New appendix criteria open for a broader concept of chronic migraine

After the introduction of chronic migraine and medication overuse headache as diagnostic entities in The International Classification of Headache Disorders, Second Edition, ICHD-2, it has been shown that very few patients fit into the diagnostic criteria for chronic migraine (CM). The system of being able to use CM and the medication overuse headache (MOH) diagnosis only after discontinuation of overuse has proven highly unpractical and new data have suggested a much more liberal use of these diagnoses. The International Headache Classification Committee has, therefore, worked out the more inclusive criteria for CM and MOH presented in this paper. These criteria are included in the appendix of ICHD-2 and are meant primarily for further scientific evaluation but may be used already now for inclusion into drug trials, etc. It is now recommended that the MOH diagnosis should no longer request improvement after discontinuation of medication overuse but should be given to patients if they have a primary headache plus ongoing medication overuse. The latter is defined as previously, i.e. 10 days or more of intake of triptans, ergot alkaloids mixed analgesics or opioids and 15 days or more of analgesics/NSAIDs or the combined use of more than one substance. If these new criteria for CM and MOH prove useful in future testing, the plan is to include them in a future revised version of ICHD-2.

Growth hormone receptor mRNA expression in non-functioning and somatotroph pituitary adenomas: implications for growth hormone substitution therapy?

The use of growth hormone (GH) in patients with GH deficiency induced by pituitary adenoma is widely accepted, but the safety of this mitogenic hormone, particularly in patients with residual tumor after neurosurgery, continues to be a concern. Since the mitogenic potency of GH is dependent upon the presence of the GH receptor (GH-R) and the subsequent IGF-1/IGF receptor (IGF-1-R) system we investigated the expression of the members of the growth hormone cascade in endocrine inactive and GH-producing pituitary adenomas. Tissue specimens of 18 clinically non-functioning pituitary adenomas and 6 GH-producing adenomas were collected following transsphenoidal surgery while normal cadaver pituitary glands served as controls. After RNA extraction, semi-quantitative RT-PCR amplification with specific primers for GH, GH-R, IGF-1 and IGF-1-R was performed. Applying this sensitive RT-PCR based approach, GH-R expression was demonstrated in all normal pituitaries, most inactive adenomas (94%), and the majority of GH-producing adenomas (66%). Both IGF-1 and IGF-1-R mRNA was detectable in the majority of inactive (72% and 77%, respectively) and somatotrophic adenomas (83% and 83%). While IGF-1-R mRNA was expressed in all normal pituitary specimen studied, IGF-1 was detectable in only 55% of them. In summary, expression of members of the GH-IGF-1 cascade could be demonstrated in a substantial subset of patients with non-functioning and GH-producing pituitary adenomas. These factors might serve as a substrate for the transduction of mitogenic effects of GH on remnant pituitary tumors during GH replacement therapy. Therefore, GH therapy should be carefully considered and patients on GH therapy kept under close observation.

Non pharmaceutical treatments for migraine

The target of non-drug treatment of migraine is to reduce attack frequency and intensity. To reach this goal, the general relationship between the patient and the physician, i.e. the drug consumer and prescriber, has to be changed fundamentally. To understand migraine attacks the patient must learn to distinguish between the cause of migraine, a special readiness of the brain to react, and the triggers of a headache attack. Today, we have access to effective methods that prevent inherited migraine from coming to an effect, or to effectively arrest an attack if it has nevertheless broken out. There are three available strategies: prevention by avoiding trigger factors, prevention via reduction of attack readiness and treatment of the acute effects of the migraine attack.

Petasites hybridus root (butterbur) is an effective preventive treatment for migraine

Objective: To evaluate the clinical efficacy of a standardized special root extract from the plant Petasites hybridus as a preventive therapy for migraine.

Methods: This is a three-arm, parallel-group, randomized trial comparing Petasites extract 75 mg bid, Petasites extract 50 mg bid, or placebo bid in 245 patients with migraine. Eligible patients met International Headache Society criteria for migraine, were ages 18 to 65, and had at least two to six attacks per month over the preceding 3 months. The main outcome measure was the decrease in migraine attack frequency per month calculated as percentage change from baseline over a 4-month treatment period.

Results: Over 4 months of treatment, in the per-protocol analysis, migraine attack frequency was reduced by 48% for Petasites extract 75 mg bid (p = 0.0012 vs placebo), 36% for Petasites extract 50 mg bid (p = 0.127 vs placebo), and 26% for the placebo group. The proportion of patients with a ≥50% reduction in attack frequency after 4 months was 68% for patients in the Petasites extract 75-mg arm and 49% for the placebo arm (p < 0.05). Results were also significant in favor of Petasites 75 mg at 1, 2, and 3 months based on this endpoint. The most frequently reported adverse reactions considered possibly related to treatment were mild gastrointestinal events, predominantly burping.

Conclusions:Petasites extract 75 mg bid is more effective than placebo and is well tolerated as a preventive therapy for migraine. Petasites 50 mg PO bid was not significantly more effective than placebo on the primary study endpoints.

Variability of familial hemiplegic migraine with novel A1A2 Na+/K+-ATPase variants

A1A2 Na+/K+-ATPase mutations cause familial hemiplegic migraine type 2 (FHM2). The authors identified three putative A1A2 mutations (D718N, R763H, P979L) and three that await validation (P796R, E902K, X1021R). Ten to 20% of FHM cases may be FHM2. A1A2 mutations have a penetrance of about 87%. D718N causes frequent, long-lasting HM, and P979L may cause recurrent coma. D718N and P979L may predispose to seizures and mental retardation. A1A2 does not play a major role in sporadic HM; only one variant, R383H, occurred in 1 of 24 cases.

Efficacy of 1,000 mg Effervescent Acetylsalicylic Acid and Sumatriptan in Treating Associated Migraine Symptoms

Recently a new effervescent acetylsalicylic acid (ASA) tablet with high buffering capacity has been developed. In this double-blind, 3-arm, multicenter, parallel-group study, 433 patients were treated either with 1,000 mg effervescent ASA or 50 mg encapsulated sumatriptan or placebo. The primary endpoint was the percentage of patients with complete remission of the 3 accompanying symptoms nausea, photophobia and phonophobia within 2 h after intake of the study drug. 43.8% of patients treated with ASA, 43.7% of patients treated with sumatriptan and 30.9% of patients treated with placebo showed complete remission of all 3 accompanying symptoms (p < 0.05 for ASA and sumatriptan vs. placebo). Both active treatments were superior to placebo regarding the individual symptoms photophobia and phonophobia, but not for nausea. The percentage of patients with reduction in headache severity from moderate or severe to mild or no pain (secondary objective) was 49.3% for ASA, 48.8% for sumatriptan and 32.9% for placebo. All active treatments were superior to placebo (p < 0.05). 25.3, 24.4 and 14.5% of patients treated with ASA, sumatriptan or placebo were pain free at 2 h. Drug-related adverse events were reported in 3.9, 4.7 and 6.7% of patients treated with placebo, ASA or sumatriptan. The study showed that administration of effervescent ASA leads to remission of the migraine symptoms nausea, photophobia and phonophobia, reduces migraine headache and is comparable to sumatriptan.

[Office Treatment of Migraine in 2004]

The current headache classification differentiates between migraine with and migraine without an aura. Each form is characterized by typical pain and concomitant symptoms. In the case of status migrainosus the additional administration of a corticosteroid has proven useful. To cut short mild attacks of migraine, analgesics together with an antiemetic are employed; for severe attacks, triptans are needed. The aim of migraine prophylaxis is to prevent the occurrence of medication-induced headache. It is indicated when at least 6 migraine attacks a month occur. The recommendation to apply prophylaxis in the event of at least three attacks a months is now considered obsolete.

Die medikament�se Prophylaxe der Migr�ne

Migraine prophylaxis with drugs is still an essential part of migraine therapy. This is especially true for those patients with frequent migraines who are in danger of developing drug-induced headaches. Migraine prophylaxis should be taken in consideration in patients who suffer from 7 or more migraine days per month in spite of all non-pharmacological efforts. When choosing a prophylactic drug not only efficacy but tolerability and safety for long-term intake should be considered. Prophylactic drugs used to be classified as drugs of first, second and third choice. According to this step care model treatment was started with a drug of first choice and only in case of lack of efficacy or adverse events a drug of lower choice was selected. Today, in contrast to the traditional step care a stratified care is favored. Treatment is individualized based on an assessment of the patients' medical needs, on comorbidity, the migraine phenotype and most importantly the individual situation of the patient in life. The paper gives an overview of the efficacy and tolerability of drugs used in migraine prophylaxis.

Experimental Model for Heart Failure in Rats - Induction and Diagnosis

BACKGROUND

Clinical heart failure is generally preceded by hypertrophy. Many animal models (e. g. toxic heart failure models) do not consider this hypertrophy. We set out to develop a heart failure model in rats by inducing pressure-overload hypertrophy.

METHODS

We induced coarctation of the aortic arch with a tantalum clip (0.35 mm internal diameter) In 3-week-old rats (n=17). Starting at seven weeks postoperatively, we measured ejection fraction (EF), fractional shortening (FS), end-systolic (LVESD) and end-diastolic (LVEDD) left ventricular dimensions by echocardiography each week. Heart, lung, and liver specimens were analyzed histopathologically at least eleven weeks after the operation.

RESULTS

Contractile function was significantly decreased in hearts from animals with aortic banding (EF: 45+/-5% vs. 73+/-5%, p<0.01; FS: 20+/-3% vs. 35+/-5%, p<0.01). At the same time, left ventricles were dilated (LVEDD: 9.1+/-0.6 mm vs. 7.4+/-0.5 mm; LVESD: 7.3+/-0.6 mm vs. 4.8+/-0.4 mm, p<0.01). These observations were associated with clinical and histopathological changes characteristic for chronic left heart failure.

CONCLUSION

Placing a tantalum clip around the aortic arch in 3-week-old rats consistently induces left ventricular decrease in contractile function and dilatation after eleven weeks.

[Treatment of migraine: analgetic plus antiemetic or tryptan]

Medical treatment of migraine has the twofold task of cutting short an acute attack and preventing further episodes. Mild attacks are treated with analgesics and antiemetics. Fixed combination preparations are associated with the risk of analgesic-induced headaches and nephropathy and should not be employed. Severe attacks are treated with triptanes, depending on a number of features of the attack. A "migraine status" requires a special approach. When migraine occurs on more than seven days a month, prophylactic measures are indicated with the aim of preventing drug-induced headache. The objective is a 50% reduction in the number of attacks.

[Botulinum toxin in specific pain therapy]

Botulinum toxin has been used for therapeutic purposes in medicine for more than 20 years. Its effective use now covers more than 50 conditions in a wide variety of areas. Its medicinal use was initially based on its blockade of neuromuscular and neurosecretory transfers. Its use for conditions in the field of specific pain therapy is currently authorized in Germany for spastic torticollis, blepharospasm, hemifacial spasm, spastic equine gait in cases of idiopathic cerebral paresis, and spasticity of the arm following stroke. New publications suggest that it can usefully be employed for numerous other painful conditions. The modes of action known today are not confined to the blockade of cholinergic innervation.Indeed, there is also evidence that therapeutic effects are mediated through a normalization of muscle spindle activity, retrograde intake into the CNS with modulation of the central neuropeptide function, inhibition of sterile neurogenic inflammation, and normalization of endplate dysfunction. In view of the methodological peculiarities of studies in the field of pain therapy, such as injection techniques, injection sites, blind study techniques, dosage etc., the scientific evidence for its use in a wide variety of pain syndromes is still patchy in many areas. For this reason the use of botulinum toxin for these syndromes is only justified after full use has been made of standard therapeutic methods and evaluation in specialized centers. The possibility of considering botulinum toxin in specific pain therapy contexts is a new option for patients and doctors.However, its use calls for detailed knowledge of functional neuroanatomy and extensive practical experience and expertise.

[Prophylactic drug management of migraine]

Migraine prophylaxis with drugs is still an essential part of migraine therapy. This is especially true for those patients with frequent migraines who are in danger of developing drug-induced headaches. Migraine prophylaxis should be taken in consideration in patients who suffer from 7 or more migraine days per months in spite of all non-pharmacological efforts. When choosing a prophylactic drug not only efficacy but tolerability and safety for long-term intake should be considered. Prophylactic drugs used to be classified as drugs of first, second and third choice. According to this step care model treatment was started with a drug of first choice and only in case of lack of efficacy or adverse events a drug of lower choice was selected. Today, in contrast to the traditional step care a stratified care is favored. Treatment is individualized based on an assessment of the patients' medical needs, on comorbidity, the migraine phenotype and most important the individual situation of the patient in life. The paper gives an overview of the efficacy and tolerability of drugs used in migraine prophylaxis.

[Managing the attacks, preventing headache. Migraine therapy in 2002]

At the heart of every migraine treatment concept is the management of the acute attack with effective medication. Here, the triptans have been progressively replacing the ergot alkaloids with their unsatisfactory relationship between effect and side effects. Prophylactic medication is indicated when, despite every non-pharmaceutic measure, migraine attacks occur on seven or more days in a month. The beta receptor blockers metoprolol and propranolol have so far been considered the substances of first choice, but in practice there is now a trend towards substances with a lower potential for side effects. The article provides an up-to-date overview of the efficacy and tolerability of the various migraine prophylactics.

Classification of headaches

It was not until 1962 that the Ad-Hoc Committee of the National Institute of Health first published a classification of headache syndromes by brief glossary definitions. The general disadvantage of such glossary definitions is that they require subjective interpretation. Therefore under the chairmanship of Prof. Jes Olesen, Copenhagen, the International Headache Society published in 1988 on the basis of empirical findings a first ever headache classification using operationalized criteria. The headache classification of the International Headache Society was immediately translated into the world's major languages and was adopted by all national headache societies represented in the International Headache Society, the World Health Organisation and the World Federation of Neurology. The new classification proved so successful and enjoyed such rapid international acceptance that no revision was undertaken until 1999. The second edition, again under the chairmanship of Prof. Jes Olesen, will probably be completed in 2002. The classification produced such a high degree of inspiration and motivation of pathophysiological and epidemiological research work that knowledge in the field of headache has displayed growth unparalleled in any other field of neurological research. This development was made possible by the determined work of the Chairman of the Headache Classification Committee, Prof. Jes Olesen. He succeeded in bringing together international researchers, motivating them and jointly turning the current fund of knowledge into a evidence-based classification. Prof. Jes Olesen thus performed the decisive pioneering work for all those who have to do with headaches-patients, doctors and scientists. The IHS classification is the most frequently cited text and one of the most important milestones in the history of the scientific study of headaches.

Evidence-based medicine: botulinum toxin A in migraine and tension-type headache

The therapeutic effect of botulinum toxin in headache was observed coincidentally. The rationale for this new indication initially met with a great deal of scepticism, because the toxin's mechanism of action, cholinergic chemodenervation, does not fit the pathophysiological concept of migraine and other forms of headache. Meanwhile a fair number of studies have been published which indicate efficacy for botulinum toxin and recommend its use for the treatment of tension headache and migraine. According to the evidence-based medicine criteria, grade I evidence has been demonstrated. In addition the use of botulinum toxin for cluster-headache and secondary headache is discussed. Further large scale studies will be regarded to demonstrate the long-term efficacy.

[Epidemiology and costs of chronic pain syndromes exemplified by specific and unspecific low back pain]

Low back pain is one of the most common factors leading to longtime disability. Unspecific low back pain is predominant, i. e. low back pain without an anatomic or neurophysiological correlate. The socioeconomic impact of back pain is huge. In Germany 4% of all work force is lost only due to low back pain. Psychosocial factors are essential for the chronification and must be take into account in therapy. Conventional therapy has shown low efficacy, especially once chronification has started.

[Botulinum toxin A for the treatment of headache disorders and pericranial pain syndromes]

For 20 years botulinum toxin A has been used for the treatment of a variety of disorders characterised by pathologically increased muscle contraction. Recently, treatment of tension headache, migraine, cluster headache, and myofascial pain syndromes of neck, shoulder girdle, and back with botulinum toxin A has become a rapidly expanding new field of research. Several modes of action are discussed for these indications. The blockade of cholinergic innervation reduces muscular hyperactivity for 3 to 6 months. Degenerative changes in the musculoskeletal system of the head and neck are prevented. Nociceptive afferences and blood vessels of the pericranial muscles are decompressed and muscular trigger points and tender points are resolved. The normalisation of muscle spindle activity leads to a normalisation of muscle tone and central control mechanisms of muscle activity. Oromandibular dysfunction is eliminated and muscular stress removed. However, the effect of botulinum toxin A cannot be explained by muscular actions only. Its retrograde uptake into the central nervous system modulates the expression of substance P and enkephalins in the spinal cord and nucleus raphe. Recent findings suggest an inhibition of sterile inflammation which may lead to a blockade of the neurogenic inflammation believed to be the pathophysiological substrate of primary headache disorders. The efficacy of botulinum toxin A in the treatment of pain disorders is being investigated in several studies at the moment. The results and experiences obtained so far present new alternatives in the treatment of chronic pain disorders. The practical use of botulinum toxin A is demonstrated.

[Specialised pain therapy: does it pay for patients and health authorities?]

Specialized pain management centres have been shown to achieve significant clinical efficacy and a relevant reduction of direct and indirect costs. Furthermore, only patients are admitted after conventional therapies failed. The results of specialized pain management might be even more impressive if patients were treated earlier. Parameters of cost efficacy in pain treatment include pain reduction, reduction of drug intake, increase of physical activity, improvement of quality of life, reduction of inability to work, avoidance of early retirement.