Migraine presenting as chronic facial pain.

We report the case of a 44-year-old woman with chronic facial pain. She was treated with several analgesics, prophylactic medications and infiltrations, but all treatment modalities were ineffective. Finally, the diagnosis of medication-overuse headache complicating migraine without aura was made and an appropriate treatment was initiated. Migraine is a very common primary headache and rarely presents as isolated facial pain. Stimulation of the dura with activation of the trigeminovascular system can result in pain in any of the three divisions of the trigeminal nerve. This is the anatomic basis of migraine pain presenting as referred pain to the second division of the trigeminal nerve. The atypical presentation of migraine pain can easily lead to inappropriate treatment regimens.

New-onset and persistent migraine early after percutaneous atrial septal defect closure disappear at follow-up.

AIMS: Recently we reported that percutaneous atrial septal defect (ASD) closure had no influence on the prevalence of migraine during a short followup period. 12 % of patients however developed a new-onset migraine after the ASD closure. As it has been suggested that the closing device might induce or maintain migraine temporarily, we were interested in the prevalence of migraine at longer follow-up. METHODS: All 75 patients included in the previous study, received the same structured headache questionnaire. A neurologist, blinded to previous data, diagnosed migraine with or without aura (MA+ or MA-) according to the International Headache Criteria. McNemar paired X2 test was used to evaluate changes in the occurrence of migraine. RESULTS: Seventy-one patients (94.7%) answer the questionnaire (55 women, mean age at closure 51 +/- 18 years). Mean follow-up time was 52 +/- 13 months. The overall migraine prevalence decreased from 30.7% before to 22.5% after closure (P=0.21). A significant reduction was noted in patients with new-onset migraine early after closure (n=7), where migraine disappeared in 6 patients (P=0.031). In the group with persistent migraine early after closure (n=13), another 6 patients became migraine-free (P=0.031). CONCLUSION: Percutaneous ASD closure was not related to a significant decrease in overall migraine prevalence. However, new-onset and persistent migraine early after closure disappeared.

Almotriptan and its combination with aceclofenac for migraine attacks: a study of efficacy and the influence of auto-evaluated brush allodynia.

Early treatment and combining a triptan with a non-steroidal anti-inflammatory drug (NSAID) are thought to improve outcome during migraine attacks, possibly by counteracting the negative influence of cutaneous allodynia. The aim of this multicentre, double-blind pilot study was to evaluate the prevalence of brush allodynia and its relative influence on the efficacy of a triptan-NSAID combination compared with headache intensity at the time of treatment. In a randomized, cross-over design, 112 migraineurs treated two moderate or severe attacks with almotriptan 12.5 mg combined with either aceclofenac 100 mg or placebo. Patients used a 2-cm brush to assess cutaneous allodynia. Allodynia was reported in 34.4% of attacks. The almotriptan-aceclofenac combination was numerically superior to triptan-placebo on 2-24-h sustained pain-free (P = 0.07), 2-h pain-free (P = 0.07) and headache recurrence (P = 0.05) rates, but not on 1-h headache relief. Allodynia numerically reduced treatment success overall, but this effect was not significant for the primary outcome measures. Headache intensity had a significant negative influence on 1-h relief in both attacks (P = 0.0001 and 0.0008, chi(2)) and on 2-24-h sustained pain-free rates in triptan-placebo-treated attacks (P = 0.013). Multivariate logistic regression analysis confirmed that headache intensity at treatment intake, rather than allodynia, significantly influenced most outcome measures, predominantly so in attacks treated with almotriptan and aceclofenac. In the latter, severe compared with moderate headache intensity reduced the likelihood of achieving the primary efficacy end-points [odds ratios (OR) 0.12 and 0.33], whereas allodynia was not a significant explanatory variable (OR 0.76 and 0.65). The results apply to the protocol used here and need to be confirmed in larger studies using quantitative sensory testing.

[Transitory headaches caused by a colloid cyst of the third ventricle]. / Kortdurende hoofdpijn veroorzaakt door een colloïdcyste van de derde ventrikel.

A 34-year-old man had a history of short-lasting episodes of rotatory vertigo followed by severe headache, provoked by sudden movements of the head and body. MRI of the brain revealed hydrocephalus secondary to a colloid cyst at the level of the foramen of Monro. The patient underwent microsurgery, after which he remained without symptoms. Colloid cysts are rare, benign tumours accounting for 0.5-1.0% of all primary brain tumours. They are attached by a stalklike appendage to the roof of the third ventricle between the fornices. Typical symptoms include intermittent headache, vomiting, occasional dizziness and blurred vision. These symptoms may be secondary to intermittent obstruction of cerebrospinal-fluid outflow through the foramen of Monro. The results of clinical and neurological examination are usually normal. In any patient with short-lasting episodes of severe headache, provoked by changes in position, an MRI of the brain should be done to exclude a colloid cyst. In general, these patients do not fulfil the criteria of the International Headache Society for migraine because of the short-lasting nature of the pain.

Early outcome in acute ischemic stroke is not influenced by the prophylactic use of low-dose aspirin.

Aspirin reduces the occurrence of ischemic strokes. In some prophylactic trials it was suggested that aspirin might also lessen stroke severity, and hence improve outcome in patients sustaining an ischemic stroke. We examined stroke severity (by using the Mathew scale) and early outcome (Barthel index and mortality on day 21) in 91 patients with an acute (< 24 h) ischemic stroke in the territory of the middle cerebral artery. Twenty-seven patients were taking low-dose aspirin (100 or 200 mg/day) prior to their stroke, and 64 were not using antiplatelet drugs. There were no significant differences in baseline stroke severity, early (21 days) mortality or early disability between the two groups. The results of this small study suggest that the use of low-dose aspirin prior to an ischemic stroke does not influence the severity of that stroke and early outcome.

Dopamine agonists used in the treatment of Parkinson's disease and their selectivity for the D1, D2, and D3 dopamine receptors in human striatum.

1. It has been suggested that an ideal antiparkinsonian treatment requires stimulation of both D1 and D2 dopamine receptors. Bromocriptine and lisuride are regarded as pure D2 receptor agonists, whereas pergolide and apomorphine are thought to stimulate both D1 and D2 receptors. 2. The aim of this study was to compare the affinities of bromocriptine, lisuride, pergolide, and apomorphine for the D1, D2, and D3 receptors in postmortem human striatum. The dissociation constants (Ki values) of the dopamine agonists were determined from competition binding experiments with selective radioligands. 3. The Ki values of the orally administered agonists--bromocriptine, pergolide, and lisuride--for the D2 receptors were proportional to their optimal doses against parkinsonism. Ki(D1)/Ki(D2) ratios were 23 for lisuride, 67 for pergolide, 60 for bromocriptine, and 2.6 for apomorphine. Ki(D3)/Ki(D2) ratios were 0.4 for lisuride, 1 for pergolide, 5.4 for bromocriptine, and 21 for apomorphine. 4. The present results support the hypothesis that the antiparkinsonian effect of dopamine agonists is mediated primarily by D2 receptors. Apomorphine is a mixed D1/D2 agonist, but pergolide has no more D1 agonist properties than bromocriptine and lisuride. The role of the D3 receptors is unknown, but their activation might either be associated with the generation of psychiatric side-effects or dyskinesias, or alternatively add to antiparkinsonian activity.

The European Stroke Scale.

BACKGROUND AND PURPOSE: For detecting therapeutic effect and matching of treatment groups in stroke trials, a scale that meets the clinimetric criteria is of the utmost importance. METHODS: The European Stroke Scale consists of 14 items selected for their specificity and their prognostic value. It is designed for patients with middle cerebral artery stroke. Interrater reliability, internal consistency, and time for completion were investigated in 74 patients. Intrarater reliability was studied in 38 patients. To establish concurrent validity, two trials were performed in 20 and 44 patients. The scale was correlated with the MCA Neurological Scale, the Canadian Stroke Scale, the Scandinavian Stroke Scale, the Barthel Index, and the Rankin Scale. Correlations were calculated by means of Spearman's correlation coefficient. The trial in 44 patients also investigated the prognostic validity of the scale for 1-month and 8-month neurological, functional, and handicap status. These data were analyzed by linear regression. RESULTS: Interrater (kappa value range, 0.62 to 0.85) and intrarater (kappa value range, 0.65 to 1.00) reliability for each item was good, and internal consistency was excellent (Cronbach's alpha coefficient, 0.92). Mean time for completion was 8.2 minutes (range, 4 to 14 minutes). Correlations of the European Stroke Scale with other neurological scales ranged from 0.93 to 0.95. The correlation with the Barthel Index and the Rankin Scale was 0.84 and -0.86. The R2 values for prognostic validity ranged from 0.45 to 0.81 (P < or = .0001). CONCLUSIONS: The European Stroke Scale has been developed according to the clinimetric criteria.

Bromocriptine therapy in multiple sclerosis: an open label pilot study.

Bromocriptine suppresses the duration and severity of clinical signs of experimental allergic encephalitis, which is considered as an animal model for multiple sclerosis (MS). We conducted an open pilot study with 2.5 mg of bromocriptine two times a day on 18 patients with clinically or laboratory-supported definite MS (10 with the relapsing-remitting form and eight with the chronic progressive form). After 1 year of treatment, 14 of the 15 patients who completed the study showed disease progression as evidenced by one or more of the following parameters: worsening of the EDSS score, clinical relapses, appearance of new lesions on MRI of the brain and brainstem, or increased latencies of visual or auditory evoked responses. These findings indicate that bromocriptine does not completely suppresses ongoing disease activity in patients with multiple sclerosis.

Insulin-like growth factor-I receptors in human brain and pituitary gland: an autoradiographic study.

Insulin-like growth factor (IGF)-I receptors were studied in adult human postmortem brain and pituitary gland using quantitative autoradiography with human recombinant [125I]IGF-I. The highest densities were found in the choroid plexus, pituitary gland--where IGF-I receptors were mainly concentrated in the anterior lobe, pineal gland, glomerular layer of the olfactory bulb, and the molecular layer of the cerebellar cortex. Moderate densities were present in cerebral cortex, caudate nucleus, putamen, accumbens, the CA1, CA2, CA3 fields and dentate gyrus of the hippocampus, the dentate nucleus of the cerebellum, amygdala, thalamus, pontine nuclei, and substantia nigra. All other brain areas, including white matter, contained low densities of IGF-I receptors. The finding that several well-defined brain structures are enriched with IGF-I receptors suggests a neurotrophic/survival or neuromodulatory role of insulin-like growth factors on specific neuronal systems. IGF-I receptors observed in the white matter may be associated with oligodendrocytes.

Autoradiographic distribution of D3-type dopamine receptors in human brain using [3H]7-hydroxy-N,N-di-n-propyl-2-aminotetralin.

The regional distribution of D3 dopamine receptors was studied in human brain by quantitative autoradiography with [3H]7-hydroxy-N,N-di-n-propyl-2-aminotetralin ([3H]7-OH-DPAT). The highest densities were found in the ventral striatum/nucleus accumbens, followed by the remainder of the neostriatum, cerebral cortex, and cerebellar cortex. Moderate amounts were found in the substantia nigra. Low densities of D3 dopamine receptors were visualized in pituitary gland (posterior lobe > anterior lobe), amygdala, and hippocampus. The globus pallidus and thalamus contained lower densities. The distribution pattern is much more widespread as detected by in situ hybridisation histochemistry for D3 mRNA in human and in rat brain. Our data confirm a predilection of D3 receptors in brain areas involved in cognitive and emotional functions. The presence of D3 receptors in non-limbic parts of the neostriatum and substantia nigra suggests that they also play a role in the dopaminergic control of motor processes. Its precise function in cerebellum and pituitary gland is at present uncertain.

Serum concentrations of vitamins A and E and early outcome after ischaemic stroke.

Formation of free radicals and subsequent lipid peroxidation may have an important role in tissue injury and neuronal cell death after cerebral ischaemia. We conducted a prospective, controlled study to determine whether the endogenous antioxidant vitamins A and E had a protective function in acute ischaemic stroke. The study population consisted of 80 patients seen at the Free University Hospital in Brussels. Entry criteria were occurrence of sudden focal neurological deficit lasting more than 3 h; deficit due to acute ischaemia in the territory of the middle cerebral artery; and investigation within 24 h of onset of the episode. Outcome was assessed within the first 21 days. 80 controls matched for age and sex had various neurological disorders other than acute ischaemia. Serum concentrations of vitamins A and E were similar in the study and control groups. In the study population a serum vitamin A concentration higher than the mean of 2.27 mumol/l was associated with a higher frequency of complete recovery within the first 24 h (p less than 0.05), decreased mortality (p = 0.038), and a better outcome as assessed by the Mathew scale of neurological deficit (p less than 0.03) and the Barthel index. There was no significant difference in outcome between patients with vitamin E concentrations above or below the mean of 35.3 mumol/l. Our results suggest a beneficial effect of a high serum vitamin A concentration on early outcome in ischaemic stroke.

Idiopathic hemiparetic parkinsonism, a syndrome distinct from idiopathic parkinsonism.

Two women had a syndrome of progressive parkinsonism with ipsilateral rigidity, mild resting tremor, paresis, hyperreflexia, and an extensor plantar response. Symptoms had started 24 and 3 months after a surgical procedure in the affected limb. Neuroimaging studies were unhelpful. Both the parkinsonian features and the pyramidal tract signs responded well to dopaminergic drug treatment. We propose that the syndrome be called "idiopathic hemiparetic parkinsonism".

Central-nervous-system demyelination after immunisation with recombinant hepatitis B vaccine.

2 patients had neurological symptoms and signs, with evidence of central-nervous-system demyelination, 6 weeks after administration of recombinant hepatitis B vaccine. 1 had known multiple sclerosis but the other had no history of neurological disease; both had HLA haplotypes DR2 and B7, which are associated with multiple sclerosis. A causal link between vaccination and demyelination cannot be established from these 2 case-reports, but the time interval would fit a proposed immunological mechanism.