Cerebral reactivity in migraine patients measured with functional near-infrared spectroscopy.

BACKGROUND: There are two major theories describing the pathophysiology of migraines. Vascular theory explains that migraines resulted from vasodilation of meningeal vessels irritating the trigeminal nerves and causing pain. More recently, a neural theory of migraine has been proposed, which suggests that cortical hyperexcitability leads to cortical spreading depression (CSD) causing migraine-like symptoms. Chronic migraine requires prophylactic therapy. When oral agents fail, there are several intravenous agents that can be used. Understanding underlying causes of migraine pain would help to improve efficacy of migraine medications by changing their mechanism of action. Yet to date no study has been made to investigate the link between vascular changes in response to medications for migraine versus pain improvements. Functional near-infrared spectroscopy (NIRS) has been used as an inexpensive, rapid, non-invasive and safe technique to monitor cerebrovascular dynamics. METHOD: In this study, a multi-distance near-infrared spectroscopy device has been used to investigate the cortical vascular reactivity of migraine patients in response to drug infusions and its possible correlation with changes in pain experienced. We used the NIRS on 41 chronic migraine patients receiving three medications: magnesium sulfate, valproate sodium, and dihydroergotamine (DHE). Patients rated their pain on a 1-10 numerical scale before and after the infusion. RESULTS: No significant differences were observed between the medication effects on vascular activity from near channels measuring skin vascularity. However, far channels--indicating cortical vascular activity--showed significant differences in both oxyhemoglobin and total hemoglobin between medications. DHE is a vasoconstrictor and decreased cortical blood volume in our experiment. Magnesium sulfate has a short-lived vasodilatory effect and increased cortical blood volume in our experiment. Valproate sodium had no significant effect on blood volume. Nonetheless, all three reduced patients' pain based on self-report and no significant link was observed between changes in cortical vascular reactivity and improvement in migraine pain as predicted by the vascular theory of migraine. CONCLUSION: NIRS showed the potential to be a useful tool in the clinical setting for monitoring the vascular reactivity of individual patients to various migraine and headache medications.

A standardized online clinical education and assessment tool for neurology clerkship students assigned to multiple sites.

The Drexel neurology clerkship experience can vary from large groups at a university hospital inpatient unit to smaller groups at private physician offices. Evaluations are based on the site director's subjective assessment and performance on the National Board of Medical Examiners neurology shelf examination. We are developing a standardized online clinical neurology course and quiz for the whole clerkship. We piloted the course and quiz at a single site for one academic year and compared their test scores with a control group of students at other clerkship sites who took the online quiz without viewing the course. Students at the pilot site achieved higher scores both on the neurology shelf examination and the clinical quiz and also reported higher teaching satisfaction scores than students at all other sites. There was a 97 % participation rate in the online quiz from the other sites. Use of this online course and quiz provides effective standardized clinical neurology teaching and evaluation that can be applied to students across multiple sites.

Headache in multiple sclerosis: features and implications for disease management.

The aim of this study was to investigate the variables affecting headache occurrence in patients with multiple sclerosis (MS). Seventy-two MS patients with comorbid headaches completed a 28-item questionnaire. This evaluation assessed each patient's demographics, headache description and modifying factors, social history, and impact on quality of life. Our patients reported a wide spectrum of headache presentations, characteristics, and resulting disability. We discuss the patterns in our data in the context of current hypotheses regarding headache and MS causality. In our patients, migraines with aura strongly correlated with MS exacerbations, suggesting that they might be useful as a marker for flare-up onset. Patients' pain descriptions varied based on their headache frequency, history, and relationship to MS progression. Due to the severity of headache in MS patients and resulting impact on their activities of daily living, a thorough analysis of headache presentation is warranted in such patients.

Use of therapies other than disease-modifying agents, including complementary and alternative medicine, by patients with multiple sclerosis: a survey study.

CONTEXT: Many patients with multiple sclerosis use complementary and alternative medicine (CAM) to supplement their traditional treatment. OBJECTIVE: To identify both the prevalence and frequency of use of therapies other than disease-modifying agents (DMAs), including CAM, among patients with multiple sclerosis. DESIGN: The authors administered a 13-question survey regarding patients' current use of non-DMA therapies-including dietary supplements, exercise, and "true" CAM (eg, acupuncture, chiropractic, massage)-and mainstream treatments, including physical therapy and osteopathic manipulative treatment. Patients rated their level of disability on a scale of 1 to 10 (with 10 being most severe). SETTING: A hospital outpatient clinic in Philadelphia, Pennsylvania. PATIENTS: Inclusion criteria were physician-confirmed multiple sclerosis (either relapsing-remitting or progressive), regardless of sex, duration of disease, age at onset, disability level, or type of disease. Patients were excluded if they were younger than 18 years. MAIN OUTCOME MEASURE: Patient-reported use of non-DMA therapies and perception of disability. RESULTS: A total of 111 patients with multiple sclerosis completed the survey properly. All respondents used non-DMA therapies. Twenty-three patients (20.7%) used these therapies without concomitantly taking a DMA. A plurality (34.8%) of those patients reported a disability score of 7 or 8. Sixty-two of the 88 participants (70.5 %) who used DMAs reported disability scores of 5 or less. Sixty-five patients (58.6.%) reported exercising on a weekly basis. Among those patients, 47 (72.3%) reported a disability score of 5 or less. Sixty-four patients (57.7%) used such CAM therapies as acupuncture and massage, or such other non-DMA treatments as osteopathic manipulative treatment and psychotherapy. Among those patients, 37 (64.9%) reported a disability score of 5 or less. CONCLUSION: Many patients with multiple sclerosis are seeking more than traditional medical treatment. Physicians and other health care professionals must be aware of the extensive use of alternative modalities among these patients, and these professionals must provide guidance and monitoring in use of these therapies to improve outcomes.

Problem neurology residents: a national survey.

OBJECTIVES: Problem residents are found across most medical specialties at a prevalence of about 10%. This study was designed to explore the prevalence and causes of problem neurology residents and to compare neurology programs' responses and outcomes. METHODS: Directors of 126 US neurology residency programs were sent an electronic survey. We collected data on demographics, first and all "identifiers" of problem residents, and year of training in which the problem was found. We asked about observable signs, etiology, and who performed remediation. We asked what resources were used and what outcomes occurred. RESULTS: Ninety-five program directors completed surveys (75% response rate). Almost all neurology programs have problem residents (81%). Age, sex, marital status, being a US native, or attending a US medical school had no effect on problem status. Being a parent carried a lower likelihood of problems (32%). Most commonly the problem is acted on during the first year of training. Faculty members without defined educational roles were the most frequent first identifiers. Program directors were the most common remediators. The most common remediation techniques were increasing supervision and assigning a faculty mentor. Graduate medical education office and psychiatric or psychological counseling services were most often used. Eleven percent of problem residents required a program for impaired physicians and 14% required a leave of absence. Sixteen percent were dismissed from their programs. CONCLUSIONS: The prevalence of problem residents in neurology is similar to other disciplines, and various resources are available to remediate them.

Current status of neurology grand rounds.

OBJECTIVE: We sought to compare the current status of Neurologic Grand Rounds (NGRs) in training programs with the status observed in Medical Grand Rounds. METHODS: A survey was sent to 124 departments of neurology in the United States that are accredited by the American Council of Graduate Medical Education via an online Web tool. We collected data regarding the attendance, objectives, format, educational structure, and perceived changes and trends over time. RESULTS: Seventy-five (60%) surveys were returned: 10% were completed by the department chairperson, 4% by the chief resident, and 54% by another faculty member. NGRs were offered by 99% of the programs surveyed, and 95% of the programs conduct NGRs accredited for Continuing Medical Education. Almost all of the respondents agreed that the education of faculty, house staff, and full-time faculty was very important. Ninety-three percent of the programs hold clinical case presentations, and 60% have patients in attendance for the presentation. Programs reported that the quality, importance, and educational value of NGRs had either not changed or had increased over time (94%, 91%, and 89%, respectively). CONCLUSION: NGRs continue to be an important component of neurology residency training programs. The results of our survey were comparable to those obtained by others studying Medical Grand Rounds. Objectives, components, attendance, format, changes, and trends were also similar.

Oligomerization state-dependent elevations of adiponectin in chronic daily headache.

OBJECTIVE: To evaluate serum adiponectin levels in female episodic migraineurs (EMs) and chronic daily headache (CDH) sufferers. BACKGROUND: Obesity is a risk factor for headache "chronification." Adiponectin (ADP) is an adipocytokine secreted primarily by adipose tissue. ADP and its oligomers (high-molecular-weight [HMW], middle-molecular-weight [MMW], and low-molecular-weight [LMW] ADP) have been shown to modulate several inflammatory pathways that have also been shown to be associated with migraine pathophysiology. METHODS: Age- and body mass index (BMI)-matched women participants were enrolled. Anthropometric measures (including waist-to-hip ratio [WHR] and BMI) were measured in all participants. Serum total ADP (T-ADP) levels and its oligomers were measured in EMs during headache-free periods and CDH sufferers at baseline level of pain, as compared with healthy control subjects using ELISA. RESULTS: Although total body obesity as estimated by BMI showed no significant association between participants, visceral obesity as estimated by WHR was significantly associated with CDH as compared with EMs and controls. WHR was also inversely related to both T-ADP (p = 0.008) and HMW-ADP (p = 0.002). After adjusting for WHR, serum T-ADP levels were higher in CDH sufferers (10.1 +/- 4.0) than in both EMs (8.6 +/- 3.5) and controls (7.5 +/- 2.4) (p = 0.024). In addition, HMW-ADP was higher in CDH (6.1 +/- 2.8) as compared with EMs (4.2 +/- 1.7) and controls (3.9 +/- 1.5) (p = 0.003). MMW-ADP was also higher in CDH (2.0 +/- 1.2) as compared with EMs (1.5 +/- 0.7) and controls (1.1 +/- 0.4) (p = 0.009). CONCLUSION: Serum adiponectin levels are increased in women chronic daily headache (CDH) sufferers. In addition, visceral obesity, as measured by waist-to-hip ratio, is a risk factor for CDH in women.