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Hannigan IP, Rosengren SM, Di Tanna GL, Watson SRD, Welgampola MS. Effects of nonprescription therapies on vestibular migraine: a questionnaire-based observational study. Intern Med J 2024; 54:916-924. [PMID: 38204302 DOI: 10.1111/imj.16314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Accepted: 11/30/2023] [Indexed: 01/12/2024]
Abstract
BACKGROUND Vestibular migraine (VM) is a common cause of recurrent vertigo. Migraine headache preventative therapies are currently prescribed to control vertigo symptoms in VM. Clinical trials of nutraceuticals for migraine headache prevention have shown positive outcomes, but, to date, there have been no studies to assess their effectiveness in the management of VM. AIMS To report the effects of nonprescription therapy management on VM symptoms. METHODS We undertook a prospective, questionnaire-based assessment of patients diagnosed with VM between November 2019 and August 2021 at two Sydney tertiary referral clinics. Patients were advised on optimising sleep, hydration, exercise and nutrition and instructed to use an over-the-counter combination product containing riboflavin 200 mg, magnesium 150 mg, coenzyme Q10 75 mg and feverfew 200 mcg. Symptom severity and frequency were assessed using the Dizziness Handicap Inventory (DHI), the Vertigo Symptom Score short-form (VSS-sf) and two visual analogue scales for severity (VAS-s) and frequency (VAS-f) before and 3 months after commencing treatment. RESULT In 82 participants (78% female; mean age, 44 ± 14 years) we recorded a decrease in DHI (mean, 16.8 [95% confidence interval (CI), 12.8-20.9], VSS-sf (9.3, 7.1-11.5), VAS-s (3.0, 2.2-3.8) and VAS-f (2.8, 2.1-3.4), equating to an improvement of 44.1%, 44.9%, 44.1% and 38.9% for each measure respectively. On the DHI and VSS-sf, 41 (50%) and 44 (53.7%) patients showed improvement in their symptoms; 39 (47.6%) and 36 (43.9%) patients noted no change and two patients reported worsening. The supplement was well-tolerated. CONCLUSIONS The results provide preliminary evidence that VM symptom frequency and severity can be reduced by using nonprescription therapies.
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Affiliation(s)
- Imelda P Hannigan
- Central Clinical School, University of Sydney, Sydney, New South Wales, Australia
- Blacktown Neurology Clinic, Blacktown, New South Wales, Australia
| | - Sally M Rosengren
- Central Clinical School, University of Sydney, Sydney, New South Wales, Australia
- Institute of Clinical Neurosciences, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Gian L Di Tanna
- Biostatistics and Data Science Division, The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Shaun R D Watson
- Blacktown Neurology Clinic, Blacktown, New South Wales, Australia
- Prince of Wales Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Miriam S Welgampola
- Central Clinical School, University of Sydney, Sydney, New South Wales, Australia
- Institute of Clinical Neurosciences, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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2
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Holdridge A, Donnelly M, Kuruvilla DE. Integrative, Interventional, and Non-invasive Approaches for the Treatment for Migraine During Pregnancy. Curr Pain Headache Rep 2022; 26:323-330. [PMID: 35362816 DOI: 10.1007/s11916-022-01028-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/04/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE OF REVIEW While most women with migraine improve during pregnancy, a subset may remain unchanged or even become more severe. Given the limited evidence for the use of prescription medications during pregnancy, many look to other treatment modalities. We seek to review complementary and integrative medicine, procedural interventions, and neurostimulation to empower women with safe and effective treatment options during pregnancy. RECENT FINDINGS Migraine treatment during pregnancy remains controversial. While evidence is limited, prospective and retrospective reviews, as well as clinical experience support the use of nutraceuticals, procedural interventions, and neurostimulation during pregnancy when the appropriate risks and benefits are weighed. Empowering patients with information on complementary and integrative medicine, as well as non-systemic and interventional treatments, may help to reduce anxiety and headache burden during pregnancy. Various nutraceuticals have shown promise for the preventive management of migraine. Non-systemic interventions such as trigger point injections and peripheral and sphenopalatine nerve blocks offer effective treatment options with minimal side-effects. Options for neurostimulation have expanded in recent years and may offer safe and effective non-pharmacologic options for the management of migraine. It is imperative that providers do not minimize migraine during pregnancy and become aware of the treatment modalities available to help guide women through this experience.
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Affiliation(s)
- Ashley Holdridge
- Medical Director of The Comprehensive Headache Center, 9969 S 27th St. Suite, 3000, Franklin, 53132, WI, USA.
| | - Megan Donnelly
- Medical Director of Craniofacial Pain and Women's Neurology, Novant Health, Winston-Salem, NC, USA
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3
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Review on Headache Related to Dietary Supplements. Curr Pain Headache Rep 2022; 26:193-218. [PMID: 35254637 DOI: 10.1007/s11916-022-01019-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/27/2021] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW The lifetime prevalence of headaches is 96%. Approximately 11% of the adult population worldwide has a migraine headache. Migraine is a complex disorder that is more than a simple headache. So far, many underlying mechanisms, i.e. inflammatory, vascular, neurogenic have been hypothesized. In recent years evidences proposed that an energy deficit due to changes in mitochondrial function contributes to migraine pathophysiology as an upstream disorder. Recent insights suggested that the coexistence of sensory-stimuli surplus and energy-reserve shortage activate the trigeminovascular system. Some nutrients are considered as essential elements in mitochondrial bioenergetics and some others are known as natural immuno-modulatory components. Also, evidence showed their beneficial effect in headache prophylaxis and treatment. In present study, we aimed to review the available data in this field. RECENT FINDINGS Vitamin B group, magnesium, and Coenzyme Q10 (CoQ10) are well-known for their function in mitochondrial energy metabolism. On the other hand, studies support their beneficial role in controlling migraine headache symptoms. For instance, daily intake of 400-milligram riboflavin for 3 months resulted in more than 50% reduction in migraine attacks in more than half of the consumers. According to recent evidence, vitamin D and Omega-3 which are considered as famous immune-modulatory compounds are also reported to be effective in migraine prophylaxis. For example, every 22% reduction in migraine headache occurrence was reported for every 5 ng/ml rise in serum vitamin D. Supplementation with vitamin B group, CoQ10, magnesium, vitamin D and Omega-3 could be considered as an effective, less costly strategy in headache/migraine prophylaxis.
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The Association of Tanacetum parthenium and Salix alba Extracts Reduces Cortex Serotonin Turnover, in an Ex Vivo Experimental Model of Migraine. Processes (Basel) 2022. [DOI: 10.3390/pr10020280] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
The mixture of water extracts from Tanacetum parthenium and Salix alba was studied in an ex vivo assessment of neurotoxicity constituted by isolated mouse cortex specimens challenged with K+ 60 mM Krebs–Ringer buffer (neurotoxicity stimulus). The effects of the mixture on lactate dehydrogenase (LDH), nitrite and serotonin levels were investigated. The phytochemical profile of the mixture was also evaluated. A docking approach was conducted to predict, albeit partially, the putative mechanism underlying the observed effects. The extracts displayed a good profile of polyphenolic compounds (22 chromatographic peaks detected), with caftaric acid and epicatechin being the prominent phenols. In isolated cortex, the association of T. parthenium and S. alba extracts was effective in reducing the K+ 60 mM-induced levels of LDH and nitrites, whereas the neurotoxicity stimulus-induced serotonin depletion was prevented by the treatment. Regarding the inhibition of serotonin catabolism, epicatechin (44.65 µg/mg) and caftaric acid (10.51 µg/mg) were putatively the main compounds involved in the inhibition of monoamineoxidase-A, which is known to play a master role in serotonin turnover. Collectively, the results of the present study point to the efficacy of the present extract mixture as an innovative pharmacological tool to prevent the onset of migraine.
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Hoseini N, Yaghini O, Ghazavi M, Mansouri V, Nasiri J, Moosavian T, Salehi M. A comparative study on the efficacy of coenzyme Q10 and amitriptyline in the prophylactic treatment of migraine headaches in children: A randomized controlled trial. Adv Biomed Res 2022; 11:43. [PMID: 35814300 PMCID: PMC9259447 DOI: 10.4103/abr.abr_235_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 05/15/2021] [Accepted: 08/22/2021] [Indexed: 11/04/2022] Open
Abstract
Background: Materials and Methods: Results: Conclusions:
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6
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Rauchová H. Coenzyme Q10 effects in neurological diseases. Physiol Res 2021. [DOI: 10.33549//physiolres.934712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Coenzyme Q10 (CoQ10), a lipophilic substituted benzoquinone, is present in animal and plant cells. It is endogenously synthetized in every cell and involved in a variety of cellular processes. CoQ10 is an obligatory component of the respiratory chain in inner mitochondrial membrane. In addition, the presence of CoQ10 in all cellular membranes and in blood. It is the only endogenous lipid antioxidant. Moreover, it is an essential factor for uncoupling protein and controls the permeability transition pore in mitochondria. It also participates in extramitochondrial electron transport and controls membrane physicochemical properties. CoQ10 effects on gene expression might affect the overall metabolism. Primary changes in the energetic and antioxidant functions can explain its remedial effects. CoQ10 supplementation is safe and well-tolerated, even at high doses. CoQ10 does not cause any serious adverse effects in humans or experimental animals. New preparations of CoQ10 that are less hydrophobic and structural derivatives, like idebenone and MitoQ, are being developed to increase absorption and tissue distribution. The review aims to summarize clinical and experimental effects of CoQ10 supplementations in some neurological diseases such as migraine, Parkinson´s disease, Huntington´s disease, Alzheimer´s disease, amyotrophic lateral sclerosis, Friedreich´s ataxia or multiple sclerosis. Cardiovascular hypertension was included because of its central mechanisms controlling blood pressure in the brainstem rostral ventrolateral medulla and hypothalamic paraventricular nucleus. In conclusion, it seems reasonable to recommend CoQ10 as adjunct to conventional therapy in some cases. However, sometimes CoQ10 supplementations are more efficient in animal models of diseases than in human patients (e.g. Parkinson´s disease) or rather vague (e.g. Friedreich´s ataxia or amyotrophic lateral sclerosis).
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Affiliation(s)
- H Rauchová
- Institute of Physiology Czech Academy of Sciences, Prague, Czech Republic.
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7
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Barmherzig R, Rajapakse T. Nutraceuticals and Behavioral Therapy for Headache. Curr Neurol Neurosci Rep 2021; 21:33. [PMID: 33970348 DOI: 10.1007/s11910-021-01120-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2021] [Indexed: 12/28/2022]
Abstract
PURPOSE OF REVIEW Headache affects and disables at least 1 billion people worldwide. Patients and providers seek new therapies to relieve headache without the side effects and financial burden of current treatments. This narrative review highlights recent treatment advances in integrative headache medicine: nutraceuticals and behavioral therapies. RECENT FINDINGS Growing use of complementary and alternative medicine (CAM) therapies for headache (riboflavin, coenzyme Q10, magnesium, vitamin D, melatonin) alongside mainstream treatments is increasing with improving evidence of quality, safety, and tolerability. Increasing interest in medical cannabis is tempered by lack of evidence regarding safety and efficacy. Behavioral therapies including cognitive behavioral therapy (CBT), biofeedback, mindfulness-based stress reduction (MBSR), and acceptance and commitment therapy (ACT) improve patient resiliency and self-efficacy outcomes and reduce disability. The body of evidence for nutraceutical and behavioral CAM interventions for headache continues to grow and improve in quality. Providers and patients should educate themselves regarding CAM therapies as part of integrative headache management. Future studies should examine combinatorial trials of CAM therapies against current standards of headache care.
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Affiliation(s)
- Rebecca Barmherzig
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Thilinie Rajapakse
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada. .,Stollery Children's Hospital, Women & Children's Research Institute, Edmonton, AB, Canada.
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Kaur K, Hernandez V, Al Hajaj SW, Ebrahim AM, Razack M, ElSharief MW, Dragas D. The Efficacy of Herbal Supplements and Nutraceuticals for Prevention of Migraine: Can They Help? Cureus 2021; 13:e14868. [PMID: 33972917 PMCID: PMC8105190 DOI: 10.7759/cureus.14868] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Migraine is a common neurological disorder associated with or without aura. Although the pathophysiology of migraine is not very well understood, pro-inflammatory cytokines and oxidative stress biomarkers are found to be increased in migraine. Multiple studies have been done to see if alternative medicine such as herbal supplements and nutraceuticals are effective in the prevention and treatment of migraine headaches. This review aimed to evaluate the effect of supplements like coenzyme Q10, riboflavin (vitamin B2), feverfew, and magnesium on the frequency, severity, and duration of migraine attacks. We performed a thorough literature search using mainly PubMed. We included studies published in the last 10 years, those conducted among adult human participants 18-65 years of age, and those published in the English language. Based on the articles selected for the final review, we concluded that herbal supplements and nutraceuticals help reduce the frequency of migraine headaches; however, mixed results were seen regarding the severity and duration of headaches. Moreover, there were no concerning side effects with these supplements. Therefore, physicians can suggest herbal supplements to patients who experience adverse effects from pharmaceutical drugs and desire a more natural treatment.
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Affiliation(s)
- Kavaljeet Kaur
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Vernicia Hernandez
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Sari W Al Hajaj
- Surgery, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Ahmed M Ebrahim
- Surgery, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Mirash Razack
- Emergency Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA.,Medicine, Wuhan University, Wuhan, CHN.,Internal Medicine, Al Ain Hospital, Al Ain, ARE
| | - Mohamed W ElSharief
- Pediatrics and Child Health, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - David Dragas
- Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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9
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Vikelis M, Dermitzakis EV, Vlachos GS, Soldatos P, Spingos KC, Litsardopoulos P, Kararizou E, Argyriou AA. Open Label Prospective Experience of Supplementation with a Fixed Combination of Magnesium, Vitamin B2, Feverfew, Andrographis Paniculata and Coenzyme Q10 for Episodic Migraine Prophylaxis. J Clin Med 2020; 10:jcm10010067. [PMID: 33375459 PMCID: PMC7794912 DOI: 10.3390/jcm10010067] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 12/17/2020] [Accepted: 12/23/2020] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND To investigate the efficacy and safety of supplementation with a fixed combination of magnesium, vitamin B2, feverfew, andrographis paniculata and coenzyme Q10 in episodic migraine (EM) prevention. METHODS A pilot, single-arm, open-label study was conducted. After a one-month baseline period, the above-described supplementation was introduced in 113 EM Greek patients, who were prospectively followed-up for three months. The primary endpoint was the change in monthly migraine days between baseline period (BSL) and the third month of supplementation (T3). Secondary endpoints included changes in mean intensity of migraine and in days with use of acute migraine medications. Changes in scores of Migraine Disability Assessment questionnaire (MIDAS), Headache Impact Test-6 (HIT-6), Migraine Therapy Assessment questionnaire (MTAQ), Migraine-Specific Quality-of-life questionnaire (MSQ-QOL), Hospital Anxiety and Depression Scale (HADS) were also evaluated. Those with ≥50% reduction in monthly migraine days at T3, compared to BSL were considered supplementation-responders. RESULTS The mean number of migraine days was significantly decreased between BSL and T3 (9.4 ± 3.7 vs. 6.1 ± 3.5; p < 0.001). Likewise, days with peak headache intensity of >4/10 (5.7 ± 3.4 vs. 4.9 ± 3.1; p < 0.001) as well as days using acute headache medications per month (8.9 ± 3.6 vs. 5.7 ± 3.4; p < 0.001) were significantly reduced. At T3, 64 patients (56.6%) were classified as responders. The beneficial effect of supplementation was also associated with significant changes in HIT-6, MIDAS, MTAQ and MSQ-QOL scores. There were no safety concerns. CONCLUSIONS The supplementation we have tested appears to be an effective and well-tolerated preventive approach against EM. A randomized, placebo-controlled study is needed to confirm our results.
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Affiliation(s)
- Michail Vikelis
- Headache Clinic, Mediterraneo Hospital, 16675 Glyfada, Greece;
- Glyfada Headache Clinic, 16675 Glyfada, Greece
- Headache Outpatient Clinic, 1st Department of Neurology, National and Kapodistrian University of Athens, 11528 Athens, Greece;
- Correspondence: ; Tel.: +30-2109681760
| | | | | | | | | | - Pantelis Litsardopoulos
- Headache Outpatient Clinic, Neurology Department of the Saint Andrew’s State General Hospital of Patras, 26335 Patras, Greece; (P.L.); (A.A.A.)
| | - Evangelia Kararizou
- Headache Outpatient Clinic, 1st Department of Neurology, National and Kapodistrian University of Athens, 11528 Athens, Greece;
| | - Andreas A. Argyriou
- Headache Outpatient Clinic, Neurology Department of the Saint Andrew’s State General Hospital of Patras, 26335 Patras, Greece; (P.L.); (A.A.A.)
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Recinella L, Chiavaroli A, di Giacomo V, Antolini MD, Acquaviva A, Leone S, Brunetti L, Menghini L, Ak G, Zengin G, Di Simone SC, Ferrante C, Orlando G. Anti-Inflammatory and Neuromodulatory Effects Induced by Tanacetum parthenium Water Extract: Results from In Silico, In Vitro and Ex Vivo Studies. Molecules 2020; 26:molecules26010022. [PMID: 33374525 PMCID: PMC7793142 DOI: 10.3390/molecules26010022] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 12/17/2020] [Accepted: 12/21/2020] [Indexed: 02/07/2023] Open
Abstract
Tanacetum parthenium (feverfew) has traditionally been employed as a phytotherapeutic remedy in the treatment of migraine. In this study, a commercial T. parthenium water extract was investigated to explore its anti-inflammatory and neuromodulatory effects. Isolated mouse cortexes were exposed to a K+ 60 mM Krebs-Ringer buffer and treated with T. parthenium water extract. The prostaglandin E2 (PGE2) level, brain-derived neurotrophic factor (BDNF), interleukin-10 (IL-10), and IL-1β gene expression were evaluated in the cortex. The effects on dopamine (DA) release and dopamine transporter (DAT) gene expression were assayed in hypothalamic HypoE22 cells. A bioinformatics analysis was conducted to further investigate the mechanism of action. The extract was effective in reducing cortex PGE2 release and IL-1β gene expression. In the same experimental system, IL-10 and BDNF gene expressions increased, and in HypoE22 cells, the extract decreased the extracellular dopamine level and increased the DAT gene expression due to the direct interaction of parthenolide with the DAT. Overall, the present findings highlight the efficacy of T. parthenium water extract in controlling the inflammatory pathways that occur during cortical-spreading depression. Additionally, the inhibition of the hypothalamic DA release observed in this study further supports the role of dopaminergic pathways as key targets for novel pharmacological approaches in the management of migraine attacks.
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Affiliation(s)
- Lucia Recinella
- Department of Pharmacy, Università degli Studi “Gabriele d’Annunzio”, via dei Vestini 31, 66100 Chieti, Italy; (L.R.); (A.C.); (V.d.G.); (M.D.A.); (A.A.); (S.L.); (L.B.); (L.M.); (S.C.D.S.); (G.O.)
| | - Annalisa Chiavaroli
- Department of Pharmacy, Università degli Studi “Gabriele d’Annunzio”, via dei Vestini 31, 66100 Chieti, Italy; (L.R.); (A.C.); (V.d.G.); (M.D.A.); (A.A.); (S.L.); (L.B.); (L.M.); (S.C.D.S.); (G.O.)
| | - Viviana di Giacomo
- Department of Pharmacy, Università degli Studi “Gabriele d’Annunzio”, via dei Vestini 31, 66100 Chieti, Italy; (L.R.); (A.C.); (V.d.G.); (M.D.A.); (A.A.); (S.L.); (L.B.); (L.M.); (S.C.D.S.); (G.O.)
| | - Marco Daniel Antolini
- Department of Pharmacy, Università degli Studi “Gabriele d’Annunzio”, via dei Vestini 31, 66100 Chieti, Italy; (L.R.); (A.C.); (V.d.G.); (M.D.A.); (A.A.); (S.L.); (L.B.); (L.M.); (S.C.D.S.); (G.O.)
| | - Alessandra Acquaviva
- Department of Pharmacy, Università degli Studi “Gabriele d’Annunzio”, via dei Vestini 31, 66100 Chieti, Italy; (L.R.); (A.C.); (V.d.G.); (M.D.A.); (A.A.); (S.L.); (L.B.); (L.M.); (S.C.D.S.); (G.O.)
- Veridia Italia Srl, via Raiale 285, 65100 Pescara, Italy
| | - Sheila Leone
- Department of Pharmacy, Università degli Studi “Gabriele d’Annunzio”, via dei Vestini 31, 66100 Chieti, Italy; (L.R.); (A.C.); (V.d.G.); (M.D.A.); (A.A.); (S.L.); (L.B.); (L.M.); (S.C.D.S.); (G.O.)
| | - Luigi Brunetti
- Department of Pharmacy, Università degli Studi “Gabriele d’Annunzio”, via dei Vestini 31, 66100 Chieti, Italy; (L.R.); (A.C.); (V.d.G.); (M.D.A.); (A.A.); (S.L.); (L.B.); (L.M.); (S.C.D.S.); (G.O.)
| | - Luigi Menghini
- Department of Pharmacy, Università degli Studi “Gabriele d’Annunzio”, via dei Vestini 31, 66100 Chieti, Italy; (L.R.); (A.C.); (V.d.G.); (M.D.A.); (A.A.); (S.L.); (L.B.); (L.M.); (S.C.D.S.); (G.O.)
| | - Gunes Ak
- Department of Biology, Science Faculty, Selcuk University, Campus, 42130 Konya, Turkey;
| | - Gokhan Zengin
- Department of Biology, Science Faculty, Selcuk University, Campus, 42130 Konya, Turkey;
- Correspondence: (G.Z.); (C.F.); Tel.: +90-332-223-2781 (G.Z.); +39-0871-355-4753 (C.F.); Fax: +90-332-223-8840 (G.Z.); +39-0871-355-4755 (C.F.)
| | - Simonetta Cristina Di Simone
- Department of Pharmacy, Università degli Studi “Gabriele d’Annunzio”, via dei Vestini 31, 66100 Chieti, Italy; (L.R.); (A.C.); (V.d.G.); (M.D.A.); (A.A.); (S.L.); (L.B.); (L.M.); (S.C.D.S.); (G.O.)
| | - Claudio Ferrante
- Department of Pharmacy, Università degli Studi “Gabriele d’Annunzio”, via dei Vestini 31, 66100 Chieti, Italy; (L.R.); (A.C.); (V.d.G.); (M.D.A.); (A.A.); (S.L.); (L.B.); (L.M.); (S.C.D.S.); (G.O.)
- Correspondence: (G.Z.); (C.F.); Tel.: +90-332-223-2781 (G.Z.); +39-0871-355-4753 (C.F.); Fax: +90-332-223-8840 (G.Z.); +39-0871-355-4755 (C.F.)
| | - Giustino Orlando
- Department of Pharmacy, Università degli Studi “Gabriele d’Annunzio”, via dei Vestini 31, 66100 Chieti, Italy; (L.R.); (A.C.); (V.d.G.); (M.D.A.); (A.A.); (S.L.); (L.B.); (L.M.); (S.C.D.S.); (G.O.)
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11
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Jones JC, O'Brien MJ. Medical Therapies for Concussion. Clin Sports Med 2020; 40:123-131. [PMID: 33187603 DOI: 10.1016/j.csm.2020.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The medications used in postconcussion syndrome are typically used to help manage or minimize disruptive symptoms while recovery proceeds. These medications are not routinely used in most concussions that recover within days to weeks. However, it is beneficial to be aware of medication options that may be used in athletes with prolonged concussion symptoms or for those that have symptom burdens that preclude entry into basic concussion protocols. Medications and supplements remain a small part of the concussion treatment plan, which may include temporary academic adjustments, physical therapy, vestibular and ocular therapy, psychological support, and graded noncontact exercise.
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Affiliation(s)
- Jacob C Jones
- Department of Sports Medicine, Texas Scottish Rite Hospital for Children, Dallas, TX, USA; Department of Orthopaedic Surgery and Pediatrics, University of Texas Southwestern, Dallas, TX, USA.
| | - Michael J O'Brien
- The Micheli Center for Sports Injury Prevention, Waltham, MA, USA; Division of Sports Medicine, Department of Orthopedics, Boston Children's Hospital, Boston, MA, USA; Department of Orthopaedic Surgery, Harvard Medical School, Boston, MA, USA; Boston Children's Sports Medicine, 319 Longwood Avenue, Boston, MA 02115, USA
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12
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Dolati S, Rikhtegar R, Mehdizadeh A, Yousefi M. The Role of Magnesium in Pathophysiology and Migraine Treatment. Biol Trace Elem Res 2020; 196:375-383. [PMID: 31691193 DOI: 10.1007/s12011-019-01931-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 10/14/2019] [Indexed: 01/03/2023]
Abstract
Migraine is one of the most common recurrent types of headache and is the seventh cause of disability. This neurological disorder is characterized by having pain in head and other various symptoms such as nausea, emesis, photophobia, phonophobia, and sometimes visual sensory disorders. Magnesium (Mg) is a necessary ion for human body and has a crucial role in health and life maintenance. One of the main roles of Mg is to conserve neurons electric potential. Therefore, magnesium deficiency can cause neurological complications. Migraine is usually related to low amounts of Mg in serum and cerebrospinal fluid (CSF). Deficits in magnesium have significant role in the pathogenesis of migraine. Mg has been extensively used in migraine prophylaxis and treatment. This review summarizes the role of Mg in migraine pathogenesis and the potential utilizations of Mg in the prevention and treatment of migraine with the emphasis on transdermal magnesium delivery.
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Affiliation(s)
- Sanam Dolati
- Aging Research Institute, Tabriz University of Medical Sciences, Tabriz, Iran
- Stem Cell Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
- Student's Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Reza Rikhtegar
- Aging Research Institute, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Amir Mehdizadeh
- Liver and Gastrointestinal Diseases Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mehdi Yousefi
- Stem Cell Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.
- Liver and Gastrointestinal Diseases Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.
- Department of Immunology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran.
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Abstract
Dietary supplements are frequently used in surgical patients. Surgeons should be up to date with regard to the efficacies and potential complications related to these supplements. This article provides the most updated practices and evidence of commonly used supplements.
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Hosseini SA, Zahrooni N, Ahmadzadeh A, Ahmadiangali K, Assarehzadegan MA. The Effect of CoQ 10 Supplementation on Quality of Life in Women with Breast Cancer Undergoing Tamoxifen Therapy: A Double-Blind, Placebo-Controlled, Randomized Clinical Trial. Psychol Res Behav Manag 2020; 13:151-159. [PMID: 32110123 PMCID: PMC7039424 DOI: 10.2147/prbm.s241431] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Accepted: 02/01/2020] [Indexed: 01/05/2023] Open
Abstract
Background Survival rates among breast cancer patients and the number of patients living with treatment side effects have improved, leading to increased focus on quality of life (QOL). The objective of this study was to determine the efficacy of CoQ10 on QOL scores among breast cancer patients in Iranian undergoing tamoxifen therapy. Methods Thirty breast cancer patients were randomized into two groups. The first group received 100 mg CoQ10, and the second group took fplacebo once a day for 8 weeks. QOL was evaluated by a standard QOL questionnaire and a specific questionnaire on QOL of breast cancer patients at baseline and the end of the study. Also, physical activity of patients was assessed with the IPAQ questionnaire and dietary intake determined by a 3-day dietary record. Results The data of 30 subjects were analyzed. According to QOL C30 data, CoQ10 led to a significant increase in physical functioning (P=0.029), emotional functioning (P=0.031), and cognitive functioning (P=0.023) compared to placebo. Symptom scales revealed a notable reduction in appetite loss in the first group (P=0.01). Global health status showed no significant changes in either study arm. On the QOL BR23, progress in functions and decline in symptoms were not statistically significant. Arm symptoms showed significant reduction (P=0.022) in patients that received placebo. Conclusion This trial indicates that CoQ10 supplementation has effects in ameliorating some dimensions of QOL in breast cancer patients. To generalize the results, larger and longer intervention studies are needed. Clinical Trial Registration IRCT2015042021874N1.
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Affiliation(s)
- Seyed Ahmad Hosseini
- Nutrition and Metabolic Diseases Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Nazanin Zahrooni
- Department of Nutrition, Faculty of Paramedicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Ahmad Ahmadzadeh
- Thalassemia and Hemoglobinopathy Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Kambiz Ahmadiangali
- Biostatistics Division, Health School, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Mohammad-Ali Assarehzadegan
- Immunology Research Center, Institute of Immunology and Infectious Diseases, Iran University of Medical Science, Tehran, Iran
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15
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Goschorska M, Gutowska I, Baranowska-Bosiacka I, Barczak K, Chlubek D. The Use of Antioxidants in the Treatment of Migraine. Antioxidants (Basel) 2020; 9:E116. [PMID: 32012936 PMCID: PMC7070237 DOI: 10.3390/antiox9020116] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 01/24/2020] [Accepted: 01/26/2020] [Indexed: 12/12/2022] Open
Abstract
Despite numerous studies concerning the pathophysiology of migraine, the exact molecular mechanism of disturbances underlying migraine is still unknown. Furthermore, oxidative stress is considered to play a significant role in migraine pathogenesis. The notion of oxidative stress in migraine patients has been discussed for several decades. Over the past few years, among the substances that could potentially be used for migraine treatment, particular attention has been paid to the so-called nutraceutics, including antioxidants. Antioxidants supplied with food prevent oxidative stress by inhibiting initiation, propagation, and the oxidative chain reaction itself. Additionally, the agents used so far in the prevention of migraine indeed show some anti-oxidative action. The antioxidants discussed in the present paper are increasingly more often used by migraine patients not only due to mild or even a lack of side effects but also because of their effectiveness (decreased frequency of migraine episodes or shortening of an episode duration). The present review provides a summary of the studies on nutraceuticals with antioxidative properties.
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Affiliation(s)
- Marta Goschorska
- Department of Biochemistry and Medical Chemistry, Pomeranian Medical University in Szczecin, Powst. Wlkp. 72, 70-111 Szczecin, Poland; (I.B.-B.); (D.C.)
| | - Izabela Gutowska
- Department of Medical Chemistry, Pomeranian Medical University in Szczecin, Powst. Wlkp. 72, 70-111 Szczecin, Poland;
| | - Irena Baranowska-Bosiacka
- Department of Biochemistry and Medical Chemistry, Pomeranian Medical University in Szczecin, Powst. Wlkp. 72, 70-111 Szczecin, Poland; (I.B.-B.); (D.C.)
| | - Katarzyna Barczak
- Department of Conservative Dentistry and Endodontics, Pomeranian Medical University in Szczecin, Powst. Wlkp. 72, 70-111 Szczecin, Poland;
| | - Dariusz Chlubek
- Department of Biochemistry and Medical Chemistry, Pomeranian Medical University in Szczecin, Powst. Wlkp. 72, 70-111 Szczecin, Poland; (I.B.-B.); (D.C.)
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16
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Mansouri M, Sharifi F, Varmaghani M, Yaghubi H, Shokri A, Moghadas-Tabrizi Y, Keshtkar A, Sadeghi O. Dairy consumption in relation to primary headaches among a large population of university students: The MEPHASOUS study. Complement Ther Med 2020; 48:102269. [DOI: 10.1016/j.ctim.2019.102269] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Revised: 09/20/2019] [Accepted: 11/26/2019] [Indexed: 01/09/2023] Open
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Multiple pharmacological and toxicological investigations on Tanacetum parthenium and Salix alba extracts: Focus on potential application as anti-migraine agents. Food Chem Toxicol 2019; 133:110783. [PMID: 31491430 DOI: 10.1016/j.fct.2019.110783] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 08/11/2019] [Accepted: 08/21/2019] [Indexed: 01/06/2023]
Abstract
Migraine is one of the most common neurological disorder, which has long been related to brain serotonin (5-HT) depletion and neuro-inflammation. Despite many treatment options are available, the frequent occurrence of unacceptable adverse effects further supports the research toward nutraceuticals and herbal preparations, among which Tanacetum parthenium and Salix alba showed promising anti-inflammatory and neuro-modulatory activities. The impact of extract treatment on astrocyte viability, spontaneous migration and apoptosis was evaluated. Anti-inflammatory/anti-oxidant effects were investigated on isolated rat cortexes exposed to a neurotoxic stimulus. The lactate dehydrogenase (LDH) release, nitrite levels and 5-HT turnover were evaluated, as well. A proteomic analysis was focused on specific neuronal proteins and a fingerprint analysis was carried out on selected phenolic compounds. Both extracts appeared able to exert in vitro anti-oxidant and anti-apoptotic effects. S. alba and T. parthenium extracts reduced LDH release, nitrite levels and 5-HT turnover induced by neurotoxic stimulus. The downregulation of selected proteins suggest a neurotoxicity, which could be ascribed to an elevated content of gallic acid in both S. alba and T. parthenium extracts. Concluding, both extracts exert neuroprotective effects, although the downregulation of key proteins involved in neuron physiology suggest caution in their use as food supplements.
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Abstract
BACKGROUND Migraine is a chronic disabling neurologic condition that can be treated with a combination of both pharmacologic and complementary and integrative health options. EVIDENCE ACQUISITION With the growing interest in the US population in the use of nonpharmacologic treatments, we reviewed the evidence for supplements and behavioral interventions used for migraine prevention. RESULTS Supplements reviewed included vitamins, minerals, and certain herbal preparations. Behavioral interventions reviewed included cognitive behavioral therapy, biofeedback, relaxation, the third-wave therapies, acupuncture, hypnosis, and aerobic exercise. CONCLUSIONS This article should provide an appreciation for the wide range of nonpharmacologic therapies that might be offered to patients in place of or in addition to migraine-preventive medications.
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Affiliation(s)
- Palak S Patel
- Departments of Neurology (PSP, MTM) and Population Health (MTM), NYU Langone Health, New York, New York
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19
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Zeng Z, Li Y, Lu S, Huang W, Di W. Efficacy of CoQ10 as supplementation for migraine: A meta-analysis. Acta Neurol Scand 2019; 139:284-293. [PMID: 30428123 DOI: 10.1111/ane.13051] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2018] [Revised: 10/10/2018] [Accepted: 10/27/2018] [Indexed: 12/18/2022]
Abstract
OBJECTIVES Migraine ranks among the most frequent neurological disorders globally. Co-enzyme Q10 (CoQ10) is a nutritional agent that might play a preventative role in migraine. This meta-analysis aimed to investigate the effects of CoQ10 as a supplemental agent in migraine. SUBJECTS AND METHODS Web of Science, PubMed, and Cochrane Library were searched for potential articles that assessed the effects of CoQ10 on migraine. Data were extracted by two independent reviewers and analyzed with Revman 5.2 software (The Nordic Cochrane Centre, Copenhagen, Denmark). RESULTS We included five studies with 346 patients (120 pediatric and 226 adult subjects) in the meta-analysis. CoQ10 was comparable with placebo with respect to migraine attacks/month (P = 0.08) and migraine severity/day (P = 0.08). However, CoQ10 was more effective than placebo in reducing migraine days/month (P < 0.00001) and migraine duration (P = 0.009). CONCLUSION This is the first study to demonstrate the effects of CoQ10 supplementation on migraine. The results support the use of CoQ10 as a potent therapeutic agent with respect to migraine duration and migraine days/month. Nonetheless, more studies are needed to support the conclusions.
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Affiliation(s)
- ZhiYong Zeng
- Department of Pediatrics; The Second People’s Hospital of Longgang District; Shenzhen China
| | - YunPeng Li
- Department of Neurosurgery; The People’s Hospital of Ningdu Country; Ganzhou China
| | - ShunYu Lu
- Department of Pharmacy; The Fourth Affiliated Hospital of Guangxi Medical University/Liuzhou Worker’s Hospital; Liuzhou China
| | - WanSu Huang
- Department of Criminal Science and Technology; Guangxi Police College; Nanning China
| | - Wei Di
- Department of Neurology; Shaanxi Provincial People’s Hospital, Third Affiliated Hospital of Medical College, Xi’an Jiaotong University; Xi’an China
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Wells RE, Beuthin J, Granetzke L. Complementary and Integrative Medicine for Episodic Migraine: an Update of Evidence from the Last 3 Years. Curr Pain Headache Rep 2019; 23:10. [PMID: 30790138 PMCID: PMC6559232 DOI: 10.1007/s11916-019-0750-8] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to evaluate evidence from the last 3 years on complementary and integrative medicine treatment options for episodic migraine. Using Pubmed, Embase, and Cochrane databases, research published from 2015-2018 evaluating the modalities of mind/body therapies, supplements, and manual therapies for treatment of migraine were assessed. RECENT FINDINGS Although many studies had major methodological challenges that limit interpretation, several studies reported decreased headache frequency, improved quality of life, or less affective responses to pain. The evidence is currently most promising for the mind/body treatment options of mindfulness, yoga, and tai chi. Mindfulness meditation may be as effective as pharmacological treatment for medication-overuse headache after the offending medication is withdrawn. While older research has shown magnesium, riboflavin, feverfew, and butterbur to be helpful in migraine treatment, new research is promising to suggest potential benefit with melatonin, vitamin D, higher dosages of vitamin B6 (80 mg)/folic acid 5 mg combinations, and the combination of magnesium 112.5 mg/CoQ10 100 mg/feverfew 100 mg. Omega 3s have limited evidence of efficacy in migraine. Butterbur needs to be free of pyrrolizidine alkaloids (PA) to ensure safety given their hepatotoxicity. Physical therapy (PT) continues to have strong evidence of support, and acupuncture is superior to sham acupuncture and placebo. Side effects and risks reported were minimal and well tolerated overall, with the exception of the life-threatening risk of cervical artery dissection with high-velocity chiropractic manipulation and hepatotoxicity with the PAs in butterbur. Several studies are ongoing to further evaluate mindfulness, melatonin, PT, exercise, chiropractic manipulation, and acupuncture. The American Academy of Neurology (AAN) and American Headache Society (AHS) are currently updating the guidelines for integrative treatment options for migraine, so additional recommendations may be available soon. In conclusion, many complementary and integrative treatment options may be helpful for patients with migraines, and understanding potential efficacy, benefits, and risks can help providers discuss these modalities with their patients. Such a conversation can empower patients, build the therapeutic relationship, and increase self-efficacy, thus improving outcomes and patient-centered care.
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Affiliation(s)
- Rebecca Erwin Wells
- Department of Neurology, Wake Forest Baptist Health, Winston-Salem, NC, USA.
| | - Justin Beuthin
- Department of Neurology, Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - Laura Granetzke
- Department of Neurology, Wake Forest Baptist Health, Winston-Salem, NC, USA
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21
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Canceri JM, Brown R, Watson SR, Browne CJ. Examination of Current Treatments and Symptom Management Strategies Used by Patients With Mal De Debarquement Syndrome. Front Neurol 2018; 9:943. [PMID: 30483208 PMCID: PMC6240763 DOI: 10.3389/fneur.2018.00943] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 10/22/2018] [Indexed: 12/15/2022] Open
Abstract
Introduction: Mal de Debarquement Syndrome (MdDS) is a neurological disorder which affects the vestibular system pathways, manifesting as a constant sensation of movement in the form of rocking, bobbing, or swaying. The mechanism of MdDS is poorly understood and there is a lack of awareness amongst medical professionals about the condition. This study aimed to examine treatments and symptom management strategies used by MdDS patients and evaluate their self-reported effectiveness. Method: Motion-Triggered and Spontaneous/Other onset MdDS patients responded to a set of comprehensive questions as a retrospective survey regarding epidemiological details, diagnostic procedures, onset, and symptom triggers, hormonal influences as well as treatments and symptom management strategies used to reduce symptoms. The Motion-Triggered questionnaire was made available through Survey Monkey and the Spontaneous/Other Onset questionnaire through Qualtrics. The link for each questionnaire was made available on online MdDS support groups and on various research websites. Descriptive statistics were used for epidemiological data and Pearson's Chi Square tests were used for comparisons between and within both subtype groups. Results: A total of 370 patients participated in the surveys, with 287 valid responses collected for the section regarding treatment and symptom management strategies. The success of the treatments and symptom management strategies did not vary between subtypes Benzodiazepines/Antidepressants were reported as being most beneficial in reducing symptoms in both groups. Conclusion: This was the first attempt to evaluate the reported success of treatments and symptom management strategies in MdDS patients by assessing the patients' perceived helpfulness. The treatments and symptom management strategies reported to be the most helpful in managing and/or reducing symptoms are proposed to be effective due to their stress-reducing capacities. We hope this study will broaden MdDS awareness and that this study will increase patient knowledge regarding treatments and symptom management strategies that other patients found helpful.
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Affiliation(s)
- Josephine M Canceri
- School of Science and Health, Western Sydney University, Sydney, NSW, Australia
| | - Rachael Brown
- School of Medicine, Western Sydney University, Sydney, NSW, Australia
| | - Shaun R Watson
- Prince of Wales Private Hospital, Sydney, NSW, Australia
| | - Cherylea J Browne
- School of Science and Health, Western Sydney University, Sydney, NSW, Australia.,Translational Neuroscience Facility, School of Medical Sciences, UNSW Sydney, Sydney, NSW, Australia
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22
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Krymchantowski AV, Krymchantowski AGF, Jevoux CDC. Medication-overuse headache. Retrospective comparison of preventive treatments. ARQUIVOS DE NEURO-PSIQUIATRIA 2018; 76:668-673. [DOI: 10.1590/0004-282x20180097] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Accepted: 06/20/2018] [Indexed: 01/03/2023]
Abstract
ABSTRACT Objectives: Medication-overuse headache is commonly seen in tertiary centers. Limited evidence is available regarding treatment. We compared the use of one or two drugs, three drugs, or four pharmacological agents for the prevention of headache. Methods: This was a retrospective analysis of 149 consecutive patients. Sudden withdrawal and pharmacological prevention with one or more drugs were carried out. Adherence and the decrease of headache frequency of more than 50% were compared after four months between the one or two, three, and four drug groups. Results: There was no difference in adherence (p > 0.6). Headache frequency reduction was shown in 23 (54.8%, one or two drugs), 33 (70%, three drugs) and 11 (55%, four drugs); p = 0.13 and p = 0.98, not significant. There was a tendency towards significance between the one or two drug takers versus the three drug and four drug takers together (p = 0.09). Conclusions: The use of more drugs was not better at improving headache. However, there is the possibility that acting simultaneously on different sites may promote broader modulation and better outcome.
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