Biomedical subjects
Publications and source records attributed to S D Silberstein.
Sphenoid sinusitis, an uncommon cause of headache, is associated with significant morbidity. A 30-year-old man presented with a progressive intractable headache and aseptic meningitis. Failure to recognize sphenoid disease on brain CT delayed diagnosis; treatment with i.v. antibiotics resolved the disorder.
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Migraine is an episodic headache disorder that occurs with or without aura and is often accompanied by other symptoms. Treatment must address these associated symptoms as well as the headache, and it can involve either acute or preventive therapy alone or a combination of both. Acute therapy treats the individual attack; preventive therapy aims to reduce the frequency and severity of attacks. Drug choice requires careful consideration and depends on the character of the migraine attack. Acute drug therapy using sumatriptan, MK-462, 311C90, dihydroergotamine, nonsteroidal anti-inflammatory drugs, butorphanol, metoclopramide, and domperidone is discussed. Prophylactic drug therapy using valproate and fluoxetine is also discussed.
Epidemiologic studies provide estimates of the scope and distribution of the public health problems posed by migraine. These studies have been facilitated by the development of the International Headache Society criteria for migraine, which have now been used in separate prevalence studies in several countries. In this article, we review some of the methodological challenges in studying migraine epidemiology, report recent results from studies using IHS criteria, and suggest directions for future research.
Tension-type headache is the term designated by the International Headache Society to describe what was previously called tension headache, muscle contraction headache, psychomyogenic headache, stress headache, ordinary headache, and psychogenic headache. The International Headache Society defines tension-type headache more precisely, distinguishes between the episodic and the chronic varieties, and divides them into two groups, those associated with a disorder of the pericranial muscles and those not associated with this type of disorder. Most clinic-based studies of tension-type headache suffer from selection bias, as they include patients with more severe headaches, patients with concomitant migraine, and patients with chronic daily headache. Traditionally, episodic tension-type headache and migraine have been considered distinct disorders, and the International Headache Society continues the separation. Some believe that both migraine and tension-type headache are recurring benign headaches. Chronic tension-type headache used to be called chronic daily headache, but they are not identical. Chronic tension-type headache must be distinguished from chronic daily headache even though the International Headache Society has not done this. Chronic daily headache is a syndrome consisting of a group of disorders and can be subclassified into primary and secondary types. The primary chronic daily headache disorders include transformed migraine, chronic tension-type headache, new daily persistent headache, and hemicrania continua. Secondary causes of chronic daily headache include post-traumatic headache, cervical spine disorders, and headache associated with vascular disorders and nonvascular intracranial disorders. Patients with frequent headaches are prone to overuse analgesics, ergotamine, or both. Most patients with chronic daily headache overuse symptomatic medication.(ABSTRACT TRUNCATED AT 250 WORDS)
This study is the first double-blind placebo-controlled trial of fluoxetine for chronic daily headache (CDH) and migraine. After a one month single-blind baseline on placebo, subjects with CDH (n = 64) and migraine (n = 58) were randomly assigned to a three month trial of fluoxetine (20 mg) or an identical placebo. Fluoxetine and placebo were increased to 40 mg in the second month, depending on patient response. Patients kept daily headache records, and completed 100 mm visual analogue scales (VAS) of headache and mood each month. For the group of CDH patients on fluoxetine, overall headache status (VAS) after three months compared to the end of the single-blind placebo baseline improved a mean of 50% vs. 11% for those receiving the double-blind placebo (P = .029), with 47% vs. 23% improving at least 50% (P = .097, n.s.). Fluoxetine patients showed significant improvement in monthly mood ratings compared to placebo (.001 by the end of the study), and modest but significant improvement in daily records of headache frequency (P = .019) but not pain severity. Significant mood improvements preceded improvement in headache, reaching significance by the end of the second month on fluoxetine (P = .013), while headache improvement emerged only during the third month (P = .001). Double-blind investigator judgement identified more headache improvement in fluoxetine than placebo recipients (40% vs. 22%, P = .032).(ABSTRACT TRUNCATED AT 250 WORDS)
For a specific subgroup of patients with migraine or affective illness who experience illness progression and drug tolerance, the amygdala kindling paradigm can be a useful, but nonhomologous, model. Although these patients do not have a seizure or seizure-like disorder, kindling has been used to examine the types of memory-like mechanisms that could underlie syndrome evolution in both migraine and affective illness. While the precipitants, symptomatology, duration of attack, and aura symptoms differ among epilepsy, migraine, and the affective disorders, all are paroxysmal dysregulations that partially share effective drug treatment. The principles of seizure progression presented here may apply to affective and migraine patients whose episodes progress from isolated and intermittent to more chronic or daily. These patients may also develop tolerance to long-term prophylactic treatments.
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Optimal migraine therapy begins with an accurate diagnosis and knowledge of the symptoms that the patient finds most disturbing. Pharmacologic treatment of migraine may be acute (abortive, symptomatic) or preventive (prophylactic); both approaches are frequently required in patients with frequent, severe headaches. Drugs for acute care consist of analgesics, antiemetics, anxiolytics, nonsteroidal anti-inflammatory drugs, ergots, steroids, major tranquilizers, narcotics, and selective serotonin agonists. Preventive agents include beta-blockers, calcium channel blockers, antidepressants, serotonin antagonists, and anticonvulsants. The choice of a preventive drug depends on side effect profiles and comorbid conditions. Behavioral interventions, such as biofeedback and relaxation techniques, are an important complement to pharmacologic therapy; however, drugs are the mainstay of migraine therapy. To ensure that therapy achieves optimal results, the individual patient's preferred approach to this debilitating problem must be considered carefully.
A variety of evidence suggests a link between migraine and the female sex hormones. Women with migraine outnumber men by at least a 2:1 ratio and definite patterns of development and attacks are noted at menarche and throughout the period of menses, related to trimester of pregnancy, and again at menopause, although it may also regress. Hormonal replacement with estrogen can exacerbate migraine; oral contraceptives can change the character and frequency of migraine headache. This article will cover approaches to the therapy of hormone-related headaches associated with the menstrual cycle, menopause, and oral contraceptives.
Lumbar puncture is crucial in two distinct clinical situations in the diagnosis of the headache patient. The first is the patient who is suspected of having a symptomatic headache; the second is the patient with a chronic intractable or atypical headache disorder. This review discusses the usefulness of the lumbar puncture in the diagnosis of headache secondary to subarachnoid hemorrhage, meningitis, and intracranial hypotension and hypertension. The value of lumbar puncture in the presence of a normal CT/MRI scan is discussed.
Headache management requires a comprehensive strategy that includes accurate diagnosis, reassurance and education of the patient, nonpharmacologic methods of preventing attacks, and appropriate use of prophylactic and abortive medications. Personal input from the physician and judicious selection of headache medications are crucial. Implementation of such a strategy gives patients greater ability to control and cope with their headaches.
Throughout history writers have attempted to describe the symptoms and evoke the misery of "a dismal headache." Writers from Plato to Stephen King have used the phenomenology of headache to illustrate their work. Lewis Carroll, for example, vividly describes the central scotoma, tunnel vision, phono-phobia, vertigo, distortions in body image, dementia and visual hallucinations that often accompany migraine. Although many authors have discussed the topic seriously, others have addressed the issue in a dismissive and even contemptuous manner, relegating this very real disorder to the status of a medical stepchild. We will examine headache etiology, triggers and treatment and explore the attitudes toward headache and headache sufferers found in literature. We have recently seen a growing understanding of the physiological basis of headaches. However, this knowledge has not yet reached the level of literature or popular culture. In an age when it seems every Sunday night brings a new "disease of the week" movie, and every human ill is subjected to often intense and numbing scrutiny by the media, the anguish of a chronic migraine sufferer will probably remain unexplored--unless she kills her husband and children during an attack.
The Regional Migraine Field Trial assessed the efficacy and safety of dihydroergotamine mesylate (D.H.E. 45) for migraine in the office setting. Patients were admitted to the study provided they met the International Headache Society definition of migraine with or without aura. Thirty-eight neurologists enrolled 311 patients (274 women and 37 men) between the ages of 13 and 70 years in this open-design study. Ninety-five percent of the patients had moderate or severe headache pain at entry, and 62% had nausea. All patients received a single intramuscular injection of D.H.E. 45 1 mg. A second intramuscular injection of 1 mg was given 60 minutes after the first injection, if needed. An antiemetic was administered concomitantly with D.H.E. 45, if needed. Rescue therapy was given at the investigators' discretion. Efficacy was judged by the relief of pain, patients' ability to function, need for a second injection, need for rescue medication, and need for an antiemetic. At 30 and 60 minutes, 46% and 72% of patients had only mild or no head pain, respectively. At 24 hours, 77% of all patients had mild or no head pain. D.H.E. 45 also improved functional ability. At 30 and 60 minutes, 58% and 75% of patients had only mild or no disability, respectively. At 24 hours, 81% had mild or no impairment. Nausea was present in 62% of patients at the outset, 40% of patients at 30 minutes, and 30% at 60 minutes. An antiemetic was given to 43% of patients at the outset. The presence of nausea was similar whether or not patients received an antiemetic.(ABSTRACT TRUNCATED AT 250 WORDS)
Hemicrania continua (HC) is a rare, strictly unilateral, nonparoxysmal headache disorder characterized by its absolute responsiveness to indomethacin. The pain is usually moderate in intensity and frequently associated with a superimposed "jabs and jolts" headache. We report two cases of HC which presented as chronic daily headache (CDH) with abortive medication overuse. CDH can be due to transformed migraine (TM), new daily persistent headache (NDPH), chronic tension-type headache, and HC. All can be unilateral, and all can be associated with medication overuse. Our two cases meet the criteria for HC based on indomethacin responsiveness. One meets the criteria for TM, the other NDPH. Is HC a distinct disorder, or a subset of these other disorders? CDH with medication overuse includes in its differential diagnosis HC.
Migraine epidemiology presents methodological challenges, partially simplified by the use of the new International Headache Society (IHS) Classification. Most previously published migraine studies were clinic-based, which introduces bias since less than 5% of migraineurs consult specialists. A series of population-based studies of migraine prevalence and incidence, based on the new operational IHS criteria, are now available and are reviewed, along with the migraine personality, comorbid psychiatric conditions and neuropsychological impairment. Migraine headaches are now divided into those with aura (classic migraine) and those without aura (common migraine). Headache occurs in about 91% of men and 96% of women, migraine occurs in about 6% of men and 18% of women (one-year prevalence). Migraine is most common in the third decade of life and in lower socioeconomic groups. It is associated with an increased prevalence of depression and panic attacks.
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