Diabetes mellitus mal controlada como desencadenante de un caso de enfermedad de Marchiafava-Bignami / Marchiafava-Bignami disease triggered by poorly controlled diabetes mellitus

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Papel de los neuromoduladores en el tratamiento preventivo de la migraña / The role of the neuromodulators in the prevnetive treatment of Migraine

Resumen. Introducción. Como mínimo una cuarta parte de los pacientes que consultan por migraña necesitan tratamiento preventivo, y al menos la mitad no responden o no toleran los tratamientos preventivos clásicos: betabloqueadores, flunaricina y amitriptilina. Objetivo. Analizar la aportación de los nuevos fármacos antiepilépticos (neuromoduladores) en la prevención de la migraña. Desarrollo. Revisión crítica de los ensayos clínicos llevados a cabo con los fármacos antiepilépticos en la prevención de la migraña. El topiramato ha demostrado una eficacia incontestable en la prevención de la migraña con y sinaura, incluida la migraña crónica con y sin abuso de analgésicos, aunque uno de cada cinco pacientes no lo tolera. El ácido valproico tiene eficacia demostrada en el tratamiento preventivo de la migraña con y sin aura, si bien su perfil de tolerabilidad y la posibilidad de efectos secundarios graves hacen que deba reservarse para pacientes refractarios. La gabapentina posee una eficacia leve, claramente por debajo del topiramato y del ácido valproico. La lamotrigina es el tratamiento de elección en la prevención del aura migrañosa, pero no es eficaz en el tratamiento de la cefalea. El levetiracetam ha demostrado cierta eficacia en estudios abiertos en la prevención de la migraña en adultos y niños. La zonisamida ha mostrado buena eficacia y tolerabilidad en pacientes que habían fracasado con topiramato y presenta una vida media prolongada que facilita el cumplimiento. El resto de los fármacos antiepilépticos no ha demostrado eficacia. Conclusiones. Los neuromoduladores topiramato y ácido valproico tienen una eficacia bien demostrada en la prevención de la migraña. La lamotrigina es eficaz en la prevención del aura migrañosa. Aunque son necesarios nuevos estudios, la zonisamida podría constituir una buena opción para el tratamiento preventivo de la migraña (AU)

Summary. Introduction. More than one quarter of patients who consult due to migraine need preventive treatment. At least half of these patients do not respond or cannot tolerate classical preventatives: beta-blockers, flunarizine or amitriptyline. Aim. To analyse the role of new antiepileptics (neuromodulators) in migraine prevention. Development. Critical review of clinical trials carried out with antiepileptics for the treatment of migraine. Topiramate has demonstrated clear efficacy in the prevention of migraine with and without aura, including chronic migraine with and without analgesic overuse, although it is not tolerated by one fifth of patients. Valproic acid also has a demonstrated efficacy in the preventive treatment of migraine with and without aura, but its tolerability profile and the possibility of serious adverse events oblige us to prescribe this neuromodulator for refractory patients. Gabapentin shows a mild efficacy, clearly lower than that of topiramate and valproate. Lamotrigine is the treatment of choice in the prevention of migraine aura, but is not efficacious in the treatment of headache. Levetiracetam has shown some efficacy in open studies in migraine prevention, both in adults and children. Zonisamide has demonstrated good efficacy and tolerability in patients refractory to topiramate and shows a prolonged half life, which improves compliance. The remaining antipileptics have not shown efficacy. Conclusions. Topiramate and valproic acid have demonstrated efficacy in migraine prevention. Lamotrigine is efficacious for the treatment of migraine aura. Even though new studies are necessary, zonisamide could be a good option for the preventive treatment of migraine (AU)

[The role of the neuromodulators in the preventive treatment of migraine]. / Papel de los neuromoduladores en el tratamiento preventivo de la migraña.

INTRODUCTION: More than one quarter of patients who consult due to migraine need preventive treatment. At least half of these patients do not respond or cannot tolerate classical preventatives: beta-blockers, flunarizine or amitriptyline. AIM: To analyse the role of new antiepileptics (neuromodulators) in migraine prevention. DEVELOPMENT: Critical review of clinical trials carried out with antiepileptics for the treatment of migraine. Topiramate has demonstrated clear efficacy in the prevention of migraine with and without aura, including chronic migraine with and without analgesic overuse, although it is not tolerated by one fifth of patients. Valproic acid also has a demonstrated efficacy in the preventive treatment of migraine with and without aura, but its tolerability profile and the possibility of serious adverse events oblige us to prescribe this neuromodulator for refractory patients. Gabapentin shows a mild efficacy, clearly lower than that of topiramate and valproate. Lamotrigine is the treatment of choice in the prevention of migraine aura, but is not efficacious in the treatment of headache. Levetiracetam has shown some efficacy in open studies in migraine prevention, both in adults and children. Zonisamide has demonstrated good efficacy and tolerability in patients refractory to topiramate and shows a prolonged half life, which improves compliance. The remaining antipileptics have not shown efficacy. CONCLUSIONS: Topiramate and valproic acid have demonstrated efficacy in migraine prevention. Lamotrigine is efficacious for the treatment of migraine aura. Even though new studies are necessary, zonisamide could be a good option for the preventive treatment of migraine.

Epilepsia como forma de presentación de un aneurisma intracraneal no roto / Epilepsy as the presenting symptom of an unruptured intracranial aneurysm

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[Preventive treatment of chronic migraine with zonisamide: a study in patients who are refractory or intolerant to topiramate]. / Tratamiento preventivo de la migraña crónica con zonisamida: un estudio en pacientes refractarios o intolerantes a topiramato.

INTRODUCTION: About half of the patients with chronic migraine do not respond or do not tolerate the different migraine preventatives. AIM: To analyse the efficacy and tolerability of zonisamide in the treatment of migraine in patients who had not responded or tolerated topiramate, the current drug of choice for the treatment of this condition. PATIENTS AND METHODS: Those patients with no response or intolerance to topiramate received zonisamide. This drug was increased 25 mg per week up to a maximum of 200 mg/day. The efficacy of this drug was evaluated in terms of 'response' (reduction in attack frequency below 50%) at the third month of treatment. RESULTS: Our series comprises a total of 34 patients, most of them middle-aged women. All met chronic migraine criteria. Zonisamide showed efficacy (response) in 19 patients (56%), response being excellent in 6 (18%). Nine patients (26%) did not show response, whereas 6 (18%) did not tolerate the drug. CONCLUSIONS: The results, obtained in patients refractory to other preventatives and particularly to topiramate, suggest that zonisamide can be useful in the prevention of chronic migraine. Of course, controlled clinical trials are necessary to confirm these preliminary results.

Tratamiento preventivo de la migraña crónica con zonisamida: un estudio en pacientes refractarios o intolerantes a topiramato / Preventive treatment of chronic migraine with zonisamide: A study in patients who are refractory or intolerant to topiramate

Introducción. Alrededor de la mitad de los pacientes con migraña crónica no responden o no toleran las opcionesde tratamiento preventivo de que se dispone. Objetivo. Analizar la eficacia y tolerabilidad de la zonisamida en el tratamiento preventivo de la migraña en pacientes que no habían respondido o tolerado topiramato, el actual fármaco de elección en estaentidad. Pacientes y métodos. Aquellos pacientes con ausencia de respuesta o intolerancia a topiramato recibieron zonisamida. El fármaco se incrementó a razón de 25 mg/semana hasta un máximo de 200 mg/día. La eficacia del fármaco se evaluó en términos de ‘respuesta’ (reducción de la frecuencia de las crisis en al menos 50%) al tercer mes de tratamiento. Resultados. Nuestra serie comprende 34 pacientes, mayoritariamente mujeres de edad media. Todas cumplían criterios de migraña crónica. La zonisamida mostró eficacia (respuesta) en 19 pacientes (56%); la respuesta fue excelente en 6 (18%). Un total de 9 pacientes (26%) no consiguieron respuesta, mientras que 6 (18%) no toleraron el fármaco. Conclusiones. Los resultados, obtenidos en pacientes refractarios a otros tratamiento preventivos y en particular a topiramato, sugieren que la zonisamidapuede ser útil en la prevención de la migraña crónica. Obviamente se precisan ensayos clínicos controlados que confirmen estos resultados, que han de considerarse preliminares

Introduction. About half of the patients with chronic migraine do not respond or do not tolerate the different migraine preventatives. Aim. To analyse the efficacy and tolerability of zonisamide in the treatment of migraine in patients who had not responded or tolerated topiramate, the current drug of choice for the treatment of this condition. Patients and methods. Those patients with no response or intolerance to topiramate received zonisamide. This drug was increased 25 mg per week up to a maximum of 200 mg/day. The efficacy of this drug was evaluated in terms of ‘response’ (reduction in attack frequency below50%) at the third month of treatment. Results. Our series comprises a total of 34 patients, most of them middle-aged women. All met chronic migraine criteria. Zonisamide showed efficacy (response) in 19 patients (56%), response being excellent in 6(18%). Nine patients (26%) did not show response, whereas 6 (18%) did not tolerate the drug. Conclusions. The results, obtained in patients refractory to other preventatives and particularly to topiramate, suggest that zonisamide can be useful inthe prevention of chronic migraine. Of course, controlled clinical trials are necessary to confirm these preliminary results

[Determinants of prophylactic migraine therapy in Spain]. / Determinantes del uso de los fármacos con indicación para la profilaxis de la migrana en España.

INTRODUCTION: Migraine interferes with the quality of life of patients. Prophylactic medication is an option to be considered in cases showing inefficiency of symptomatic medication or an increase in the number of attacks. AIM: To evaluate the characteristics of patients that start on prophylactic treatment for migraine. PATIENTS AND METHODS: A multicenter epidemiologic survey was conducted in 110 neurological outpatient clinics and hospitals among adult patients of both sexes who required prophylactic treatment for migraine. Pain intensity was measured through a three-category scale: mild, moderate, or severe. Daily disability was measured by a disability questionnaire. RESULTS: A total of 735 patients with migraine who had started prophylactic treatment were considered valid for the analysis. The patients reported an average of 9.7 days with migraine in the previous month, 32% of the episodes lasting more than 24 hours. Half of the patients referred working or home disability due to migraine with a total average score of 15.1 on the disability scale (grade III). A 48% of the patients had previously received prophylactic treatment, the medications most commonly prescribed being flunarizine, propranolol and amitriptyline. At the study visit, the most commonly prescribed medications were topiramate, flunarizine, propranolol, and amitriptyline. CONCLUSIONS: Our study reveals that starting prophylactic treatment is in the majority of cases due to a high attack frequency. A clear evolution is being observed in prophylactic medication prescription, with a shift from flunarizine or propranolol to topiramate, which is prescribed more frequently nowadays.

Determinantes del uso de los fármacos con indicación para la profilaxis de la migraña en España / Determinants of prophylactic migraine therapy in Spain

La migraña interfiere de forma relevante en la calidad de vida de los enfermos y, en aquéllos con ineficaciade la medicación sintomática o mayor número de crisis, la profilaxis es una opción a tener en cuenta. Objetivo. Evaluar las características de los pacientes que inician tratamiento profiláctico antimigrañoso. Pacientes y métodos. Se realizó una encuesta epidemiológica multicéntrica en 110 consultas neurológicas ambulatorias y hospitalarias con pacientes adultosde ambos sexos que necesitasen medicación profiláctica antimigrañosa. La intensidad del dolor se midió en tres categorías: leve, moderado y grave. La discapacidad se midió con el cuestionario Migraine Disability Assesment Scale (MIDAS). Resultados.Se consideraron válidos para el análisis a 735 pacientes con migraña que iniciaron tratamiento profiláctico. En el mes anterior, los enfermos presentaron una media de 9,7 días con migraña, y en el 32% los episodios duraron más de 24 horas. El 50% refería discapacidad laboral o doméstica por la migraña, con una puntuación media de 15,1 en el MIDAS (grado III).El 48% de los pacientes había recibido algún tratamiento profiláctico previo, y los fármacos utilizados con mayor frecuencia eran flunaricina, propranolol y amitriptilina. En la visita del estudio, los fármacos profilácticos que se prescribieron con mayorfrecuencia fueron topiramato, flunaricina, propranolol y amitriptilina. Conclusiones. El presente estudio revela que el inicio de profilaxis está determinado en la mayoría de los casos por una frecuencia elevada de crisis. En la prescripción de fármacosprofilácticos se observa un cambio de tendencia terapéutica, pasando del uso de flunaricina y propranolol, al incremento de uso de topiramato

Migraine interferes with the quality of life of patients. Prophylactic medication is an option to beconsidered in cases showing inefficiency of symptomatic medication or an increase in the number of attacks. Aim. To evaluate the characteristics of patients that start on prophylactic treatment for migraine. Patients and methods. A multicenter epidemiologic survey was conducted in 110 neurological outpatient clinics and hospitals among adult patients of both sexes who required prophylactic treatment for migraine. Pain intensity was measured through a three-categoryscale: mild, moderate, or severe. Daily disability was measured by a disability questionnaire. Results. A total of 735 patients with migraine who had started prophylactic treatment were considered valid for the analysis. The patients reported an average of 9.7 days with migraine in the previous month, 32% of the episodes lasting more than 24 hours. Half of the patients referred working or home disability due to migraine with a total average score of 15.1 on the disability scale(grade III). A 48% of the patients had previously received prophylactic treatment, the medications most commonly prescribed being flunarizine, propranolol and amitriptyline. At the study visit, the most commonly prescribed medications were topiramate, flunarizine, propranolol, and amitriptyline. Conclusions. Our study reveals that starting prophylactic treatmentis in the majority of cases due to a high attack frequency. A clear evolution is being observed in prophylactic medication prescription, with a shift from flunarizine or propranolol to topiramate, which is prescribed more frequently nowadays

Patrón de abuso de analgésicos en la cefalea crónica diaria: un estudio en población general / Abuse pattern of analgesics in chronic daily headache: a study in the general population

Fundamento y objetivo. El patrón de abuso de analgésicos no es bien conocido en personas con «cefalea crónica diaria y abuso de analgésicos» (CAA) en la población general. El objetivo de este estudio ha sido conocer el tipo de analgésicos consumidos por grupo farmacológico y principio activo en sujetos con CAA en una amplia muestra de la población general. Pacientes y método. Se distribuyó un cuestionario que investigaba la frecuencia de cefalea y el consumo de analgésicos entre las personas mayores de 14 años (9.984 habitantes) de la población semiurbana de Santoña (Cantabria). Un total de 4.855 sujetos rellenaron el cuestionario. Si bien los criterios de CAA exigen cefalea mayor o igual a 15 días al mes, aquellos individuos (n = 332) que referían consumo subjetivo de analgésicos por cefalea mayor o igual a 10 días en este período cumplimentaron un diario de cefaleas durante un mes. Un total de 72 individuos cumplían criterios de CAA (1,48% de la población general). Las variedades de CAA se clasificaron de acuerdo con los criterios de Silberstein et al. Resultados. El mayor consumo correspondió al grupo de analgésicos simples con un 34,7% del total de sujetos, seguido por el de analgésicos combinados y ergotamínicos consumidos por el 27,8% y 22,2%, respectivamente. El 12,5% tomaba opioides solos o asociados y en quinto lugar los triptanes, que eran consumidos por el 2,8% del total de sujetos. Los principios activos más utilizados fueron: paracetamol (54%), cafeína (49%), derivados ergóticos (38%) y propifenazona (35%). Los sujetos detectados consumieron una media de 2,5 principios activos simultáneamente. La media de unidades consumidas en sus diversas presentaciones por los sujetos con CAA fue de 50 unidades/mes.Conclusiones. Este estudio muestra que la CAA es un problema sanitario importante. En nuestro medio, el 85% de las personas con CAA de la población utilizan analgésicos y/o ergóticos. Estas medicaciones se dispensan sin receta, por lo que debería regularse su obtención en las oficinas de farmacia

Background and objective. The abuse pattern of analgesics is not well known in persons with «chronic daily headache and analgesic abuse» (CHA) in the general population. The objective of this study was to know the type of analgesics used by pharmacological group and the active ingredient in subjects with CHA in a large sample of the general population. Patients and methods. A questionnaire was distributed that investigated the frequency of headache and analgesic consumption among persons over 14 years (9,984 inhabitants) of the semiurban population of Santoña (Cantabria). A total of 4,855 subjects filled out the questionnaire. Although the CHA criteria require headache ≥ 15 days a month, those individuals (n = 332) that report subjective consumption of analgesics for headache ≥ 10 days in this period filled out a headache diary for one month. A total of 72 individuals fulfilled CHA criteria (1.48% of the general population). The varieties of CHA were classified according to the Silberstein et al criteria. Results. The greatest consumption corresponded to the simple analgesic group with 34.7% of all the subjects followed by those of combined analgesics and ergotaminics consumed by 27.8% and 22.2% respectively. A total of 12.5% took opioids alone or associated and triptans were in the fifth place. The latter were consumed by 2.8% of all the subjects. The active ingredients used most were: paracetamol (54%), caffeine (49%), ergotic derivatives (38%) and propyphenazone (35%). The subjects detected consumed a mean of 2.5 active ingredients simultaneously. The mean units consumed in their different presentation by the subjects with CHA was 50 units/month. Conclusions. This study shows that CHA is a significant health care problem. In our setting, 85% of the persons with CHA of the population used analgesics and/or ergotics. These medications were given without prescription so that their obtention should be regulated in the pharmacy offices

[Abuse pattern of analgesics in chronic daily headache: a study in the general population]. / Patrón de abuso de analgésicos en la cefalea crónica diaria: un estudio en población general.

BACKGROUND AND OBJECTIVE: The abuse pattern of analgesics is not well known in persons with "chronic daily headache and analgesic abuse" (CHA) in the general population. The objective of this study was to know the type of analgesics used by pharmacological group and the active ingredient in subjects with CHA in a large sample of the general population. PATIENTS AND METHODS: A questionnaire was distributed that investigated the frequency of headache and analgesic consumption among persons over 14 years (9,984 inhabitants) of the semiurban population of Santoña (Cantabria). A total of 4,855 subjects filled out the questionnaire. Although the CHA criteria require headache > or = 15 days a month, those individuals (n = 332) that report subjective consumption of analgesics for headache > or = 10 days in this period filled out a headache diary for one month. A total of 72 individuals fulfilled CHA criteria (1.48% of the general population). The varieties of CHA were classified according to the Silberstein et al criteria. RESULTS: The greatest consumption corresponded to the simple analgesic group with 34.7% of all the subjects followed by those of combined analgesics and ergotaminics consumed by 27.8% and 22.2% respectively. A total of 12.5% took opioids alone or associated and triptans were in the fifth place. The latter were consumed by 2.8% of all the subjects. The active ingredients used most were: paracetamol (54%), caffeine (49%), ergotic derivatives (38%) and propyphenazone (35%). The subjects detected consumed a mean of 2.5 active ingredients simultaneously. The mean units consumed in their different presentation by the subjects with CHA was 50 units/month. CONCLUSIONS: This study shows that CHA is a significant health care problem. In our setting, 85% of the persons with CHA of the population used analgesics and/or ergotics. These medications were given without prescription so that their obtention should be regulated in the pharmacy offices.

¿Un triptán para cada paciente? / A tryptone for every patient?

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