Syndrome of spontaneous intracranial hypotension.
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Humans↗
Biomedical subjects
S D Silberstein
Publications and source records attributed to S D Silberstein.
Safety of divalproex sodium in migraine prophylaxis: an open-label, long-term study. Long-term Safety of Depakote in Headache Prophylaxis Study Group.
CONTEXT: The adverse event profile of long-term divalproex therapy for epilepsy is well established, but little is known about the tolerability or safety of divalproex in long-term migraine prophylaxis. OBJECTIVE: Evaluate the long-term safety and efficacy of divalproex sodium in migraine prophylaxis. DESIGN: Open-label, long-term study, of up to 3 years, of patients who completed one of two multicenter, double-blind, randomized, placebo-controlled studies. SETTING: Eighteen headache/neurology centers throughout the United States. PATIENTS: One hundred sixty-three patients: 46 treated with placebo, 117 treated with divalproex for migraine in previous studies. INTERVENTION: Divalproex therapy initiated at 500 mg/day (250 mg twice daily), with adjustment in dose and dosing frequency possible after 1 to 3 days. MAIN OUTCOME MEASURES: Number and proportion of patients reporting treatment-emergent adverse events, prevalence and incidence for each treatment-emergent adverse event, vital signs, body weight, 4-week migraine rates and proportion of patients with 50% or greater reduction in rate over time. RESULTS: Treatment lasted more than 180 days for 71% of patients and more than 360 days for 48% of patients. Improvements in the 4-week, change-from-baseline migraine rates were seen during each of the 3- and 6-month time intervals. CONCLUSIONS: Divalproex is effective for migraine prophylaxis, and initial benefits are maintained for periods in excess of 1080 days.
Adult↗
Menstrual migraine.
Migraine in women is influenced by hormonal changes throughout the life cycle: menarche, menstruation, oral contraceptive use, pregnancy, menopause, and hormonal replacement therapy (HRT). Based on clinical experience, the frequency of menstrual migraine has been reported to be as high as 60%-70%. Most women have increased headache and migraine attacks (usually without aura) at the time of menses. Attacks occurring only with menstruation, even if infrequent, are called true menstrual migraine. Attacks occurring both at menstruation and at other times of the month could be called "menstrually triggered migraine." Menstrual migraine occurs at the time of the greatest fluctuation in estrogen levels. Estrogen withdrawal is probably the trigger for migraine attacks in susceptible women. Drugs that are proven effective or commonly used for the acute treatment of menstrual migraine include nonsteroidal anti-inflammatory drugs (NSAIDs), dihydroergotamine, the triptans, and the combination of aspirin, acetaminophen, and caffeine. The goal of standard continuous preventive therapy is to reduce the frequency, duration, and intensity of attacks. Preventive therapy may eliminate all headaches except those associated with menses. Women already using prophylactic medication who continue to have menstrual migraine can increase the dose of their medication prior to their menses. Women who do not use preventive medicine or have migraine exclusively with their menses can be treated perimenstrually with short-term prophylaxis. If severe menstrual migraine cannot be controlled by acute and preventive treatment, hormonal therapy may be indicated.
Adult↗
Drug-induced headache.
Headaches are extremely common and have various causes. Drugs may initiate a new type of headache or exacerbate a preexisting headache disorder. Medication withdrawal or rebound headaches may also occur. This article reviews the possible relationships between drugs and headaches.
Acute Disease↗
Post-lumbar puncture headache.
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Headache↗
Methysergide.
Methysergide is a semisynthetic ergot alkaloid ergometrine derivative, introduced in pharmacotherapy for migraine prophylaxis as a specific serotonin (5HT) receptor antagonist. Methysergide is not just a 5HT2 antagonist, it is also a 5HT1 agonist. Open and controlled studies attest to methysergide's efficacy. It may be more effective in resistant cases with a high attack frequency and may act synergistically with ergotamine and dihydroergotamine (DHE) for breakthrough attacks. Contraindications include pregnancy, peripheral vascular disorders, severe arteriosclerosis, coronary artery disease, severe hypertension, thrombophlebitis or cellulitis of the legs, peptic ulcer disease, fibrotic disorders, lung diseases, collagen disease, liver or renal function impairment, valvular heart disease, debilitation, or serious infection. Methysergide can induce retroperitoneal fibrosis and pleural and heart valve fibrosis with an estimated incidence of 1 in 5,000 treated patients. Therefore, it should be reserved for severe cases in which other migraine preventive drugs are not effective.
Humans↗
Comprehensive management of headache and depression.
Migraine is a highly prevalent episodic headache disorder. When migraine and depression occur together, therapeutic opportunities, as well as limitations, exist. The effective treatment of both migraine and depression begins with making an accurate diagnosis and explaining it to the patient. Behavioral interventions, such as maintaining a regular schedule, getting adequate sleep and exercise, and giving up tobacco, are often useful. In addition, patients with comorbid depression often need supportive psychotherapy. Patients with depression often need antidepressant therapy independent of their migraine attack frequency. Although the mechanism of antidepressants in headache prophylaxis is unknown, it is not the result of treating masked depression. Preventive migraine medication is usually given daily to decrease the frequency of migraine attacks. For the patient with migraine and depression, use an antidepressant. While tricyclic antidepressants may be more effective for migraine, selective serotonin reuptake inhibitors are just as effective for depression and have fewer side effects. For the patient with migraine and epilepsy, or migraine and manic depressive illness, divalproex sodium is the drug of choice. Drug combinations are commonly used for patients with refractory headache disorders. Some combinations, such as antidepressants and beta-blockers, are suggested even in depressed patients.
Depression↗
Idiopathic intracranial hypertension without papilledema: a case-control study in a headache center.
OBJECTIVE: To compare the clinical features of patients with chronic daily headache (CDH) with idiopathic intracranial hypertension without papilledema (IIHWOP) to those with normal CSF pressure. METHODS: A case-control study was conducted at a tertiary headache center. Cases consisted of 25 consecutive patients (24 women, 1 man, 38 +/- 6 years) with IIHWOP diagnosed between June 1989 and June 1996. IIHWOP was diagnosed if pressure was 200 mm CSF on two occasions and there was no papilledema. Control subjects consisted of patients with refractory CDH who had normal CSF pressure on lumbar puncture performed between June 1992 and June 1996 (n = 60, 50 women, 10 men, 36 +/- 11 years). A structured telephone follow-up was done from July 1996 to March 1997. Comparisons made between the two groups included demographics and headache profiles, both at the initial evaluation and at follow-up. RESULTS: The initial headache characteristics did not differ between the two groups: most had transformed migraine with analgesic overuse. Significant predictors of IIHWOP included pulsatile tinnitus (odds ratio [OR] = 13.0) and obesity (OR = 4.4). Visual symptoms did not differ significantly. The prognosis of the two groups of patients was similar. CONCLUSIONS: Pulsatile tinnitus and obesity suggest possible IIHWOP in patients with CDH. Treatment of patients with increased intracranial pressure was not satisfactory.
Adult↗
Migraine: a "woman's disease?".
Migraine, a chronic disorder characterized by episodes of headache, has a profound effect on the well-being and general functioning of its victims, not only during the acute attacks, but also in terms of impairment of school achievement, work performance, and family/social relationships. Despite staggering social and economic costs, it remains under-diagnosed and under-treated worldwide. Migraine has been labeled a "woman's disease" because it is three times more common in women than men, the attacks tend to be more severe and disabling among women and, in some women, they seem to be modulated by such hormonal "milestones" as menarche, menstruation, pregnancy and menopause. After a brief review of the diagnosis of migraine, this article will examine the nuances responsible for that label and their implications for treatment.
Female↗
Migraine and pregnancy.
Migraine and tension-type headache are primary headache disorders that occur during pregnancy. Migraine sometimes occurs for the first time with pregnancy. Most migraineurs improve while pregnant; however, migraine often recurs postpartum. Some disorders that produce headache, such as stroke, cerebral venous thrombosis, eclampsia, and SAH, occur more frequently during pregnancy. Diagnostic testing serves to exclude organic causes of headache, to confirm the diagnosis, and to establish a baseline before treatment. If neurodiagnostic testing is indicated, the study that provides the most information with the least fetal risk is the study of choice. Although drugs are used commonly during pregnancy, there is insufficient knowledge about their effects on the growing fetus. Most drugs are not teratogenic. Adverse effects, such as spontaneous abortion, development defects, and various postnatal effects, depend on the dose and route of administration and the timing of the exposure relative to the period of fetal development. Although medication use should be limited, it is not absolutely contraindicated in pregnancy. In migraine, the risk of status migrainosus may be greater than the potential risk of the medication use to treat the pregnant patient. Nonpharmacologic treatment is the ideal solution; however, analgesics, such as acetaminophen and narcotics, can be used on a limited basis. Preventive therapy is a last resort.
Diagnosis, Differential↗
Preventive treatment of migraine: an overview.
The pharmacologic treatment of migraine may be acute (abortive, symptomatic) or preventive (prophylactic). Most migraine preventive medications were designed to treat other disorders (e.g., propranolol for hypertension, valproate for epilepsy, etc.). Preventive medication is usually given daily for months or years; however, treatment can be episodic, subacute, or chronic. The medications can be divided into two major categories: (i) Alternatives of high efficacy, which include beta-blockers, tricyclic antidepressants, and divalproex, and of lower efficacy, which include selective serotonin reuptake inhibitors, calcium channel antagonists, and non-steroidal antiinflammatory drugs, and (ii) second-line choices of high efficacy, which include methysergide and monoamine oxidase inhibitors. The choice of preventive treatment depends on the individual drug's efficacy and side effects, the patient's wants, needs, and response to prior treatment, and the presence of any comorbid or coexistent disease.
Humans↗
The rise and fall of estrogen levels.
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Estrogens↗
Ineffectiveness of neurokinin-1 antagonist in acute migraine: a crossover study.
Lanepitant is a high-affinity, selective neurokinin-1 receptor (NK-1) and is effective in the dural inflammation model of acute migraine. Lanepitant 30, 80, and 240 mg given orally was evaluated in a double-blind, placebo-controlled crossover study to determine its effect in reducing migraine pain and severity of associated symptoms. Outpatients treated four migraine headaches of moderate or severe pain intensity with study drug according to a randomization schedule. They recorded their pain intensity and severity of migraine-associated symptoms at 30, 60, 90, and 120 min. Although 53 patients were randomly allocated to a treatment sequence, only 40 patients completed all treatments. There was no statistically significant difference in improvement in migraine pain at any time for any of the treatments. Additionally, there was no change in severity of migraine-associated symptoms associated with lanepitant therapy. No adverse events could be attributed to lanepitant. Lanepitant was ineffective orally in treating acute migraine in this trial. This may be due to poor bioavailability during a migraine attack. Alternatively, the neurogenic inflammation hypothesis may not apply to migraine.
Acute Disease↗
Improvement in migraine-specific quality of life in a clinical trial of rizatriptan.
A validated migraine-specific questionnaire (24-h Migraine Quality of Life Questionnaire: 24-h MQoLQ) was used to assess the impact of migraine and migraine therapy on health-related quality of life during an acute migraine attack. Male and female migraineurs aged 18-55 years were randomized to placebo (n=41), rizatriptan 2.5 mg (n=47), 5 mg (n=74), or 10 mg (n=85) in a triple-blind, placebo-controlled clinical trial. Rizatriptan 5 mg and 10 mg were significantly more efficacious than placebo on pain relief and functional disability. After accounting for multiple comparisons to placebo, rizatriptan 10 mg showed significantly better responses compared to placebo on three of five domains of 24-h MQoLQ (social functioning, migraine symptoms, and feelings/concerns). The O'Brien's Rank Sum Test statistic showed a statistically significant overall difference on the 24-h MQoLQ between the 10 mg rizatriptan and placebo groups (p=0.005) and for the overall dose trend (p< or =0.001).
Adult↗
Paroxysmal headache caused by colloid cyst of the third ventricle: case report and review of the literature.
Colloid cysts of the third ventricle are benign tumors that may cause brief, severe headache and, rarely, death. We present a patient with frequent, episodic, brief, severe headaches of 2 weeks' duration who suddenly became obtunded. We reviewed the literature on the symptomatology of colloid cysts and conclude that any patient with less than a 1-year history suggestive of a third ventricular colloid cyst causing brief, severe headaches should be aggressively investigated.
Adult↗
Droperidol treatment of status migrainosus and refractory migraine.
We conducted a pilot study of intravenous droperidol in 35 patients (32 women and 3 men; mean age 43 years) with status migrainosus (n = 25) or refractory migraine (n = 10) in an ambulatory infusion center. Headache was graded as severe in 21 patients and moderate in 14. An intravenous line was started and kept open. Droperidol (2.5 mg) was given intravenously every 30 minutes until either three doses were given or the patient was completely or almost headache-free prior to the next dose. Seven patients received one dose, 12 received two doses, and 16, three doses (mean 5.6 mg). Our success rate (headache-free or mild headache) was 88% (22 of 25) in patients with status migrainosus and 100% (10 of 10) in patients with refractory migraine. The average time to headache improvement was 40 minutes (n = 35), to mild headache--60 minutes (n = 32), and to headache-free--105 minutes (n = 28). Nausea, vomiting, and light and sound sensitivity resolved in all but 5 patients. Four patients had an asymptomatic systolic blood pressure drop > or = 20 mm Hg. Most patients were sedated (34 of 35). Five patients developed akathisia and 1 dystonia. At follow-up 24 hours after discharge, the recurrence rate (headache intensity from none or mild to moderate or severe) was 23% in status migrainosus and 10% in refractory migraine. Twenty-one patients were sedated, while 19 had extrapyramidal symptoms, mainly restlessness. Droperidol is effective and safe in treating status migrainosus or refractory migraine. Hypotension was uncommon. Patients should be warned of sedation and akathisia.
Adolescent↗
Migraine treatment.
Migraine is a primary headache disorder characterized by recurring attacks of pain and associated symptoms. Migraine sufferers require a continuum of clinical care that depends on their disability and response to treatment. Treatment consists of: (1) prevention of attacks by avoidance of triggers; (2) the use of nonpharmacologic treatments; (3) treatment of the acute attack; and (4) long-term prophylactic therapy. Migraine is comorbid for affective disorders, epilepsy, stroke, and mitral valve prolapse. The therapy selected depends on the headache severity and frequency, the pattern of associated symptoms, comorbid illnesses, and the patient's treatment response profile. Acute treatment can be symptomatic or specific, using drugs such as dihydroergotamine (DHE) or sumatriptan. Preventive treatment can be episodic, subacute, or chronic. The major drug groups include beta-adrenergic blockers, anti-depressants, calcium channel blockers, serotonin antagonists, anticonvulsants, and nonsteroidal anti-inflammatory drugs (NSAIDs). These can be divided into two major categories and second-line choices.
Analgesics↗
Unilateral hypnic headache: a case study.
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Aged↗