ABSTRACT
PURPOSE OF REVIEW: Management of chronic daily headaches (CDH) remains challenging due to the limited efficacy of standard prophylactic pharmacological measures. Several studies have reported that repetitive transcranial magnetic stimulation (rTMS) can effectively treat chronic headaches. The objective was to determine the utility of rTMS for immediate post-treatment and sustained CDH prophylaxis. RECENT FINDINGS: All procedures were conducted per PRISMA guidelines. PubMed, Scopus, Web of Science, and ProQuest databases were searched for controlled clinical trials that have tested the efficacy of rTMS on populations with CDH. DerSimonian-Laird random-effects meta-analyses were performed using the 'meta' package in R to examine the post- vs. pre-rTMS changes in standardized headache intensity and frequency compared to sham-control conditions. Thirteen trials were included with a combined study population of N = 538 patients with CDH (rTMS, N = 284; Sham, N = 254). Patients exposed to rTMS had significantly reduced standardized CDH intensity and frequency in the immediate post-treatment period (Hedges' g = -1.16 [-1.89, -0.43], p = 0.002 and Δ = -5.07 [-10.05, -0.11], p = 0.045 respectively). However, these effects were sustained marginally in the follow-up period (Hedges' g = -0.43 [-0.76, -0.09], p = 0.012 and Δ = -3.33 [-5.52, -1.14], p = 0.003). Significant between-study heterogeneity was observed, at least partially driven by variations in rTMS protocols. Despite the observed clinically meaningful and statistically significant benefits in the immediate post-treatment period, the prophylactic effects of rTMS on CDH do not seem to sustain with discontinuation. Thus, the cost-effectiveness of the routine use of rTMS for CDH prophylaxis remains questionable. REGISTRATION: Protocol preregistered in PROSPERO International Prospective Register of Systematic Reviews (CRD42021250100).
ABSTRACT
An uncommon but serious adverse drug reaction after phenytoin administration is known as purple glove syndrome (PGS). Initial presentation is characterized by pain, skin discoloration, and edema, that can progress to necrosis. The pathophysiology remains uncertain; however, multiple mechanisms have been reported including extravasation. We describe a case of a 61-year-old patient who was brought to the hospital with altered mental status due to status epilepticus. The patient received multiple doses of lorazepam; eventually was started on levetiracetam and valproate, including loading doses. The seizures were poorly controlled despite treatment, and intravenous (IV) phenytoin was added. The next day, bluish discoloration and swelling to bilateral upper distal extremities were noted on physical examination. Consequently, IV phenytoin was discontinued immediately due to high suspicion of PGS. Skin discoloration and edema gradually improved after one week, confirming a case of mild PGS.
