[Zonisamide in the preventive treatment of refractory migraine]. / Zonisamida en el tratamiento preventivo de la migraña refractaria.

INTRODUCTION: Chronic migraine refractory to preventive treatment is a common clinical situation in general neurology clinics. The aim is to analyse our experience with zonisamide in the preventive treatment of patients with frequent refractory migraine. PATIENTS AND METHODS: Those patients with no response or intolerance to topiramate and at least one more preventative received zonisamide. This drug was increased 25 mg per week up to 200 mg/day. The efficacy of zonisamide was evaluated in terms of 'response' (reduction in attack frequency below 50%) at the third month of treatment. RESULTS: Our series comprises a total of 172 patients, with ages ranging from 22 to 69 years. 85% were women. The final dosage of zonisamide was 50-200 mg/day, with the 100 mg/day being the most frequently administered dose. Zonisamide was efficacious (response) in 76 (44%) patients; response being excellent in 22 (13%). MIDAS score was reduced by 43.2%. Zonisamide was not tolerated by 27% of the patients, mainly due to subjective mental slowness or digestive symptoms. CONCLUSIONS: These results, obtained in a big sample of patients refractory or intolerant to topiramate and other preventatives, indicate that, at least in conditions of daily clinical practice, zonisamide, at relatively low dosages, is an option to be considered for the preventive treatment of patients with frequent migraine.

Zonisamida en el tratamiento preventivo de la migraña refractaria / Zonisamide in the preventive treatment of refractory migraine

Introducción. La migraña crónica refractaria al tratamiento preventivo habitual es una situación frecuente en consultas de neurología. Se pretende analizar la experiencia con zonisamida en el tratamiento de pacientes con migraña frecuente refractaria. Pacientes y métodos. Aquellos pacientes sin respuesta o con intolerancia a topiramato y al menos otro fármaco preventivo para la migraña recibieron zonisamida. El fármaco se incrementó a razón de 25 mg/semana, hasta un máximo de 200 mg/día. La eficacia de la zonisamida se evaluó en términos de ‘respuesta’ (disminución en la frecuencia de las crisis al menos del 50%) al tercer mes del tratamiento. Resultados. Nuestra serie comprende 172 pacientes de entre 22 y 69 años. El 81% eran mujeres. Las dosis de zonisamida oscilaron entre 50 y 200 mg/día, y la dosis más frecuentemente administrada fue de 100 mg/día. La zonisamida mostró eficacia (respuesta) en 76 (44%) de los pacientes; la respuesta fue excelente en 22 (13%). La puntuación en el test de MIDAS se redujo en un 43,2%. Un 27% de los pacientes no toleró el fármaco, fundamentalmente por bradipsiquia subjetiva o clínica digestiva. Conclusiones. Estos resultados, obtenidos en un número amplio de pacientes refractarios o intolerantes a topiramato y otros fármacos, indican que, al menos en condiciones de práctica clínica, la zonisamida, en dosis relativamente bajas, es una opción que se debe considerar en el tratamiento preventivo del paciente con migraña frecuente

Introduction. Chronic migraine refractory to preventive treatment is a common clinical situation in general neurology clinics. The aim is to analyse our experience with zonisamide in the preventive treatment of patients with frequent refractory migraine. Patients and methods. Those patients with no response or intolerance to topiramate and at least one more preventative received zonisamide. This drug was increased 25 mg per week up to 200 mg/day. The efficacy of zonisamide was evaluated in terms of ‘response’ (reduction in attack frequency below 50%) at the third month of treatment. Results. Our series comprises a total of 172 patients, with ages ranging from 22 to 69 years. 85% were women. The final dosage of zonisamide was 50-200 mg/day, with the 100 mg/day being the most frequently administered dose. Zonisamide was efficacious (response) in 76 (44%) patients; response being excellent in 22 (13%). MIDAS score was reduced by 43.2%. Zonisamide was not tolerated by 27% of the patients, mainly due to subjective mental slowness or digestive symptoms. Conclusions. These results, obtained in a big sample of patients refractory or intolerant to topiramate and other preventatives, indicate that, at least in conditions of daily clinical practice, zonisamide, at relatively low dosages, is an option to be considered for the preventive treatment of patients with frequent migrainev

Miliary brain metastases presenting as rapidly progressive dementia.

We report the case of a 79-year-old woman who developed a rapidly progressive dementia (RPD) with severe memory impairment, early visual hallucinations and extrapyramidal signs. Symptoms started suddenly after hip replacement surgery following an accidental fall. Motor epileptic seizures appeared at the end of the illness. Dementia worsened gradually leading to akinetic mutism. She died five and a half months after the onset of symptoms. MRI showed cerebral atrophy but failed to detect any other lesion. Results of all laboratory tests performed were negative. After the most frequent treatable diseases were excluded, the diagnosis of dementia with Lewy bodies was initially considered. CJD was also suggested based on the rapid evolution of the disease and the positivity of 14-3-3 protein in CSF. Neuropathological examination revealed an extensive miliary metastatic dissemination from an unknown primary adenocarcinoma. Pulmonary origin was suggested according to the immunohistochemical profile. Histopathological changes of Alzheimer's disease were also observed in the cerebral cortex and hippocampus. Neither Lewy bodies nor PrP deposits were found. The sudden onset of the dementia just after the hip replacement surgery raises the possibility of a pathological fracture with secondary tumoral microembolic dissemination. Despite its rarity, this entity should be included in the differential diagnosis of RPD. This case illustrates the definite importance of neuropathological post-mortem examination in order to elucidate the different types of dementia.