[Headache and migraine]

Headaches are one of the most common disorders and symptoms in daily medical practice. There has been dramatic progress of knowledge in the fields of epidemiology, pathophysiology, acute treatment, and preventive therapy over the past 100 years. Triptans have been the breakthrough in the treatment of acute migraine attacks. Beta blockers, calcium antagonists, and neuromodulators are available for preventive migraine therapy. Treatment for chronic tension headache is still unsatisfying. Cluster headache is part of the group of trigemino-autonomic headaches. Headache from medication overuse plays an increasingly important role. New medical care structures such as integrated headache care provide better support for patients with chronic headache disorders.

Long-term outcome of Guillain-Barré syndrome

OBJECTIVES

To investigate long-term neurological residua after Guillain-Barré syndrome (GBS) and to evaluate the predictive value of respiratory insufficiency during the acute stage of the disease.

METHODS

Thirty-four patients with GBS including 5 patients with Miller-Fisher syndrome admitted to a university hospital between 1994 and 2002 underwent a neurological and electrophysiological follow-up examination 7 - 86 months after onset of GBS.

RESULTS

Of the 34 patients, 5 patients had completely recovered, 11 patients demonstrated mild residual symptoms and/or signs, and 18 patients presented with functionally relevant neurological deficits predominantly in the lower extremity, although all patients could walk without assistance and none showed respiratory failure. Nerve conduction studies revealed abnormal findings in 30 patients. Autonomic function testing of the cardiovascular system showed a pathological blood pressure response to standing in 27 of 33 patients. No association was found between the course of the disease and sleep-disordered breathing at follow-up. Age at onset, need for mechanical ventilation, and duration of the plateau phase correlated with severity of neurological residua at follow-up.

CONCLUSIONS

There was a high persistence of residual sensorimotor signs and symptoms after GBS in our cohort. In addition, abnormal blood pressure declines not associated with clinically overt orthostatic dysregulation were detected in the majority of our patients at follow-up. This is in contrast to previous reports describing a gradual improvement of autonomic dysfunction after 2 - 18 months. A combined prognostic score based on patient age, duration of the plateau phase, and ventilatory failure in the acute stage of GBS might predict the long-term outcome.

[What should be done after the first TIA?]

Transient ischaemic attacks (TIA) are neurological events caused by temporary cerebrovascular disorders whose effects can be fully reversed within 24 hours. TIAs are forewarnings of an impending stroke. On the average, 15% of the patients suffer a stroke within 90 days after a TIA; half of the strokes occur within the first 48 hours. This necessitates very prompt diagnosis that includes medical examination, determination of risk factors, ultrasound examination of the cerebral vessels, cerebral imaging, ECG and echocardiography. Secondary prevention includes administering platelet inhibitors or, in case of cardiogenic embolism, oral anticoagulants, treatment of vascular risk factors and a change in lifestyle. Surgical or interventional therapy is indicated if severe stenosis of the cerebral arteries is present.

Prevalence of trigeminal autonomic symptoms in migraine: a population-based study

Epidemiological data on trigeminal unilateral autonomic symptoms in patients with migraine are scarce. The authors wanted to provide a population-based evaluation of the prevalence of unilateral autonomic features in migraine patients and an assessment of the expression of unilaterality of autonomic symptoms and head pain in patients with UAs compared to other migraine patients. A population based sample of 6000 inhabitants of the city of Essen in Germany was screened using a previously validated standard questionnaire. Three thousand three hundred and sixty subjects (56% of a total 6000) responded. 841 subjects had migraine, out of which 226 reported accompanying unilatral auetonomic symptoms (26.9%, CI 95% [23.9-30%]). Unilateral autonomic symptoms in patients with migraine are common and have been widely underestimated in the past. One out of four migraine patients regularly experiences one or more unilateral autonomic symptoms during their attack. Migraine patients with accompanying autonomic symptoms seem to experience their pain more unilateral and more severe than non-UA patients.

Efficacy and safety of 1,000mg effervescent aspirin: individual patient data meta-analysis of three trials in migraine headache and migraine accompanying symptoms

Migraine is often associated with health consequences including impaired quality of life, and the cost of treating migraine headaches places a significant financial burden on patients who suffer from migraines. Nonsteroidal anti-inflammatory drugs (NSAIDs) and triptans are commonly used for the treatment of acute migraine attacks. Aspirin is widely accepted as a treatment option for migraine pain relief and could provide an alternative not only for treatment of moderate migraine attacks, but also for severe migraine attacks. The efficacy and safety of 1,000 mg effervescent aspirin (eASA) was evaluated in comparison to 50 mg sumatriptan and placebo in an individual patient data meta-analysis of three randomized, placebo-controlled, single- dose migraine trials. Pain-relief at 2 h, pain-free at 2 h and sustained pain-free up to 24 h were calculated. For eASA, the response rates were 51.5 % (95 % CI: 46.6-56.5 %), 27.1 % (95 % CI: 22.6-31.4 %), and 23.5 % (95 % CI: 19.3-27.7 %). For sumatriptan, the response rates were 46.6 % (95% CI: 40.0-53.2 %), 29% (95 % CI: 23.0-34.9 %), and 22.2 % (95 % CI: 16.7-27.6 %). The corresponding rates for placebo were 33.9 % (95% CI: 29.1-38.6 %), 15.1 % (95 % CI: 11.5-18.7 %), and 14.6 % (95 % CI: 11.0-18.1 %). The treatment effect of eASA and sumatriptan were significantly different from placebo (p < 0.001), but differences between eASA and sumatriptan were not significant. The remission of accompanying symptoms and the subgroup analyses of patients with moderate or severe migraine pain at baseline revealed no significant differences between eASA and sumatriptan. Safety was evaluated based on the frequency of reported adverse events, and treatment with eASA was associated with lower incidence of adverse events than was with sumatriptan. This individual patient data meta-analysis provided evidence that eASA 1,000 mg is as effective as sumatriptan 50mg for the treatment of acute migraine attacks and has a better side effect profile. This is also true for patients with moderate as well as severe headache at baseline. Patients therefore should be advised to use eASA first for migraine attacks and use a triptan in case of no response.

Kopfschmerzpatienten im klinischen Alltag

In routine clinical practice, the question whether instrumental examinations of patients with headaches should be carried out, is not always easy. If secondary headaches are suspected, with atypical presentation and focal neurological signs or symptoms, magnetic resonance imaging (MRI) may be indicated. In primary headaches, such as migraine, tension headache or trigemino-autonomic headaches, no further diagnostic procedures are warranted, as long as the clinical presentation is typical (i.e. corresponds to the International Headache Society guidelines) and neurological examination is normal. This article reviews the evidence from the literature and recommendations of European and American task forces regarding the use of instrumental examinations in case of non-acute primary headache.

Central sensitization of the trigeminal and somatic nociceptive systems in medication overuse headache mainly involves cerebral supraspinal structures

Trigeminal and somatic nociceptive systems were studied in controls (n=15), episodic migraine (n=16), analgesics (n=14) and triptan-induced medication overuse headache (MOH) (n=15) before and after withdrawal. Patients with MOH and comorbid depressive symptoms and depression without headache were studied to investigate the influence of depression. Trigeminal nociception was studied by simultaneous registration of pain-related cortical potentials (PREP) and nociceptive blink reflex (nBR) following nociceptive-specific electrical stimulation of the forehead. Somatic nociception was evaluated using PREP of upper limbs. We found facilitation of both trigeminal and somatic PREP but not of nBR in MOH, which normalized after withdrawal. No differences were found comparing analgesics vs. triptan MOH. No differences were observed between controls and patients with episodic migraine and depression without headache. A transient facilitation was found of trigeminal and somatic nociceptive systems in MOH, which was more pronounced on a supraspinal level.

Gray matter decrease in patients with chronic tension type headache

Using MRI and voxel-based morphometry, the authors investigated 20 patients with chronic tension type headache (CTTH) and 20 patients with medication-overuse headache and compared them to 40 controls with no headache history. Only patients with CTTH demonstrated a significant gray matter decrease in regions known to be involved in pain processing. The finding implies that the alterations are specific to CTTH rather than a response to chronic head pain or chronification per se.

Company reference estimates for productivity loss due to migraine and productivity gains using rizatriptan 10 mg in Germany

The prevalence of migraine in Germany is up to 14% in the female and up to 8% in the male population and peaks between the age of 35 and 45. Few studies have investigated the productivity loss and resulting costs attributable to migraine in Germany or addressed the question whether these costs can be reduced by optimal treatment. In recent years, 5-HT(1B/D) agonists (so-called triptans), a generation of drugs highly specific for migraine treatment, have been introduced. Seven 5-HT(1B/D) agonists have been approved in Germany with more than 20 dosage forms. We present a model that enables employers to estimate the annual cost of migraine and the annual cost that could be saved by treatment of migraine with rizatriptan compared with the use of non-specific antimigraine medication. A representative German company with 10,000 employees is used for the reference case analysis. This company is predicted to have 580 female and 284 male employees with migraine. These employees are estimated to lose 6992 workdays or 31.8 person years of productive effort annually due to migraine, valued approximately 1,431,719 euros. The value of work loss that could be avoided by treating migraine with rizatriptan is estimated at 619,094 euros annually. These data indicate that costs arising from lost productivity can be reduced by treating migraine headaches with a triptan.

Two models for outcome prediction - a comparison of logistic regression and neural networks

OBJECTIVES

Accurately predicting disease progress from a set of predictive variables is an important aspect of clinical work. For binary outcomes, the classical approach is to develop prognostic logistic regression (LR) models. Alternatively, machine learning algorithms were proposed with artificial neural networks (ANN) having become popular over the last decades. Although some studies have compared predictive accuracies of LR and ANN models, some concerns regarding their methodological quality have been voiced. Our comparison has the advantage of being based on two large independent data sets allowing for elaborate model development and independent validation.

METHODS

From the German Stroke Database, a learning data set including 1754 prospectively recruited patients with acute ischemic stroke was used. Utilizing LR and ANN, two prognostic models were developed predicting restitution of functional independence and survival after 100 days. The resulting models were applied to classify 1470 patients with acute ischemic stroke; this test data set was collected independently from the learning data. Error fractions in the test data were determined, and differences in error fractions between the algorithms were calculated with 95% confidence intervals.

RESULTS

For most prognostic models, error fractions in the test data were below 40%. There was no difference between the algorithms except for the model predicting completely versus incompletely restituted or deceased patients (difference in error fractions = 4.01% [2.10-5.96%], p = 0.0001).

CONCLUSIONS

The conscientiously applied LR remains the gold standard for prognostic modelling; however, ANN can be an alternative automated "quick and easy" multivariate analysis.

Efficacy and safety of 6.25 mg t.i.d. feverfew CO2-extract (MIG-99) in migraine prevention--a randomized, double-blind, multicentre, placebo-controlled study

The efficacy and tolerability of a CO(2)-extract of feverfew (MIG-99, 6.25 mg t.i.d.) for migraine prevention were investigated in a randomized, double-blind, placebo-controlled, multicentre, parallel-group study. Patients (N = 170 intention-to-treat; MIG-99, N = 89; placebo, N = 81) suffering from migraine according to International Headache Society criteria were treated for 16 weeks after a 4-week baseline period. The primary endpoint was the average number of migraine attacks per 28 days during the treatment months 2 and 3 compared with baseline. Safety parameters included adverse events, laboratory parameters, vital signs and physical examination. The migraine frequency decreased from 4.76 by 1.9 attacks per month in the MIG-99 group and by 1.3 attacks in the placebo group (P = 0.0456). Logistic regression of responder rates showed an odds ratio of 3.4 in favour of MIG-99 (P = 0.0049). Adverse events possibly related to study medication were 9/107 (8.4%) with MIG-99 and 11/108 (10.2%) with placebo (P = 0.654). MIG-99 is effective and shows a favourable benefit-risk ratio.

[Treatment and prophylaxis for cluster headaches and other trigeminal autonomic headaches. Revised recommendations of the German Migraine and Headache Society]

Following the new IHS classification, cluster headache, paroxysmal hemicrania, and short-lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT syndrome) are included in the classification as trigeminal autonomic cephalgias (TAC). The similarities of these syndromes suggest a considerable shared pathophysiology. These syndromes have in common that they involve activation of trigeminovascular nociceptive pathways with reflex cranial autonomic activation. Clinically, this physiology predicts pain with some combination of lacrimation, conjunctival injection, nasal congestion, or eyelid edema. Broadly the management of TAC comprises acute and prophylactic treatment. Some types of trigeminal autonomic headaches such as paroxysmal hemicrania and hemicrania continua have, unlike cluster headaches, a very robust response to indomethacin, leading to a consideration of indomethacin-sensitive headaches. This review covers the clinical picture and therapeutic options. Although studies following the criteria of evidence-based medicine (EBM) are rare, most patients can be treated sufficiently.

Medication overuse headache: rates and predictors for relapse in a 4-year prospective study

We present a prospective 4-year follow-up study of 96 patients with medication overuse headache following withdrawal. Complete datasets were available from 85 patients (89%) 6 months, from 79 patients (82%) 1 year and from 75 patients (78%) 4 years after withdrawal. Twenty-six patients (31%) relapsed within the first 6 months after withdrawal. The number of relapses increased to 32 (41%) 1 year and to 34 (45%) 4 years after withdrawal. The 4-year relapse rate was lower in migraine than in tension-type headache (32% vs. 91%, P<or=0.001) and combination of migraine and tension-type headache (32% vs. 70%, P<or=0.027) and also lower in patients overusing triptans than analgesics (21% vs. 71%, P<or=0.001). The study suggests that the majority of relapses occur within the first year after withdrawal and that the long-term success of withdrawal depends on the type of primary headache and the type of overused medication.

Clinical features and therapy of medication overuse headache

Inappropriate use of headache medication (>15 times/month) for the treatment of headache episodes may contribute to the development of chronic headache which is refractory to most treatments. Physicians experienced in the treatment of migraine and other headaches are well aware that the daily intake of antipyretic or antiinflammatory analgesics, opioids, ergot alkaloids and "triptans" may result in chronic daily headache. Conversely, if a patient complains of chronic headache and takes pain medication every day, this headache is most likely to be caused and sustained by the medication and will vanish or improve with abstinence. Treatment includes drug withdrawal followed by structured acute therapy and initiation of migraine prophylactic treatment.