Saint Anthony's fire revisited. Vascular problems associated with migraine medication

Ergotamine and related compounds have been used for many years in the management of migraine. This review highlights the potential for toxic effects upon the arterial system which may arise from the use of ergot medications. Data on four female patients aged from 30 to 49 years were collected retrospectively from in-patient records and out-patient follow-up between 1978 and 1990. All four patients presented with the symptoms and signs of arterial obstruction and all had been prescribed ergot preparations as treatment and prophylaxis of migraine, for periods ranging from three to 12 years. Two patients had an acute arterial obstruction that resolved completely when the migraine medication was withdrawn. Two had chronic obstructions and radiological and surgical examination gave evidence of arterial stenosis. These two patients were treated with bypass surgery. Review of the literature indicated that other authors had described similar cases but without specifying the methods of data collection. This report supports the findings of others regarding the toxic effects of ergot preparations upon the arterial system, which may take the form of chronic or acute obstruction. General practitioners and physicians should be aware of the possible complications arising from prolonged or excessive use of ergot medications.

[Non-tropical sprue and chronic inflammatory rectal stenosis in a patient with abuse of ergotamine-containing suppositories]

A 51 year old Yugoslavian patient was admitted to our hospital in reduced general condition with distinct hypocalcemia, osteomalacia, and with rectum stenosis. Our investigations led to the diagnosis of a malabsorption syndrome due to non-tropical sprue. The most likely cause of the rectum stenosis is an abuse of ergotamine-containing suppositories for several years. A gluten-free diet and the interruption of the use of the suppositories improved her general condition remarkably.

Daily chronic headache

Headache is a disabling condition, and medical science has not, until recently, begun to address it in a fashion consistent with its widespread impact. Despite the limitations in our current understanding, as well as the historical prejudice directed toward patients with this condition, current understanding and treatment approaches can provide hope and relief for most patients who have these disorders.

[Ergotamine induced ischemia]

Drugs containing ergotamine are commonly used in the treatment of migraine. Hypersensitivity to these drugs may be triggered off even with intake of recommended doses, inducing peripheral ischemia. Contributing factors to ergotism are concurrent fever, liver disease and drugs such as erythromycin or propranolol. We present a case history and different methods of treatment.

Ergotamine-induced solitary rectal ulcer

A rare case of ergotamine-induced solitary rectal ulcer is described in a 41 year old woman who used high doses of ergotamine tartrate-containing suppositories for severe migraine headaches. Complete recovery of the ulcer was noticed after cessation of treatment with the suppositories. The relevant literature is discussed.

Effects of increasing dietary levels of endophyte-infected tall fescue seed on diet digestibility and ruminal kinetics in sheep

Three experiments were conducted with sheep to determine the effects of 1) increasing the dietary concentration of ergovaline and 2) environmental temperature on site of nutrient digestion and ruminal passage rates. Dietary ergovaline concentration, a measure of endophyte-alkaloid concentration, was modified by substituting ergovaline-infected for noninfected tall fescue seed. Ruminal and total tract OM, NDF and cellulose digestibilities were less (P less than .10) and ruminal fluid dilution rate (%/h) and fluid outflow (liters/h) were greater (P less than .05) when diets contained 3 ppm ergovaline than when diets contained 0 ppm ergovaline. An interaction (P less than .05) between dietary ergovaline concentration (0 vs 1.5 ppm) and environmental temperature (27 vs 34 degrees C) was found for OM intake and NDF and cellulose digestion. Ruminal fluid dilution and outflow rates decreased (P less than .01) even though water consumption increased (P less than .01) with increasing temperature. Rectal temperature increased (P less than .01) when ergovaline and ergotamine tartrate were fed and when sheep were exposed to increased environmental temperature. Under the dietary (and environmental) conditions described, our results suggest that alkaloid(s) present in infected tall fescue seed inhibit ruminal fiber digestion and increase the sensitivity of sheep to heat stress.

[Ergotism: an occasional unrecognized cause of acute ischemia of the extremities]

Vasospasm related to ergot intoxication has been recognised since the Middle Ages when it occurred due to ingestion of rye contaminated with Claviceps purpurea. Today ergotism is a rare cause of peripheral ischaemia, most often associated with ergotamine tartrate therapy for migraine headaches. Recognition of the typical angiographic pattern is important, as the classic drug history may not be obtained, and the cause of the ischaemia can be overlooked. Early diagnosis is important as the outcome may be serious if left untreated. Arterial vasospasm, collateralisation, and secondary thrombus formation are the major angiographic findings. Ergotism responds to conservative therapy which includes drug withdrawal, intravenous nitroprusside, fluid therapy and heparinisation. We describe the angiographic findings of four cases and report on the results of therapy.

Specific drug binding to rat liver cytochrome P-450 isozymes induced by pregnenolone-16 alpha-carbonitrile and macrolide antibiotics. Implications for drug interactions

Clinical interactions of macrolides with various drugs lead to elimination impairment, increase of plasma concentration and overdose-like effects, resulting from modifications of their metabolism. Previous studies have shown that treatment of rats by the macrolide antibiotics of the oleandomycin and erythromycin series lead to the induction of an hepatic cytochrome P-450 which is implicated into their own metabolism. We have characterized PCN or macrolides induced cytochromes P-450 by their specific ability to interact with macrolide derivatives and, using the cytochrome P-450 spectral binding assays, we have shown that some compounds, implicated in drug interaction with macrolides, interact preferentially with the same cytochromes. This strongly suggests that specific blockage of cytochrome P-450 IIIA1 family by macrolides, is responsible for these drug interactions and that these interactions can be predicted easily by simple in vitro tests such as those described herein.

Pressor effect of inhaled ergotamine in orthostatic hypotension

Treatment of orthostatic hypotension due to autonomic failure frequently necessitates use of pressor agents. Because venous pooling contributes significantly to this disorder, the venoconstrictive properties of ergotamine offer theoretical advantages over pure arteriolar pressor agents. However, the low and erratic bioavailability of oral preparations has hindered the use of ergotamine. Accordingly, the efficacy of inhaled ergotamine tartrate (1 puff, 0.36 mg) was compared to placebo in 8 patients with severe autonomic failure. Blood pressure was monitored in the seated position with an automated device. Ergotamine produced significant increases in systolic (29 +/- 5 mm Hg, p less than 0.01 by analysis of variance) and diastolic (13 +/- 1 mm Hg, p less than 0.001) blood pressures compared to placebo (-9 +/- 5 and -2 +/- 3, respectively). Upright blood pressure 2 hours after administration was significantly greater with ergotamine (119 +/- 8/69 +/- 6 mm Hg) vs placebo (82 +/- 7/59 +/- 5 mm Hg, p less than 0.05). Motionless standing time, a measurement of functional capacity, also improved with ergotamine (200 +/- 58 vs 85 +/- 22 seconds). No side effects were noted, but patients with coronary or peripheral artery disease were excluded. Inhaled ergotamine may provide an effective and practical therapy for disabling orthostatic hypotension due to autonomic failure.

Silent myocardial ischemia is not a benign sign

1. Objectively, provoked angina is different from non-provoked angina. a) During pacing stress testing, provoked angina showed lesser increase in coronary sinus blood flow. b) During Ergotamine testing, variant angina showed a more marked decrease in flow. c) The myocardial lactate extraction ratio was lower during the pacing induced angina. 2. During the asymptomatic period, the polyparametric changes which would become manifest appeared following differing intervals. The early recognition of the myocardial ischemia was achieved by detection of the abnormality of the regional cardiac wall motion using a newly developed device, the cardiomoveogram. 3. Therefore, we can at least conclude that silent myocardial ischemia is not a good prognostic sign.

Gastrointestinal vascular ischemia caused by ergotamine

In the investigation of abdominal pain due to ergotism, arteriography will show vascular abnormalities similar to those observed peripherally in this disorder. Ergotism is rare, and failure to diagnose it will result in ineffectual therapy. In the majority of situations, ergotism can usually be successfully treated by withdrawal alone. In situations of threatened limb or organ loss, sodium nitroprusside appears to rapidly reverse the vasospasm due to ergotism and is likely the therapy of choice.

Enhancing the effectiveness of abortive therapy: a controlled evaluation of self-management training

Research suggests that approximately one half of recurrent headache sufferers fail to adhere properly to drug treatment regimens with as many as two thirds of patients failing to make optimal use of abortive medications such as ergotamine. In spite of these findings there are no controlled studies that have attempted to evaluate methods for improving adherence to drug regimens for the treatment of chronic headache disorders. In an initial effort to address this adherence problem thirty-four recurrent migraine sufferers were randomized to abortive therapy with ergotamine tartrate plus caffeine (standard abortive therapy) or to standard abortive therapy accompanied by a brief educational intervention designed to facilitate the migraine sufferer's effective use of ergotamine. Patients who received the adjunctive educational intervention attempted to abort a greater percentage of their migraine attacks (70% vs 40%) and showed larger reduction in headache activity (e.g., 40% vs 26% reduction in month two of treatment). However, patients in both treatment groups used similar amounts of abortive medication when attempting to abort a migraine attack and showed similar reductions in analgesic medication use with abortive therapy. There results suggest that brief educational interventions designed to address the problem of patient adherence may yield significant improvements in standard therapies. We argue that such educational interventions deserve more attention in the headache treatment literature than they have received to date.

Triple stage quadrupole mass spectrometric determination of bromocriptine in human plasma with negative ion chemical ionization

A new MS/MS assay for the quantitative determination of bromocriptine in body fluids is presented. The selective reagent gas in combination with the registration of selected, characteristic negative ions (SIM) after collision activated decomposition (CAD) in a Triple-Stage-Quaddrupole-mass spectrometer, provides an exceptional selective and sensitive assay in the low pg/ml range. The lower limit of detection was about 1 pg/ml (at optimal measuring conditions) and the calibration curve was linear in the range of 10-200 pg/ml. The coefficient of variation for the imprecision and inaccuracy data was typically below 10%; the recovery from plasma always exceeded 75%. The sample introduction to the mass spectrometer was done by a direct exposure probe (DEP). Thus, the method is well suited for the reliable, rapid processing of large sample numbers generated e.g. from clinical studies evaluating the pharmacokinetics and/or bioavailability/bioequivalence of different formulations or from drug monitoring/clinical response programs. The assay has been successfully approved in several clinical studies evaluating different bromocriptine preparations.

Placebo-controlled double-blind trial of pirprofen and an ergotamine tartrate compound in migraine attacks

Sixty-one patients, 16 with classic and 45 with common migraine, were treated during three subsequent attacks with pirprofen, a new inhibitor of prostaglandin synthesis; an ergotamine tartrate compound; or placebo, in a randomized, double-blind multicentre study. Pain relief after a single dose and reduction of the attack intensity occurred most often with pirprofen in patients who needed more than one dose. Among them, however, the duration of attack was shortest with ergotamine. Working ability was well preserved with pirprofen, especially among patients with common migraine, and this treatment was ranked highest by the patients. However, no statistically significant differences were found between pirprofen and ergotamine. No serious side effects were observed with pirprofen. This study establishes the usefulness of pirprofen in the treatment of acute migraine.

[Proctomucosectomy and colo-anal anastomosis in rectovaginal fistula following the use of suppositories containing ergotamine]

We observed a rectovaginal fistula in 2 patients who had applied ergotamine suppositories against migraine headaches. The local effect of ergotamine on the rectum mucosa as well as the higher systemic concentration after rectal application seem to promote the development of a rectovaginal fistula. Different methods for the surgical fistula repair are discussed, depending on location and diameter of the fistula. In our patients we have carried out the abdomino-transanal resection of the rectum with sutured colo-anal anastomosis.

Chronic ergotamine abuse: evidence of functional impairment of long ascending spinal tracts

22 migraine patients with a history of chronic ergotamine abuse were compared with 12 patients with a similar intake of dihydroergotamine. The study of somatosensory-evoked potentials showed that 50% of the patients with a history of ergotamine abuse had increased central conduction times after stimulation of the tibial nerve. Corticomotoneuronal latencies obtained by noninvasive electrical stimulation of the motor cortex were normal in 5 patients. The functional sensory deficits were not related to clinical impairment and were more frequently observed in patients with a comparatively high mean daily and cumulative intake.