Cerebral blood flow is not coupled to neuronal activity during stimulation of the facial nerve vasodilator system

There is a considerable body of evidence to suggest that activation of vasodilator fibers in the parasympathetic facial (VIIn) nerve can increase cerebral blood flow. The changes seen with VIIn stimulation raise the question as to whether they occur independent or in parallel with changes in cerebral metabolism. In these studies cerebral cortical perfusion was monitored continuously using laser Doppler flowmetry (CBFLDF) in the alpha-chloralose anesthetised cat. Cell firing in the region underlying the laser Doppler probe was monitored using tungsten-in-glass microelectrodes whose signals were amplified and filtered, and then monitored on-line by a microcomputer. Thus measures of both blood flow and local functional activity could be obtained that were continuous and contemporaneous. The VIIn was electrically stimulated through a craniotomy after isolation from the brainstem. CBFLDF and cell firing were monitored during several physiological manoeuvres. Hypercapnia produced the expected increase in CBFLDF that was brisk and stimulus locked. Cell firing did not alter except for a brief increase that was seen at the initiation of the hypercapnia and not maintained. The CBFLDF signal autoregulated to a level of 50-60 mmHg with no change in cellular activity. To determine if classical dynamic flow/metabolism coupling was present bicuculline, a GABAA receptor antagonist was superfused over the cortex. This led to increases in both CBFLDF and cell firing that were tightly and clearly linked. Stimulation of the VIIn led to a marked increase in the CBFLDF signal (47 +/- 7%) that was not accompanied by changes in cell firing.(ABSTRACT TRUNCATED AT 250 WORDS)

Human in vivo evidence for trigeminovascular activation in cluster headache. Neuropeptide changes and effects of acute attacks therapies

Cluster headache is a rare very severe disorder that is clinically well characterized with a relatively poorly understood pathophysiology. In this study patients with episodic cluster headache fulfilling the criteria of the International Headache Society were examined during an acute spontaneous attack of headache to determine the local cranial release of neuropeptides. Blood was sampled from the external jugular vein ipsilateral to the pain before and after treatment of the attack. Samples were assayed for calcitonin gene-related peptide (CGRP), vasoactive intestinal polypeptide (VIP), substance P and neuropeptide Y. Attacks were treated with either oxygen inhalation, sumatriptan or an opiate. Thirteen patients were studied of whom 10 were male and three female. All had well-established typical attacks of cluster headache when blood was sampled. During the attacks external jugular vein blood levels of CGRP and VIP were raised while there was no change in neuropeptide Y or substance P. Calcitonin gene-related peptide levels rose to 110 +/- 7 pmol/l (normal: < 40) while VIP levels rose to 20 +/- 3 pmol/l (normal: < 7). Treatment with both oxygen and subcutaneous sumatriptan reduced the CGRP level to normal, while opiate administration did not alter the peptide levels. These data demonstrate for the first time in vivo human evidence for activation of the trigeminovascular system and the cranial parasympathetic nervous system in an acute attack of cluster headache. Furthermore, it is shown that both oxygen and sumatriptan abort the attacks and terminate activity in the trigeminovascular system.

Deficits in the function of small and large afferent fibers in confirmed cases of carpal tunnel syndrome

Nerve conduction studies and measurements of thermal thresholds (hot and cold) were performed in 25 healthy control subjects and 24 patients with carpal tunnel syndrome: first, to compare the extent of abnormality demonstrable in the function of large and small afferent axons; second, to correlate these abnormalities with clinical severity; and third, to validate a modified form of palmar stimulation as an additional neurophysiological test in suspected carpal tunnel syndrome. The routine nerve conduction studies compared the amplitudes and conduction velocities from digit II and digit V to wrist and for the digit-II potential between wrist and elbow. With palmar stimulation, the palm-to-wrist segment was compared to the simultaneously evoked antidromic digital potential (palm-to-index). Thermal threshold testing involved determination of hot and cold thresholds for digit II and digit V using an automated forced-choice procedure. In the patients there was selective slowing of conduction across the palm-to-wrist segment with normal velocities distally and proximally, and there was clear evidence of abnormal small-fiber function, with higher thresholds for both hot and cold sensation. However, the thermal abnormalities also involved the ulnar territory, equally so for cold threshold but significantly less so for hot threshold. Thermal threshold testing confirmed the clinical impression that small-fiber dysfunction is important in carpal tunnel syndrome, but the abnormal findings for the ulnar-innervated digit V suggest that this test will not be routinely useful for the early detection of compression or entrapment neuropathies.

Plasma neuropeptide Y in the symptomatic limb of patients with causalgic pain

The aim of this experiment was to measure the concentration of neuropeptide Y (NPY), a vasoactive transmitter which co-exists with noradrenaline in sympathetic nerve terminals, in venous blood taken from the painful and contralateral limbs of 16 patients with features of reflex sympathetic dystrophy (RSD) or causalgia. In nine patients tapping the skin of the affected limb provoked pain (allodynia). In seven of the nine patients with allodynia the concentration of NPY was lower on the painful side; similar results were obtained in only two of seven patients without widespread allodynia. In addition, the concentration of NPY was generally lower in the painful limb if it was warmer than the contralateral limb. These findings suggest that a reduction in sympathetic activity might accompany allodynia and influence vasomotor disturbances in patients with causalgic pain.

Lignocaine and headache: an electrophysiological study in the cat with supporting clinical observations in man

Chronic daily headache (CDH) is a particularly difficult type of headache to manage, with an uncertain pathophysiology. Intravenous administration of lignocaine has been suggested as a possibly useful option in the control of this syndrome. We have surveyed prospectively patients with CDH (selected for this study as those with 6 or more months of continuous pain with at least weekly exacerbations that, taken in isolation, would fulfil International Headache Society diagnostic criteria for migraine without aura). Intravenous lignocaine (2 mg/min) by infusion over a 2-day period rendered 26% of patients pain free, with a further 42% having at least a 50% improvement in the pain. Continued benefit was associated with commencement of prophylaxis with a tricyclic antidepressant or monoamine oxidase inhibitor after completion of the lignocaine infusion. In an animal model of craniovascular nociception, using electrical stimulation of the superior sagittal sinus and recording of single unit activity and sensory evoked potentials in the spinal trigeminal nucleus in the upper cervical spinal cord of the anaesthetised cat, the effect of lignocaine was examined. Lignocaine reduced both the probability of cell firing and the size of the trigeminal evoked potential in the animals studied. The reduction was both substantial (more than 25% in each case) and dose-dependent. Taken together the data suggest that CDH is likely to be a disorder of central craniovascular nociceptive control and that lignocaine acts to interrupt a part of the pathway involved but is unlikely to act at the central generator of the disorder.

The clinical profile of sumatriptan: cluster headache

Cluster headache is a rare form of severe idiopathic headache characterized by unilateral short-lasting episodes of excruciating pain in association with autonomic disturbances. Subcutaneous sumatriptan has been investigated as an acute treatment for cluster headache in two randomized, double-blind, placebo-controlled, crossover trials. About 75% of patients given subcutaneous sumatriptan 6 mg reported headache relief within 15 min, in comparison with 26-35% given placebo (p < 0.001 in both studies). The need for rescue medication (100% oxygen by inhalation) at 15 min was significantly lower after sumatriptan treatment as were the severity of functional disability and incidence of non-headache symptoms. Results of a long-term study indicate that the tolerability and efficacy of sumatriptan 6 mg is maintained in long-term use, and that there is no evidence of tachyphylaxis.

Anti-migraine compounds fail to modulate the propagation of cortical spreading depression in the cat

Leao's cortical spreading depression (SD) is often cited as the pathophysiological substrate for the neurological symptoms of migraine with aura. If this is the case it might be expected that drugs useful as anti-migraine agents, particularly those useful in prophylaxis, may alter or prevent SD. Indeep it has been suggested that the anti-migraine compound dihydroergotamine (DHE) blocks or reduces the speed of propagation of SD in the rabbit. In this study we attempted to further investigate the effects of DHE and other anti-migraine drugs on SD by measuring cortical blood flow with laser Doppler flowmetry (CBFLDF) and cortical single unit activity in the alpha-chloralose-anaesthetised cat. The following substances were tested: DHE, acetylsalicylic acid, lignocaine, metoprolol, clonazepam and valproate. The NMDA-receptor blocker MK-801 and halothane (1.5%) were used as reference substances that reliably block SD. The outcome measures were speed of propagation of the wave of SD across the cortex and the CBFLDF increase during the hyperaemic phase of SD. Data were taken from three control episodes (60 min apart) and after drug administration. The rate of propagation was significantly reduced from the first control period (3.0 +/- 0.3 mm/min) to the subsequent 2 control observations (2.3 +/- 0.1 mm/min) even without any drug treatment. Following the control observations the test drug was administered and a further SD elicited. This fourth SD was reliably blocked by MK-801 and halothane. None of the other test drugs inhibited SD, reduced the rate of propagation or changed the amplitude of the CBFLDF increase.(ABSTRACT TRUNCATED AT 250 WORDS)

Expression of c-Fos-like immunoreactivity in the caudal medulla and upper cervical spinal cord following stimulation of the superior sagittal sinus in the cat

Migraine is an episodic vascular headache with a well-recognized clinical picture but a poorly understood pathogenesis. Stimulation of a pain-sensitive trigeminally innervated intracranial structure, the superior sagittal sinus (SSS), was undertaken to map the higher-order neurons potentially involved in the processing of vascular head pain. The animals were prepared for stimulation by exposure of the sinus and then maintained under alpha-chloralose anaesthesia for 24 h before SSS stimulation, perfusion and immunohistochemical processing for the detection of Fos protein. Examination of the medulla and upper cervical cord revealed marked increases in Fos-like immunoreactivity in laminae I and IIo of the trigeminal nucleus caudalis and the dorsal horn of the upper cervical spinal cord. In addition, Fos-like immunoreactivity was observed in lamina X of the upper cervical spinal cord, in the commissural and medial nuclei of the solitary tract and in the nucleus retroambigualis. The use of immunohistochemical detection of Fos has allowed visualization of several populations of neurons likely to be involved in the central neural processing of vascular headache syndromes, particularly migraine.

Intravenous acetylsalicylic acid inhibits central trigeminal neurons in the dorsal horn of the upper cervical spinal cord in the cat

Acetylsalicylic acid (ASA) is one of the most commonly used substances in the treatment of headache and other pain syndromes. It is only recently that its efficacy in the treatment of acute attacks and in the prophylaxis of migraine has been proven in clinical trials. Various peripheral and central mechanisms have been proposed for the analgesic effects of acetylsalicylic acid and its mode of action in migraine. The possible actions of acetylsalicylic acid in migraine include local analgesic effects, changes in cerebral serotonin turnover, modulation of antinociceptive neurons in the hypothalamus and inhibition of the release of algogenic peptides during neurogenic inflammation. In this study trigeminal somatosensory evoked potentials and single unit activity of central trigeminal neurons in the dorsolateral C2 spinal cord were monitored during electrical stimulation of the superior sagittal sinus in the cat. Intravenous administration of the soluble acetylsalicylic salt (acetylsalicylic lysinate, 30 mg/kg) reduced the peak-to-peak amplitudes of somatosensory evoked potentials from 219 +/- 11 mV by 18% after 45 minutes and by 26% after 60 minutes. Naloxone injection (0.5 mg/kg and 1.5 mg/kg) did not reverse the inhibition caused by ASA. The probability of trigeminal cell tiring was reduced in 63% percent of the monitored single units. The effect was not mediated through naloxone-sensitive opioid receptors and was independent from ASA-induced peripheral blockade of neuropeptides during neurogenic inflammation. The non-steroidal anti-inflammatory agent ketorolac (0.4 mg/kg, IVI) a new cyclooxygenase inhibitor, also reduced the somatosensory evoked potentials by 30% following the same time course.(ABSTRACT TRUNCATED AT 250 WORDS)

Inhibition by sumatriptan of central trigeminal neurones only after blood-brain barrier disruption

1. The 5-hydroxytryptamine (5-HT1)-like agonist, sumatriptan, is highly efficient in the relief of migraine headache and its accompanying symptoms. 2. Experimental evidence has indicated that its site of action may be on the cranial vessels or on the trigeminal innervation of the cranium, or both, since sumatriptan does not pass the blood-brain barrier easily under normal circumstances. It is, however, not clear whether the blood-brain barrier is normal or abnormal during a migraine attack. 3. In this study, single unit activity and trigeminal somatosensory evoked potentials in central trigeminal neurones were monitored during electrical stimulation of the superior sagittal sinus. 4. Intravenous administration of sumatriptan (100 micrograms kg-1) did not alter trigeminal evoked activity unless the permeability of the blood-brain barrier had been increased by infusion of an hyperosmolar mannitol solution. After blood-brain barrier disruption, sumatriptan decreased the peak-to-peak amplitude of evoked potentials by 40 +/- 6% and the probability of firing of single units by 30 +/- 9%. Mannitol infusions alone in control animals caused no changes in evoked potentials or single unit activity. 5. The data suggest that in normal circumstances sumatriptan does not have sufficient access to trigeminal neurons to alter their function.

Noncholinergic, nonadrenergic cortical vasodilatation elicited by thalamic centromedian-parafascicular complex

The centromedian-parafascicular complex (CMPf) of the intralaminar thalamus was stimulated in anesthetized, ventilated rats, and cerebral cortical perfusion was continuously measured using laser Doppler flowmetry. Stimulation led to a frequency- and intensity-dependent increase in cortical perfusion (vasodilatation). The maximum response was seen at a rate of 200/s, and studied at 150 microA, was a 120 +/- 27% (n = 6) increase in flow. The mean time from the initiation of stimulation to a change in the cerebral blood flow measured by laser Doppler flowmeter signal was 800 +/- 100 ms (n = 13). The response to electrical stimulation was not blocked after high spinal cord section. Chemical stimulation of the CMPf neurons by microinjection of carbachol led to a 98 +/- 15% (n = 4) increase in flow. The response to electrical stimulation was not blocked by the muscarinic antagonist scopolamine (1 mg/kg) or by the nicotinic antagonist mecamylamine (4 mg/kg). It was also unaffected by the beta-adrenoceptor antagonist propranolol (1.5 mg/kg). These data add to understanding of the CMPf cerebral vasodilator response by demonstrating a robust stimulus-locked change in cortical perfusion that does not involve a cholinergic or adrenergic mechanism. It is also shown to be frequency and intensity dependent, consistent with a functioning physiological system, and has a rapid onset consistent with a primarily neurally mediated phenomenon. Furthermore, it is elicited by pathways that may possibly be entirely within the central nervous system and is due to activation of cell bodies within the region.

Inhibition of calcitonin gene-related peptide by h-CGRP(8-37) antagonizes the cerebral dilator response from nasociliary nerve stimulation in the cat

The head is innervated by neurons with cell bodies in the trigeminal ganglion that contain both calcitonin gene-related peptide (CGRP) and substance P. The CGRP-containing neurons preferentially innervate the cerebral vessels and when activated produce both an increase in blood flow and local release of CGRP. In this study, the CGRP antagonist h-CGRP(8-37) was examined for its ability to interfere with trigeminal-evoked cerebral vasodilator responses in the alpha-chloralose anaesthetised cat. Nasociliary nerve stimulation produced a characteristic frequency-dependent increase in cerebral cortical blood flow with a mean maximum of 35 +/- 7% at 20 Hz. Following administration of h-CGRP(8-37), this response was reduced by half with a general shift to the right of the frequency-response curve. These data further support the view that CGRP is an important transmitter agent in the trigeminovascular system that is responsible for a great part of the vasodilator capacity of trigeminal neurons.

PACAP, a VIP-like peptide: immunohistochemical localization and effect upon cat pial arteries and cerebral blood flow

Pituitary adenylate cyclase activating peptide (PACAP) is a vasoactive intestinal polypeptide (VIP)-like peptide recently isolated from ovine hypothalami. Nerve fibers containing PACAP immunoreactivity were present in the adventitia and the adventitia-media border of cat cerebral arteries. Double immunostaining revealed that PACAP-immunoreactive nerve fibers constituted a subpopulation of the VIP-containing fibers. PACAP effected a concentration-dependent relaxation of feline middle cerebral arteries that had been precontracted with prostaglandin F2 alpha. The maximum relaxation, 24 and 34% of precontraction, was achieved with PACAP-38 and PACAP-27, respectively, at a concentration of 10(-6) M. In cats anesthetized with alpha-chloralose, intracerebral microinjection of PACAP effected a moderate increase in cerebral blood flow. The maximal increase (18.6 +/- 6%) was observed following the injection of 5 micrograms PACAP.

Examination of the involvement of neuropeptide Y (NPY) in cerebral autoregulation using the novel NPY antagonist PP56

The contribution of neurotransmitters known to be present in the cervical sympathetic nervous system to cerebral autoregulation was evaluated in the anaesthetised cat using a continuous measurement of cerebral cortical perfusion with laser Doppler flowmetry and an in vitro pial vessel preparation. Autoregulation was tested by venesection and fluid administration to achieve changes in blood pressure from -40% of resting control levels to +80% and flow was monitored. Between -20% and +50% there was no significant alteration in cortical blood flow with perfusion following blood pressure passively outside these ranges. The non-competitive neuropeptide Y antagonist PP56 shifted the level at which the change in flow was passively dependent on blood pressure from +60% to +38%. The pial vessel study demonstrated that PP56 shifted the dose-response curve for the vasoconstrictor effect of NPY with a maximal reduction of 22 +/- 6%. These data suggest that the cervical sympathetic nerves with NPY play an active role in cerebral autoregulation. Furthermore in view of the longer time course of action of neuropeptide Y, it is an ideal transmitter candidate to be involved in cerebral autoregulation and any compound that blocks its action must be considered to potentially alter the normal cerebrovascular physiology.

The trigeminovascular system and migraine: studies characterizing cerebrovascular and neuropeptide changes seen in humans and cats

Both clinical and physiological consideration of migraine suggests that the pathophysiology of the syndrome is intimately linked to the trigeminal innervation of the cranial vessels, the trigeminovascular system. Studies were conducted in cats and humans to examine the interaction of these systems with the effective acute antimigraine drugs dihydroergotamine and sumatriptan. In the animal studies cats were anesthetized and prepared for routine physiological monitoring as well as for blood sampling from the external jugular veins. Cerebral blood flow was monitored continuously using laser Doppler flowmetry and the effect of trigeminal ganglion stimulation on both cerebral blood flow and jugular vein peptide levels determined prior to and after administration of either sumatriptan or dihydroergotamine. Stimulation of the trigeminal ganglion led to a frequency-dependent increase in cerebral blood flow, with a mean maximum of 43 +/- 9% at a stimulus frequency of 20 per second. There was a marked reduction in these responses by some 50% after administration of either sumatriptan or dihydroergotamine. Trigeminal ganglion stimulation at a frequency of 5 per second also led to a release into the cranial circulation of calcitonin gene-related peptide (CGRP), with the level rising from 67 +/- 3 to 82 +/- 5 pmol/liter on the side of stimulation. These increases were also markedly antagonized by both sumatriptan and dihydroergotamine. Human studies were conducted as part of the overall evaluation of sumatriptan for the treatment of acute migraine. In 7 of 8 patients responding to subcutaneous sumatriptan administration, elevated CGRP levels (60 +/- 8 pmol/liter) were normalized, with the headache being relieved (40 +/- 8 pmol/liter).(ABSTRACT TRUNCATED AT 250 WORDS)

Nitric oxide synthesis couples cerebral blood flow and metabolism

The most fundamental aspect of the cerebral circulation is the well-described coupling of cerebral metabolic activity and cerebral blood flow. A number of substances have been proposed to link flow and metabolism, including K+, pH and adenosine. In the alpha-chloralose anaesthetised cat we studied simultaneously cerebral neuronal activity and local blood flow to attempt to dissociate the two and thus determine the coupling substance. Neuronal activity was determined by monitoring unit firing in the parietal cortex with tungsten in glass microelectrodes while local cerebral blood flow in the same area was monitored continuously using laser Doppler flowmetry. To initiate an increase in metabolic activity and, pari passu, blood flow spreading depression was elicited by needle stick injury. Spreading depression when initiated causes a wave of depolarization, measured as an increased firing rate and associated marked (400 +/- 95%) increase in local cerebral blood flow. Intravenous administration of NG-nitro-L-arginine methyl ester (1-NAME), a potent nitric oxide synthase inhibitor, produced a complete blockade of the hyperemia associated with spreading depression but no change in either resting cell firing or spreading depression-evoked increases in firing rate. These data demonstrate at least for spreading depression-elicited increases in metabolic activity, that nitric oxide (NO) is a key coupling compound that links changes in cerebral blood flow and metabolism. These data imply that NO may have a more general role in flow/metabolism coupling and further studies in other situations are required to determine the extent to which NO is responsible for this fundamental cerebrovascular phenomenon.

The oligemic phase of cortical spreading depression is not blocked by tirilazad mesylate (U-74006F)

Cortical spreading depression is characterised by a wave of depolarization that moves across the cortex leaving in its wake a state of hyperpolarization. Characteristic changes in cerebral blood flow are also seen and these consist of a wave of hyperemia followed by an oligemia, the latter lasting some hours in some experimental animals including the cat. In this study cerebral blood flow was measured using laser Doppler flowmetry in the anesthetised ventilated cat. Spreading depression was initiated with a pin-prick injury prior to or following administration of U74006F (tirilizad mesylate; 3 mg/kg, ivi) or an identical volume of vehicle. Laser Doppler probes were placed bilaterally and in each case studied both the hyperemic and oligemic phases of spreading depression were preserved after administration of either U74006F or its vehicle. These data suggest that free radical mechanisms have no significant role in mediating the blood flow changes of spreading depression and are consistent with data in the literature of a quantitative using single-point measurements that again U74006F does not affect spreading depression.

Cocaine abuse simulating the aura of migraine

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Activation of the trigeminovascular system by mechanical distension of the superior sagittal sinus in the cat

Distension of dural sinuses in man produces migraine-like pain. In eight alpha-chloralose anaesthetized cats mechanical distension of the superior sagittal sinus with a small intraluminal device was used to activate single units in the dorsolateral C2 spinal cord. Units in this region have been shown to respond to electrical stimulation of the superior sagittal sinus in the cat model. Linked responses to mechanical dilatation could only be obtained with very rapid stretching stimuli or high amplitudes of distension of the vessel. Lower thresholds for transduction of distension in the vessel wall may depend on transferral to the dura or biochemical or neural pre-sensitization of the superior sagittal sinus. These data are consistent with the view that migraine is not primarily a vascular disorder but requires at least humoral or neural facilitation.

Subcortical cerebral blood flow and metabolic changes elicited by cortical spreading depression in rat

Changes in cerebral cortical perfusion (CBFLDF), local cerebral blood flow (lCBF) and local cerebral glucose utilization (lCGU) elicited by unilateral cortical spreading depression (SD) were monitored and measured in separate groups of rats anesthetized with alpha-chloralose. CBFLDF was recorded with laser Doppler flowmetry, while lCBF and lCGU were measured by the quantitative autoradiographic [14C]iodoantipyrine and [14C]-2-deoxyglucose methods, respectively. SD elicited a wave of hyperemia after a latency of 2 to 3 min followed by an oligemic phase. Ninety minutes following the onset of SD cortical (frontal, parietal and occipital) lCBF and lCGU were essentially the same as on the contralateral side and in sham-treated rats. However, alteration in the lCBF and lCGU in upper and lower brainstem persisted. The present results demonstrate, for the first time, that long-lasting cerebrovascular and metabolic alterations take place within the subcortical regions following SD. These regions provide an attractive site to integrate observations in man concerning spreading depression and the aura of migraine with the other features of the syndrome.

Cutaneous sensory stimulation leading to facial flushing and release of calcitonin gene-related peptide

A patient is described with a 17-year history of intractable left-sided facial pain. The pain occurred daily in 5 sec spasms to a maximum of one every 2-3 min and was restricted to the left upper face. It was associated with rhinorrhoea on the left and often with ipsilateral facial flushing. Conventional therapy, including carbamazepine, baclofen and three posterior fossa explorations, had not provided lasting relief. Local facial stimulation by tapping a painful trigger point led to both pain and flushing of the face ipsilaterally. During this flushing, blood was collected and assayed using sensitive radioimmunoassays for several neuropeptides (neuropeptide Y, substance P, vasoactive intestinal polypeptide and calcitonin gene-related peptide). A marked (119%) increase in calcitonin gene-related peptide was noted in the external jugular vein blood ipsilaterally during the flushing with no change in the other peptides measured. To quantitate the effect of calcitonin gene-related peptide on human extracranial vessels, standard pharmacological procedures were used to examine the potency of the peptide as a vasodilator of human facial artery. The IC50 of calcitonin gene-related peptide for the prostaglandin F2 alpha-precontracted human facial artery was 10(-9) mol/l. The relevance of these observations to the clinical problem of migraine is considered.

The hospital management of severe migrainous headache

In a two year period, 47 patients with migraine were hospitalized for the management of severe headache; 18 had acute migraine (duration less than 72 hours), 17 had status migrainosus (duration by definition more than 72 hours), and 12 had chronic daily headaches qualitatively of a migraine type. Treatment in all comprised cessation of all previous medication, plus one of the following: intravenous DHE, intravenous lidocaine, a combination of lidocaine + DHE, or subcutaneous sumatriptan. Improvement from DHE, lidocaine, or both was slow and often incomplete. Sumatriptan was not used in patients with chronic daily headaches; in the 8 cases of acute migraine or status migrainosus in which it was used, improvement was rapid and complete in seven.