Eating attitudes of migraine patients in Turkey: a prospective multi-center study.

BACKGROUND: Migraine is a disease characterized by headache attacks. The disease is multifactorial in etiology and genetic and environmental factors play role in pathogenesis. Migraine can also be accompanied by psychiatric disorders like neurotism and obsessive compulsive disorder. Stress, hormonal changes and certain food intake can trigger attacks in migraine. Previous studies showed that eating attitudes and disorders are prevalant in patients with migraine. Eating disorders are psychiatric disorders related to abnormal eating habits. Both migraine and eating disorders are common in young women and personality profiles of these patient groups are also similar. A possible relationship which shows that migraine and eating habits are related can lead to a better understanding of disease pathogenesis and subsequently new therapeutic options on both entities. Association of migraine in relation to severity, depression and anxiety and eating habits and disorders were aimed to be investigated in this study. METHODS: The study was designed as a prospective, multi-center, case control study. Twenty-one centers from Turkey was involved in the study. The gathered data was collected and evaluated at a single designated center. From a pool of 1200 migraine patients and 958 healthy control group, two groups as patient group and study group was created with PS matching method in relation to age, body-mass index, marital status and employment status. Eating Attitudes Test-26 (EAT-26), Beck's Depression Inventory (BDI) and Beck's Anxiety Inventory (BAI) were applied to both study groups. The data gathered was compared between two groups. RESULTS: EAT-26 scores and the requirement for referral to a psychiatrist due to symptoms related to eating disorder were both statistically significantly higher in patient group compared to control group (p = 0.034 and p = 0.0001 respectively). Patients with migraine had higher scores in both BDI and BAI compared to control group (p = 0.0001 and p = 0.0001 respectively). Severity of pain or frequency of attacks were not found to be related to eating attitudes (r:0.09, p = 0.055). CONCLUSIONS: Migraine patients were found to have higher EAT-26, BDI and BAI scores along with a higher rate of referral to a psychiatrist due to symptoms. Results of the study showed that eating habits are altered in migraine patients with higher risk of eating disorders. Depression and anxiety are also found to be common amongst migraine patients.

Does proton pump inhibitor reduce the antiaggregant efficacy of aspirin in ischemic stroke?

OBJECTIVE: To evaluate the effect of using acetylsalicylic acid (aspirin) together with lansoprazole in the secondary prevention of ischemic stroke. MATERIALS AND METHODS: 199 patients with a diagnosis of ischemic stroke and transient ischemic attack (TIA) using 100 mg aspirin regularly were included in the study. All patients were evaluated for the presence of aspirin resistance before starting the study. 57 patients with aspirin resistance were excluded from the study. The remaining 142 patients were divided into two groups: the 1st group consisted of those with stomach discomfort and the 2nd group consisted of those without stomach discomfort. Patients in group 1 were given 30 mg of lansoprazole taken before breakfast in addition to aspirin therapy. All patients were re-evaluated for the presence of aspirin resistance at a one-month follow-up. The antiaggregant activity was evaluated by the impedance aggregometry method in both groups. RESULTS: Of 142 patients, 75 were in group 1, and 67 were in group 2. There was no difference between the two groups in terms of age and gender distribution of vascular risk factors. There was no statistically significant difference between the two groups in terms of aspirin efficacy. The dose of aspirin was increased in patients with aspirin resistance (AR). CONCLUSION: The combination of 30 mg lansoprazole and 100 mg aspirin does not cause a decrease in antiaggregant activity in the early period, but chronic use was not evaluated in this study. Patients with AR may benefit from an increase in the dose of aspirin.

Assessment of safety and feasibility of non-invasive vagus nerve stimulation for treatment of acute stroke.

BACKGROUND: Non-invasive vagus nerve stimulation (nVNS) using a hand-held stimulator placed on the neck is an FDA-approved treatment for primary headache disorders. The safety of nVNS is unknown in stroke patients. OBJECTIVE: To assess the safety and feasibility of nVNS for the acute treatment of stroke. METHODS: TR-VENUS (clinicaltrials.gov identifier NCT03733431) was a randomized, sham-controlled, open-label, multicenter trial conducted in patients with acute ischemic stroke (IS) or intracerebral hemorrhage (ICH). Patients were randomly assigned to standard-dose nVNS, high-dose nVNS, or sham stimulation. The primary endpoint was a composite safety outcome defined as bradycardia or reduction in mean arterial blood pressure during treatment or progression of neurological or death within 24 h of treatment. The feasibility endpoints were the proportion of eligible subjects receiving nVNS within 6 h of symptom onset and the proportion completing all pre-specified treatment doses. Efficacy assessments included infarct growth from baseline to 24 h after treatment. RESULTS: Sixty-nine patients (61 IS, 8 ICH) completed the study. The composite safety outcome was achieved in 32.0% in sham and 47.7% in nVNS group (p = 0.203). Treatment was initiated in all but two randomized patients. All dosed subjects received 100% of prespecified stimulations. A non-significant reduction in infarct growth was observed in the high-dose nVNS group (184.2% in sham vs. 63.3% in high-dose nVNS; p = 0.109). CONCLUSIONS: The results of this study suggest that nVNS may be safe and feasible in the setting of acute stroke. These findings support further development of nVNS as a potential treatment for acute ischemic stroke.

Contribution of verbal suggestion to the therapeutic efficacy of an analgesic agent for acute primary headache.

OBJECTIVE: The therapeutic response of a patient cannot purely be explained by the method of therapy or the efficacy of a drug. Clinician-patient interaction, psychosocial factors, patients' expectations, hopes, beliefs and fears are all related to the healing outcome. Malleability and suggestibility are also important in the placebo or nocebo effect. The purpose of this study was to evaluate whether adding brief verbal suggestions for pain relief could change the magnitude of an analgesic's efficacy. METHODS: This prospective study was performed in the emergency department of a university hospital. Patients who were ordered analgesia with diclofenac sodium for primary headache were divided into three groups. All groups were informed that they would be administered a pain killer by intramuscular injection. The second and third groups were given positive and reduced treatment expectations about the therapeutic efficacy, respectively. Patients were asked to rate their pain on a VAS at 0 and 45 minutes and if they needed any additional analgesic 45 minutes after the injection. RESULTS: A total of 153 patients were included in the study. The paired univariate analyses showed significant differences for all groups between 0- and 45-minute VAS scores. However, there was no difference between the three groups according to the differences in VAS scores between 45 and 0 minutes and according to the administration of an additional drug. CONCLUSION: Simple verbal suggestions did not alter the efficacy of an analgesic agent for headache in an emergency setting. The contributions of suggestibility, desire and expectation in acute primary headache patients should be further investigated.

Elevated S100B and neuron specific enolase levels in patients with migraine-without aura: evidence for neurodegeneration?

Although migraine has mainly been considered as a benign disease, there is cumulative evidence of silent changes in the brain, brainstem, or cerebellum and subtle subclinical cerebellar dysfunction. In this study, in order to investigate a possible neuronal and/or glial damage at the cellular level in migraine, we measured and compared serum levels of S100B which is a protein marker of glial damage or activation, and neuron specific enolase (NSE) which is a marker of neuronal damage, in migraine patients and control subjects. Serum levels of S100B and NSE were measured in blood samples from 41 patients with migraine-without aura taken during a migraine attack (ictal) and in the attack-free period between migraine attacks (interictal) and 35 age- and sex-matched controls. Patients with migraine-without aura had significantly higher ictal serum levels of S100B and NSE (P < 0.05, for both) than control subjects; whereas in the interictal phase, there was a significant increment only in S100B levels (P < 0.05) compared to controls. On the other hand, serum levels of S100B and NSE in ictal and interictal blood samples did not differ significantly. The findings of increased ictal serum S100B and NSE levels together with increased interictal levels of S100B suggested that migraine might be associated with glial and/or neuronal damage in the brain and a prolonged disruption of blood-brain barrier. Increased interictal serum levels of S100B might point out to an insidious and slow damaging process in migraine patients.

Transcranial Doppler ultrasonographic evaluation of cerebral circulation during passive tilting in patients with Parkinson's disease.

PURPOSE: To assess the effects of the tilt test on cerebral blood flow velocity (CBFV), blood pressure, and heart rate in patients with Parkinson's disease (PD) without symptomatic orthostatic dysautonomia. METHODS: Thirty patients with idiopathic PD and 15 healthy controls were included. Mean middle cerebral artery blood flow velocity (CBFV) was recorded with transcranial Doppler sonography, while systolic (SBP), diastolic (DBP), and mean (MBP) blood pressure and heart rate were measured in the supine position and after passive tilting. RESULTS: There was no difference in resting SBP, DBP, or MBP between patients and controls. CBFV was lower at rest in patients than in controls and dropped significantly and similarly after tilting in both groups. SBP decreased in patients during the first 5 minutes of tilting (p < 0.05), whereas it increased progressively after the first minute in controls. In patients, DBP decreased slightly and MBP dropped during the first 2 minutes, then increased. Baseline heart rate was higher in patients than in controls (p < 0.05) and increased in both groups during tilting. CONCLUSION: Our results suggest that cardiovascular responses to tilting are delayed in PD patients and that subclinical autonomic dysfunction may be present even in the absence of symptomatic orthostatic dysautonomia.

Transient partial ophthalmoplegia and Horner's syndrome after intraoral local anesthesia.

Local neurological symptoms and signs are infrequent after intraoral anesthesia for dental procedures, thus diagnosis may be challenging for a neurologist unfamiliar with this benign phenomenon. Unnecessary diagnostic procedures may be performed and can be associated with complications. We present a 19-year old woman with transient diplopia, miosis, partial enophthalmia and lacrimation on the side of injection after intraoral anesthesia with prilocaine.

The effect of the menstrual cycle on the optic nerve head analysis of migrainous women.

PURPOSE: To determine the effect of the menstrual cycle on the optic nerve head topographic analysis of normally menstruating migrainous women. MATERIAL AND METHODS: Randomly selected one eye of 44 migrainous and 49 healthy control women with regular menstrual cycles were included in the study. All subjects underwent complete ocular examination. Optic nervehead topographic analysis were performed using a confocal scanning laser ophthalmoscope, HRT II (Heidelberg Retinal Tomograph II, software version 1.6;Heidelberg Engineering, Heidelberg, Germany). They were repeated for two times during the menstrual cycle: in follicular phase (7th to 10th day of the cycle) and in the luteal phase (days 3 to 4 before the menstrual bleeding). Serum estradiol, progesterone, and luteinizing hormone measurements were repeated at each menstrual phase. RESULTS: The mean age of migrainous and control subjects were 31.5 + 5.1 years and 33.4 +/- 3.7 years, respectively (P > 0.05). Their mean disc areas were 2.26 +/- 0.46 mm(2) and 1.95 +/- 0.39 mm(2), respectively(P < 0.05). Control subjects did not demonstrate any difference in the disc topography (P > 0.05). The parameter rim volume decreased, while the parameters cup volume and cup shape measure increased significantly in the luteal phase of the migrainous women (all P values <0.05). Mean intraocular pressure of the migrainous women decreased significantly in luteal phase (P < 0.05). CONCLUSION: Significant differences exist in the optic rim and cup parameters during the menstrual cycle of the migrainous women. Further clinical trials on ocular blood flow changes during the menstrual cycle of the migrainous women may highlight the role of sex steroids in the optic nerve head of the migrainous women.

Effect of the menstrual cycle on standard achromatic and blue-on-yellow visual field analysis of women with migraine.

BACKGROUND: It has been postulated that migraine and glaucoma may have common vascular causative factors. Significant sex-based differences in the incidence of many important ocular conditions raise the possibility that estrogens may have direct effects on the eye. We performed a study to determine the effect of the menstrual cycle on standard achromatic automated perimetry (SAP) and short-wavelength automated perimetry (SWAP) (blue-on-yellow perimetry) of women with migraine. METHODS: Both eyes of 73 normally menstruating women (31 subjects with migraine and 42 healthy control subjects) were included in the study. Subjects underwent a complete ocular examination including SAP and SWAP in both the follicular phase (12th to 13th day of the cycle) and the luteal phase (1 to 2 days before the onset of bleeding) of two consecutive menstrual cycles.We performed visual field analysis using the Humphrey Field Analyzer II with the full-threshold central 30-2 program. Mean sensitivity was calculated for the superior temporal, inferior temporal, superior nasal and inferior nasal regions separately. RESULTS: Thirteen subjects were lost to follow-up (5 in the migraine group and 8 in the control group), leaving 26 subjects and 34 subjects respectively. There was no significant difference in mean age between the two groups (33.9 years [standard deviation (SD) 3.4 years] vs. 35.1 years [SD 3.3 years]). The mean duration of migraine was 7.6 (SD 3.1) years (range 3-14 years). In both groups, serum estradiol levels were significantly lower (p = 0.001) and serum progesterone levels were significantly higher (p < 0.001) in the luteal phase than in the follicular phase. In the control group, the mean sensitivity values with SWAP were significantly lower in the luteal phase than in the follicular phase (p = 0.04). A similar decrease was observed for the subjects with migraine with both SAP and SWAP (p = 0.01). There was no difference in regional mean sensitivity between the two phases with either perimetric test in the control group. For the subjects with migraine, there was no difference in regional mean sensitivity between the two phases with SAP. However, with SWAP, the mean sensitivity for the nasal visual field locations was significantly lower in the luteal phase than in the follicular phase (p = 0.01). INTERPRETATION: Our study provides further evidence of an effect of sex hormones on the visual field of women with migraine. In addition to assessment of intraocular pressure, menstrual cycle phases should be considered in women with migraine at risk for glaucomatous optic neuropathy.

Prolonged hyperglycemia in the early subacute period after cerebral infarction: effects on short term prognosis.

Although the adverse effect of admission hyperglycemia in cerebral infarction on prognosis is well known, studies generally have not questioned the effect of hyperglycemia in the early subacute period on prognosis after a stroke. Forty-six patients with acute ischemic stroke were seperated into 3 groups: Group 1) Known diabetes or admission blood glucose (ABG) > or = 140 mg/dl and HbA1c > or = 8,0%); Group 2) ABG > or = 140 mg/dl and HbA1c < 8,0%; and Group 3) ABG < 140 mg/dl and HbA1c < 8,0%. Blood glucose was followed-up 4 times a day for 10 days after the stroke and the mean of these measurements was calculated as the mean of glycemic regulation (MGR). Neurological evaluation was done at presentation and on day 10 and 30 with the National Institute of Health (NIH) scale. Oedema, lesion size and presence of hemorrhagic transformation were evaluated using CT. The MGR was significantly higher in group 1 compared to the other two groups (p < 0,001 and p < 0,01) and in group 2 compared to group 3 (p < 0,001). Patients with clinical worsening had a significantly higher MGR (p < 0,05). Patients with marked cerebral edema had a significantly higher MGR (p < 0,01) compared to patients with lesser edema. No correlation was found between MGR and lesion size or hemorrhagic transformation. Our results show that hyperglycemia in the early subacute period after cerebral infarction is associated with more pronounced cerebral edema and has an adverse effect on short term prognosis. We suggest that studies investigating the effect of insulin infusion on stroke prognosis should also consider infusions for a longer period than 24 hours.

Validity and reliability of the Turkish Migraine Disability Assessment (MIDAS) questionnaire.

OBJECTIVES: The aim of this study is to assess the comprehensibility, internal consistency, patient-physician reliability, test-retest reliability, and validity of Turkish version of Migraine Disability Assessment (MIDAS) questionnaire in patients with headache. BACKGROUND: MIDAS questionnaire has been developed by Stewart et al and shown to be reliable and valid to determine the degree of disability caused by migraine. DESIGN AND METHODS: This study was designed as a national multicenter study to demonstrate the reliability and validity of Turkish version of MIDAS questionnaire. Patients applying to 17 Neurology Clinics in Turkey were evaluated at the baseline (visit 1), week 4 (visit 2), and week 12 (visit 3) visits in terms of disease severity and comprehensibility, internal consistency, test-retest reliability, and validity of MIDAS. Since the severity of the disease has been found to change significantly at visit 2 compared to visit 1, test-retest reliability was assessed using the MIDAS scores of a subgroup of patients whose disease severity remained unchanged (up to +/-3 days difference in the number of days with headache between visits 1 and 2). RESULTS: A total of 306 patients (86.2% female, mean age: 35.0 +/- 9.8 years) were enrolled into the study. A total of 65.7%, 77.5%, 82.0% of patients reported that "they had fully understood the MIDAS questionnaire" in visits 1, 2, and 3, respectively. A highly positive correlation was found between physician and patient and the applied total MIDAS scores in all three visits (Spearman correlation coefficients were R= 0.87, 0.83, and 0.90, respectively, P <.001). Internal consistency of MIDAS was assessed using Cronbach's alpha and was found at acceptable (>0.7) or excellent (>0.8) levels in both patient and physician applied MIDAS scores, respectively. Total MIDAS score showed good test-retest reliability (R= 0.68). Both the number of days with headache and the total MIDAS scores were positively correlated at all visits with correlation coefficients between 0.47 and 0.63. There was also a moderate degree of correlation (R= 0.54) between the total MIDAS score at week 12 and the number of days with headache at visit 2 + visit 3, which quantify headache-related disability over a 3-month period similar to MIDAS questionnaire. CONCLUSION: These findings demonstrated that the Turkish translation is equivalent to the English version of MIDAS in terms of internal consistency, test-retest reliability, and validity. Physicians can reliably use the Turkish translation of the MIDAS questionnaire in defining the severity of illness and its treatment strategy when applied as a self-administered report by migraine patients themselves.

Utility of transcranial doppler ultrasonography for confirmatory diagnosis of brain death: two sides of the coin.

BACKGROUND: Although the clinical examination and documentation of the clinical signs of brain death are very uniform, there are significant differences in the guidelines for using technical confirmatory tests to corroborate the clinical signs. The current study examined the utility of transcranial Doppler ultrasonography (TCD) for confirmation of brain death. METHODS: After 19 patients were excluded from the study because of lack of bone window or because an apnea test could not be performed because of desaturation, 100 patients (61 patients with clinical brain death, and 39 control patients with Glasgow Coma Score<5) were included in the study. The following TCD findings were accepted as confirmatory of brain death when they were found bilaterally or in at least three different arteries for at least 3 minutes within the same examination: (1) brief systolic forward flow or systolic spikes and diastolic reverse flow, (2) brief systolic forward flow or systolic spikes and no diastolic flow, or (3) no demonstrable flow in a patient in whom flow had been clearly documented in a previous TCD examination. RESULTS: The sensitivity and specificity of the first TCD examination for confirmation of brain death were 70.5% and 97.4%, respectively. Eighteen patients with clinical brain death required repeat TCD examinations because of detection of forward systolo-diastolic flow or a diastolic to-and-fro flow pattern, which were not confirmatory for the diagnosis of brain death. Brain death was confirmed ultrasonographically in 12 of 18 patients in a second examination after 12.6 +/- 8.3 hours of clinical brain death, in 2 patients in a third TCD examination, and in 1 patient in a fourth examination. Three clinically brain-dead patients had died before the diagnosis was confirmed by repeat TCD examinations. The sensitivity of TCD reached 100% in our study population after the fourth examination. CONCLUSION: The sensitivity of TCD is increased with repeat examinations and should be repeated in cases in which systolo-diastolic forward flow is demonstrated after the first TCD. TCD may prolong or shorten the time to declaration of brain death. The necessity of demonstrating cerebral circulatory arrest in patients with clinical brain death is debatable.

Factors affecting one year mortality and functional outcome after first ever ischemic stroke in the region of Antalya, Turkey (a hospital-based study).

In order to establish good health politics for stroke survivors, regional differences in factors affecting the outcome of patients have to be known. For this purpose we investigated factors affecting 1 year mortality and functional outcome in patients with first-ever-in a lifetime stroke in the region of Antalya, Turkey. One-hundred and forty-seven patients with a first ever stroke were included and followed up for at least one year. The modified Rankin Scale was used for evaluation of handicap. Several factors known to affect prognosis such as demographic features, socioeconomic status, stroke subtype, neurological findings and stroke risk factors were compared between patients who died during follow-up and survivors. Of the 147 patients 35 (23.8%) died during the course of the study. Multivariate logistic regression analysis showed that only illiteracy, being single or widowed and presence of urinary incontinence were significant predictors of being dead at the end of 1 year. In the survivors factors independently affecting dependence at the end of one year were age, presence of coma on admission and urinary incontinence. Our results suggest that not only stroke severity but also socioeconomic variables are important in determining the prognosis of stroke patients.

Effect of donepezil on EEG spectral analysis in Alzheimer's disease.

EEG spectral analysis allows a quantitative analysis of changes in the frequency bands during disease progression in Alzheimer's disease (AD) and could be used to monitor treatment and disease progression. Eighteen patients with probable AD were evaluated by Folstein Mini Mental State Examination (MMSE) and EEG spectral analysis before donepezil treatment, 2 months after 5 mg/day and 4 months after the dose was raised to 10 mg/day. EEG evaluations were done in 4 derivations (T3-T5, T4-T6, C3-P3, C4-P4). Six months after treatment there was a significant reduction in the temporal delta amplitudes and an increase in the amplitudes of all the other frequency ranges including theta amplitudes both in the temporal and centroparietal derivations. MMSE scores increased during treatment but the change was not significant. These findings show that donepezil exerts a positive effect on EEG in AD by decreasing delta activity and increasing alpha and beta activity. The increase in theta activity after treatment may reflect a therapeutic shift of delta activity to theta activity.

Normalization of high interictal cerebrovascular reactivity in migraine without aura by treatment with flunarizine.

BACKGROUND: Modification of migraine-associated cerebrovascular reactivity may provide insight into the mechanism of action of a given therapeutic intervention. METHODS: With transcranial Doppler and a breath-holding index, cerebrovascular reactivity to hypercapnia was evaluated in 20 patients with migraine without aura interictally and in 11 healthy controls. Patients were started on prophylactic treatment with flunarizine 10 mg per day, and measurements were repeated at the end of every month for 3 months. Headache status was evaluated clinically via a headache index. Headache index; breath-holding index; systolic, diastolic, and mean blood flow velocities; and pulsatility index measurements were recorded at every session. RESULTS: The baseline breath-holding index was significantly higher in the migraine group compared to the control group (P =.002). No difference in other parameters was found between the groups. The change in the headache index was significant (P<.001), indicating a beneficial effect from flunarizine. The breath-holding index improved significantly after treatment (P<.001), and the baseline difference in the breath-holding index between the pretreatment migraine group and the control group was no longer evident at 3 months. There was no significant change with treatment in the other transcranial Doppler parameters. CONCLUSIONS: Our finding of unchanged blood flow velocities but normalized cerebrovascular reactivity after treatment suggests that the mechanism of action of flunarizine in migraine does not involve a vasodilatory effect on cerebral vessels. It may be instead that flunarizine modifies cerebrovascular reactivity through its action on centrally located structures that subserve autonomic vascular control.