Clinical Features of Migraine: A Cross-Sectional Study in Patients Aged Three to Sixty-Nine

We investigated 260 consecutive patients classified as migraine cases aged 3-69 at two tertiary headache centres, one for children and adolescents and the other for adults to evaluate the relationship between age and clinical features of migraine cross-sectionally. We only included subjects with definite migraine without or with aura and we excluded subjects with coexisting tension-type headache, medication overuse and/or other clinically relevant disorders. The percentage of males decreased markedly from childhood to adulthood and this affected the evalution of age-related changes in male patients, as only large differences reached the level of statistical significance. In females, the headache duration and the prevalence of unilateral, pulsating pain, photophobia and phonophobia increased, whereas the prevalence of aggravation by physical activity decreased with age. In conclusion, this cross-sectional, clinic-based study on a strictly defined sample of 260 consecutive patients with definite migraine covering a wide range of age from the very young to the old suggests marked age-related differences of the clinical features of migraine in females and failed to demonstrate similar differences in males due to the small number of adult male migraineurs.

Facial pain in a Neurological Tertiary Care Centre — Evaluation of the International Classification of Headache Disorders

The aim of this study was to examine the diagnostic spectrum of facial pain and to evaluate the clinical features relevant to the differential diagnosis in a neurological tertiary care centre. This is the first investigation comparing the first with the second edition of the International Classification of Headache Disorders (ICHD-I, ICHD-II) in consecutively referred patients comprising a broad spectrum of disorders without restricting the inclusion to certain diagnoses. Studying 97 consecutive patients referred for facial pain, we found trigeminal neuralgia or other types of cranial neuralgia in 38% and 39% according to ICHD-I and ICHD-II, respectively; persistent idiopathic facial pain was diagnosed in 27% and 21%, respectively. The proportion of patients who could not be classified was 24% in ICHD-I and 29% in ICHD-II. Six per cent of the patients had cluster headache or chronic paroxysmal hemicrania, the remaining 5% had various other disorders. The agreement between ICHD-I and ICHD-II was very good to perfect. In ICHD-II, sensitivity and specificity were similar to ICHD-I, the specificity and negative predictive value were imrpoved in single features of trigeminal neuralgia, but were widely unchanged in persistent idiopathic facial pain. The number of patients who could not be classified was larger in ICHD-II than in ICHD-I. Modifying the diagnostic criteria for different types of facial pain, in particular changes in the criteria of persistent idiopathic facial pain, might be helpful in reducing the number of patients with unclassifiable facial pain.

Prospective Analysis of Factors Related to Migraine Attacks: The PAMINA Study

Migraine is related to numerous factors such as hormones, stress or nutrition, but information about their actual importance is limited. Therefore, we analysed prospectively a wide spectrum of factors related to headache in migraineurs. We examined 327 migraineurs recruited via newspapers who kept a comprehensive diary for 3 months. Statistical analysis comprising 28 325 patient days and 116 dichotomous variables was based on the interval between two successive headache attacks. We calculated univariate Cox regression analyses and included covariables with a P-value of <0.05 in two stepwise multivariate Cox regression analyses, the first accounting for a correlation of the event times within a subject, the second stratified by the number of headache-free intervals. We performed similar analyses for the occurrence of migraine attacks and for the persistence of headache and migraine. Menstruation had the most prominent effect, increasing the hazard of occurrence or persistence of headache and migraine by up to 96%. All other factors changed the hazard by <35%. The two days before menstruation and muscle tension in the neck, psychic tension, tiredness, noise and odours on days before headache onset increased the hazard of headache or migraine, whereas days off, a divorced marriage, relaxation after stress, and consumption of beer decreased the hazard. In addition, three meteorological factors increased and two others decreased the hazard. In conclusion, menstruation is most important in increasing the risk of occurrence and persistence of headache and migraine. Other factors increase the risk less markedly or decrease the risk.

Sequential MRI in a case of Creutzfeldt-Jakob disease

A 48-year-old man suddenly developed clinically and electroencephalographically nonspecific dementia. On MRI sequences, only diffusion-weighted images (DWI) of the cortex were unequivocally pathological. Obvious atrophy and basal ganglia signal changes appeared only 9 months after the onset. Brain biopsy confirmed Creutzfeldt-Jakob disease (CJD). In rapidly progressive dementia, we recommend DWI for early diagnosis of CJD.

Are there predictive factors for long-term outcome after withdrawal in drug-induced chronic daily headache?

OBJECTIVES

To investigate prognostic factors for long-term outcome of patients after inpatient withdrawal because of drug-induced chronic daily headache.

PROCEDURES

Fifty-five patients (36 females) were re-examined by means of a standardized interview after inpatient withdrawal. The mean observation period was 9.28 +/- 2.85 years (mean +/- SD; median 8.58; range 5.00-13.50).

RESULTS

Five years after withdrawal, one-third of the patients (34.6%) had an overall favourable outcome, one-third (32.7%) had no recurrent drug overuse and reported a clear-cut improvement of headache, and one-third (32.7%) developed recurrent drug overuse. Most relapses occurred within 2 years, and a small percentage within 5 years. No predictors for long-term outcome after inpatient withdrawal were found.

CONCLUSIONS

All patients with drug-induced chronic daily headache should be considered as good candidates for inpatient withdrawal, and no patient should be excluded from that therapy.

A dose-defining study of sumatriptan suppositories in the acute treatment of migraine

In this dose-ranging, randomised, multinational, multicentre, double-blind, placebo-controlled, parallel group study, 431 patients treated a single migraine attack with study medication: sumatriptan suppository 6 mg, 12.5 mg, 25 mg, 50 mg, 100 mg, or placebo. Patients were treated in the clinic with a single dose in suppository form. All doses of sumatriptan, except 6 mg, were significantly better than placebo (p < 0.004) and achieved similar rates of headache relief within two hours of dosing. The highest response rate was in the 25 mg group (72%) compared with placebo (37%) (p < 0.001). Fewer patients required rescue medication in the active groups (1% 100 mg to 13% 6 mg) compared with placebo (17%), and more patients were able to work and function normally two hours after dosing (41%, 100 mg; 20%, placebo). The overall incidence of adverse events was similar in the placebo, 6 mg and 12.5 mg groups (14-17%) but higher in the 25 mg, 50 mg and 100 mg groups (25%, 32% and 29% respectively). Analysis of plasma sumatriptan levels indicated rapid rectal absorption for all doses (median tmax = 1.0 hr). It is concluded that sumatriptan, in doses above 6 mg, is an effective and well tolerated treatment for acute migraine. From this study doses of 12.5 mg and 25 mg sumatriptan were identified as having the best efficacy/safety profile and were evaluated further.

Cardiac effects of sumatriptan: findings of Holter monitoring and review of the literature

The aim of this study was to elucidate possible electrocardiographic effects of sumatriptan in a selected group of patients with severe headache requiring in-patient treatment. The patients (n = 21) were treated with sumatriptan in addition to various other compounds and were asked to record any symptoms following the administration of sumatriptan. In addition, Holter monitoring was performed in all subjects. In agreement with other studies, the adverse events reported by the patients were not related to ECG changes and, vice versa, ECG changes were not accompanied by clinical symptoms. The Holter findings before and after administration of sumatriptan were significantly different in three patients, i.e. recurrent episodes of ST depression and increase in extrasystoles. These changes occurred within a period of 1.45 to 18 hours and were not reproducible when Holter monitoring was repeated without sumatriptan. Even though the findings might be explained by spontaneous variability of Holter monitoring or other factors, this study does not definitely discount the possibility that sumatriptan may cause ST segment changes and increase pre-existing extrasystoles. Controlled studies are required to clarify this issue.

Long-term outcome of patients with headache and drug abuse after inpatient withdrawal: five-year follow-up

Thirty-eight patients with "chronic daily" headache and ergotamine and/or analgesics abuse according to the criteria proposed by the International Headache Society were re-investigated 5 years after inpatient drug withdrawal. At the end of the observation period, 19 patients (50.0%) had their headaches on only 8 days per month or less, 18 patients (47.4%) were free of symptoms or had only mild headaches. A close correlation was found between the frequency of headache and the duration of drug abuse, as well as between the intensity of headache and the number of tablets taken per month. Frequency and intensity of headache had changed within the first 2 years after withdrawal, but remained stable afterwards. Fifteen patients (39.5%) reported on recurrent drug abuse. Patients with migraine showed a tendency towards a better prognosis compared to patients with tension-type headache or with combined migraine and tension-type headache. The results of this study highlight the long-term efficacy of inpatient drug withdrawal in patients with headache and ergotamine and/or analgesics abuse.

Magnesium in the prophylaxis of migraine--a double-blind placebo-controlled study

The migraine prophylactic effect of 10 mmol magnesium twice-daily has been evaluated in a multicentre, prospective, randomized, double-blind, placebo-controlled study. Patients with two to six migraine attacks per month without aura, and history of migraine of at least 2 years, were included. A 4-week baseline period without medication was followed by 12 weeks of treatment with magnesium or placebo. The primary efficacy end-point was a reduction of at least 50% in intensity or duration of migraine attacks in hours at the end of the 12 weeks of treatment compared to baseline. With a calculated total sample size of 150 patients, an interim analysis was planned after completing treatment of at least 60 patients, which in fact was performed with 69 patients (64F, 5M), aged 18-64 years. Of these, 35 had received magnesium and 34 placebo. The number of responders was 10 in each group (28.6% under magnesium and 29.4% under placebo). As determined in the study protocol, this was a major reason to discontinue the trial. With regard to the number of migraine days or migraine attacks there was no benefit with magnesium compared to placebo. There were no centre-specific differences, and the final assessments of treatment efficacy by the doctor and patient were largely equivocal. With respect to tolerability and safety, 45.7% of patients in the magnesium group reported primarily mild adverse events like soft stool and diarrhoea in contrast to 23.5% in the placebo group.

Cyclandelate in the prophylaxis of migraine: a randomized, parallel, double-blind study in comparison with placebo and propranolol. The Study group

Cyclandelate inhibits calcium-induced contraction of vascular smooth muscle cells, platelet aggregation induced by thrombin, platelet-activating-factor and adenosine, and also suppresses a provoked 5HT release from platelets. This pharmacological profile suggests that cyclandelate may have a potential prophylactic effect in migraine. To test this hypothesis, a double-blind multicentre study was performed in 214 patients to investigate the efficacy and tolerability of cyclandelate compared to placebo and propranolol. After a 4-week baseline period, eligible patients (randomization 3:2:3) were treated for 12 weeks with daily doses of 1.200 mg cyclandelate (n = 81), placebo (n = 55) or 120 mg propranolol (n = 78). The number of migraine attacks (> or = 50% responders) and the migraine duration/month were compared based on the difference between baseline and the last 4 weeks of prophylactic treatment. The percentage of patients with a reduction in migraine attacks of > or = 50% treated with cyclandelate (37.0%) or propranolol (42.3%) was not significantly superior to placebo (30.9%; p > 0.025). The mean duration of migraine in hours (h) per month decreased in both active treatment groups (cyclandelate: 36.8 h, p = 0.046; propranolol: 34.4 h, p = 0.039) compared to placebo (13.7 h) without reaching statistical significance (alpha/2 = 0.025). The clinical efficacy of cyclandelate and propranolol was comparable. Adverse experiences were reported by 13 patients (16.0%) treated with cyclandelate, by 5 patients (9.1%) treated with placebo and by 19 patients (24.4%) treated with propranolol. These were drug-related in 7.1% (n = 6) of patients treated with cyclandelate and in 9% (n = 7) of patients treated with propranolol. In summary, cyclandelate has a comparable efficacy to that of propranolol, an established drug of first choice in the prophylaxis of migraine. Both drugs were better than placebo, but not significantly so. Both active treatments were well tolerated.

[Sumatriptan--side effects and problems in routine clinical practice]

AIM

The study tried to investigate the efficacy, adverse events and possible risk factors of sumatriptan in daily clinical practice.

PATIENTS AND METHODS

72 outdoor patients, who had treated their headaches at least once with sumatriptan, partly prescribed to them by outdoor physicians, were asked about their experiences with the drug. According to the criteria of the International Headache Society (1988) 55 patients were suffering from migraine, 11 from cluster headache and 6 from tension-type headache.

RESULTS

Migraine and cluster patients rated the drug as effective as described in literature. Adverse events were reported by 69% of the patients which was more frequent than in most clinic studies described. Adverse events were usually not serious and transient. They were reported significantly more often by migraine patients than by patients with cluster headache and might not all be correlated to the therapy of sumatriptan.

CONCLUSION

Sumatriptan has shown to be effective in the treatment of an acute migraine- and cluster-headache. The risk as to severe adverse events, especially cardial adverse events, exists if contraindications for sumatriptan are not considered. Sumatriptan should therefore only be prescribed to carefully diagnosed migraine and cluster headache patients. It should, however, not be given to patients suffering from drug abuse, because they might just change over to sumatriptan.

Improvement of decreased critical flicker frequency (CFF) in headache patients with drug abuse after successful withdrawal

A considerable proportion of headache patients fulfill the criteria of "drug abuse" (definition according to the International Headache Society [IHS] criteria). These patients exhibit markedly reduced vigilance and continuous performance, as shown by the results of critical flicker frequency (CFF) analysis. The present study deals with the question whether this impairment of vigilance and continuous performance is reversible. Forty-eight headache patients with drug abuse were investigated three times by means of CFF analysis: immediately before (A), immediately after (B), and 3 weeks after having finished (C) inpatient drug withdrawal. Immediately after withdrawal, a significant decrease of headache intensity was observed. The CFF values, however, remained unchanged at a depressed level, probably due to withdrawal medication and the initial sedative side effects of thymoleptic agents (given as prophylaxis). Three weeks after withdrawal, however, the CFF values were significantly improved, and were now within a range not far from the normal values known from a healthy general population. Thus, even after many years of drug abuse, headache patients have a good chance to improve their vigilance and continuous performance and to reach normal or close to normal levels.

D2 receptor blockade by flunarizine and cinnarizine explains extrapyramidal side effects. A SPECT study

Twenty-six patients under treatment with the calcium channel blockers flunarizine (Fz) or cinnarizine (Cz) were examined-with single-photon emission computed tomography using [123I]iodobenzamide as a ligand. The striatal dopamine D2 receptor-binding potential was determined and found to be reduced by 14 to 63% (39.5 +/- 15.0%; p < 0.0001) in patients compared with age-matched control values. This reduction was larger in 12 patients with extrapyramidal symptoms and was only slowly reversible after discontinuation of treatment. Patients treated for > 6 months had significantly larger reductions than patients treated for a shorter period. Parkinsonian symptoms were only seen in patients older than 50 years. Our findings prove a neuroleptic-like action of Fz and Cz, which seems to be the major reason for their extrapyramidal side effects. Older age and long-term treatment are predisposing factors for these effects.

[Drug therapy of migraine--a review of the literature]

The medical treatment of migraine has two objective points: therapy for treating symptoms of an acute attack and prophylactic therapy for reducing frequency and severity of migraine attacks. A number of different therapeutic approaches for a symptomatic and a prophylactic therapy exists. The following article tries to give a survey of possible treatment strategies of migraine published within the last three years.

MMPI and critical flicker frequency (CFF) analysis in headache patients with and without drug abuse

Sixty-three headache patients (migraine: n = 28; tension-type headache: n = 35) who fulfilled the IHS criteria of 'drug abuse' were investigated by means of the Minnesota Multiphasic Personality Inventory (MMPI) and the Critical Flicker Frequency (CFF) analysis. The results were compared to those of 63 headache patients without drug abuse (matched-pair case-control study). With respect to the MMPI results, no statistically significant differences between patients with drug abuse and patients without drug abuse were found. However, patients with drug abuse showed significantly decreased CFF values compared to patients without drug abuse. This was true both for patients with migraine and for patients with tension-type headache. Thus, CFF analysis may serve as a useful method to differentiate between headache patients with drug abuse and those without drug abuse.

Dopamine D2 receptor blockade and antimigraine action of flunarizine

We studied in vivo the influence of flunarizine on dopamine D2 receptors and investigated whether dopamine D2 receptor blockade is involved in its antimigraine action. Eleven migraine patients, treated with flunarizine, 10 mg per day, underwent single photon emission computer tomography (SPECT) using [123I] labeled iodobenzamide, a ligand with high affinity and high specificity for D2 receptors. There was a reduction of the dopamine D2 receptor binding potential in all patients compared to age-matched controls. The efficacy of flunarizine in migraine prophylaxis failed to correlate with the degree of the dopamine D2 receptor blockade. The antimigraine action of flunarizine may not involve antidopaminergic mechanisms.

Use and abuse of analgesics in tension-type headache

Eighty patients suffering from tension-type headache for an average of 21 years were asked to report on all drugs they had ever taken (type, dosage, duration of intake, efficacy) or were taking currently. The patients had consumed on average 6.3 different drugs. The cumulative doses of derivatives of para-aminophenol, pyrazolone, and salicylic acid in some cases reached a maximum of several kilograms. Most drugs were classified by the patients as "moderately effective". The rating "very effective" was assigned primarily to barbiturates; however, barbiturates are no longer used as components of compound analgesic drugs in Austria. At the time of investigation, patients consumed 2.5 (mean) different drugs, primarily as compound preparations. Seventeen patients (21%) showed signs of possible analgesics- or ergotamine-induced headache and were therefore advised to undergo withdrawal therapy. Our results show that patients with tension-type headache are at considerable risk of becoming drug-dependent and of acquiring analgesics-induced headache.

Efficacy and tolerability of amitriptylinoxide in the treatment of chronic tension-type headache: a multi-centre controlled study

Amitriptyline is the medication of first choice in the treatment of chronic tension-type headache. In 197 patients with chronic tension-type headache (87M and 110F with a mean age of 38 +/- 13 (18-68)) efficacy and tolerability of 60-90 mg amitriptylinoxide (AO) were compared with 50-75 mg amitriptyline (AM) and placebo (PL) in a double-blind, parallel-group trial consisting of a four weeks' baseline phase and 12 weeks of treatment. The primary study endpoint was a reduction of at least 50% of the product of headache duration and frequency and a reduction of at least 50% in headache intensity. Statistics used were Fisher's exact test and analysis of variance. No significant difference emerged between AO, AM and PL with respect to the primary study endpoint. Treatment response occurred in 30.3% of the AO, 22.4% of the AM and 21.9% of the PL group. A reduction in headache duration and frequency of at least 50% was found in 39.4% on AO, in 25.4% on AM and in 26.6% on PL (PAO-PL = .1384, PAM-PL = 1.000, PAO-AM = .0973). A reduction in headache intensity of at least 50% was found in 31.8% on AO, in 26.9% on AM and in 26.6% on PL (PAO-PL = .5657, PAM-PL = 1.000, PAO-AM = .5715). Trend analysis with respect to a significant reduction of headache intensity (p < 0.05) and the product of headache duration and frequency revealed a superior effect of AO.(ABSTRACT TRUNCATED AT 250 WORDS)

[SUNCT syndrome--case report and review of the literature]

The SUNCT syndrome is a recently described headache disorder characterised by shortlasting, unilateral headache attacks with conjunctival injection and tearing. Our report presents a further case and compares the findings in our patient with those in the cases described earlier. In addition, we review the literature and discuss possible aetiological and pathogenetic factors as well as the differential diagnosis of SUNCT syndrome, trigeminal neuralgia and cluster headache syndromes.

[Effectiveness and tolerance of amitriptyline oxide in chronic tension headache--a multicenter double-blind study versus amitriptyline versus placebo]

Tricyclic antidepressants, especially amitriptyline, are the medication of first choice in the treatment of chronic tension headache. Few previous studies meet modern standards of study design and statistical analysis. Tolerability and efficacy of 60-90 mg amitriptyline oxide (AO) as a single dose in the evening were compared with 50-75 mg amitriptyline (AM) and placebo (PL) in a double-blind, parallel-group trial consisting of a 4-week baseline phase and 12 weeks of treatment. The 3-armed study was conducted in 7 centers. The inclusion criterion was tension-type headache on at least 15 days monthly with a duration of at least 6 months. Exclusion criteria were a migraine history, previous participation in another clinical trial within the last 3 months, drug abuse, medication with other antidepressants or tranquilizers, current use of other acknowledged prophylactic headache medication, lack of compliance, major psychiatric disorder according to DSM-III and medical contra-indications against tricyclic antidepressants. The primary study endpoint was a reduction at least 50% of the product of headache duration and frequency and a reduction at least 50% in headache intensity. Statistics used were Fisher's Exact Test and an analysis of variance. A total of 211 patients were included in this trial. One hundred ninety-seven cases, 87 males and 110 females, with a mean age of 38 +/- 13 (18-68) years, could be analysed completely (66 AO, 67 AM, 64 PL). With regard to the strictly defined primary study endpoint, no significant difference emerged between AO, AM and PL: treatment responders were 30.3% with AO, 22.4% with AM and 21.9% with PL (PAO-PL = 0.3210, PAM-PL = 1.000, PAO-AM = 0.3299 respectively).(ABSTRACT TRUNCATED AT 250 WORDS)

Tension headache and the cervical spine--plain X-ray findings

The aim of the present study was to investigate if there is any causal connection between plain X-ray findings of the cervical spine and tension headache. We evaluated the X-rays of the cervical spine of 243 patients, in 91 of which the diagnosis was "tension headache", in 102 "headache not fulfilling the criteria of tension headache" and in 50 "spondylogenic complaints without headache". We compared these three groups with regard to frequency and severity of radiologically assessable changes of the cervical spine and found that patients with tension headache had normal findings significantly more often and significantly less often functional or organic changes or both than patients of the other two groups. The radiologically assessable changes of the cervical spine are unlikely to have an essential role in the cause or mechanism of tension headache.

Long-term results of migraine prophylaxis with flunarizine and beta-blockers

We followed-up 64 migraine patients after discontinuation of successful interval prophylaxis with flunarizine, propranolol or metoprolol, to investigate how long the therapeutic success would last, if further prophylaxis would be successful again, and what factors would influence the prognosis. We found that 16 out of 64 patients experienced a lasting reduction of migraine frequency, whereas 48 patients did improve initially, but later experienced a relapse. Further prophylaxis was effective in 29, poorly effective in 11, and ineffective in 8 of these patients; in 7 of the 8 non-responders prophylaxis was not changed. Negative prognostic factors were frequent attacks, a history of analgesic abuse and/or analgesic withdrawal therapy and ineffective previous prophylaxis. In conclusion, the therapeutic success decreases dramatically in the majority of patients several months after discontinuation of prophylaxis; further prophylaxis is more effective if the substance class is changed; increased analgesic intake is the most important prognostic factor. As a strategy for migraine prophylaxis we propose sequential changing of interval prophylaxis or--in patients with negative prognostic factors--long-term prophylaxis.

Thalamic ischemia in transient global amnesia: a SPECT study

We performed 99mTc-HMPAO SPECT in a patient during transient global amnesia and twice thereafter. SPECT during the attack showed a significant diminution of regional blood flow in the left thalamus and a less marked diminution in the right thalamus. Quantitative evaluation of global 99mTc-HMPAO uptake indicated a diffuse depression of cerebral blood flow. At follow-up to 40 days after the attack, global uptake and thalamic flow indices normalized, but there was a persistent reduction of left frontal flow values.

Subarachnoid hemorrhage of unknown etiology: early prognostic factors for long-term functional capacity

Forty-one patients suffering subarachnoid hemorrhage (SAH) of unknown etiology were re-investigated at an average of 91 months after the bleed to determine functional capacity. Nineteen patients were performing at their previous level of work, five were employed part-time, and four could not work due to the SAH. Five patients showed a moderate disability in activities of daily living but were not dependent on help, one patient was severely disabled, and two had died. There was one rebleed. Early prognosis of an unfavorable outcome was possible on the basis of three clinical variables on admission: a history of hypertension, a Hunt and Hess grade of greater than II, and the presence of focal neurological deficits. In addition, the presence of an organic mental syndrome at discharge was identified as a predictive factor for reduced functional capacity later on. Other clinical variables in the acute stage, including sex, age, history of headache, interval between SAH and admission, impaired consciousness, and cognitive deficits, were not related to a limited functional level. Residual neurological deficits and the Glasgow Outcome Scale score on discharge were also not predictive of restrictions in global functions evaluated by means of the Karnofsky Performance Scale status at follow-up review.

[The significance of EMG artefacts in isoelectric EEG]

Five potential organ donors showed muscle artefacts during isoelectrical EEG recording. The electromyographic examination revealed MUAP activity occurring as doublets, triplets and quadruplets. All patients had normal blood chemistry except reduced CO2 and increased O2 partial pressures. We assume that the recorded "tetaniform" muscle activity is due to hyperexcitability of the nerve membrane caused by artificial hyperventilation.

[24-hour blood pressure determination in Shy-Drager syndrome. A case report]

The case history is presented of a 57 year-old male patient suffering from the Shy-Drager syndrome. This syndrome was first described by G. M. Shy and G. A. Drager in 1960. The clinical manifestations are extrapyramidal, with Parkinsonian features, combined with severe orthostatic hypotension and failure of the autonomic nervous system. Apart from the standard clinical investigations in this condition, namely the orthostasis test and polygraphic recording of the EEG, ECG, breathing and blood pressure on the tilting table, additional non-invasive long-term determination of the blood pressure was carried out. This method allows simultaneous measurement of blood pressure and heart rate without appreciably interfering with the patient's daily activities.

Longterm prognosis of analgesic withdrawal in patients with drug-induced headaches

We studied long-term prognosis and prognostic variables for therapeutic outcome of analgesic withdrawal in 54 patients with drug-induced headaches. The duration of headache history was 21.9 +/- 12.8 years. Each patient took an average of 38.8 +/- 22.8 tablets or suppositories a week and an average of 2.5 distinct drugs. Most patients used drugs containing several components. Caffeine was contained in at least one drug in all cases, ergotamine in 80.0% and pyrazolone in 77.1%. All patients were admitted to the hospital for two weeks. The analgesics were discontinued abruptly and the withdrawal symptoms were alleviated by neuroleptics and neurotropics. During the second week of hospital stay we started a basic therapy with calcium antagonists or beta blockers in patients suffering from migraine initially and with tricyclic antidepressants, physical therapy or biofeedback in patients suffering from tension type headaches initially. At the end of the study (mean follow-up period = 16.8 +/- 13.6 months) 38 patients (70.1%) were evaluated. 76.3% of these patients had significantly reduced their analgesic intake, 60.5% had experienced a significant relief of headache both in intensity and frequency, and 23.7% were therapeutic failures. Analysis of the time course of relapse revealed the first six months after hospital discharge as the critical period determining long-term success. The variables tested for prognostic relevance (age, sex, duration of headache history, number of tablets or suppositories taken a week, organic mental syndrome, and type of initial headaches) were not statistically significant.

[Stress management in migraine]

The aim of this study was to investigate the physiological and psychological mechanisms underlying migraine, 21 patients with migraine, 21 healthy controls and a group of 21 asthmatics participated in the investigation. All patients and controls were female. Using flicker frequency analysis we determined unspecific cortical activation, whereas autonomic activation was measured by means of the skin conductance level and the skin conductance response. Furthermore, stress management was objectivated by a self-rating scale (SVF). Our findings suggest the hypothesis of inadequate regulation of autonomic especially sympathetic reactions, which along with inadequate stress overcoming mechanisms appear to be of importance in the triggering of migraine attacks.

[The distal portion of the ulnar nerve--recording technic and normal values]

Normal values for the distal portion of the ulnar nerve are proposed. In 52 normals without clinical symptoms of peripheral nerve lesion the following neurographic parameters were recorded on the right side and in 45 cases on the left side, too: distal latency wrist-hypothenar, compound action potential from hypothenar, distal latency wrist-M, adductor pollicis, compound action potential from the M. adductor pollicis, antidrome nerve conduction velocity wrist-digit V, difference of latencies M. adductor pollicis-hypothenar, difference of compound action potential hypothenar-M. adductor pollicis and side differences of these parameters. A linear regression analysis was performed to investigate the dependence of these parameters from age. Our normal values allow an exact localisation of peripheral lesions of the ulnar nerve (Loge de Guyon, Ramus volaris superficialis, Ramus profundus).

[On the problem of post-traumatic headache]

Posttraumatic headache is a general term for pain localized in the head or neck, occurring after head trauma and of varied aetiology and pathogenesis. In many cases one only finds a time-dependent relation to trauma, but no causal one. There is no uniform, typical "posttraumatic headache". The headaches are commonly caused by injury to scalp, cervical spine and intracranial structures. A reciprocal influence exists between these functionally disturbed structures and a relation to psychogenic factors, which are essential co-factors. Usually it is difficult to decide whether posttraumatic headaches are exclusively caused by organic or psychogenic factors. Probably both factors are involved to an individually different degree.

Unilateral stenosis of the vertebral artery--secondary finding with no prognostic relevance?

The outcome of 142 patients suffering from ischemic cerebral circulation disorders was followed up over a period of 33 months on average. The spontaneous course of 25 patients with unilateral, hemodynamically ineffective stenoses of the vertebral artery was compared with that of 107 patients without vertebral artery stenoses. Within the first 12 months, novel clinically manifest cerebrovascular events were observed in 16.0% of patients without vertebral artery stenosis (deaths 5.0%), but in only 4.3% of the patients with vertebral artery stenosis (no deaths). Within 30 months, only 2 of the 13 patients with vertebral artery stenosis had suffered a new cerebrovascular attack. At the end of the observation period, 39.3% of the patients without vertebral artery stenosis and 48.0% of the patients with vertebral artery stenosis were significantly disabled in their social life or had died. An additional unilateral hemodynamically irrelevant vertebral artery stenosis did not influence the rate of reinfarction or the remission of neurological deficits, independently of age, the degree of the circulatory disorder, the vascular territory involved, the presence of an organic psychosyndrome, or of additional stenoses in the carotid arteries. Consequently, a vertebral artery stenosis narrowing the vessel diameter to less than 1/3 is without prognostic relevance.

[Creutzfeldt-Jakob disease. Clinical aspects and diagnosis based on 2 cases]

The case histories are presented of two patients with Creutzfeldt-Jakob disease. The clinical diagnosis was confirmed on autopsy. A 51-year-old man and a 63-year-old woman developed--after a period of non-specific prodromal symptoms--a rapidly progressive dementia accompanied by cerebellar, pyramidal and extrapyramidal signs. The clinical features, the course of the disease and the results of investigations are discussed, as well as the differential diagnosis.

[Possibilities of early diagnosis of intracranial meningioma based on clinical symptoms]

In a retrospective study, 56 patients with intracranial meningiomas were investigated. The diagnosis was verified by computer tomography with subsequent selective cerebral angiography in all cases. At the time of admission, 62.5% of the patients had functional losses affecting the cranial nerves, 44% functional losses involving the long nerve tracts and 23.2% had cerebellar symptoms. Nonspecific clinical symptoms found comprised headaches in 61% of the patients; these were already present almost three and a half years before the final diagnosis. There was a marked organic psychological disorder in 50% of the patients which had already been present retrospectively for an average of 10 months. Cerebral convulsive attacks were present in 27% of the patients with partial convulsions (mainly of the "temporal lobe type") which had already been present for an average of 40 months before diagnosis; in the general tonic-clonic convulsions, the diagnosis was already made an average of six weeks after the first attack. These data show that nonspecific symptoms such as headaches, organic psychological disorders and cerebral convulsions may be early indicators for the presence of an intracranial space occupation and should be investigated further without delay.

[Prevention of migraine using flunarizine (results of a pilot study using Amalium)]

A short episode of focal cortical hypoxia seems to be the turning-point in the genesis of the migraine attack. This pathophysiological situation induces vascular changes according to the hypothesis of Wolff. Under such conditions some Ca-antagonists develop antihypoxic and antivasoconstrictive properties. The efficiency of Flunarizine as potent prophylactic drug in migraine therapy is well documented in many double-blind randomized studies versus placebo or other antimigrainous drugs. Based on the positive results of these studies, we liked to investigate the efficiency and tolerability of Flunarizine also in a sample on n = 44 adults Austrian patients recruited from the Headache-Ambulance of the Neurological Department, University of Vienna. After a 3 months treatment with Flunarizine, 10 mg daily, there was a drug free follow-up period of 4 to 12 months. After this time in 29 patients (66.6%) there was a decrease of attack frequency of more than 50%. 12 (27.3%) of them were completed free of attacks. Beside this, the intake of attack ameliorating drugs (ergotamine, analgetics) was markedly reduced. Treatment was well tolerated. Weight gain was observed in 20.3% of patients likely correlating with the therapeutic efficiency. Due to its efficiency, safety and its long-lasting therapeutic effect, Flunarizine appears to be a very suitable agent in the prophylaxis of migraine.

[Rare pathomorphologic findings in complicated migraine]

137 patients suffering from classical or complicated migraine were investigated in the Neurology Department of the University of Vienna between 1971 and 1984. 13 of these patients were found to have pathological alterations and their case histories are presented. Clinically, 11 patients suffered from migraine accompagnée (in 2 cases accompanied by epileptic seizures), 1 patient had ophthalmoplegic migraine and 1 had a subarachnoid haemorrhage imitating migraine. The underlying pathological findings were: 1 tumour, 4 arteriovenous malformations, 4 aneurysms, 1 arterio-venous shunt, 1 pathological vascular network, 1 Moya-Moya syndrome and 1 intracerebral haemorrhage without detectable source of bleeding. 8 of the patients underwent successful surgery and most of them showed subsequent clinical improvement. The family history was positive in only 2 patients. The time interval between the occurrence of the first symptoms and the establishment of the final diagnosis was up to 25 years. The neurologist should undertake extensive investigation of the patient, including cerebral angiography, if the following criteria apply: hemicrania consistently on the same side; change in type of headache after a number of years; uniform complicating neurological symptoms; additional occurrence of epileptic seizures; manifestation of neurological symptoms after the prodromal phase; persistent neurological signs without remission; negative family history; persisting diffuse or locally accentuated EEG changes; pathological CAT results.

[EEG findings in complicated migraine]

In the past 11 years 115 patients with complicated migraine were examined at the Neurological University Clinic of Vienna (34 male, 81 female, age range 15-65 years, mean age 32 years). About 80% suffered not only from complicated but also from uncomplicated migraine. 6 cases had ophthalmoplegic migraine, 3 cases typical basilaris migraine and the rest (n = 106) migraine accompagnée. The complicated neurological symptoms consisted in most cases of transient sensory and/or motor deficits (n = 37), 15 of these cases had additional visual field deficits. 36 cases had combination of marked aphasia with sensory and/or motor deficits, 16 were monosymptomatic with severe hemihypaesthesia, 10 cases had only motor deficits. The complicating symptoms (i.e. neurological deficits) occurred before attacks of headache and autonomic symptoms in 85 cases. The man frequency of complicated migraine showed a maximum of 1-2 attacks per year (n = 28), the mean duration of single attacks were 15-45 minutes in most cases (n = 31). Only 3 cases had presistent deficits. All patients were examined with EEG, 24.3% of standard EEG done at an any timepoint within the first 3 month after the last attacke revealed no abnormality, 8.7% cases had diffuse slowing, 14.8% bilateral dyshythmia over tempro-frontal areas, other 19.2% asymmetries of this activity and surprisingly 33.1% foci. The maximum of abnormal activities was over frontal and temporal areas. Marked spikes and sharp waves etc. was observed only in 8%. This is the distribution of abnormal EEGs with regard to the severity of abnormalities.(ABSTRACT TRUNCATED AT 250 WORDS)