Background. - Mood disorders of anxiety and depression are well known to be comorbid with primary headache disorders. Less is known of the comorbidity of other somatic symptoms with headache. Methods. - Headache Clini...Background. - Mood disorders of anxiety and depression are well known to be comorbid with primary headache disorders. Less is known of the comorbidity of other somatic symptoms with headache. Methods. - Headache Clinic patients were screened with the Primary Care Evaluation of Mental Disorders (PRIME- MD), a multidimensional psychiatric screening tool. The prevalence of somatic symptoms was compared by headache diagnosis, frequency of severe headache, and psychiatric diagnosis. Follow- up data were obtained 6 months after consultation. Results. - Clinical diagnoses and PRIME- MD data were available for 289 patients. Associated somatic symptoms were more frequent in patients with chronic migraine (mean 5.5, P < .001) and chronic daily headache (CDH) (6.3, P = .008) compared to episodic migraine (4.0); in patients with severe headache >2 days per week compared to ≤ 2 days per week (6.15 vs. 4.15, P < .001); and in patients with a clinical diagnosis of anxiety or depression, or both, compared to no anxiety or depression, (5.7, P = .05,5.2, P < .05, and 6.8, P < .001, respectively, vs. 4.5). The most common specific symptoms were fatigue (73% ), sleep difficulty (60% ), and nausea/indigestion (55% ). Compared to a primary care sample, patients with severe headache >2 days per week had significantly higher somatic counts (P = .01). Six- month follow- up data were available for 140 patients. Associated symptoms decreased both for patients with and without decrease in severe headache frequency (mean reduction of 1.0, P = .01 and 0.8, P = .003, respectively). Conclusion. - Associated somatic symptoms are more common in patients with chronic migraine and CDH, with more frequent severe headaches, and with associated anxiety or depression. Patients with episodic migraine have similar somatic prevalence as a previously studied primary care population. The spectrum of headache disorders may be characterized as showing increasing somatic prevalence as headaches, particularly severe headaches, become more frequent.展开更多
Objective. -To investigate the efficacy and tolerability of almotriptan 12.5 mg in migraine patients who respond poorly to sumatriptan 50 mg. Background. -Poor response to sumatriptan therapy for acute migraine attack...Objective. -To investigate the efficacy and tolerability of almotriptan 12.5 mg in migraine patients who respond poorly to sumatriptan 50 mg. Background. -Poor response to sumatriptan therapy for acute migraine attacks has been documented in the literature, but few controlled trials have investigated the efficacy of an alternative triptan in this subgroup of patients. Methods. -Patients with an International Headache Society diagnosis of migraine who self-described as experiencing at least two unsatisfactory responses to sumatriptan treated their first migraine attack with open-label sumatriptan 50 mg. Patients who did not achieve 2-hour pain relief (improvement of headache from moderate/severe to mild/no headache) were then randomized to treat their second attack with almotriptan 12.5 mg or placebo under double-blind conditions. Results. -In the first attack, 221 of 302 participants (73%) did not achieve 2-hour pain relief with sumatriptan and were randomized to treatment of their second attack with almotriptan 12.5 mg or placebo. Of the 198 sumatriptan nonresponders who treated their second attack (99 almotriptan; 99 placebo), 70%had severe headache pain at baseline. Two-hour pain-relief rates were significantly higher with almotriptan compared to placebo (47.5%vs 23.2%; P < .001). A significant treatment effect for almotriptan was also seen in pain-free rates at 2 hours (33.3%vs 14.1%; P < .005) and sustained freedom from pain (20.9%vs 9.0%; P < .05). In the second attack, 7.1%of patients in the almotriptan group experienced adverse events compared to 5.1%in the placebo group (P=.77). Conclusions. -Almotriptan 12.5 mg is an effective and well-tolerated alternative for patients who respond poorly to sumatriptan 50 mg. A poor response to one triptan does not predict a poor response to other agents in that class.展开更多
PURPOSE: Topical nitroglycerin has been widely used as a means for avoiding surgery in patients with anal fissure. However, nitroglycerin has not been universally accepted for this application because of inconsistency...PURPOSE: Topical nitroglycerin has been widely used as a means for avoiding surgery in patients with anal fissure. However, nitroglycerin has not been universally accepted for this application because of inconsistency of efficacy and side effects. This study compares conventional digital application with precise intra-anal dosing of nitroglycerin using a specialized dose-delivery device and anal cannula. METHODS: Twenty-six consecutive patients (13 males) with chronic anal fissure and no previous treatment were randomly allocated to receive 0.75 ml of 0.3 percent nitroglycerin ointment (2.25 mg nitroglycerin) t.i.d. intra-anal using the cannula (Group A) or perianally with the gloved finger (Group B). Nitroglycerin dosage was controlled in Group A by the dose-delivery device connected to the cannula and by single-dose preloaded syringes in Group B. RESULTS: Anal manometry: pressure reduction after application of nitroglycerin was 47 ±18.6 in Group A and 20.7 ±13.4 percent in Group B (P < 0.01). Headach-es were reported by 1 of 10 patients in Group A and 10 of 12 patients in Group B (P = 0.0027). Seven patients of Group B had to be crossed to intra-anal treatment as a result of intensity of headaches. Pain relief was noted by 8 of 10 and 9 of 12 patients in Groups A and B, respectively (P = 0.6). Sphincterotomy was required in only 13.6 percent of all patients. CONCLUSIONS: Controlled intra-anal dosing of topical nitroglycerin produces a significantly greater reduction in sphincteric pressure and lower incidence of headaches than with perianal administration of the same dose of ointment. These results suggest a new paradigm for increasing safety and efficacy of dose-depen-dent prescription anal topical medications.展开更多
Background: HELLP syndrome (a combination of hemolysis, elevated liver enzyme levels, and low platelet count) is a severe variant of preeclampsia that generally occurs before delivery but can occur post partum. This s...Background: HELLP syndrome (a combination of hemolysis, elevated liver enzyme levels, and low platelet count) is a severe variant of preeclampsia that generally occurs before delivery but can occur post partum. This syndrome is more common than eclampsia and frequently leads to devastating neurological consequences such as intracerebral hemorrhage. Objective: Although mentioned in the obstetric literature, there has been sparse reporting in the neurology literature specifically regarding intracerebral hemorrhage in HELLP syndrome. We illustrate such a case and review the existing literature regarding this severe complication. Setting: Obstetric unit at an academic medical center. Patient: A 34-year-old primigravida experienced a pontine hemorrhage and subsequent respiratory arrest 22 hours after a normal delivery. This hemorrhage occurred 7 hours after the sudden onset of hypertension, severe headache, and intermittent abdominal pain. Results: Laboratory and postmortem evidence suggested HELLP syndrome with disseminated intravascular coagulation as the cause of her intracerebral hemorrhage. Conclusions: Our case suggests the importance of the neurology consultant’s familiarity with HELLP syndrome and the need for thorough laboratory testing and close monitoring in the puerperal patient with headache and hypertension.展开更多
文摘Background. - Mood disorders of anxiety and depression are well known to be comorbid with primary headache disorders. Less is known of the comorbidity of other somatic symptoms with headache. Methods. - Headache Clinic patients were screened with the Primary Care Evaluation of Mental Disorders (PRIME- MD), a multidimensional psychiatric screening tool. The prevalence of somatic symptoms was compared by headache diagnosis, frequency of severe headache, and psychiatric diagnosis. Follow- up data were obtained 6 months after consultation. Results. - Clinical diagnoses and PRIME- MD data were available for 289 patients. Associated somatic symptoms were more frequent in patients with chronic migraine (mean 5.5, P < .001) and chronic daily headache (CDH) (6.3, P = .008) compared to episodic migraine (4.0); in patients with severe headache >2 days per week compared to ≤ 2 days per week (6.15 vs. 4.15, P < .001); and in patients with a clinical diagnosis of anxiety or depression, or both, compared to no anxiety or depression, (5.7, P = .05,5.2, P < .05, and 6.8, P < .001, respectively, vs. 4.5). The most common specific symptoms were fatigue (73% ), sleep difficulty (60% ), and nausea/indigestion (55% ). Compared to a primary care sample, patients with severe headache >2 days per week had significantly higher somatic counts (P = .01). Six- month follow- up data were available for 140 patients. Associated symptoms decreased both for patients with and without decrease in severe headache frequency (mean reduction of 1.0, P = .01 and 0.8, P = .003, respectively). Conclusion. - Associated somatic symptoms are more common in patients with chronic migraine and CDH, with more frequent severe headaches, and with associated anxiety or depression. Patients with episodic migraine have similar somatic prevalence as a previously studied primary care population. The spectrum of headache disorders may be characterized as showing increasing somatic prevalence as headaches, particularly severe headaches, become more frequent.
文摘Objective. -To investigate the efficacy and tolerability of almotriptan 12.5 mg in migraine patients who respond poorly to sumatriptan 50 mg. Background. -Poor response to sumatriptan therapy for acute migraine attacks has been documented in the literature, but few controlled trials have investigated the efficacy of an alternative triptan in this subgroup of patients. Methods. -Patients with an International Headache Society diagnosis of migraine who self-described as experiencing at least two unsatisfactory responses to sumatriptan treated their first migraine attack with open-label sumatriptan 50 mg. Patients who did not achieve 2-hour pain relief (improvement of headache from moderate/severe to mild/no headache) were then randomized to treat their second attack with almotriptan 12.5 mg or placebo under double-blind conditions. Results. -In the first attack, 221 of 302 participants (73%) did not achieve 2-hour pain relief with sumatriptan and were randomized to treatment of their second attack with almotriptan 12.5 mg or placebo. Of the 198 sumatriptan nonresponders who treated their second attack (99 almotriptan; 99 placebo), 70%had severe headache pain at baseline. Two-hour pain-relief rates were significantly higher with almotriptan compared to placebo (47.5%vs 23.2%; P < .001). A significant treatment effect for almotriptan was also seen in pain-free rates at 2 hours (33.3%vs 14.1%; P < .005) and sustained freedom from pain (20.9%vs 9.0%; P < .05). In the second attack, 7.1%of patients in the almotriptan group experienced adverse events compared to 5.1%in the placebo group (P=.77). Conclusions. -Almotriptan 12.5 mg is an effective and well-tolerated alternative for patients who respond poorly to sumatriptan 50 mg. A poor response to one triptan does not predict a poor response to other agents in that class.
文摘PURPOSE: Topical nitroglycerin has been widely used as a means for avoiding surgery in patients with anal fissure. However, nitroglycerin has not been universally accepted for this application because of inconsistency of efficacy and side effects. This study compares conventional digital application with precise intra-anal dosing of nitroglycerin using a specialized dose-delivery device and anal cannula. METHODS: Twenty-six consecutive patients (13 males) with chronic anal fissure and no previous treatment were randomly allocated to receive 0.75 ml of 0.3 percent nitroglycerin ointment (2.25 mg nitroglycerin) t.i.d. intra-anal using the cannula (Group A) or perianally with the gloved finger (Group B). Nitroglycerin dosage was controlled in Group A by the dose-delivery device connected to the cannula and by single-dose preloaded syringes in Group B. RESULTS: Anal manometry: pressure reduction after application of nitroglycerin was 47 ±18.6 in Group A and 20.7 ±13.4 percent in Group B (P < 0.01). Headach-es were reported by 1 of 10 patients in Group A and 10 of 12 patients in Group B (P = 0.0027). Seven patients of Group B had to be crossed to intra-anal treatment as a result of intensity of headaches. Pain relief was noted by 8 of 10 and 9 of 12 patients in Groups A and B, respectively (P = 0.6). Sphincterotomy was required in only 13.6 percent of all patients. CONCLUSIONS: Controlled intra-anal dosing of topical nitroglycerin produces a significantly greater reduction in sphincteric pressure and lower incidence of headaches than with perianal administration of the same dose of ointment. These results suggest a new paradigm for increasing safety and efficacy of dose-depen-dent prescription anal topical medications.
文摘Background: HELLP syndrome (a combination of hemolysis, elevated liver enzyme levels, and low platelet count) is a severe variant of preeclampsia that generally occurs before delivery but can occur post partum. This syndrome is more common than eclampsia and frequently leads to devastating neurological consequences such as intracerebral hemorrhage. Objective: Although mentioned in the obstetric literature, there has been sparse reporting in the neurology literature specifically regarding intracerebral hemorrhage in HELLP syndrome. We illustrate such a case and review the existing literature regarding this severe complication. Setting: Obstetric unit at an academic medical center. Patient: A 34-year-old primigravida experienced a pontine hemorrhage and subsequent respiratory arrest 22 hours after a normal delivery. This hemorrhage occurred 7 hours after the sudden onset of hypertension, severe headache, and intermittent abdominal pain. Results: Laboratory and postmortem evidence suggested HELLP syndrome with disseminated intravascular coagulation as the cause of her intracerebral hemorrhage. Conclusions: Our case suggests the importance of the neurology consultant’s familiarity with HELLP syndrome and the need for thorough laboratory testing and close monitoring in the puerperal patient with headache and hypertension.
