Placebo and nocebo in the treatment of migraine: How much does real world effectiveness depend on contextual effects?

PURPOSE

Treatments in medicine impact individuals beyond their intended effects, due to phenomena such as the placebo and nocebo effects. The placebo effect arises from the positive expectation of a treatment being beneficial, while the nocebo effect stems from the negative expectation of a treatment causing harm. Both in real-world practice and clinical trials, treatments can lead to outcomes unrelated to their intended mechanism of action, which we categorize as placebo and nocebo responses. These responses, combined with the inherent fluctuation in a condition's natural progression, regression to the mean, and random comorbidities, make up a significant part of the therapeutic experience. Particularly in pain management, placebo and nocebo effects play a substantial role. By addressing modifiable contextual factors such as patient expectations, lifestyle choices, and the therapeutic relationship, healthcare providers can enhance the effectiveness of migraine treatments, paving the way for a more comprehensive, individualized approach to patient care. We must also consider non-modifiable factors like personal experiences, beliefs, and information from social media and the internet.

CONCLUSION

This review offers a summary of our current understanding of the placebo and nocebo effects in migraine management.

COVID-19 vaccination-related headache showed two different clusters in the long-term course: a prospective multicenter follow-up study (COVA-Head Study)

BACKGROUND

Although acute headache following COVID-19 vaccination is widely acknowledged, the long-term progression of these headaches remains poorly understood. Our objective was to identify various phenotypes of prolonged or worsened headaches associated with COVID-19 vaccination and document any changes in these phenotypes over an extended period. Additionally, we aimed to document the diverse headache presentations among patients with pre-existing primary headaches.

METHODS

A multinational, prospective observational study was conducted to investigate prolonged or worsened headaches associated with COVID-19 vaccination. Questionnaires assessing COVID-19 vaccination-related headaches at three time points (initial visit, 3rd month follow-up, and 6th month follow-up) were developed for the study. Headache specialists/clinicians evaluated patients using these questionnaires in a prospective manner. Repeated K-means cluster analysis was performed to identify patient profiles with prolonged or worsened headaches related to COVID-19 vaccination.

RESULTS

Among the 174 patients included in the study, there was a female-to-male ratio of 128 (73.6%) to 46 (26.4%). The mean age of the patient group was 45.2 ± 13.3 years, and 107 patients (61.5%) had a pre-existing history of primary headaches. Through the analysis, two major clusters were identified based on headache characteristics at each visit. During the first visit (n = 174), Cluster 1 primarily comprised patients with a history of primary headaches, frontal localization of pain, throbbing pain type, more severe headaches accompanied by symptoms such as nausea, phonophobia, photophobia, and osmophobia, and worsened by physical activity. In contrast, Cluster 2 consisted of patients with longer headache durations (over one month) and a stabbing/pressing quality of pain. Patients in Cluster 1 had a higher prevalence of migraine as the pre-existing primary headache disorder compared to Cluster 2 (90.48% vs. 68.18%, respectively; p = 0.005).

CONCLUSION

The identification of two distinct phenotypes of prolonged or worsened headaches related to COVID-19 vaccination can provide valuable clinical insights. Having an awareness of the potential worsening of headaches following COVID-19 vaccination, particularly in patients with a primary headache disorder such as migraine, can help clinicians and headache experts anticipate and adjust their treatment strategies accordingly. This knowledge can aid in preplanning treatment modifications and optimize patient care.

Quality of life in people with multiple sclerosis receiving glatiramer acetate or interferon in Greek clinical practice

Aim: To evaluate glatiramer acetate (GA) or IFN-β effects on quality of life (QoL) in people with relapsing/remitting multiple sclerosis (PwRRMS) in Greece. Methods: A prospective, practice-based study. QoL/function/symptoms were assessed by seven questionnaires/scales. Results: Significant increases in Short Form-36 (SF-36) health survey scores occurred with GA in four of the eight domains and three of the eight domains at 6 and 12 months, respectively, versus baseline. Similar and significant SF-36 score improvements occurred with GA in treatment-naive PwRRMS. SF-36 scores were unaffected in GA-treated, IFN-β treatment-experienced PwRRMS, or with IFN-β versus baseline. Slight improvements in fatigue and sexual satisfaction were evident (6 months). No deteriorations were seen in the other four instruments. Conclusion: The findings show that 12-month treatment with GA, but not IFN-β, improved certain QoL parameters in treatment-naive PwRRMS.

Structured headache services as the solution to the ill-health burden of headache. 2. Modelling effectiveness and cost-effectiveness of implementation in Europe: methodology

BACKGROUND

Health economic evaluations support health-care decision-making by providing information on the costs and consequences of health interventions. No universally accepted methodology exists for modelling effectiveness and cost-effectiveness of interventions designed to close treatment gaps for headache disorders in countries of Europe (or elsewhere). Our aim here, within the European Brain Council's Value-of-Treatment project, was to develop headache-type-specific analytical models to be applied to implementation of structured headache services in Europe as the health-care solution to headache.

METHODS

We developed three headache-type-specific decision-analytical models using the WHO-CHOICE framework and adapted these for three European Region country settings (Luxembourg, Russia and Spain), diverse in geographical location, population size, income level and health-care systems and for which we had population-based data. Each model compared current (suboptimal) care vs target care (delivered in accordance with the structured headache services model). Epidemiological and economic data were drawn from studies conducted by the Global Campaign against Headache; data on efficacy of treatments were taken from published randomized controlled trials; assumptions on uptake of treatments, and those made for Healthy Life Year (HLY) calculations and target-care benefits, were agreed with experts. We made annual and 5-year cost estimates from health-care provider (main analyses) and societal (secondary analyses) perspectives (2020 figures, euros).

RESULTS

The analytical models were successfully developed and applied to each country setting. Headache-related costs (including use of health-care resources and lost productivity) and health outcomes (HLYs) were mapped across populations. The same calculations were repeated for each alternative (current vs target care). Analyses of the differences in costs and health outcomes between alternatives and the incremental cost-effectiveness ratios are presented elsewhere.

CONCLUSIONS

This study presents the first headache-type-specific analytical models to evaluate effectiveness and cost-effectiveness of implementing structured headache services in countries in the European Region. The models are robust, and can assist policy makers in allocating health budgets between interventions to maximize the health of populations.

Structured headache services as the solution to the ill-health burden of headache. 3. Modelling effectiveness and cost-effectiveness of implementation in Europe: findings and conclusions

BACKGROUND

There have been several calls for estimations of costs and consequences of headache interventions to inform European public-health policies. In a previous paper, in the absence of universally accepted methodology, we developed headache-type-specific analytical models to be applied to implementation of structured headache services in Europe as the health-care solution to headache. Here we apply this methodology and present the findings.

METHODS

Data sources were published evidence and expert opinions, including those from an earlier economic evaluation framework using the WHO-CHOICE model. We used three headache-type-specific analytical models, for migraine, tension-type-headache (TTH) and medication-overuse-headache (MOH). We considered three European Region case studies, from Luxembourg, Russia and Spain to include a range of health-care systems, comparing current (suboptimal) care versus target care (structured services implemented, with provider-training and consumer-education). We made annual and 5-year cost estimates from health-care provider and societal perspectives (2020 figures, euros). We expressed effectiveness as healthy life years (HLYs) gained, and cost-effectiveness as incremental cost-effectiveness-ratios (ICERs; cost to be invested/HLY gained). We applied WHO thresholds for cost-effectiveness.

RESULTS

The models demonstrated increased effectiveness, and cost-effectiveness (migraine) or cost saving (TTH, MOH) from the provider perspective over one and 5 years and consistently across the health-care systems and settings. From the societal perspective, we found structured headache services would be economically successful, not only delivering increased effectiveness but also cost saving across headache types and over time. The predicted magnitude of cost saving correlated positively with country wage levels. Lost productivity had a major impact on these estimates, but sensitivity analyses showed the intervention remained cost-effective across all models when we assumed that remedying disability would recover only 20% of lost productivity.

CONCLUSIONS

This is the first study to propose a health-care solution for headache, in the form of structured headache services, and evaluate it economically in multiple settings. Despite numerous challenges, we demonstrated that economic evaluation of headache services, in terms of outcomes and costs, is feasible as well as necessary. Furthermore, it is strongly supportive of the proposed intervention, while its framework is general enough to be easily adapted and implemented across Europe.

352. Seronegative Relapse of Brucellosis in the Central Nervous System

Background

Brucellosis is the most common zoonotic infection in the world. High risk areas include the Mediterranean Basin, Eastern Europe and the Middle East. Clinical presentation is quite heterogenous.

CNS involvement (neurobrucellosis) varies widely, from 0,5 to 25%. This reflects a high prevalence in endemic areas and the lack of established criteria for a diagnosis. We present a patient with a seronegative relapse of brucellosis, confined in the CNS, identified by Brucella IgG ELISA and 16S rRNA sequencing.

Methods

Case Report

Results

A 60-year-old man, farmer, with a history of systematic brucellosis two years before admission, presented with high fever, headache and agitation. A serum agglutination test and anti-Brucella IgG ELISA were negative at baseline. Spinal tap revealed lymphocytosis and low glucose. CSF culture was negative. The patient received ceftriaxone, ampicillin and acyclovir with an initial remission. A week later the patient’s symptoms relapsed. Administration of ceftriaxone and acyclovir was reinitiated with clinical improvement, however, lymphocytic meningitis persisted even after 15 days of treatment.

Brain MRI demonstrated nonspecific white matter hyperintensities and severe meningitis as identified by contrast-enhanced 3D Flair MRI. CSF oligoclonal bands showed intrathecal immunoglobin synthesis. CSF agglutination tests and CSF IgG ELISA were positive for Brucella. Though CSF PCR for Brucella was negative, 16S rRNA sequencing revealed the presence of Brucella spp. Patient was treated with ceftriaxone and dexamethasone and despite an initial worsening of neurological symptoms of tremor, loss of balance, hearing loss and diplopia, a clinical remission was achieved after a month and a laboratory remission after eight months of treatment.

Brain MRI: 3D Flair Sequence with Contrast Enhancement

Table. CSF Parameters

Conclusion

Neurobrucellosis presents with a variety of clinical symptoms and it should always be considered in neurological patients in highly endemic areas. Establishing a diagnosis is challenging. In our patient, CSF oligoclonal bands and the agglutination test in the CSF helped in achieving a diagnosis, suggesting their possible role in the diagnostic criteria. Although still under debate, the use of corticosteroids in our patient as well as the prolonged use of ceftriaxone in the therapeutic regime were crucial.

Disclosures

All Authors: No reported disclosures

Is There a Brain/Heart Interaction in Rheumatoid Arthritis and Seronegative Spondyloartropathies? A Combined Brain/Heart Magnetic Resonance Imaging Reveals the Answer

PURPOSE OF REVIEW

To present the interaction between brain/heart and emphasize the role of combined brain/heart magnetic resonance imaging (MRI) in patients with rheumatoid arthritis (RA) and other seronegative spondyloarthropathies (SNA).

RECENT FINDINGS

Both traditional cardiovascular disease (CVD) risk factors and intrinsic RA/SNA features contribute to the increased CVD-related morbidity/mortality. CVD in RA usually occurs a decade earlier than age- and sex-matched controls, and RA patients are twice more likely to develop myocardial infarction irrespective of age, history of prior CVD, and traditional CVD risk factors. RA also increases risk of non-ischemic heart failure (HF), valvular disease, and myo-pericarditis. CVD in SNA affects more commonly patients with long-standing disease. Ascending aortitis, aortic/mitral insufficiency, conduction defects, and diastolic dysfunction are the commonest findings in ankylosing spondylitis (AS). CVD is also the leading cause of death in psoriatic arthritis (PsA), due to myopericarditis, diastolic dysfunction, and valvular disease. Brain damage, due to either ischemic or hemorrhagic stroke and silent vascular damage, such as white matter hyperenhancement (WMH), is increased in both RA/SNA and may lead to cognitive dysfunction, depression, and brain atrophy. Magnetic resonance imaging (MRI) is ideal for serial brain/heart evaluation of patients with systemic diseases. RA/SNA patients are at high risk for brain/heart damage at early age, irrespectively of classic risk factors. Until more data will be obtained, a combined brain/heart MRI evaluation can be proposed in RA/SNA with new onset of arrhythmia and/or HF, cognitive dysfunction and/or depression.

AB0553 THE NOCEBO PHENOMENON PARTLY ACCOUNTS FOR DIARRHOEA AMONG PARTICIPANTS IN THE RANDOMIZED PLACEBO-CONTROLLED TRIAL OF NINTEDANIB FOR INTERSTITIAL LUNG DISEASE ASSOCIATED WITH SYSTEMIC SCLEROSIS (SENSCIS)

Background:

The nocebo phenomenon, the opposite of placebo, defined as unfavourable changes in a patient’s symptoms or condition resulting from negative anticipations to treatment and possibly leading to suboptimal outcomes and non- adherence, is more frequent than previously thought in rheumatology practice[1]. The tyrosine kinase inhibitor nintedanib has shown efficacy for the treatment of systemic sclerosis (SSc)-associated interstitial lung disease in SENSCIS, a recent randomized controlled trial (RCT)[2]. Diarrhoea was the most frequently reported adverse event in SENSCIS.

Objectives:

To test whether the nocebo phenomenon is involved in the prevalence of diarrhoea as an adverse event in trials with nintedanib.

Methods:

We compared the incidence of diarrhoea in the placebo arm between SENSCIS and all other placebo controlled RCTs involving >40 SSc patients in each arm, as well as between SENSCIS and all other nintedanib RCTs published so far. We also compared the strength of the warnings for diarrhea (ie times word is mentioned and number of lines devoted to nintedanib related “diarrhoea”) in the informed consent forms (ICFs) of different nintedanib RCTs

Results:

The mean percentage of patients reporting diarrhoea was 32% in the placebo arm and 76% in the active treatment arm in SENSCIS. These numbers are comparing to a prevalence of only 7% (range 2.3-9.1%) and 9% (range 5.8-14%), respectively of other RCTs in SSc (bosentan, n=2; macitentan, n=2; tocilizumab, n=1). Since the estimated point prevalence of diarrhoea in an SSc cohort similar to SENSCIS would not exceed 15% based on the literature, there was an at least 2-fold increase in the occurrence of diarrhoea in the placebo group during SENSCIS. More importantly, when looking into other nintedanib RCTs (Table 1), we found that patients reporting diarrhoea in the placebo arm were 20% and 18% in cancer and idiopathic pulmonary fibrosis (IPF) trials, respectively, which is almost half than in SENSCIS. Consistent with our hypothesis, the percentage of diarrhoea in the placebo arms of the different nintedanib RCTs increased along with the number of mentions and the number of lines devoted to “diarrhoea” in the respective ICFs.

Table 1.

Percentage of patients developing diarrhoea in phase III nintedanib RCTs and diarrhoea-related warnings in ICFs

Published RCT(year of publication)Treatment indicationplacebo arm, Nnintedanib arm, N (mg/bid)Adjunctive treatment% DiarrhoeaMentions of ‘diarrhoea’/lines devoted in ICFPlaceboActive treatmentSENSCIS(2019)SSc-ILD288288(150)48% MMF5% MTX31.675.79/11INBUILD(2019)Progressive Fibrosing ILD including SSc-ILD and other CTD-ILDs331332 (150)18% ≥1 from biologics, DMARDs, corticoids23.966.98/10INPULSIS1(2014)IPF204309 (150)21% corticosteroids18.661.53/3INPULSIS2(2014)IPF219329 (150)21% corticosteroids18.363.23/3LUME-Lung 1(2014)Lung cancer659655(200)docetaxel21.842.32/4LUME-Lung 2(2016)Lung cancer360353(200)pemetrexed15.434.94/5LUME-meso phase III(2019)Malignant pleural mesothelioma229229(200)pemetrexed & cisplatin23.053.04/5

Conclusion:

These results indicate that the nocebo phenomenon is partially involved in the high prevalence of diarrhoea among SSc patients participating in the SENSCIS trial. Whether patients with SSc have increased susceptibility to the nocebo phenomenon when compared to patients with IPF or cancer deserves further study.

References:

[1]KravvaritiE et al.Nat. Rev. Rheumatol.2018;14,727.

[2]Distler O et al.N. Engl. J. Med.2019;380:2518.

Disclosure of Interests:

Vasiliki-Kalliopi Bournia Grant/research support from: Travel Grant from Boehringer Ingelheim, Dimos Mitsikostas: None declared, Oliver Distler Grant/research support from: Grants/Research support from Actelion, Bayer, Boehringer Ingelheim, Competitive Drug Development International Ltd. and Mitsubishi Tanabe; he also holds the issued Patent on mir-29 for the treatment of systemic sclerosis (US8247389, EP2331143)., Consultant of: Consultancy fees from Actelion, Acceleron Pharma, AnaMar, Bayer, Baecon Discovery, Blade Therapeutics, Boehringer, CSL Behring, Catenion, ChemomAb, Curzion Pharmaceuticals, Ergonex, Galapagos NV, GSK, Glenmark Pharmaceuticals, Inventiva, Italfarmaco, iQvia, medac, Medscape, Mitsubishi Tanabe Pharma, MSD, Roche, Sanofi and UCB, Speakers bureau: Speaker fees from Actelion, Bayer, Boehringer Ingelheim, Medscape, Pfizer and Roche, Petros Sfikakis Grant/research support from: Grant/research support from Abvie, Novartis, MSD, Actelion, Amgen, Pfizer, Janssen Pharmaceutical, UCB

Non-invasive vagus nerve stimulation (nVNS) for the preventive treatment of episodic migraine: The multicentre, double-blind, randomised, sham-controlled PREMIUM trial

INTRODUCTION

Non-invasive vagus nerve stimulation (nVNS; gammaCore®) has the potential to prevent migraine days in patients with migraine on the basis of mechanistic rationale and pilot clinical data.

METHODS

This multicentre study included a 4-week run-in period, a 12-week double-blind period of randomised treatment with nVNS or sham, and a 24-week open-label period of nVNS. Patients were to administer two 120-second stimulations bilaterally to the neck three times daily (6-8 hours apart).

RESULTS

Of 477 enrolled patients, 332 comprised the intent-to-treat (ITT) population. Mean reductions in migraine days per month (primary outcome) were 2.26 for nVNS (n = 165; baseline, 7.9 days) and 1.80 for sham (n = 167; baseline, 8.1 days) (p = 0.15). Results were similar across other outcomes. Upon observation of suboptimal adherence rates, post hoc analysis of patients with ≥ 67% adherence per month demonstrated significant differences between nVNS (n = 138) and sham (n = 140) for outcomes including reduction in migraine days (2.27 vs. 1.53; p = 0.043); therapeutic gains were greater in patients with aura than in those without aura. Most nVNS device-related adverse events were mild and transient, with application site discomfort being the most common.

CONCLUSIONS

Preventive nVNS treatment in episodic migraine was not superior to sham stimulation in the ITT population. The "sham" device inadvertently provided a level of active vagus nerve stimulation. Post hoc analysis showed significant effects of nVNS in treatment-adherent patients. Study identification and registration: PREMIUM; NCT02378844; https://clinicaltrials.gov/ct2/show/NCT02378844.

Headache service quality: the role of specialized headache centres within structured headache services, and suggested standards and criteria as centres of excellence

In joint initiatives, the European Headache Federation and Lifting The Burden have described a model of structured headache services (with their basis in primary care), defined service quality in this context, and developed practical methods for its evaluation.Here, in a continuation of the service quality evaluation programme, we set out ten suggested role- and performance-defining standards for specialized headache centres operating as an integral component of these services. Verifiable criteria for evaluation accompany each standard. The purposes are five-fold: (i) to inspire and promote, or stimulate the establishment of, specialized headache centres as centres of excellence; (ii) to define the role of such centres within optimally structured and organized national headache services; (iii) to set out criteria by which such centres may be recognized as exemplary in their fulfilment of this role; (iv) to provide the basis for, and to initiate and motivate, collaboration and networking between such centres both nationally and internationally; (v) ultimately to improve the delivery and quality of health care for headache.

Guideline on the use of onabotulinumtoxinA in chronic migraine: a consensus statement from the European Headache Federation

OnabotulinumtoxinA is being increasingly used in the management of chronic migraine (CM). Treatment with onabotulinumtoxinA poses challenges compared with traditional therapy with orally administered preventatives. The European Headache Federation identified an expert group that was asked to develop the present guideline to provide recommendations for the use of onabotulinumtoxinA in CM. The expert group recommend onabotulinumtoxinA as an effective and well-tolerated treatment of CM. Patients should preferably have tried two to three other migraine prophylactics before start of onabotulinumtoxinA. Patients with medication overuse should be withdrawn from the overused medication before initiation of onabotulinumtoxinA if feasible, if not onabotulinumtoxinA can be initiated from the start or before withdrawal. OnabotulinumtoxinA should be administered according to the PREEMPT injection protocol, i.e. injecting 155 U–195 U to 31–39 sites every 12-weeks. We recommend that patients are defined as non-responders, if they have less than 30% reduction in headache days per month during treatment with onabotulinumtoxinA. However other factors such as headache intensity, disability and patient preferences should also be considered when evaluating response. Treatment should be stopped, if the patient does not respond to the first two to three treatment cycles. Response to continued treatment with onabotulinumtoxinA should be evaluated by comparing the 4 weeks before with the 4 weeks after each treatment cycle. It is recommended that treatment is stopped in patients with a reduction to less than 10 headache days per month for 3 months and that patients are re-evaluated 4–5 months after stopping onabotulinumtoxinA to make sure that the patient has not returned to CM. Questions regarding efficacy and tolerability of onabotulinumtoxinA could be answered on the basis of scientific evidence. The other recommendations were mainly based on expert opinion. Future research on the treatment of CM with onabotulinumtoxinA may further improve the management of this highly disabling disorder.

Benefit-risk assessment of erenumab and current migraine prophylactic treatments using the likelihood of being helped or harmed

Objective

This study evaluated the benefit-risk profile of erenumab relative to other therapies approved for migraine prophylaxis and available in the majority of European countries.

Methods

Trials were identified via a published systematic literature review updated to December 2017 using MEDLINE. Erenumab’s pivotal trials study reports were also included (NCT02066415, NCT02456740). From these sources, ≥ 50% responder rates and discontinuations due to adverse events were extracted to generate numbers needed to treat and harm and likelihood of being helped or harmed, a quantitative benefit-risk measure.

Results

Eleven articles (nine randomized clinical trials) met the inclusion/exclusion criteria. Low numbers needed to treat (range: 4–13) were observed for most treatments, while numbers needed to harm showed substantial differences (erenumab’s higher numbers needed to harm indicating better tolerability). In chronic and episodic migraine, likelihoods of being helped or harmed for erenumab 70 mg were 143 and 167, and 42 and 167 for erenumab 140 mg. Likelihoods of being helped or harmed in chronic migraine were 2 and 3 for topiramate (two studies) and 4 for onabotulinumtoxinA. In episodic migraine, likelihoods of being helped or harmed were 2 for topiramate and 2 for propranolol.

Conclusions

While all prophylactic treatments were more likely to help than harm (likelihood of being helped or harmed > 1), erenumab showed a likelihood of being helped or harmed of high magnitude, supporting its favorable benefit-risk profile across the entire migraine frequency spectrum, in contrast with other prophylactic treatments.

Variables Affecting Factors Associated with Primary Headache

Primary headache syndromes’ development is associated with biological, psychological and social parameters. Factors such as daily habits, behavioral characteristics and sleep disorders also play an important role. We aim to identify the variables which affect the above factors. The study included 111 patients affected by primary headache. The patients were stratified into subgroups according to gender, age, occupation and headache type. Women attained higher scores than men in three of the evaluation rating scales and lower scores in the severity of dependence scale. Occupation was associated with SF36 and Hamilton anxiety scale. Unemployed had higher scores in Hamilton anxiety. Migraineurs and occupied individuals have lower SF36 scores. Women are associated with depression, anxiety and higher disability derived from headache. Men are more prone to dependence on opioids. Unemployment was linked with anxiety and well-being. The migraneurs presented a decreased level of quality of life.

Recommendations for Mechanical Thrombectomy in Patients with Acute Ischemic Stroke : A Clinical Guide by the Hellenic Stroke Organization

This document presents the consensus recommendations of the Hellenic Stroke Organization which can be of assistance to the treating stroke physicians.

A Randomized, Double-Blind, Placebo-Controlled Study of Venlafaxine XR in Out-Patients With Tension-Type Headache

The aim of this study was to evaluate in a double-blind, randomized, placebo-controlled study the safety and efficacy of venlafaxine extended release (XR) in the prophylactic treatment of out-patients with tension-type headache (TTH) and no current depression or anxiety disorders. Sixty neurology and headache clinic out-patients meeting the International Headache Society diagnostic criteria for TTH were treated with venlafaxine XR (150 mg/day, n = 34) or placebo ( n = 26) for 12 weeks. The primary efficacy variable was the decline in number of days with headache. At end-point, the venlafaxine XR group had a significantly greater decrease in the number of days with headache compared with placebo ( P = 0.05). Differences with regard to secondary efficacy variables where not significant. The number needed to treat for responders (≥50% reduction in days with headache) was 3.48. Six patients in the venlafaxine XR group interrupted therapy due to adverse events, while no patients in the placebo group did so for the same reason. The number needed to harm was 5.58. This study provides preliminary evidence for the efficacy and safety of venlafaxine XR 150 mg/day in reducing the number of days with TTH.

External ophthalmoplegia with ragged-red fibres and acetylcholine receptor antibodies

The cases of two elderly women with external ophthalmoplegia, generalized muscle weakness and serum anti-acetylcholine receptor antibodies, are presented. The electophysiological studies showed a myopathic pattern but no indications of myasthenia after repetitive stimulation. The edrophonium test was negative and there was no response to anticholinesterase medication. In addition, elevated serum lactic acid levels and ragged-red muscle fibres in the muscle biopsy, were observed in both patients. These findings are discussed in relation to the fact that anti-acetylcholine receptor antibodies are diagnostic of myasthenia gravis, whereas ragged-red fibres and elevated lactic acid are correlated with mitochondrial myopathies.

The effects of valproate in brain monoamines of juvenile rats after stress

1. Clinical data suggest that valproate (VPA) may be useful in prophylaxis of affective disorders, which show disturbances of the serotoninergic system. On the other hand, chronic stress has an adverse effect on affective disorders, those with disturbances of the serotonergic system, especially. 2. In order to study the effects of VPA on brain monoamines and acute stress, 200 mgr VPA/Kgr was administered intraperitoneal (ip) to juvenile male rats; the control group was treated with NaCL 0.9% ip. After 30 min, all animals were evoked on predictable neurogenic or systemic stress (30 min foot shock, or 15 min ether stress, respectively), and 48 hours later, VPA or NaCL were administered ip again; 30 min afterwards, the rats were decapitated. Rats without stress were also sacrificed 30 min after VPA or NaCL administration. 3. Measurements of brain monoamines noradrenaline (NA), dopamine (DA), 5-hydroxytryptamine (5-HT), and their metabolites 3,4-dihydroxyphenylacetic acid (DOPAC), and 5-hydroxyindoleacetic acid (5-HIAA), were done in Frontal Cortex (FC), Hypothalamus (HY) and Striatum (S), by High Performance Liquid Chromatography (HPLC). 4. Compared with the control stress group the level of 5-HIAA in the FC was significantly increased (P < 0.01) in VPA stress rats; in the HY and in S the increase of 5-HIAA was not significant. No remarkable differences were observed in NA, DA, 5-HT and DOPAC concentrations, in any of the brain regions. No changes in brain monoamine levels were found in non stress rats, either. 5. The augmentation of 5-HIAA level after VPA administration and after stress, in correlation with the decrease of 5-HIAA that is observed in depression, support the hypothesis that VPA may be effective in affective disorders by influencing the serotoninergic system.