Pain relief by somatostatin in attacks of cluster headache

The pain relieving effect of somatostatin treatment during 72 attacks of cluster headache in 8 male patients was compared to treatment with ergotamine or placebo in a double-blind study. Infusion of somatostatin (25 micrograms/min for 20 min i.v.) reduced the maximal pain intensity and the duration of pain significantly compared to placebo treatment, and to a degree comparable to ergotamine tartrate treatment (250 micrograms i.m.). The results obtained provide new information concerning the possible mechanism of cluster headache attacks and suggest a new therapeutic approach.

PREGANGLIONIC AND POSTGANGLIONIC STIMULATION OF THE GUINEA-PIG ISOLATED VAS DEFERENS PREPARATION

The isolated vas deferens of the guinea-pig contracted when stimulated transmurally with parallel wire electrodes. These contractions persisted in concentrations of hexamethonium, pentolinium, nicotine and mecamylamine which at the same time abolished the responses to hypogastric nerve stimulation. Procaine and lignocaine in local anaesthetic concentrations abolished the responses to transmural stimulation but potentiated the contractions produced by added noradrenaline. Guanethidine and bretylium in concentrations specific for adrenergic neurone blockade abolished the contractions due to transmural stimulation without impairing the responses of the muscle to added noradrenaline or acetylcholine. In contrast, high concentrations of the adrenergic-blocking agents phentolamine and dihydroergotamine were needed to block the contractions due to transmural stimulation; these concentrations also blocked the response to added noradrenaline but simultaneously reduced the responses to added acetylcholine or potassium chloride. Preparations from guinea-pigs previously treated with reserpine at first responded normally to transmural stimulation; thereafter the contractions diminished progressively but were never abolished. Hyoscine and atropine produced a small decrease in the response to transmural stimulation when present in concentrations up to 1x10(-5) and a larger decrease only in concentrations of 1x10(-4) or greater. Hemicholinium produced a small decrease of the contractions due to transmural stimulation in concentrations up to 1x10(-4); concentrations of 5x10(-4) present for 1 hr produced only a slightly greater reduction in response. These experiments show that when the guinea-pig vas deferens is removed without the hypogastric nerve and stimulated transmurally by the method described, contractions are produced mainly by excitation of postganglionic adrenergic nerves.

Reversible cerebral arteriopathy associated with the administration of ergot derivatives

Three cases of intracranial arteriopathy associated with the administration of ergot derivatives are reported. In the first case, excessive doses of dihydroergotamine and of ergotamine tartrate seemed to be the cause, but simultaneous treatment with an antibiotic and the existence of a cytomegalovirus infection could have favoured the arteriopathic process. The second patient also received excessive doses of these two drugs, but in addition she was taking oestrogen and progesteron containing contraceptives. In the third case, an intravenous injection of methylergometrine in a dose of 0.2 mg seemed to have initiated the arteriopathy. Arteriograms were comparable in all three cases, with segmental stenosis of several cerebral arteries, whereas internal carotid and vertebral arteries remained normal. In the first case a control cerebral arteriography was normal one month later. These findings suggest that widespread cerebral arteriopathy can appear in subjects who chronically abuse ergotamine tartrate.

Ergotamine tartrate dependency: features and possible mechanisms

Based on our clinical experience and the data reviewed and presented in this report, we propose that a state of physical dependency to ergotamine tartrate exists. This dependency state is characterized by the irresistible and dependable use of ergotamine tartrate and is contingent upon a self-sustaining, rhythmic headache/medication cycle that reflects the dependency. The headache and accompaniments (withdrawal headache?) represent the primary withdrawal symptoms. The presence of this state appears to render patients refractory to other forms of preventative therapy, which can be effective only when ergotamine is discontinued and the cycle broken. If the condition is left untreated, it is likely though by no means certain that the more traditional aspects of ergotism will evolve, although variable susceptibility and tolerance to ergotamine tartrate have been demonstrated. The mechanism of this disorder remains uncertain but might be related to the influence of ergotamine tartrate on the limbic-hypothalamic-pituitary-adrenal axis and other aminergic centers (locus ceruleus), areas considered by some as the central loci for the pathogenesis and associated symptoms of migraine.

Acute migraine attack therapy: comparison of naproxen sodium and an ergotamine tartrate compound

The efficacy of safety of naproxen sodium and ergotamine tartrate were compared for the treatment of acute migraine attack in a randomized, parallel trial with 114 participating patients. At the start of symptoms, patients took either three tablets of naproxen sodium (275 mg each) or one of an ergotamine combination (containing 2 mg ergotamine tartrate, 91.5 mg caffeine, and 50 mg cyclizine chlorhydrate). Patients were followed for three months or until six attacks were monitored, whichever came first. Both medications substantially shortened the duration of migraine attacks and reduced the severity of symptoms. When the test medications were taken within 2 h of onset of attack, naproxen sodium was statistically significantly more effective than the ergotamine combination in reducing the severity of headache pain, nausea, and lightheadedness. The ergotamine combination was associated with significantly more vomiting, need for rescue medication, and side effects than was naproxen sodium. Four patients required discontinuation of the ergotamine combination and one of naproxen sodium. Both patients and investigators rated tolerance for naproxen sodium as superior to tolerance for the ergotamine combination. Naproxen sodium seems to be an effective and safe treatment for migraine attacks.

Epinephrine release and liver glycogen levels after carbon tetrachloride administration

Two hours after the intraduodenal administration of carbon tetrachloride to rats, a decrease in the adrenal epinephrine level was detected, with a concomitant increase in serum epinephrine level. A simultaneous rise in liver phosphorylase activity and blood glucose concentration was seen. Two hours later these values all had returned to normal. Depletion of liver glycogen and increase in serum transaminase were noted 7 hr after CCl4 administration. Ergotamine could diminish the depletion of glycogen but had no effect on transaminase activity. Phenoxybenzamine did not inhibit liver glycogen depletion, but significantly decreased the transminase activity. Both antiadrenergic drugs were injected 1 hr after CCl4 administration. These results indicate that release of epinephrine due to the administration of CCl4 occurs much earlier than the 20-hr period previously reported. Decrease in the resultant depletion of glycogen had no effect on the increase in liver damage.

Conformational analysis of the ergot alkaloids ergotamine and ergotaminine

Conformational analyses by 1H NMR and potential-energy calculations are reported for the ergot alkaloids ergotamine and ergotaminine, both as free bases and as the protonated species. In the neutral forms in CDCl3. two strong intramolecular hydrogen bonds fix the molecules in folded conformations, but the protonated species adopt a more extended conformation, with a single intramolecular hydrogen bond. Of the 24 alternative conformations available to ergotamine, the most likely biologically active species in environments with low dielectric constants, e.g., the presumed ergotamine binding site, is the folded, hydrogen-bonded conformation observed for the neutral molecule in CDCl3 solution.

Effects of increasing dietary levels of endophyte-infected tall fescue seed on diet digestibility and ruminal kinetics in sheep

Three experiments were conducted with sheep to determine the effects of 1) increasing the dietary concentration of ergovaline and 2) environmental temperature on site of nutrient digestion and ruminal passage rates. Dietary ergovaline concentration, a measure of endophyte-alkaloid concentration, was modified by substituting ergovaline-infected for noninfected tall fescue seed. Ruminal and total tract OM, NDF and cellulose digestibilities were less (P less than .10) and ruminal fluid dilution rate (%/h) and fluid outflow (liters/h) were greater (P less than .05) when diets contained 3 ppm ergovaline than when diets contained 0 ppm ergovaline. An interaction (P less than .05) between dietary ergovaline concentration (0 vs 1.5 ppm) and environmental temperature (27 vs 34 degrees C) was found for OM intake and NDF and cellulose digestion. Ruminal fluid dilution and outflow rates decreased (P less than .01) even though water consumption increased (P less than .01) with increasing temperature. Rectal temperature increased (P less than .01) when ergovaline and ergotamine tartrate were fed and when sheep were exposed to increased environmental temperature. Under the dietary (and environmental) conditions described, our results suggest that alkaloid(s) present in infected tall fescue seed inhibit ruminal fiber digestion and increase the sensitivity of sheep to heat stress.

Enhancing the effectiveness of abortive therapy: a controlled evaluation of self-management training

Research suggests that approximately one half of recurrent headache sufferers fail to adhere properly to drug treatment regimens with as many as two thirds of patients failing to make optimal use of abortive medications such as ergotamine. In spite of these findings there are no controlled studies that have attempted to evaluate methods for improving adherence to drug regimens for the treatment of chronic headache disorders. In an initial effort to address this adherence problem thirty-four recurrent migraine sufferers were randomized to abortive therapy with ergotamine tartrate plus caffeine (standard abortive therapy) or to standard abortive therapy accompanied by a brief educational intervention designed to facilitate the migraine sufferer's effective use of ergotamine. Patients who received the adjunctive educational intervention attempted to abort a greater percentage of their migraine attacks (70% vs 40%) and showed larger reduction in headache activity (e.g., 40% vs 26% reduction in month two of treatment). However, patients in both treatment groups used similar amounts of abortive medication when attempting to abort a migraine attack and showed similar reductions in analgesic medication use with abortive therapy. There results suggest that brief educational interventions designed to address the problem of patient adherence may yield significant improvements in standard therapies. We argue that such educational interventions deserve more attention in the headache treatment literature than they have received to date.

Drug abuse in migraine patients

Records of all patients discharged with a diagnosis of migraine from 2 Danish neurological departments were examined to determine the incidence of drug abuse. These departments had fixed uptake areas with a population of approximately 500,000 during the 5 year study period (1-1-1976--31-12-1980). Patients were selected for detailed analysis if (1) they used morphinomimetic drugs once a month or more, (2) took 7 or more tablets of weak analgesics a day or (3) consumed more than 60 mg ergotamine a month. A total of 92 patients fulfilled these criteria, 27 only because of ergotamine overuse. Injections of morphinomimetic drugs were given once a week or more frequently to 32 patients. These patients also usually had an escalating consumption and were usually regarded as abusers by their doctors. During admission morphinomimetics were discontinued. None deteriorated, 1/3 remained unchanged whereas 2/3 improved. Thus 32 patients can be regarded as abusers of morphinomimetics which represents an annual incidence of 13 per million inhabitants. We caution against the use of morphinomimetics in migraine.

Intramuscular ergotamine: plasma levels and dynamic activity

Ergotamine tartrate (0.5 mg) was injected intramuscularly into 10 subjects with migraine. The effect on peripheral arteries, measured as a decrease in toe-arm systolic gradients, developed slowly and was well sustained after 29 hr. In contrast, ergotamine was quickly absorbed (t1/2 = 3 min) and plasma levels (measured by HPLC) declined, with a biologic t1/2 of 2.5 hr. A hypothetic effect compartment model was adopted and kinetic and dynamic data were simultaneously fitted on a computer. Calculated from mean data, the rate constant for equilibration of the drug between plasma and effector site was 0.07 hr-1, with a t1/2 of 9.9 hr, and the steady-state plasma concentration resulting in 50% of maximal effect (Cpss50) was 0.24 ng/ml. The largest variability for the estimated kinetic and dynamic parameters among subjects was found for Cpss50 (coefficient of variation = 110%), indicating that, in addition to some kinetic variability, dynamic variability (difference in sensitivity) should be anticipated in the therapeutic use of ergotamine.