Decreasing incidence of stroke, ischaemic heart disease and dementia in Norway, 1990-2019, a Global Burden of Disease study: an opportunity.

BACKGROUND AND PURPOSE: The declining incidence of stroke, ischaemic heart disease (IHD) and dementia (the 'triple threat') in Norway encourages further investigation. The risks and trends of the three conditions were analysed using data from the Global Burden of Disease study. METHODS: Global Burden of Disease 2019 estimations were used for age-, sex- and risk-factor-specific incidence and prevalence of the 'triple threat', their risk-factor-attributed deaths and disability combined, their age-standardized rates per 100,000 population in 2019 and their changes during 1990-2019. Data are presented as means and 95% uncertainty intervals. RESULTS: In 2019, 71.1 thousand Norwegians were living with dementia, 157.2 thousand with IHD and 95.2 thousand with stroke. In 2019, there were 9.9 thousand (8.5 to 11.3) new cases of dementia (35.0% increase since 1990), 17.0 thousand (14.6 to 19.6) with IHD (3.6% decrease) and 8.0 thousand (7.0 to 9.1) with stroke (12.9% decrease) in Norway. During 1990-2019, their age-standardized incidence rates decreased significantly-dementia by -5.4% (-8.4% to -3.2%), IHD by -30.0% (-31.4% to -28.6%) and stroke by -35.3% (-38.3% to -32.2%). There were significant declines in the attributable risks to both environmental and behavioural factors in Norway, but contradictory trends for metabolic risk factors during 1990-2019. CONCLUSIONS: The risk of the 'triple threat' conditions is declining in Norway, despite the increased prevalence. This offers the opportunity to find out why and how and to accelerate their joint prevention through new approaches and the promotion of the National Brain Health Strategy.

Headache and migraine during pregnancy and puerperium: the MIGRA-study.

There is little prospectively gathered data on the course of headaches during pregnancy and postpartum, and the influence of breastfeeding is unclear. This is a large, prospective study, which invited all pregnant women in the catchment area during a defined period. All participants (n = 2,126) filled in questionnaires concerning headache. Among these, a total of 208 women with migraine according to the International Headache Society criteria also filled in detailed headache diaries during pregnancy and the puerperal period. Freedom from earlier headaches during pregnancy was significantly more common than new onset of headache during pregnancy (p < 0.001). This was not influenced by prior use of oral contraceptives. According to the diaries, there was a gradual decrease during pregnancy in the frequency of all headaches and of self-considered migraine. There was also a significant decrease in the duration of headaches (p < 0.001) during pregnancy compared to before. Earlier parity did not influence the course. Apart from a significant increase during the first week postpartum (p < 0.01), the overall occurrence of headaches during puerperium did not differ from the pregnancy period. Compared to pregnancy, there was a postpartum increase in the mean intensity (p < 0.01) and duration (p = 0.050) of headaches, as well as in the mean number of analgesics used (p < 0.001). Breastfeeding did not influence the occurrence of headaches postpartum. These data are of practical value for informing pregnant migraineurs about the typical clinical prospects and for giving advice on breastfeeding.

Quantitative EEG in patients with alcohol-related seizures.

BACKGROUND: To investigate whether quantitative electroencephalography (QEEG) recorded within a few days after a generalized seizure can improve the discrimination between alcohol-related seizures (ARSs), seizures in epilepsy and other seizures. In addition, we wanted to evaluate the influence of various external factors on QEEG, e.g., drug use, time from seizure occurrence, and alcohol intake. METHODS: An ARS was defined by (i) scores ≥8 in the Alcohol Use Disorders Identification Test (AUDIT) and (ii) no history of epilepsy. Twenty-two ARS patients, 21 epileptic patients with seizures (ES), 30 AUDIT-negative patients with seizures (OS), and 37 well-controlled epileptic outpatients (EPO) were included. EEG from 79 sciatica patients (SC) served as an additional control group. EEG was recorded in relaxed wakefulness with eyes closed. Spectral analysis of ongoing resting EEG activity was performed. For the main analysis, spectral band amplitudes were averaged across 14 electrodes. RESULTS: Major quantitative EEG abnormalities were mainly seen in the ES group. AUDIT score correlated negatively with QEEG band amplitudes in patients with seizures unrelated to alcohol, but not in the ARS group. Recent alcohol intake correlated negatively with delta and theta amplitude. We could not confirm that beta activity is increased in ARS subjects. CONCLUSIONS: A QEEG with slightly reduced alpha amplitude supports a clinical diagnosis of ARS. An abnormally slow QEEG profile and asymmetry in the temporal regions indicates ES. QEEG predicted the clinical diagnosis better than standard EEG.

The EEG response to photic stimulation is not increased in alcohol-related seizures.

OBJECTIVE: To investigate the occipital EEG response to 18 and 24Hz photic stimulation (the H-response) in alcohol-related seizures (ARS). METHOD: Twenty-two ARS patients, 15 of whom had a withdrawal seizure (WS) were compared with patients with recent seizures of other causes: 21 patients with epilepsy, and 30 Alcohol Use Disorders Identification Test (AUDIT) negative patients with other seizures. EEG from 37 out-patients with epilepsy and 79 sciatica patents served as patient-controls. The spectral amplitude around 18 and 24Hz and a new photic H-ratio (24/18Hz relative amplitude) was calculated. RESULTS: The H-ratio was significantly reduced in the ARS group compared to the sciatica group. H-ratio reduction correlated with the AUDIT score in ARS patients (p=0.02). No differences between WS and non-WS patients were found for H-response variables. CONCLUSION: A dose-response relationship between AUDIT and the photic response H-ratio was observed in ARS patients. The EEG-driving response to 24Hz flashes was not increased in ARS. SIGNIFICANCE: The relative decrease in 24Hz photic response in ARS reflected drinking severity. The H-ratio is a candidate biomarker for ARS on the group level, although the moderate effect size precludes its use in individual patients.

Angiotensin-converting enzyme gene insertion/deletion polymorphism in migraine patients.

BACKGROUND: The main objective of this study was to investigate the angiotensin converting enzyme (ACE) genotype as a possible risk factor for migraine (both with and without aura) compared to controls. We also wanted to examine whether a clinical response to an ACE inhibitor, lisinopril, or an angiotensin II receptor blocker, candesartan, in migraine prophylaxis was related to ACE genotype. METHODS: 347 migraine patients aged 18-68 (155 migraine without aura (MoA), 187 migraine with aura (MwA) and 5 missing aura subgroup data) and 403 healthy non-migrainous controls > 40 years of age were included in the study. A polymerase chain reaction (PCR) was performed on the genomic DNA samples to obtain the ACE insertion (I)/deletion(D) polymorphisms. RESULTS: No significant differences between migraine patients and controls were found with regard to ACE genotype and allele distributions. Furthermore, there was no significant difference between the controls and the MwA or MoA subgroups. CONCLUSION: In our sample there is no association between ACE genotype or allele frequency and migraine. In addition, ACE genotype in our experience did not predict the clinical response to lisinopril or candesartan used as migraine prophylactics.

Migraine aura or transient ischemic attacks? A five-year follow-up case-control study of women with transient central nervous system disorders in pregnancy.

BACKGROUND: Migraine aura may be difficult to differentiate from transient ischemic attacks and other transient neurological disorders in pregnant women. The aims of the present study were to investigate and diagnose all pregnant women with transient neurological disorders of suspected central nervous system origin, and to compare this group with a control group of pregnant women with regard to vascular risk factors and prognosis. METHODS: During a 28 month period, 41 patients were detected with transient neurological symptoms during pregnancy. These were studied in detail with thorough clinical and laboratory investigations in order to make a certain diagnosis and to evaluate whether the episodes might be of a vascular nature. For comparison, the same investigations were performed in 41 pregnant controls. To assess the prognosis, both patients and controls were followed with questionnaires every year for five years. RESULTS: Migraine with aura was the most common cause of symptoms during pregnancy, occurring in 34 patients, while 2 were diagnosed with stroke, 2 with carpal tunnel syndrome, 1 with partial epilepsy, 1 with multiple sclerosis and 1 with presyncope. Patients had more headache before pregnancy than controls, but the average levels of vascular risk factors were similar. None of the patients or the controls reported cerebrovascular episodes during the five-year follow-up. CONCLUSION: The diagnosis of migraine aura was difficult because for many patients it was their first ever attack and headache tended to be absent or of non-migraineous type. The aura features were more complex, with several aura symptoms and a higher prevalence of sensory and dysphasic aura than usual. Gradually developing aura symptoms, or different aura symptoms occurring in succession as described in the International Classification of Headache Disorders, seem to be useful for differentiating aura from other transient disorders. A meticulous history and clinical neurological examination are more useful than routine supplementary investigations for cerebrovascular disease. The five-year follow-up clearly indicates that migraine with aura in pregnancy usually has a good prognosis with regard to cerebrovascular events.

Involvement of the renin-angiotensin system in migraine.

Migraine is a common episodic headache that predominantly affects young adults, particularly women in their most productive years. Many of the prophylactic agents available today have side-effects that are not compatible with long-term use. The discovery that drugs influencing the renin-angiotensin system (RAS), which have few side-effects, were effective in some patients with migraine led to several studies investigating a possible link between the angiotensin system and migraine pathophysiology. Clinical trials indicated that angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs) are effective in the prophylactic treatment of migraine. These findings are further supported by pharmacoepidemiological, genetic, and physiological studies. In addition, it is known that the RAS has neurophysiological, chemical, and immunological effects that are of relevance in migraine pathophysiology. On the basis of evidence presented in this review, we find it likely that the RAS has a clinically important role in migraine pathophysiology. The effect of ARBs and ACEIs on migraine is probably not attributable to their effect on blood pressure. The RAS has several actions that may be relevant in migraine pathophysiology, but the reason for the prophylactic effect of ARBs/ACEIs in migraine remains a matter of speculation.

A structured, nurse-led intervention program improves quality of life in patients with epilepsy: a randomized, controlled trial.

We tested the hypothesis that structured epilepsy nursing improves quality of life (QOL). One hundred fourteen adult patients with uncontrolled epilepsy were randomly assigned to either an intervention group or a control group. The intervention group was offered an interactive, 1-day group education program followed by extended nurse follow-up and counseling. The nurse was present at as many outpatient consultations as possible and performed repeated consultations by telephone. All patients completed the QOLIE-89 before randomization and after 2 years. QOL was significantly improved from inclusion to completion of study in the intervention group (P=0.019), mainly in the subitems for Health Discouragement (P=0.01), Medication Effects (P=0.035), and Physical Role Limitations (P=0.05). To our knowledge, this is the first study to demonstrate a significant effect of a structured nurse-led intervention program in QOL of patients with epilepsy.

Low socioeconomic status is associated with chronic musculoskeletal complaints among 46,901 adults in Norway.

AIMS: A study was undertaken to evaluate the relationship between socioeconomic status (SES) and chronic musculoskeletal complaints (MSC), and to determine how this relationship is influenced by change in SES. METHODS: Two consecutive public health surveys within the county of Nord-Trøndelag, Norway, were conducted in 1984-86 (HUNT-1) and 1995-97 (HUNT-2). Among 46,901 adults who participated in both surveys, 24,127 persons (51%) in HUNT-2 who reported MSC continuously for at least 3 months during the past year were defined as having chronic MSC. Prevalence of chronic MSC was estimated at nine anatomical sites using multiple logistic regression with odds ratio (OR) and 95% confidence interval (CI) as measures of association with SES. RESULTS: When defining SES by educational level, type of occupation, or income, low status was associated with increased prevalence of chronic MSC (age-adjusted analyses). The negative influence of low education or low occupation level was not eliminated by increasing the level of education or occupation from HUNT-1 to HUNT-2, in contrast with what was found for individuals with higher income level in HUNT-2 than in HUNT-1. The relationship with SES was more evident among individuals with musculoskeletal symptoms 15 days during the past month than among those with less than 15 days, evident at all nine different anatomical sites. The strongest relationship was found between low SES and prevalence of widespread chronic MSC. CONCLUSIONS: Individuals with low SES had higher prevalence of chronic MSC than those with high SES. Future studies should try to clarify whether chronic MSC are a cause or consequence of low SES.

Does hypertension protect against chronic musculoskeletal complaints? The Nord-Trøndelag Health Study.

BACKGROUND: Although an inverse relationship between pain sensitivity and hypertension has been described, it is still unknown whether hypertension may protect against chronic musculoskeletal complaints (MSCs). The aim of this study was to evaluate the relationship between blood pressure (BP) and prevalence of chronic MSCs at various anatomical sites. METHODS: Two consecutive public health studies within the county of Nord-Trøndelag, Norway, were conducted between January 5, 1984, and February 15, 1986 (Nord-Trøndelag Health Study [HUNT] 1), and from August 1995 to June 1997 (HUNT-2). Among 46 901 adults who participated in both surveys, 24 127 (51.4%) in HUNT-2 who reported MSCs continuously for at least 3 months during the past year were defined as having chronic MSCs. The prevalence of chronic MSCs was estimated using multiple logistic regression, with odds ratio and 95% confidence interval as measures of association with systolic and diastolic BP. RESULTS: A high systolic and diastolic BP was associated with a 10% to 60% lower prevalence of chronic MSCs, and there was a strong linear trend (P<.001) of decreasing prevalence of chronic MSCs with increasing BP values. The findings were remarkably consistent at all anatomical sites, for both sexes, across all age groups, and for systolic and diastolic BP measured in HUNT-1 and HUNT-2. CONCLUSIONS: Individuals with a high BP had a lower prevalence of chronic MSCs than individuals with a normal BP. One possible explanation may be the phenomenon of hypertension-associated hypalgesia, due to an interaction between the cardiovascular and pain regulatory systems. The effect of antihypertensive medication on this interaction should be evaluated in further studies.

Do high TSH values protect against chronic musculoskeletal complaints? The Nord-Trøndelag Health Study (HUNT).

The aim of this large cross-sectional population-based study was to examine a possible positive or negative association between thyroid dysfunction and chronic musculoskeletal complaints (MSC). Between 1995 and 97, all 94,197 adults in Nord-Trøndelag County in Norway were invited to participate in a health survey. A total of 64,787 (69%) responded to questions related to MSC, whereof thyroid-stimulating hormone (TSH) was measured in 34,960 individuals. These included a 5% random sample of women and men 20-40 years of age (n=2165), nearly all women above 40 (n=19,308), a random sample which included 50% of men older than 40 years (n=9983), and 3504 (97%) with self-reported thyroid dysfunction. Among the 64,787 participants, 30,158 (47%) who reported MSC continuously for at least 3 months during the past year where defined as having chronic MSC. Associations between thyroid dysfunction and chronic MSC were assessed in multivariate analyses, estimating prevalence odds ratios (ORs) with 95% confidence intervals (CIs). High TSH values were associated with lower prevalence of chronic MSC at ten anatomical sites among women with no history of thyroid dysfunction. Among these, chronic MSC was less likely (OR=0.6, 95% CI 0.4-0.8) if TSH >or=10 mU/L than in women with normal TSH (0.2-4 mU/L). Chronic MSC was less likely among women with high TSH values. The mechanism is unclear and, theoretically, may reflect a fundamental gender-specific relationship between TSH and pain perception in the central nervous system.

[Disagreement about epilepsy and driving]. / Uenighet om epilepsi og bilkjøring.

BACKGROUND: To find out how current regulations concerning epilepsy and driving licence are applied in clinical practice in Norway. MATERIAL AND METHODS: A questionnaire was sent to all 344 members of the Norwegian Neurological Association. RESULTS: 56% responded within 3 months, most of them (152) working in the field of clinical neurology. The majority (73%) did not see reporting a "situation-related" seizure to the authorities as obligatory, but almost all of these respondents (94%) would temporarily disallow driving. 60% did not consider it obligatory to report the exclusive occurrence of simple partial seizures with retained consciousness and motor control. A surprisingly large number (36%) would never recommend dispensation from the rule instituting a one-year driving ban. 39% generally used EEG in the assessment of driving fitness, whereas 17 % rarely did so. Only 50% instructed their patients not to drive during antiepileptic drug withdrawal. 45% did not consider seizure recurrence resulting from consented withdrawal to activate the obligation to report. CONCLUSION: There is poor consensus among neurologists on many aspects of driving and epilepsy, particularly on the assessment of risk when drugs are withdrawn. These issues should be focused on in graduate and postgraduate education in clinical neurology.

An easily performed group education programme for patients with uncontrolled epilepsy--a pilot study.

The factual knowledge of epilepsy is often insufficient among patients with this disorder. Compliance problems due to ignorance are common, and counselling is extremely important. We have developed a simple 1-day, low-cost group education programme for patients with epilepsy, intended to be suitable in routine care. The programme aims to help patients to achieve an improved understanding of the disorder and was carried out for a total of 54 consecutive patients with at least one seizure during the last year. This hospital-based 6-hour interactive course is organised by an epilepsy nurse and contains the following elements: basic knowledge about epilepsy, living with epilepsy, visit to the EEG lab, social security system and medical treatment. It was evaluated by means of a semi-structured interview and was found generally useful by all the participants. Sixty-five percent considered the sharing of experience with other patients to be the most valuable element. The ideal group size was found to be six to eight. Heterogeneity concerning age, sex and competence seemed to increase the interaction within the groups. This pilot study indicates that group education may be a useful approach in the clinic.

Prophylactic treatment of migraine with an angiotensin II receptor blocker: a randomized controlled trial.

CONTEXT: There is a paucity of effective, well-tolerated drugs available for migraine prophylaxis. OBJECTIVE: To determine whether treatment with the angiotensin II receptor blocker candesartan is effective as a migraine-prophylactic drug. DESIGN AND SETTING: Randomized, double-blind, placebo-controlled crossover study performed in a Norwegian neurological outpatient clinic from January 2001 to February 2002. PATIENTS: Sixty patients aged 18 to 65 years with 2 to 6 migraine attacks per month were recruited mainly from newspaper advertisements. INTERVENTIONS: A placebo run-in period of 4 weeks was followed by two 12-week treatment periods separated by 4 weeks of placebo washout. Thirty patients were randomly assigned to receive one 16-mg candesartan cilexetil tablet daily in the first treatment period followed by 1 placebo tablet daily in the second period. The remaining 30 received placebo followed by candesartan. MAIN OUTCOME MEASURES: The primary end point was number of days with headache; secondary end points included hours with headache, days with migraine, hours with migraine, headache severity index, level of disability, doses of triptans, doses of analgesics, acceptability of treatment, days of sick leave, and quality-of-life variables on the Short Form 36 questionnaire. RESULTS: In a period of 12 weeks, the mean number of days with headache was 18.5 with placebo vs 13.6 with candesartan (P =.001) in the intention-to-treat analysis (n = 57). Some secondary end points also favored candesartan, including hours with headache (139 vs 95; P<.001), days with migraine (12.6 vs 9.0; P<.001), hours with migraine (92.2 vs 59.4; P<.001), headache severity index (293 vs 191; P<.001), level of disability (20.6 vs 14.1; P<.001) and days of sick leave (3.9 vs 1.4; P =.01), although there were no significant differences in health-related quality of life. The number of candesartan responders (reduction of > or =50% compared with placebo) was 18 (31.6%) of 57 for days with headache and 23 (40.4%) of 57 for days with migraine. Adverse events were similar in the 2 periods. CONCLUSION: In this study, the angiotensin II receptor blocker candesartan provided effective migraine prophylaxis, with a tolerability profile comparable with that of placebo.

Cervicogenic headache, migraine, and tension-type headache. Pressure-pain threshold measurements.

Pressure-pain threshold (PPT) measurements were performed with a pressure algometer, at 22 specified points in the head in patients with cervicogenic headache (n = 32), migraine (with and without aura) (n = 26) and tension-type headache (n = 17). Comparisons were made with a group of healthy controls (n = 20). The average PPT differed significantly between the groups (ANOVA, F = 9.5, P < 0.0005), largely caused by the low threshold in cervicogenic headache patients. There were no significant differences between controls and the 2 other headache groups. In the cervicogenic headache group, the lowest PPT was found in the occipital part of the head on the side with pain predominance. The ratio between the dominant and non-dominant sides (all 11 points on each side) was 0.85 in cervicogenic headache, whereas it was 0.99 in migraine patients with side preponderance of the pain. The present results support the view that the pathogenesis of cervicogenic headache differs from that of migraine and tension-type headache. The results may further support the theory that fibres from the C2 level (innervating the occipital part of the head) may be included in the pathogenetic mechanism in cervicogenic headache.

Cervicogenic headache, migraine without aura and tension-type headache. Diagnostic blockade of greater occipital and supra-orbital nerves.

The diagnostic value of greater occipital and supra-orbital nerve blockades in patients with cervicogenic headache, migraine without aura, and tension-type headache was investigated. The pain reduction after greater occipital nerve blockade was significantly more marked in the cervicogenic headache group than in the other categories. Moreover, pain reduction in the forehead was generally only found in the cervicogenic headache patients (77%). Pain reduction (in %) was significantly more marked following the greater occipital than the supra-orbital nerve blockade. The volume effect per se was evaluated by saline injection. This procedure did not result in distinct pain reduction. The effect obtained in cervicogenic headache is, accordingly, probably due to the local anaesthesia. The present results support the postulate that different pathogenetic factors probably are responsible for cervicogenic headache, tension-type headache, and migraine without aura.

Cervicogenic headache: anesthetic blockades of cervical nerves (C2-C5) and facet joint (C2/C3).

In a series of 14 patients with cervicogenic headache, cervical nerve blockades (C2-C5 and facet joint C2/C3) have been carried out in order to elucidate possible underlying mechanisms and to evaluate the diagnostic potential of these procedures. Blockade of the C2 nerve resulted in freedom from pain in 5 of 10 patients and seemed to be the most informative procedure. Two patients out of 9 reported freedom from pain following C2/C3 facet joint injection. No patients experienced complete pain relief following C3, C4 or C5 blockades. C4 and C5 nerve blockades are probably of little value in the work-up of such patients. When evaluating the C2/C3 facet joint injection, one has to take possible leakage of anesthetic agent from the joint into consideration, since the third occipital nerve which runs close to the facet joint may be anesthetized through the leakage.

Cefaléia cervicogênica: relato de um caso / Cervicogenic headache: report of a case

A produçäo de cefaléias a partir de anormalidades no pescoço nunca foi sistematizada a ponto de permitir o estudo de sua patogenia, embora fosse fato conhecido há muitos anos. Sjaastad et al. descreveram, em 1983, grupo de pacientes com uma cefaléia uniforme e estereotipada. Os ataques se caracterizam por dor moderada, unilateral sem mudança de lado, de longa duraçäo, recorrendo em poucas semanas. A cefaléia podia ser provocada por certos movimentos do prescoço ou por commpressäo de pontos desencadeadores ali localizados. A dor se iniciava na regiäo cervical, irradiando-se para as áreas órbito-fronto-temporal e/ou facial. A denominaçäo "cefaléia cervicogênica" (CC) foi proposta para esta entidade. Sua fisiopatogenia näo é completamente conhecida. Bloqueios da raiz C2 e do nervo grande occipital eliminam a dor. Apresentamos um caso de CC, fazendo alguns comentários acerca do seu quadro clínico, fisiopatologia e tratamento