[Update on collaborative autopsy-based research in German pathology, neuropathology, and forensic medicine]

BACKGROUND

Autopsies are a valuable tool for understanding disease, including COVID-19.

MATERIALS AND METHODS

The German Registry of COVID-19 Autopsies (DeRegCOVID), established in April 2020, serves as the electronic backbone of the National Autopsy Network (NATON), launched in early 2022 following DEFEAT PANDEMIcs.

RESULTS

The NATON consortium's interconnected, collaborative autopsy research is enabled by an unprecedented collaboration of 138 individuals at more than 35 German university and non-university autopsy centers through which pathology, neuropathology, and forensic medicine autopsy data including data on biomaterials are collected in DeRegCOVID and tissue-based research and methods development are conducted. More than 145 publications have now emerged from participating autopsy centers, highlighting various basic science and clinical aspects of COVID-19, such as thromboembolic events, organ tropism, SARS-CoV‑2 detection methods, and infectivity of SARS-CoV-2 at autopsy.

CONCLUSIONS

Participating centers have demonstrated the high value of autopsy and autopsy-derived data and biomaterials to modern medicine. The planned long-term continuation and further development of the registry and network, as well as the open and participatory design, will allow the involvement of all interested partners.

Headache service quality: the role of specialized headache centres within structured headache services, and suggested standards and criteria as centres of excellence

In joint initiatives, the European Headache Federation and Lifting The Burden have described a model of structured headache services (with their basis in primary care), defined service quality in this context, and developed practical methods for its evaluation.Here, in a continuation of the service quality evaluation programme, we set out ten suggested role- and performance-defining standards for specialized headache centres operating as an integral component of these services. Verifiable criteria for evaluation accompany each standard. The purposes are five-fold: (i) to inspire and promote, or stimulate the establishment of, specialized headache centres as centres of excellence; (ii) to define the role of such centres within optimally structured and organized national headache services; (iii) to set out criteria by which such centres may be recognized as exemplary in their fulfilment of this role; (iv) to provide the basis for, and to initiate and motivate, collaboration and networking between such centres both nationally and internationally; (v) ultimately to improve the delivery and quality of health care for headache.

Therapy susceptible germline-related BRCA 1-mutation in a case of metastasized mixed adeno-neuroendocrine carcinoma (MANEC) of the small bowel

Background

Adenocarcinomas or combined adeno-neuroendocrine carcinomas (MANEC) of small bowel usually have a dismal prognosis with limited systemic therapy options. This is the first description of a patient showing a germline-related BRCA1 mutated MANEC of his ileum. The tumor presented a susceptibility to a combined chemotherapy and the PARP1-inhibitor olaparib.

Case presentation

A 74-year old male patient presented with a metastasized MANEC of his ileum. Due to clinical symptoms his ileum-tumor and the single brain metastasis were removed. We verified the same pathogenic (class 5) BRCA1 mutation in different tumor locations. There was no known personal history of a previous malignant tumor. Nevertheless we identified his BRCA1 mutation as germline-related. A systemic treatment was started including Gemcitabine followed by selective internal radiotherapy (SIRT) to treat liver metastases and in the further course Capecitabine but this treatment finally failed after 9 months and all liver metastases showed progression. The treatment failure was the reason to induce an individualized therapeutic approach using combined chemotherapy of carboplatin, paclitaxel and the Poly (ADP-ribose) polymerase- (PARP)-inhibitor olaparib analogous to the treatment protocol of Oza et al.

All liver metastases demonstrated with significant tumor regression after 3 months and could be removed. In his most current follow up from December 2017 (25 months after his primary diagnosis) the patient is in a very good general condition without evidence for further metastases.

Conclusion

We present first evidence of a therapy susceptible germline-related BRCA1 mutation in small bowel adeno-neuroendocrine carcinoma (MANEC). Our findings offer a personalized treatment option. The germline background was unexpected in a 74-year old man with no previously known tumor burden. We should be aware of the familiar background in tumors of older patients as well.

Classification of Headaches

It was not until 1962 that the Ad-Hoc Committee of the National Institute of Health first published a classification of headache syndromes by brief glossary definitions. The general disadvantage of such glossary definitions is that they require subjective interpretation. Therefore under the chairmanship of Prof. Jes Olesen, Copenhagen, the International Headache Society published in 1988 on the basis of empirical findings a first ever headache classification using operationalized criteria. The headache classification of the International Headache Society was immediately translated into the world's major languages and was adopted by all national headache societies represented in the International Headache Society, the World Health Organisation and the World Federation of Neurology. The new classification proved so successful and enjoyed such rapid international acceptance that no revision was undertaken until 1999. The second edition, again under the chairmanship of Prof. Jes Olesen, will probably be completed in 2002. The classification produced such a high degree of inspiration and motivation of pathophysiological and epidemiological research work that knowledge in the field of headache has displayed growth unparalleled in any other field of neurological research. This development was made possible by the determined work of the Chairman of the Headache Classification Committee, Prof. Jes Olesen. He succeeded in bringing together international researchers, motivating them and jointly turning the current fund of knowledge into a evidence-based classification. Prof. Jes Olesen thus performed the decisive pioneering work for all those who have to do with headaches-patients, doctors and scientists. The IHS classification is the most frequently cited text and one of the most important milestones in the history of the scientific study of headaches.

Placebo-Controlled Comparison of Effervescent Acetylsalicylic Acid, Sumatriptan and Ibuprofen in the Treatment of Migraine Attacks

Acetylsalicylic acid (ASA) in combination with metoclopramide has been frequently used in clinical trials in the acute treatment of migraine attacks. Recently the efficacy of a new high buffered formulation of 1000 mg effervescent ASA without metoclopramide compared to placebo has been shown. To further confirm the efficacy of this new formulation in comparison with a triptan and a nonsteroidal anti-inflammatory drug (ibuprofen) a three-fold crossover, double-blind, randomized trial with 312 patients was conducted in Germany, Italy and Spain. Effervescent ASA (1000 mg) was compared to encapsulated sumatriptan (50 mg), ibuprofen (400 mg) and placebo. The percentage of patients with reduction in headache severity from moderate or severe to mild or no pain (primary endpoint) was 52.5% for ASA, 60.2% for ibuprofen, 55.8% for sumatriptan and 30.6% for placebo. All active treatments were superior to placebo ( P < 0.0001), whereas active treatments were not statistically different. The number of patients who were pain-free at 2 h was 27.1%, 33.2%, 37.1% and 12.6% for those treated with ASA, ibuprofen, sumatriptan or placebo, respectively. The difference between ASA and sumatriptan was statistically significant ( P = 0.025). With respect to other secondary efficacy criteria and accompanying symptoms no statistically significant differences between ASA and ibuprofen or sumatriptan were found. Drug-related adverse events were reported in 4.1%, 5.7%, 6.6% and 4.5% of patients treated with ASA, ibuprofen sumatriptan or placebo. This study showed that 1000 mg effervescent ASA is as effective as 50 mg sumatriptan and 400 mg ibuprofen in the treatment of migraine attacks regarding headache relief from moderate/severe to mild/no pain at 2 h. Regarding pain-free at 2 h sumatriptan was most effective.

Efficacy of Phenazone in the Treatment of Acute Migraine Attacks: A Double-Blind, Placebo-Controlled, Randomized Study

In this study we compared the efficacy of 1000 mg phenazone with that of placebo in the treatment of acute migraine attacks in a randomized double-blind, placebo-controlled study of 208 patients. The main target criterion was the number of patients with a pain reduction from severe or moderate to slight or no pain 2 h after taking the pain medication. The percentage of patients satisfying the main target criterion was 48.6% for phenazone and 27.2% ( P < 0.05) for placebo. Freedom from pain after 2 h was reported by 27.6% with phenazone treatment and 13.6% ( P < 0.05) with placebo. Compared with placebo, the phenazone treatment also resulted in a significant improvement in the associated migraine symptoms of nausea, phonophobia and photophobia. Of patients treated with phenazone 11.4%, and 5.8% of those treated with placebo reported adverse events. There was no significant difference between the groups with regard to numbers of patients with adverse events. No serious adverse events occurred. The results show that phenazone at a dosage of 1000 mg is effective and well tolerated in the treatment of acute migraine attacks.

[Classification and therapy of medication-overuse headache: impact of the third edition of the International Classification of Headache Disorders]

The diagnosis of medication-overuse headache (MOH) is of central importance because this secondary headache disorder can be treated very effectively and patients do not usually respond to headache prophylaxis as long as MOH persists. The article describes important changes in the diagnostic criteria of different MOH subtypes after publication of the International Classification of Headache Disorders (ICHD-3beta) in 2013. The new classification has a crucial and direct impact on prevention and treatment of MOH. In addition interactions exist with the new criteria of chronic migraine. With a controlled medication intake scheme according to the 10-20 rule and using a medication break, MOH usually remits in most patients. If patient education and advice does not lead to remission of MOH, a specialized managed medication break or withdrawal treatment becomes necessary. This can be done on an outpatient, day clinic or inpatient basis. In uncomplicated cases, the results of these three treatment settings do not differ. From a cost-effectiveness standpoint, the outpatient treatment should be given priority. In complicated cases, a fully inpatient withdrawal treatment using a multimodal treatment concept is significantly superior.

[Integrated headache care network. Kiel Migraine and Headache Center and German National Headache Treatment Network]

Migraine and other headaches affect 54 million people in Germany. They rank among the ten most severely disabling complaints and the three most expensive neurological disorders. Nevertheless, they are not adequately recognized in the healthcare system with sketchy diagnoses and inadequate treatment. This inadequate care is not primarily due to a lack of medical and scientific knowledge on the development and treatment of headaches but is predominantly due to organizational deficits in the healthcare system and in the implementation of current knowledge. To overcome the organizational barriers the national headache treatment network was initiated in Germany. For the first time it allows national cross-sectoral and multidisciplinary links between inpatient and outpatient care. A hand in hand treatment programme, better education, better information exchange between all partners and combined efforts using clearly defined treatment pathways and goals are the basis for state of the art and efficient treatment results. The treatment network is geared towards the specialized treatment of severely affected patients with chronic headache disorders. A national network of outpatient and inpatient pain therapists in both practices and hospitals works hand in hand to optimally alleviate pain in a comprehensive cross-sectoral and multidisciplinary manner. For therapy refractive disorders, a high-intensive supraregional fully inpatient treatment can be arranged. This concept offers for the first time a nationwide coordinated treatment without limitation by specialization and bureaucratic remuneration sectors.

[Lateral asymmetry of the human pain sensitivity.]

In repeated clinical studies a preponderance of pain syndromes on the left side of the body has frequently been observed. Experimental studies in humans revealed a lower pain threshold on the left, nondominant side. On the other hand, some studies do not confirm this lateralization. Since pain threshold is not a very valid measure of pain sensitivity in the range beyond threshold, and since clinical studies are limited by simply counting the incidence of the pain syndromes, we investigated whether a significant lateralization of pain sensitivity exists in the entire range beyond pain threshold. Handedness and gender were included as factors. For experimental pain stimulation in 24 subjects three different methods were used: local pressure on the middle phalanxes, a modified submaximal effort tourniquet test, and submerging the hands into cold water. For pain measurement beyond threshold we used the category splitting procedure (Heller).All three methods of stimulation produced corresponding results. Lefthanded subjects showed decreased pain sensitivity on the left side, right-handed subjects on the right side. This was true for the total range of pain sensitivity. For pain induced by pressure, lateral asymmetry increased with pain intensity, for the other two methods it was constant. Lateral asymmetry was found in all subjects, but significant differences could only be demonstrated in female Ss. It is concluded that both gender and handedness contribute to lateral asymmetry of pain sensitivity in man.

[Different headache forms of chapter 4 of the International Headache Classification]

Chapter 4 of the International Classification of Headaches contains a group of clinically very heterogeneous primary headache forms. Little is known about the pathogenesis of these headache types and therapy is usually based on isolated case reports and uncontrolled studies. The forms include primary stabbing headache, primary cough headache, primary exertional headache, primary headache associated with sexual activity, hypnic headache, primary thunderclap headache, hemicrania continua and the new daily persistent headache. Some of these headache forms may be of a symptomatic nature and require careful examination, imaging and further tests. Primary and secondary headache forms must be carefully distinguished.

[Botulinum toxin type A in the prophylactic treatment of chronic migraine]

Since the second edition of the International classification of headache disorders (ICDH-II 2004), chronic migraine has been listed amongst migraine complications. Compared to episodic migraine the prevalence of chronic migraine is low, its impact, however, significant. Until recently no prophylactic drug had been approved for chronic migraine prophylaxis. After case reports had stated an effect of botulinum toxin type A on migraine, several randomized placebo-controlled studies were conducted in episodic headache; the results, however, were disappointing. Only when botulinum toxin type A was used in chronic migraine in the PREEMPT (phase 3 research evaluating migraine prophylaxis therapy) trials, its superiority compared to placebo was established. Thus, for the first time a prophylactic drug against chronic migraine is available which is both effective and well tolerated. Botox® has been licensed in England for the prophylaxis of headaches in adults with chronic migraine in 2010. Approval for its use in Germany has been applied for.

The Migraine Intervention Score - a tool to improve efficacy of triptans in acute migraine therapy: the ALADIN study

BACKGROUND

The 'Migraine Intervention Score' (MIS) is a new self-administered scale that can be used to quantify the severity of specific migraine symptoms. The objective of this study was to determine if MIS could be used to improve the efficacy of frovatriptan 2.5 mg in the early treatment of migraine attacks for clinical practice.

METHODS

In this prospective observational study, patients suffering from migraines with or without aura were enrolled and permitted to choose the time of self-medication with frovatriptan 2.5 mg. At the time of intake of medication, patients evaluated the severity of individual migraine symptoms using MIS. The scores for each symptom were then totalled to provide an overall level of symptom severity. A total of 1620 patients completed the treatment of three migraine attacks with frovatriptan. A total of 1518 patients could be analysed with respect to the documented efficacy parameters of the third attack. Patients initiating treatment at low symptom severity levels were compared with those initiating treatment at high symptom severity levels.

RESULTS

Time to the achievement of the primary endpoint (headache response) was significantly lower in patients who initiated treatment at low vs. high symptom severity levels (42.06 ± 32.33 vs. 49.25 ± 34.92 min; p = 0.0023). Likewise, patients who initiated treatment at low symptom severity levels achieved complete headache relief more rapidly (79.37 ± 65.33 vs. 96.05 ± 100.85 min; p = 0.0109) and required escape medication less frequently (3.88% vs. 13.73%; p < 0.0001).

CONCLUSIONS

The initiation of attack treatment with frovatriptan at low severity of migraine symptoms is more effective than starting therapy at higher symptom levels. Together with the low recurrence headache rate, the decreased necessity for escape medication and the low number of tablets needed, these data demonstrate that operationalised intervention with frovatriptan 2.5 mg is a valuable method for improving the treatment of migraine attacks.

Integrated headache care

Patients with chronic or difficult to treat headaches are generally under the care of general practictioners or neurologists in private practice. Some are referred to a headache specialist for evaluation and advice. Treatment is often provided by the referring physician. An alternative is a multidisciplinary headache centre, where care is provided by different disciplines (neurology, behavioural psychology, psychiatry, psychosomatic medicine, physical therapy, sport therapy) across sectors of the healthcare system involving out- and inpatient care and treatment. This is called integrated headache care. This review summarizes experiences in integrated headache care settings in Europe and the USA, describes these settings, and reports outcome data.

[Development and implementation of integrated health care in pain medicine : the nationwide German headache treatment network]

Integrated care builds interdisciplinary networks across the different healthcare sectors. A conjoint effort toward clearly defined treatment goals is crucial for medically effective and economically efficient care. Allowing creativity in the implementation of integrated care triggers competition for more effective ideas and better solutions. Based on a summary of the development of integrated care and the example of the nationwide German headache treatment network, the successful organization and implementation of this cross-sectoral care within pain medicine is illustrated. An interdisciplinary nationwide network of pain therapists working hand in hand across the sectors, both in the outpatient and inpatient setting, and employing modern treatment regimens results in optimal pain relief. The treatment quality is assessed by continuous accompanying research and sustainable cost efficiency in all sectors of healthcare is confirmed through analysis of both direct and indirect costs. The project was started in May 2007. In the meantime, almost all large statutory health insurance providers in Germany have joined this healthcare project. The large treatment network confirms the significant clinical and economic efficiency of pain medicine. It demonstrates that coordinated modern therapy effectively relieves pain, lowers costs sustainably, and reduces sick leave. Patient satisfaction is very high. The healthcare providers may directly participate in treatment success through risk-sharing.

Tonabersat, a gap-junction modulator: efficacy and safety in two randomized, placebo-controlled, dose-ranging studies of acute migraine

Tonabersat is a novel benzopyran derivative that blocks the cortical spreading depression proposed to be associated with migraine attacks. The ability of single oral doses of 15, 25, 40 and 80 mg of tonabersat to relieve the symptoms of moderate to severe migraine was evaluated in 859 migraineurs enrolled in two dose-ranging, double-blind, randomized, placebo-controlled, parallel-group trials, one international and the other North American. In the international study, significantly more patients given tonabersat than given placebo experienced relief of headache pain at 2 h (15 mg, 36.8%; 40 mg, 40.7%), the principal efficacy variable, and at 4 h (40 mg, 63.0%) and complete abolition of headache at 4 h (40 mg, 34.3%). None of the primary or secondary efficacy variables indicated significant differences between tonabersat and placebo in the North American study. Tonabersat was generally well tolerated, with dizziness and nausea the most common side-effects. Serious adverse events were uncommon, and no patient withdrew from either study because of adverse events. These results suggest a possible interplay between tonabersat pharmacokinetics (the relatively long time required to reach maximum plasma concentrations) and patient characteristics (previous triptan exposure) in the management of acute migraine attacks. Based on the pharmacokinetics and actions on cortical spreading depression, tonabersat may have potential value in migraine prophylaxis.

Genetic association study of endothelin-1 and its receptors EDNRA and EDNRB in migraine with aura

The effect of endothelin-1 and its receptors EDNRA and EDNRB in migraine with aura (MA) susceptibility is not established yet. We studied the association between the MA end-diagnosis and three migraine trait components and 32 single nucleotide polymorphisms (SNPs) capturing the variation of endothelin genes in 850 Finnish migraine patients and 890 non-migrainous individuals. The SNPs showing evidence of association were further studied in 648 German migraine patients and 651 non-migrainous individuals. No significant association was detected. However, the homozygous minor genotype (5% in cases) of the EDNRA SNP rs2048894 showed nominal association with MA both in the Finnish sample (P = 0.015) and in the pooled sample [odds ratio (OR) 1.61, 95% confidence interval (CI) 1.12-2.32, P = 0.010] when adjusted for gender and sample origin. The trait age of onset < 20 years was also associated with rs2048894 (OR 1.69, 95% CI 1.13-2.54, P = 0.011) in the pooled sample. To confirm this finding studies on even larger samples are required.

[Pain therapy in addicted patients]

Each individual is entitled to an adequate and sufficient pain therapy. However, only a few studies have examined the peculiarities of pain management in drug-dependent or formerly addicted patients. Any addiction is disadvantageous for a successful pain therapy, since some of the prescribed drugs may themselves cause addiction. Drug-dependent patients are often tolerant to opioids. Additionally, there is a risk of iatrogenic pain becoming chronic due to disregard for already known risk factors and comorbidities. However, a history of addiction should not prevent sufficient pain therapy, especially since there is no risk of addiction when the pain therapy employed is adequate for the pathophysiology involved. There are adequate pain therapies for addicted patients. The best results are achieved by taking into account the physiological and psychological peculiarities of drug-dependent patients. Importantly, this should be combined with a variety of different, optimized, multimodal therapeutic regimes, as well as with an interdisciplinary approach.

Proposals for new standardized general diagnostic criteria for the secondary headaches

Headache classification is a dynamic process through clinical testing and re-testing of current and proposed criteria. After publication of the second edition of the International Classification of Headache Disorders (ICHD-II), need arose for revisions in the classification of medication overuse headache and chronic migraine. These changes made apparent a further need for broader revisions to the standard formulation of diagnostic criteria for the secondary headaches. Currently, the fourth criterion makes impossible the definitive diagnosis of a secondary headache until the underlying cause has resolved or been cured or greatly ameliorated by therapy, at which time the headache may no longer be present. Given that the main purpose of diagnostic criteria is to enable a diagnosis at the onset of a disease in order to guide treatment, this is unhelpful in clinical practice. In the present paper we propose maintaining a standard approach to the secondary headaches using a set of four criteria A, B, C and D, but we construct these so that the requirement for resolution or successful treatment is removed. The proposal for general diagnostic criteria for the secondary headaches will be entered into the internet-based version of the appendix of ICHD-II. During 2009 the Classification Committee will apply the general criteria to all the specific types of secondary headaches. These, and other changes, will be included in a revision of the entire classification entitled ICHD-IIR, expected to be published in 2010. ICHD-IIR will be printed and posted on the website and will be the official classification of the International Headache Society. Unfortunately, it will be necessary to translate ICHD-IIR into the many languages of the world, but the good news is that no major changes to the headache classification are then foreseen for the next 10 years. Until the printing of ICHD-IIR, the printed ICHD-II criteria remain in place for all other purposes. We issue a plea to the headache community to use and study these proposed general criteria for the secondary headaches in order to provide more evidence for their utility-before their incorporation in the main body of the classification.

[Headache and facial pain in the elderly]

Whilst headache disorders belong to the most common health problems of the younger population, the occurrence diminishes with advancing age. However, in individual cases headaches may be especially severe in old age significantly reducing the quality of life. Typical causes of headache in the elderly are giant cell arteritis (arteritis temporalis), cranial neuralgia and hypnic headache. The incidence of intracranial mass lesions also increases with age. In addition to these secondary forms of headache, the typical primary headache disorders migraine, tension headache and cluster headache may also persist in the elderly. In drug treatment of headaches in the elderly, an impairment of renal and/or hepatic function has to be taken in account, as should be the potential multimorbidity of elderly patients.

[Classification of headache disorders]

In 2003 the International Headache Society (IHS) published the second edition of the International Classification of Headache Disorders. Diagnostic criteria for no less than 206 separate headache diagnoses are presented in the parts (I) primary headaches, (II) secondary headaches and (III) cranial neuralgia, central and primary facial pain. The headaches are classified according to the etiology in case of the secondary headaches and according to the phenomenology in case of the primary headaches. It is the task of the headache specialist to identify the correct headache diagnose with the smallest effort possible. Both, the differentiation between secondary and primary headaches and the differentiation between the various primary headaches are of equal importance.

[Acetylsalicylic acid in self-medication of migraine. A pharmacy-based observational study]

BACKGROUND

The aim of the study was to investigate the efficacy and tolerability of acetylsalicylic acid in the treatment of acute migraine attacks by self-medication under daily life conditions when bought in a pharmacy and also the ability of patients to self-diagnose correctly.

METHODS

A total of 296 patients were recruited from 156 pharmacies and recorded up to 3 migraine attacks. Following an advisory discussion the pharmacists gave a questionnaire to persons who had purchased acetylsalicylic acid (Aspirin Migraine) in the pharmacy to treat migraine. A total of 578 questionnaires containing 36 questions about demographic details, headache phenotype, medical history, efficacy over 2 h and tolerability of the preparation were analyzed.

RESULTS

The IHS criteria (1988) for migraine were identified correctly by 92.7% of the patients. In 66.3% of the attacks, the intensity of the headache was reported as severe. In 60% of the documented attacks, a decrease from severe or moderate to mild or no headache was recorded after medication, and freedom from headache was achieved in 35.8%. The effect was reproducible over 3 migraine attacks. Nausea, photophobia and phonophobia were reduced by 71-86% compared to the baseline level. Side-effects were reported twice as often by the participants in response to closed questions than to open questions (16.6 vs. 8.3%).

CONCLUSION

A high percentage of migraine patients are capable of diagnosing their condition themselves when they seek advice in a pharmacy. The data on efficacy confirm the results from controlled clinical studies. The same parameters as those used in controlled clinical studies can also be recorded in pharmacy-based observational studies, therefore, the safety and tolerability of the medication can be recorded under real conditions.

Variation of the serotonin transporter gene SLC6A4 in the susceptibility to migraine with aura

To replicate a reported association between migraine with aura (MA) and a promoter polymorphism in the serotonin transporter gene (SLC6A4), we performed a case-control study in a large German sample comprising 472 patients with MA and 506 controls. Neither this polymorphism nor a systematic analysis with single nucleotide polymorphisms capturing the main haplotype diversity of the SLC6A4 locus provided evidence for a contribution of SLC6A4 to the predisposition of complex inherited MA.

[Prophylactic measures and acute treatment of migraine]

The treatment of migraine consists of the acute treatment of the migraine attack and prophylactic measures for either pharmacological or non-pharmacological management. Since the retreat of the ergotamines one can only choose between one of the well-established analgesics and one of seven triptans for the treatment of the migraine attack. Although neither a new triptan nor an innovative new application form has been introduced, the year 2006 will be remembered as the year when the first triptan (naratriptan) was released as a prescription-free over-the-counter drug and when the first sumatriptan generics were marketed in Germany. In addition to the beta-blockers metoprolol and propranolol and the calcium antagonist flunarizine two antiepileptic drugs, topiramate and valproic acid, have been rated as first-line prophylactic drugs in Germany. Due to an extensive and successful study program topiramate has been officially approved in Germany.

Botulinum toxin type A in the prophylactic treatment of chronic tension-type headache: a multicentre, double-blind, randomized, placebo-controlled, parallel-group study

We studied the safety and efficacy of 0 U, 50 U, 100 U, 150 U (five sites), 86 Usub and 100 Usub (three sites) botulinum toxin type A (BoNTA; BOTOX); Allergan, Inc., Irvine, CA, USA) for the prophylaxis of chronic tension-type headache (CTTH). Three hundred patients (62.3% female; mean age 42.6 years) enrolled. For the primary endpoint, the mean change from baseline in the number of TTH-free days per month, there was no statistically significant difference between placebo and four BoNTA groups, but a significant difference favouring placebo vs. BoNTA 150 was observed (4.5 vs. 2.8 tension headache-free days/month; P = 0.007). All treatment groups improved at day 60. Although efficacy was not demonstrated for the primary endpoint, at day 90, more patients in three BoNTA groups had >or=50% decrease in tension headache days than did placebo (P <or= 0.024). Most treatment-related adverse events were mild or moderate, and transient. BoNTA was safe and well-tolerated in the study.