case reports and case series were being found, describing in total n = 28 patients. Dopamine replacement therapy dependence (DRTD) and pathological gambling (PG) were reported in conjunction with DBS of the nucleus subthalamicus (STN). Addiction to alcohol, nicotine and heroin were reported in conjunction with DBS of the nucleus accumbens (NAc). These findings were collected in a spreadsheet and discussed. CONCLUSIONS: For STN DBS remissions of PG and DRTD are only reported during the underlying treatment of Parkinson's disease. As method of action therefore the reduction of Parkinsonian medication seems more probable. For NAc DBS remissions of addiction to alcohol, nicotine and heroin are reported during the underlying treatment of heterogonous psychiatric disorders. In contrast to STN DBS this refers to possible, maybe supportive effects of NAc DBS. The exact methods of action are not well understood, but an high motivation of the patients to stay abstinent seems to be of relevance for the effect of NAc DBS.

Headache Forum PMID: 18604773 [PubMed - in process]Efficacy of methylprednisolone pulse therapy in children with rheumatoid arthritis. Headache Forum Related Articles

Efficacy of methylprednisolone pulse therapy in children with rheumatoid arthritis.

Clin Rheumatol. 2008 Jul 5;

Authors: Aghighi Y, Attarod L, Javanmard M

Pulse therapy is one of the most well-known methods used in the treatment of juvenile rheumatoid arthritis. This study assessed the outcome of methylprednisolone pulse therapy, its rate of efficacy, and its associated complications in patients with juvenile rheumatoid arthritis (JRA). This cross-sectional study was performed on 120 children with JRA who attended the Pediatric Ward of Imam Khomeini Hospital from 1994 to 2004 and who had undergone around 500 cycles of methylprednisolone pulse therapies. Clinical signs, including signs of improvement, complications, or recurrence of disease, were noted. SPSS version 11.5 and paired t test were used to compare the variables prior to and after treatment. Clinical signs observed included: feeling of weakness (100%), malaise (98.3%), loss of appetite (93.3%), fever (88.3%), skin rash (28%), lymphadenopathy (18.3%), serositis (4.2%), splenomegaly (3.3%), and hepatomegaly (1.7%); however, none of these findings were present after pulse therapy. The number of swollen and tender joints, duration of morning stiffness, erythrocyte sedimentation rate, C-reactive protein, and hemoglobin levels showed significant improvement after pulse therapy. Complications of pulse therapy included tachycardia (n = 16, 13.3%), hypertension (n = 10, 8.3%), headache (n = 2, 1.7%), and flashing (n = 2, 1.7%). The mean duration of remission was 3.3 +/- 0.7 months.

Headache Forum PMID: 18604580 [PubMed - as supplied by publisher][Multimodal group therapy for the elderly with chronic pain : Concept and results in a before and after comparison.] Headache Forum Related Articles

[Multimodal group therapy for the elderly with chronic pain : Concept and results in a before and after comparison.]

Schmerz. 2008 Jul 6;

Authors: Mattenklodt P, Ingenhorst A, Wille C, Flatau B, Hafner C, Geiss C, Sittl R, Ulrich K, Griessinger N

BACKGROUND: Multimodal pain therapy programs are increasingly being recommended as an effective treatment option also for elderly patients with chronic pain. However, data from Germany are limited. PATIENTS AND METHODS: A multimodal group program adapted to the specific needs of elderly pain patients over 70 years old (20 treatment days, over 10 weeks) was started in our pain clinic in June 2005. We evaluated clinical, psychometric and physical data at the beginning and at the end of the treatment program, and compared outcome results with a waiting list control group. RESULTS: A total of 24 patients (mean age 76.2+/-4.79 years) could be evaluated of which 21 patients suffered from musculoskeletal pain, 2 from neuropathic pain syndromes and 1 from headache. In the waiting-list control group 13 patients were included. There were no significant between-group differences regarding age, stages of chronification, pain intensity, duration of pain and pain diagnosis. Mean pain intensity (NRS 0-10, mean +/- standard deviation) decreased significantly from 6.75 (+/-1.85) to 5.17 (+/-1.71; p <0.001; effect size d=0.86). Depression scores (ADS T-values) improved significantly from 59.26 (+/-8.34) to 51.26 (+/-9.70; p<0.01; effect size d=0.96). Other psychometric and most of the physical performance values also improved significantly (predominantly medium and large effect sizes). There were no significant changes in pain intensity or psychometric measures in the waiting-list control group. CONCLUSIONS: A multimodal pain therapy program for elderly patients (over 70 years old) is an effective treatment option to reduce pain intensity and pain disability. Furthermore, life quality and physical performance improved. Long-term effects still have to be evaluated.

Headache Forum PMID: 18604566 [PubMed - as supplied by publisher]Enteric Fever: A retrospective 6-year analysis of 82 paediatric cases in a teaching hospital. Headache Forum Related Articles

Enteric Fever: A retrospective 6-year analysis of 82 paediatric cases in a teaching hospital.

Kathmandu Univ Med J (KUMJ). 2007 Apr-Jun;5(2):181-7

Authors: Malla T, Malla KK, Thapalial A, Shaw C

Objective: To evaluate the clinical and laboratory properties, to see the response to therapy, incidence of antimicrobial resistance and complications of Enteric Fever in children. Methods: This is a retrospective study of 82 cases of enteric fever admitted in department of pediatrics, Manipal Teaching hospital, Pokhara, Nepal .Study period was six years from (Jan 2000 to Dec 2005). Results: Total of 82 cases of Salmonella infections were admitted .There were 50 (60%) males and 32 (40%) females. Most of the patients were above the age of five. The leading clinical feature were Fever (100%) , GI symptoms (73%), followed by splenomegaly (60%), hepatomegaly (58%) , chills & rigor (41%), headache(33%),coated tongue(17%), lymphadenopathy (13%), Respiratory signs (13%) , toxic look (7%). The laboratory reports revealed leucopenia in 26% and leukocytosis in 16%. Widal test was positive in 83%, Blood culture was positive in 37 %.Bone marrow was done in 8 cases, out of which 5(62.5%) were culture positive. Out of 35 culture positive cases 32 were Salmonella typhi and 3 were Salmonella paratyphi A. Regarding the treatment 55% were treated with ciprofloxacin, 29 % with ceftriaxone , 7% with ampicillin , 6% with cefotaxime and 2.4 % with chloramphenicol . Response to therapy was assessed by day of defervescence after antibiotics. Best response was observed with ciprofloxacin (4.7 days) followed by ceftriaxone (5days), ampicillin (5.5 days), cefotaximee (6.4 days), chloramphenicol (10 days) respectively. In the antibiogram resistance was 43% with chloramphenicol, 37% with ampicillin, 31% with trimethoprim- sulfamethoxazole, 5.7%with ciprofloxacin and 4% with cefotaxime .Resistance was 0% with ceftriaxone, cefuroxime, and ofloxacin. Gentamycin was found to show high sensitivity (91%). The complications observed were anemia in 10%, 5% had neurologic signs like clouding of consciousness and 3.7% had CNS irritability. Conclusion: It is important to include Enteric fever in the differential diagnosis of febrile patients with abdominal symptoms. Though blood culture is the definite test, Widal test plays supportive role in diagnosis of enteric fever, especially when patients come after a course of antibiotics. Sometimes when both blood culture and Widal tests are negative Bone marrow can be the diagnostic tool for the diagnosis. Based on this analysis ciprofloxacin is still a good drug for the treatment of Enteric Fever. Ceftriaxone, Cefuroxime and Ofloxacin can be considered as first line treatment for Enteric fever since resistance was nil with these drugs on culture reports. Key words: Enteric fever, salmonella infections.

Headache Forum PMID: 18604016 [PubMed - in process]Otogenic pneumococcal meningitis with pneumocephalus. Headache Forum Related Articles

Otogenic pneumococcal meningitis with pneumocephalus.

J Emerg Med. 2008 Jun 30;

Authors: Damergis JA, Chee K, Amitai A

Streptococcus pneumoniae accounts for approximately 50% of bacterial meningitis cases in the United States annually. Since the advent of antibiotics, pneumococcal meningitis as a complication of a primary otogenic focus has been rare in the United States. The widespread use of immunosuppressants and increasing bacterial resistance to commonly prescribed antibiotics may contribute to a higher incidence of complications of otitis media in the future, similar to that of the pre-antibiotic era. We report a case of otogenic pneumococcal meningitis with pneumocephalus in an adult male on chronic immunosuppressant therapy. A 33-year-old man with Crohn's disease and azathioprine use presented to our Emergency Department with progressive headache while taking antibiotics for otitis media. Initial computed tomography scan of the brain revealed pneumocephaly, and cerebrospinal fluid analysis and culture diagnosed pneumococcal meningitis. The patient continued to have fevers while receiving intravenous antibiotics and underwent bilateral myringotomies; his clinical course subsequently improved significantly. Meningitis is a rare complication of Streptococcus pneumoniae infections since the advent of antibiotics; however, it may become more frequent with increasing antibiotic resistance and a growing population of immunocompromised patients. Additionally, pneumocephalus in the setting of meningitis and otitis media should raise the suspicion for mastoiditis (even without overt clinical findings) and early consultation with an otolaryngologist is warranted.

Headache Forum PMID: 18597973 [PubMed - as supplied by publisher]Humanistic, utilization, and cost outcomes associated with the use of botulinum toxin for treatment of refractory migraine headaches in a managed care organization. Headache Forum Related Articles

Humanistic, utilization, and cost outcomes associated with the use of botulinum toxin for treatment of refractory migraine headaches in a managed care organization.

J Manag Care Pharm. 2008 Jun;14(5):442-50

Authors: Mitchell MP, Schaecher K, Cannon HE, Speckman M

BACKGROUND: Few patients with migraine syndrome receive treatment with preventive medication regimens, and some of these patients fail to gain adequate migraine relief. Botulinum toxin has been suggested to be effective in the treatment of migraine for a select population. An integrated health system created a medical policy and a supporting preauthorization form that permits coverage of botulinum toxin for the off-label treatment of migraine for patients who (1) fail at least 3 drug classes for acute treatment, (2) fail at least 4 different preventive medication classes, and (3) receive consultation from a neurologist. OBJECTIVES: To (1) evaluate the impact of botulinum toxin therapy on quality-of-life (QOL) measures evaluated by direct member survey results, and (2) assess the use and cost of migraine-related medications and overall medical and pharmacy services pre- and post-botulinum toxin therapy. METHODS: The study was a retrospective analysis of administrative claims data from a 500,000-member integrated health system for the time period January 1, 2003, to October 31, 2007. Administrative claims data were used to identify members with a billing code (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM]) for migraine (346.xx), tension headache (307.81), or headache (784.0) diagnosed by a neurologist. Administrative claims data for these patients were then queried for the use of botulinum toxin for dates of service from January 1, 2003, through October 31, 2006. A survey was sent to the identified patients (N=54) to assess 6 QOL measures associated with the use of botulinum toxin. Self-reported symptomatic improvement was assessed using a 5-point Likert scale for 6 questions regarding headache severity, headache frequency, use of rescue medications, productivity/absenteeism, recreational activities, and life enjoyment. For the subset of patients (n = 32) who maintained health plan eligibility from 18 months before through 18 months after the first botulinum toxin therapy claim (index date), medical and pharmacy claims data were used to assess the utilization and cost of specific medications and overall pharmacy and medical costs for the 18-month pre-index and post-index periods. Cost was defined as allowed charge, which is the sum of plan cost and member cost. RESULTS: Of 54 surveys sent to all patients identified as having used botulinum toxin for the treatment of migraine from January 1, 2003, to October 31, 2006, 34 surveys were returned (63%). Almost 3 of 4 respondents (73%) reported moderate or better improvement in overall migraine or headache QOL measures, and 27% reported little or no improvement. For the 32 patients with continuous eligibility for the total observation period of 36 months, the average migraine-related pharmacy utilization, excluding botulinum toxin, increased by 50.5%, from 1.84 claims per patient per month (PPPM) in the 18-month pre-index period to 2.77 claims PPPM in the 18-month post-index period (P = 0.011) and by 59.5% by mean days supply (42.58 days to 67.93, P=0.008). Total migraine-related pharmacy cost increased by 80.9%, from $142.08 PPPM to $256.97 PPPM (P=0.013). Acute-treatment migraine-related pharmacy utilization increased from 1.23 claims PPPM to 1.92 claims PPPM (P=0.004). There was no significant change in either the number of claims for migraine prophylaxis medications (0.61 PPPM to 0.85 PPPM, P=0.121) or the use of hospital emergency room services related to migraine or headache (0.07 PPPM vs. 0.10 PPPM, P=0.449). The mean migraine-related and nonmigraine-related (i.e., all-cause) combined medical/hospital and pharmacy expense, including botulinum toxin, increased by 111.3%, from $651.13 PPPM in the pre-index period to $1,376.05 PPPM in the post-index period (P<0.001). CONCLUSION: The majority of patients who received botulinum toxin for refractory migraine reported improvement in disease-specific symptoms and overall QOL, but total medical and pharmacy costs were higher in the period after treatment, and there was no reduction in the use of other migraine-related medications.

Headache Forum PMID: 18597573 [PubMed - in process][Unusual clinical manifestation of Lyme disease--report of 2 cases] Headache Forum Related Articles

[Unusual clinical manifestation of Lyme disease--report of 2 cases]

Przegl Lek. 2007;64(12):1031-2

Authors: Ołdak E, Sulik A, Rozkiewicz D, Pogorzelska E, Pogorzelska M

Unusual clinical manifestation of Lyme borreliosis in two children has been presented. We discuss patient from Borrelia-endemic area who presented with persistent headache, weakness and fever. The second patient experienced acute flu-like signs with associated neck pain and stiffness (probable diagnosis). After two weeks lasting antibiotic therapy (ceftriaxone, ampicillin) nonspecific symptoms and signs decreased.

Headache Forum PMID: 18595510 [PubMed - indexed for MEDLINE]Aliskiren. Headache Forum Related Articles

Aliskiren.

Am J Health Syst Pharm. 2008 Jul 15;65(14):1323-32

Authors: Daugherty KK

PURPOSE: The pharmacology, bioavailability and pharmacokinetics, clinical efficacy, adverse effects and toxicity, drug interactions, and dosage and administration of aliskiren as well as safety and economic issues related to its use are reviewed. SUMMARY: Aliskiren is the first of a new class of antihypertensive agents, direct renin inhibitors, that act by blocking the rate- limiting step of the renin-angiotensin- aldosterone system (RAAS). It was approved by the Food and Drug Administration in 2007 for use as monotherapy or in combination with other antihypertensives. Clinical studies comparing aliskiren monotherapy with placebo indicated a dose-dependent reduction in both systolic and diastolic blood pressure (BP). Greater reductions in BP have been achieved when aliskiren was used in combination with hydrochlorothiazide or an angiotensin-receptor blocker. The most common adverse effects reported in clinical trials were headache, fatigue, dizziness, diarrhea, and nasopharyngitis. Aliskiren has not been studied in patients with moderate renal dysfunction; as a RAAS-acting drug, it should be prescribed for such patients only with caution. CONCLUSION: Aliskiren at a dosage of 150 or 300 mg daily may be a good option for control of mild-to-moderate hypertension in patients with or without diabetes in whom first-line antihypertensives have failed to adequately control BP; comparative studies with other antihypertensives are needed to determine which patients can most benefit from aliskiren therapy.

Headache Forum PMID: 18593678 [PubMed - indexed for MEDLINE]Thyroid-stimulating hormone pituitary adenomas. Headache Forum Related Articles

Thyroid-stimulating hormone pituitary adenomas.

J Neurosurg. 2008 Jul;109(1):17-22

Authors: Clarke MJ, Erickson D, Castro MR, Atkinson JL

OBJECT: Thyroid-stimulating hormone (TSH)-secreting pituitary adenomas are rare, representing < 2% of all pituitary adenomas. METHODS: The authors conducted a retrospective analysis of patients with TSH-secreting or clinically silent TSH-immunostaining pituitary tumors among all pituitary adenomas followed at their institution between 1987 and 2003. Patient records, including clinical, imaging, and pathological and surgical characteristics were reviewed. Twenty-one patients (6 women and 15 men; mean age 46 years, range 26-73 years) were identified. Of these, 10 patients had a history of clinical hyperthyroidism, of whom 7 had undergone ablative thyroid procedures (thyroid surgery/(131)I ablation) prior to the diagnosis of pituitary adenoma. Ten patients had elevated TSH preoperatively. Seven patients presented with headache, and 8 presented with visual field defects. All patients underwent imaging, of which 19 were available for imaging review. Sixteen patients had macroadenomas. RESULTS: Of the 21 patients, 18 underwent transsphenoidal surgery at the authors' institution, 2 patients underwent transsphenoidal surgery at another facility, and 1 was treated medically. Patients with TSH-secreting tumors were defined as in remission after surgery if they had no residual adenoma on imaging and had biochemical evidence of hypo-or euthyroidism. Patients with TSH-immunostaining tumors were considered in remission if they had no residual tumor. Of these 18 patients, 9 (50%) were in remission following surgery. Seven patients had residual tumor; 2 of these patients underwent further transsphenoidal resection, 1 underwent a craniotomy, and 4 underwent postoperative radiation therapy (2 conventional radiation therapy, 1 Gamma Knife surgery, and 1 had both types of radiation treatment). Two patients had persistently elevated TSH levels despite the lack of evidence of residual tumor. On pathological analysis and immunostaining of the surgical specimen, 17 patients had samples that stained positively for TSH, 8 for alpha-subunit, 10 for growth hormone, 7 for prolactin, 2 for adrenocorticotrophic hormone, and 1 for follicle-stimulating hormone/luteinizing hormone. Eleven patients (61%) ultimately required thyroid hormone replacement therapy, and 5 (24%) required additional pituitary hormone replacement. Of these, 2 patients required treatment for new anterior pituitary dysfunction as a complication of surgery, and 2 patients with preoperative partial anterior pituitary dysfunction developed complete panhypopituitarism. One patient had transient diabetes insipidus. The remainder had no change in pituitary function from their preoperative state. CONCLUSIONS: Thyroid-stimulating hormone-secreting pituitary lesions are often delayed in diagnosis, are frequently macroadenomas and plurihormonal in terms of their pathological characteristics, have a heterogeneous clinical picture, and are difficult to treat. An experienced team approach will optimize results in the management of these uncommon lesions.

Headache Forum PMID: 18590428 [PubMed - indexed for MEDLINE]The syndrome of headache with neurologic deficits and cerebrospinal fluid lymphocytosis mimicking acute ischemic stroke. Headache Forum Related Articles

The syndrome of headache with neurologic deficits and cerebrospinal fluid lymphocytosis mimicking acute ischemic stroke.

J Stroke Cerebrovasc Dis. 2008 Jul-Aug;17(4):246-7

Authors: Ariës MJ, van Oostrom JC, de Keyser J

Headache with neurologic deficits and cerebrospinal fluid lymphocytosis is a benign condition with a transient ischemic attack-like presentation. We present a case of a 22-year-old man with episodes of right-sided weakness, global dysphasia, and right-sided homonymous hemianopsia associated with frequent vomiting. Systemic thrombolytic therapy was considered. A subsequent magnetic resonance image with diffusion-weighted images revealed normal findings. A diagnosis of headache with neurologic deficits and cerebrospinal fluid lymphocytosis was made based mainly on clinical symptoms and cerebrospinal fluid analysis. With the current pressure on "door-to-needle" time for thrombolysis, it is important to keep an open eye to stroke mimics and exclude them if possible. We, therefore, strongly advise considering noninvasive magnetic resonance diffusion-weighted imaging in patients with unusual presentations (e.g., the vomiting in our patient) before thrombolysis.

Headache Forum PMID: 18589348 [PubMed - in process]Botulinum toxin A injection into corrugator muscle for frontally localised chronic daily headache or chronic tension-type headache. Headache Forum Related Articles

Botulinum toxin A injection into corrugator muscle for frontally localised chronic daily headache or chronic tension-type headache.

J Laryngol Otol. 2008 Jun 30;:1-6

Authors: de Ru JA, Buwalda J

Objective:To describe our results with botulinum toxin type A injection for headache in carefully selected patients, and to present the rationale behind this therapy.Setting:Tertiary referral centre.Patients and methods:This article describes a case series of 10 consecutive patients with frontally localised headache, whose pain worsened when pressure was applied at the orbital rim near the supratrochlear nerve. The patients received a local anaesthetic nerve block with Xylocaine 2 per cent at this site. If this reduced the pain, they were then offered treatment with botulinum toxin.Intervention:Injection with 12.5 IU of botulinum toxin A into the corrugator supercilii muscle on both sides (a total of 25 IU).Main outcome measure:Pain severity scoring by the patients, ranging from zero (no pain) to 10 (severe pain) on a verbal scale.Results:Following injection, all patients had less pain for approximately two months. This treatment did not appear to have lasting side effects.Conclusion:Xylocaine injection is a good predictor of the effectiveness of botulinum toxin injection into the corrugator muscle as treatment of frontally localised headache. We hypothesise that this pain is caused by entrapment of the supratrochlearis nerve in the corrugator muscle. Furthermore, we found botulinum toxin injection to be a safe and effective means of achieving pain relief in this patient group.

Headache Forum PMID: 18588738 [PubMed - as supplied by publisher]Levofloxacin-induced delirium with psychotic features. Headache Forum Related Articles

Levofloxacin-induced delirium with psychotic features.

Gen Hosp Psychiatry. 2008 Jul-Aug;30(4):381-3

Authors: Kiangkitiwan B, Doppalapudi A, Fonder M, Solberg K, Bohner B

OBJECTIVE: To raise awareness of a rare but serious adverse effect of a commonly used medication. METHOD: Report of a case. RESULTS: A previously healthy 42-year-old woman presented with acute-onset delirium with psychotic features as a consequence of levofloxacin therapy. Withdrawal of the medication was associated with return of the patient's normal mental status. CONCLUSION: The new quinolone derivatives (levofloxacin, sparfloxacin, grepafloxacin, trovafloxacin, gatifloxacin and moxifloxacin), also called gyrase inhibitors, are known for their potential to cause central nervous system-related adverse effects, including headache, dizziness and insomnia. Risk factors for neurotoxicity include renal insufficiency, underlying central nervous system (CNS) disease and increased CNS penetration of drug. Acute delirium resulting from levofloxacin therapy is an exceedingly rare complication that has been thought to occur more commonly in elderly patients. Here, we describe levofloxacin-induced delirium with psychotic features in a relatively young, otherwise healthy female.

Headache Forum PMID: 18585545 [PubMed - in process]Patients' help-seeking behaviours for health problems associated with methadone and buprenorphine treatment. Headache Forum Related Articles

Patients' help-seeking behaviours for health problems associated with methadone and buprenorphine treatment.

Drug Alcohol Rev. 2008 Jul;27(4):393-7

Authors: Winstock AR, Lea T, Sheridan J

INTRODUCTION AND AIMS: Clients in opioid substitution therapy often have considerable unmet health-care needs. The current study aimed to explore health problems related to opioid substitution therapy among clients on methadone and buprenorphine treatment. DESIGN AND METHODS: A self-complete, cross-sectional survey conducted among 508 patients receiving methadone and buprenorphine treatment at community pharmacies in New South Wales (NSW), Australia. RESULTS: The most common problems for which participants had ever sought help were dental (29.9%), constipation (25.0%) and headache (24.0%). The most common problems for which participants would currently like help were dental (41.1%), sweating (26.4%) and reduced sexual enjoyment (24.2%). There were no significant differences between those currently on methadone and those currently on buprenorphine for any of the health problems explored, nor differences for gender or treatment duration. Participants on methadone doses 100 mg or above were significantly more likely to want help currently for sedation. DISCUSSION AND CONCLUSIONS: The considerable unmet health care needs among participants in this study suggest that treatment providers should consider improving the detection and response to common health problems related to opioid substitution therapy.

Headache Forum PMID: 18584389 [PubMed - indexed for MEDLINE]Use of the neuro-wrap system for severe post-electroconvulsive therapy headaches. Headache Forum Related Articles

Use of the neuro-wrap system for severe post-electroconvulsive therapy headaches.

J ECT. 2008 Jun;24(2):152-5

Authors: Kramer BA, Kadar AG, Clark K

OBJECTIVE: To determine, in a nonblinded trial, if the Neuro-Wrap system is effective in reducing the severity of pain in patients with severe post-electroconvulsive therapy (ECT) headaches not adequately responsive to routine analgesic treatment. BACKGROUND: A very troubling side effect of ECT is severe post-ECT headaches. Although these headaches usually respond to routine analgesic medication, some patients continue to experience severe headache despite treatment. This very unpleasant sensation, repeated with each ECT, may cause patients to prematurely stop ECT and experience a relapse in their psychiatric symptoms. "Cold therapy" has been used for a long time as an adjunct to treat headache and pain. The Neuro-Wrap system is a method to provide temperature-controlled cooling to the head without the need to frequently reapply ice packs or physically hold the ice packs in position. It has been used successfully for patients with migraine headaches. This is the first report of its use with patients experiencing severe post-ECT headaches. METHODS: The study comprised a total of 14 patients receiving ECT who experienced a severe headache for 2 successive ECT treatments or 2 of their last 4 treatments and who had only partial or no response to usual analgesic treatment for their headache. After completion of the ECT, the Neuro-Wrap was placed on the head of the patient for a maximum of 40 minutes. Patients continued to receive analgesic medication as needed for relief of headache pain. Patients were their own control group. RESULTS: A total of 85 Neuro-Wrap treatments were given to 14 patients ranging in age from 23 to 71 years old. Nine patients reported clearly positive results on 67 different occasions. Three reported mild alleviation of headaches on 15 occasions. The remaining 2 patients had a total of 3 treatments with no benefit. After the initial treatment, 12 of 14 patients wanted to use the machine after all their subsequent ECT sessions. CONCLUSIONS: Cold therapy with Neuro-Wrap is an effective alternative treatment for refractory headaches caused by ECT.

Headache Forum PMID: 18580561 [PubMed - in process]The practice of electroconvulsive therapy in Malawi. Headache Forum Related Articles

The practice of electroconvulsive therapy in Malawi.

J ECT. 2008 Jun;24(2):137-40

Authors: Selis MA, Kauye F, Leentjens AF

OBJECTIVES: To describe the practice of electroconvulsive therapy (ECT), including indications, efficacy, and side effects, in patients treated with unmodified ECT at Zomba Mental Hospital (ZMH) in Malawi. METHODS: A naturalistic, descriptive cohort study that includes all patients receiving ECT in March and April 2006. Efficacy of ECT treatment was assessed with the "Clinical Global Impression" of change scale, and side effects and complications were systematically assessed with a checklist. RESULTS: The circumstances and procedure of ECT at ZMH are described. Forty-seven patients underwent unmodified ECT for various affective and psychotic disorders. Depending on the indication, improvement was reported in 71% to 90%. Cognitive side effects (confusion and amnesia), muscle aches, headache, and lesions of the oral cavity were the most prevalent side effects. Serious complications were not encountered. CONCLUSIONS: Unmodified ECT in Malawi is an effective treatment with less severe side effects than commonly thought. Efforts to improve treatment standards are undertaken.

Headache Forum PMID: 18580558 [PubMed - in process][Neurological complications in renal transplant recipients] Headache Forum Related Articles

[Neurological complications in renal transplant recipients]

Acta Med Croatica. 2008;62 Suppl 1:76-81

Authors: Basić-Jukić N, Basić-Kes V, Kes P, Furić-Cunko V, Bacić-Baronica K

Renal transplantation is method of choice for treatment of patients with end-stage renal disease without contraindications for immunosuppressive therapy. Neurological complications occur frequently in renal transplant recipients. They may be the consequence of immunosuppressive treatment, but more often evolve as the consequence of previous disturbances which developed during the state of uraemia and treatment with dialysis. The most pronounced neurotoxic effect has calcineurin inhibitors tacrolimus and cyclosporine. The spectrum of neurological disturbances caused by calcineurin inhibitors range from very mild symptoms as paraesthesiae, tremor, headache or flushing, to severe changes that may cause lethal outcome. Peripheral neuropathies in renal transplant recipients may occur in the form of mononeuropathy or polyneuropathy. Cerebrovascular diseases are consequence of changes on blood vessels caused by uraemia, dialysis and side effects of immunosuppressive drugs. They cause death in 8% of renal transplant recipients. Central nervous system (CNS) infections usually occur during the first posttransplant year. Unclear symptomatology frequently postpones the diagnosis. Diagnostic evaluation should include magnetic resonance imaging for localization of the process, as well as lumbal puncture in cases without contraindications for the procedure, in order to determine the causative agent. Regarding the ominous prognosis of CNS infections in the immunocompromised host, only timely diagnosis may improve survival. The most common causative agents are Cryptococcus neoformans, Listeria monocytogenes and Aspergillus funigatus. Viral infections also occur, and are commonly caused by herpes virideae, varicella-zoster virus and papova virus. CNS infections clinically present as meningitis, progressive dementia or focal neurological defect. The most common primary brain tumors are B-cell lymphomas, but glioblastoma, hemangioblastoma, leiomyosarcoma or glioma may also occur. In cases of neurological posttransplant complications, optimal treatment should be guided by neurologist, nephrologist and infectologist, in some cases also by neurosurgeons.

Headache Forum PMID: 18578336 [PubMed - in process]Atypical antipsychotic treatment of disruptive behavior disorders in children and adolescents. Headache Forum Related Articles

Atypical antipsychotic treatment of disruptive behavior disorders in children and adolescents.

J Clin Psychiatry. 2008;69 Suppl 4:9-14

Authors: Findling RL

Disruptive behavior disorders, including conduct disorder, oppositional defiant disorder, and disruptive behavior disorder not otherwise specified, are serious conditions in children and adolescents that include a behavior pattern of violating the basic rights of others and age-appropriate rules or standards and may include aggressive behavior. Although no pharmacotherapy is currently approved for use in this population, evidence suggests that atypical antipsychotic treatment may be useful in patients with these conditions who present with problematic aggression. Currently, research on risperidone shows it to be effective in treating aggressive behavior in this patient population. Limited research is also available on olanzapine, quetiapine, and aripiprazole, but more research is needed on these and other agents. As with any pharmacotherapy, adverse events (including weight gain, headache, and somnolence) should be carefully considered with these medications, especially in children and adolescents, and it is important to properly dose and monitor patients during medication therapy.

Headache Forum PMID: 18533763 [PubMed - indexed for MEDLINE]Efficacy and tolerability of coadministration of rizatriptan and acetaminophen vs rizatriptan or acetaminophen alone for acute migraine treatment. Headache Forum Related Articles

Efficacy and tolerability of coadministration of rizatriptan and acetaminophen vs rizatriptan or acetaminophen alone for acute migraine treatment.

Headache. 2008 Jun;48(6):921-30

Authors: Freitag F, Diamond M, Diamond S, Janssen I, Rodgers A, Skobieranda F

OBJECTIVE: To evaluate the efficacy and tolerability of coadministration of rizatriptan and acetaminophen in the acute treatment of migraine. BACKGROUND: Rizatriptan is a selective 5-HT1B/1D agonist approved for the acute treatment of migraine. Acetaminophen has been studied for acute migraine treatment. In consideration of the prominent central and peripheral mechanisms in migraine, the use of "multi-mechanism therapy" is gaining momentum in the treatment of acute migraine attacks. STUDY DESIGN: This was a randomized, double-blind, placebo-controlled trial conducted at 10 centers. Eligible patients with migraine according to International Headache Society criteria treated a single migraine attack of moderate or severe intensity within 4 h from pain onset. Patients were randomized into 1 of 4 groups (rizatriptan 10 mg + acetaminophen 1000 mg [RA], rizatriptan alone [R], acetaminophen alone [A], and placebo [P]). There were 3 co-primary hypotheses tested sequentially for 2-h pain relief: (1) RA would be superior to P; (2) if the first was fulfilled, RA would be superior to A; and (3) if the first 2 were fulfilled, RA would be superior to R. RESULTS: Of 173 patients who treated a migraine, 123 patients (71.5%) achieved pain relief within 2 h. RA (90%) was significantly better than P (46%) and A (70%), but only numerically better than R (77%) for 2-h pain relief. No significant differences were seen between the active treatment groups in adverse events. CONCLUSION: Rizatriptan coadministered with acetaminophen achieved 2 of the 3 primary hypotheses, proving superior to both acetaminophen and placebo for 2-h pain relief, but failing to achieve superiority to rizatriptan alone. RA was as well tolerated as each of the individual agents.

Headache Forum PMID: 18572432 [PubMed - in process]Exercise in migraine therapy--is there any evidence for efficacy? A critical review. Headache Forum Related Articles

Exercise in migraine therapy--is there any evidence for efficacy? A critical review.

Headache. 2008 Jun;48(6):890-9

Authors: Busch V, Gaul C

BACKGROUND: Some migraine patients find that regular exercise helps in reducing the frequency of headache attacks. In addition, exercise in migraine is recommended from many headache experts. However, most of these recommendations refer to some anecdotal reports or observational studies in literature stating that regular exercise can reduce the frequency and severity of migraine. OBJECTIVE: The purpose of this review is to investigate whether recommendations for exercise in migraine are based on sufficient data to cope with requirements of an evidence-based modern migraine therapy. The review summarizes and discusses all available trials on this topic. RESULTS: Eight studies und 4 case reports investigated the therapeutic role of aerobic exercise on migraine headache. Some results are controversial regarding the efficacy of sports intervention in migraine. The majority of studies did not find a significant reduction of headache attacks or headache duration and only indicate a reduction of pain intensities in migraine patients due to regular exercise. The grade of recommendation of exercise in migraine based on evidence based medicine (EBM)-criteria is presently B-C. But due to methodological limitations, the available data are insufficient for a final statement on this topic. CONCLUSIONS: To further recommend exercise in migraine based on EBM-criteria, more studies are imperative. Future studies should adhere to the rules for randomized clinical trials in pharmacological migraines prophylaxis. Implications for further studies are given.

Headache Forum PMID: 18572431 [PubMed - in process]Esomeprazole in acute and maintenance treatment of reflux oesophagitis: a multicentre prospective study. Headache Forum Related Articles

Esomeprazole in acute and maintenance treatment of reflux oesophagitis: a multicentre prospective study.

Adv Ther. 2008 Jun;25(6):552-66

Authors: Atug O, Giral A, Kalayci C, Dolar E, Isitan F, Oguz D, Ovunc O, Ozgur O, Soykan I, Simsek I, Unal S, Yenice N

INTRODUCTION: The aim of this study was to assess the efficacy and safety of esomeprazole 40 mg once daily (q.d.) in healing reflux oesophagitis at 4 and 8 weeks, and the efficacy of esomeprazole 20 mg q.d. for 12 weeks in the maintenance of remission. METHODS: A total of 235 patients with endoscopically proven reflux oesophagitis were enrolled in this study, which consisted of two phases (healing and maintenance therapy). Patients who showed complete endoscopic and symptomatic healing at the end of 4 or 8 weeks were switched to maintenance treatment with esomeprazole 20 mg q.d. for 12 weeks. The primary efficacy endpoint was healing of reflux oesophagitis at week 8. Secondary assessments included the proportion of patients with symptomatic relapse in the maintenance phase. RESULTS: At the end of week 8, 88% (95% life-table confidence intervals [CI]: 84%, 92%) of patients were healed endoscopically and 90.6% of the patients were asymptomatic. Patient age, gender and Helicobacter pylori status had no effect on the efficacy of treatment. During the 12-week maintenance treatment phase, symptomatic relapse ratios were 0.5%, 2.2%, and 0%, for the first, second, and third 4-week periods, respectively. The proportions of patients satisfied with treatment were 95% and 99.4% at the end of acute and maintenance treatment, respectively. The most common adverse effects were headache, upper respiratory tract infection and abdominal pain. CONCLUSIONS: Esomeprazole is effective in the healing of reflux oesophagitis, the resolution of heartburn, and in maintaining symptomatic remission. The effectiveness of esomeprazole in patients with gastroesophageal reflux disease is not affected by the presence of H. pylori.

Headache Forum PMID: 18568450 [PubMed - in process]Effect of doxazosin gastrointestinal therapeutic system as third-line antihypertensive therapy on blood pressure and lipids in the Anglo-Scandinavian Cardiac Outcomes Trial. Headache Forum Related Articles

Effect of doxazosin gastrointestinal therapeutic system as third-line antihypertensive therapy on blood pressure and lipids in the Anglo-Scandinavian Cardiac Outcomes Trial.

Circulation. 2008 Jul 1;118(1):42-8

Authors: Chapman N, Chang CL, Dahlöf B, Sever PS, Wedel H, Poulter NR,

BACKGROUND: The role of doxazosin in treatment of hypertension remains controversial. METHODS AND RESULTS: We evaluated the effects on blood pressure (BP) and biochemical parameters of doxazosin GITS (gastrointestinal therapeutic system) as a third-line antihypertensive agent among 10,069 participants in the Anglo-Scandinavian Cardiac Outcomes Trial--Blood Pressure Lowering Arm (ASCOT-BPLA) whose BP remained above 140/90 mm Hg (130/80 mm Hg in those with diabetes mellitus). Among those who received doxazosin, mean age was 63 years (SD 9 years), 79% were male, and 32% had diabetes. Doxazosin was initiated a median of 8 months (interquartile range 3 to 24 months) after randomization and was added to a mean of 2.0 (SD 0.3) other antihypertensive drugs; the mean starting and final doses were 4.1 (SD 0.6) and 7.0 (SD 3.1) mg, respectively. During a median of 12 months (interquartile range 4 to 31 months) of uninterrupted doxazosin treatment, during which other antihypertensive treatments remained unchanged, mean BP fell 11.7/6.9 mm Hg (SD 18.8/9.6 mm Hg, P<0.0001) from 158.7/89.2 mm Hg (SD 18.3/10.6 mm Hg). After the addition of doxazosin, 29.7% of participants achieved target BP. There was no apparent excess of heart failure among doxazosin users. There were associated modest favorable effects on plasma lipid profiles, but a small rise in fasting plasma glucose was observed. Doxazosin was generally well tolerated, with 7.5% of participants discontinuing the drug because of adverse events, most frequently dizziness, fatigue, headache, and edema. CONCLUSIONS: alpha-Blockers are no longer recommended as add-on therapy in some hypertension guidelines. However, although they are nonrandomized and were not placebo-controlled, the present findings suggest that doxazosin is a safe and effective third-line antihypertensive agent.

Headache Forum PMID: 18559700 [PubMed - in process]Benefit-risk assessment of telithromycin in the treatment of community-acquired pneumonia. Headache Forum Related Articles

Benefit-risk assessment of telithromycin in the treatment of community-acquired pneumonia.

Drug Saf. 2008;31(7):561-75

Authors: Brown SD

The purpose of this review is to assess the benefits and risks associated with the use of the ketolide antibacterial telithromycin, currently licensed for the treatment of adults with mild to moderate community-acquired pneumonia (CAP). Telithromycin is active against both the major (Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis) and atypical/intracellular (Chlamydophila pneumoniae, Legionella pneumophila and Mycoplasma pneumoniae) CAP pathogens. It is associated with a low potential to select for resistance and has maintained its in vitro activity against isolates of respiratory pathogens in countries where it has been in clinical use for several years. In randomized clinical trials, telithromycin has demonstrated efficacy comparable to the established antibacterial classes (macrolides, fluoroquinolones and beta-lactams) in the treatment of CAP.The safety profile of telithromycin is broadly similar to that of other antibacterials used to treat CAP. The most common adverse events are gastrointestinal adverse effects and headache; these are generally mild to moderate in severity and reversible. Telithromycin appears to be well tolerated by adult patients in all age groups, including those with co-morbid conditions. In common with other antibacterials, telithromycin has the potential to affect the corrected QT interval; the concomitant use of cisapride or pimozide with telithromycin is contraindicated, while telithromycin should be avoided in patients receiving Class IA or Class III antiarrhythmic drugs. Visual disturbances (usually transient) have occurred in a small proportion of patients treated with telithromycin; it is recommended that activities such as driving are minimized during treatment. Telithromycin is contraindicated in patients with myasthenia gravis. Hepatic dysfunction may occur in some patients taking telithromycin; rare cases of acute hepatic failure and severe liver injury, including deaths, have been reported. As telithromycin is an inhibitor of the cytochrome P450 (CYP) 3A4 system, coadministration of telithromycin with drugs metabolized by this pathway may require dose adjustments (e.g. with benzodiazepines) or a temporary hiatus in the use of the coadministered drug (e.g. HMG-CoA reductase inhibitors) metabolized by CYP3A4. Telithromycin may potentiate the effects of oral anticoagulants; careful monitoring is recommended in patients receiving telithromycin and oral anticoagulants simultaneously.Although serious and sometimes fatal events have occurred in patients receiving telithromycin therapy, current data indicate that telithromycin offers an acceptable benefit risk ratio in the treatment of mild to moderate CAP.

Headache Forum PMID: 18558790 [PubMed - in process]Subarachnoid placement of stem cells in neurological disorders. Headache Forum Related Articles

Subarachnoid placement of stem cells in neurological disorders.

Transplant Proc. 2008 May;40(4):1145-7

Authors: Mehta T, Feroz A, Thakkar U, Vanikar A, Shah V, Trivedi H

BACKGROUND: "Medically untreatable neurological disorders" is an area where stem cell (SC) therapy has generated hope in the last decade. Among various routes for SC infusion, subarachnoid placement via the lumbar route is particularly challenging because of technical difficulties in this group of patients. We carried out a prospective, single-center, clinical study to analyze the technical difficulties and short- and long-term effects of SC infusion in various neurological conditions. PATIENTS AND METHODS: One hundred eighty patients underwent subarachnoid placement of SCs between December 2005 and October 2007. Technical difficulties in the form of localization of subarachnoid space, number of attempts, and postprocedural complications were evaluated. Functional evaluation was done with Hauser Ambulation Index by the SC transplant team on a regular basis. The Institutional Review Board approved of informed consent forms and study protocol. RESULTS: Of 180 patients, we encountered technical difficulties in 52 (29%) in the form of general anesthesia supplementation and difficulty localizing the lumbar space. In 102 (56.6%) patients, side effects were observed (headache, low-grade fever, and meningism), which resolved with symptomatic treatment within 24 hours. On long-term follow-up, functional indices improved in 57 (31.67%) patients, including 54 patients with traumatic paraplegia/quadriplegia, two with cerebral palsy, and one with viral encephalitis. CONCLUSION: Subarachnoid placement of SCs is safe with no long term adverse effects.

Headache Forum PMID: 18555135 [PubMed - indexed for MEDLINE]Giant cell arteritis presenting as a breast lesion: report of a case and review of the literature. Headache Forum Related Articles

Giant cell arteritis presenting as a breast lesion: report of a case and review of the literature.

Am J Med Sci. 2008 Jun;335(6):489-91

Authors: Marie I, Audeguy P, François A, DE Kergal F, Richard C

Giant cell arteritis (GCA) mainly affects arteries arising from the external carotid arteries, although it may also be responsible for extracephalic clinical presentation related to impairment of vessels other than the carotids, such as the aorta as well arteries of the lower and upper limbs (10%-30% of cases). However, breast involvement is considered to be a rare complication of GCA. We recently observed a case of particular interest as the patient developed superficial mammary arteriolitis, bilaterally, revealing GCA with favorable outcome after institution of steroid therapy. Our case report reinforces the possibility of an unusual presentation of GCA. Indeed, we suggest that an evaluation for GCA affecting the breast should be made in elderly women exhibiting breast nodule(s)/mass(es) associated with other features of GCA (that are: headache, jaw claudication, constitutional signs, polymyalgia rheumatica). Furthermore, we also suggest that the prevalence of breast impairment may be underestimated in GCA as the breast is supplied mainly by 2 branches of the subclavian artery (ie, the internal mammary artery [as in the present case report] and the lateral thoracic artery), which is often involved in GCA.

Headache Forum PMID: 18552581 [PubMed - indexed for MEDLINE][Thrombophlebitis of venous sinuses in otitis media] Headache Forum Related Articles

[Thrombophlebitis of venous sinuses in otitis media]

Otolaryngol Pol. 2007;61(5):769-73

Authors: Kuczkowski J

Thrombophlebitis of dura venous sinuses is a rare intracranial complication of otitis media, which may be sometimes accompanied by symptoms or sepsis. Anatomical conditions and early diagnosis of this vascular complication determine the treatment modality. Aim of this study was the assessment of diagnostics and treatment of venous sinuses thrombophlebitis in acute and chronic otitis media considering anatomy and the venous sinuses and status of coagulation system. Otogenic thrombophlebitis may occur in lateral, transverse, upper and lower petrosal sinuses, and rarely in cavernous. In some cases thrombophlebitis proces may expand into brain or emissary mastoid veins. Lateral sinus thrombophlebitis in chronic otitis media usually appears clinically as septic fever, earache, and increasing neurologic signs. In acute otitis media when thrombophlebitis develops the patient complains about headache, high fever and visual acquity. Diagnosis of venous sinus thrombophlebitis is based on clinical signs, radiological imaging (CT scan, MRI), bacteriological examinations and laboratory biochemical tests. Contrast enhanced CT scan shows "delta sign". Septic thrombophlebitis sinus sigmoidei is caused by mixed bacterial flora. Surgical treatment in cases with septic thrombus consists of radical modiffied ear operation and lateral sinus exposure. Thrombectomy and jugular vein ligation is performed when sepsis or thrombus is present. Mastoidectomy and tympanic cavity drainage is performed in cases with lateral sinus thrombosis in acute mastoiditis. Intravenous antibiotics therapy should be continued for 2 weeks. Anticoagulants should be given taking into consideration parameters of coagulation system and the type of thrombus. Treatment results of venous sinuses thrombophlebitis are good if they are not accompanied by other intracranial complications.

Headache Forum PMID: 18552016 [PubMed - in process]Long-term effect of tacrolimus therapy in patients with refractory ulcerative colitis. Headache Forum Related Articles

Long-term effect of tacrolimus therapy in patients with refractory ulcerative colitis.

Aliment Pharmacol Ther. 2008 Sep 1;28(5):589-97

Authors: Yamamoto S, Nakase H, Mikami S, Inoue S, Yoshino T, Takeda Y, Kasahara K, Ueno S, Uza N, Kitamura H, Tamaki H, Matsuura M, Inui K, Chiba T

BACKGROUND: Little is known about long-term outcome of tacrolimus therapy for ulcerative colitis. Aim To evaluate long-term efficacy and safety of tacrolimus in Japanese patients with refractory ulcerative colitis. METHODS: Twenty-seven patients with UC refractory to conventional therapy were administered tacrolimus with trough whole-blood levels of 10-15 ng/mL to induce remission and 5-10 ng/mL to maintain remission. Median treatment duration was 11 months (1-39 months) and median follow-up duration was 17 months (2-65 months). Evaluation of the clinical response was based on a modified Truelove-Witts severity index (MTWSI). RESULTS: Tacrolimus produced a clinical response in 21 patients (77.8%), and remission was achieved in 19 of these 21 (70.4%) within 30 days. Overall cumulative colectomy-free survival was estimated as 62.3% at 65 months. In 18 of 19 patients treated with corticosteroids at the initiation of tacrolimus therapy, corticosteroids were discontinued or tapered. Adverse events were tremor (25.9%), renal function impairment (18.5%), infectious disease (14.8%), hot flashes (11.1%), hyperkalaemia (7.4%), headache (7.4%), epigastralgia (7.4%) and nausea (3.7%). No mortality occurred. CONCLUSION: Long-term administration of tacrolimus appears to be an effective and well-tolerated treatment for Japanese patients with refractory ulcerative colitis.

Headache Forum PMID: 18549460 [PubMed - in process]Examining the utility of in-clinic "rescue" therapy for acute migraine. Headache Forum Related Articles

Examining the utility of in-clinic "rescue" therapy for acute migraine.

Headache. 2008 Jun;48(6):939-43

Authors: Morey V, Rothrock JF

BACKGROUND: Management options currently are limited for patients with acute migraine whose symptoms prove refractory to self-administered therapy. OBJECTIVE: To evaluate the clinical utility and cost-effectiveness of a management program offering in-clinic "rescue" treatment for patients with acute migraine. METHODS: Two hundred consecutive migraine patients presenting to a university-based headache clinic were randomized to receive either optimal self-administered medical therapy for acute migraine ("standard therapy") or similar therapy plus the option of in-clinic parenteral drug administration should self-administered therapy prove ineffective ("rescue therapy"). Patients randomized to the latter group were restricted to a maximum of 2 "rescue visits" per month, and all patients were followed for one year. Patients "rescued" in clinic were contacted by telephone 24 hours following treatment to evaluate their treatment response. The primary analysis involved a comparison of the number of emergency department (ED) visits for headache recorded within each group over the one-year period of study. For all ED visits in the rescue group and for a randomly selected and equal number of ED visits within the standard group, the direct costs associated with those visits were assessed, and the direct costs of all in-clinic rescue visits also were recorded and analyzed. RESULTS: The 2 groups studied were similar in terms of age, gender ratio, migraine subtype, migraine-related disability status at baseline and type/extent of medical insurance coverage. Over the one-year study period, the rescue group recorded 423 in-clinic rescue visits and reported 27 ED visits for headache treatment. The standard therapy group reported 73 ED visits (27 vs 73 visits; P < .01). The total direct costs associated with ED visits were $45,330 for the rescue group (mean $1690 per ED visit) and (by extrapolation from the sample selected) $147,971 for the standard therapy group (mean $2027 per ED visit). The total direct cost of the 423 "rescue visits" was $33,647 (mean $80 per visit). In 79% of the 423 rescue encounters, the patients involved reported no residual functional disability 24 hours following treatment. Of those in the rescue group who sought in-clinic rescue, 89% reported themselves "very satisfied" with such management. CONCLUSION: Providing the alternative of in-clinic "rescue" for acute migraine refractory to self-administered therapy offers an attractive alternative for patients and appears to substantially lower use of an ED for headache treatment and the cost associated with that use.

Headache Forum PMID: 18549372 [PubMed - in process]Continuous opioid therapy (COT) is rarely advisable for refractory chronic daily headache: limited efficacy, risks, and proposed guidelines. Headache Forum Related Articles

Continuous opioid therapy (COT) is rarely advisable for refractory chronic daily headache: limited efficacy, risks, and proposed guidelines.

Headache. 2008 Jun;48(6):838-49

Authors: Saper JR, Lake AE

Intractable pain, headache or otherwise, is a devastating and life-controlling experience. The need to effectively and aggressively control pain is a fundamental tenet of clinical care. In the past several years, increasing advocacy for continuous opioid therapy has become an important, if not controversial, theme in the development of treatment guidelines and teaching programs. Ironically, the increasing willingness of physicians to prescribe scheduled opioids for their headache and pain patients has occurred in the absence of compelling data demonstrating efficacy or long-term safety. To the contrary, two meta-analyses on chronic noncancer pain (CNCP) and one long-term uncontrolled study on headache patients demonstrate a relatively small number of patients benefiting from the treatment. Recent neuroscience data on the effects of opioids on the brain raise serious concern for long-term safety and also provide the basis for the mechanism by which chronic opioid use might induce progression of headache frequency and severity. Significant adverse effects, including influence on sexual hormonal balances, physical and psychological dependence, the development of opioid-induced hyperalgesia, and cardiac arrhythmia and sudden death that can be seen with standard dosages of methadone, make a strong argument against widespread use of continuous opioid therapy (COT) in otherwise healthy young and middle-aged headache patients. We believe that COT should be used in rare circumstances for chronic headache patients, and propose initial guidelines for selecting patients and monitoring treatment. The physician should be well versed in the details of opioid prescribing, administration, and monitoring, and should be prepared to discontinue opioids when clinical justification, patient behavior, or failure to achieve therapeutic goals make discontinuance necessary.

Headache Forum PMID: 18549361 [PubMed - in process]Pearls from an inpatient headache unit. Headache Forum Related Articles

Pearls from an inpatient headache unit.

Headache. 2008 Jun;48(6):820-7

Authors: Saper JR

Much can be learned from treating over 15,000 headache hospitalized patients over the course of 30 years. By the very need to be admitted, these individuals are complicated, both physiologically and often psychologically. Founded in 1978, the Michigan Head Pain and Neurological Institute and its hospital unit developed a set of criteria for admission and a growing staff of professionals to serve this complex population of patients. Experience has taught us many lessons; several are considered in this review. Among the important topics discussed are: admission criteria to the hospital unit; treatment protocols and other hospital-based strategies; integration of behavioral therapy and therapists into the treatment system; diagnostic testing of patients with intractable headache; identifying the "problem patient" and "medication misuse" early in the course of therapy; approaching the headache patient with cluster B personality disorder; and the use of interventional and anesthesiological treatment for intractable headache. Outcome data and a review of recent publications are presented.

Headache Forum PMID: 18549359 [PubMed - in process][Auto-injection with epinephrine in the finger of a 5-year-old child] Headache Forum Related Articles

[Auto-injection with epinephrine in the finger of a 5-year-old child]

Ned Tijdschr Geneeskd. 2008 Apr 26;152(17):1005-8

Authors: Janssen RL, Roeleveld-Versteegh AB, Wessels-Basten SJ, Hendriks T

A 5-year-old boy with food allergies complicated by anaphylactic reactions with dyspnoea and angioedema had been prescribed an autoinjector with epinephrine (0.15 mg) so that his parents could treat him at home if necessary. The patient accidentally injected himself in a finger, which likely makes him the youngest patient to receive an epinephrine auto-injection reported to date. Treatment consisted of phentolamine (0.15 mg in 0.5 ml normal saline) injected subcutaneously at the site of accidental injection; the dose and volume were not adapted according to the age and body weight of the patient as only a local effect was intended. Finger circulation was restored within 20 minutes. Headache, nausea and vomiting were observed after 30 minutes and were most likely a systemic side effect of phentolamine. No other complications occurred. The patient recovered fully and was discharged the following morning. Intramuscular epinephrine autoinjection is standard therapy for severe anaphylactic reactions. The epinephrine autoinjector was introduced in 1980. As allergy and anaphylaxis become more common, increasing numbers of autoinjectors are prescribed, and it is likely that the number of accidental digital autoinjections will also increase. These digits are then at risk of ischaemic necrosis. There is no consensus on therapeutic strategies in such cases. Phentolamine administration appears to be an effective intervention. However, several recent studies have shown that epinephrine may be used safely in hand surgery, which suggests that accidental digital epinephrine autoinjection may not always require immediate treatment.

Headache Forum PMID: 18549176 [PubMed - indexed for MEDLINE][Vasculitis as a reason of chronic headache] Headache Forum Related Articles

[Vasculitis as a reason of chronic headache]

Praxis (Bern 1994). 2008 Mar 19;97(6):322-5

Authors: Ataia I, Casaulta C, von Vigier RO, Pfammatter JP, Brekenfeld C, Sauvain MJ, Steinlin M

A 13-year-old girl presented to our emergency with a one week history of fever and skin rash and new onset of chorea for the last three days. There was a long standing history of right predominant headache; followed by personality change, fatigue, arthralgia and weight loss over the last few months. Previous investigations by head CT and ophthalmological examination did not explain the symptoms. Further investigations revealed peri- and pancarditis with aortic insufficiency, a renal involvement with elevated creatinin, protein- and hematuria and a hemolytic anemia. Diagnosis of lupus eythematodes was confirmed by high ANA, anti-dsDNS and Anticardiolipin antibodies. Within the first 48 hours after admission there was significant deterioration with reduced vigilance and dysarthria. MRI of the brain and dopplersonography of cerebral vessels showed a complete thrombosis of the right medial cerebral artery with a small net of collaterals, irregularities of the left cerebral artery due to vasculitis and several subacute leftsided ischemias. Immunosuppressive therapy with high-dose corticosteroids and cyclophosphamid together with antithrombotic therapy induced an improvement of neurologic, renal and cardiac function.

Headache Forum PMID: 18548940 [PubMed - indexed for MEDLINE]Physical therapy and exercise in headache. Headache Forum Related Articles

Physical therapy and exercise in headache.

Cephalalgia. 2008 Jul;28 Suppl 1:36-8

Authors: Fernández-de-Las-Peñas C

To date the effects of physical therapy or exercise in headaches has hardly been analysed. Conflicting results in previous studies might be due to the low number of clinical trials plus an indiscriminate application of different techniques. As different pathogenic mechanisms seem to be involved in each headache, the most appropriate techniques might differ in each case. Future research should address the evaluation of specific physical therapy procedures for each headache disorder, and the identification of those subgroups of patients who are most likely to benefit from a particular intervention.

Headache Forum PMID: 18494995 [PubMed - indexed for MEDLINE]Physical therapy and exercise in headache. Headache Forum Related Articles

Physical therapy and exercise in headache.

Cephalalgia. 2008 Jul;28 Suppl 1:35

Authors: Antonaci F

Headache Forum PMID: 18494994 [PubMed - indexed for MEDLINE][Serial whole-body cryotherapy in the criostream for inflammatory rheumatic diseases. A pilot study] Headache Forum Related Articles

[Serial whole-body cryotherapy in the criostream for inflammatory rheumatic diseases. A pilot study]

Med Klin (Munich). 2008 Jun 15;103(6):383-8

Authors: Lange U, Uhlemann C, Müller-Ladner U

BACKGROUND AND PURPOSE: Local as well as whole-body cryotherapy is used to relieve pain and inflammation in rheumatic diseases. In comparison with a chamber-based whole-body cryotherapy, the novel criostream whole-body therapy (single-person cabin with cold air cooled by liquid nitrogen) as an innovative technique offers not only a rapid therapeutic effect but also a considerable reduction in costs. The aim of this study was to compare the effect of whole-body cryotherapy in the criostream on pain reduction, disease activity and pro-inflammatory cytokines (tumor necrosis factor-[TNF-]alpha and interleukin-[IL-]1), and improvement in functional scores. PATIENTS AND METHODS: Ten patients with different active inflammatory rheumatic diseases (four patients with rheumatoid arthritis, three patients with ankylosing spondylitis, and three patients with psoriatic arthritis/spondylitis) underwent nine sessions of whole-body cryotherapy in 5 days for a short time period (at first 90 s, with step-up in each application to 2.5 min total time). RESULTS: Pain and disease activity scores decreased significantly, and, subsequently, also the functional scores showed a significant amelioration. Furthermore, there was a significant reduction in TNF-alpha (p < 0.01) and IL-1 (p < 0.05). Side effects were reported only after the first application in two cases (headache and sensation of cold). CONCLUSION: The criostream offers an elegant and, from the patient's point of view, attractive therapeutic agent in the multimodal treatment concept for inflammatory rheumatic diseases.

Headache Forum PMID: 18548207 [PubMed - in process]Hypothalamic deep-brain stimulation: target and potential mechanism for the treatment of cluster headache. Headache Forum Related Articles

Hypothalamic deep-brain stimulation: target and potential mechanism for the treatment of cluster headache.

Cephalalgia. 2008 Jul;28(7):799-803

Authors: May A

Recently, functional imaging data have underscored the crucial role of the hypothalamus in trigemino-autonomic headaches, a group of severe primary headaches. This prompted the application of hypothalamic deep-brain stimulation (DBS), with the intention to preventing cluster headache (CH) attacks in selected severe therapy-refractory cases. To date, a total of 50 operated intractable CH patients, one patient with short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing and three with atypical facial pain, have been reported. However, it is not apparent why the spontaneous bursts of activation in the inferior posterior hypothalamus result in excruciating head pain, whereas continuous electrical stimulation of the identical area is able to prevent these attacks. Recently, this issue has been addressed by examining 10 operated chronic CH patients, using H(2)(15)O-positron emission tomography and alternately switching the hypothalamic stimulator on and off. The stimulation-induced activation in the ipsilateral posterior inferior hypothalamic grey (the site of the stimulator tip) as well as activation and de-activation in several cerebral structures belonging to neuronal circuits usually activated in pain transmission. These data argue against an unspecific antinociceptive effect or pure inhibition of hypothalamic activity as the mode of action of hypothalamic DBS and suggest functional modulation of the pain-processing network.

Headache Forum PMID: 18547217 [PubMed - indexed for MEDLINE]Stroke awareness among cardiovascular disease patients. Headache Forum Related Articles

Stroke awareness among cardiovascular disease patients.

Arq Neuropsiquiatr. 2008 Jun;66(2A):209-12

Authors: Coelho Rde S, Freitas WM, Campos GP, Teixeira RA

BACKGROUND: The early recognition of stroke signs and symptoms is of great relevance concerning the outcome, since it enhances the chances of thrombolytic therapy use. PURPOSE: To compare the knowledge of stroke among a community-based sample and patients treated in a cardiologic clinic. METHOD: We applied a questionnaire during one morning to people who were walking in a park (Pa) and spontaneously stopped at a health tent and during one week to patients of a cardiologic clinic (Ca). The survey assessed demographic details, awareness of stroke symptoms and signs, risk factors and general concepts of stroke. RESULTS: A total of 222 questionnaires were answered, 109 by the cardiologic clinic group and 113 by the park group. The park group recognized better three associated symptoms: headache (Ca: 39%; Pa: 61%; p: 0.001), loss of vision (Ca: 15.8%; Pa: 30.9%; p: 0.007) and unilateral paralysis/weakness (Ca: 26%; Pa: 41%; p: 0.026). The park group recognized better 3 risk factors: diabetes (Ca: 22.9%; Pa: 37.2%; p: 0.021), smoking (Ca: 51.4%; Pa: 67.2%; p: 0.011) and high cholesterol (Ca: 54.1%; Pa: 69.9%; p: 0.015). CONCLUSION: Our results suggest that patients treated in a cardiologic clinic do not show a better knowledge of stroke when compared to a community-based sample. Campaigns to increase stroke knowledge can have a great impact on public health, especially among enhanced risk groups, such as cardiovascular patients.

Headache Forum PMID: 18545784 [PubMed - in process][Mechanism of therapy effects by botulinum neurotoxin] Headache Forum Related Articles

[Mechanism of therapy effects by botulinum neurotoxin]

Med Arh. 2008;62(1):53-5

Authors: Alajbegović A, Alajbegović S, Resić H

Botulinum neurotoxin (BoNT) is produced by Clostridium botulinum as a complex of proteins containing the neurotoxin itself and other nontoxic proteins. Activation of the neurotoxin occurs upon proteolytic cleavage into the heavy and light chains. This di-chain moiety is essential for neurotoxin and each chain is playing a unique role; the heavy chain mediates neurospecifics cell binding and entry, whereas the light chain, a protease, catalyzes the cleavage and inactivation of neuronal proteins that mediate neurotransmitter release. There are seven BoNT serotypes (A,B,CI,D,E,F, and G), all of which inhibit acetylcholine release, though their intracellular target proteins, the characteristics of their actions, and their potencies vary substantially. BoNT type A has been the most widely studied and applied serotype for therapeutic purposes. It has been a mainstay in the treatment of cervical dystonia, blepharospasm, and hemifacial spasm for years. BoNT has more recently emerged as an increasingly important therapeutic option in the clinical management of a broad array of conditions, including other focal dystonias, spasticity, cerebral palsy, equinovarus, gastrointestinal (GI) and urogenital disorders, hypersecretory disorders, facial lines due to hyperfunctional facial muscles and recently, musculoskeletal pain disorders and headache.

Headache Forum PMID: 18543757 [PubMed - indexed for MEDLINE]Mind-body interventions: applications in neurology. Headache Forum Related Articles

Mind-body interventions: applications in neurology.

Neurology. 2008 Jun 10;70(24):2321-8

Authors: Wahbeh H, Elsas SM, Oken BS

OBJECTIVE: Half of the adults in the United States use complementary and alternative medicine with mind-body therapy being the most commonly used form. Neurology patients often turn to their physicians for insight into the effectiveness of the therapies and resources to integrate them into their care. The objective of this article is to give a clinical overview of mind-body interventions and their applications in neurology. METHODS: Medline and PsychInfo were searched on mind-body therapies and neurologic disease search terms for clinical trials and reviews and published evidence was graded. RESULTS: Meditation, relaxation, and breathing techniques, yoga, tai chi, and qigong, hypnosis, and biofeedback are described. Mind-body therapy application to general pain, back and neck pain, carpal tunnel syndrome, headaches, fibromyalgia, multiple sclerosis, epilepsy, muscular dysfunction, stroke, aging, Parkinson disease, stroke, and attention deficit-hyperactivity disorder are reviewed. CONCLUSIONS: There are several conditions where the evidence for mind-body therapies is quite strong such as migraine headache. Mind-body therapies for other neurology applications have limited evidence due mostly to small clinical trials and inadequate control groups.

Headache Forum PMID: 18541886 [PubMed - indexed for MEDLINE]Nebivolol: a new antihypertensive agent. Headache Forum Related Articles

Nebivolol: a new antihypertensive agent.

Am J Health Syst Pharm. 2008 Jun 15;65(12):1125-33

Authors: Gray CL, Ndefo UA

PURPOSE: The pharmacology, pharmacokinetics, clinical efficacy, adverse effects, safety, economic issues, dosage, and place in therapy of nebivolol are reviewed. SUMMARY: Nebivolol is a novel, highly selective beta(1)-receptor blocker that causes peripheral vasodilation by increasing the production and release of nitric oxide and decreasing nitric oxide degradation. The nitric oxide-mediated effects of nebivolol lead to decreases in systemic vascular resistance and large artery stiffness and possible reversal of endothelial dysfunction. Clinical studies have shown nebivolol to be at least as effective at lowering blood pressure as other antihypertensive drugs, including other beta-blockers. The most frequent adverse events reported in nebivolol clinical trials were transient headache, dizziness, and tiredness. In a large trial in patients with heart failure, nebivolol was shown to reduce the composite endpoint of mortality and hospitalizations. Nebivolol is highly lipophilic and is rapidly absorbed after oral administration. The nebivolol dose most commonly used in clinical trials for hypertension was 5 mg daily; no significant further decreases in blood pressure were shown with higher doses. The average dose in clinical trials for patients with heart failure was 5-10 mg daily. Dosage adjustments are recommended in elderly patients and patients with severe renal impairment. CONCLUSION: Nebivolol is a unique, highly selective beta-blocker with vasodilatory properties mediated through the nitric oxide pathway; it may be useful in the treatment of uncomplicated mild-to-moderate essential hypertension and in patients with heart failure.

Headache Forum PMID: 18541682 [PubMed - indexed for MEDLINE]Treatment results of boron neutron capture therapy using intra-arterial administration of boron compounds for recurrent head and neck cancer. Headache Forum Related Articles

Treatment results of boron neutron capture therapy using intra-arterial administration of boron compounds for recurrent head and neck cancer.

Br J Radiol. 2008 Jun 9;

Authors: Fuwa N, Suzuki M, Sakurai Y, Nagata K, Kinashi Y, Masunaga S, Maruhashi A, Imahori Y, Kodaira T, Tachibana H, Nakamura T, Ono K

During this study, in order to accumulate boron in the tumour, boron neutron capture therapy (BNCT) using intra-arterial administration of boron compounds was performed for recurrent head and cancer. Of the five patients treated, one achieved a complete response and four achieved a partial response. There was one case of transient headache but no severe adverse effects were observed. The advantages of using an intra-arterial administration route for BNCT, which causes the selective killing of tumour cells, might therefore shed new light on the treatment of recurrent head and neck malignancies. These promising results require further verification and optimization of the BNCT schedule; however, dose escalation would appear to be justified because the toxicity appears to be very low.

Headache Forum PMID: 18541628 [PubMed - as supplied by publisher]Parenteral dexamethasone for acute severe migraine headache: meta-analysis of randomised controlled trials for preventing recurrence. Headache Forum Related Articles

Parenteral dexamethasone for acute severe migraine headache: meta-analysis of randomised controlled trials for preventing recurrence.

BMJ. 2008 Jun 14;336(7657):1359-61

Authors: Colman I, Friedman BW, Brown MD, Innes GD, Grafstein E, Roberts TE, Rowe BH

OBJECTIVE: To examine the effectiveness of parenteral corticosteroids for the relief of acute severe migraine headache and prevention of recurrent headaches. DESIGN: Meta-analysis. DATA SOURCES: Electronic databases (Cochrane Central Register of Controlled Trials, Medline, Embase, LILACS, and CINAHL), conference proceedings, clinical practice guidelines, contacts with industry, and correspondence with authors. SELECTION CRITERIA: Randomised controlled trials in which corticosteroids (alone or combined with standard abortive therapy) were compared with placebo or any other standard treatment for acute migraine in adults. REVIEW METHODS: Two reviewers independently assessed relevance, inclusion, and study quality. Weighted mean differences and relative risks were calculated and are reported with 95% confidence intervals. RESULTS: From 666 potentially relevant abstracts, seven studies met the inclusion criteria. All included trials used standard abortive therapy and subsequently compared single dose parenteral dexamethasone with placebo, examining pain relief and recurrence of headache within 72 hours. Dexamethasone and placebo provided similar acute pain reduction (weighted mean difference 0.37, 95% confidence interval -0.20 to 0.94). Dexamethasone was, however, more effective than placebo in reducing recurrence rates (relative risk 0.74, 95% confidence interval 0.60 to 0.90). Side effect profiles between dexamethasone and placebo groups were similar. CONCLUSION: When added to standard abortive therapy for migraine headache, single dose parenteral dexamethasone is associated with a 26% relative reduction in headache recurrence (number needed to treat=9) within 72 hours.

Headache Forum PMID: 18541610 [PubMed - indexed for MEDLINE]Craniosacral therapy for migraine: protocol development for an exploratory controlled clinical trial. Headache Forum Related Articles

Craniosacral therapy for migraine: protocol development for an exploratory controlled clinical trial.

BMC Complement Altern Med. 2008;8:28

Authors: Mann JD, Faurot KR, Wilkinson L, Curtis P, Coeytaux RR, Suchindran C, Gaylord SA

BACKGROUND: Migraine affects approximately 20% of the population. Conventional care for migraine is suboptimal; overuse of medications for the treatment of episodic migraines is a risk factor for developing chronic daily headache. The study of non-pharmaceutical approaches for prevention of migraine headaches is therefore warranted. Craniosacral therapy (CST) is a popular non-pharmacological approach to the treatment or prevention of migraine headaches for which there is limited evidence of safety and efficacy. In this paper, we describe an ongoing feasibility study to assess the safety and efficacy of CST in the treatment of migraine, using a rigorous and innovative randomized controlled study design involving low-strength static magnets (LSSM) as an attention control intervention. METHODS: The trial is designed to test the hypothesis that, compared to those receiving usual care plus a treatment with low-strength static magnets (attention-control complementary therapy), subjects receiving usual medical care plus CST will demonstrate significant improvement in: quality-of-life as measured by the Headache Impact Test (HIT-6); reduced frequency of migraine; and a perception of clinical benefit. Criteria for inclusion are either gender, age > 11, English or Spanish speaking, meeting the International Classification of Headache Disorders (ICHD) criteria for migraine with or without aura, a headache frequency of 5 to 15 per month over at least two years. After an 8 week baseline phase, eligible subjects are randomized to either CST or an attention control intervention, low strength static magnets (LSSM). To evaluate possible therapist bias, videotaped encounters are analyzed to assess for any systematic group differences in interactions with subjects. RESULTS: 169 individuals have been screened for eligibility, of which 109 were eligible for the study. Five did not qualify during the baseline phase because of inadequate headache frequency. Nineteen have withdrawn from the study after giving consent. CONCLUSION: This report endorses the feasibility of undertaking a rigorous randomized clinical trial of CST for migraine using a standardized CST protocol and an innovative control protocol developed for the study. Subjects are able and willing to complete detailed headache diaries during an 8-week baseline period, with few dropouts during the study period, indicating the acceptability of both interventions. TRIAL REGISTRATION: ClinicalTrials.gov NCT00665236.

Headache Forum PMID: 18541041 [PubMed - indexed for MEDLINE][Case of posterior reversible encephalopathy syndrome with cerebral vasoconstriction] Headache Forum Related Articles

[Case of posterior reversible encephalopathy syndrome with cerebral vasoconstriction]

Rinsho Shinkeigaku. 2008 May;48(5):355-8

Authors: Koga Y, Isobe N, Tateishi T, Osoegawa M, Ohyagi Y, Kira J

A 56-year-old woman attended our hospital because of acute severe (thunderclap) headache. Neurological examination was normal and no abnormality was found on head CT or by cerebrospinal fluid examination. A few days later, she experienced a recurrence and suffered a seizure in her left upper and lower extremities. On neurological examination, she had conjugate deviation of the eyes toward the right side and left lower limb paralysis with Chaddock sign. MRI showed multiple hyperintense lesions in the bilateral occipital and parietal lobes, predominantly in the subcortical white matter at the right side on T2-weighted and FLAIR images. We diagnosed posterior reversible encephalopathy syndrome (PRES) because the ADC map showed a vasogenic edema pattern (increased ADC values in the hypodense lesions on diffusion-weighted image). Her blood pressure was normal and there were no underling diseases. As MRA showed vasoconstriction especially in bilateral posterior cerebral arteries, we initiated a therapy with a Ca-channel blocker. On follow-up MRI, the hyperintense lesions on T2-weighted and FLAIR images had almost disappeared, and vasoconstriction was also improved on MRA. This case suggested that cerebral vasoconstriction could underlie both thunderclap headache and PRES.

Headache Forum PMID: 18540385 [PubMed - indexed for MEDLINE]Comparative cross-over study of sildenafil and apomorphine for treating erectile dysfunction. Headache Forum Related Articles

Comparative cross-over study of sildenafil and apomorphine for treating erectile dysfunction.

BJU Int. 2008 Jun 4;

Authors: Afif-Abdo J, Teloken C, Damião R, Koff W, Wroclawski E, Yamasaki R, Torres LO, Sabaneeff J, Faria G, Pompeo AC, Cortado P, Glina S

OBJECTIVE To compare the effectiveness, safety and tolerability of sildenafil and apomorphine in Brazilian patients with erectile dysfunction (ED) of various causes. PATIENTS AND METHODS In all, 108 patients (mean age 55 years, sd 11) and documented ED for >/=6 months were included in 12 centres in Brazil. The patients were initially followed for 2 weeks and then randomized to initial treatment with apomorphine or sildenafil, taken before sexual intercourse, no more than once a day. The initial dose (2 mg apomorphine and 50 mg sildenafil) could be adjusted (to 3 mg apomorphine, or to 25 or 100 mg for sildenafil) depending on the effectiveness and tolerability during the first 4 weeks of treatment. The patients were re-evaluated after 8 weeks on treatment and, after a wash-out period of 2 weeks (no treatment), received the other study drug (other than that received in the first phase), and then had the same procedures as in the first phase. RESULTS In all, 97 patients were evaluated for therapeutic effectiveness, the overall effectiveness being assessed using two questions; sildenafil had a significantly higher proportion of affirmative answers for both (P < 0.001). Likewise, the estimates for the mean (sd) proportion of successful sexual intercourse, of 83.3 (4.7)% vs 40.3 (4.7)% and the total ED Inventory of Treatment Satisfaction score, of 86.7 (2.9) vs 56.9 (2.9) (P < 0.001) were higher for sildenafil. At the end of the study, 93.8% of the patients randomized to initial therapy with apomorphine declared a preference for sildenafil, and 81.3% of those initially treated with sildenafil declared a preference for that drug. The two drugs were well tolerated, and the main adverse events for apomorphine were nausea, vomiting, headache, taste perversion and dizziness; for sildenafil they were headache, flushing or vasodilatation, abdominal pain or dyspepsia and nasal congestion. CONCLUSIONS Sildenafil is more effective than apomorphine for treating ED, in the domains of erectile function, satisfaction with sexual intercourse and overall satisfaction, and was the drug preferred by most of the patients.

Headache Forum PMID: 18537952 [PubMed - as supplied by publisher]Central nervous system involvement in pediatric rheumatic diseases: current concepts in treatment. Headache Forum Related Articles

Central nervous system involvement in pediatric rheumatic diseases: current concepts in treatment.

Curr Pharm Des. 2008;14(13):1295-301

Authors: Duzova A, Bakkaloglu A

Central nervous system (CNS) manifestations are not rare in pediatric rheumatic diseases. They may be a relatively common feature of the disease, as in systemic lupus erythematosus (SLE) and Behçet's disease. Direct CNS involvement of a systemic rheumatic disease, primary CNS vasculitis, indirect involvement secondary to hypertension, hypoxia and metabolic changes, and drug associated adverse events may all result in CNS involvement. We have reviewed the CNS manifestations of SLE, Behçet's disease, Henoch-Schönlein purpura, polyarteritis nodosa, juvenile idiopathic arthritis, juvenile ankylosing spondylitis, familial Mediterranean fever, scleroderma, sarcoidosis, Wegener's granulomatosis, Takayasu's arteritis, CINCA syndrome, Kawasaki disease, and primary CNS vasculitis; and adverse CNS effects of anti-rheumatic drugs in pediatric patients. The manifestations are diverse; ranging from headache, seizures, chorea, changes in personality, depression, memory and concentration problems, cognitive impairment, cerebrovascular accidents to coma, and death. The value of cerebrospinal fluid (CSF) examination (pleocytosis, high level of protein), auto-antibodies in serum and CSF, electroencephalography, neuroimaging with computerized tomography, magnetic resonance imaging, SPECT, PET, and angiography depends on the disease. Brain biopsy is gold standard for the diagnosis of CNS vasculitis, however it may be inconclusive in 25% of cases. A thorough knowledge of the rheumatic diseases and therapy-related adverse events is mandatory for the management of a patient with rheumatic disease and CNS involvement. Severe CNS involvement is associated with poor prognosis, and high mortality rate. High dose steroid and cyclophosphamide (oral or intravenous) are first choice drugs in the treatment; plasmapheresis, IVIG, thalidomide, and intratechal treatment may be valuable in treatment-resistant, and serious cases.

Headache Forum PMID: 18537653 [PubMed - indexed for MEDLINE]Menstrual-related pain conditions: dysmenorrhea and migraine. Headache Forum Related Articles

Menstrual-related pain conditions: dysmenorrhea and migraine.

J Womens Health (Larchmt). 2008 Jun;17(5):879-91

Authors: Mannix LK

Menstrual disorders affect millions of women in the United States and represent an important health burden. The most common menstrual disorders are dysmenorrhea and headache; these conditions are leading causes of work or school absenteeism and substantially impact quality of life. Headache associated with menses is often migraine and referred to as menstrual migraine. Although the pathogenesis of menstrual-related pain conditions is not fully understood, menstrual-related overproduction of prostaglandins is implicated in the pathophysiology of both menstrual migraine and dysmenorrhea. In clinical practice, nonsteroidal anti-inflammatory drugs (NSAIDs) are considered the first-line therapeutic option for managing pain associated with dysmenorrhea. NSAIDs also play a role in the acute treatment and intermittent prophylaxis of migraine. Triptans, a class of highly selective serotonin receptor agonists, represent the gold standard for acute treatment of migraine. In addition, hormone therapy is effective in many cases for treating dysmenorrhea and may be beneficial in the management of menstrual migraine. Thus, overlapping treatment regimens may be advantageous in treating the coexisting menstrual-related pain conditions of dysmenorrhea and migraine.

Headache Forum PMID: 18537489 [PubMed - in process]Prochlorperazine vs. Promethazine for Headache Treatment in the Emergency Department: A Randomized Controlled Trial. Headache Forum Related Articles

Prochlorperazine vs. Promethazine for Headache Treatment in the Emergency Department: A Randomized Controlled Trial.

J Emerg Med. 2008 Jun 4;

Authors: Callan JE, Kostic MA, Bachrach EA, Rieg TS

Headache is a very common medical complaint. Four to six percent of the population will have a debilitating headache in their lifetime; and 1-2% of all Emergency Department (ED) visits involve patients with headaches. Although promethazine is used frequently, it has never been studied as a single-agent treatment in undifferentiated headache. We hypothesized that promethazine would be superior to prochlorperazine in the treatment of headache. We conducted a prospective, double-blinded, randomized, controlled trial on patients presenting to our ED between May and August 2005 with a chief complaint of headache. Each subject was randomized to receive either intravenous promethazine 25 mg or prochlorperazine 10 mg, and graded the intensity of their headache on serial 100-mm visual analog scales (VAS). Patients with dystonic reactions or akathesia were treated with diphenhydramine. Adequate pain relief was defined as an absolute decrease in VAS score of 25 mm. After discharge from the ED, patients were queried regarding the recurrence of headache symptoms, the need for additional pain medications, and the occurrence of any side effects since discharge. Thirty-five patients were enrolled in each group. Both drugs were shown to be effective in treatment of headaches. Prochlorperazine provided a faster rate of pain resolution and less drowsiness when compared to promethazine. Both medications were individually effective as abortive therapy for headache. Prochlorperazine was superior to promethazine in the rate of headache reduction and rate of home drowsiness, with similar rates of akathesia, nausea resolution, patient satisfaction, and headache recurrence within 5 days of discharge.

Headache Forum PMID: 18534808 [PubMed - as supplied by publisher]reports. Key words: Enteric fever, salmonella infections.

PMID: 18604016 [PubMed - in process]Otogenic pneumococcal meningitis with pneumocephalus. Related Articles

Otogenic pneumococcal meningitis with pneumocephalus.

J Emerg Med. 2008 Jun 30;

Authors: Damergis JA, Chee K, Amitai A

Streptococcus pneumoniae accounts for approximately 50% of bacterial meningitis cases in the United States annually. Since the advent of antibiotics, pneumococcal meningitis as a complication of a primary otogenic focus has been rare in the United States. The widespread use of immunosuppressants and increasing bacterial resistance to commonly prescribed antibiotics may contribute to a higher incidence of complications of otitis media in the future, similar to that of the pre-antibiotic era. We report a case of otogenic pneumococcal meningitis with pneumocephalus in an adult male on chronic immunosuppressant therapy. A 33-year-old man with Crohn's disease and azathioprine use presented to our Emergency Department with progressive headache while taking antibiotics for otitis media. Initial computed tomography scan of the brain revealed pneumocephaly, and cerebrospinal fluid analysis and culture diagnosed pneumococcal meningitis. The patient continued to have fevers while receiving intravenous antibiotics and underwent bilateral myringotomies; his clinical course subsequently improved significantly. Meningitis is a rare complication of Streptococcus pneumoniae infections since the advent of antibiotics; however, it may become more frequent with increasing antibiotic resistance and a growing population of immunocompromised patients. Additionally, pneumocephalus in the setting of meningitis and otitis media should raise the suspicion for mastoiditis (even without overt clinical findings) and early consultation with an otolaryngologist is warranted.

PMID: 18597973 [PubMed - as supplied by publisher]Humanistic, utilization, and cost outcomes associated with the use of botulinum toxin for treatment of refractory migraine headaches in a managed care organization. Related Articles

Humanistic, utilization, and cost outcomes associated with the use of botulinum toxin for treatment of refractory migraine headaches in a managed care organization.

J Manag Care Pharm. 2008 Jun;14(5):442-50

Authors: Mitchell MP, Schaecher K, Cannon HE, Speckman M

BACKGROUND: Few patients with migraine syndrome receive treatment with preventive medication regimens, and some of these patients fail to gain adequate migraine relief. Botulinum toxin has been suggested to be effective in the treatment of migraine for a select population. An integrated health system created a medical policy and a supporting preauthorization form that permits coverage of botulinum toxin for the off-label treatment of migraine for patients who (1) fail at least 3 drug classes for acute treatment, (2) fail at least 4 different preventive medication classes, and (3) receive consultation from a neurologist. OBJECTIVES: To (1) evaluate the impact of botulinum toxin therapy on quality-of-life (QOL) measures evaluated by direct member survey results, and (2) assess the use and cost of migraine-related medications and overall medical and pharmacy services pre- and post-botulinum toxin therapy. METHODS: The study was a retrospective analysis of administrative claims data from a 500,000-member integrated health system for the time period January 1, 2003, to October 31, 2007. Administrative claims data were used to identify members with a billing code (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM]) for migraine (346.xx), tension headache (307.81), or headache (784.0) diagnosed by a neurologist. Administrative claims data for these patients were then queried for the use of botulinum toxin for dates of service from January 1, 2003, through October 31, 2006. A survey was sent to the identified patients (N=54) to assess 6 QOL measures associated with the use of botulinum toxin. Self-reported symptomatic improvement was assessed using a 5-point Likert scale for 6 questions regarding headache severity, headache frequency, use of rescue medications, productivity/absenteeism, recreational activities, and life enjoyment. For the subset of patients (n = 32) who maintained health plan eligibility from 18 months before through 18 months after the first botulinum toxin therapy claim (index date), medical and pharmacy claims data were used to assess the utilization and cost of specific medications and overall pharmacy and medical costs for the 18-month pre-index and post-index periods. Cost was defined as allowed charge, which is the sum of plan cost and member cost. RESULTS: Of 54 surveys sent to all patients identified as having used botulinum toxin for the treatment of migraine from January 1, 2003, to October 31, 2006, 34 surveys were returned (63%). Almost 3 of 4 respondents (73%) reported moderate or better improvement in overall migraine or headache QOL measures, and 27% reported little or no improvement. For the 32 patients with continuous eligibility for the total observation period of 36 months, the average migraine-related pharmacy utilization, excluding botulinum toxin, increased by 50.5%, from 1.84 claims per patient per month (PPPM) in the 18-month pre-index period to 2.77 claims PPPM in the 18-month post-index period (P = 0.011) and by 59.5% by mean days supply (42.58 days to 67.93, P=0.008). Total migraine-related pharmacy cost increased by 80.9%, from $142.08 PPPM to $256.97 PPPM (P=0.013). Acute-treatment migraine-related pharmacy utilization increased from 1.23 claims PPPM to 1.92 claims PPPM (P=0.004). There was no significant change in either the number of claims for migraine prophylaxis medications (0.61 PPPM to 0.85 PPPM, P=0.121) or the use of hospital emergency room services related to migraine or headache (0.07 PPPM vs. 0.10 PPPM, P=0.449). The mean migraine-related and nonmigraine-related (i.e., all-cause) combined medical/hospital and pharmacy expense, including botulinum toxin, increased by 111.3%, from $651.13 PPPM in the pre-index period to $1,376.05 PPPM in the post-index period (P<0.001). CONCLUSION: The majority of patients who received botulinum toxin for refractory migraine reported improvement in disease-specific symptoms and overall QOL, but total medical and pharmacy costs were higher in the period after treatment, and there was no reduction in the use of other migraine-related medications.

PMID: 18597573 [PubMed - in process][Unusual clinical manifestation of Lyme disease--report of 2 cases] Related Articles

[Unusual clinical manifestation of Lyme disease--report of 2 cases]

Przegl Lek. 2007;64(12):1031-2

Authors: Ołdak E, Sulik A, Rozkiewicz D, Pogorzelska E, Pogorzelska M

Unusual clinical manifestation of Lyme borreliosis in two children has been presented. We discuss patient from Borrelia-endemic area who presented with persistent headache, weakness and fever. The second patient experienced acute flu-like signs with associated neck pain and stiffness (probable diagnosis). After two weeks lasting antibiotic therapy (ceftriaxone, ampicillin) nonspecific symptoms and signs decreased.

PMID: 18595510 [PubMed - indexed for MEDLINE]Aliskiren. Related Articles

Aliskiren.

Am J Health Syst Pharm. 2008 Jul 15;65(14):1323-32

Authors: Daugherty KK

PURPOSE: The pharmacology, bioavailability and pharmacokinetics, clinical efficacy, adverse effects and toxicity, drug interactions, and dosage and administration of aliskiren as well as safety and economic issues related to its use are reviewed. SUMMARY: Aliskiren is the first of a new class of antihypertensive agents, direct renin inhibitors, that act by blocking the rate- limiting step of the renin-angiotensin- aldosterone system (RAAS). It was approved by the Food and Drug Administration in 2007 for use as monotherapy or in combination with other antihypertensives. Clinical studies comparing aliskiren monotherapy with placebo indicated a dose-dependent reduction in both systolic and diastolic blood pressure (BP). Greater reductions in BP have been achieved when aliskiren was used in combination with hydrochlorothiazide or an angiotensin-receptor blocker. The most common adverse effects reported in clinical trials were headache, fatigue, dizziness, diarrhea, and nasopharyngitis. Aliskiren has not been studied in patients with moderate renal dysfunction; as a RAAS-acting drug, it should be prescribed for such patients only with caution. CONCLUSION: Aliskiren at a dosage of 150 or 300 mg daily may be a good option for control of mild-to-moderate hypertension in patients with or without diabetes in whom first-line antihypertensives have failed to adequately control BP; comparative studies with other antihypertensives are needed to determine which patients can most benefit from aliskiren therapy.

PMID: 18593678 [PubMed - indexed for MEDLINE]Thyroid-stimulating hormone pituitary adenomas. Related Articles

Thyroid-stimulating hormone pituitary adenomas.

J Neurosurg. 2008 Jul;109(1):17-22

Authors: Clarke MJ, Erickson D, Castro MR, Atkinson JL

OBJECT: Thyroid-stimulating hormone (TSH)-secreting pituitary adenomas are rare, representing < 2% of all pituitary adenomas. METHODS: The authors conducted a retrospective analysis of patients with TSH-secreting or clinically silent TSH-immunostaining pituitary tumors among all pituitary adenomas followed at their institution between 1987 and 2003. Patient records, including clinical, imaging, and pathological and surgical characteristics were reviewed. Twenty-one patients (6 women and 15 men; mean age 46 years, range 26-73 years) were identified. Of these, 10 patients had a history of clinical hyperthyroidism, of whom 7 had undergone ablative thyroid procedures (thyroid surgery/(131)I ablation) prior to the diagnosis of pituitary adenoma. Ten patients had elevated TSH preoperatively. Seven patients presented with headache, and 8 presented with visual field defects. All patients underwent imaging, of which 19 were available for imaging review. Sixteen patients had macroadenomas. RESULTS: Of the 21 patients, 18 underwent transsphenoidal surgery at the authors' institution, 2 patients underwent transsphenoidal surgery at another facility, and 1 was treated medically. Patients with TSH-secreting tumors were defined as in remission after surgery if they had no residual adenoma on imaging and had biochemical evidence of hypo-or euthyroidism. Patients with TSH-immunostaining tumors were considered in remission if they had no residual tumor. Of these 18 patients, 9 (50%) were in remission following surgery. Seven patients had residual tumor; 2 of these patients underwent further transsphenoidal resection, 1 underwent a craniotomy, and 4 underwent postoperative radiation therapy (2 conventional radiation therapy, 1 Gamma Knife surgery, and 1 had both types of radiation treatment). Two patients had persistently elevated TSH levels despite the lack of evidence of residual tumor. On pathological analysis and immunostaining of the surgical specimen, 17 patients had samples that stained positively for TSH, 8 for alpha-subunit, 10 for growth hormone, 7 for prolactin, 2 for adrenocorticotrophic hormone, and 1 for follicle-stimulating hormone/luteinizing hormone. Eleven patients (61%) ultimately required thyroid hormone replacement therapy, and 5 (24%) required additional pituitary hormone replacement. Of these, 2 patients required treatment for new anterior pituitary dysfunction as a complication of surgery, and 2 patients with preoperative partial anterior pituitary dysfunction developed complete panhypopituitarism. One patient had transient diabetes insipidus. The remainder had no change in pituitary function from their preoperative state. CONCLUSIONS: Thyroid-stimulating hormone-secreting pituitary lesions are often delayed in diagnosis, are frequently macroadenomas and plurihormonal in terms of their pathological characteristics, have a heterogeneous clinical picture, and are difficult to treat. An experienced team approach will optimize results in the management of these uncommon lesions.

PMID: 18590428 [PubMed - indexed for MEDLINE]The syndrome of headache with neurologic deficits and cerebrospinal fluid lymphocytosis mimicking acute ischemic stroke. Related Articles

The syndrome of headache with neurologic deficits and cerebrospinal fluid lymphocytosis mimicking acute ischemic stroke.

J Stroke Cerebrovasc Dis. 2008 Jul-Aug;17(4):246-7

Authors: Ariës MJ, van Oostrom JC, de Keyser J

Headache with neurologic deficits and cerebrospinal fluid lymphocytosis is a benign condition with a transient ischemic attack-like presentation. We present a case of a 22-year-old man with episodes of right-sided weakness, global dysphasia, and right-sided homonymous hemianopsia associated with frequent vomiting. Systemic thrombolytic therapy was considered. A subsequent magnetic resonance image with diffusion-weighted images revealed normal findings. A diagnosis of headache with neurologic deficits and cerebrospinal fluid lymphocytosis was made based mainly on clinical symptoms and cerebrospinal fluid analysis. With the current pressure on "door-to-needle" time for thrombolysis, it is important to keep an open eye to stroke mimics and exclude them if possible. We, therefore, strongly advise considering noninvasive magnetic resonance diffusion-weighted imaging in patients with unusual presentations (e.g., the vomiting in our patient) before thrombolysis.

PMID: 18589348 [PubMed - in process]Botulinum toxin A injection into corrugator muscle for frontally localised chronic daily headache or chronic tension-type headache. Related Articles

Botulinum toxin A injection into corrugator muscle for frontally localised chronic daily headache or chronic tension-type headache.

J Laryngol Otol. 2008 Jun 30;:1-6

Authors: de Ru JA, Buwalda J

Objective:To describe our results with botulinum toxin type A injection for headache in carefully selected patients, and to present the rationale behind this therapy.Setting:Tertiary referral centre.Patients and methods:This article describes a case series of 10 consecutive patients with frontally localised headache, whose pain worsened when pressure was applied at the orbital rim near the supratrochlear nerve. The patients received a local anaesthetic nerve block with Xylocaine 2 per cent at this site. If this reduced the pain, they were then offered treatment with botulinum toxin.Intervention:Injection with 12.5 IU of botulinum toxin A into the corrugator supercilii muscle on both sides (a total of 25 IU).Main outcome measure:Pain severity scoring by the patients, ranging from zero (no pain) to 10 (severe pain) on a verbal scale.Results:Following injection, all patients had less pain for approximately two months. This treatment did not appear to have lasting side effects.Conclusion:Xylocaine injection is a good predictor of the effectiveness of botulinum toxin injection into the corrugator muscle as treatment of frontally localised headache. We hypothesise that this pain is caused by entrapment of the supratrochlearis nerve in the corrugator muscle. Furthermore, we found botulinum toxin injection to be a safe and effective means of achieving pain relief in this patient group.

PMID: 18588738 [PubMed - as supplied by publisher]Levofloxacin-induced delirium with psychotic features. Related Articles

Levofloxacin-induced delirium with psychotic features.

Gen Hosp Psychiatry. 2008 Jul-Aug;30(4):381-3

Authors: Kiangkitiwan B, Doppalapudi A, Fonder M, Solberg K, Bohner B

OBJECTIVE: To raise awareness of a rare but serious adverse effect of a commonly used medication. METHOD: Report of a case. RESULTS: A previously healthy 42-year-old woman presented with acute-onset delirium with psychotic features as a consequence of levofloxacin therapy. Withdrawal of the medication was associated with return of the patient's normal mental status. CONCLUSION: The new quinolone derivatives (levofloxacin, sparfloxacin, grepafloxacin, trovafloxacin, gatifloxacin and moxifloxacin), also called gyrase inhibitors, are known for their potential to cause central nervous system-related adverse effects, including headache, dizziness and insomnia. Risk factors for neurotoxicity include renal insufficiency, underlying central nervous system (CNS) disease and increased CNS penetration of drug. Acute delirium resulting from levofloxacin therapy is an exceedingly rare complication that has been thought to occur more commonly in elderly patients. Here, we describe levofloxacin-induced delirium with psychotic features in a relatively young, otherwise healthy female.

PMID: 18585545 [PubMed - in process]Patients' help-seeking behaviours for health problems associated with methadone and buprenorphine treatment. Related Articles

Patients' help-seeking behaviours for health problems associated with methadone and buprenorphine treatment.

Drug Alcohol Rev. 2008 Jul;27(4):393-7

Authors: Winstock AR, Lea T, Sheridan J

INTRODUCTION AND AIMS: Clients in opioid substitution therapy often have considerable unmet health-care needs. The current study aimed to explore health problems related to opioid substitution therapy among clients on methadone and buprenorphine treatment. DESIGN AND METHODS: A self-complete, cross-sectional survey conducted among 508 patients receiving methadone and buprenorphine treatment at community pharmacies in New South Wales (NSW), Australia. RESULTS: The most common problems for which participants had ever sought help were dental (29.9%), constipation (25.0%) and headache (24.0%). The most common problems for which participants would currently like help were dental (41.1%), sweating (26.4%) and reduced sexual enjoyment (24.2%). There were no significant differences between those currently on methadone and those currently on buprenorphine for any of the health problems explored, nor differences for gender or treatment duration. Participants on methadone doses 100 mg or above were significantly more likely to want help currently for sedation. DISCUSSION AND CONCLUSIONS: The considerable unmet health care needs among participants in this study suggest that treatment providers should consider improving the detection and response to common health problems related to opioid substitution therapy.

PMID: 18584389 [PubMed - indexed for MEDLINE]Use of the neuro-wrap system for severe post-electroconvulsive therapy headaches. Related Articles

Use of the neuro-wrap system for severe post-electroconvulsive therapy headaches.

J ECT. 2008 Jun;24(2):152-5

Authors: Kramer BA, Kadar AG, Clark K

OBJECTIVE: To determine, in a nonblinded trial, if the Neuro-Wrap system is effective in reducing the severity of pain in patients with severe post-electroconvulsive therapy (ECT) headaches not adequately responsive to routine analgesic treatment. BACKGROUND: A very troubling side effect of ECT is severe post-ECT headaches. Although these headaches usually respond to routine analgesic medication, some patients continue to experience severe headache despite treatment. This very unpleasant sensation, repeated with each ECT, may cause patients to prematurely stop ECT and experience a relapse in their psychiatric symptoms. "Cold therapy" has been used for a long time as an adjunct to treat headache and pain. The Neuro-Wrap system is a method to provide temperature-controlled cooling to the head without the need to frequently reapply ice packs or physically hold the ice packs in position. It has been used successfully for patients with migraine headaches. This is the first report of its use with patients experiencing severe post-ECT headaches. METHODS: The study comprised a total of 14 patients receiving ECT who experienced a severe headache for 2 successive ECT treatments or 2 of their last 4 treatments and who had only partial or no response to usual analgesic treatment for their headache. After completion of the ECT, the Neuro-Wrap was placed on the head of the patient for a maximum of 40 minutes. Patients continued to receive analgesic medication as needed for relief of headache pain. Patients were their own control group. RESULTS: A total of 85 Neuro-Wrap treatments were given to 14 patients ranging in age from 23 to 71 years old. Nine patients reported clearly positive results on 67 different occasions. Three reported mild alleviation of headaches on 15 occasions. The remaining 2 patients had a total of 3 treatments with no benefit. After the initial treatment, 12 of 14 patients wanted to use the machine after all their subsequent ECT sessions. CONCLUSIONS: Cold therapy with Neuro-Wrap is an effective alternative treatment for refractory headaches caused by ECT.

PMID: 18580561 [PubMed - in process]The practice of electroconvulsive therapy in Malawi. Related Articles

The practice of electroconvulsive therapy in Malawi.

J ECT. 2008 Jun;24(2):137-40

Authors: Selis MA, Kauye F, Leentjens AF

OBJECTIVES: To describe the practice of electroconvulsive therapy (ECT), including indications, efficacy, and side effects, in patients treated with unmodified ECT at Zomba Mental Hospital (ZMH) in Malawi. METHODS: A naturalistic, descriptive cohort study that includes all patients receiving ECT in March and April 2006. Efficacy of ECT treatment was assessed with the "Clinical Global Impression" of change scale, and side effects and complications were systematically assessed with a checklist. RESULTS: The circumstances and procedure of ECT at ZMH are described. Forty-seven patients underwent unmodified ECT for various affective and psychotic disorders. Depending on the indication, improvement was reported in 71% to 90%. Cognitive side effects (confusion and amnesia), muscle aches, headache, and lesions of the oral cavity were the most prevalent side effects. Serious complications were not encountered. CONCLUSIONS: Unmodified ECT in Malawi is an effective treatment with less severe side effects than commonly thought. Efforts to improve treatment standards are undertaken.

PMID: 18580558 [PubMed - in process][Neurological complications in renal transplant recipients] Related Articles

[Neurological complications in renal transplant recipients]

Acta Med Croatica. 2008;62 Suppl 1:76-81

Authors: Basić-Jukić N, Basić-Kes V, Kes P, Furić-Cunko V, Bacić-Baronica K

Renal transplantation is method of choice for treatment of patients with end-stage renal disease without contraindications for immunosuppressive therapy. Neurological complications occur frequently in renal transplant recipients. They may be the consequence of immunosuppressive treatment, but more often evolve as the consequence of previous disturbances which developed during the state of uraemia and treatment with dialysis. The most pronounced neurotoxic effect has calcineurin inhibitors tacrolimus and cyclosporine. The spectrum of neurological disturbances caused by calcineurin inhibitors range from very mild symptoms as paraesthesiae, tremor, headache or flushing, to severe changes that may cause lethal outcome. Peripheral neuropathies in renal transplant recipients may occur in the form of mononeuropathy or polyneuropathy. Cerebrovascular diseases are consequence of changes on blood vessels caused by uraemia, dialysis and side effects of immunosuppressive drugs. They cause death in 8% of renal transplant recipients. Central nervous system (CNS) infections usually occur during the first posttransplant year. Unclear symptomatology frequently postpones the diagnosis. Diagnostic evaluation should include magnetic resonance imaging for localization of the process, as well as lumbal puncture in cases without contraindications for the procedure, in order to determine the causative agent. Regarding the ominous prognosis of CNS infections in the immunocompromised host, only timely diagnosis may improve survival. The most common causative agents are Cryptococcus neoformans, Listeria monocytogenes and Aspergillus funigatus. Viral infections also occur, and are commonly caused by herpes virideae, varicella-zoster virus and papova virus. CNS infections clinically present as meningitis, progressive dementia or focal neurological defect. The most common primary brain tumors are B-cell lymphomas, but glioblastoma, hemangioblastoma, leiomyosarcoma or glioma may also occur. In cases of neurological posttransplant complications, optimal treatment should be guided by neurologist, nephrologist and infectologist, in some cases also by neurosurgeons.

PMID: 18578336 [PubMed - in process]Atypical antipsychotic treatment of disruptive behavior disorders in children and adolescents. Related Articles

Atypical antipsychotic treatment of disruptive behavior disorders in children and adolescents.

J Clin Psychiatry. 2008;69 Suppl 4:9-14

Authors: Findling RL

Disruptive behavior disorders, including conduct disorder, oppositional defiant disorder, and disruptive behavior disorder not otherwise specified, are serious conditions in children and adolescents that include a behavior pattern of violating the basic rights of others and age-appropriate rules or standards and may include aggressive behavior. Although no pharmacotherapy is currently approved for use in this population, evidence suggests that atypical antipsychotic treatment may be useful in patients with these conditions who present with problematic aggression. Currently, research on risperidone shows it to be effective in treating aggressive behavior in this patient population. Limited research is also available on olanzapine, quetiapine, and aripiprazole, but more research is needed on these and other agents. As with any pharmacotherapy, adverse events (including weight gain, headache, and somnolence) should be carefully considered with these medications, especially in children and adolescents, and it is important to properly dose and monitor patients during medication therapy.

PMID: 18533763 [PubMed - indexed for MEDLINE]Efficacy and tolerability of coadministration of rizatriptan and acetaminophen vs rizatriptan or acetaminophen alone for acute migraine treatment. Related Articles

Efficacy and tolerability of coadministration of rizatriptan and acetaminophen vs rizatriptan or acetaminophen alone for acute migraine treatment.

Headache. 2008 Jun;48(6):921-30

Authors: Freitag F, Diamond M, Diamond S, Janssen I, Rodgers A, Skobieranda F

OBJECTIVE: To evaluate the efficacy and tolerability of coadministration of rizatriptan and acetaminophen in the acute treatment of migraine. BACKGROUND: Rizatriptan is a selective 5-HT1B/1D agonist approved for the acute treatment of migraine. Acetaminophen has been studied for acute migraine treatment. In consideration of the prominent central and peripheral mechanisms in migraine, the use of "multi-mechanism therapy" is gaining momentum in the treatment of acute migraine attacks. STUDY DESIGN: This was a randomized, double-blind, placebo-controlled trial conducted at 10 centers. Eligible patients with migraine according to International Headache Society criteria treated a single migraine attack of moderate or severe intensity within 4 h from pain onset. Patients were randomized into 1 of 4 groups (rizatriptan 10 mg + acetaminophen 1000 mg [RA], rizatriptan alone [R], acetaminophen alone [A], and placebo [P]). There were 3 co-primary hypotheses tested sequentially for 2-h pain relief: (1) RA would be superior to P; (2) if the first was fulfilled, RA would be superior to A; and (3) if the first 2 were fulfilled, RA would be superior to R. RESULTS: Of 173 patients who treated a migraine, 123 patients (71.5%) achieved pain relief within 2 h. RA (90%) was significantly better than P (46%) and A (70%), but only numerically better than R (77%) for 2-h pain relief. No significant differences were seen between the active treatment groups in adverse events. CONCLUSION: Rizatriptan coadministered with acetaminophen achieved 2 of the 3 primary hypotheses, proving superior to both acetaminophen and placebo for 2-h pain relief, but failing to achieve superiority to rizatriptan alone. RA was as well tolerated as each of the individual agents.

PMID: 18572432 [PubMed - in process]Exercise in migraine therapy--is there any evidence for efficacy? A critical review. Related Articles

Exercise in migraine therapy--is there any evidence for efficacy? A critical review.

Headache. 2008 Jun;48(6):890-9

Authors: Busch V, Gaul C

BACKGROUND: Some migraine patients find that regular exercise helps in reducing the frequency of headache attacks. In addition, exercise in migraine is recommended from many headache experts. However, most of these recommendations refer to some anecdotal reports or observational studies in literature stating that regular exercise can reduce the frequency and severity of migraine. OBJECTIVE: The purpose of this review is to investigate whether recommendations for exercise in migraine are based on sufficient data to cope with requirements of an evidence-based modern migraine therapy. The review summarizes and discusses all available trials on this topic. RESULTS: Eight studies und 4 case reports investigated the therapeutic role of aerobic exercise on migraine headache. Some results are controversial regarding the efficacy of sports intervention in migraine. The majority of studies did not find a significant reduction of headache attacks or headache duration and only indicate a reduction of pain intensities in migraine patients due to regular exercise. The grade of recommendation of exercise in migraine based on evidence based medicine (EBM)-criteria is presently B-C. But due to methodological limitations, the available data are insufficient for a final statement on this topic. CONCLUSIONS: To further recommend exercise in migraine based on EBM-criteria, more studies are imperative. Future studies should adhere to the rules for randomized clinical trials in pharmacological migraines prophylaxis. Implications for further studies are given.

PMID: 18572431 [PubMed - in process]Esomeprazole in acute and maintenance treatment of reflux oesophagitis: a multicentre prospective study. Related Articles

Esomeprazole in acute and maintenance treatment of reflux oesophagitis: a multicentre prospective study.

Adv Ther. 2008 Jun;25(6):552-66

Authors: Atug O, Giral A, Kalayci C, Dolar E, Isitan F, Oguz D, Ovunc O, Ozgur O, Soykan I, Simsek I, Unal S, Yenice N

INTRODUCTION: The aim of this study was to assess the efficacy and safety of esomeprazole 40 mg once daily (q.d.) in healing reflux oesophagitis at 4 and 8 weeks, and the efficacy of esomeprazole 20 mg q.d. for 12 weeks in the maintenance of remission. METHODS: A total of 235 patients with endoscopically proven reflux oesophagitis were enrolled in this study, which consisted of two phases (healing and maintenance therapy). Patients who showed complete endoscopic and symptomatic healing at the end of 4 or 8 weeks were switched to maintenance treatment with esomeprazole 20 mg q.d. for 12 weeks. The primary efficacy endpoint was healing of reflux oesophagitis at week 8. Secondary assessments included the proportion of patients with symptomatic relapse in the maintenance phase. RESULTS: At the end of week 8, 88% (95% life-table confidence intervals [CI]: 84%, 92%) of patients were healed endoscopically and 90.6% of the patients were asymptomatic. Patient age, gender and Helicobacter pylori status had no effect on the efficacy of treatment. During the 12-week maintenance treatment phase, symptomatic relapse ratios were 0.5%, 2.2%, and 0%, for the first, second, and third 4-week periods, respectively. The proportions of patients satisfied with treatment were 95% and 99.4% at the end of acute and maintenance treatment, respectively. The most common adverse effects were headache, upper respiratory tract infection and abdominal pain. CONCLUSIONS: Esomeprazole is effective in the healing of reflux oesophagitis, the resolution of heartburn, and in maintaining symptomatic remission. The effectiveness of esomeprazole in patients with gastroesophageal reflux disease is not affected by the presence of H. pylori.

PMID: 18568450 [PubMed - in process]Effect of doxazosin gastrointestinal therapeutic system as third-line antihypertensive therapy on blood pressure and lipids in the Anglo-Scandinavian Cardiac Outcomes Trial. Related Articles

Effect of doxazosin gastrointestinal therapeutic system as third-line antihypertensive therapy on blood pressure and lipids in the Anglo-Scandinavian Cardiac Outcomes Trial.

Circulation. 2008 Jul 1;118(1):42-8

Authors: Chapman N, Chang CL, Dahlöf B, Sever PS, Wedel H, Poulter NR,

BACKGROUND: The role of doxazosin in treatment of hypertension remains controversial. METHODS AND RESULTS: We evaluated the effects on blood pressure (BP) and biochemical parameters of doxazosin GITS (gastrointestinal therapeutic system) as a third-line antihypertensive agent among 10,069 participants in the Anglo-Scandinavian Cardiac Outcomes Trial--Blood Pressure Lowering Arm (ASCOT-BPLA) whose BP remained above 140/90 mm Hg (130/80 mm Hg in those with diabetes mellitus). Among those who received doxazosin, mean age was 63 years (SD 9 years), 79% were male, and 32% had diabetes. Doxazosin was initiated a median of 8 months (interquartile range 3 to 24 months) after randomization and was added to a mean of 2.0 (SD 0.3) other antihypertensive drugs; the mean starting and final doses were 4.1 (SD 0.6) and 7.0 (SD 3.1) mg, respectively. During a median of 12 months (interquartile range 4 to 31 months) of uninterrupted doxazosin treatment, during which other antihypertensive treatments remained unchanged, mean BP fell 11.7/6.9 mm Hg (SD 18.8/9.6 mm Hg, P<0.0001) from 158.7/89.2 mm Hg (SD 18.3/10.6 mm Hg). After the addition of doxazosin, 29.7% of participants achieved target BP. There was no apparent excess of heart failure among doxazosin users. There were associated modest favorable effects on plasma lipid profiles, but a small rise in fasting plasma glucose was observed. Doxazosin was generally well tolerated, with 7.5% of participants discontinuing the drug because of adverse events, most frequently dizziness, fatigue, headache, and edema. CONCLUSIONS: alpha-Blockers are no longer recommended as add-on therapy in some hypertension guidelines. However, although they are nonrandomized and were not placebo-controlled, the present findings suggest that doxazosin is a safe and effective third-line antihypertensive agent.

PMID: 18559700 [PubMed - in process]Benefit-risk assessment of telithromycin in the treatment of community-acquired pneumonia. Related Articles

Benefit-risk assessment of telithromycin in the treatment of community-acquired pneumonia.

Drug Saf. 2008;31(7):561-75

Authors: Brown SD

The purpose of this review is to assess the benefits and risks associated with the use of the ketolide antibacterial telithromycin, currently licensed for the treatment of adults with mild to moderate community-acquired pneumonia (CAP). Telithromycin is active against both the major (Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis) and atypical/intracellular (Chlamydophila pneumoniae, Legionella pneumophila and Mycoplasma pneumoniae) CAP pathogens. It is associated with a low potential to select for resistance and has maintained its in vitro activity against isolates of respiratory pathogens in countries where it has been in clinical use for several years. In randomized clinical trials, telithromycin has demonstrated efficacy comparable to the established antibacterial classes (macrolides, fluoroquinolones and beta-lactams) in the treatment of CAP.The safety profile of telithromycin is broadly similar to that of other antibacterials used to treat CAP. The most common adverse events are gastrointestinal adverse effects and headache; these are generally mild to moderate in severity and reversible. Telithromycin appears to be well tolerated by adult patients in all age groups, including those with co-morbid conditions. In common with other antibacterials, telithromycin has the potential to affect the corrected QT interval; the concomitant use of cisapride or pimozide with telithromycin is contraindicated, while telithromycin should be avoided in patients receiving Class IA or Class III antiarrhythmic drugs. Visual disturbances (usually transient) have occurred in a small proportion of patients treated with telithromycin; it is recommended that activities such as driving are minimized during treatment. Telithromycin is contraindicated in patients with myasthenia gravis. Hepatic dysfunction may occur in some patients taking telithromycin; rare cases of acute hepatic failure and severe liver injury, including deaths, have been reported. As telithromycin is an inhibitor of the cytochrome P450 (CYP) 3A4 system, coadministration of telithromycin with drugs metabolized by this pathway may require dose adjustments (e.g. with benzodiazepines) or a temporary hiatus in the use of the coadministered drug (e.g. HMG-CoA reductase inhibitors) metabolized by CYP3A4. Telithromycin may potentiate the effects of oral anticoagulants; careful monitoring is recommended in patients receiving telithromycin and oral anticoagulants simultaneously.Although serious and sometimes fatal events have occurred in patients receiving telithromycin therapy, current data indicate that telithromycin offers an acceptable benefit risk ratio in the treatment of mild to moderate CAP.

PMID: 18558790 [PubMed - in process]Subarachnoid placement of stem cells in neurological disorders. Related Articles

Subarachnoid placement of stem cells in neurological disorders.

Transplant Proc. 2008 May;40(4):1145-7

Authors: Mehta T, Feroz A, Thakkar U, Vanikar A, Shah V, Trivedi H

BACKGROUND: "Medically untreatable neurological disorders" is an area where stem cell (SC) therapy has generated hope in the last decade. Among various routes for SC infusion, subarachnoid placement via the lumbar route is particularly challenging because of technical difficulties in this group of patients. We carried out a prospective, single-center, clinical study to analyze the technical difficulties and short- and long-term effects of SC infusion in various neurological conditions. PATIENTS AND METHODS: One hundred eighty patients underwent subarachnoid placement of SCs between December 2005 and October 2007. Technical difficulties in the form of localization of subarachnoid space, number of attempts, and postprocedural complications were evaluated. Functional evaluation was done with Hauser Ambulation Index by the SC transplant team on a regular basis. The Institutional Review Board approved of informed consent forms and study protocol. RESULTS: Of 180 patients, we encountered technical difficulties in 52 (29%) in the form of general anesthesia supplementation and difficulty localizing the lumbar space. In 102 (56.6%) patients, side effects were observed (headache, low-grade fever, and meningism), which resolved with symptomatic treatment within 24 hours. On long-term follow-up, functional indices improved in 57 (31.67%) patients, including 54 patients with traumatic paraplegia/quadriplegia, two with cerebral palsy, and one with viral encephalitis. CONCLUSION: Subarachnoid placement of SCs is safe with no long term adverse effects.

PMID: 18555135 [PubMed - indexed for MEDLINE]Giant cell arteritis presenting as a breast lesion: report of a case and review of the literature. Related Articles

Giant cell arteritis presenting as a breast lesion: report of a case and review of the literature.

Am J Med Sci. 2008 Jun;335(6):489-91

Authors: Marie I, Audeguy P, François A, DE Kergal F, Richard C

Giant cell arteritis (GCA) mainly affects arteries arising from the external carotid arteries, although it may also be responsible for extracephalic clinical presentation related to impairment of vessels other than the carotids, such as the aorta as well arteries of the lower and upper limbs (10%-30% of cases). However, breast involvement is considered to be a rare complication of GCA. We recently observed a case of particular interest as the patient developed superficial mammary arteriolitis, bilaterally, revealing GCA with favorable outcome after institution of steroid therapy. Our case report reinforces the possibility of an unusual presentation of GCA. Indeed, we suggest that an evaluation for GCA affecting the breast should be made in elderly women exhibiting breast nodule(s)/mass(es) associated with other features of GCA (that are: headache, jaw claudication, constitutional signs, polymyalgia rheumatica). Furthermore, we also suggest that the prevalence of breast impairment may be underestimated in GCA as the breast is supplied mainly by 2 branches of the subclavian artery (ie, the internal mammary artery [as in the present case report] and the lateral thoracic artery), which is often involved in GCA.

PMID: 18552581 [PubMed - indexed for MEDLINE][Thrombophlebitis of venous sinuses in otitis media] Related Articles

[Thrombophlebitis of venous sinuses in otitis media]

Otolaryngol Pol. 2007;61(5):769-73

Authors: Kuczkowski J

Thrombophlebitis of dura venous sinuses is a rare intracranial complication of otitis media, which may be sometimes accompanied by symptoms or sepsis. Anatomical conditions and early diagnosis of this vascular complication determine the treatment modality. Aim of this study was the assessment of diagnostics and treatment of venous sinuses thrombophlebitis in acute and chronic otitis media considering anatomy and the venous sinuses and status of coagulation system. Otogenic thrombophlebitis may occur in lateral, transverse, upper and lower petrosal sinuses, and rarely in cavernous. In some cases thrombophlebitis proces may expand into brain or emissary mastoid veins. Lateral sinus thrombophlebitis in chronic otitis media usually appears clinically as septic fever, earache, and increasing neurologic signs. In acute otitis media when thrombophlebitis develops the patient complains about headache, high fever and visual acquity. Diagnosis of venous sinus thrombophlebitis is based on clinical signs, radiological imaging (CT scan, MRI), bacteriological examinations and laboratory biochemical tests. Contrast enhanced CT scan shows "delta sign". Septic thrombophlebitis sinus sigmoidei is caused by mixed bacterial flora. Surgical treatment in cases with septic thrombus consists of radical modiffied ear operation and lateral sinus exposure. Thrombectomy and jugular vein ligation is performed when sepsis or thrombus is present. Mastoidectomy and tympanic cavity drainage is performed in cases with lateral sinus thrombosis in acute mastoiditis. Intravenous antibiotics therapy should be continued for 2 weeks. Anticoagulants should be given taking into consideration parameters of coagulation system and the type of thrombus. Treatment results of venous sinuses thrombophlebitis are good if they are not accompanied by other intracranial complications.

PMID: 18552016 [PubMed - in process]Long-term effect of tacrolimus therapy in patients with refractory ulcerative colitis. Related Articles

Long-term effect of tacrolimus therapy in patients with refractory ulcerative colitis.

Aliment Pharmacol Ther. 2008 Sep 1;28(5):589-97

Authors: Yamamoto S, Nakase H, Mikami S, Inoue S, Yoshino T, Takeda Y, Kasahara K, Ueno S, Uza N, Kitamura H, Tamaki H, Matsuura M, Inui K, Chiba T

BACKGROUND: Little is known about long-term outcome of tacrolimus therapy for ulcerative colitis. Aim To evaluate long-term efficacy and safety of tacrolimus in Japanese patients with refractory ulcerative colitis. METHODS: Twenty-seven patients with UC refractory to conventional therapy were administered tacrolimus with trough whole-blood levels of 10-15 ng/mL to induce remission and 5-10 ng/mL to maintain remission. Median treatment duration was 11 months (1-39 months) and median follow-up duration was 17 months (2-65 months). Evaluation of the clinical response was based on a modified Truelove-Witts severity index (MTWSI). RESULTS: Tacrolimus produced a clinical response in 21 patients (77.8%), and remission was achieved in 19 of these 21 (70.4%) within 30 days. Overall cumulative colectomy-free survival was estimated as 62.3% at 65 months. In 18 of 19 patients treated with corticosteroids at the initiation of tacrolimus therapy, corticosteroids were discontinued or tapered. Adverse events were tremor (25.9%), renal function impairment (18.5%), infectious disease (14.8%), hot flashes (11.1%), hyperkalaemia (7.4%), headache (7.4%), epigastralgia (7.4%) and nausea (3.7%). No mortality occurred. CONCLUSION: Long-term administration of tacrolimus appears to be an effective and well-tolerated treatment for Japanese patients with refractory ulcerative colitis.

PMID: 18549460 [PubMed - in process]Examining the utility of in-clinic "rescue" therapy for acute migraine. Related Articles

Examining the utility of in-clinic "rescue" therapy for acute migraine.

Headache. 2008 Jun;48(6):939-43

Authors: Morey V, Rothrock JF

BACKGROUND: Management options currently are limited for patients with acute migraine whose symptoms prove refractory to self-administered therapy. OBJECTIVE: To evaluate the clinical utility and cost-effectiveness of a management program offering in-clinic "rescue" treatment for patients with acute migraine. METHODS: Two hundred consecutive migraine patients presenting to a university-based headache clinic were randomized to receive either optimal self-administered medical therapy for acute migraine ("standard therapy") or similar therapy plus the option of in-clinic parenteral drug administration should self-administered therapy prove ineffective ("rescue therapy"). Patients randomized to the latter group were restricted to a maximum of 2 "rescue visits" per month, and all patients were followed for one year. Patients "rescued" in clinic were contacted by telephone 24 hours following treatment to evaluate their treatment response. The primary analysis involved a comparison of the number of emergency department (ED) visits for headache recorded within each group over the one-year period of study. For all ED visits in the rescue group and for a randomly selected and equal number of ED visits within the standard group, the direct costs associated with those visits were assessed, and the direct costs of all in-clinic rescue visits also were recorded and analyzed. RESULTS: The 2 groups studied were similar in terms of age, gender ratio, migraine subtype, migraine-related disability status at baseline and type/extent of medical insurance coverage. Over the one-year study period, the rescue group recorded 423 in-clinic rescue visits and reported 27 ED visits for headache treatment. The standard therapy group reported 73 ED visits (27 vs 73 visits; P < .01). The total direct costs associated with ED visits were $45,330 for the rescue group (mean $1690 per ED visit) and (by extrapolation from the sample selected) $147,971 for the standard therapy group (mean $2027 per ED visit). The total direct cost of the 423 "rescue visits" was $33,647 (mean $80 per visit). In 79% of the 423 rescue encounters, the patients involved reported no residual functional disability 24 hours following treatment. Of those in the rescue group who sought in-clinic rescue, 89% reported themselves "very satisfied" with such management. CONCLUSION: Providing the alternative of in-clinic "rescue" for acute migraine refractory to self-administered therapy offers an attractive alternative for patients and appears to substantially lower use of an ED for headache treatment and the cost associated with that use.

PMID: 18549372 [PubMed - in process]Continuous opioid therapy (COT) is rarely advisable for refractory chronic daily headache: limited efficacy, risks, and proposed guidelines. Related Articles

Continuous opioid therapy (COT) is rarely advisable for refractory chronic daily headache: limited efficacy, risks, and proposed guidelines.

Headache. 2008 Jun;48(6):838-49

Authors: Saper JR, Lake AE

Intractable pain, headache or otherwise, is a devastating and life-controlling experience. The need to effectively and aggressively control pain is a fundamental tenet of clinical care. In the past several years, increasing advocacy for continuous opioid therapy has become an important, if not controversial, theme in the development of treatment guidelines and teaching programs. Ironically, the increasing willingness of physicians to prescribe scheduled opioids for their headache and pain patients has occurred in the absence of compelling data demonstrating efficacy or long-term safety. To the contrary, two meta-analyses on chronic noncancer pain (CNCP) and one long-term uncontrolled study on headache patients demonstrate a relatively small number of patients benefiting from the treatment. Recent neuroscience data on the effects of opioids on the brain raise serious concern for long-term safety and also provide the basis for the mechanism by which chronic opioid use might induce progression of headache frequency and severity. Significant adverse effects, including influence on sexual hormonal balances, physical and psychological dependence, the development of opioid-induced hyperalgesia, and cardiac arrhythmia and sudden death that can be seen with standard dosages of methadone, make a strong argument against widespread use of continuous opioid therapy (COT) in otherwise healthy young and middle-aged headache patients. We believe that COT should be used in rare circumstances for chronic headache patients, and propose initial guidelines for selecting patients and monitoring treatment. The physician should be well versed in the details of opioid prescribing, administration, and monitoring, and should be prepared to discontinue opioids when clinical justification, patient behavior, or failure to achieve therapeutic goals make discontinuance necessary.

PMID: 18549361 [PubMed - in process]Pearls from an inpatient headache unit. Related Articles

Pearls from an inpatient headache unit.

Headache. 2008 Jun;48(6):820-7

Authors: Saper JR

Much can be learned from treating over 15,000 headache hospitalized patients over the course of 30 years. By the very need to be admitted, these individuals are complicated, both physiologically and often psychologically. Founded in 1978, the Michigan Head Pain and Neurological Institute and its hospital unit developed a set of criteria for admission and a growing staff of professionals to serve this complex population of patients. Experience has taught us many lessons; several are considered in this review. Among the important topics discussed are: admission criteria to the hospital unit; treatment protocols and other hospital-based strategies; integration of behavioral therapy and therapists into the treatment system; diagnostic testing of patients with intractable headache; identifying the "problem patient" and "medication misuse" early in the course of therapy; approaching the headache patient with cluster B personality disorder; and the use of interventional and anesthesiological treatment for intractable headache. Outcome data and a review of recent publications are presented.

PMID: 18549359 [PubMed - in process][Auto-injection with epinephrine in the finger of a 5-year-old child] Related Articles

[Auto-injection with epinephrine in the finger of a 5-year-old child]

Ned Tijdschr Geneeskd. 2008 Apr 26;152(17):1005-8

Authors: Janssen RL, Roeleveld-Versteegh AB, Wessels-Basten SJ, Hendriks T

A 5-year-old boy with food allergies complicated by anaphylactic reactions with dyspnoea and angioedema had been prescribed an autoinjector with epinephrine (0.15 mg) so that his parents could treat him at home if necessary. The patient accidentally injected himself in a finger, which likely makes him the youngest patient to receive an epinephrine auto-injection reported to date. Treatment consisted of phentolamine (0.15 mg in 0.5 ml normal saline) injected subcutaneously at the site of accidental injection; the dose and volume were not adapted according to the age and body weight of the patient as only a local effect was intended. Finger circulation was restored within 20 minutes. Headache, nausea and vomiting were observed after 30 minutes and were most likely a systemic side effect of phentolamine. No other complications occurred. The patient recovered fully and was discharged the following morning. Intramuscular epinephrine autoinjection is standard therapy for severe anaphylactic reactions. The epinephrine autoinjector was introduced in 1980. As allergy and anaphylaxis become more common, increasing numbers of autoinjectors are prescribed, and it is likely that the number of accidental digital autoinjections will also increase. These digits are then at risk of ischaemic necrosis. There is no consensus on therapeutic strategies in such cases. Phentolamine administration appears to be an effective intervention. However, several recent studies have shown that epinephrine may be used safely in hand surgery, which suggests that accidental digital epinephrine autoinjection may not always require immediate treatment.

PMID: 18549176 [PubMed - indexed for MEDLINE][Vasculitis as a reason of chronic headache] Related Articles

[Vasculitis as a reason of chronic headache]

Praxis (Bern 1994). 2008 Mar 19;97(6):322-5

Authors: Ataia I, Casaulta C, von Vigier RO, Pfammatter JP, Brekenfeld C, Sauvain MJ, Steinlin M

A 13-year-old girl presented to our emergency with a one week history of fever and skin rash and new onset of chorea for the last three days. There was a long standing history of right predominant headache; followed by personality change, fatigue, arthralgia and weight loss over the last few months. Previous investigations by head CT and ophthalmological examination did not explain the symptoms. Further investigations revealed peri- and pancarditis with aortic insufficiency, a renal involvement with elevated creatinin, protein- and hematuria and a hemolytic anemia. Diagnosis of lupus eythematodes was confirmed by high ANA, anti-dsDNS and Anticardiolipin antibodies. Within the first 48 hours after admission there was significant deterioration with reduced vigilance and dysarthria. MRI of the brain and dopplersonography of cerebral vessels showed a complete thrombosis of the right medial cerebral artery with a small net of collaterals, irregularities of the left cerebral artery due to vasculitis and several subacute leftsided ischemias. Immunosuppressive therapy with high-dose corticosteroids and cyclophosphamid together with antithrombotic therapy induced an improvement of neurologic, renal and cardiac function.

PMID: 18548940 [PubMed - indexed for MEDLINE]Physical therapy and exercise in headache. Related Articles

Physical therapy and exercise in headache.

Cephalalgia. 2008 Jul;28 Suppl 1:36-8

Authors: Fernández-de-Las-Peñas C

To date the effects of physical therapy or exercise in headaches has hardly been analysed. Conflicting results in previous studies might be due to the low number of clinical trials plus an indiscriminate application of different techniques. As different pathogenic mechanisms seem to be involved in each headache, the most appropriate techniques might differ in each case. Future research should address the evaluation of specific physical therapy procedures for each headache disorder, and the identification of those subgroups of patients who are most likely to benefit from a particular intervention.

PMID: 18494995 [PubMed - indexed for MEDLINE]Physical therapy and exercise in headache. Related Articles

Physical therapy and exercise in headache.

Cephalalgia. 2008 Jul;28 Suppl 1:35

Authors: Antonaci F

PMID: 18494994 [PubMed - indexed for MEDLINE][Serial whole-body cryotherapy in the criostream for inflammatory rheumatic diseases. A pilot study] Related Articles

[Serial whole-body cryotherapy in the criostream for inflammatory rheumatic diseases. A pilot study]

Med Klin (Munich). 2008 Jun 15;103(6):383-8

Authors: Lange U, Uhlemann C, Müller-Ladner U

BACKGROUND AND PURPOSE: Local as well as whole-body cryotherapy is used to relieve pain and inflammation in rheumatic diseases. In comparison with a chamber-based whole-body cryotherapy, the novel criostream whole-body therapy (single-person cabin with cold air cooled by liquid nitrogen) as an innovative technique offers not only a rapid therapeutic effect but also a considerable reduction in costs. The aim of this study was to compare the effect of whole-body cryotherapy in the criostream on pain reduction, disease activity and pro-inflammatory cytokines (tumor necrosis factor-[TNF-]alpha and interleukin-[IL-]1), and improvement in functional scores. PATIENTS AND METHODS: Ten patients with different active inflammatory rheumatic diseases (four patients with rheumatoid arthritis, three patients with ankylosing spondylitis, and three patients with psoriatic arthritis/spondylitis) underwent nine sessions of whole-body cryotherapy in 5 days for a short time period (at first 90 s, with step-up in each application to 2.5 min total time). RESULTS: Pain and disease activity scores decreased significantly, and, subsequently, also the functional scores showed a significant amelioration. Furthermore, there was a significant reduction in TNF-alpha (p < 0.01) and IL-1 (p < 0.05). Side effects were reported only after the first application in two cases (headache and sensation of cold). CONCLUSION: The criostream offers an elegant and, from the patient's point of view, attractive therapeutic agent in the multimodal treatment concept for inflammatory rheumatic diseases.

PMID: 18548207 [PubMed - in process]Hypothalamic deep-brain stimulation: target and potential mechanism for the treatment of cluster headache. Related Articles

Hypothalamic deep-brain stimulation: target and potential mechanism for the treatment of cluster headache.

Cephalalgia. 2008 Jul;28(7):799-803

Authors: May A

Recently, functional imaging data have underscored the crucial role of the hypothalamus in trigemino-autonomic headaches, a group of severe primary headaches. This prompted the application of hypothalamic deep-brain stimulation (DBS), with the intention to preventing cluster headache (CH) attacks in selected severe therapy-refractory cases. To date, a total of 50 operated intractable CH patients, one patient with short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing and three with atypical facial pain, have been reported. However, it is not apparent why the spontaneous bursts of activation in the inferior posterior hypothalamus result in excruciating head pain, whereas continuous electrical stimulation of the identical area is able to prevent these attacks. Recently, this issue has been addressed by examining 10 operated chronic CH patients, using H(2)(15)O-positron emission tomography and alternately switching the hypothalamic stimulator on and off. The stimulation-induced activation in the ipsilateral posterior inferior hypothalamic grey (the site of the stimulator tip) as well as activation and de-activation in several cerebral structures belonging to neuronal circuits usually activated in pain transmission. These data argue against an unspecific antinociceptive effect or pure inhibition of hypothalamic activity as the mode of action of hypothalamic DBS and suggest functional modulation of the pain-processing network.

PMID: 18547217 [PubMed - indexed for MEDLINE]Stroke awareness among cardiovascular disease patients. Related Articles

Stroke awareness among cardiovascular disease patients.

Arq Neuropsiquiatr. 2008 Jun;66(2A):209-12

Authors: Coelho Rde S, Freitas WM, Campos GP, Teixeira RA

BACKGROUND: The early recognition of stroke signs and symptoms is of great relevance concerning the outcome, since it enhances the chances of thrombolytic therapy use. PURPOSE: To compare the knowledge of stroke among a community-based sample and patients treated in a cardiologic clinic. METHOD: We applied a questionnaire during one morning to people who were walking in a park (Pa) and spontaneously stopped at a health tent and during one week to patients of a cardiologic clinic (Ca). The survey assessed demographic details, awareness of stroke symptoms and signs, risk factors and general concepts of stroke. RESULTS: A total of 222 questionnaires were answered, 109 by the cardiologic clinic group and 113 by the park group. The park group recognized better three associated symptoms: headache (Ca: 39%; Pa: 61%; p: 0.001), loss of vision (Ca: 15.8%; Pa: 30.9%; p: 0.007) and unilateral paralysis/weakness (Ca: 26%; Pa: 41%; p: 0.026). The park group recognized better 3 risk factors: diabetes (Ca: 22.9%; Pa: 37.2%; p: 0.021), smoking (Ca: 51.4%; Pa: 67.2%; p: 0.011) and high cholesterol (Ca: 54.1%; Pa: 69.9%; p: 0.015). CONCLUSION: Our results suggest that patients treated in a cardiologic clinic do not show a better knowledge of stroke when compared to a community-based sample. Campaigns to increase stroke knowledge can have a great impact on public health, especially among enhanced risk groups, such as cardiovascular patients.

PMID: 18545784 [PubMed - in process][Mechanism of therapy effects by botulinum neurotoxin] Related Articles

[Mechanism of therapy effects by botulinum neurotoxin]

Med Arh. 2008;62(1):53-5

Authors: Alajbegović A, Alajbegović S, Resić H

Botulinum neurotoxin (BoNT) is produced by Clostridium botulinum as a complex of proteins containing the neurotoxin itself and other nontoxic proteins. Activation of the neurotoxin occurs upon proteolytic cleavage into the heavy and light chains. This di-chain moiety is essential for neurotoxin and each chain is playing a unique role; the heavy chain mediates neurospecifics cell binding and entry, whereas the light chain, a protease, catalyzes the cleavage and inactivation of neuronal proteins that mediate neurotransmitter release. There are seven BoNT serotypes (A,B,CI,D,E,F, and G), all of which inhibit acetylcholine release, though their intracellular target proteins, the characteristics of their actions, and their potencies vary substantially. BoNT type A has been the most widely studied and applied serotype for therapeutic purposes. It has been a mainstay in the treatment of cervical dystonia, blepharospasm, and hemifacial spasm for years. BoNT has more recently emerged as an increasingly important therapeutic option in the clinical management of a broad array of conditions, including other focal dystonias, spasticity, cerebral palsy, equinovarus, gastrointestinal (GI) and urogenital disorders, hypersecretory disorders, facial lines due to hyperfunctional facial muscles and recently, musculoskeletal pain disorders and headache.

PMID: 18543757 [PubMed - indexed for MEDLINE]Mind-body interventions: applications in neurology. Related Articles

Mind-body interventions: applications in neurology.

Neurology. 2008 Jun 10;70(24):2321-8

Authors: Wahbeh H, Elsas SM, Oken BS

OBJECTIVE: Half of the adults in the United States use complementary and alternative medicine with mind-body therapy being the most commonly used form. Neurology patients often turn to their physicians for insight into the effectiveness of the therapies and resources to integrate them into their care. The objective of this article is to give a clinical overview of mind-body interventions and their applications in neurology. METHODS: Medline and PsychInfo were searched on mind-body therapies and neurologic disease search terms for clinical trials and reviews and published evidence was graded. RESULTS: Meditation, relaxation, and breathing techniques, yoga, tai chi, and qigong, hypnosis, and biofeedback are described. Mind-body therapy application to general pain, back and neck pain, carpal tunnel syndrome, headaches, fibromyalgia, multiple sclerosis, epilepsy, muscular dysfunction, stroke, aging, Parkinson disease, stroke, and attention deficit-hyperactivity disorder are reviewed. CONCLUSIONS: There are several conditions where the evidence for mind-body therapies is quite strong such as migraine headache. Mind-body therapies for other neurology applications have limited evidence due mostly to small clinical trials and inadequate control groups.

PMID: 18541886 [PubMed - indexed for MEDLINE]Nebivolol: a new antihypertensive agent. Related Articles

Nebivolol: a new antihypertensive agent.

Am J Health Syst Pharm. 2008 Jun 15;65(12):1125-33

Authors: Gray CL, Ndefo UA

PURPOSE: The pharmacology, pharmacokinetics, clinical efficacy, adverse effects, safety, economic issues, dosage, and place in therapy of nebivolol are reviewed. SUMMARY: Nebivolol is a novel, highly selective beta(1)-receptor blocker that causes peripheral vasodilation by increasing the production and release of nitric oxide and decreasing nitric oxide degradation. The nitric oxide-mediated effects of nebivolol lead to decreases in systemic vascular resistance and large artery stiffness and possible reversal of endothelial dysfunction. Clinical studies have shown nebivolol to be at least as effective at lowering blood pressure as other antihypertensive drugs, including other beta-blockers. The most frequent adverse events reported in nebivolol clinical trials were transient headache, dizziness, and tiredness. In a large trial in patients with heart failure, nebivolol was shown to reduce the composite endpoint of mortality and hospitalizations. Nebivolol is highly lipophilic and is rapidly absorbed after oral administration. The nebivolol dose most commonly used in clinical trials for hypertension was 5 mg daily; no significant further decreases in blood pressure were shown with higher doses. The average dose in clinical trials for patients with heart failure was 5-10 mg daily. Dosage adjustments are recommended in elderly patients and patients with severe renal impairment. CONCLUSION: Nebivolol is a unique, highly selective beta-blocker with vasodilatory properties mediated through the nitric oxide pathway; it may be useful in the treatment of uncomplicated mild-to-moderate essential hypertension and in patients with heart failure.

PMID: 18541682 [PubMed - indexed for MEDLINE]Treatment results of boron neutron capture therapy using intra-arterial administration of boron compounds for recurrent head and neck cancer. Related Articles

Treatment results of boron neutron capture therapy using intra-arterial administration of boron compounds for recurrent head and neck cancer.

Br J Radiol. 2008 Jun 9;

Authors: Fuwa N, Suzuki M, Sakurai Y, Nagata K, Kinashi Y, Masunaga S, Maruhashi A, Imahori Y, Kodaira T, Tachibana H, Nakamura T, Ono K

During this study, in order to accumulate boron in the tumour, boron neutron capture therapy (BNCT) using intra-arterial administration of boron compounds was performed for recurrent head and cancer. Of the five patients treated, one achieved a complete response and four achieved a partial response. There was one case of transient headache but no severe adverse effects were observed. The advantages of using an intra-arterial administration route for BNCT, which causes the selective killing of tumour cells, might therefore shed new light on the treatment of recurrent head and neck malignancies. These promising results require further verification and optimization of the BNCT schedule; however, dose escalation would appear to be justified because the toxicity appears to be very low.

PMID: 18541628 [PubMed - as supplied by publisher]Parenteral dexamethasone for acute severe migraine headache: meta-analysis of randomised controlled trials for preventing recurrence. Related Articles

Parenteral dexamethasone for acute severe migraine headache: meta-analysis of randomised controlled trials for preventing recurrence.

BMJ. 2008 Jun 14;336(7657):1359-61

Authors: Colman I, Friedman BW, Brown MD, Innes GD, Grafstein E, Roberts TE, Rowe BH

OBJECTIVE: To examine the effectiveness of parenteral corticosteroids for the relief of acute severe migraine headache and prevention of recurrent headaches. DESIGN: Meta-analysis. DATA SOURCES: Electronic databases (Cochrane Central Register of Controlled Trials, Medline, Embase, LILACS, and CINAHL), conference proceedings, clinical practice guidelines, contacts with industry, and correspondence with authors. SELECTION CRITERIA: Randomised controlled trials in which corticosteroids (alone or combined with standard abortive therapy) were compared with placebo or any other standard treatment for acute migraine in adults. REVIEW METHODS: Two reviewers independently assessed relevance, inclusion, and study quality. Weighted mean differences and relative risks were calculated and are reported with 95% confidence intervals. RESULTS: From 666 potentially relevant abstracts, seven studies met the inclusion criteria. All included trials used standard abortive therapy and subsequently compared single dose parenteral dexamethasone with placebo, examining pain relief and recurrence of headache within 72 hours. Dexamethasone and placebo provided similar acute pain reduction (weighted mean difference 0.37, 95% confidence interval -0.20 to 0.94). Dexamethasone was, however, more effective than placebo in reducing recurrence rates (relative risk 0.74, 95% confidence interval 0.60 to 0.90). Side effect profiles between dexamethasone and placebo groups were similar. CONCLUSION: When added to standard abortive therapy for migraine headache, single dose parenteral dexamethasone is associated with a 26% relative reduction in headache recurrence (number needed to treat=9) within 72 hours.

PMID: 18541610 [PubMed - indexed for MEDLINE]Craniosacral therapy for migraine: protocol development for an exploratory controlled clinical trial. Related Articles

Craniosacral therapy for migraine: protocol development for an exploratory controlled clinical trial.

BMC Complement Altern Med. 2008;8:28

Authors: Mann JD, Faurot KR, Wilkinson L, Curtis P, Coeytaux RR, Suchindran C, Gaylord SA

BACKGROUND: Migraine affects approximately 20% of the population. Conventional care for migraine is suboptimal; overuse of medications for the treatment of episodic migraines is a risk factor for developing chronic daily headache. The study of non-pharmaceutical approaches for prevention of migraine headaches is therefore warranted. Craniosacral therapy (CST) is a popular non-pharmacological approach to the treatment or prevention of migraine headaches for which there is limited evidence of safety and efficacy. In this paper, we describe an ongoing feasibility study to assess the safety and efficacy of CST in the treatment of migraine, using a rigorous and innovative randomized controlled study design involving low-strength static magnets (LSSM) as an attention control intervention. METHODS: The trial is designed to test the hypothesis that, compared to those receiving usual care plus a treatment with low-strength static magnets (attention-control complementary therapy), subjects receiving usual medical care plus CST will demonstrate significant improvement in: quality-of-life as measured by the Headache Impact Test (HIT-6); reduced frequency of migraine; and a perception of clinical benefit. Criteria for inclusion are either gender, age > 11, English or Spanish speaking, meeting the International Classification of Headache Disorders (ICHD) criteria for migraine with or without aura, a headache frequency of 5 to 15 per month over at least two years. After an 8 week baseline phase, eligible subjects are randomized to either CST or an attention control intervention, low strength static magnets (LSSM). To evaluate possible therapist bias, videotaped encounters are analyzed to assess for any systematic group differences in interactions with subjects. RESULTS: 169 individuals have been screened for eligibility, of which 109 were eligible for the study. Five did not qualify during the baseline phase because of inadequate headache frequency. Nineteen have withdrawn from the study after giving consent. CONCLUSION: This report endorses the feasibility of undertaking a rigorous randomized clinical trial of CST for migraine using a standardized CST protocol and an innovative control protocol developed for the study. Subjects are able and willing to complete detailed headache diaries during an 8-week baseline period, with few dropouts during the study period, indicating the acceptability of both interventions. TRIAL REGISTRATION: ClinicalTrials.gov NCT00665236.

PMID: 18541041 [PubMed - indexed for MEDLINE][Case of posterior reversible encephalopathy syndrome with cerebral vasoconstriction] Related Articles

[Case of posterior reversible encephalopathy syndrome with cerebral vasoconstriction]

Rinsho Shinkeigaku. 2008 May;48(5):355-8

Authors: Koga Y, Isobe N, Tateishi T, Osoegawa M, Ohyagi Y, Kira J

A 56-year-old woman attended our hospital because of acute severe (thunderclap) headache. Neurological examination was normal and no abnormality was found on head CT or by cerebrospinal fluid examination. A few days later, she experienced a recurrence and suffered a seizure in her left upper and lower extremities. On neurological examination, she had conjugate deviation of the eyes toward the right side and left lower limb paralysis with Chaddock sign. MRI showed multiple hyperintense lesions in the bilateral occipital and parietal lobes, predominantly in the subcortical white matter at the right side on T2-weighted and FLAIR images. We diagnosed posterior reversible encephalopathy syndrome (PRES) because the ADC map showed a vasogenic edema pattern (increased ADC values in the hypodense lesions on diffusion-weighted image). Her blood pressure was normal and there were no underling diseases. As MRA showed vasoconstriction especially in bilateral posterior cerebral arteries, we initiated a therapy with a Ca-channel blocker. On follow-up MRI, the hyperintense lesions on T2-weighted and FLAIR images had almost disappeared, and vasoconstriction was also improved on MRA. This case suggested that cerebral vasoconstriction could underlie both thunderclap headache and PRES.

PMID: 18540385 [PubMed - indexed for MEDLINE]Comparative cross-over study of sildenafil and apomorphine for treating erectile dysfunction. Related Articles

Comparative cross-over study of sildenafil and apomorphine for treating erectile dysfunction.

BJU Int. 2008 Jun 4;

Authors: Afif-Abdo J, Teloken C, Damião R, Koff W, Wroclawski E, Yamasaki R, Torres LO, Sabaneeff J, Faria G, Pompeo AC, Cortado P, Glina S

OBJECTIVE To compare the effectiveness, safety and tolerability of sildenafil and apomorphine in Brazilian patients with erectile dysfunction (ED) of various causes. PATIENTS AND METHODS In all, 108 patients (mean age 55 years, sd 11) and documented ED for >/=6 months were included in 12 centres in Brazil. The patients were initially followed for 2 weeks and then randomized to initial treatment with apomorphine or sildenafil, taken before sexual intercourse, no more than once a day. The initial dose (2 mg apomorphine and 50 mg sildenafil) could be adjusted (to 3 mg apomorphine, or to 25 or 100 mg for sildenafil) depending on the effectiveness and tolerability during the first 4 weeks of treatment. The patients were re-evaluated after 8 weeks on treatment and, after a wash-out period of 2 weeks (no treatment), received the other study drug (other than that received in the first phase), and then had the same procedures as in the first phase. RESULTS In all, 97 patients were evaluated for therapeutic effectiveness, the overall effectiveness being assessed using two questions; sildenafil had a significantly higher proportion of affirmative answers for both (P < 0.001). Likewise, the estimates for the mean (sd) proportion of successful sexual intercourse, of 83.3 (4.7)% vs 40.3 (4.7)% and the total ED Inventory of Treatment Satisfaction score, of 86.7 (2.9) vs 56.9 (2.9) (P < 0.001) were higher for sildenafil. At the end of the study, 93.8% of the patients randomized to initial therapy with apomorphine declared a preference for sildenafil, and 81.3% of those initially treated with sildenafil declared a preference for that drug. The two drugs were well tolerated, and the main adverse events for apomorphine were nausea, vomiting, headache, taste perversion and dizziness; for sildenafil they were headache, flushing or vasodilatation, abdominal pain or dyspepsia and nasal congestion. CONCLUSIONS Sildenafil is more effective than apomorphine for treating ED, in the domains of erectile function, satisfaction with sexual intercourse and overall satisfaction, and was the drug preferred by most of the patients.

PMID: 18537952 [PubMed - as supplied by publisher]Central nervous system involvement in pediatric rheumatic diseases: current concepts in treatment. Related Articles

Central nervous system involvement in pediatric rheumatic diseases: current concepts in treatment.

Curr Pharm Des. 2008;14(13):1295-301

Authors: Duzova A, Bakkaloglu A

Central nervous system (CNS) manifestations are not rare in pediatric rheumatic diseases. They may be a relatively common feature of the disease, as in systemic lupus erythematosus (SLE) and Behçet's disease. Direct CNS involvement of a systemic rheumatic disease, primary CNS vasculitis, indirect involvement secondary to hypertension, hypoxia and metabolic changes, and drug associated adverse events may all result in CNS involvement. We have reviewed the CNS manifestations of SLE, Behçet's disease, Henoch-Schönlein purpura, polyarteritis nodosa, juvenile idiopathic arthritis, juvenile ankylosing spondylitis, familial Mediterranean fever, scleroderma, sarcoidosis, Wegener's granulomatosis, Takayasu's arteritis, CINCA syndrome, Kawasaki disease, and primary CNS vasculitis; and adverse CNS effects of anti-rheumatic drugs in pediatric patients. The manifestations are diverse; ranging from headache, seizures, chorea, changes in personality, depression, memory and concentration problems, cognitive impairment, cerebrovascular accidents to coma, and death. The value of cerebrospinal fluid (CSF) examination (pleocytosis, high level of protein), auto-antibodies in serum and CSF, electroencephalography, neuroimaging with computerized tomography, magnetic resonance imaging, SPECT, PET, and angiography depends on the disease. Brain biopsy is gold standard for the diagnosis of CNS vasculitis, however it may be inconclusive in 25% of cases. A thorough knowledge of the rheumatic diseases and therapy-related adverse events is mandatory for the management of a patient with rheumatic disease and CNS involvement. Severe CNS involvement is associated with poor prognosis, and high mortality rate. High dose steroid and cyclophosphamide (oral or intravenous) are first choice drugs in the treatment; plasmapheresis, IVIG, thalidomide, and intratechal treatment may be valuable in treatment-resistant, and serious cases.

PMID: 18537653 [PubMed - indexed for MEDLINE]Menstrual-related pain conditions: dysmenorrhea and migraine. Related Articles

Menstrual-related pain conditions: dysmenorrhea and migraine.

J Womens Health (Larchmt). 2008 Jun;17(5):879-91

Authors: Mannix LK

Menstrual disorders affect millions of women in the United States and represent an important health burden. The most common menstrual disorders are dysmenorrhea and headache; these conditions are leading causes of work or school absenteeism and substantially impact quality of life. Headache associated with menses is often migraine and referred to as menstrual migraine. Although the pathogenesis of menstrual-related pain conditions is not fully understood, menstrual-related overproduction of prostaglandins is implicated in the pathophysiology of both menstrual migraine and dysmenorrhea. In clinical practice, nonsteroidal anti-inflammatory drugs (NSAIDs) are considered the first-line therapeutic option for managing pain associated with dysmenorrhea. NSAIDs also play a role in the acute treatment and intermittent prophylaxis of migraine. Triptans, a class of highly selective serotonin receptor agonists, represent the gold standard for acute treatment of migraine. In addition, hormone therapy is effective in many cases for treating dysmenorrhea and may be beneficial in the management of menstrual migraine. Thus, overlapping treatment regimens may be advantageous in treating the coexisting menstrual-related pain conditions of dysmenorrhea and migraine.

PMID: 18537489 [PubMed - in process]Prochlorperazine vs. Promethazine for Headache Treatment in the Emergency Department: A Randomized Controlled Trial. Related Articles

Prochlorperazine vs. Promethazine for Headache Treatment in the Emergency Department: A Randomized Controlled Trial.

J Emerg Med. 2008 Jun 4;

Authors: Callan JE, Kostic MA, Bachrach EA, Rieg TS

Headache is a very common medical complaint. Four to six percent of the population will have a debilitating headache in their lifetime; and 1-2% of all Emergency Department (ED) visits involve patients with headaches. Although promethazine is used frequently, it has never been studied as a single-agent treatment in undifferentiated headache. We hypothesized that promethazine would be superior to prochlorperazine in the treatment of headache. We conducted a prospective, double-blinded, randomized, controlled trial on patients presenting to our ED between May and August 2005 with a chief complaint of headache. Each subject was randomized to receive either intravenous promethazine 25 mg or prochlorperazine 10 mg, and graded the intensity of their headache on serial 100-mm visual analog scales (VAS). Patients with dystonic reactions or akathesia were treated with diphenhydramine. Adequate pain relief was defined as an absolute decrease in VAS score of 25 mm. After discharge from the ED, patients were queried regarding the recurrence of headache symptoms, the need for additional pain medications, and the occurrence of any side effects since discharge. Thirty-five patients were enrolled in each group. Both drugs were shown to be effective in treatment of headaches. Prochlorperazine provided a faster rate of pain resolution and less drowsiness when compared to promethazine. Both medications were individually effective as abortive therapy for headache. Prochlorperazine was superior to promethazine in the rate of headache reduction and rate of home drowsiness, with similar rates of akathesia, nausea resolution, patient satisfaction, and headache recurrence within 5 days of discharge.

PMID: 18534808 [PubMed - as supplied by publisher]

Go to our headache forum