Nasally Delivered 0.5% Timolol Beta Blocker Successfully Treats Acute Migraines in a Referral Headache Clinic: A Case Series.

This is the first reported case series of nasally delivered beta blocker (timolol 0.5%) for the treatment of acute migraine. In a retrospective chart review, 16 patients were found who had received intranasal timolol for sub-optimally treated acute migraines. Of these, 10 (62.5%) reported to their provider that the medication was helpful. Encouragingly, the treatment was beneficial even for patients previously refractory to other medications. Intranasal timolol was well tolerated, with only one patient reporting mild nasal congestion and no other side effects reported. These findings suggest the need for a prospective pilot study followed by a larger double-blind randomized placebo-controlled trial to determine the overall efficacy and safety of nasally delivered beta blockers for acute migraine treatment.

The clinical value of chloral hydrate in the routine electroencephalogram.

PURPOSE: To evaluate the diagnostic yield and clinical impact of chloral hydrate (CH) in the routine EEG. METHODS: The EEG results and records of all patients receiving CH during routine EEG (CH-EEG) at Mayo Clinic Rochester between 4/1/07 and 9/30/07 (n=216 total; 148 adults) were reviewed for clinical indication, presence of epileptiform abnormalities and EEG duration. The results were compared to an equivalent number of consecutive EEGs performed without CH over the same time period (non-CH-EEGs). The clinical impact of the CH-EEG findings was evaluated by evaluating resulting clinical decisions made in the medical record. Chi-squared analysis was performed for discontinuous data, Student's t-test for continuous data. RESULTS: The proportion of EEGs with sleep-specific epileptiform abnormalities (SSEAs) was not statistically different (7.8% CH-EEG vs. 10.5% non-CH-EEG, p=0.34). CH was ordered more often by non-epileptologists than epileptologists (57% vs. 35%, p=0.0004). The mean acquisition time was greater for CH-EEGs (66.9min vs. 55.1min; p<<0.001). CH-EEGs resulted in a change in clinical management in 5/216 (2.3%). DISCUSSION: Compared to non-CH-EEGs, CH-EEGs were no more likely to show SSEAs, prolonged the acquisition time, and were associated with changes in clinical care in <3%. Routine use of CH in outpatient EEG is not strongly supported by these data.

Central pontine myelinolysis in a patient with hyperosmolar hyperglycemia and consistently normal serum sodium.

INTRODUCTION: Central pontine myelinolysis (CPM) is almost always described in association with a disturbance in sodium homeostasis, most commonly rapid correction of chronic hyponatremia. It has only rarely been described in patients with disturbances of serum osmolality in the absence of abnormal serum sodium concentrations. METHODS: Case report. RESULTS: A 93 year-old-man developed marked gait ataxia 2 days after the diagnosis and treatment of hyperosmolar hyperglycemia. MRI demonstrated a symmetric lesion in the central pons consisting of increased T2 signal intensity and restricted diffusion, consistent with CPM. Calculated serum osmolality on admission was 344 mOsm/kg and fell to 300 mOsm/Kg over 20 h. Serum sodium concentration stayed between 137 and 140 mEq/l throughout the admission. One month after admission, his ataxia had nearly completely resolved and the MRI changes had improved. CONCLUSION: CPM can develop in the setting of hyperosmolar hyperglycemia without abnormalities of sodium homeostasis. This supports the theory that the pathogenesis of CPM is dependent on a relatively hypertonic insult, which may occur independently of sodium abnormalities. CPM can present as isolated gait ataxia. Clinical manifestations of the disorder may show significant improvement despite a dramatic initial presentation.