[Initial situation and approach to the care of migraine in neurology services in Spain: the PRIMERA study]. / Situacion de partida y abordaje asistencial de la migrana en las consultas de neurologia de Espana. Estudio PRIMERA.

INTRODUCTION: Despite the high degree of disability it entails, many patients with migraine have never visited their doctor for this reason. It is necessary to conduct a study to examine the characteristics of first-time visits as a step that must be carried out prior to establishing specific intervention measures for this group of patients. AIM: To determine the profile of the patients with migraine who visit a neurology service for the first time, together with the diagnostic and therapeutic attitudes that neurologists display towards them. PATIENTS AND METHODS: We conducted a cross-sectional, multi-centre study of neurology services across the country. The research included 168 neurologists who recruited 851 patients (74.6% females; mean age: 34.0 ± 10.7 years). Disability was assessed by means of the specific migraine questionnaire (Headache Impact Test) and the generic disability questionnaire (Sheehan Disability Scale). RESULTS: A third (66.5%) of the patients went for consultation following their doctor's advice, while the remaining 33.5% went on their own accord. Only 55.9% had been previously diagnosed with migraine. The main reasons for visiting were ineffective symptomatic treatment (25%) and an increase in the frequency or intensity of the attacks (23.4%). Although 70.3% of the patients had high disability scores on the Headache Impact Test, only 17.4% used specific treatment and only 13.3% were on preventive treatment. CONCLUSIONS: The PRIMERA study confirms, once again, that migraine is an under-diagnosed and under-treated condition in our setting, which means that specific educational interventions and training are still required for this pathology.

[Recurring neuromyelitis without optic neuritis: a case report]. / Neuromielitis recidivante sin neuritis optica: a proposito de un caso.

INTRODUCTION: Neuromyelitis optica, or Devic's disease, is an inflammatory, demyelinating disease of the central nervous system that selectively affects the optic nerves and the spinal cord, with a high rate of relapses. Anti-aquaporin-4 (AQP4) antibodies are a highly specific marker for this condition. CASE REPORT: A 66-year-old female with longitudinally extensive dorsal transverse myelitis with complete remission following steroidal treatment and later acute relapse, with palsy in one limb. The differential diagnoses considered included a spinal tumour and arteriovenous malformation of the spinal cord. Being positive for AQP4 was the decisive factor in the final diagnosis. CONCLUSIONS: Early detection of anti-AQP4 antibodies together with appropriate immunotherapy can be the key to a better prognosis. An early diagnosis is essential to be able to start treatment at an early stage and thus prevent relapses and severe sequelae.

Utilidad del dúplex orbitario para la valoración de atrofia del nervio óptico en enfermedades desmielinizantes: estudio piloto / Transorbital echography for assessment of optical nerve atrophy in demyelinating diseases: a pilot study

Introducción. Las enfermedades desmielinizantes son un grupo heterogéneo de procesos en los que se daña la mielina. Es bien conocida la predilección de estas patologías por el nervio óptico (NO).Sujetos y métodos. Estudio observacional prospectivo de casos y controles mediante ecografía del NO de pacientes diagnosticadosde enfermedad desmielinizante (n = 31) y de controles sanos (n = 24). La edad media de los casos es de 48,3 ±11,8 años, y de los controles, de 48,7 ± 9,9 años. El 46% de los controles y el 35% de los casos eran varones.Resultados. Se encontraron diferencias estadísticamente significativas entre casos y controles en cuanto al diámetro delNO tanto derecho (3,64 ± 0,58 mm en controles frente a 2,84 ± 0,56 mm en los pacientes; p < 0,001) como izquierdo (3,95 ± 0,84 mm en controles frente a 2,74 ± 0,54 mm en pacientes; p < 0,001). No se encontraron diferencias significativasen la velocidad pico sistólica de la arteria oftálmica entre ambos grupos, ni tampoco en el diámetro del NO de los casos con antecedentes de neuritis óptica y los que no presentaban dicho antecedente.Conclusiones. El dúplex del nervio óptico es una herramienta útil, accesible y no invasiva para la valoración de la existenciade atrofia óptica. De la misma forma que los potenciales evocados visuales están alterados en un número importante de pacientes sin antecedentes claros de haber sufrido neuritis óptica, el estudio del grosor del NO mediante Dopplertranscraneal también podría utilizarse como marcador paraclínico de enfermedad desmielinizante (AU)

Introduction. Demielinating diseases are a group of heterogenic diseases in whom mieline is attacked. The optic nerve(ON) is one of the most commonly affected.Subjects and methods. An observational prospective case-control study with ON orbital echography was developed. Thecase group was formed by 31 demielinating diseases patients and the control group was formed by 24 healthy people. Mean age of cases: 48.3 ± 11.8 years old, controls 48.7 ± 9.9 years old. 46% of controls and 35% of cases were males.Results. We found statistical significance differences between cases and controls regarding the diameter of right (controls3.64 ± 0.58 mm vs patients 2.84 ± 0.56 mm; p < 0.001) and left ON (controls 3.95 ± 0.84 mm vs patients 2.74 ± 0.54 mm; p < 0.001). We found no differences between maximum systolic and median velocities regarding ophthalmic arteries in both groups, neither for previous acute optical neuritis history or visual evocated potentials.Conclusions. ON evaluation with transorbital echography is an easy, feasible, non invasive, useful and costless technique for the evaluation of the ON atrophy. As for visual evocated potentials are abnormal in a huge number of patients withoutprevious optical neuritis evidence, the diameter of ON measured by transorbital Doppler could be a consistent paraclinic marker of these diseases (AU)

[Personality factors, degree of disability and therapeutic management of patients with migraine visiting a neurology unit for the first time (Psicomig study)]. / Factores de personalidad, grado de discapacidad y abordaje terapeutico de los pacientes con migrana atendidos en primera consulta en neurologia (estudio Psicomig).

INTRODUCTION: Migraine has recently been associated to certain personality profiles and styles of coping. AIM: To explore the association between personality factors, disability and the therapeutic management of migraine. PATIENTS AND METHODS: We conducted an epidemiological, cross-sectional, multi-centre study with patients with migraine visiting a neurology unit for the first time. Socio-demographic and clinical data were collected about the patients. The NEO-FFI (Neuroticism-Extraversion-Openness Five-Factor Inventory) was used to evaluate personality factors; the degree of disability was evaluated using the Headache Impact Test (HIT-6) and the number of lost workday equivalents (LWDE) was measured. Bivariate logistic regression analyses were also performed. RESULTS: A total of 736 patients were recruited, of whom 700 were suitable for inclusion in the analysis (75.6% females; mean age: 35.5 ± 11.5 years). In all, 68.9% presented migraine without aura, 1-4 seizures/month (66.7%) and of moderate intensity (58.1%). A total of 76.1% of patients had severe disability according to the HIT-6. Of the 554 active patients, the mean number of lost workday equivalents in the previous three months was 6.8 ± 8.2. Patients showed greater emotional instability than the general population and they scored lower on extraversion, openness, agreeableness and conscientiousness. All the patients were being treated for their migraine: 47.3% by means of stepped treatment between seizures; 39.9% intra-seizures, and stratified in only 12.9%. CONCLUSIONS: This study confirms the impact of migraine in terms of disability and in terms of loss of labour output, together with its association with personality factors.

[The hypothalamus in SUNCT syndrome: similarities and differences with the other trigeminal-autonomic cephalalgias]. / El hipotálamo en el SUNCT: similitudes y diferencias con las otras cefaleas trigeminoautonómicas.

INTRODUCTION: SUNCT belongs to the group of trigeminal-autonomic cephalalgias (TAC) --cluster headache and paroxysmal hemicranias--, since its shares a series of features with them. SUNCT was finally included in this group when the hypothalamus was proved to play a key role in its pathophysiology, an aspect that it has in common with other TAC. However, its clinical resemblance to trigeminal neuralgia of the first branch is notable, although it is accepted that the genesis of the trigeminal neuralgia is peripheral. DEVELOPMENT: The article presents the evidence available to date that has made it possible to associate the hypothalamus with SUNCT, as well as outlining its similarities and differences with respect to other TAC. This evidence is clinical, hormonal, from functional neuroimaging (activation of the posteroinferior hypothalamus) and from therapeutic outcomes (with deep hypothalamic stimulation). Likewise, a detailed description is provided of both the neuroanatomical bases (the hypothalamus as part of the neural networks involved in processes concerned with behaviour, memory, antinociceptive control, waking-sleep control and other circadian rhythms, etc.) and the neurochemical bases (orexins, somatostatin and endogenous opiates) that would support the hypotheses which researchers are attempting to establish to fit the evidence discussed earlier, which would have many points that overlap from one TAC to another. CONCLUSIONS: The question as to whether the hypothalamus is the/a generator of TAC or whether it is an element that allows its development remains open to debate, as does the issue of which would be the most plausible explanation for the phenotypic differences between them. Future studies will allow the enigma of SUNCT and the other TAC to be explained.

El hipotálamo en el SUNCT: similitudes y diferencias con las otras cefaleas trigeminoautonómicas / The hypothalamus in sunct syndrome: similarities and differences with the other trigeminal-autonomic cephalalgias

Introducción. El SUNCT forma parte del grupo de cefaleas trigeminoautonómicas (CTA) –cefalea en racimos y hemicraniasparoxísticas–, al compartir con ellas una serie de características. El impulso final para incluir el SUNCT en estegrupo fue la demostración de que el hipotálamo es pieza clave en su fisiopatología, dato común con las otras CTA. Sin embargo,su parecido clínico con la neuralgia trigeminal de la primera rama también es llamativo, aunque se admite que la génesisde la neuralgia trigeminal es periférica. Desarrollo. Se exponen las evidencias disponibles hasta el momento actual que hanpermitido involucrar al hipotálamo en el SUNCT, así como sus similitudes y diferencias con las otras CTA. Se trata de evidenciasclínicas, hormonales, de neuroimagen funcional (activación del hipotálamo posteroinferior) y de resultado terapéutico(con estimulación hipotalámica profunda). Asimismo, se detallan las bases neuroanatómicas (el hipotálamo como parte de lasredes neurales involucradas en procesos comportamentales, de memoria, de control antinociceptivo, de control del ritmo vigilia-sueño y otros ritmos circadianos, etc.) y neuroquímicas (orexinas, somatostatina y opiáceos endógenos), que sustentaríanlas hipótesis que tratan de establecerse en virtud de las evidencias previamente comentadas, las cuales tendrían muchospuntos de solapamiento entre las distintas CTA. Conclusión. Queda aún abierto el debate sobre si el hipotálamo es el generadorde las CTA o si es un elemento permisivo en su desarrollo, y cuál sería la explicación más plausible para las diferenciasfenotípicas entre ellas. Posteriores estudios podrán ir aclarando el enigma del SUNCT y de las otras CTA(AU)

Introduction. SUNCT belongs to the group of trigeminal-autonomic cephalalgias (TAC) –cluster headache andparoxysmal hemicranias–, since its shares a series of features with them. SUNCT was finally included in this group when thehypothalamus was proved to play a key role in its pathophysiology, an aspect that it has in common with other TAC. However,its clinical resemblance to trigeminal neuralgia of the first branch is notable, although it is accepted that the genesis of thetrigeminal neuralgia is peripheral. Development. The article presents the evidence available to date that has made it possibleto associate the hypothalamus with SUNCT, as well as outlining its similarities and differences with respect to other TAC. Thisevidence is clinical, hormonal, from functional neuroimaging (activation of the posteroinferior hypothalamus) and fromtherapeutic outcomes (with deep hypothalamic stimulation). Likewise, a detailed description is provided of both theneuroanatomical bases (the hypothalamus as part of the neural networks involved in processes concerned with behaviour,memory, antinociceptive control, waking-sleep control and other circadian rhythms, etc.) and the neurochemical bases(orexins, somatostatin and endogenous opiates) that would support the hypotheses which researchers are attempting toestablish to fit the evidence discussed earlier, which would have many points that overlap from one TAC to another.Conclusions. The question as to whether the hypothalamus is the/a generator of TAC or whether it is an element that allows itsdevelopment remains open to debate, as does the issue of which would be the most plausible explanation for the phenotypicdifferences between them. Future studies will allow the enigma of SUNCT and the other TAC to be explained(AU)

Aproximación clínica a las neuralgias craneales / A clinical approach to cranial neuralgias

Resumen. Introducción. La International Association for the Study of Pain define una neuralgia como el dolor sentido en el territorio de distribución de un nervio o raíz nerviosa. Aunque el criterio más importante para su diagnóstico es el espacial, es el conjunto de muchas características clínicas lo que nos va a permitir distinguir una neuralgia de otros dolores del área craneofacial. Desarrollo. Conocer los territorios de distribución sensitiva de los nervios o raíces es crítico para definir la localización del dolor en las neuralgias. Otros atributos también ayudan en su diagnóstico: la cualidad del dolor (paroxístico, urentequemante, sordo), el perfil temporal (segundos-minutos frente a horas-días), la ausencia de fenómenos acompañantes distintos de algunas manifestaciones de disfunción sensitiva, especialmente en las formas sintomáticas (hipoanestesia, parestesias, disestesias, alodinia, hiperalgesia, hiperpatía), la provocación del dolor por estímulos táctiles o mecánicos en el territorio doloroso (zonas ‘gatillo’) o la presencia de un signo de Tinel positivo, la respuesta al bloqueo anestésico del nervio o raíz y la respuesta a determinados fármacos. Conclusiones. Aunque la neuralgia trigeminal es la más frecuente, existen otras muchas neuralgias craneofaciales, teóricamente tantas como raíces nerviosas y nervios se encargan de la inervación sensitiva de estas regiones anatómicas. Su conocimiento es imprescindible para un correcto diagnóstico (AU)

Summary. Introduction. The International Association for the Study of Pain defines neuralgia as the pain that is felt in the distribution of a nerve or nerve root. Although the most important criterion for its diagnosis is spatial, distinguishing between neuralgia and other types of pain in the craniofacial area will only be possible by looking at a set of many clinical characteristics as a whole. Development. Knowledge of the territories of sensory distribution of the nerves or roots is essential to be able to define the location of the pain in neuralgias. Other attributes are also useful for diagnosing them: the quality of the pain (paroxysmal, stinging-burning, dull), the time profile (seconds-minutes versus hours-days), the absence of accompanying phenomena other than certain manifestations of sensory dysfunction, especially in the symptomatic forms (hypoanaesthesia, paresthesias, dysesthesias, allodynia, hyperalgesia, hyperpathy), pain triggered by tactile or mechanical stimuli in the painful territory (‘trigger’ zones) or a positive Tinel’s sign, the response to anaesthetic blockade of the nerve or root, and the response to certain drugs. Conclusions. Although trigeminal neuralgia is the most frequent, there are many other kinds of craniofacial neuralgias, in fact, theoretically, the total number is the same as the number of nerve roots and nerves responsible for the sensory innervation of these anatomical regions. It is essential to be familiar with them to obtain a correct diagnosis (AU)

[A clinical approach to cranial neuralgias]. / Aproximación clínica a las neuralgias craneales.

INTRODUCTION: The International Association for the Study of Pain defines neuralgia as the pain that is felt in the distribution of a nerve or nerve root. Although the most important criterion for its diagnosis is spatial, distinguishing between neuralgia and other types of pain in the craniofacial area will only be possible by looking at a set of many clinical characteristics as a whole. DEVELOPMENT: Knowledge of the territories of sensory distribution of the nerves or roots is essential to be able to define the location of the pain in neuralgias. Other attributes are also useful for diagnosing them: the quality of the pain (paroxysmal, stinging-burning, dull), the time profile (seconds-minutes versus hours-days), the absence of accompanying phenomena other than certain manifestations of sensory dysfunction, especially in the symptomatic forms (hypoanaesthesia, paresthesias, dysesthesias, allodynia, hyperalgesia, hyperpathy), pain triggered by tactile or mechanical stimuli in the painful territory ('trigger' zones) or a positive Tinel's sign, the response to anaesthetic blockade of the nerve or root, and the response to certain drugs. CONCLUSIONS: Although trigeminal neuralgia is the most frequent, there are many other kinds of craniofacial neuralgias, in fact, theoretically, the total number is the same as the number of nerve roots and nerves responsible for the sensory innervation of these anatomical regions. It is essential to be familiar with them to obtain a correct diagnosis.

Hemangioblastoma quístico de bulbo raquídeo / Cystic bulbar hemangioblastoma

Introducción. Los hemangioblastomas son neoplasias de naturaleza vascular y de características benignas. Representan entre el 2 y el 3% de los tumores cerebrales, y entre el 7 y el 12% de los procesos neoformativos localizados en la fosa posterior. La primera descripción de esta enfermedad se remonta al año 1904, cuando von Hippel hizo pública la primera descripción del hemangioma retiniano. Caso clínico. Varón de 41 años que acudió a su médico, tras presentar durante tres semanas episodios intermitentes de hipo, autolimitados y de duración variable, en ocasiones relacionados con la ingesta y en otras aparecían de forma espontánea. En la exploración neurológica llamaba la atención la presencia de hipoestesia toracoabdominal izquierda. Mediante técnicas de neuroimagen se diagnosticó una lesión tumoral, bien delimitada, quística, de localización bulbar. El abordaje quirúrgico se realizó mediante craniectomía suboccipital, y se llevó a cabo una extirpación completa de la lesión. El estudio anatomopatológico confirmó el diagnóstico de hemangioblastoma. El paciente evolucionó satisfactoriamente, sin presentar nueva clínica neurológica. Conclusión. La localización más frecuente de los hemangioblastomas es en el vérmix y los hemisferios cerebelosos, siendo infrecuente la localización bulbar, que representa un porcentaje inferior al 5% de los hemangioblastomas cerebrales, así como la forma de presentación clínica mediante hipo persistente

Introduction. Hemangioblastomas are neoplasm of vascular type having benign characteristics. They representbetween 2-3% of brain tumors and 7-12% of neoformative processes in the posterior fossa. The first description of the disease goes back to the year 1904, when Eugene von Hippel made the description of retinal haemangioblastoma. Case report. A male patient of 41 years-old who went to his doctor after three weeks of having intermittent episodes of hiccups. In the neurological examination the presence of left thoracic-abdominal hypoesthesia was shown. Brain tumor was diagnosed by neuroimagetechniques. It was well defined, cystic and placed in bulbar region. Surgical approach was carried out by means of suboccipital craniectomy, with the complete removal of the lesion. The histological study confirmed the hemangioblastoma diagnosis. The patient evolved satisfactory, without presenting new neurological symptoms. Conclusion. The most frecuent localization of hemangioblastomas is in vermix and cerebellum hemispheres. The bulbar localization is infrequent (whichrepresents less percentage than 5% of cerebral hemangioblastomas) likewise the clinical manifestation though hiccups

[Cystic bulbar hemangioblastoma]. / Hemangioblastoma quístico de bulbo raquídeo.

INTRODUCTION: Hemangioblastomas are neoplasm of vascular type having benign characteristics. They represent between 2-3% of brain tumors and 7-12% of neoformative processes in the posterior fossa. The first description of the disease goes back to the year 1904, when Eugene von Hippel made the description of retinal haemangioblastoma. CASE REPORT: A male patient of 41 years-old who went to his doctor after three weeks of having intermittent episodes of hiccups. In the neurological examination the presence of left thoracic-abdominal hypoesthesia was shown. Brain tumor was diagnosed by neuroimage techniques. It was well defined, cystic and placed in bulbar region. Surgical approach was carried out by means of suboccipital craniectomy, with the complete removal of the lesion. The histological study confirmed the hemangioblastoma diagnosis. The patient evolved satisfactory, without presenting new neurological symptoms. CONCLUSION: The most frecuent localization of hemangioblastomas is in vermix and cerebellum hemispheres. The bulbar localization is infrequent (which represents less percentage than 5% of cerebral hemangioblastomas) likewise the clinical manifestation though hiccups.

Perfusion computed tomography-guided subacute endovascular reperfusion in a patient with carotid occlusion.

Most patients with symptomatic internal carotid artery occlusion have a single minor or major hemispheric stroke. A minority of patients have ipsilateral retinal ischemia, recurrent strokes, or transient ischemic attacks. Whereas spontaneous carotid recanalization is rare, acute surgical recanalization has been attempted, with mixed results. Recently, acute endovascular recanalization has been performed and described as feasible and relatively safe. We describe a patient with symptom recurrence related to hemodynamic factors after occlusion of the carotid artery who was successfully treated 14 days after symptom onset.

[Recommendations guide for the treatment of migraine in the clinical practice]. / Guía de recomendaciones para el tratamiento de la migraña en la práctica clínica.

Migraine is the most frequent neurological reason for consultation. The differences regarding health care system, type of professional seeing these patients and therapeutic armamentarium available in the different countries are important, which makes it very recommendable to have an action guide that reflects the local clinical practice. Following the year 2005 WHO recommendations in its "Global Campaign" against migraine, the coordinators of the Headache Study Groups of the Spanish Society of Neurology, the Spanish Society of Family and Community Medicine, the Spanish Society of Rural and General Medicine, the Spanish Society of General Medicine and the Global Campaign decided to jointly make this guide. To do so, they made a search in MEDLINE, using the terms "migraine", "migraine treatment" and "headache guidelines" and "migraine guidelines". The most relevant articles were analyzed, including the references that we considered to be of interest. Furthermore, we reviewed the most important textbooks on headache and migraine. In this paper, we detail the recommendations agreed on, according to the evidence grade, on symptomatic and preventive treatment of migraine.

Guía de recomendaciones para el tratamiento de la migraña en la práctica clínica / Recommendations guide for the treatment of migraine in the clinical practice

La migraña es el motivo neurológico de consulta más frecuente. Las diferencias en cuanto a sistema sanitario, tipo de profesional que atiende a estos pacientes y arsenal terapéutico disponible en los diversos países son importantes, lo que hace muy recomendable disponer de una guía de actuación que refleje la práctica clínica local. Siguiendo las recomendaciones de la OMS en su «Campaña Global» frente a la migraña del año 2005, los coordinadores de los Grupos de Estudio de Cefaleas de la Sociedad Española de Neurología, de la Sociedad Española de Medicina de Familia y Comunitaria, de la Sociedad Española de Medicina Rural y Generalista, de la Sociedad Española de Medicina General y de la Campaña Global decidieron llevar a cabo conjuntamente esta guía. Para ello se efectuó una búsqueda en MEDLINE utilizando los términos «migraine», «migraine treatment» «headache guidelines» y «migraine guidelines». Los artículos más relevantes fueron analizados, incluidas las referencias que consideramos de interés. Además, revisamos los libros de texto más importantes en cefalea y migraña. En este manuscrito detallamos las recomendaciones consensuadas, según grado de evidencia, acerca del tratamiento sintomático y preventivo de la migraña (AU)

Migraine is the most frequent neurological reason for consultation. The differences regarding health care system, type of professional seeing these patients and therapeutic armamentarium available in the different countries are important, which makes it very recommendable to have an action guide that reflects the local clinical practice. Following the year 2005 WHO recommendations in its «Global Campaign» against migraine, the coordinators of the Headache Study Groups of the Spanish Society of Neurology, the Spanish Society of Family and Community Medicine, the Spanish Society of Rural and General Medicine, the Spanish Society of General Medicine and the Global Campaign decided to jointly make this guide. To do so, they made a search in MEDLINE, using the terms «migraine», «migraine treatment» and «headache guidelines» and «migraine guidelines». The most relevant articles were analyzed, including the references that we considered to be of interest. Furthermore, we reviewed the most important textbooks on headache and migraine. In this paper, we detail the recommendations agreed on, according to the evidence grade, on symptomatic and preventive treatment of migraine (AU)

Almotriptan and zolmitriptan in the acute treatment of migraine.

OBJECTIVE: To compare almotriptan and zolmitriptan in the treatment of acute migraine. METHODS: This multicentre, double-blind trial randomized adult migraineurs to almotriptan 12.5 mg (n = 532) or zolmitriptan 2.5 mg (n = 530) for the treatment of a single migraine attack. The primary end point was sustained pain free plus no adverse events (SNAE); other end points included pain relief and pain free at several time points, sustained pain free, headache recurrence, use of rescue medication, functional impairment, time lost because of migraine, treatment acceptability, and overall treatment satisfaction. RESULTS: No significant difference was seen in SNAE (almotriptan 29.2% vs zolmitriptan 31.8%) or the other efficacy end points measured. The incidence of triptan-associated AEs and triptan-associated central nervous system AEs was significantly lower for patients receiving almotriptan compared to zolmitriptan. CONCLUSIONS: Almotriptan and zolmitriptan were associated with similar efficacy and overall tolerability in the treatment of acute migraine. Almotriptan was associated with a significantly lower rate of triptan-associated AEs.

Estrategias terapéuticas utilizadas por neurólogos y médicos de atención primaria en el tratamiento sintomático de la migraña. Resultados de los estudios de opinión Strategia-I y Strategia-II / Therapeutic strategies used by neurologists and primary care physicians in the symptomatic treatment of migraine. Findings from strategia-i and strategia-ii opinion studies

Introducción. Existen pocos trabajos que hayan abordadoel tema de la estratificación del tratamiento médico en la migraña,y más escasos aún son los estudios encaminados a conocer lasactitudes que, al respecto, adoptan los médicos con sus pacientes.Los estudios Strategia-I y II se diseñaron con este fin. Sujetos y métodos.Participaron 162 neurólogos y 3.168 médicos de atenciónprimaria (MAP). Los participantes cumplimentaron una encuestade opinión elaborada ad hoc en la que se definían las diferentes estrategiasposibles: a) Tratamiento escalonado entre ataques (el pacientetoma un fármaco durante varias crisis y, si no resulta eficaz,lo sustituye por otro en las siguientes); b) Tratamiento escalonadointraataque (el paciente trata su crisis con un fármaco y, si éste nofunciona, recurre a otro como medicación de rescate; y c) Tratamientoestratificado (el médico clasifica al paciente en función dela discapacidad provocada por la migraña y le recomienda, de entrada,el fármaco más apropiado). Resultados. La mayoría de participantes(90,7% de neurólogos, 85,2% de MAP) referían utilizaruna única estrategia. El tratamiento estratificado resultó ser el preferidopor ambos colectivos (67,6% de neurólogos, 43,8% de MAP;p < 0,0001). Sólo el 16% de los encuestados admitió usar algunaescala de discapacidad. Los antiinflamatorios no esteroideos sonlos fármacos elegidos si la discapacidad es leve-moderada, mientrasque si es moderada-grave se prefieren los triptanes (92,9% deneurólogos, 78,8% de MAP; p < 0,001). Conclusiones. La estrategiade tratamiento estratificado es la más utilizada en las consultasde neurología y atención primaria en España, aunque existen diferenciassignificativas entre ambos colectivos. Los triptanes se percibencomo los fármacos ideales en las situaciones de discapacidadmoderada-grave

Introduction. Few studies have been carried out on the subject of stratification of medical care for migraines, and evenfewer have been conducted with the aim of determining the attitudes adopted by physicians towards their patients when dealingwith this issue. Strategia-I and II studies were designed for this purpose. Subjects and methods. The sample consisted of 162neurologists and 3,168 Primary Care physicians (PCP). Participants in the studies filled out an opinion survey that was producedad hoc and included the different possible strategies, namely a) Stepped care between attacks (the patient takes medicationduring several attacks and, if it is not effective, it is replaced by another in successive attacks); b) Stepped care within attacks(the patient treats his or her seizures with medication and, if it does not work, another is used as rescue medication); and c)Stratified care (the physician classifies the patient according to the degree of disability produced by the migraine and recommendsthe most appropriate drug at the start). Results. Most participants in the study (90.7% of neurologists, 85.2% of PCP) reportedusing a single strategy. Stratified care was found to be the preferred choice by both collectives (67.6% of neurologists, 43.8% ofPCP; p < 0.0001). Only 16% of the respondents admitted using some disability scale. Nonsteroidal antiinflammatory drugs arethe medication chosen if disability is mild-moderate, while triptans are preferred if it is moderate-severe (92.9% of neurologists,78.8% of PCP; p < 0.001). Conclusions. The strategy based on stratified care is the most widely used in visits to Neurology andPrimary Care in Spain, although there are significant differences between the two collectives. Triptans are perceived as being theideal medication in situations involving moderate-severe disability

[Therapeutic strategies used by neurologists and primary care physicians in the symptomatic treatment of migraine. Findings from Strategia-I and Strategia-II opinion studies]. / Estrategias terapéuticas utilizadas por neurólogos y médicos de atención primaria en el tratamiento sintomático de la migraña. Resultados de los estudios de opinión Strategia-I y Strategia-II.

INTRODUCTION: Few studies have been carried out on the subject of stratification of medical care for migraines, and even fewer have been conducted with the aim of determining the attitudes adopted by physicians towards their patients when dealing with this issue. Strategia-I and II studies were designed for this purpose. SUBJECTS AND METHODS: The sample consisted of 162 neurologists and 3,168 Primary Care physicians (PCP). Participants in the studies filled out an opinion survey that was produced ad hoc and included the different possible strategies, namely a) Stepped care between attacks (the patient takes medication during several attacks and, if it is not effective, it is replaced by another in successive attacks); b) Stepped care within attacks (the patient treats his or her seizures with medication and, if it does not work, another is used as rescue medication); and c) Stratified care (the physician classifies the patient according to the degree of disability produced by the migraine and recommends the most appropriate drug at the start). RESULTS: Most participants in the study (90.7% of neurologists, 85.2% of PCP) reported using a single strategy. Stratified care was found to be the preferred choice by both collectives (67.6% of neurologists, 43.8% of PCP; p < 0.0001). Only 16% of the respondents admitted using some disability scale. Nonsteroidal antiinflammatory drugs are the medication chosen if disability is mild-moderate, while triptans are preferred if it is moderate-severe (92.9% of neurologists, 78.8% of PCP; p < 0.001). CONCLUSIONS: The strategy based on stratified care is the most widely used in visits to Neurology and Primary Care in Spain, although there are significant differences between the two collectives. Triptans are perceived as being the ideal medication in situations involving moderate-severe disability.

[Spanish contribution to the clinical development of eletriptan: an analysis of controlled studies]. / Contribución española al desarrollo clínico de eletriptán: un análisis de los estudios controlados.

INTRODUCTION: Eletriptan is a recently marketed second-generation triptan with a potent agonist activity on 5-HT1B/ 1D receptors. Our aim has been to analyze the specific results from the Spanish participation in phase IIIa and IIIb clinical trials vs placebo and compare them with the results obtained in the global clinical development of eletriptan. PATIENTS AND METHODS: Analysis of the results obtained in 40 centers in Spain (358 patients) vs global sample 4,677 patients) for the first migraine attack in 6 controlled clinical trials with eletriptan 40 mg, eletriptan 80 mg and placebo. This ad hoc analysis was carried out for those treatment groups with more than 50 patients, which reduced the final number of patients from Spain to 250. RESULTS: The proportion of patients with relief at 2 hours (main endpoint) in the Spanish sample was 22 %, 59 % and 67 % for placebo, eletriptan 40 mg and eletriptan 80 mg, respectively. These values were significantly higher (p < 0.05) than those of placebo and similar to those from the total sample. The proportion of pain free patients at 2 hours in the Spanish sample was 10 %, 36 % and 41 % for placebo, eletriptan 40 mg and eletriptan 80 mg, respectively. These values were significantly better than those for placebo (p < 0.05) and about 15 %-20 % higher than those from the total sample. Recurrence rate in the Spanish sample was 50 %, 16 % and 25 % for placebo, eletriptan 40 and eletriptan 80 mg, respectively, and did not differ from that of the total sample. Sustained relief for the two eletriptan doses was 46 % for both eletriptan 40 and eletriptan 80, this being significant (p < 0.05) over placebo (11 %) for the Spanish sample and similar to that of the global sample. The results for other efficacy parameters, such as need of rescue medication, functional response at 2 hours, complete response for pain-freeness and acceptability followed a similar pattern. Eletriptan was, in general, well-tolerated. Adverse events were slight-moderate in intensity, transient and were not different, either in profile or proportion, from those from the global sample. CONCLUSIONS: These results confirm eletriptan 40 mg and 80 mg as an excellent option for the symptomatic treatment of migraine in our setting.