Injectable sumatriptan for cyclic vomiting syndrome in adults: a case series.

OBJECTIVE: To better familiarize the reader with a migraine-related disorder, cyclic vomiting syndrome (CVS) in adults, and to discuss its diagnosis and treatment. BACKGROUND: CVS is a profoundly disabling disorder characterized by recurrent, stereotypic episodes of incapacitating nausea and vomiting, separated by completely asymptomatic intervals. CVS episodes tend to start at the same time of day, persist for the same duration, and present with the same intensity and associated symptoms. Most patients experience prodromal symptoms and can identify triggers that precipitate attacks, such as menstruation, lack of sleep, certain foods, physical exertion, and stress. The prevalence of CVS in adults is unknown, but since its occurrence in this age group has been little recognized, patients typically experience lengthy delay in diagnosis or misdiagnosis. METHOD: Literature review, case reports, and discussion. RESULTS: Given genetic links of CVS to migraine, as well as its comorbidity, typical migraine triggers, and response to similar acute and preventive medications, CVS likely represents a disorder on the migraine spectrum. CONCLUSION: Adult CVS is not only highly comorbid with migraine, but it responds to migraine preventives, and in some cases to injectable sumatriptan even in the absence of headache.

The point prevalence of dizziness or vertigo in migraine--and factors that influence presentation.

OBJECTIVE: To ascertain and characterize the point prevalence of dizziness or vertigo in migraineurs presenting for routine appointments at a specialty headache clinic. BACKGROUND: Migraine, dizziness, and vertigo are all common in the general population, affecting 13%, 20-30%, and 5-10% respectively. Thereby, chance concurrence of migraine with either dizziness or vertigo would be expected in roughly 4% of the general population. It is the authors' clinical impression that severe attacks of migraine are far more commonly associated with these complaints than chance would predict. METHODS: This is a prospective, cross-sectional study of 462 consecutive patients who presented for consultation at a specialty headache clinic over a 4-month period of time. During routine check-in procedures, patients were asked to report their headache pain on a 1-10 Likert scale. Patients were also asked to report if they were currently experiencing dizziness or vertigo. Responses to these questions were recorded along with vital signs. Diagnosis of migraine with or without aura was made by headache medicine specialists in accordance with International Classification of Headache Disorders--second edition criteria. Chi-square analysis was used to examine the prevalence of vertigo or dizziness in subjects with varying intensity of headache, and by history of aura. RESULTS: Of the 425 evaluable subjects, 28% experienced aura. Subjects' average age was 43.8 years (range 15 to 76 years); 89.5% were female. At the time of evaluation, 72.4% of subjects reported some degree of ongoing headache pain and 15.7% reported concurrent dizziness or vertigo. The prevalence of dizziness or vertigo was twice as high (24.5% vs 12.1%) in migraine with aura compared to migraine without aura (P < .01), and prevalence increased with age (P < .05). There was a strong correlation between migraine pain and subjective complaint of vertigo (P < .001). When migraine pain was present at an intensity of 7 or greater (on a scale of 1-10), almost half of the subjects (47.5%) reported concomitant dizziness or vertigo. CONCLUSIONS: Subjective complaints of dizziness or vertigo appear to be relatively common accompaniments of migraine, particularly migraine with aura, and prevalence increases with age. Disequilibrium symptoms have a strong and positive association with the severity of migraine pain. With co-occurrence higher than expected by chance, the relationship either reflects comorbidity or these symptoms may be part of the migraine presentation. With a point prevalence of 15.7%, and factors that link expression both to the intensity of migraine pain and to migraine aura, the authors believe that the true relationship may prove to be the latter.

Patient characteristics associated with frequent calls to a headache specialty clinic.

OBJECTIVE: To identify characteristics of patients who frequently initiate contact with a headache specialty clinic outside of scheduled appointments. MATERIALS AND METHODS: We scanned records of all telephone calls received during 1 calendar year at an academic headache clinic to identify frequent callers. High-frequency (HF) callers were defined as established patients who initiated calls on ≥20 days during the year. We compared these patients with a cohort of established low-frequency (LF) callers who initiated no telephone calls during the same year. Clinic records were analyzed for demographic characteristics, diagnoses, and medication use. Additionally, we administered a questionnaire to clinic physicians and administrative staff querying their perception of each patient's demands on clinic resources. RESULTS: High-frequency (n=26) and LF (n=18) callers did not differ significantly in marital status, ethnicity, diagnosis, or age. There was a trend toward female gender among HF callers and toward being outside of a body mass index range of 19 to 30 kg/m2. The groups were similar in their use of triptans and botulinum toxin treatments, but HF callers were more likely to be opioid users (96% vs 11.1%) and more likely to be taking multiple opioids in substantially higher potency, dosage, and quantity (154.4 mg vs 1.4 mg morphine equivalents/day). More than 80% of each group were migraineurs, but HF callers were more likely to have comorbid psychiatric disorders (P<0.05). High-frequency callers were also more likely to be rated by administrative staff and physicians as demanding and time-consuming. CONCLUSIONS: In this university-based headache specialty clinic, HF callers were more likely to be opioid users on high morphine-equivalent doses. Compared with LF callers, HF callers placed a greater burden on health care resources as perceived by staff and physicians.

Presence of neck pain may delay migraine treatment.

OBJECTIVE: To determine whether the presence of neck pain (NP) is associated with a delay in migraine treatment. BACKGROUND: We have previously shown that 1) NP is exceedingly common in migraine; 2) its presence on the day preceding migraine is associated with impaired treatment response; and 3) NP is predictive of migraine-related disability independent of headache frequency and severity. MATERIALS AND METHODS: This was a prospective, observational, cross-sectional study of 113 patients with migraine, ranging in attack frequency from episodic to chronic migraine. Subjects were examined by headache specialists to confirm the diagnosis of migraine and exclude both cervicogenic headache and fibromyalgia. Details of all headaches were recorded over the course of at least 1 month and until 6 qualifying migraines had been treated. Subjects were permitted to treat at the stage they customarily treated. A chi-square test of independence was performed to examine the relationship between the presence of NP and treatment within 30 minutes of headache onset. Analysis of variance was used to test the relationship of NP intensity with headache intensity at the time of migraine treatment. RESULTS: Subjects recorded 2411 headache days, 786 of which were migraines, the majority of which were treated in the moderate pain stage. Presence of NP in the hour preceding initial migraine treatment was associated with delay in treatment beyond 30 minutes of headache onset (P < 0.01) and initiation of treatment at a greater headache pain intensity (P < 0.001). When NP accompanied migraine, those with moderate or severe NP were more likely to treat within 30 minutes of headache onset than those with mild NP (P < 0.05). CONCLUSION: Presence of NP was associated with delayed treatment of migraine, as indicated not only by higher pain burden at time of treatment but also by delay beyond 30 minutes.