Clinical Features of Migraine: A Cross-Sectional Study in Patients Aged Three to Sixty-Nine

We investigated 260 consecutive patients classified as migraine cases aged 3-69 at two tertiary headache centres, one for children and adolescents and the other for adults to evaluate the relationship between age and clinical features of migraine cross-sectionally. We only included subjects with definite migraine without or with aura and we excluded subjects with coexisting tension-type headache, medication overuse and/or other clinically relevant disorders. The percentage of males decreased markedly from childhood to adulthood and this affected the evalution of age-related changes in male patients, as only large differences reached the level of statistical significance. In females, the headache duration and the prevalence of unilateral, pulsating pain, photophobia and phonophobia increased, whereas the prevalence of aggravation by physical activity decreased with age. In conclusion, this cross-sectional, clinic-based study on a strictly defined sample of 260 consecutive patients with definite migraine covering a wide range of age from the very young to the old suggests marked age-related differences of the clinical features of migraine in females and failed to demonstrate similar differences in males due to the small number of adult male migraineurs.

Facial pain in a Neurological Tertiary Care Centre — Evaluation of the International Classification of Headache Disorders

The aim of this study was to examine the diagnostic spectrum of facial pain and to evaluate the clinical features relevant to the differential diagnosis in a neurological tertiary care centre. This is the first investigation comparing the first with the second edition of the International Classification of Headache Disorders (ICHD-I, ICHD-II) in consecutively referred patients comprising a broad spectrum of disorders without restricting the inclusion to certain diagnoses. Studying 97 consecutive patients referred for facial pain, we found trigeminal neuralgia or other types of cranial neuralgia in 38% and 39% according to ICHD-I and ICHD-II, respectively; persistent idiopathic facial pain was diagnosed in 27% and 21%, respectively. The proportion of patients who could not be classified was 24% in ICHD-I and 29% in ICHD-II. Six per cent of the patients had cluster headache or chronic paroxysmal hemicrania, the remaining 5% had various other disorders. The agreement between ICHD-I and ICHD-II was very good to perfect. In ICHD-II, sensitivity and specificity were similar to ICHD-I, the specificity and negative predictive value were imrpoved in single features of trigeminal neuralgia, but were widely unchanged in persistent idiopathic facial pain. The number of patients who could not be classified was larger in ICHD-II than in ICHD-I. Modifying the diagnostic criteria for different types of facial pain, in particular changes in the criteria of persistent idiopathic facial pain, might be helpful in reducing the number of patients with unclassifiable facial pain.

Prospective Analysis of Factors Related to Migraine Attacks: The PAMINA Study

Migraine is related to numerous factors such as hormones, stress or nutrition, but information about their actual importance is limited. Therefore, we analysed prospectively a wide spectrum of factors related to headache in migraineurs. We examined 327 migraineurs recruited via newspapers who kept a comprehensive diary for 3 months. Statistical analysis comprising 28 325 patient days and 116 dichotomous variables was based on the interval between two successive headache attacks. We calculated univariate Cox regression analyses and included covariables with a P-value of <0.05 in two stepwise multivariate Cox regression analyses, the first accounting for a correlation of the event times within a subject, the second stratified by the number of headache-free intervals. We performed similar analyses for the occurrence of migraine attacks and for the persistence of headache and migraine. Menstruation had the most prominent effect, increasing the hazard of occurrence or persistence of headache and migraine by up to 96%. All other factors changed the hazard by <35%. The two days before menstruation and muscle tension in the neck, psychic tension, tiredness, noise and odours on days before headache onset increased the hazard of headache or migraine, whereas days off, a divorced marriage, relaxation after stress, and consumption of beer decreased the hazard. In addition, three meteorological factors increased and two others decreased the hazard. In conclusion, menstruation is most important in increasing the risk of occurrence and persistence of headache and migraine. Other factors increase the risk less markedly or decrease the risk.

The classification of chronic headache: room for further improvement?

In this commentary, the authors briefly discuss their views on some of the limitations in the current terminology and classification of chronic headache. Suggestions for consideration and further debate include the acceptance of chronic daily headache as the umbrella term for this group of headache disorders, a more consistent definition of 'chronic' and the use of a multi-axial classification approach.

Family-based analysis of serotonin transporter gene polymorphisms in migraine with and without aura

Genetic epidemiological twin studies have demonstrated a significant heritability for migraine, with > 60% of liability to migraine either with or without aura coming from additive genetic factors. Because of the essential role of serotonin in the pathophysiology and treatment of migraine, genes of the serotonin system are candidates for involvement in migraine. Consequently, we examined two functional VNTR polymorphisms in the serotonin transporter gene, the 5-HTTLPR and the intron 2 VNTR, in a sample of 212 family trios each with a proband with childhood migraine, 153 with migraine without aura (MoA) and 59 with migraine with aura (MA). For the first time, we used transmission disequilibrium test analysis with the program TDTPHASE to examine the transmission of these two markers and their haplotypes to offspring affected by migraine. We found no significant transmission distortion of any marker, with the common L allele of the 5-HTTLPR transmitted 170 times and not transmitted 178 times, and the S allele 130 vs. 122 times. Likewise, the common 12 allele of the intron 2 VNTR was transmitted 201 times and not transmitted 188 times, and the 10 allele 107 vs. 120 times. The markers were not associated with MoA and MA and none of the haplotypes was associated with overall migraine, MoA or MA. The 5-HTTLPR and the intron 2 VNTRs do not play a major role in susceptibility to migraine.

Family-based association analysis of functional VNTR polymorphisms in the dopamine transporter gene in migraine with and without aura

Because of the role of dopamine in triggering migraine attacks, genes of the dopamine system are candidates for involvement in migraine. We examined three VNTR polymorphisms in the dopamine transporter, the 5'UTR VNTR, the intron 8 VNTR and the intron 14 VNTR, in a sample of 205 family trios. We used the transmission disequilibirium test (TDT) to examine the transmission of these three markers and their haplotypes to offspring affected by migraine. We found no significant transmission distortion of any marker. Likewise haplotypes of the three markers did not show significant overall or individual association with migraine. Finally we examined migraine with and without aura, and likewise found no association between dopamine transporter VNTRs or their haplotypes and either classification of the disease. We conclude that functional genetic variation in the dopamine transporter does not act as a significant risk factor for migraine.

Clinical features, classification and prognosis of migraine and tension-type headache in children and adolescents: a long-term follow-up study

We performed a long-term follow-up examination in children and adolescents with migraine and tension-type headache (TTH) in order to investigate the evolution of clinical features and headache diagnoses, to compare International Classification of Headache Disorders (ICHD)-I and ICHD-II criteria and to identify prognostic factors. We re-examined 227 patients (52.4% female, age 17.6 +/- 3.1 years) 6.6 +/- 1.6 years after their first presentation to a headache centre using identical semistructured questionnaires. Of 140 patients initially diagnosed with migraine, 25.7% were headache free, 48.6% still had migraine and 25.7% had TTH at follow-up. Of 87 patients with TTH, 37.9% were headache free, 41.4% still had TTH and 20.7% had migraine. The number of subjects with definite migraine was higher in ICHD-II than in ICHD-I at baseline and at follow-up. The likelihood of a decrease in headache frequency decreased with a changing headache location at baseline (P < 0.0001), with the time between baseline and follow-up (P = 0.0019), and with an initial diagnosis of migraine (P = 0.014). Female gender and a longer time between headache onset and first examination tended to have an unfavourable impact. In conclusion, 30% of the children and adolescents presenting to a headache centre because of migraine or TTH become headache-free in the long-term. Another 20-25% shift from migraine to TTH or vice versa. ICHD-II criteria are superior to those of ICHD-I in identifying definite migraine in children and adolescents presenting to a headache centre. The prognosis is adversely affected by an initial diagnosis of migraine and by changing headache location, and it tends to be affected by an increasing time between headache onset and first presentation.

[Subjective family image in anorexia nervosa and bulimia nervosa in adolescence: a controlled study]

OBJECTIVES

The family environments of patients with eating disorders have been studied extensively in recent decades. The "Subjective Family Image Test" is an instrument developed especially to measure differential perceptions by family members. Assessments of subjective family image in families of adolescents by means of this test have been carried out in only a few samples.

METHODS

We aimed first to investigate subjective perceptions by adolescents of their family relations in a larger clinical sample of female adolescents (n = 118) suffering from anorexia nervosa of either subtype or from bulimia nervosa and to compare these perceptions with those of healthy controls (n = 96). Second we investigated intra-familial differences in perception.

RESULTS

The main findings were that bulimia nervosa patients perceived lower individual autonomy and lower emotional connectedness than all other groups, the adolescents with bulimia perceived significantly lower autonomy and emotional connectedness within the family than their fathers, and the restrictive anorexia nervosa patients perceived higher connectedness than their fathers. The relevance of these findings for understanding family dynamics are discussed.

Clinical management of young patients presenting with headache

Headache is a common symptom in young patients and requires a clearly structured, individual approach. The history and the clinical examination are prerequisites for planning further management of the condition. The IHS classification is particularly useful in the differential diagnosis of idiopathic headache. Additional diagnostic testing should not be performed routinely, but on an individual basis depending on the patient's history and neurological findings. The acute therapy of idiopathic headache in young patients has been evaluated in few studies only. However, there is general agreement that (in subjects requiring medication) paracetamol, acetylsalicylic acid and ibuprofen are most useful for treating migraine attacks, whereas analgesics should widely be avoided in tension-type headache. For the prophylaxis of migraine and tension-type headache, non-pharmacological measures such as regulation of lifestyle, relaxation training and psychological or psychotherapeutic interventions are much more important than pharmacotherapy, which is required in a small number of patients only.

Characteristics of self-regulation in adolescent patients with anorexia nervosa

The purpose of the study was to investigate the different modes of self-regulation in adolescent anorexia nervosa (AN). A self-system questionnaire, the Narcissism Inventory, was given to 61 adolescent females with AN and 61 controls. Patients with AN reported higher overall disturbances in self-regulation than controls. In particular, a highly unstable self-system, a tendency to use idealization as modus of regulation, and high narcissistic gain from their illness was found in the patient group; however, the patients did not report a 'classic narcissistic self'. Furthermore, we were able to differentiate between two clusters of patients, one with high (n = 34) and one with low (n = 27) disturbance in self-regulation; the latter reported a shorter duration of illness and lower oral control but did not differ on any other clinical variables. Stronger relationships were found between the dimension 'endangered self' and the overall scores of the Eating Attitudes Test (EAT) and the Eating Disorder Inventory (EDI) as well as two subscales of the EAT and five of the EDI. Our study in anorexic adolescents demonstrated that the self-system is experienced as highly unstable, that idealization is used as mode of regulation, and that the dimension of the 'classic narcissistic self' is less important in this patient group. It is important to evaluate the system of self-regulation for planning treatment in the individual patient according to their needs.

Long-term MRI observations of childhood-onset relapsing-remitting multiple sclerosis

PURPOSE

Long-term MRI follow-up of childhood-onset relapsing-remitting multiple sclerosis (RRMS) was carried out in 4 cases. MRI findings were correlated with clinical course and characteristic differences from adult-onset RRMS were elaborated.

METHODS

Two girls and one boy with true childhood-onset, and one girl with juvenile-onset RRMS underwent 5-16 MRI examinations within 6-8 years. The total number of lesions, the numbers of new, active, disappearing and reappearing lesions, infratentorial and U-fibre lesions, "giant" plaques and "black holes" were counted. Callosal atrophy and general brain atrophy were assessed. The findings were related to the physical status according to the Expanded Disability Status Scale (EDSS).

RESULTS AND CONCLUSIONS

Results showed that the primary differences in childhood-onset RRMS compared to adult-onset RRMS lie in the lack of, or slower development of irreversible changes ("black hole" formation, brain atrophy). Despite callosal atrophy and intensive U-fibre region involvement, school performance was unchanged. Regarding the frequency of "giant" lesions, an even more pronounced white matter involvement was found in our children compared to adults. All children exhibited a rather "benign" disease course. A more intensive remyelination, less severe neuronal loss, and higher functional brain plasticity at younger ages may account for these differences.

Migrainous disorder and headache of the tension-type not fulfilling the criteria: a follow-up study in children and adolescents

In this follow-up study in children and adolescents with recurrent headaches classified as migrainous disorder (IHS 1.7) and headache of the tension-type not fulfilling the criteria (IHS 2.3), 28.6% were headache-free and 71.4% still had headaches 2-5 years after the first examination. The majority remained in the same one-digit IHS diagnosis, whereas 20% changed from migraine to tension-type headache or vice versa. The number of IHS criteria fulfilled increased significantly from the first to the second examination. The reason for diagnosing IHS 1.7 and IHS 2.3 most often was a short headache duration or headache characteristics not meeting the criteria. By reducing the minimum headache duration to 1 h, 11 of 58 patients could be diagnosed as migraine without aura. There was a remarkable overlap in the diagnostic criteria for migraine without aura and tension-type headache. In IHS 1.7 and IHS 2.3 this overlap exceeded 80%, with a trend to decrease at the second examination.

Virchow-Robin spaces in childhood migraine

Virchow-Robin spaces (VRS) are pia-lined extensions of the subarachnoid space which surround penetrating arteries as they enter the brain on its surface. Using high-resolution MRI, which shows small penetrating arteries, we studied a possible association of accentuated VRS in children with tension-type headache (TTH) or migraine. We studied 58 children aged 3-14 years (mean 10.8 years) with a clinical diagnosis of migraine (31) or TTH (27), who underwent cerebral MRI, and 30 headache-free patients of the same age (mean 10.2 years) and 30 adult migraineurs with postpubertal onset of symptoms, who served as controls. The images were reviewed for structural abnormalities in the regions of the small penetrating arteries. Accentuated VRS were found in 61% of the children with migrainous headaches and in 22% of children of those with TTH. Prominent VRS were seen in 27% of the control children and in only 13% of the adults. Small infarcts and gliosis were rare in children with or without headache, but were seen in 30% of the adult migraineurs. Our findings show that accentuated VRS are significantly more common in children with migraine than in those with TTH or headache-free controls. Detection of accentuated VRS may therefore enhance differential diagnosis of primary headaches in children, contributing to an improvement in management.

Psychosocial factors in children and adolescents with migraine and tension-type headache: a controlled study and review of the literature

We investigated 341 children and adolescents to evaluate the relevance of psychosocial factors in idiopathic headache. According to the criteria of the International Headache Society, 151 subjects had migraine and 94 had tension-type headache (TTH). Ninety-six subjects were headache-free controls. Psychosocial factors covered family and housing conditions, school problems, relations in the peer group, and several other items. We found that migraine patients did not differ from headache-free controls. Patients with TTH more often had divorced parents than the headache-free controls, and they had fewer peer relations than migraineurs and controls. In addition, migraine patients were significantly more often absent from school due to headache. All other psychosocial factors failed to discriminate between the three study groups. In conclusion, this controlled study in children and adolescents suggests that migraine is not related to family and housing conditions, school situation, or peer relations, whereas TTH is associated with a higher rate of divorced parents and fewer peer relations.

Postural control and lifetime alcohol consumption in alcohol-dependent patients

OBJECTIVES

The aim of this study was to examine the relationship between alcohol consumption and postural control in alcohol-dependent patients.

MATERIAL AND METHODS

Posturographic measurements were performed in 82 abstinent patients and in 54 healthy controls. The findings in the patients were compared with those in the controls as well as with the daily alcohol consumption, the consumption during 6 months before the admission for alcohol withdrawal therapy and the estimated lifetime alcohol consumption.

RESULTS

Postural control was impaired in alcohol-dependent patients compared to healthy controls. This impairment was related with the lifetime alcohol consumption, but not with the alcohol consumption per day and prior to admission, respectively. Comparing healthy controls, and alcohol-dependent patients with an estimated lifetime alcohol consumption of < 1000 kg and > or = 1000 kg revealed a significant increase in 6 of 8 sway parameters. Furthermore, the lifetime alcohol consumption increased significantly from patients with normal posturographic and clinical findings to those with abnormalities in both examinations.

CONCLUSION

This study suggests that postural imbalance in abstinent alcohol-dependent patients is related to the lifetime alcohol consumption.

Ataxia of stance in different types of alcohol dependence--a posturographic study

The aim of this study was to assess the prevalence of ataxia of stance in different types of alcohol-dependent patients. Posturographic measurements were performed in 82 abstinent alcohol-dependent patients and 54 healthy controls in order to analyse postural control. According to Lesch and co-workers, alcohol dependence was classified as total abstinence (Type I), drinking without loss of control (Type II), fluctuating course (Type III), and persistent severe drinking (Type IV). The mechanisms of alcohol dependence in these subtypes can be summarized as follows: Type I patients drink alcohol to counteract symptoms of alcohol withdrawal; Type II patients use alcohol as an agent for solving conflicts; Type III patients drink alcohol to 'treat' an affective disorder; and Type IV patients have a history of pre-alcoholic neurological and/or psychiatric disorders. The neurological examination showed pathological findings in 39%, whereas posturographic measurements uncovered impaired postural control in 61% (chi2 = 8.8, P = 0.003). Comparing the different study groups revealed that ataxia of stance was most common in alcohol-dependent patients classified as Type IV (tau = 0.24, P = 0.005). In conclusion, posturographic measurements are superior to the clinical examination in detecting postural imbalance in alcohol-dependent patients. The prevalence of postural imbalance is highest in patients classified by Lesch as Type IV. Consequently, this type of alcohol dependence -- characterized by pre-alcoholic neurological and/or psychiatric disorders, bears the highest risk of developing ataxia of stance.

Awareness of early-onset anorexia nervosa

The aim of the study was to determine whether physicians consider anorexia nervosa as a possible diagnosis in children and adolescents presenting various somatic symptoms including significant weight loss. Questionnaires were handed out to participants of a national general medical congress in Austria. The questionnaire included two case vignettes of children with anorexia nervosa and questions about diagnosis, differential diagnoses and management. Anorexia nervosa was considered as possible primary diagnosis in both cases by 3.8% of the respondents and 11.4% suspected a psychosomatic or psychiatric disorder as primary diagnosis in both cases. These findings demonstrate a limited awareness of anorexia nervosa and of a psychosomatic or psychiatric origin of somatic symptoms including weight loss in children and adolescents among physicians. Recognizing anorexia nervosa in an early stage and referring the patients for a psychiatric evaluation as soon as possible is a prerequisite for specialized treatment and might improve the long-term outcome of this severe disorder. Increased educational efforts are required to improve the knowledge among primary care physicians about eating disorders.

IHS criteria and gender: a study on migraine and tension-type headache in children and adolescents

The aim of this study was to investigate whether the IHS criteria for migraine and tension-type headache depend on gender. Among 409 children and adolescents with recurrent idiopathic headache seen at a university outpatient clinic, girls had significantly more often migraine with aura. Also, there was a trend towards a higher frequency of tension-type headache in girls. In migraine, aggravation of headache by physical activity and occurrence of aura symptoms were more common in females, whereas vomiting and phonophobia occurred more often in males. In tension-type headache, females more often reported mild intensity of headache. All other criteria were similar in both sexes. Age influenced the expression of some of the accompanying symptoms in the various types of migraine, but had only minimal influence on other diagnostic criteria of migraine and tension-type headache in females as well as in males. Our study suggests that the frequency of migraine (except that of migraine with aura) is similar among girls and boys, that tension-type headache may occur more often in girls, and that gender has some influence on the IHS criteria for migraine, but almost no influence on those of tension-type headache.

IHS criteria for migraine and tension-type headache in children and adolescents

We investigated the influence of age on the IHS criteria for migraine and tension-type headache in 437 consecutive children and adolescents and found the following age-associated statistically significant differences: migraine duration, occurrence of migraine aura, and bilateral location of tension-type headache were more often fulfilled by adolescents, whereas aggravation of headache by physical activity (in migrainous disorder) and photophobia (in migraine with aura) were more often fulfilled by children. Accordingly, there are only a few differences concerning the fulfillment of the IHS criteria for migraine and tension-type headache in children and adolescents. Independent of age, the intensity of headache and the presence or absence of nausea are most important for differentiating the two major types of idiopathic headache. The sensitivity of the IHS criteria for migraine could be increased by reducing the minimum duration of migraine and by allowing the diagnosis of migraine when severe headache is associated with nausea, even though the criteria of location, quality, and aggravation by physical activity are not fulfilled.

Magnetic resonance imaging for recurrent headache in childhood and adolescence

We investigated 429 consecutive patients, aged 5 to 18 (mean: 11.0 +/- 3.1) years, diagnosed with migraine or tension-type headache. The patients underwent either MRI or exclusively clinical follow-up examinations. Magnetic resonance imaging revealed normal findings in 82.3% and structural changes in 17.7%. However, the vast majority of these changes had minimal or no pathological relevance, and a causal relationship to the patient's headache could not be proven in any case. In the non-MRI group, clinical follow-up examinations confirmed the initial diagnosis in all patients and MRI was not required in any of these subjects. In conclusion, our study shows a poor relation between recurrent headache fulfilling the criteria of migraine and tension-type headache and structural changes incidentally detected by MRI. In addition, it suggests that clinical follow-up examinations are reliable. Accordingly, MRI is not required for routine examination of recurrent headache in children and adolescents, but it should be performed in patients with abnormal neurological findings, atypical headache pattern, or significant change of preexisting headache.

Freud and migraine: the beginning of a psychodynamically oriented view of headache a hundred years ago

Sigmund Freud, the famous Viennese founder of psychoanalysis, suffered from recurrent episodes of severe headache. Autobiographic and biographic data make it evident that he had migraine. Freud's theoretical approaches to pain in general and to migraine in particular are discussed. Initially, Freud's theories on the etiopathogenesis of pain and migraine focused on neurophysiological hypotheses which are of historical interest. They were replaced by psychodynamic hypotheses which are still important for our current understanding of pain and headache. These psychodynamic pain theories are reviewed and their importance for headache research is discussed.

D2 receptor blockade by flunarizine and cinnarizine explains extrapyramidal side effects. A SPECT study

Twenty-six patients under treatment with the calcium channel blockers flunarizine (Fz) or cinnarizine (Cz) were examined-with single-photon emission computed tomography using [123I]iodobenzamide as a ligand. The striatal dopamine D2 receptor-binding potential was determined and found to be reduced by 14 to 63% (39.5 +/- 15.0%; p < 0.0001) in patients compared with age-matched control values. This reduction was larger in 12 patients with extrapyramidal symptoms and was only slowly reversible after discontinuation of treatment. Patients treated for > 6 months had significantly larger reductions than patients treated for a shorter period. Parkinsonian symptoms were only seen in patients older than 50 years. Our findings prove a neuroleptic-like action of Fz and Cz, which seems to be the major reason for their extrapyramidal side effects. Older age and long-term treatment are predisposing factors for these effects.

Diagnosis of headache in childhood and adolescence: a study in 437 patients

We investigated whether the criteria for idiopathic headache published by the International Headache Society (IHS) are useful in childhood and adolescence and compared the diagnoses according to this classification with those of Vahlquist. We used a semi-structured questionnaire to examine a total of 437 children and adolescents referred consecutively to a headache outpatient clinic. Twenty-eight of 437 patients were excluded because of symptomatic or unclassifiable headache. Of 409 patients with idiopathic headache, 70.4% had definite migraine or tension-type headache (IHS 1.1, 1.2, 2.1, 2.2), 20.5% had a migrainous disorder (IHS 1.7) and 9.1% had headache of the tension-type not fulfilling the criteria (IHS 2.3). In the differential diagnosis of migraine and tension-type headache the intensity of pain, aggravation of headache by physical activity, nausea and vomiting were the most important features. The quality of pain, photo- and phonophobia were less helpful and location least important. The duration of migraine attacks was less than 2 h in 19.0% of the migraine patients. In general, the diagnostic criteria of migraine were highly specific but less sensitive, and those of tension-type headache highly sensitive but less specific. The agreement between IHS criteria and those of Vahlquist was marked (kappa = 0.57). We conclude that the IHS criteria are useful for classifying headache in children and adolescents referred to a headache outpatient clinic. A forthcoming modification of the IHS criteria should consider a reduction of the minimum duration of migraine attacks from 2 h to 1 h and should try to increase the sensitivity of the criteria for migraine and the specificity of the criteria for tension-type headache.

Migraine and stroke in childhood and adolescence

Over 3 years we evaluated two patients, an adolescent and a child, with migraine-like headache and ischemic stroke. Based on our clinical observations and on literature review of migraine and stroke in the pediatric age group, we believe that the criteria of migrainous infarction outlined by the International Headache Society (IHS) could be occasionally too restrictive. Therefore, we suggest subclassifying migrainous infarction into: (i) "definite", referring to the patients whose ischemic stroke fulfills all the IHS criteria, (ii) "possible", referring to ischemic strokes which fulfill some, but not all, criteria. This subclassification of migrainous infarction may be relevant in clinical practice and in human research studies.

Dopamine D2 receptor blockade and antimigraine action of flunarizine

We studied in vivo the influence of flunarizine on dopamine D2 receptors and investigated whether dopamine D2 receptor blockade is involved in its antimigraine action. Eleven migraine patients, treated with flunarizine, 10 mg per day, underwent single photon emission computer tomography (SPECT) using [123I] labeled iodobenzamide, a ligand with high affinity and high specificity for D2 receptors. There was a reduction of the dopamine D2 receptor binding potential in all patients compared to age-matched controls. The efficacy of flunarizine in migraine prophylaxis failed to correlate with the degree of the dopamine D2 receptor blockade. The antimigraine action of flunarizine may not involve antidopaminergic mechanisms.

[Idiopathic headache in childhood and adolescence]

This review of the literature covers classification, epidemiology and clinical aspects of idiopathic headache in childhood and adolescence. In addition, pathogenetic models taking into account the complex involvement of organic, psychological and psychosocial factors are critically reviewed. A general pathogenetic model of migraine may be characterized by a given predisposition, various co-factors which enhance the tendency, and finally, trigger mechanisms which induce an attack. No generally accepted model exists for tension-type headache. In assessing the importance of various factors thought to be related to idiopathic headache, it is necessary to differentiate between causal relation, unspecific association, and coincidence. The aim of this review is to present potential factors influencing headache in childhood and adolescence and to discuss these factors critically with regard to their etiopathogenetic importance. Organic factors seem to be most important in migraine, whereas psychological and (psycho)social factors may influence any type of headache. Briefly, migraine in childhood and adolescence seems to be definitively associated with vegetative dysfunction, abdominal symptoms and hormonal factors and possibly with allergic reactions, whereas a relation to epilepsy can be excluded. There is absolutely no evidence for a typical personality of migraine patients. Various psychic reactions, however, are important in all types of headache. Depression and anxiety in young headache patients seem to be related generally to pain, but not specifically to headache. However, school problems, learning disabilities and stress coping behaviour seem to be related directly to recurrent headache. Additionally, there is evidence that the prevalence of headache is associated with low economic status.

Posturographic measurement of body sway in survivors of severe closed head injury

Postural imbalance was measured in 39 survivors of severe closed head injury 7 to 66 months after head injury using a posturographic platform. The results were compared with those derived from age-matched healthy control subjects. Severe postural imbalance, particularly in an anteroposterior direction, was found in 16 patients, whereas 9 patients showed moderate imbalance and 14 patients showed normal results in the posturographic investigation. Low initial Glasgow Coma Scale scores and deep parenchymal brain lesions demonstrated by magnetic resonance imaging were shown to be significant indicators of subsequent severe postural imbalance. The duration of posttraumatic amnesia, the localization and size of cortical contusions and subcortical white matter lesions, on the contrary, were not associated with postural imbalance in the long-term outcome.

[SUNCT syndrome--case report and review of the literature]

The SUNCT syndrome is a recently described headache disorder characterised by shortlasting, unilateral headache attacks with conjunctival injection and tearing. Our report presents a further case and compares the findings in our patient with those in the cases described earlier. In addition, we review the literature and discuss possible aetiological and pathogenetic factors as well as the differential diagnosis of SUNCT syndrome, trigeminal neuralgia and cluster headache syndromes.

Tension headache and the cervical spine--plain X-ray findings

The aim of the present study was to investigate if there is any causal connection between plain X-ray findings of the cervical spine and tension headache. We evaluated the X-rays of the cervical spine of 243 patients, in 91 of which the diagnosis was "tension headache", in 102 "headache not fulfilling the criteria of tension headache" and in 50 "spondylogenic complaints without headache". We compared these three groups with regard to frequency and severity of radiologically assessable changes of the cervical spine and found that patients with tension headache had normal findings significantly more often and significantly less often functional or organic changes or both than patients of the other two groups. The radiologically assessable changes of the cervical spine are unlikely to have an essential role in the cause or mechanism of tension headache.

Long-term results of migraine prophylaxis with flunarizine and beta-blockers

We followed-up 64 migraine patients after discontinuation of successful interval prophylaxis with flunarizine, propranolol or metoprolol, to investigate how long the therapeutic success would last, if further prophylaxis would be successful again, and what factors would influence the prognosis. We found that 16 out of 64 patients experienced a lasting reduction of migraine frequency, whereas 48 patients did improve initially, but later experienced a relapse. Further prophylaxis was effective in 29, poorly effective in 11, and ineffective in 8 of these patients; in 7 of the 8 non-responders prophylaxis was not changed. Negative prognostic factors were frequent attacks, a history of analgesic abuse and/or analgesic withdrawal therapy and ineffective previous prophylaxis. In conclusion, the therapeutic success decreases dramatically in the majority of patients several months after discontinuation of prophylaxis; further prophylaxis is more effective if the substance class is changed; increased analgesic intake is the most important prognostic factor. As a strategy for migraine prophylaxis we propose sequential changing of interval prophylaxis or--in patients with negative prognostic factors--long-term prophylaxis.

[24-hour blood pressure determination in Shy-Drager syndrome. A case report]

The case history is presented of a 57 year-old male patient suffering from the Shy-Drager syndrome. This syndrome was first described by G. M. Shy and G. A. Drager in 1960. The clinical manifestations are extrapyramidal, with Parkinsonian features, combined with severe orthostatic hypotension and failure of the autonomic nervous system. Apart from the standard clinical investigations in this condition, namely the orthostasis test and polygraphic recording of the EEG, ECG, breathing and blood pressure on the tilting table, additional non-invasive long-term determination of the blood pressure was carried out. This method allows simultaneous measurement of blood pressure and heart rate without appreciably interfering with the patient's daily activities.