Thyreotoxikose bei langjähriger Multipler Sklerose? – Fallstricke der MS-Therapie mit Biotin

Hochdosis-Biotin ist ein neuartiger Wirkansatz für Patienten mit progredienter Multipler Sklerose (MS), der aktuell in klinischen Studien getestet wird. Artifizielle Veränderungen von Labortests sind eine häufige Komplikation. Wir berichten von einem 44-jährigen Patienten mit vermeintlicher Thyreotoxikose unter Hochdosis-Biotintherapie. Durch potenzielle Interaktionen mit Labortests ist der Einsatz von hochdosiertem Biotin nur mit Vorsicht unter Berücksichtigung von Risikofaktoren (z. B. kardiale Erkrankungen) und erst nach intensiver Beratung sinnvoll. Das Mitführen einer Kurzinformation bei den Ausweispapieren ist anzuraten.

Clinical experience with THC:CBD oromucosal spray in patients with multiple sclerosis-related spasticity

This detailed medical charts' data collection study conducted at a multiple sclerosis (MS) clinic in Germany evaluated the effectiveness of tetrahydrocannabinol (THC)/cannabidiol (CBD) oromucosal spray in patients with resistant MS spasticity. Over a 15-month timeframe, THC:CBD spray was initiated in 166 patients. Mean follow-up was 9 months. In all, 120 patients remained on treatment for a response rate of 72%. THC:CBD spray was used as add-on therapy in 95 patients and as monotherapy in 25 patients to achieve best-possible therapeutic results. Among responders, the mean spasticity 0-10 numerical rating scale (NRS) score decreased by 57%, from 7.0 before treatment to 3.0 within 10 days of starting THC:CBD spray. The mean dosage was 4 sprays/day. Most patients who withdrew from treatment (40/46) had been receiving THC:CBD spray for less than 60 days. Main reasons for treatment discontinuation were: adverse drug reactions, mainly dizziness, fatigue and oral discomfort (23 patients; 13.9%); lack of efficacy (14 patients; 8.4%); or need for a baclofen pump (9 patients; 5.4%). No new safety signals were noted with THC:CBD spray during the evaluation period. In this routine clinical practice setting at an MS clinic in Germany, THC:CBD spray was effective and well tolerated as add-on therapy or as monotherapy in a relevant proportion of patients with resistant MS spasticity.

Familial Mediterranean fever-associated mutation pyrin E148Q as a potential risk factor for multiple sclerosis

BACKGROUND

Familial Mediterranean fever (FMF) is an inherited autoinflammatory disease caused by mutations in the MEFV gene and characterized by recurrent febrile polyserositis. A possible association of FMF and multiple sclerosis (MS) has been suggested in cohorts from Turkey and Israel.

OBJECTIVE

The objective of this study was to investigate the prevalence of MEFV mutations in subjects with MS and in controls in Germany.

METHODS

One-hundred and fifty seven MS patients with at least one symptom or without symptoms suggestive of FMF from our outpatient clinic were investigated for mutations in exons 2, 3, and 10 of the MEFV gene (group 1). 260 independent MS patients (group 2) and 400 unrelated Caucasian controls (group 3) were screened selectively for the low-penetrance pyrin mutations E148Q and K695R RESULTS: In group 1, 19 MS patients (12.1%) tested positive for a mutation in the MEFV gene, mainly the E148Q (n=7) substitution. Fifteen of the 19 mutation-positive individuals reported at least one symptom suggestive of FMF. In three cases, we could identify additional family members with MS. In these pedigrees, the E148Q exchange co-segregated with MS (p=0.026). Frequencies of the pyrin E148Q and K695R mutations were not statistically different between MS group 2 and controls but they occurred with a surprisingly high frequency in the German population.

CONCLUSION

The MEFV gene appears to be another immunologically relevant gene locus which contributes to MS susceptibility. In particular, the pyrin E148Q mutation, which co-segregated with disease in three MS families, is a promising candidate risk factor for MS that should be further explored in larger studies.

Force-pain relationship in functional magnetic and electrical stimulation of subjects with paresis and preserved sensation

OBJECTIVE

Using "painless" magnetic stimulation (FMS) to support the cycling of paretic subjects with preserved sensation is possible and potentially superior to electrical stimulation (FES). We investigated the dependence of the torque and the pain evoked by FMS and FES on stimulation conditions in order to optimize magnetic stimulation.

METHODS

Torque and pain induced by quadriceps stimulation in 13 subjects with paresis and preserved sensation (due to multiple sclerosis) were compared under the conditions: (1) small vs large stimulated surfaces of the thigh, (2) varying contraction velocities of the muscle (isometric vs 15 and 30 rpm isokinetic speed), (3) FMS vs FES modalities, and (4) varying magnetic coil locations.

RESULTS

Torque and pain significantly depended on the amount of surface and location of stimulation during FMS, on the stimulation modality, and on the muscle contraction velocity during FES and FMS. FMS with a saddle-shaped coil produced more torque (p<0.05) than any other stimulation modality, even at 30 rpm velocity.

CONCLUSIONS

To support leg cycling of subjects with preserved sensation, the application of FMS stimulation with a large-surface saddle-shaped coil and the focusing of stimulation on the lateral-frontal surface of the thigh produces greater torque and less pain than FES.

SIGNIFICANCE

Optimized magnetic stimulation is a superior alternative to electrical stimulation in the rehabilitation of subjects with preserved sensation.

Current management of pain associated with multiple sclerosis

While pain is a common problem in patients with multiple sclerosis (MS), it is not frequently mentioned by patients and a more direct approach is required in order to obtain information about pain from patients. Many patients with MS experience more than one pain syndrome; combinations of dysaesthesia, headaches and/or back or muscle and joint pain are frequent. For each pain syndrome a clear diagnosis and therapeutic concept needs to be established. Pain in MS can be classified into four diagnostically and therapeutically relevant categories: (i) neuropathic pain due to MS (pain directly related to MS); (ii) pain indirectly related to MS; (iii) MS treatment-related pain; and (iv) pain unrelated to MS. Painful paroxysmal symptoms such as trigeminal neuralgia (TN), or painful tonic spasms are treated with antiepileptics as first choice, e.g. carbamazepine, oxcarbazepine, lamotrigine, gabapentin, pregabalin, etc. Painful 'burning' dysaesthesias, the most frequent chronic pain syndrome, are treated with TCAs such as amitriptyline, or antiepileptics such as gabapentin, pregabalin, lamotrigine, etc. Combinations of drugs with different modes of action can be particularly useful for reducing adverse effects. While escalation therapy may require opioids, there are encouraging results from studies regarding cannabinoids, but their future role in the treatment of MS-related pain has still to be determined. Pain related to spasticity often improves with adequate physiotherapy. Drug treatment includes antispastic agents such as baclofen or tizanidine and in patients with phasic spasticity, gabapentin or levetiracetam are administered. In patients with severe spasticity, botulinum toxin injections or intrathecal baclofen merit consideration. While physiotherapy may ameliorate malposition-induced joint and muscle pain, additional drug treatment with paracetamol (acetaminophen) or NSAIDs may be useful. Moreover, painful pressure lesions should be avoided by using optimally adjusted aids. Treatment-related pain associated with MS can occur with subcutaneous injections of interferon-beta or glatiramer acetate, and may be reduced by optimizing the injection technique and by local cooling. Systemic (particularly 'flu-like') adverse effects of interferons, e.g. myalgias, can be reduced by administering paracetamol, ibuprofen or naproxen. A potential increase in the frequency of pre-existing headaches after starting treatment with interferons may require optimization of headache attack therapy or even prophylactic treatment. Pain unrelated to MS, such as back pain or headache, is common in patients with MS and may deteriorate as a result of the disease. In summary, a careful analysis of each pain syndrome will allow the design of the appropriate treatment plan using various medical and nonmedical options (multimodal therapy), and will thus help to improve the quality of life (QOL) of the patients.

[Acute headaches--when to treat immediately, when to wait]

Headaches are among the most frequently named symptoms in general practices. About 90% of the patients suffer from idiopathic headaches, for example, migraine or tension headaches, which are treated according to guidelines. An acute headache can however also be a symptom of a serious primary disease, such as subarachnoidal haemorrhage, arterial dissection, cerebral infarction, cerebral venous thrombosis or acute glaucoma. Patients with suspected symptomatic headaches must be immediately referred to a specialist or hospital for further diagnosis and therapy.

Palliative care in patients with severe multiple sclerosis: two case reports and a survey among German MS neurologists

Due to its chronic and fluctuating time course, multiple sclerosis (MS), thus far, has not been regarded as a focus of palliative care. However, sometimes we are confronted with severely affected MS patients, who suffer from complex medical, physical and psychosocial problems, which are not fully covered by the current health care services. We present two cases of severely affected MS patients we saw in our outpatient MS clinic, and who, we believe, are candidates for palliative care. The first patient, with primary chronic progressive (pcP) MS for many years (Expanded Disability Status Scale (EDSS): 8.0) presented with complex painful dysaesthesias and a depressive syndrome. He refused any treatment, and finally committed suicide with the help of a euthanasia group in Switzerland. The second patient was also severely affected by a secondary chronic progressive (scP) MS (EDSS: 9.0) and was finally admitted to our palliative care unit due to a complex pain syndrome associated with panic attacks and anxiety. She spent three weeks on the palliative care unit and her symptoms improved gradually after changing and optimising her pain medication. The patient was discharged with home care and is seen regularly on the palliative care unit. Additionally, as a first step, a questionnaire was sent to 53 German MS specialists regarding their general view on the needs for palliative care in MS. Our two cases and the results of the questionnaire demonstrated that MS patients and their caregivers are confronted with a variety of symptoms which are difficult to treat, and are a cause of great suffering for the patients, including ataxia, depression and fatigue. The data of the questionnaire also showed that neurologists usually do not deal with end-of-life care issues in MS.More research is needed to define the role of palliative care in MS and establish appropriate interventions to improve the quality of life in advanced stage MS patients and their relatives.

Late-onset tumor necrosis factor receptor–associated periodic syndrome in multiple sclerosis patients carrying theTNFRSF1A R92Q mutation

OBJECTIVE

Tumor necrosis factor receptor-associated periodic syndrome (TRAPS) is an autosomal-dominantly inherited autoinflammatory disorder caused by mutations in the TNFRSF1A gene. It is characterized by episodes of autoinflammation usually associated with fever, abdominal pain, myalgia, exanthema, arthralgia/arthritis, and ocular involvement. We undertook this study to investigate the prevalence of TRAPS in patients with multiple sclerosis (MS) who reported, in addition to their neurologic symptoms, at least 2 other symptoms compatible with TRAPS.

METHODS

Twenty-five unrelated MS patients were prospectively screened for TNFRSF1A mutations. In addition, blood samples from 365 unrelated MS patients and 407 unrelated Caucasian controls were analyzed to determine the R92Q carrier frequency.

RESULTS

Six of 25 adult MS patients (24%) with symptoms suggestive of TRAPS were found to carry the identical arginine-to-glutamine substitution at amino acid position 92 (R92Q or p.Arg121Gln) encoded by exon 4 of the TNFRSF1A gene. All R92Q heterozygotes had similar symptoms, including arthralgias/arthritis, myalgias, urticarial rash, and severe fatigue, which began before the onset of MS. In 5 of the 6 patients, we could identify family members who had TRAPS symptoms and had inherited the identical mutation. The R92Q exchange was also detected in 17 of 365 unselected MS patients (4.66%) and in 12 of 407 controls (2.95%) (P = 0.112). Three patients were heterozygous carriers of MEFV variants, in 1 patient in combination with the R92Q mutation.

CONCLUSION

Autoinflammatory syndromes and especially late-onset TRAPS should be considered in MS patients who report symptoms such as arthralgias/arthritis, myalgias, urticarial rash, and severe fatigue.

The effect of glatiramer acetate treatment on pre-existing headaches in patients with MS

During the first 6 months of glatiramer acetate therapy in 82 consecutive patients with multiple sclerosis, in only 6% frequency of pre-existing headaches increased by more than 50%. This is less than the headache aggravation reported in an earlier study in up to 35% of patients during the first 6 months on interferon beta.

[Therapy of pain syndromes in multiple sclerosis -- an overview with evidence-based recommendations]

While pain is a common problem in multiple sclerosis (MS) patients, it is frequently overlooked and has to be asked for actively. Pain can be classified into 4 diagnostically and therapeutically relevant categories. 1. PAIN DIRECTLY RELATED TO MS: Painful paroxysmal symptoms like trigeminal neuralgia or painful tonic spasms are treated with carbamazepine as first choice, or lamotrigine, gabapentin, oxcarbazepine and other anticonvulsants. Painful "burning" dysaesthesia, the most frequent chronic pain syndrome, are treated with tricyclic antidepressants or carbamazepine, further options include gabapentin or lamotrigine. While escalation therapy may require opioids, the role of cannabinoids in the treatment of pain still has to be determined. 2. PAIN INDIRECTLY RELATED TO MS: Pain related to spasticity often improves with adequate physiotherapy. Drug treatment includes antispastic agents like baclofen or tizanidine, alternatively gabapentin. In severe cases botulinum toxin injections or intrathecal baclofen merit consideration. Physiotherapy and physical therapy may ameliorate malposition-induced joint and muscle pain. Moreover, painful pressure lesions should be avoided using optimally adjusted aids. 3. Treatment-related pain can occur with subcutaneous injections of beta interferons or glatiramer acetate and may be reduced by optimizing the injection technique and by local cooling. Systemic side effects of interferons like myalgias can be reduced by paracetamol or ibuprofen. 4. Pain unrelated to MS such as back pain or headache are frequent in MS patients and may be worsened by the disease. Treatment should be follow established guidelines. In summary, a careful analysis of the pain syndrome will allow the design of the appropriate treatment plan using various medical and non-medical options and thus will help to ameliorate the patients' quality of life.

Lebensqualit�t bei Multipler Sklerose

Measuring quality of life (QOL) has made essential contributions for the management of patients with multiple sclerosis (MS). QOL measures may be used for helping to assess the complex changes which patients with MS have to go through during the disease trajectory, and they may be used for pharmacoeconomic research. The large number of tests available includes generic ones such as Short Form SF-36 and Sickness Impact Profile, health-related ones such as MSQOL-54, FAMS, or HAQUAMS, and patient generated measures such as the Patient Generated Index and SEIQOL-DW. Depression, cognitive impairment, and fatigue are important factors influencing QOL. Since the different tests measure quite different facets of QOL, this review intends to help the reader select a tool suited to the aim and specific question. It is hoped that QOL measures may help to better understand patients, to become a more helpful medical partner, to assist patients to develop perspectives for their future, and to decide about therapies or even palliative interventions.

Schmerzen bei Multipler Sklerose?ein immer noch untersch�tztes Problem

We evaluated the 1-year prevalence of pain syndromes and quality of care among 157 consecutive multiple sclerosis (MS) inpatients (90 f, 67 m) aged 19-85 years, with extended disability status scores of 1.0-8.5 and clinically definite MS. In a standardized questionnaire, only severe pain (pain intensity on visual analog scale of at least 4/10) was documented and classified which had occurred more often than three times or lasted longer than 1 week within the last year. Of 157 patients, 61% reported 176 pain syndromes: most frequent were headaches (40%), dysesthetic limb pain (19%), back pain (17%), and painful spasms (11%). Twelve percent of the pain syndromes were classified as worst symptom of MS, and in 68% insufficient care by the physicians consulted was reported. This was even true for the most frequent pain, migraine, in which clear treatment recommendations exist. There is thus an urgent need for physicians to keep this problem in mind when treating MS patients.

Interferon beta but not glatiramer acetate therapy aggravates headaches in MS

Type and frequency of headaches during immunomodulatory therapy in MS were determined in 167 consecutive patients. In a prospective group of 65 patients beginning interferon beta therapy, headache frequency and duration increased in 18% of all and in 35% of patients with pre-existing headache by more than 50% during the first 6 months. In two retrospective groups, increased headache frequency was reported by 34% of 53 patients on interferon beta, but by only 6% of 49 patients during at least 6 months of glatiramer acetate therapy.

Measurement of ataxic symptoms with a graphic tablet: standard values in controls and validity in Multiple Sclerosis patients

Aim of our study was to find a specific measure for the intensity of upper limb tremor and other ataxic symptoms in Multiple Sclerosis (MS) patients, and to establish standard values and test quality parameters. Three hundred and forty-two consecutive patients with different symptoms in the upper limbs (upper motor neuron symptoms, cerebellar upper limb ataxia, and/or sensory deficits in the upper limbs) and 140 healthy controls took part in the study. All patients and controls had to trace over a 25 cm high figure '8' on a graphic tablet, to tap with the stylus on the tablet and to perform the nine-hole-peg test (9HPT). Patients were additionally examined using clinical standard scales to classify motor dysfunctions of the upper limbs. One hundred and eighty-nine patients and 27 controls were tested twice to investigate the test reliability. Kinematic analysis of the tablet data was performed by kernel estimators, oscillatory activity by spectral analysis. Total power in the 2--10 Hz band was very specific for ataxia versus other motor symptoms. Tapping and 9HPT could well distinguish patients from controls, and patients with predominant motor neuron or cerebellar symptoms from patients with predominant sensory dysfunctions. Mean drawing error did not differ between motor and sensory dysfunctions. The test--retest reliability was similarly high for both spectral analysis and 9HPT.

Day-to-day variability of maximum walking distance in MS patients can mislead to relevant changes in the Expanded Disability Status Scale (EDSS): average walking speed is a more constant parameter

In this preliminary study we measured maximum walking distance and walking time on four consecutive days in 29 patients with clinically stable multiple sclerosis (MS). Patients were included in the study if they could achieve a maximum unaided walking distance of 100 up to 500 m. Our results showed a certain day-to-day variability of maximum walking distance, in some cases meaning changes up to 1.5 points in the expanded disability status scale (EDSS), which could be misinterpreted as a progression of the disease. Simultaneous measurements of maximum walking time showed a similar variability, unlike the mean walking speed which turned out to be more stable. Our results therefore suggest that scoring of MS patients should not be based on one single measurement of the maximum walking distance. The more reliable parameter appears to be the mean walking speed.

Influence of visual and proprioceptive afferences on upper limb ataxia in patients with multiple sclerosis

Our objective was to investigate how cooling of the arm and vision influence pointing movements in healthy subjects and patients with cerebellar limb ataxia due to clinically proven multiple sclerosis. An infrared video motion analysis system was used to record the unrestricted, horizontal pointing movements toward a target under three different conditions involving a moving, stationary, or imaginary target; a visual, or acoustic trigger; and vision or memory guidance. All three tasks were performed before and after cooling the arm in ice water. Patients had more hypermetric and slower pointing movements than controls under all tested conditions. Patients also had significantly larger three-dimensional finger sway paths during the postural phase and larger movement angles of the wrist joint. Memory-guided movements were the most hypermetric recorded in both groups. Cooling of the limb had no effect on amplitude or peak velocity of the pointing movement in either group under all tested conditions, but significantly reduced the three-dimensional finger sway path during the postural phase in patients with limb ataxia. Cooling-induced reduction of the finger sway was largest in those patients with the largest finger sway before cooling. In conclusion, the cooling-induced reduction of the proprioceptive afferent inflow, most probably of group I spindle afferents, reduces postural tremor of patients with cerebellar dysfunction.

[Local ice application in therapy of kinetic limb ataxia. Clinical assessment of positive treatment effects in patients with multiple sclerosis]

Upper limb ataxia is one of the most disabling symptoms of patients with multiple sclerosis (MS). There are some clinically tested therapeutic strategies, especially with regard to cerebellar tremor. But most of the methods used for treatment of limb ataxia in physiotherapy and occupational therapy are not systematically evaluated, e.g. the effect of local ice applications, as reported by MS patients and therapists, respectively. We investigated 21 MS patients before and in several steps 1 up to 45 min after cooling the most affected forearm. We used a series of 6 tests, including parts of neurological status and activities of daily living as well. At each step skin temperature and nerve conduction velocity were recorded. All tests were documented by video for later offline analysis. Standardized evaluation was done by the investigators and separately by an independent second team, both of them using numeric scales for quality of performance. After local cooling all patients showed a positive effect, especially a reduction of intentional tremor. In most cases this effect lasted 45 min, in some patients even longer. We presume that a decrease in the proprioceptive afferent inflow-induced by cooling-may be the probable cause of this reduction of cerebellar tremor. Patients can use ice applications as a method of treating themselves when a short-time reduction of intention tremor is required, e.g. for typing, signing or self-catheterization.

Headache and the cervical spine: a critical review

Headache related to the cervical spine is often misdiagnosed and treated inadequately because of confusing and varying terminology. Primary headaches such as tension-type headache and migraine are incorrectly categorized as "cervicogenic" merely because of their occipital localization. Cervicogenic headache as described by Sjaastad presents as a unilateral headache of fluctuating intensity increased by movement of the head and typically radiates from occipital to frontal regions. Definition, pathophysiology; differential diagnoses and therapy of cervicogenic headache are demonstrated. Ipsilateral blockades of the C2 root and/or greater occipital nerve allow a differentiation between cervicogenic headache and primary headache syndromes such as migraine or tension-type headache. Neither pharmacological nor surgical or chiropractic procedures lead to a significant improvement or remission of cervicogenic headache. Pains of various anatomical regions possibly join into a common anatomical pathway, then present as cervicogenic headache, which should therefore be understood as a homogeneous but also unspecific pattern of reaction.

Drug therapy for acquired pendular nystagmus in multiple sclerosis

Acquired pendular nystagmus (APN) is regularly accompanied by oscillopsia and impairment of static visual acuity. Therapeutic approaches to APN remain controversial, and there is no generally accepted therapeutic approach. We tested 14 patients who had suffered from APN caused by multiple sclerosis for several years; 12 patients presented with fixational pendular nystagmus (increasing during fixation) and 2 with spontaneous pendular nystagmus. All 11 patients with fixational pendular nystagmus who were given memantine, a glutamate antagonist, experienced complete cessation of the nystagmus. In contrast, scopolamine caused no (6 of 8) or only a minor (10-50%) reduction of the nystagmus (2 of 8). It was concluded that memantine is a safe treatment option for APN.

[Headache and the cervical spine. A critical review]

Headache in association with the cervical spine is often misdiagnosed and treated inadequately due to confusing and varying terminology. Primary headaches such as tension-type headache and migraine are incorrectly categorized as "cervicogenic" merely because of their occipital localization. Cervicogenic headache described by Sjastaad presents as a unilateral headache of fluctuating intensity increased by movement of the head and typically radiating from occipital to frontal regions. Definition, pathophysiology, differential diagnosis and therapy of cervicogenic headache shall be demonstrated. Ipsilateral blockades of the C2/ C3 root and/or the major occipital nerve allow a differentiation between migraine and other primary headache syndromes. Neither pharmacological nor surgical or chiropractic procedures lead to an improvement or remission of cervicogenic headache. Pain of various anatomical regions possibly join into a common anatomical pathway then presenting as cervicogenic headache, which should therefore be understood as a homogeneous but also unspecific pattern of reaction.

[Acute foot drop paralysis in multiple sclerosis. Peroneal nerve compression as differential diagnosis of acute onset]

We report on ten patients with clinically definite multiple sclerosis (MS) and acute weakness during dorsiflexion of the foot and toes. Assuming an attack, two patients were treated with corticosteroids, but without any effect. Since there were very few clinical hints (hyposensitivity in the area of distribution of n. peronaeus superficialis in one, positive Hoffmann-Tinel signs in two cases) only detailed neurophysiological examinations finally resulted in locating circumscribed lesions of the peroneal nerves (mainly localized at the head of the fibula), which consequently ended up in peripheral paresis of the dorsiflexion muscles. In six cases the peroneal lesion was caused by direct pressure on the nerve (hard crossing of the legs in five patients, pressing the caput fibulae against the wheelchair in one), and in the other three cases by stretching of the nerve due to genu recurvatum. Seven patients forced this posture with the intention of compensating for ataxia of the trunk and/or gait. After a period of avoiding these mechanisms, we saw five patients for follow-up examinations with evident improvements in the clinical and neurophysiological aspects.

[Syringomyelia, a neglected differential diagnosis in multiple sclerosis. 6 cases from a specialty clinic for multiple sclerosis]

During the last 5 years 11 patients with syringomyelia have been found among 4348 patients (0.25%) entering our hospital, which specializes in multiple sclerosis. Six of these 11 patients had been diagnosed earlier as suffering from multiple sclerosis, some of them after a protracted course of neurological illness. In all 6 patients examination of the cerebrospinal fluid was normal, and visual-evoked potentials (VEP) were normal in all but one case, which is described in detail as case 2 in this report. Magnetic resonance imaging (MRI) showed a Chiari malformation in 3 of 6 syringomyelia patients, who came to us under the diagnosis of multiple sclerosis. MRI also showed subcortical white matter lesions in 5 of 6 patients with syringomyelia. In summary, the diagnosis of multiple sclerosis should be reexamined when one of the following signs is present: (1) demonstration of Chiari malformation; (2) cerebrospinal fluid is normal; (3) visual-evoked potentials are normal. These signs may suggest syringomyelia even after years of primary progressive or relapsing remitting development of multiple neurological deficits and MRI visible white matter abnormalities.

Cervicogenic headache: electronystagmography, perception of verticality and posturography in patients before and after C2-blockade

Fourteen patients with cervicogenic headache (9F, 5M) with a mean age of 42.8 (29-58) years were examined, before and within two hours after unilateral anaesthetic C2-blockades, clinically as well as by means of electronystagmography, subjective visual vertical test and posturography. After C2-blockade, patients exhibited a slight gait deviation to the injected side without eye movement disorder, dysmetria or ataxia. Although in two of nine patients there was a small influence on lateral body sway on posturography, no specific pattern of abnormalities in eye-head-body coordination could be found before or after C2-blockades. Thus, there is no clinical evidence for a significant reproducible influence of the second cervical root on oculomotor or cerebellar function in cervicogenic headache. These findings confirm earlier data in animal experiments.

Atypical facial pain--application of the IHS criteria in a clinical sample

Atypical facial pain is a residual category for otherwise unclassifiable pain syndromes in the facial region. In 35 patients (31F, 4M) with a mean age of 53.2 +/- 14.9 years and a chronic facial pain syndrome we tested the new diagnostic criteria of the International Headache Society (IHS). There was a marked female preponderance, vague description of symptoms and a long history of incorrect diagnoses. A high number of invasive procedures (3.5 +/- 3.0 (1-13)) were performed in this group. In agreement with the IHS criteria, an operation or injury to the face was a suspected cause in 43%. In contrast to the IHS criteria, our patient sample had dysaesthesiae (63%), bilateral occurrence (37%), remission periods (57%), pain attacks (23%) and superficial as well as deep pain. The IHS classification is insufficient to separate atypical facial pain from other primary headache and facial pain syndromes. We suggest a modified version of the IHS criteria for atypical facial pain.

[Atypical facial pain--quality of IHS (International Headache Society) criteria and psychometric data]

Atypical facial pain is generally an unclearly defined pain syndrome. We tested in 35 patients (31 women, 4 men) with a mean age of 53.2 +/- 14.9 years and a chronic facial pain syndrome the quality of the new diagnostic criteria of the International Headache Society (IHS), at the same time using the SCL-90-R (Self-Report Symptom Inventory), to identify any associated psychopathology. In accordance with the literature there is a marked female preponderance, an altogether vague description of symptoms and a long history of incorrect diagnoses. Of note is the high number of invasive procedures (3.5 +/- 3.0). In agreement with the IHS commentary, an operation or injury to the face was a suspected cause in 43%. In contrast to the IHS criteria, we found in our patient sample dysaesthesia (63%), bilateral occurrence (37%), remission periods (57%), pain attacks (23%) and presence of superficial as well as deep pain. Depression is by no means the only psychopathological abnormality in atypical facial pain; a broad spectrum of complaints is seen. The IHS classification appears insufficient to separate atypical facial pain from other primary headache and facial pain syndromes. We therefore suggest a modified version of the IHS criteria for atypical facial pain.

Cerebrovascular risk factors in migraine with prolonged aura and without aura

The role of cerebrovascular risk factors such as mitral valve prolapse, platelet aggregation, platelet activation and cardiac arrythmias in migraine was investigated in a total of 44 migraineurs (32 migraineurs without aura and 12 with prolonged aura) and 32 controls. Comparing the total of migraineurs and the two subgroups with controls, mitral valve prolapse, a raised thromboxane B2 level, at least one platelet aggregation dysfunction or an abnormality in 24-h ECG was statistically seen no more often than in the control group. Neither did combinations of the variables occur more frequently. Altogether, this study showed no increased coincidence of migraine with prolonged aura and migraine without aura with the above parameters. The absence of cardiac and haematological abnormalities in migraine with prolonged aura focuses attention on the control of the cortical microcirculation.

MMPI personality profiles in patients with primary headache syndromes

The role of psychological factors in the course of primary headache syndromes is still controversial. Using the Minnesota Multiphasic Personality Inventory (MMPI) we investigated the personality profiles of 434 headache patients (160 migraineurs, 95 with tension type headache, 30 with cluster headache and 149 with combination headache) in accordance with the IHS criteria. In the first three MMPI scales (hypochondria, depression, hysteria) there was a slight increase in T mean values to over 60, but still in the range of two standard deviations of the normal population. There were no statistically significant differences between the four headache groups and between patients with and without analgesic abuse. It was impossible to distinguish headache groups on the basis of their personality profiles by means of reclassification with discriminant analysis. In a cluster analysis, patients with cluster headache showed the highest number (20%) of abnormalities, but also the highest percentage (13%) of completely normal results. Our findings--a cross section analysis of personality profiles--contradict many other MMPI-based studies.

[Cluster headache and chronic paroxysmal hemicrania: current therapy]

In acute attacks of cluster headache (CH), the mainstays of treatment are inhalation of pure oxygen (due to lack of any side effects), ergotamine aerosol, and intranasal application of local anaesthetics. The following treatments have hitherto been recommended for the prevention of attacks: young patient with first manifestation-methysergide; middle aged patient with episodic or chronic CH-steroids; older patient with history of resistance to therapy-lithium. These guidelines have been superceded as a result of the demonstration of the efficacy of several other drugs which have reduced side effects. This increased variety of treatments also reduces the importance of clinical differentiation between episodic and chronic cluster headache. Today, the drugs of first choice for treatment of episodic cluster headache are steroids or calcium channel blockers like verapamil, replacing methysergide which is now drug of second choice. In chronic CH, verapamil and lithium are normally prescribed, steroids-possibly in combination with one of the other drugs-are regarded as drugs of second choice. Another possibility, used with increasing frequency, is valproate acid, and the experimental drug budipine may be a further alternative in therapy resistant patients. There is no convincing role for invasive surgical procedures, particularly in the light of the increased number of effective drugs. The treatment of choice for chronic paroxysmal hemicrania is indometacin, although individual patients may respond to salicylates, naproxene, prednisone and ergotamine.

[Tension headache--a review]

Tension headache (TH) is an ill-defined headache syndrome, characterized by bilateral, daily headaches with fronto-occipital localisation. TH is often accompanied by a migraine and an abuse of analgesics and/or ergotamine. In the etiology of TH vascular, muscular and psychogenic factors are assumed. Floating transitions to common migraine are discussed. The increased muscle tension is not specific for TH, but more probably a consequence of TH. In addition a decrease of the pain threshold with a deficiency of the antinociceptive system is supposed. The efficacy of tricyclic antidepressives in TH is based on potentiation of serotonergic and noradrenergic mechanisms and - besides their analgetic potencies - upon an increase of the pain threshold. TH prophylaxis is indicated if patients suffer from TH more than ten times per month. Medication are tricyclic antidepressives of the amitriptyline-type. Prophylaxis of TH can only be successful if a simultaneous abuse of analgesics and/or ergotamine is discontinued. In addition, EMG-biofeedback, as well as relaxation - and vasoconstriction training might be helpful in specific cases.

Cervicogenic headache: results of computer-based measurements of cervical spine mobility in 15 patients

Head and neck pain are often attributed to impaired mobility of the cervical spine. No established methods exist to examine such an impaired mobility objectively in patients with cervicogenic headache. Therefore, functional roentgenograms of the cervical spine in maximum ventral and dorsal flexion were analyzed in 15 patients with cervicogenic headache and in 18 controls. Qualitative radiologic evaluation showed no significant differences in either group. A computer-based technique to assess the mobility of the cervical spine demonstrated a statistically pronounced hypomobility of the craniocervical joints C0/C2 and an impaired overall mobility of the upper cervical spine (C0-C5) in the cervicogenic headache group. The most evident hypomotility was found in segment C0/C1. Interesting was, furthermore, a probably compensatory hypermotility in segment C6/C7. These findings did not correlate with the results of the qualitative radiologic evaluation.

Mitral valve prolapse and platelet aggregation in patients with hemiplegic and non-hemiplegic migraine

Migraine and mitral valve prolapse (MVP) share a number of features. Both migraine and MVP show platelet dysfunctions and an increased risk of transient ischemic attacks (TIA) and stroke. There is a strikingly high incidence of migraine among MVP patients. The focal neurological deficits associated with hemiplegic migraine resemble TIA symptoms which may occur in MVP patients. Furthermore, the risk of cerebral infarction in migraineurs is reported to be higher than in the general population. The results of our study with 43 patients suffering from non-hemiplegic migraine (common and classical migraine) and 19 migraineurs with a hemiplegic migraine indicate that hemiplegic migraine is not associated with MVP and increased platelet aggregation more frequently than other migraine forms. Independent of migraine type, there is no difference between patients with and without mitral valve prolapse with respect to platelet dysfunction.

Combination headache: practical experience with a combination of a beta-blocker and an antidepressive

In the prophylaxis of migraine beta-blockers are commonly used. In the therapy of tension headache (TH) the use of tricyclic antidepressives is widespread. Therefore, from a rational point of view, one should combine an antidepressive and a beta-blocker in the treatment of combination headache (CH), in which patients have both migraine and TH. In an open uncontrolled study, 61 patients with CH received a combination of an antidepressive (amitriptyline) or amitriptyline-N-oxide and a beta-blocker (propranolol or metoprolol) for at least 3 months. The 61 patients kept a diary in which they recorded frequency and duration of migraine attacks and tension headaches. The median migraine attack frequency decreased in the 3 months from four to two and the mean attack duration per month from 2 to 0.7 days. TH frequency was reduced from a median of 21 days to 6 days; TH duration fell from a median of 21 days to 2.7 days. At first sight, this treatment appears to be highly effective, at least when judged by the results at the group level. Nevertheless, in an open uncontrolled study like this, one must be aware of many problems, which are discussed in detail.

Onset of nocturnal attacks of chronic cluster headache in relation to sleep stages

Nocturnal attacks are symptomatic of numerous primary headache syndromes. It has proven possible to verify, with polygraphic sleep recordings, a strict correlation between the onset of headache attacks and the rapid eye movements (REM) stage for migraineurs, patients with chronic paroxysmal hemicrania and cluster headache (CH). The purpose of this study was to investigate the correlation between attack onset of chronic CH and sleep stages, the REM stage in particular. Nine patients from our headache outpatient service with a diagnosis of CH were examined in this study. All medication was discontinued at least one week prior to sleep polygraphias, which were conducted in a sleep laboratory on two consecutive nights. Any attacks were treated with oxygen inhalation during the drug-free period. EEG, EMG, and EOG were continuously monitored during the sleep polygraphias. Eight patients had 25 CH attacks during 12 of the 17 nights recorded. Only three of these patients had arousals with attacks in the REM stage and these amounted to five of the 25 recorded attacks. Eleven attacks were in stage 2, four in stage 1 and two in stage 3. These results correlate with recent findings according to which headache attacks were often related to REM in episodic CH, but rarely in the chronic type. Whether or not different pathogenic mechanisms are involved in the episodic and the chronic type of CH is a matter for further discussion.

Chronic paroxysmal hemicrania: the first possible bilateral case

There are three headaches syndromes that are typically characterized by strictly unilateral and always same-sided attacks: cluster headache, "cervicogenic" headache, and chronic paroxysmal hemicrania (CPH). In rare cases, cluster headache also occurs bilaterally; "cervicogenic" headaches probably as well. We present a patient with a probable bilateral CPH. To our knowledge no such case has previously been described.

Functional radiographs of the craniocervical region and the cervical spine. A new computer-aided technique

Disabilities of the articulations of the head and cervical spine can often be detected only by exact measurement of functional radiographs. From two radiographs, one in flexion and one in extension, not only can the total mobility of the head be measured, but also the mobility of the individual articulations can be evaluated by taking exact measurements of the position of each vertebra. A method for semi-automatic measuring of such pairs of radiographs is presented. Edges and structures of the bones that are clearly visible in both radiographs are digitized on a graphics tablet. Then, by computer program, each vertebra of the first radiograph is shifted and rotated until it fits best to the respective vertebra of the second radiograph. Thus, for each articulation, the mobility angle and the location of the mobility axis relative to the adjacent vertebra, can be computed. First experiences with this method are presented.

[Migraine and beta blocker. An overview]

Migraine is considered to be a primarily neurogenic disease. In this common headache syndrome beta-blockers are widely used as prophylactic drugs. In the meantime there is evidence for central beta-receptors. The effect of beta-blockers is considered to be based on a reduction of the increased sympathetic tonus and its influence on the intracerebral vessels. Beta-blockers--such as Atenolol, Metoprolol, Nadolol, Pindolol, Propranolol and Timolol which differ according to their intrinsic activity, their selectiv cardiac effects, their membran stabilizing ability, their hydro- or lipophily as well as according to their plasmaprotein binding capacity are used. Therefore, it is more likely that beta-blockers develop their effect through a stabilisation of the intrasynaptic serotonin-level in the serotonergic neurons of the brainstem.

[Chronic paroxysmal hemicrania. A review based on personal cases]

Chronic paroxysmal Hemicrania (CPH) is a headache syndrome first described in 1974. Since then about 60 cases have been reported in the world literature. CPH is characterised by headache attacks occurring daily and always strictly unilaterally. The frequency of the attacks varies from 5 to 30 per 24 hours, the single attack having an usual length of 2 to 30 minutes. The prompt response to indomethacin is the decisive diagnostic criterion of this headache syndrome. The clinical picture, the treatment, some aspects of the pathogenesis and the differential diagnosis of CPH are described by means of case reports. To our knowledge these are the first four cases reported in West Germany.