Management of medication overuse headache: 1-year randomized multicentre open-label trial.

It is a general belief that patients with medication overuse headache (MOH) need withdrawal of acute headache medication before they respond to prophylactic medication. In this 1-year open-labelled, multicentre study intention-to-treat analyses were performed on 56 patients with MOH. These were randomly assigned to receive prophylactic treatment from the start without detoxification, undergo a standard out-patient detoxification programme without prophylactic treatment from the start, or no specific treatment (5-month follow-up). The primary outcome measure, change in headache days per month, did not differ significantly between groups. However, the prophylaxis group had the greatest decrease in headache days compared with baseline, and also a significantly more pronounced reduction in total headache index (headache days/month x headache intensity x headache hours) at months 3 (P = 0.003) and 12 (P = 0.017) compared with the withdrawal group. At month 12, 53% of patients in the prophylaxis group had > or = 50% reduction in monthly headache days compared with 25% in the withdrawal group (P = 0.081). Early introduction of preventive treatment without a previous detoxification programme reduced total headache suffering more effectively compared with abrupt withdrawal. (ClinicalTrials.gov number, NCT00159588).

When should an epidural blood patch be performed in postlumbar puncture headache? A theoretical approach based on a cohort of 79 patients.

The aim of the present study was to decide on which day in the course of postlumbar puncture headache (PPH) an epidural blood patch (EBP) should be performed to minimize suffering. A cohort of 79 patients (64 female, 15 male) was followed prospectively for 14 days and the consequences of performing an EBP on different days were studied. If no EBP was performed, the patients would accumulate 141 days with PPH5 (bedridden most of the day), 216 days with PPH4-5 (bedridden more than half the day), and 293 days with PPH3-5 (bedridden half the day or more). If these patients were patched on day 2, 3 or 4 after an initial observation of the PPH grade on day 1, the expected suffering was substantially reduced, and the more the earlier in the course the EBP was performed. If the strategy was to treat only patients with PPH5 with an expected 90% success rate, the reduction compared with no treatment was 50% if treated on day 2, 37% if treated on day 3, and 29% if treated on day 4. The corresponding figures for treating patients with PPH4-5 was a 51, 44 and 29% reduction, and for PPH3-5 the reduction was 62, 49 and 35%, respectively. Irrespective of strategy, the expected reduction of suffering in the cohort was greatest when the EBP was performed early in the course of PPH. It is suggested that the decision to perform an EBP should be made at an early stage and offered to patients who have to lie in bed for more than half a day despite conservative treatment.

The importance of sex, age, needle size, height and body mass index in post-lumbar puncture headache.

In this prospective study 37% of 239 patients developed a post-lumbar puncture headache (PPH) after a diagnostic lumbar puncture. PPH was more prevalent in females than males (46% vs. 21%; P = 0.0003) as were the severest form of PPH (64% vs. 23%; P = 0.02) and nausea (74% vs. 39%; P = 0.01) in those who developed PPH. Females scored their pain in the upright position more severe on a 100-mm visual analogue scale than males (median 60 mm vs. 47.5 mm; P = 0.02). The frequency of PPH was higher with the use of a 20-gauge compared with a 22-gauge needle in all patients (50% vs. 26%; P = 0.0002) and in females (57% vs. 36%; P = 0.02) and males (38% vs. 10%; P = 0.004), separately. Neither age, weight, height, nor body mass index (BMI), influenced the prevalence of PPH, but tinnitus was more prevalent in tall compared with smaller patients (53% vs. 17%; P = 0.02). Old age was associated with a long median pain delay upon rising, and also, small patients tended to report a longer median pain delay than tall patients. The pain intensity changed more slowly upon rising and reclining in patients with a high BMI than in those with a lower BMI (median 60 s vs. 12 s; P = 0.02). The results concerning height, BMI and needle size might be anticipated according to the leakage theory. In a multivariate analysis sex (P = 0.0003) and needle size (P = 0.0002) were related to the development of PPH on a statistically significant level. Furthermore, the pain severity was positively related to female sex (P = 0.03) and young age (P = 0.03). The pain delay increased with age (P = 0.008) and the pain decrease time increased with an increasing BMI (P = 0.04).

The time course of post-lumbar puncture headache.

According to the leakage theory, the time taken for pain to develop upon rising to the upright position will increase during the time course of post-lumbar puncture headache (PPH) as a consequence of the decreasing size of the healing dural rent, and the pain will decline. The aim of the present prospective study was to test this hypothesis, and to describe the temporal course of time and pain variables in PPH. The study showed that the course was fairly stable for all variables except on the first day, the second last day, and the last day. In the recumbent position, the headache was more severe on the first day (p<0.05) and milder on the last day (p<0.001) compared with the interim days; maximal headache in the upright position was milder on the second last (p<0.005) and last days (p<0.0001). Compared with the interim days, the time prior to increase of pain upon rising was shorter on the first day (p<0.05) and longer on the last day (p<0.001), and from start of increase until maximum was longer on the last day (p<0.01). The time to pain relief upon lying down did not vary significantly throughout the PPH period. The mobility of the patient as expressed by the PPH grade was fairly stable throughout the course of PPH until it increased in the last 2 days. The results are in good accord with the leakage theory.

Pain location and associated symptoms in post-lumbar puncture headache.

In this prospective study of 239 patients, 88 (37%) suffered from post-lumbar puncture headache (PPH). The pain was located within the region innervated by the trigeminal nerve in 49% of the drawings, within the occipital and/or suboccipital region in 11%, and within the combined trigeminal/occipital region in 39%. The headache was unilateral at least once in 34% of the patients. Changes in pain location from one region to the other and/or between bilateral and unilateral headache were observed in 54% of the patients throughout the PPH period. Associated symptoms were experienced by 85%, nausea (73%) and dizziness (60%) being the most frequently reported. In the upright position, nausea, dizziness, and tinnitus tended to be present during a fairly large part of the PPH period (57-63% of the days), vomiting occurring only occasionally (28%). The intensity of associated symptoms was positively correlated to PPH severity. Pain in the combined trigeminal/occipital region was most severe and related to more associated symptoms than pain in other regions, and unilateral pain was milder than bilateral pain. Pain in the occipital and/or suboccipital region was mildest. The severity of nausea decreased significantly on the last 2 days of the PPH period, and the intensity of dizziness decreased when PPH was about to subside. Tinnitus is probably due to a cochlear dysfunction, and presents special characteristics. Its incidence was not clearly related to PPH severity and it increased with increasing duration of PPH; its intensity did not decline when PPH was about to wane.

Post-lumbar puncture headache: clinical features and suggestions for diagnostic criteria.

The aim of the present prospective study was to describe clinical features of post-lumbar puncture headache (PPH), and to test the validity of the diagnostic criteria of the International Headache Society (IHS). Eighty-eight of the 239 included patients (36.8%) experienced PPH. Females were affected more frequently than males (45.2% vs 21.4%; p < 0.001). First onset of PPH occurred within the first day in 40 patients (53%), within 2 days in 89%, and never after the fourth day. When PPH occurred for the first time on the day the lumbar puncture was performed, it was usually experienced much later in the day (median 14.00 h) than it first occurred on the second day (median 09.30 h) or later. The median duration of PPH was 6 days (range 1-29 days). Patients with headache performed a "Rising Manoeuvre" twice daily as long as the headache period lasted, and recorded pain and time variables. The severity of PPH was negatively correlated to the time till the headache started or worsened upon rising (T1) and the time from the headache started to increase till it reached its maximum (T2), but was not significantly correlated to the time to restitution upon lying down (T3). The results are in good accordance with the leakage theory. T1 varied from immediate onset to 265 min (median 20 sec). T2 (median 30 sec, range 0-60 min) and T3 (median 20 sec, range 0-15 min) varied considerably as well. During the course of PPH, 45% of the patients occasionally reported non-postural headache or no headache when the Rising Manoeuvre was performed. It is suggested that PPH should be diagnosed in any patient who experiences postural headache at least once within 4 days of lumbar puncture.

MMPI profiles in post-lumbar puncture headache.

From the original material of 300 patients, of whom 37.3% had experienced a post-lumbar puncture headache (PPH), a total of 20 males and 50 females were evaluated with the Minnesota Multiple Personality Inventory (MMPI). The test was administered on average 33 months after the lumbar puncture (range 13-51), at a time when anxiety and depression related to the original investigation for a possible organic neurologic disease were expected to affect the results minimally. In the present material PPH was experienced by 45.7% of the patients, 40% of the males, and 48% of the females. Patients without PPH were used as controls. The selected material was a representative sample of the original material both as to distribution of age, proportion of organic diagnoses, and frequency of PPH. The MMPI disclosed no statistically significant differences between PPH patients and controls regarding personality traits.

[Diet therapy in Parkinson disease]. / Diettbehandling ved Parkinsons sykdom.

The significance of restrictions on protein for patients with Parkinson's disease is reviewed. Large neutral amino acids and levodopa share the same saturated carrier system through the blood-brain-barrier. Fluctuating patients are sensitive to a decreased supply of levodopa from the blood, and clinical studies show that an increased concentration of large neutral amino acids in the blood decreases mobility and reduces "on-time". A reduction of protein intake to 0.75-0.8 g/kg body weight/day has been recommended. A protein redistribution diet implying that less than 10% of the daily protein is taken in daytime and the rest in the evening, gives best results. However, in the elderly, protein restrictions may lead to a lasting negative nitrogen balance, and even in younger patients the supply of certain minerals and vitamins may become too low or marginally adequate. The diet must therefore be used with caution.

A double-blind study of ibuprofen versus placebo in the treatment of acute migraine attacks.

The efficacy of ibuprofen, a non-steroidal anti-inflammatory drug, was assessed in the acute treatment of migraine. Twenty-five patients completed a double-blind placebo-controlled multicrossover trial. The initial dose of ibuprofen was 1200 mg. Six migraine attacks were randomly treated in each patient, three with ibuprofen and three with placebo. The results indicated a statistically significant reduction in the duration of the migraine attacks and also a statistically significant reduction in the severity of headache and nausea in the ibuprofen-treated attacks. The use of additional medication was significantly reduced in the ibuprofen-treated attacks (25.6% vs 57.5%). No serious side effects were reported. Ibuprofen is valuable in the treatment of acute migraine attacks.

The significance of age, sex, and cerebrospinal fluid pressure in post-lumbar-puncture headache.

In this study of 300 neurological inpatients aged between 18 and 60 years the incidence of post-lumbar-puncture headache (PPH) was 37.3%. The more severe the headache, the more frequently it was associated with dizziness, nausea, vomiting, and tinnitus. If PPH occurred during the first day after lumbar puncture (LP), it was more severe, and lasted longer than PPH, which started later. The incidence of PPH and associated symptoms decreased with increasing age, and was much higher in females than males. The sex difference was nearly exclusively explained by a marked preponderance of PPH in females below 40 years of age, i.e. women in the fertile age. Furthermore, there was a decreased incidence of PPH and associated symptoms in patients with an initial higher than average cerebrospinal fluid (CSF) pressure (162 mm H2O). All these differences were statistically significant. Particularly high frequencies of PPH were found in young women with an initial CSF pressure lower than mean.

Post-lumbar-puncture headache: the significance of body posture. A controlled study of 300 patients.

In this single-blind, randomized study of post-lumbar-puncture headache (PPH) in 300 neurologic inpatients the significance of body posture after lumbar puncture (LP) was evaluated. Immediate mobilization was compared with bed rest for 6 h (3 h prone followed by 3 h supine posture). Contrary to the widely held belief, this investigation did not show significant differences between recumbent and ambulant patients as to frequency of PPH in the total material (39% versus 35%) or when men (31% versus 29%) and women (48% versus 41%) were evaluated separately. Headache associated with nausea was significantly more frequent in the recumbent than in the ambulant patients both in the total material (23% versus 13%) and in women (35% versus 16%). Thus, immediate mobilization seems to be preferable after LP.

Tizanidine in the management of trigeminal neuralgia.

In a double-blind study the efficacy and tolerability of tizanidine was compared with those of carbamazepine in the management of trigeminal neuralgia. Six patients were allocated to treatment with tizanidine and six to carbamazepine. After individual titration the maximum daily doses were 18 mg and 900 mg, respectively. Among the efficacy factors used, the visual analog scale (VAS) and the overall efficacy as assessed by patients and investigator turned out to be the most appropriate. The results indicate that tizanidine was well tolerated, but the effects, if any, were inferior to those of carbamazepine.

Late-onset hereditary myopathy with abnormal mitochondria and progressive dementia.

A family with autosomal dominant late-onset progressive dementia and myopathy is described. Electron microscopy of muscle revealed abnormal mitochondria in the proband. Thus, the disease may be classified as a "mitochondrial encephalomyopathy". The cases are unique because dementia was a dominating feature and because the symptoms developed late in life. These cases may represent a new subgroup of the mitochondrial encephalomyopathies.