Short-term effectiveness of simple advice as a withdrawal strategy in simple and complicated medication overuse headache.

BACKGROUND AND PURPOSE: The aim of this study was to compare the effectiveness of intensive advice (to withdraw the overused medication/s) as a withdrawal strategy in patients with simple and complicated medication overuse headache (MOH). METHODS: One hundred consecutive MOH patients were included in the study. Exclusion criteria were co-existent severe medical or psychiatric illnesses, treatment with migraine prophylactic drugs within the past 3 months, and overuse of opioids and/or barbiturate-containing agents. MOH was defined as complicated in patients fulfilling at least one of the following criteria: (i) a diagnosis of co-existent, significant, and complicating medical illnesses; (ii) a current diagnosis of mood disorder, anxiety disorder, eating disorder, or substance addiction disorder; (iii) a relapse after previous detoxification treatment; (iv) psycho-social and environmental problems; and (v) daily use of multiple doses of symptomatic medication/s. Withdrawal therapy was considered successful if, after 2 months, the patient had had reverted to an intake of NSAIDs lower than 15 days/month or to an intake of other symptomatic medication/s lower than 10 days/month. RESULTS: Fifty-one patients had simple MOH and 49 patients had complicated MOH. Eleven patients failed to attend follow-up visits (simple MOH=3, complicated MOH=8, P>0.05). Of all the patients included in the study, we were able to detoxify 79% (92.1% of the patients with simple MOH and 65.3% of those with complicated MOH, P<0.01). CONCLUSIONS: Simple advice is highly effective in simple MOH and effective in most complicated MOH patients and should be regarded as the first step in a step-care approach to MOH management.

Medication overuse headache: predictors and rates of relapse in migraine patients with low medical needs. A 1-year prospective study.

The aim of this study was to evaluate the rates and predictors of relapse, after successful drug withdrawal, in migraine patients with medication overuse headache (MOH) and low medical needs. The study population, study design, inclusion criteria and short-term effectiveness of the medication withdrawal strategies have been described elsewhere (Rossi et al., Cephalalgia 2006; 26:1097). Relapsers were defined as those patients fulfilling, at follow-up, the new International Classification of Headache Disorders, 2nd edn, appendix criteria for MOH. Complete datasets were available for 83 patients. At 1 year's follow up, the relapse rate was 20.5%. Univariate analysis showed that patients who relapsed had a longer duration of migraine with more than eight headache days/month, a longer duration of drug overuse, had tried a greater number of preventive treatments in the past, had a lower reduction of headache frequency after withdrawal, and had previously consulted a greater number of specialists. Binary logistic regression analysis was performed, and three variables emerged as significant predictors of relapse: duration of migraine with more than eight headache days/month [odds ratio (OR) 1.57, P = 0.01], a higher frequency of migraine after drug withdrawal (OR 1.48, P = 0.04) and a greater number of previous preventive treatments (OR 1.54, P = 0.01). In patients with migraine plus MOH and low medical needs, relapse seems to depend on a greater severity of baseline migraine.

Advice alone vs. structured detoxification programmes for medication overuse headache: a prospective, randomized, open-label trial in transformed migraine patients with low medical needs.

The aim of this study was to compare the effectiveness of strong advice to withdraw the overused medication with the effectiveness of two structured pharmacological detoxification strategies in a cohort of patients diagnosed with probable migraine overuse headache (MOH) plus migraine and presenting low medical needs. One hundred and twenty patients participated in the study. Exclusion criteria included: previous detoxification treatments, coexistent medical or psychiatric illnesses and overuse of agents containing opioids, benzodiazepines and barbiturates. Group A received only intensive advice to withdraw the overused medication. Group B underwent a standard out-patient detoxification programme (advice+prednisone+preventive treatment). Group C underwent a standard in-patient withdrawal programme (as in group B + fluid replacement and antiemetics). Withdrawal therapy was considered successful if, after 2 months, the patient had reverted to an episodic pattern of headache and to an intake of symptomatic medication on fewer than 10 days/month. We were able to detoxify 75.4% of the whole cohort, 77.5% of patients in group A, 71.7% of patients in group B and 76.9% of those in group C (P>0.05). In patients with migraine plus MOH and low medical needs, effective drug withdrawal may be obtained through the imparting of advice alone.

Seasonal, extratrigeminal, episodic paroxysmal hemicrania successfully treated with single suboccipital steroid injections.

This case report describes a case of extratrigeminal, episodic paroxysmal hemicrania with a clear seasonal temporal pattern, successfully treated with repeated single suboccipital steroid injections. The pathophysiological and clinical implications of this observation are discussed.

Prevalence, pattern and predictors of use of complementary and alternative medicine (CAM) in migraine patients attending a headache clinic in Italy.

The use of complementary and alternative medicine (CAM) in migraine is a growing phenomenon about which little is known. This study was undertaken to evaluate the rates, pattern and presence of predictors of CAM use in a clinical population of patients with different migraine subtypes. Four hundred and eighty-one migraineurs attending a headache clinic were asked to undergo a physician-administered structured interview designed to gather information on CAM use. Past use of CAM therapies was reported by 31.4% of the patients surveyed, with 17.1% having used CAM in the previous year. CAM therapies were perceived as beneficial by 39.5% of the patients who had used them. A significantly higher proportion of transformed migraine patients reported CAM treatments as ineffective compared with patients suffering from episodic migraine (73.1% vs. 50.7%, P < 0.001). The most common source of a recommendation of CAM was a friend or relative (52.7%). In most cases, migraineurs' recourse to CAM treatments was specifically for their headache (89.3%). Approximately 61% of CAM users had not informed their medical doctors of their CAM use. The most common reason for deciding to try a CAM therapy was that it offered a 'potential improvement of headache' (47.7%). The greatest users of CAM treatments were: patients with a diagnosis of transformed migraine; those who had consulted a high number of specialists and reported a higher lifetime number of conventional medical visits; those with a comorbid psychiatric disorder; those with a high income; and those whose headache had been either misdiagnosed or not diagnosed at all. Our findings suggest that headache clinic migraine patients, in their need of and quest for care, seek and explore both conventional and CAM approaches. Physicians should be made aware of this patient-driven change in the medical climate in order to prevent misuse of healthcare resources and to be better equipped to meet patients' needs.

Fatigue and magnetic resonance imaging activity in multiple sclerosis.

Fatigue is a frequent and often severe symptom in multiple sclerosis. Pathogenic mechanisms proposed for fatigue include the release of proinflammatory cytokines, which is thought to have an important effect on changes in the blood-brain barrier (BBB). To investigate whether fatigue is related to BBB disruption we studied 11 relapsing-remitting MS patients participating in a multicenter longitudinal study comparing the sensitivity of monthly enhanced magnetic resonance imaging (MRI) after standard-dose and triple-dose injection of gadolinium-diethylene triaminopentoacetic acid (Gd-DTPA). Serial Gd-enhanced MRI studies were performed in two separate sessions every 4 weeks for 3 months. An expanded version of the Fatigue Severity Scale, including 29 items, was administered 24 h before each MRI examination. No relationship was found between the number and volume of Gd-enhancing lesions and fatigue scores at any monthly examination over the study period. Furthermore changes in MRI activity were not significantly related to changes in fatigue scores. These results were obtained on triple-dose delayed scanning, which is more sensitive than standard-dose scanning in detecting areas of BBB disruption. Our preliminary results thus do not support the hypothesis of a relationship between BBB alterations and fatigue severity in multiple sclerosis.

Multiple sclerosis in childhood: clinical features of 149 cases.

From the retrospective study of 3375 patients affected by clinically definite or probable multiple sclerosis (MS), 149 patients were collected with onset of the disease before the age of 16 years (4.4%). Female/male ratio was higher than that of the adult onset MS (AOMS) population (2.2 vs 1.6) particularly at ages of onset after 12 years (3.0, P = 0.007 vs AOMS). Among initial symptoms, those suggesting brainstem dysfunction (25%) were more frequent compared to other systems and compared to AOMs symptoms; motor and sensory disturbances were slightly less frequent (respectively 17.5% and 18.3%). Optic neuritis appeared in 16.5% of cases with onset in childhood and in 16.2% of cases with AOMS, cerebellar disturbances respectively in 9.1% and 7.7%. The first interattack-interval and the clinical course of early onset MS did not differ significantly from AOMS. In early onset MS patients with disease duration < 8 years, cases with EDSS > 6 were slightly more frequent than in the AOMS group (P = 0.04). The frequency of cases for different levels of disability was similar for disease duration > 8 years.

[Pancreatic assessment by magnetic resonance imaging: an improvement in the diagnostic results with new study technics]. / Valutazione del pancreas con Risonanza Magnetica: miglioramento dei risultati diagnostici con nuove tecniche di studio.

Magnetic resonance imaging of the pancreas has been, limited by a series of artifacts with a resulting poor contrast to noise ratio. Nevertheless, technological progress has allowed to reduce not only scanning time but also the number of artifacts, by increasing the number of excitations and matrix size. Moreover, tissue contrast can now be modified. In our study performed on 5 normal volunteers and 20 patients with different pancreatic diseases conditions, fast SE sequences with and without fat suppression were used, with an overall increase in contrast to noise ratio. In all patients MR images allowed the accurate definition of the lesions: in 8 adenocarcinoma patients the lesion could be depicted, including the 2 lesions CT had poorly demonstrated. Also in the 3 patients with endocrine tumors, MRI depicted small tumors which were later confirmed at surgery. This new protocol makes MRI a very sensitive and accurate tool in the study of neoplastic and inflammatory pancreatic diseases thus, MRI is not only a complementary tool to CT but an even better study technique. In particular, its higher contrast to noise ratio allows a dramatic improvement in the depiction of small solid lesions, especially those not altering pancreatic outline. This study proves that MRI, when adequately performed, is a very accurate tool to study, in a very short time, the pancreas and peripancreatic region, yielding much better results than all the other diagnostic imaging modalities.

Sleep abnormalities in traumatic apallic syndrome.

Sleep patterns in 10 patients with traumatic apallic syndrome were studied, together with 10 healthy controls matched for sex and age. All patients underwent neurological examination, brain CT, and polysomnographic recording within six months (mean 99 (SD 45) range 47-180 days) from the onset of symptoms. Clinical follow up was performed six months after enrollment in the study. Sleep patterns were recorded in nine out of 10 patients. In the tenth patient there was no rhythm resembling physiological sleep. This patient was the only one who remained in a persistent vegetative state and died before the six month follow up. The severity of neurological deficit at follow up was significantly related to the duration of coma. There was no significant difference between patients and controls with respect to sleep architecture. The time spent awake after sleep onset was longer in patients than controls. Our data highlight the presence of sleep fragmentation in traumatic apallic syndrome, which might be due to changes in brain structures responsible for sleep maintenance. The absence of sleep-wake cycles might indicate a poor outcome.

[Magnetic resonance angiography of the intracranial circle using magnetization transfer contrast (MTC)]. / Angiografia con Risonanza Magnetica del circolo intracranico con tecnica di trasferimento della magnetizzazione (MTC).

Magnetic Resonance Angiography (MRA) is becoming an accurate technique to study vascular conditions, especially when the intracranial circulation is involved. Nevertheless, the contrast-to-noise (C/N) ratio in MRA images is often inadequate to obtain diagnostic images. C/N ratio can be increased by using magnetization transfer contrast (MTC), the technique which allows to reduce the signal from the stationary tissues surrounding vascular structures. To demonstrate the value of MTC, 10 healthy volunteers and 10 patients with different cerebral vascular conditions were examined. All exams were performed using 3D MOTSA (Multiple Overlapping Thin Slab Acquisition) Time of Flight sequences, with and without MTC. A quantitative analysis was carried out in the images with and without MTC, measuring the signal intensity value in the regions of interest at the vascular and stationary structures. A qualitative analysis was also carried out with a double blind study by two independent radiologists. Our results showed that MTC allows to reduce stationary tissues signal intensity, without affecting flowing blood signal intensity. Therefore, the C/N ratio is increased, thus allowing better depiction of smaller peripheral branches. In conclusion, MTC applied to intracranial MRA allows image quality to be markedly improved, with an overall increase in the diagnostic accuracy of this technique.

Central pontine myelinolysis: report of an asymptomatic case.

Central pontine myelinolysis (CPM), a disorder occurring for the most part in alcohol abusers, is characterized by the symmetric and selective destruction of medullated sheaths in the central pontine region. Detection of CPM in the pre-symptomatic phase may improve the outcome, which is usually serious. We describe a case of CPM in a 48-year-old female alcohol abuser who was seen at our out-patient clinic for a history of generalized seizures. Neurological examination was normal while magnetic resonance imaging revealed a pontine lesion consistent with CPM. On the basis of this report we hypothesize that the possibility to detect CPM in the pre-symptomatic phase will lead to increased diffusion of magnetic resonance imaging, and in turn to improved therapeutic strategies, such as the use of greater caution when correcting plasma electrolyte imbalance in alcoholics.

Antiphospholipid antibodies and cerebral artery dissection: two frequent causes of brain ischemia in young adults.

As part of a multicenter study on ischemic stroke in the young, we report the occurrence of high antiphospholipid antibody (aPLs) levels and cerebral dissection in 75 patients. These represent the two most frequent non-thromboembolic causes of cerebral ischemia in our population. Increased aPL titres were found in nine cases (12%); cerebral artery dissection in eleven (14%). Our data stress the need to modify the classical diagnostic approach to cerebral ischemia by including hematological assessments and new neuroimaging techniques as screening tests.