Diagnosis and treatment of disorders of intracranial pressure: consensus statement of the Spanish Society of Neurology's Headache Study Group.

Primary intracranial pressure disorders include idiopathic intracranial hypertension and spontaneous intracranial hypotension. Remarkable advances have been made in the diagnosis and treatment of these 2entities in recent years. Therefore, the Spanish Society of Neurology's Headache Study Group (GECSEN) deemed it necessary to prepare this consensus statement, including diagnostic and therapeutic algorithms to facilitate and improve the management of these disorders in clinical practice. This document was created by a committee of experts belonging to GECSEN, and is based on a systematic review of the literature, incorporating the experience of the participants, and establishes practical recommendations with levels of evidence and grades of recommendation.

[New therapeutic era for migraine attacks with recently approved monoclonal antibodies, ditans and gepants]. / Nueva era terapéutica para el ataque de migraña con los recientemente aprobados anticuerpos monoclonales, ditanes y gepantes.

Treatment of migraine attacks is advised in all patients, using non-steroidal anti-inflammatory drugs when the pain is mild and triptans when the pain intensity is moderate-severe. However, the effectiveness of these drugs is moderate, a high percentage of patients have side effects, and triptans are contraindicated in people with a history of stroke, ischaemic heart disease or poorly controlled hypertension. Hence, there is an urgent need for new therapeutic alternatives. In recent years, new drugs for migraine attacks have become available, most notably ditans (lasmiditan) and gepants (ubrogepant and rimegepant). Furthermore, eptinezumab, which has been approved for the preventive treatment of migraine in adults, has also been used for migraine attacks. This manuscript reviews the efficacy and safety results of the new drugs for migraines that will soon be on the market.

TITLE: Nueva era terapéutica para el ataque de migraña con los recientemente aprobados anticuerpos monoclonales, ditanes y gepantes.El tratamiento de los ataques de migraña se aconseja en todos los pacientes, utilizando antiinflamatorios no esteroideos cuando el dolor es leve y triptanes cuando la intensidad del dolor es moderada-grave. Sin embargo, la efectividad de estos fármacos es modesta, un porcentaje elevado de pacientes presenta efectos secundarios y los triptanes están contraindicados en las personas con antecedentes de ictus, cardiopatía isquémica o hipertensión mal controlada. Por tanto, es imprescindible disponer de nuevas alternativas terapéuticas. En los últimos años han ido apareciendo nuevos fármacos para los ataques de migraña, entre los que destacan los ditanes (lasmiditán) y los gepantes (ubrogepant y rimegepant). Por otro lado, el eptinezumab, que ha sido aprobado para el tratamiento preventivo de la migraña en adultos, se ha utilizado también para los ataques de migraña. En este manuscrito se revisan los resultados de eficacia y seguridad de los nuevos fármacos para los ataques de migraña que se comercializarán próximamente.

Characterisation of the management of patients with migraine in the primary care setting in Spain. Analysis of the results of the European My-LIFE anamnesis project.

INTRODUCTION: Migraine affects more than 4.5 million people in Spain, resulting in a considerable socioeconomic impact. Although national and international guidelines have been published, the management of patients with migraine, especially those with chronic migraine, is inadequate. SUBJECTS AND METHODS: We conducted a survey among 40 primary care (PC) physicians in Spain as part of a European project involving 201 physicians from 5 countries. RESULTS: Most participants issued diagnoses of episodic migraine and chronic migraine (93% vs 65%); 82.5% indicated that they did not refer these patients to specialists, and 100% of PC physicians stated that they were responsible for patient follow-up. The main tools used in PC for diagnosis and follow-up were clinical interviews, medical histories, and the patient diaries. Our data revealed that the treatments prescribed were not in accordance with the national and international guidelines. Participants who did not refer patients estimated that only 48% of patients received preventive treatment, and that the assessment of efficacy was based on patient perception. Seventy percent of respondents indicated a need for migraine training. Finally, 100% of participants considered that a guide for medical history taking and referral would be essential or useful for the management of migraine in PC. CONCLUSIONS: The survey results revealed a need for training and guidance in PC to improve the diagnosis and management of patients with migraine, particularly chronic migraine.

Calcitonin gene-related peptide in migraine: from pathophysiology to treatment.

INTRODUCTION: It has been observed in recent years that levels of such molecules as calcitonin gene-related peptide (CGRP) and, to a lesser extent, the pituitary adenylate cyclase-activating peptide are elevated during migraine attacks and in chronic migraine, both in the cerebrospinal fluid and in the serum. Pharmacological reduction of these proteins is clinically significant, with an improvement in patients' migraines. It therefore seems logical that one of the main lines of migraine research should be based on the role of CGRP in the pathophysiology of this entity. DEVELOPMENT: The Spanish Society of Neurology's Headache Study Group decided to draft this document in order to address the evidence on such important issues as the role of CGRP in the pathophysiology of migraine and the mechanism of action of monoclonal antibodies and gepants; and to critically analyse the results of different studies and the profile of patients eligible for treatment with monoclonal antibodies, and the impact in terms of pharmacoeconomics. CONCLUSIONS: The clinical development of gepants, which are CGRP antagonists, for the acute treatment of migraine attacks, and CGRP ligand and receptor monoclonal antibodies offer promising results for these patients.

CGRP en migraña: de la fisiopatología a la terapéutica / Calcitonin gene–related peptide in migraine: from pathophysiology to treatment

Introducción: En los últimos años se ha observado que moléculas como el péptido relacionado con el gen de la calcitonina (CGRP) y, en menor grado, el péptido activador de la adenilato-ciclasa pituitaria estaban elevadas durante los ataques de migraña y en la migraña crónica tanto en líquido cefalorraquídeo como en suero y que su reducción farmacológica tenía una significación clínica con una mejoría en la migraña de los pacientes. Es lógico por tanto que una de las principales líneas de investigación en migraña se base en el papel del CGRP en la fisiopatología de esta entidad. Desarrollo: Desde el Grupo de Estudio de Cefaleas de la Sociedad Española de Neurología nos planteamos la redacción de este documento, cuyo objetivo es abordar, basándonos en la evidencia publicada, cuestiones tan importantes como el papel del CGRP en la fisiopatología de la migraña, el mecanismo de acción de los anticuerpos monoclonales y de los gepantes, el análisis crítico de los resultados de los diferentes estudios, el perfil del paciente que podría ser candidato al tratamiento con anticuerpos monoclonales y su impacto en términos de farmacoeconomía. Conclusiones: El desarrollo clínico de los gepantes, antagonistas del CGRP, para el tratamiento agudo del ataque de migraña y de los anticuerpos monoclonales contra ligando y contra el receptor del CGRP ofrecen resultados esperanzadores para nuestros pacientes. (AU)

Introduction: It has been observed in recent years that levels of such molecules as calcitonin gene–related peptide (CGRP) and, to a lesser extent, the pituitary adenylate cyclase–activating peptide are elevated during migraine attacks and in chronic migraine, both in the cerebrospinal fluid and in the serum. Pharmacological reduction of these proteins is clinically significant, with an improvement in patients’ migraines. It therefore seems logical that one of the main lines of migraine research should be based on the role of CGRP in the pathophysiology of this entity. Development: The Spanish Society of Neurology's Headache Study Group decided to draft this document in order to address the evidence on such important issues as the role of CGRP in the pathophysiology of migraine and the mechanism of action of monoclonal antibodies and gepants; and to critically analyse the results of different studies and the profile of patients eligible for treatment with monoclonal antibodies, and the impact in terms of pharmacoeconomics. Conclusions: The clinical development of gepants, which are CGRP antagonists, for the acute treatment of migraine attacks, and CGRP ligand and receptor monoclonal antibodies offer promising results for these patients. (AU)

1st Post-European Headache Federation Meeting: a review of the latest developments presented at the 2020 European Headache Federation Congress. / I Reunión Post-European Headache Federation: revisión de las novedades presentadas en el Congreso de la European Headache Federation de 2020.

INTRODUCTION: After the European Headache Federation (EHF) Congress, renowned Spanish neurologists specialised in migraine presented the most significant latest developments in research in this field at the Post-EHF Meeting. DEVELOPMENT: The main data presented concerning the treatment of chronic and episodic migraine were addressed, with attention paid more specifically to those related to preventive treatments and real-life experience in the management of the disease. An important review was carried out of the new therapeutic targets and the possibilities they offer in terms of understanding the pathophysiology of migraine and its treatment. An update was also presented of the latest developments in the treatment of migraine with fremanezumab, a monoclonal antibody recently authorised by the European Medicines Agency. Participants were also given an update on the latest developments in basic research on the pathology, as well as an overview of the symptoms of migraine and COVID-19. Finally, the repercussions of migraine in terms of its burden on the care and economic resources of the health system were addressed, along with its impact on society. CONCLUSIONS: The meeting summarised the content presented at the 14th EHF Congress, which took place in late June/early July 2020.

TITLE: I Reunión Post-European Headache Federation: revisión de las novedades presentadas en el Congreso de la European Headache Federation de 2020.Introducción. Tras la celebración del congreso de la European Headache Federation (EHF), reconocidos neurólogos españoles expertos en el tratamiento de la migraña expusieron en la Reunión Post-EHF las principales novedades presentadas en el congreso y relacionadas con ese ámbito. Desarrollo. Se abordan los principales datos presentados relacionados con el tratamiento de la migraña crónica y episódica; concretamente, los relacionados con los tratamientos preventivos y la experiencia en vida real en el manejo de la enfermedad. Se hizo una importante revisión de las nuevas dianas terapéuticas y las posibilidades que ofrecen en cuanto al conocimiento de la fisiopatología de la migraña y su tratamiento. Asimismo, se hizo una actualización de las novedades presentadas en el tratamiento de la migraña con fremanezumab, anticuerpo monoclonal recientemente autorizado por la Agencia Europea de Medicamentos. Se hizo una actualización de las novedades en investigación básica en la patología, así como una relación de los síntomas de migraña y COVID-19. Finalmente, se abordaron las implicaciones de la migraña en la carga sanitaria asistencial y económica, y su impacto en la sociedad. Conclusiones. En la reunión se hizo un resumen del contenido presentado en el 14 Congreso de la EHF, que tuvo lugar a finales de junio y principios de julio de 2020.

I Reunión Post-European Headache Federation: revisión de las novedades presentadas en el Congreso de la European Headache Federation de 2020 / 1st Post-European Headache Federation Meeting: a review of the latest developments presented at the 2020 European Headache Federation Congress

Introducción: Tras la celebración del congreso de la European Headache Federation (EHF), reconocidos neurólogos españoles expertos en el tratamiento de la migraña expusieron en la Reunión Post-EHF las principales novedades presentadas en el congreso y relacionadas con ese ámbito. Desarrollo: Se abordan los principales datos presentados relacionados con el tratamiento de la migraña crónica y episódica; concretamente, los relacionados con los tratamientos preventivos y la experiencia en vida real en el manejo de la enfermedad. Se hizo una importante revisión de las nuevas dianas terapéuticas y las posibilidades que ofrecen en cuanto al conocimiento de la fisiopatología de la migraña y su tratamiento. Asimismo, se hizo una actualización de las novedades presentadas en el tratamiento de la migraña con fremanezumab, anticuerpo monoclonal recientemente autorizado por la Agencia Europea de Medicamentos. Se hizo una actualización de las novedades en investigación básica en la patología, así como una relación de los síntomas de migraña y COVID-19. Finalmente, se abordaron las implicaciones de la migraña en la carga sanitaria asistencial y económica, y su impacto en la sociedad. Conclusiones: En la reunión se hizo un resumen del contenido presentado en el 14 Congreso de la EHF, que tuvo lugar a finales de junio y principios de julio de 2020.(AU)

Introduction: After the European Headache Federation (EHF) Congress, renowned Spanish neurologists specialised in migraine presented the most significant latest developments in research in this field at the Post-EHF Meeting. Development: The main data presented concerning the treatment of chronic and episodic migraine were addressed, with attention paid more specifically to those related to preventive treatments and real-life experience in the management of the disease. An important review was carried out of the new therapeutic targets and the possibilities they offer in terms of understanding the pathophysiology of migraine and its treatment. An update was also presented of the latest developments in the treatment of migraine with fremanezumab, a monoclonal antibody recently authorised by the European Medicines Agency. Participants were also given an update on the latest developments in basic research on the pathology, as well as an overview of the symptoms of migraine and COVID-19. Finally, the repercussions of migraine in terms of its burden on the care and economic resources of the health system were addressed, along with its impact on society. Conclusions: The meeting summarised the content presented at the 14th EHF Congress, which took place in late June/early July 2020.(AU)

Documento de revisión y actualización de la cefalea por uso excesivo de medicación (CUEM) / Document of revision and updating of medication overuse headache (MOH)

Introducción: La cefalea con uso excesivo de medicación es una cefalea secundaria en la que el uso regular o frecuente de medicación analgésica produce un aumento de la frecuencia de una cefalea de base, pasando de episódica a crónica. La prevalencia de esta entidad está en torno al 1-2%, siendo más frecuente en mujeres entre 30 y 50 años con comorbilidades psiquiátricas como depresión o ansiedad y otros procesos de dolor crónico. Es importante conocer el manejo de esta entidad. Por este motivo, el Grupo de Estudios de Cefaleas de la Sociedad Española de Neurología ha pretendido realizar este documento de consenso sobre esta patología.DesarrolloEsta guía ha sido redactada por un grupo de expertos a partir de la revisión de la evidencia científica publicada y estableciendo recomendaciones prácticas para su adecuado manejo y tratamiento. El tratamiento de la cefalea con uso excesivo de medicación tiene varios pilares fundamentales y suele ser complejo: información y educación sobre el desarrollo de la cefalea con uso excesivo de medicación, tratamiento preventivo, suspensión del fármaco de uso frecuente y tratamiento de deshabituación. Es importante el seguimiento de pacientes con riesgo de recurrencias.ConclusionesEsperamos que este documento resulte de utilidad y permita su aplicación práctica en la consulta diaria y que sirva para actualizar y mejorar el conocimiento del manejo de esta patología. (AU)

Introduction: Medication overuse headache is a secondary headache in which the regular or frequent use of analgesics can increase the frequency of the episodes, causing the transition from episodic to chronic headache. The prevalence of medication overuse headache is approximately 1-2%, with higher rates among women aged 30-50 years and with comorbid psychiatric disorders such as depression or anxiety, or other chronic pain disorders. It is important to be familiar with the management of this disease. To this end, the Spanish Society of Neurology's Headache Study Group has prepared a consensus document addressing this disorder.DevelopmentThese guidelines were prepared by a group of neurologists specialising in headache after a systematic literature review and provides consensus recommendations on the proper management and treatment of medication overuse headache. The treatment of medication overuse headache is often complex, and is based on 4 fundamental pillars: education and information about the condition, preventive treatment, discontinuation of the drug being overused, and treatment for withdrawal symptoms. Follow-up of patients at risk of recurrence is important.ConclusionsWe hope that this document will be useful in daily clinical practice and that it will update and improve understanding of medication overuse headache management. (AU)

Document of revision and updating of medication overuse headache (MOH). / Documento de revisión y actualización de la cefalea por uso excesivo de medicación (CUEM).

INTRODUCTION: Medication overuse headache is a secondary headache in which the regular or frequent use of analgesics can increase the frequency of the episodes, causing the transition from episodic to chronic headache. The prevalence of medication overuse headache is approximately 1-2%, with higher rates among women aged 30-50 years and with comorbid psychiatric disorders such as depression or anxiety, or other chronic pain disorders. It is important to be familiar with the management of this disease. To this end, the Spanish Society of Neurology's Headache Study Group has prepared a consensus document addressing this disorder. DEVELOPMENT: These guidelines were prepared by a group of neurologists specialising in headache after a systematic literature review and provides consensus recommendations on the proper management and treatment of medication overuse headache. The treatment of medication overuse headache is often complex, and is based on 4 fundamental pillars: education and information about the condition, preventive treatment, discontinuation of the drug being overused, and treatment for withdrawal symptoms. Follow-up of patients at risk of recurrence is important. CONCLUSIONS: We hope that this document will be useful in daily clinical practice and that it will update and improve understanding of medication overuse headache management.

Calcitonin gene-related peptide in migraine: from pathophysiology to treatment. / CGRP en migraña: de la fisiopatología a la terapéutica.

INTRODUCTION: It has been observed in recent years that levels of such molecules as calcitonin gene-related peptide (CGRP) and, to a lesser extent, the pituitary adenylate cyclase-activating peptide are elevated during migraine attacks and in chronic migraine, both in the cerebrospinal fluid and in the serum. Pharmacological reduction of these proteins is clinically significant, with an improvement in patients' migraines. It therefore seems logical that one of the main lines of migraine research should be based on the role of CGRP in the pathophysiology of this entity. DEVELOPMENT: The Spanish Society of Neurology's Headache Study Group decided to draft this document in order to address the evidence on such important issues as the role of CGRP in the pathophysiology of migraine and the mechanism of action of monoclonal antibodies and gepants; and to critically analyse the results of different studies and the profile of patients eligible for treatment with monoclonal antibodies, and the impact in terms of pharmacoeconomics. CONCLUSIONS: The clinical development of gepants, which are CGRP antagonists, for the acute treatment of migraine attacks, and CGRP ligand and receptor monoclonal antibodies offer promising results for these patients.

[Triptans in clinical practice: effectiveness, tolerance and patient's satisfaction with medication (TRIPRACLI study)]. / Los triptanes en la practica clinica: eficacia, tolerancia y satisfaccion del paciente con los farmacos (estudio TRIPRACLI).

INTRODUCTION AND AIMS: This study was aimed determining the effectiveness, tolerance and satisfaction of patients with migraine as regards different triptans, according to the characteristics of their attacks. At the same time it sought to establish a predictive model that can be used to recommend one or another, depending on those characteristics. PATIENTS AND METHODS: Retrospective observation-based study conducted in headache units in a number of different centres. Patients included in the study were those with migraine who used the same triptan to treat their attacks. Data concerning preference, effectiveness, speed and tolerance were analysed. RESULTS: The analysis included 160 patients (88 females), with a mean age of 42.92 years. The most commonly used triptans were eletriptan, almotriptan and rizatriptan. Both patients and doctors reported a high degree of satisfaction (88% and 65%) with the triptan that was used. In the surveys on preference, patients preferred their current triptan to the previous one (83%) or to non-specific drugs. The overall score on a visual analogue scale was above 7 for all the triptans, without any differences from one to another. On analysing the use of a particular triptan depending on the characteristics of the attacks, no statistically significant differences were found. CONCLUSIONS: In this selected group of patients, triptans are a treatment that patients claim to be very satisfied with. Although there are no overall differences in the scores among different triptans, the fact that certain triptans are used more by patients after previous experiences with others suggests that they are more effective. We did not find any parameter that predicts the use of a particular triptan.

Migraña crónica, un nuevo concepto necesario / No disponible

No disponible

The impact of allodynia on the efficacy of almotriptan when given early in migraine: data from the "Act when mild" study.

The objective of this study was to evaluate the impact of allodynia on treatment outcomes in the patients with acute migraine treated in the "Act when Mild" (AwM) study. AwM, a randomized placebo-controlled trial, studied almotriptan 12.5 mg in the early treatment (within 1 hr) of acute migraine when the pain was still mild, and investigated clinical outcomes in the presence or absence of allodynia, which was prospectively recorded using patient questionnaires. Of the total population, 39% (n = 404) reported allodynia that did not alter the efficacy of almotriptan administered for early/mild pain in terms of 2-hr pain-free rates (53.9% for allodynic patients vs. 52.5% for nonallodynic patients). Similarly, sustained pain-free rates were 47.2% versus 45.5%, and migraine duration 1.40 versus 1.54 hr, respectively. However, allodynia impaired the effectiveness of almotriptan in the patients with moderate/severe pain in terms of longer migraine duration, fewer patients achieving pain-free status, and more requiring rescue medication. In conclusion, the lack of effect of allodynia on the efficacy of almotriptan given for early/mild migraine pain might help explain the improved outcomes associated with the early-treatment strategy in AwM. Moreover, the data suggest that pain intensity is the main driver of triptan response, and not the presence or absence of allodynia.

Efficacy of almotriptan in early intervention for treatment of acute migraine in a primary care setting: the START study.

AIMS: The benefits of taking almotriptan early for acute migraine when pain is mild have clearly been demonstrated in the neurology setting. The aim of this study was to determine whether similar benefits with early intervention of almotriptan can be achieved in everyday general practice, where most migraineurs are managed. METHODS: In this European, prospective, observational study, patients were asked to treat up to three migraine attacks over a 2-month period with almotriptan 12.5 mg administered within 1 h of pain onset and when pain was mild (early + mild intervention group). RESULTS: A total of 501 patients were enrolled in primary care centres across Spain, France and Italy. The intention-to-treat analysis involved 454 patients who reported 1174 migraine attacks, with early intervention being used in 138 of these attacks. A greater proportion of patients who took almotriptan early + mild for their first migraine attack (n = 42) were pain free at 2 h compared with those in the non-early + mild intervention group (n = 410) (62% vs. 35%; p < 0.001). Similar results were obtained for all migraine attacks comparison [65% (n = 138) vs. 38% (n = 1036); p < 0.001]. Other secondary end-points were also significantly in favour of early + mild treatment, including sustained pain free (SPF), SPF with no adverse events (SNAE), and time lost because of migraine (all p < 0.001). Almotriptan was well tolerated with no serious adverse events reported. CONCLUSIONS: In the primary care setting, early intervention with almotriptan for treatment of migraine provides significant clinical benefits compared with delaying treatment and/or waiting until pain intensity has progressed beyond mild.

[Pharyngeal-cervical-brachial variant of Guillain-Barré syndrome: a well-defined clinical condition with a heterogeneous immunological profile]. / Variante faringocervicobraquial del síndrome de Guillain-Barré: una entidad clínica bien definida con un perfil inmunológico heterogéneo.

INTRODUCTION: The pharyngeal-cervical-brachial variant of Guillain-Barre syndrome (GBS) is rare. This variant has its own specific clinical aspects but a heterogeneous immunological profile. CASE REPORT: A 38-year-old male who presented progressive symptoms of dysphagia, dysphonia and weakness hindering movement of the upper limbs. Two weeks earlier, the patient had presented acute self-limiting diarrhoea. He displayed predominantly right-side bilateral peripheral facial paresis, and paresis of the 9th and 12th cranial nerves and upper limbs (proximal 0/5, distal 1/5), although strength in the lower limbs was not compromised; sensitivity was preserved and deep tendon reflexes were diminished (0 in the upper limbs and + in the lower extremities). At 24 hours after admission, he suffered severe respiratory distress and had to be moved to the Intensive Care Unit with invasive mechanical ventilation. An electronystagmography/electromyogram study revealed severe demyelinating damage that predominantly involved the brain, but also included a small axonal component. The most striking immunological finding was the presence of positive IgG anti-GQ1b, IgM anti-GMI and IgM anti-asialo GM1 titres. CONCLUSIONS: The pharyngeal-cervical-brachial variant is a clinical condition with its own clinical characteristics and well-established diagnostic criteria that allow it to be distinguished from the other variants of GBS. Our case highlights the wide clinical spectrum of acute inflammatory demyelinating polyradiculoneuropathies and the important degree of heterogeneity that exists as regards the immunological parameters.

Variante faringocervicobraquial del síndrome de Guillain-Barré: una entidad clínica bien definida con un perfil inmunológico heterogéneo / Pharyngel-cervical-brachial variant of guillain-barre syndrome: A well-defined clinical condition with a heterogeneous immunological profile

Introducción. Una variante poco frecuente del síndrome de Guillain-Barré (SGB) es la faringocervicobraquial. Dicha variante posee aspectos clínicos específicos, pero un perfil inmunológico heterogéneo. Caso clínico. Varón de 38 años de edad que presentó cuadro progresivo de disfagia, disfonía y debilidad para movilizar las extremidades superiores. Dos semanas antes, presentó un cuadro diarreico autolimitado. Mostraba paresia facial periférica bilateral de predominio derecho, y paresia de los IX y XII pares craneales y de miembros superiores (proximal 0/5, distal 1/5), sin afectación de la fuerza en miembros inferiores, sensibilidad conservada y reflejos osteotendinosos disminuidos (0 en miembros superiores y + en inferiores). A las 24 horas de ingreso sufrió deterioro respiratorio grave, que requirió traslado a la Unidad de Cuidados Intensivoscon ventilación mecánica invasiva. La electronis-tagmografía/electromiograma mostró un grave daño desmielinizante de predominio cefálico y cierto componente axonal. Inmunológicamente destacó la presencia de títulos positivos de IgG anti-GQ1b, IgM anti-GM1 e IgM anti-asialo GM1. Conclusiones. La variante faringocervicobraquial es una entidad clínica con características clínicas propias y criterios diagnósticos establecidos que permiten distinguirla de las otras variantes del SGB. Nuestro caso pone de relieve el amplio espectro clínico de las polirradiculoneuropatías desmielinizantes inflamatorias agudas y la gran heterogeneidad existente respecto a parámetros inmunológicos

Introduction. The pharyngeal-cervical-brachial variant of Guillain-Barré syndrome (GBS) is rare. This variant has its own specific clinical aspects but a heterogeneous immunological profile. Case report. A 38-year-old male who presented progressive symptoms of dysphagia, dysphonia and weakness hindering movement of the upper limbs. Two weeks earlier, the patient had presented acute self-limiting diarrhoea. He displayed predominantly right-side bilateral peripheral facial paresis, and paresis of the 9th and 12th cranial nerves and upper limbs (proximal 0/5, distal 1/5), although strength in the lower limbs was not compromised; sensitivity was preserved and deep tendon reflexes were diminished (0 in the upper limbs and + in thelower extremities). At 24 hours after admission, he suffered severe respiratory distress and had to be moved to the Intensive Care Unit with invasive mechanical ventilation. An electronystagmography/electromyogram study revealed severe demyelinating damage that predominantly involved the brain, but also included a small axonal component. The most striking immunologicalfinding was the presence of positive IgG anti-GQ1b, IgM anti-GMI and IgM anti-asialo GM1 titres. Conclusions. Thepharyngeal-cervical-brachial variant is a clinical condition with its own clinical characteristics and well-established diagnostic criteria that allow it to be distinguished from the other variants of GBS. Our case highlights the wide clinical spectrum of acute inflammatory demyelinating polyradiculoneuropathies and the important degree of heterogeneity that existsas regards the immunological parameters

Early vs. non-early intervention in acute migraine-'Act when Mild (AwM)'. A double-blind, placebo-controlled trial of almotriptan.

The study was designed to compare the response to almotriptan in migraine patients who take medication early in the course of the attack with that when medication is taken after pain has become moderate or severe. A randomized, four-arm, multicentre, multinational, double-blind, placebo-controlled trial of almotriptan (12.5 mg) comparing treatment administration when pain intensity was mild and within 1 h of headache onset vs. pain that had become moderate or severe was conducted. Of 491 migraineurs enrolled, 403 were evaluable [intention-to-treat population (ITT)]. Their mean age was 38 years, 84% were female and they had a mean of 3.7 attacks/month. Of these patients, 10% did not take medication according to their randomly allocated basal pain intensity (mild or moderate/severe) and were subsequently reassigned to that group for this analysis-'Act when Mild (AwM)' group. In the almotriptan arms, 53% of mild basal pain and 38% of moderate/severe basal pain patients were pain free at 2 h (P = 0.03; primary end-point). Corresponding proportions in the placebo groups were 25% and 17% (statistically significant vs. respective almotriptan arms). Secondary end-points (ITT) were also significantly in favour of early intervention with almotriptan, both between and across treatment groups, such as sustained pain free: 45.6% vs. 30.5% (P = 0.02). Adverse events were reported in < 5% of treated patients in all groups (NS), with no serious events. Treatment with almotriptan while migraine pain is still mild provides statistically significant and clinically relevant enhancements in efficacy compared with treatment when pain has reached higher severity levels.

[Symptomatic treatment of migraine with zolmitriptan: experience with 82 patients]. / Tratamiento sintomático de la migraña con zolmitriptán: experiencia con 82 pacientes.

OBJECTIVES: To analyze our experience with the new, 5 mg intranasal formulation of zolmitriptan in the symptomatic treatment of migraine attacks. PATIENTS AND METHODS: This series includes 82 patients who had treated an average of 7 migraine attacks. Eighty patients had taken oral triptans and 20 subcutaneous sumatriptan. The main reasons for using nasal zolmitriptan were: poor efficacy of oral triptans (41.5 % of the patients), use of subcutaneous sumatriptan (24.4%) or medical criteria (34.5%). RESULTS: Among the 80 patients who had been treated with oral triptans, 50 (62.5 %) preferred nasal zolmitriptan, 14 (17.5 %) oral triptans and the remaining 16 (20 %) did not express any preference. The main reasons for this preference were shorter speed of action and better efficacy. Within those 20 patients who were using subcutaneous sumatriptan, 8 (40 %) preferred subcutaneous sumatriptan, 5 (25%) nasal zolmitriptan and 7 (35%) did not express any preference. The reasons for preference of intranasal zolmitriptan over subcutaneous sumatriptan were greater convenience, better tolerability and lower price. A total of 55 patients noticed efficacy within 60 min. Half experienced at least one adverse event, always mild. The most frequent were local: bad taste (n=23) or nasal irritation/itching (n=8). CONCLUSIONS: The new intranasal formulation of 5 mg zolmitriptan is a good option for the symptomatic treatment of migraine, which could be considered as an intermediate between oral triptans and the subcutaneous formulation of sumatriptan.

Tratamiento sintomático de la migraña con zolmitriptán: experiencia con 82 pacientes / Symptomatic treatment of migraine with zolmitriptan: experience with 82 patients

Objetivos. Analizar nuestra experiencia con la nueva formulación nasal de zolmitriptán de 5 mg en el tratamiento sintomático de las crisis de migraña. Pacientes y métodos. La serie incluye 82 pacientes que habían tratado una media de siete crisis. Un total de 80 habían tomado triptanes orales y 20 sumatriptán subcutáneo. Las razones principales para la utilización de zolmitriptán nasal fueron: pobre eficacia de los triptanes orales (41,5% de los pacientes). de sumatriptán subcutáneo (24,4 %) o bien criterio médico (34,1%). Resultados. De los 80 pacientes que se habían tratado con triptanes orales, 50 (62,5%) prefirieron la formulación nasal de zolmitriptán, 14 (17,5%) los triptanes orales y los 16 restantes (20%) no expresaron preferencia. Las principales razones para la preferencia del zolmitriptán nasal fueron una mayor rapidez de acción y eficacia. De los 20 pacientes que usaban sumatriptán subcutáneo, 8 (40%) prefirieron éste, 5 (25 %) zolmitriptán nasal y 7 (35 %) no expresaron preferencia. Las razones para la preferencia de zolmitriptán nasal sobre sumatriptán subcutáneo fueron: mayor comodidad, menos efectos adversos y menor precio. Un total de 55 pacientes notaron eficacia antes de 60 mino La mitad de los pacientes aquejaron algún efecto adverso, siempre leves. Los más frecuentes fueron locales: mal sabor (n = 23) o irritación/picor nasal (n=8). Conclusiones. La formulación nasal de zolmitriptán de 5 mg es una nueva opción para el tratamiento sintomático de las crisis de migraña, que pudiéramos considerar como intermedia entre los triptanes orales y la formulación subcutánea de sumatriptán

Objectives: To analyze our experience with the new, 5 mg intranasal formulation of zolmitriptan in the symptomatic treatment of migraine attacks. Patients and methods: This series includes 82 patients who had treated an average of 7 migraine attacks. Eighty patients had taken oral triptans and 20 subcutaneous sumatriptan. The main reasons for using nasal zolmitriptan were: poor efficacy of oral triptans (41.5 % of the patients), use of subcutaneous sumatriptan (24.4%) or medical criteria (34.5%). Results: Among the 80 patients who had been treated with oral triptans, 50 (62.5 %) preferred nasal zolmitriptan, 14 (17.5 %) oral triptans and the remaining 16 (20 %) did not express any preference. The main reasons for this preference were shorter speed of action and better efficacy. Within those 20 patients who were using subcutaneous sumatriptan, 8 (40 %) preferred subcutaneous sumatriptan, 5 (25%) nasal zolmitriptan and 7 (35%) did not express any preference. The reasons for preference of intranasal zolmitriptan over subcutaneous sumatriptan were greater convenience, better tolerability and lower price. A total of 55 patients noticed efficacy within 60 min. Half experienced at least one adverse event, always mild. The most frequent were local: bad taste (n=23) or nasal irritation/itching (n=8). Conclusions: The new intranasal formulation of 5 mg zolmitriptan is a good option for the symptomatic treatment of migraine, which could be considered as an intermediate between oral triptans and the subcutaneous formulation of sumatriptan