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Biomedical subjects

Elizabeth Loder

Publications and source records attributed to Elizabeth Loder.

At least 19 recordsLinked to original sources
PubMed2006

Cluster headache and the heart.

Cluster headache is a rare but debilitating recurrent headache disorder. It is most common in middle-aged and older men, a group with a high prevalence of cardiovascular disease. This article reviews available information regarding the association of cluster headache and the heart in three selected areas: 1) the known effects of cluster headache on cardiovascular parameters such as heart rate and rhythm and blood pressure; 2) the prevalence of cardiac risk factors in subjects with cluster headache; and 3) the connection between patent foramen ovale and cluster headache. Some evidence suggests that cardiovascular risk factors, especially cigarette smoking, may be more common in cluster headache sufferers. There also is evidence that disturbances of autonomic function or certain structural cardiac anomalies may be more common in cluster headache sufferers. In addition, a number of important treatment options for cluster headache have effects on cardiovascular function that must be considered in planning therapy. The implications of these findings for clinical practice are discussed.

Blood Pressure↗
PubMed2006

The impact of migraine on daily activities: effect of topiramate compared with placebo.

OBJECTIVE: Assess the impact of migraine preventive therapy on patient-reported routine daily activities using the Migraine Specific Questionnaire (MSQ) and the Medical Outcomes Study Short Form-36 (SF-36) in patients with migraine who participated in a 26-week, randomized, double-blind, placebo-controlled trial of topiramate for migraine prevention. METHODS: Patients were required to have 3-12 migraines and < or = 15 headache days/month during the baseline phase. Patients who failed > 2 adequate regimens of migraine preventive therapy were excluded. MSQ and SF-36 data were collected at baseline, weeks 8, 16, and 26 from 469 patients receiving either topiramate 50, 100, or 200 mg/day or placebo. Patients entered a double-blind, 8-week titration period followed by an 18-week maintenance period. Two activity-related MSQ domains (Role Restrictive [RR] and Role Prevention [RP]) and two activity-related SF-36 domains (Role Physical [SF-36-RP] and Vitality [SF-36-VT]) were prospectively designated as the outcome measures. Changes in MSQ and SF-36 scores during the double-blind phase relative to prospective baseline scores were compared between topiramate- and placebo-treated groups. Specifically, a mixed-effect piecewise linear regression model was used to estimate average domain score over time, and areas under the domain-over-time curve (AUC) were compared using a 2-sided t-test, with multiplicity adjustment. RESULTS: In the intent-to-treat population (N = 469), topiramate (all doses) significantly improved mean MSQ-RR domain scores versus placebo (topiramate 50 mg/day, p = 0.035; topiramate 100 mg/day; p < 0.001; topiramate 200 mg/day, p = 0.001). Topiramate-associated improvements in mean MSQ-RP domain scores were significant versus placebo only for topiramate 100 mg/day (p = 0.045). SF-36-RP and SF-36-VT domain scores improved (not significant versus placebo) for topiramate 100 and 200 mg/day. Changes in these MSQ and SF-36 domain scores significantly correlated with changes in mean monthly migraine frequency. CONCLUSION: Improvements in patient-reported outcomes specific for migraine (measured by the MSQ) were significantly better for patients receiving topiramate than for those receiving placebo. Improvements in the prospectively selected MSQ and SF-36 domains were significantly correlated with the decrease in mean monthly migraine frequency observed with topiramate treatment.

Activities of Daily Living↗
PubMed2005

Cluster headache from the patient's point of view.

The medical literature provides few opportunities for physicians to read and reflect on detailed, first-hand narratives of individual patient experiences. The author invited patients with cluster headache to respond in writing to a series of open-ended questions about their experience with the illness. The patient responses provide important information for physicians and others who seek a more complete understanding of cluster headache.

Cluster Headache↗
PubMed2005

General principles of migraine management: the changing role of prevention.

The role of preventive treatment in the management of migraine must be reassessed. Many patients who would benefit from preventive therapy do not receive it, and many might benefit from earlier and more aggressive use of preventive therapy. Physicians who treat migraine have long recognized that a subset of patients with episodic migraine evolve to chronic forms of the disorder that are difficult to treat and have a poor outcome. This article reviews the evidence for current and emerging prophylactic migraine treatment and raises the possibility that timely use of prophylactic treatment might modify or prevent the transformation to chronic migraine and the extreme disability that characterizes a small but significant subset of the migraine population. Along with aggressive treatment of the acute pain and other symptoms of migraine, prevention of progression to severe forms of this disorder will increasingly be a focus and goal of the treatment.

Anticonvulsants↗
PubMed2005

Pain-free rates with zolmitriptan 2.5 mg ODT in the acute treatment of migraine: results of a large double-blind placebo- controlled trial.

CONTEXT: Zolmitriptan 2.5 mg orally disintegrating tablets (ODT) allow patients to take the medication without fluids, which is convenient and avoids the risk of fluid-induced exacerbation of nausea/vomiting. OBJECTIVE: To evaluate the efficacy and tolerability of zolmitriptan 2.5 mg ODT taken as soon as possible after onset of a migraine. DESIGN: Multicenter, double-blind, parallel-group, placebo-controlled two-attack trial. SETTING: Outpatient headache clinics in the US. PATIENTS: 608 patients were randomized; 566 patients treated at least 1 migraine and were included in the tolerability assessment (565 patients were included in the intent-to-treat population). INTERVENTION: Patients were randomized to either zolmitriptan 2.5 mg ODT or placebo. Patients treated up to 2 migraine attacks as soon as possible after the start of their migraine pain. MAIN OUTCOME MEASURE: Pain-free rates at 2 h. RESULTS: Zolmitriptan 2.5 mg ODT (n = 281) demonstrated a significant pain-free rate vs. placebo (n = 284) at 2 h (40% vs. 20%, p < 0.001), 1.5 h (25% vs. 15%, p < 0.001), and 1 h (13% vs. 8%, p = 0.004). Sustained pain-free rate was significantly higher than placebo (31% vs. 15%; p < 0.001). Return to normal activities favored zolmitriptan 2.5 mg ODT at 1 h (p = 0.004), 1.5 h (p < 0.001), and 2 h (p < 0.001). Adverse events associated with zolmitriptan 2.5 mg ODT were those commonly reported with the use of triptans. CONCLUSIONS: Zolmitriptan 2.5 mg ODT, taken as early as possible after onset of a migraine attack, is effective in the treatment of migraine, producing a significantly higher pain-free rate than placebo 2 h post-dose, and also at the earlier time points of 1 h and 1.5 h post-dose.

Acute Disease↗
PubMed2005

Fixed drug combinations for the acute treatment of migraine : place in therapy.

Fixed drug combinations (FDCs) combine standardised doses of two or more drugs in a single tablet, injection, nasal spray or suppository. FDCs may improve treatment compliance, efficacy or tolerability through a variety of mechanisms. At present, FDCs are commonly used in migraine treatment, and more are in development. This systematic review identified 43 prospective trials of FDCs in use for the acute treatment of migraine. Quantitative combination and analysis of the data were not possible, but results of the review support the following qualitative conclusions. First, many FDCs in use for the acute treatment of migraine are older drugs. In these cases, clinical trial evidence that the FDC is efficacious or has important advantages over its treatment components is lacking. The benefits assumed for some common FDC ingredients such as caffeine and metoclopramide are not clearly confirmed in these trials. Secondly, the use of barbiturate-containing FDCs for the acute treatment of migraine is not evidence based, and these drugs are frequently implicated in the development of dependence or medication-induced headache syndromes. Thirdly, studied opioid-containing FDCs are generally superior to placebo, but evidence regarding the safety and tolerability of their repeated use in the treatment of migraine is lacking; clinical experience dictates caution in the use of these agents. Fourthly, ergotamine-containing FDCs are generally superior to placebo, but perform poorly in comparison with single-agent selective serotonin 5-HT(1B/1D) receptor agonists ('triptans'), NSAIDs or even isometheptene or opioid comparators, and are less well tolerated. Fifthly, the most consistent and impressive evidence of benefit is for NSAID-containing FDCs. These invariably outperform placebo and are equivalent or superior to active comparators. Finally, with renewed interest in the use of FDCs for the acute treatment of migraine, high-quality evidence of a benefit for such treatments is emerging. An FDC containing a triptan and NSAID seems most likely to provide efficacy and tolerability benefits in the acute treatment of migraine. Such an FDC is in development but not yet approved for use.

Analgesics, Opioid↗
PubMed2004

Medicolegal issues in cluster headache.

This paper identifies legal issues of relevance to the diagnosis and treatment of cluster headache, including areas of actual and potential malpractice liability. Legal topics that are relevant to cluster headache can be divided into five categories: diagnostic-related issues, risks inherent in the disease process, prescribing and treatment-related problems, research-related issues, and disability determination.

Cluster Headache↗
PubMed2004

Migraine diagnosis and treatment.

Migraine is a prevalent condition that causes significant disability in otherwise healthy persons. Diagnosis is clinical, based on recognition of a constellation of signs and symptoms. Treatment includes nonpharmacologic management, including lifestyle alterations,abortive treatment of individual attacks, and preventive medications for patients with frequent or troublesome attacks. Guidelines are available that summarize the quality of evidence for individual interventions, but treatment must be individualized.

Analgesics↗
PubMed2004

Efficacy and tolerability of oral zolmitriptan in menstrually associated migraine: a randomized, prospective, parallel-group, double-blind, placebo-controlled study.

BACKGROUND: Approximately 60% of female migraineurs report experiencing migraine in association with menstruation, while 7% to 25% experience attacks almost exclusively with menstruation. OBJECTIVE: To examine the efficacy and tolerability of oral zolmitriptan in the acute treatment of menstrually associated migraine. In this study, menstrually associated migraine was defined as migraine that consistently occurred from 72 hours before to 5 days after onset of menses. Methods.-Participants were women with regular menstrual cycles, aged 18 to 55 years, who had experienced migraine with at least two thirds of prior menstrual cycles. Subjects were randomized to treat one attack per menstrual cycle for 3 months with either zolmitriptan or placebo. Treatment was intensity based: mild migraines were treated with half of a 2.5-mg zolmitriptan tablet, moderate migraines were treated with zolmitriptan 2.5 mg, and severe migraines were treated with 5 mg (two 2.5-mg tablets) of zolmitriptan, or placebo. RESULTS: Of the 579 women enrolled in the study, 260 were treated with zolmitriptan and 251 were assigned placebo. Twelve hundred thirty-two attacks were treated, and a 2-hour headache response was achieved in 48% of zolmitriptan-treated attacks as compared with 27% of placebo-assigned attacks (P <.0001). Zolmitriptan was superior to placebo in achieving a headache response as early as 30 minutes (18% versus 14%, P=.03) and at 1 hour (33% versus 23%, P <.001). Drug-related adverse events were reported in 16% of subjects receiving zolmitriptan and 9% of subjects receiving placebo. CONCLUSION: Oral zolmitriptan exhibits efficacy and good tolerability in the treatment of menstrually associated migraine. Improvement over placebo was observed as early as 30 minutes following treatment.

Adolescent↗
PubMed2003

Oral phenobarbital loading: a safe and effective method of withdrawing patients with headache from butalbital compounds.

BACKGROUND: The overuse of short-acting barbiturate medications for the acute treatment of headache is a common problem in the United States. Most experts agree that withdrawal from these medications is necessary for subsequent headache treatment to be successful, yet there are few published articles outlining effective methods of drug withdrawal. OBJECTIVE: To evaluate the safety and effectiveness of phenobarbital loading for withdrawal from overuse of short-acting barbiturate compounds in inpatients with headache. DESIGN AND METHODS: We performed a retrospective chart review of 18 consecutive patients in an inpatient pain rehabilitation program who were withdrawn from overuse of butalbital-combination medications using a phenobarbital-loading protocol. RESULTS: Eighteen patients with headache hospitalized in an inpatient pain unit for withdrawal from overuse of combination butalbital preparations underwent a phenobarbital-loading protocol. Short-acting barbiturate medications were discontinued, and patients received 120 mg of oral phenobarbital until their score on a predetermined scale reached target levels, and the drug was then discontinued. All patients were effectively treated with no serious adverse events. The median number of doses required varied significantly, and could not be predicted by the patient's prior intake. CONCLUSIONS: Management of butalbital withdrawal can be simplified by using a phenobarbital-loading protocol, taking advantage of the natural tapering afforded by the drug's long half-life. This method possesses most of the characteristics of an ideal drug withdrawal program for patients with headache who are overusing medications.

Administration, Oral↗
PubMed2003

Who will prescribe? A proposal for specialized opioid management clinics.

There is currently no uniform system of providing care for patients with chronic nonmalignant pain who require ongoing opioid maintenance therapy. Some patients receive care in a general practice setting, while others are managed in pain clinics where opioid management is only one of many services provided. Current events involving increased abuse and diversion of opioid medications suggest the need for improved case management and coordination when opioids are used for chronic nonmalignant pain. Based on the model of anticoagulation clinics, the author proposes the development of specialized opioid management clinics. These clinics would: 1) evaluate patient-specific risks and benefits of therapy; 2) supervise the mechanics of opioid prescribing; 3) provide systematic and secure monitoring of patient adherence to therapy; 4) assess goals of therapy and progress towards them; 5) coordinate opioid treatment with other pain-related treatment; 6) supply education to patients, family members and caregivers about the appropriate use of opioids; 7) maintain communication with other caregivers and pharmacists; and 8) provide regular psychological assistance and support for patients.

Journal Article↗
PubMed2003

Rehabilitation hospital staff knowledge and attitudes regarding pain.

No published studies exist that document pain-related knowledge, attitudes, or educational needs of clinical staff in a rehabilitation hospital; the purpose of this study was to obtain such information to aid in the development of an institutional pain care improvement project. A survey regarding knowledge and attitudes about pain and perceived areas of educational need was administered to all staff with inpatient care responsibilities. Results show that rehabilitation hospital staff hold generally progressive attitudes toward the treatment of pain but with a substantial degree of ambivalence about the use of opioids in the treatment of pain. Staff rate their own lack of education about pain management as one of the chief barriers to effective pain management, and a large percentage report feeling uncomfortable with various technical aspects of pain care. We discuss the implications of this survey for understanding and improving pain care in rehabilitation settings.

Analgesics↗
PubMed2003

Safety of sumatriptan in pregnancy: a review of the data so far.

The high prevalence of migraine in women during their reproductive years means that new drug treatments for migraine, such as the serotonin 5-HT(1B/1D) receptor agonists (the 'triptans'), are likely to be widely used by women of childbearing potential. Scrutiny of these agents in an effort to detect any signal of teratogenicity is thus important. A systematic review of the medical literature was conducted to identify information regarding the safety of sumatriptan during pregnancy. This agent was chosen to be investigated because it has been available for the longest and is the most widely used of the triptan class. Information was obtained regarding the impact of migraine on pregnancy outcome, and data on sumatriptan use in pregnancy were obtained from animal studies, preclinical drug trials, postmarketing surveillance efforts, prospective pregnancy registries, national birth registries and teratogen information services. Synthesis of information from these sources is sufficient to rule out a large increase in birth defects from sumatriptan use during pregnancy and is reassuring for cases where inadvertent exposure to sumatriptan during pregnancy has occurred. However, current information is not sufficient to rule out small increases in the risk for birth defects. For this reason, caution should be exercised in making a positive recommendation for the use of sumatriptan during pregnancy.

Animals↗
PubMed2002

Prophylaxis of menstrual migraine with triptans: problems and possibilities.

Menstruation is a prominent, predictable attack trigger for many women with migraine. If abortive therapy of menstrual attacks is ineffective, prophylactic therapy is used to prevent attacks or render them shorter and less resistant to acute therapy. Interest is increasing in the use of triptan medications for the prophylaxis of menstrual migraine, and clinical trials to evaluate this approach are underway. Potential problems with triptan prophylaxis of menstrual migraine that deserve attention include the lack of consensus on the definition of menstrual migraine and the difficulty in making a reliable diagnosis of the disorder. Unconvincing demonstrations of efficacy and unresolved cost and safety concerns should temper enthusiasm for their use in this manner. Further studies, using a consistent definition of menstrual association and employing diary validation of the diagnosis, are needed to determine the efficacy of the triptans in women who consistently experience migraine attacks associated with menstruation. Triptans would have to show compelling advantages over other therapy to be a plausible prophylactic treatment for menstrual migraine.

Adult↗