Cerebrovascular reactivity during the Valsalva maneuver in migraine, tension-type headache and medication overuse headache.

The aim of this study was to investigate, by means of transcranial Doppler ultrasound (TCD), cerebrovascular reactivity during the Valsalva maneuver (VM) during the headache-free interval in patients with migraine (M), migraine plus tension-type headache (M+TTH), and migraine plus medication overuse headache (M+MOH). A total of 114 patients (n=60 M, n=38 M+TTH, n=16 M+MOH) and n=60 controls were investigated; diagnoses were made according to the International Headache Society criteria. All subjects underwent TCD monitoring and, simultaneously, non-invasive assessment of arterial blood pressure and end-tidal CO2. Two indices were determined: the cerebrovascular Valsalva ratio (CVR) was calculated as the maximum end-diastolic flow velocity acceleration during the late straining phase of the VM [cm/s2] and the centroperipheral Valsalva ratio (CPVR) was defined as the quotient of CVR to the concomitant arterial blood pressure acceleration [cm/mmHg x s]. The dynamic cerebrovascular autoregulatory response to the VM, measured as CVR, was increased in patients with M and M+TTH compared to age-matched healthy subjects. By contrast, CPVR (i.e. the quotient of the cerebrovascular to the peripheral autonomic response), was increased in M patients compared to healthy subjects and all other headache conditions tested. Cerebrovascular autoregulatory response during the VM was increased in M patients compared to age-matched normal healthy subjects, indicating a disturbed autonomic control of cerebral vasoreactivity. The CPVR seems to be a sensitive parameter for distinguishing between M patients and M+TTH or M+MOH patients.

[AC-STB: dedicated software for managed healthcare of chronic headache patients]. / AC-STB: Eine sektorenübergreifende Software zur Dokumentation und Verlaufskontrolle von Kopfschmerzpatienten.

This paper examines a new approach to managed healthcare where a network of care providers exchanges patient information through the internet. Integrating networks of clinical specialists and general care providers promises to achieve qualitative and economic improvements in the German healthcare system. In practice, problems related to patient management and data exchange between the managing clinic and assorted caregivers arise. The implementation and use of a cross-spectrum computerized solution for the management of patients and their care is the key for a successful managed healthcare system. This paper documents the managed healthcare of chronic headache patients and the development of an IT-solution capable of providing distributed patient care and case management.

[Anxiety and depression in headache patients. The example of managed care of chronic headache patients in Bavaria]. / Angst und Depression bei Kopfschmerzpatienten. Das Beispiel der Integrierten Versorgung chronischer Kopfschmerzpatienten in Bayern.

BACKGROUND: The prevalence of anxiety and depression and the influence of headache severity on these illnesses were examined in patients who were part of the managed care of headache in Bavaria. PATIENTS AND METHODS: A total of 181 patients with headache were screened for anxiety and depression with the German version of the Hospital Anxiety and Depression Scale (HADS-D). Headache severity was evaluated using the Migraine Disability Assessment Questionnaire (MIDAS). Apart from purely descriptive evaluations, Spearman's coefficients of correlation were calculated. RESULTS: Of the patients 22.7% and 44.7% obtained results at or above the limit of the normal range of depression and anxiety, respectively and 19.3% had results at or above the limit of the normal range for both illnesses. There were significant coefficients of correlation between the severity of headache and both anxiety and depression. CONCLUSION: The results confirm the necessity for an interdisciplinary procedure in treating headache patients in order to achieve a successful therapy. Such a treatment can be realised with the concept of managed care.

[Semantic dementia. A case report in the context of an independent medical examination]. / Semantische Demenz. Ein kasuistischer Beitrag zur Differenzialdiagnostik der degenerativen Demenzen.

Semantic dementia (SD) is a relatively rare primary degenerative brain disease, often with onset before the age of 65, which belongs to the group of frontotemporal lobar degenerations. The central characteristic of SD is a progressive loss of semantic knowledge with manifestation in aphasia as well as impaired face and object recognition. A reliable discrimination of SD from other neurodegenerative conditions, in particular from Alzheimer's disease, may be a challenge for neurologists as well as neuropsychologists. In the first place, a sound knowledge base is expected from the expert in order to minimize false diagnoses. To illustrate this, a detailed case history of a 55-year old patient is presented who was referred for an independent medical and neuropsychological examination for disability benefits. The referral question was Pick's disease. However, the clinical manifestation as well as the results of a comprehensive neuropsychological evaluation clearly indicated the diagnosis of SD with neuroimaging and neuropsychological evidence of marked right temporal lobe atrophy. The case history highlights a number of problems inherent in current practice of dementia assessment. For differential diagnosis of dementing conditions, a thorough neuropsychological assessment appears to be indispensable.

Exteroceptive silent periods of temporalis muscle activity: correlation with neuropsychological findings.

The latency and duration of the early (ES 1) and late (ES 2) exteroceptive silent period of temporalis muscle activity were determined in 51 neurological patients. We investigated whether these electrophysiological parameters correlated with neuropsychological variables of the patients using standardized scores for personality index, state of well-being and physical symptoms. There were no correlations between personality traits and the electrophysiological parameters, while we found significant correlations between the duration of ES 2 and momentary psychological and physical well-being variables. Moreover, the score of the momentary well-being item 'general feeling of well-being' was demonstrated to moderate significantly the ES 2 duration (P = 0.018). Therefore, neuropsychological factors prove to be of great relevance to the exteroceptive silent periods of temporalis muscle activity.

Exteroceptive suppression of temporalis muscle activity: findings in headache.

Exteroceptive suppression of temporalis muscle activity was proposed by Schoenen and co-workers in 1987 as a tool in headache diagnosis and research. Their finding of a decreased or abolished second silent period (ES2) in chronic tension-type headache sufferers has been confirmed by several independent laboratories during the last five years. Temporalis silent periods have also been studied in various other types of headaches. Their modulation by neuropsychological factors and pharmacological agents has also been investigated as well as their retest reliability. The pathophysiological concept of muscle contraction in tension-type headache has been challenged by studies using temporalis silent periods. The exteroceptive suppression of temporalis muscle activity points unequivocally towards a central pathogenetic mechanism, although it remains unclear whether the abnormalities of temporalis ES2 represent the primary dysfunction or a secondary phenomenon in chronic tension-type headache.

Exteroceptive suppression of temporalis muscle activity: perspectives in headache and pain research.

The paper describes possible future applications of the exteroceptive suppression (ES) of temporalis muscle activity in headache and pain research. ES is examined as a method for investigating the pathophysiology of pain mechanisms, for assisting clinical diagnosis, and for evaluating therapeutic effects. ES is one of the newest methods in headache research which permits an objective analysis of head pain as well as pain mechanisms and accordingly has an important future in headache research.

Transcranial Doppler ultrasonic features in chronic tension-type headache.

We studied vascular features in patients suffering from chronic headache of the tension-type by means of transcranial Doppler ultrasound (TCD). Blood flow velocities of the basal cerebral arteries and the submandibular extracranial part of the internal carotid artery were compared between 20 chronic tension-type headache sufferers and the same number of age- and sex-matched control subjects. There were no significant differences of ultrasonic features between the groups. Changes in blood flow velocities do not seem to be involved in the pathogenetic mechanisms of chronic tension-type headache.

Transcranial Doppler ultrasonic features in episodic tension-type headache.

In a pilot study we used transcranial Doppler ultrasound (TCD) to measure cerebral blood flow velocities in 21 headache-free episodic tension-type headache sufferers and in the same number of age- and sex-matched control subjects. We found increased blood flow velocities in the anterior, middle and posterior cerebral arteries and a decreased pulsality index in the middle and posterior cerebral arteries in tension-type headache sufferers compared to controls. Vascular bruits were significantly more frequent in the basal cerebral arteries of the patients compared to controls. There were no significant asymmetries of blood flow velocities in corresponding arteries. The findings suggest a multifactorial pathogenesis in episodic tension-type headache including vascular abnormalities.

The "temporalis-inhibitory reflex" in post-lumbar puncture headache.

Nausea and rigidity of the neck muscles, typical symptoms of post-lumbar puncture syndrome (PPS), may also be found in patients suffering from chronic headache of the tension-type. A decreased duration of the late suppression period of temporal muscle activity indicating a central disturbance of pericranial muscle control, can be observed in these patients. We have studied the temporalis-inhibitory reflex in 47 neurological inpatients requiring lumbar puncture. There were no significant differences of latencies or durations of temporalis silent periods between patients with and without PPS before, and 48 h following, lumbar puncture.

[Drug-induced headache]. / Medikamentös induzierter Kopfschmerz.

Migraine or tension-type headache lasting for several years is frequently complicated by chronic daily headaches. Those patients recurrently take analgesics or ergotamines. Headache induced by chronic ergotamine use is well known. Recent studies, however, have shown that a similar form of headache is caused by analgesic abuse. Treatment of drug-induced headaches envisages withdrawal of the headache medication.

EMG analysis of the late exteroceptive suppression period of temporal muscle activity in episodic and chronic tension-type headaches.

EMG analysis of the late exteroceptive suppression period of the temporal muscle activity is discussed as comparative methodology in the assessment of patients suffering from chronic tension-type headache and from migraineurs. After electrical perioral trigeminal nerve stimulation during maximum voluntary jaw occlusion, early (ES1) and late (ES2) exteroceptive suppression periods can be registered above the temples using surface EMG recordings. In patients suffering from chronic tension-type headache the duration of the late suppression period is shortened (p less than 0.001) compared to migraineurs or controls. However, patients suffering from episodic tension-type headache display late suppression periods of temporal muscle activity of differing lengths.

[EMG analysis of exteroceptive suppression of temporal muscle activity in tension headache]. / EMG-Analyse der exterozeptiven Suppression der Temporalismuskelaktivität bei Kopfschmerzen vom Spannungstyp.

In modification of a method published by Schoenen et al., early (ES 1) and late (ES 2) exteroceptive suppression periods elicited by perioral electrical trigeminus-stimulation during teeth-clenching were recorded with surface electrodes over the temporalis muscles. 29 patients with chronic tension headache, 20 with migraine, 7 patients with combined tension headache and migraine and 19 controls were examined. Duration of the late suppression period for the mean of three single shocks was highly significantly reduced in chronic tension headache sufferers and patients with combined tension headache and migraine when compared with migraine cases or controls. These results are in agreement with those of Schoenen et al. EMG analysis of temporalis late exteroceptive suppression is a helpful diagnostic method in primary headache. The reduction of ES 2 in chronic tension headache sufferers might suggest a deficient activation or excessive inhibition of the motoric trigeminus nucleus by pontobulbar inhibitory neurons which receive a strong input from limbic and nociceptive structures.

[The value of transcranial Doppler sonography in neurosurgery]. / Stellenwert der transkraniellen Dopplersonographie in der Neurochirurgie.

Transcranial doppler ultrasound (TCD) is suitable in the diagnosis of vasospasm in subarachnoid hemorrhage. The value of TCD in intracranial malformations and other neurosurgical disorders will be discussed. TCD is a screening-method in the diagnosis of brain death.