Ear acupuncture and fMRI: a pilot study for assessing the specificity of auricular points.

In recent years research explored different acupuncture stimulation techniques but interest has focused primarily on somatic acupuncture and on a limited number of acupoints. As regards ear Acupuncture (EA) there is still some criticism about the clinical specificity of auricular points/areas representing organs or structures of the body. The aim of this study was to verify through (Functional magnetic resonance imaging) fMRI the hypothesis of EA point specificity using two auricular points having different topographical locations and clinical significance. Six healthy volunteers underwent two experimental fMRI sessions: the first was dedicated to the stimulation of Thumb Auricular Acupoint (TAA) and the second to the stimulation of Brain Stem Auricular Acupoint (BSAA). The stimulation of the needle placed in the TAA of the left ear produced an increase in activation bilaterally in the parietal operculum, region of the secondary somatosensory area SII. Stimulation of the needle placed in the BSAA of the left ear showed a pattern that largely overlapped regions belonging to the pain matrix, as shown to be involved in previous somatic acupuncture studies but with local differences in the left amygdala, anterior cingulate cortex, and cerebellum. The differences in activation patterns between TAA and BSAA stimulation support the specificity of the two acupoints. Moreover, the peculiarity of the regions involved in BSAA stimulation compared to those involved in the pain matrix, is in accordance with the therapeutic indications of this acupoint that include head pain, dizziness and vertigo. Our results provide preliminary evidence on the specificity of two auricular acupoints; further research is warranted by means of fMRI both in healthy volunteers and in patients carrying neurological/psychiatric syndromes.

Is migraine a risk factor in pregnancy?

Most epidemiological studies demonstrate that women suffering from migraine note significant improvement of their headaches during pregnancy. It is generally supposed, by both headache specialists and gynaecologists, that migraine does not involve any risk to the mother or the foetus. Specific investigations of the medical complications of pregnancy in migrainous women, however, have recently cast doubt on this assumption. Most studies, indeed, have revealed a significant association between migraine and hypertension in pregnancy (i. e., preeclampsia and gestational hypertension). Migraine has also been recently postulated as one of the major risk factors for stroke during pregnancy and the puerperium. There is thus an urgent need for prospective studies of large numbers of pregnant women to determine the real existence and extent of the risks posed by migraine during pregnancy.

Why do we need NIRS in migraine?

Migraine patients may present altered values of the parameters related to their cerebral circulation. The non-invasive assessment of the autoregulation of such patients can be helpful in investigating the causes of migraine. We developed a joint analysis protocol based on transcranial Doppler (TCD) and near-infrared spectroscopy (NIRS) for assessing cerebral autoregulation. We tested 30 healthy subjects and 30 patients suffering from migraine without aura. We measured the baseline values of cerebral blood flow velocity (CBFV) in the middle cerebral arteries and the concentration of oxygenated (oxy-Hb) and reduced (deoxy-Hb) haemoglobin in brain tissue. Afterwards, the subjects performed a breath-holding (BH) task. In baseline conditions, we did not find significant difference between the CBFVs of healthy subjects and of migraineurs, even though the latter group showed a greater dispersion of the velocities (healthy: 70.6+/-6.8 cm/s; migraine: 71.5+/-14.4 cm/s). Strong differences in the CBFV were observable during the BH task: migraineurs showed a smaller BH index than controls (0.83+/-0.55% vs. 1.29+/-0.71%; p<0.005) and a reduced increase of the oxy-Hb (migraineurs: 0.033+/-0.019 micromol/l/s; healthy: 0.055+/-0.037 micromol/l/s; p<0.01). Also, we found a different haemoglobin balancing during the BH phase between migraineurs and controls, revealing that migraineurs do not show a marked vasodilation as functional response to the CO(2) increase. We propose this joint analysis protocol to assess cerebral autoregulation of migraine patients, and suggest NIRS as a low-cost, easy, reliable and fast technique to deeply investigate cerebral coupling deregulations.

Naproxen sodium in short-term prophylaxis of pure menstrual migraine: pathophysiological and clinical considerations.

We investigated the biological and clinical effects of naproxen sodium (NxS) in the short-term prophylaxis of pure menstrual migraine (PMM) in 25 women suffering from migraine without aura, occurring exclusively from 2 days before to 5 days after menstruation onset. Daily oral NxS (550 mg) from 7 days before menstruation to 7 days after menstruation onset was given for 3 menstrual cycles, and 5 days before menstruation to 5 days after menstruation onset over the next 3 menstrual cycles. In the month before initiation of treatment and in the third month of treatment, 6-keto-PGF1(alpha), TXB(2) and PGE(2) were measured in plasma before menstruation (day -2) and on the second day (day +2) after bleeding onset. In the 20 women analysed, 6-keto-PGF1(alpha) was 17% lower (p<0.0001) and TXB(2) was 30% lower (p<0.0001) on day -2 during treatment than the same day pretreatment; TXB(2) was also lower (p<0.02) on day +2 during treatment than day +2 pretreatment. The 6-keto-PGF1(alpha)/TXB(2) ratio was higher (p<0.01) on day -2 treatment than day -2 pretreatment. PGE(2) levels were significantly lower (p<0.002) on day +2 than pre-treatment values on the same day. The number of attacks reduced from 1.7+/-0.11 pretreatment to 1.2+/-0.10 at the 3rd month (p<0.001), to 1.1+/-0.06 at the 6th month (p<0.0001). The duration reduced from 25.6+/-4.42 h pretreatment to 15.5+/-4.43 h in the 3rd month (p<0.02), to 13.35+/-4.26 h in the 6th month (p<0.001). The intensity reduced from 2.4+/-0.11 pretreatment, to 1.2+/-0.10 in the 3rd month of treatment (p<0.0001), and 1.1+/-0.07 in the 6th month (p<0.0001).

Transcranial Doppler for monitoring the cerebral blood flow dynamics: normal ranges in the Italian female population.

AIM: This study was aimed at recording, by means of a transcranial Doppler (TCD) device, the values of blood flow velocities (BFV) in the middle cerebral artery (MCA) in physiological conditions, in a population of healthy women in various ages of their life, in order to establish normative data in an Italian female population. METHODS: Our sample consisted of 100 healthy women (mean age 38 +/-15.14 years, range 12-78) that underwent an investigation of the intracranial circulation by means of TCD. Patients were subdivided into 4 age groups: less than 20 years; 20-34 years; 35-50 years; more than 50 years. RESULTS: No statistically significant differences were present between the mean BFV in the left and right MCAs of the subjects considered as a unique population (left MCA 68.06+/-9.22 cm/s; right MCA 66.71+/-8.79 cm/s). The BFVs tended to significantly decrease with the increasing of age. In fact, they were so distributed: left MCA 82.55+/-6.85 cm/s and right MCA 80.27+/-4.13 cm/s in the younger group; left MCA 72.15+/-6.37 cm/s and right MCA 70.68+/-6.79 cm/s in women aged 20-34; left MCA 63.85+/-7.08 cm/s and right MCA 63.06+/-7.29 cm/s in women aged 35-50; left MCA 60.67+/-6.85 cm/s and right MCA 59.10+/-5.36 cm/s in the last group. CONCLUSIONS: The present study defined a normal age-related range of variations in MCA BFVs, useful for future comparisons in studies involving pathological female subjects.

Advanced strategies of short-term prophylaxis in menstrual migraine: state of the art and prospects.

Patients suffering from menstrual migraine (MM) may be ideal candidates for an intermittent prophylaxis, usually termed short-term or mini-prophylaxis. It covers the whole period of vulnerability, e. g., the perimenstrual period, starting some days before the expected onset of MM attack. Theoretically MM attacks are an optimal target for drugs specifically developed for acute head pain. Unfortunately, due to their particular tendency to be longer, more intense and less responsive to analgesics, symptomatic approaches alone are not often able to completely control pain and its correlates. Many drugs have been proposed for short-term prophylaxis of MM. In this paper we analyse only non-steroidal anti-inflammatory drugs, coxibs and triptans (especially those with longer half-life, naratriptan and frovatriptan). Moreover, MM can be prevented by a variety of hormonal manipulations, including oral contraceptives, which may be administered with an extended-dosing strategy; oestrogen replacement therapy; antioestrogen agents (danazol, tamoxifen); gonadotropin-releasing hormone agonists followed by oestrogen add-back therapy. Finally, the use of some products, such as magnesium and phytoestrogens, that probably meet the requirements of those patients that appreciate a more "natural" approach, is discussed.

Oral contraceptives in women with migraine: balancing risks and benefits.

Oral contraceptives (OCs) are a safe and highly effective method of birth control, but can also be associated with some risks, mainly a potential thrombotic risk. OCs may condition the course of headache and sometimes start it, but their influence on the clinical evolution of migraine is not easily assessable. The last Classification of Headache Disorders of the International Headache Society clearly identifies an "exogenous hormone-induced headache" that could be triggered by intake of OCs. Old high-dose OCs could effectively worsen headache in a significant proportion of patients, but the newest formulations influence headache course to a lesser extent. In any case, while an increase in migraine frequency or intensity do not oblige the cessation of OCs, experiencing a migraine aura for the first time, or even a clear worsening of a preexistent aura suggest discontinuation of OCs. Even if both migraine and OCs intake are associated with an increased risk of ischaemic stroke, migraine per se is not a contraindication for OCs use; however, patients suffering from migraine with aura generally show a greater thrombotic risk than women with migraine without aura. Other risk factors (patient's age, tobacco use, hypertension, hyperlipidaemia, obesity and diabetes) must be carefully considered when prescribing OCs in migraine patients. Furthermore, all OCs, even those with low oestrogen content, are a major risk for venous thrombosis, particularly in women with hereditary thrombophilia. A thorough laboratory control of the genetics of prothrombotic factors and coagulative parameters should precede any decision of OCs prescription in migraine patients.

Picotamide in migraine aura prevention: a pilot study.

In an open, preliminary trial we evaluated the use of picotamide, an antiplatelet drug, in the prophylactic treatment of migraine aura (MA). Twenty-two women suffering from migraine with typical aura or MA without headache, diagnosed according to International Headache Society criteria, entered a nine-month study. They underwent a three-month run-in period free of prophylactic drugs, followed by a six-month treatment period (subdivided in two trimesters, TI and TII) with 300 mg of picotamide administered twice daily. A detailed diary reporting neurological symptoms, duration and frequency of MA was compiled by patients along the trial time. The number of MA significantly decreased during treatment (from 6.85+/-3.82 in the run-in trimester to 2.85+/-2.72 during TI and to 2.55+/-2.89 during TII). Also, MA duration was decreased significantly, being 36.75+/-20.28 min during run-in, 20.00+/-16.94 during TI and 17.75+/-16.26 during TII. In 25% of patients MA totally disappeared. The number and the features of aura neurological symptoms were also positively modified by the use of picotamide. No serious adverse event was provoked by picotamide administration. Picotamide is effective in reducing MA frequency, duration and symptomatology. The effect is clearly evident in the first trimester of treatment and is maintained with no further modifications during the second trimester.

Non-pharmacological approaches to chronic headaches: transcutaneous electrical nerve stimulation, lasertherapy and acupuncture in transformed migraine treatment.

In an open, randomized trial, we evaluated transcutaneous electrical nerve stimulation (TENS), infrared lasertherapy and acupuncture in the treatment of transformed migraine, over a 4-month period free of prophylactic drugs. Sixty women suffering from transformed migraine were assigned, after a one month run-in period, to three different treatments: TENS (Group T; n=20), infrared lasertherapy (Group L; n=20) or acupuncture (Group A; n=20). In each group the patients underwent ten sessions of treatment and monthly control visits. In Group T patients were treated for two weeks (5 days/week) simultaneously with three TENS units with different stimulation parameters (I: pulse rate = 80 Hz, pulse width = 120 micros; II: 120 Hz, 90 micros; III: 4 Hz, 200 micros). In Group L an infrared diode laser (27 mW, 904 nm) was applied every other day on tender scalp spots. In Group A acupuncture was carried out twice a week in the first two weeks and weekly in the next 6 weeks. A basic formula (LR3, SP6, LI4, GB20, GV20 and Ex-HN5) was always employed; additional points were selected according to each patient's symptomatology. The number of days with headache per month significantly decreased during treatment in all groups. The response in the groups differed over time, probably due to the different timing of applications of the three methods. TENS, lasertherapy and acupuncture proved to be effective in reducing the frequency of headache attacks. Acupuncture showed the best effectiveness over time.

[Migraine during pregnancy and lactation: treatment of the acute attack and non-pharmacological prophylactic strategies]. / L'emicrania in corso di gravidanza e allattamento: trattamento dell'attacco acuto e strategie non farmacologiche di profilassi.

Migraine is a typical "women's disease": the fluctuations of sex hormones, in particular estrogens, during woman's reproductive life show a direct and major influence on migraine course. Even if during pregnancy a high percentage of migraineurs report an improvement of symptomatology, it is still controversial how to manage migraine crises occurring during pregnancy, considering that almost all drugs are partially or totally contraindicated during gestation. The most important drugs employed in acute attack management (triptans, non steroidal anti-inflammatory drugs, analgesics, antiemetics, ergot derivatives and combination products) are reviewed and the indications and contraindications of their use during the 3 trimesters of pregnancy and during lactation, taking into consideration the indications of the Food and Drug Administration and of the American Academy of Pediatrics, are analysed. Furthermore, the therapeutic effects of the 2 most important non pharmacological therapies used for migraine prophylaxis, biofeedback and acupuncture, are discussed. For this latter therapy, the personal preliminary positive experience using a predetermined formula of acupoints for the combined treatment of migraine and hyperemesis gravidarum is reported.

Access to databases in complementary medicine.

Access to medical databases is a keystone for obtaining up-to-date and complete information for physicians. In the last few years, the rapid growth of the World Wide Web has given rise to an information revolution, enabling health care providers to gain access (often free) to an expanding volume of information that was previously inaccessible. Search engines and online databases assist the search for health information. In this article we examine the biomedical databases of primary interest in the field of alternative and complementary medicine, dividing them into Web accessible and nonaccessible databases and emphasizing the freely available ones. A further classification is major biomedical bibliographic databases specific to complementary medicine, and dedicated therapy or modality-specific databases.

Two-dimensional echocardiographic evaluation of right ventricular ejection fraction: comparison between three different methods.

Twelve patients with chronic cor pulmonale due to chronic obstructive pulmonary disease have been examined with 2D echocardiography, performing four-chamber view by apical and subcostal approaches, and the right ventricular outflow tract view by the subcostal approach. These views have permitted evaluation of right ventricular volumes, and hence right ventricular ejection fraction, by the use of three different geometrical formulae: the biplane area-length method, Simpson's rule and the pyramidal method. The ejection fraction values obtained from each method have been compared to those obtained by equilibrium radionuclide angiocardiography. Four-chamber apical and subcostal views were satisfactorily recorded in 10 of the 12 patients (83.3%), and right ventricular outflow tract view in 8 patients (66.6%). No significant statistical differences have been found between measurements obtained from the three different echocardiographic examinations performed on each subject by the same operator, so demonstrating a satisfactory reproducibility of the technique. The highest correlation coefficient for ejection fraction was shown by Simpson's rule (r = 0.96, p less than 0.001), with a very narrow confidence intervals, while the r values for the biplane area-length method was 0.63 (p less than 0.05) and for the pyramidal method 0.50 (not statistically significant), with increasingly wider confidence intervals. The statistically significant difference between the three correlation coefficients demonstrates the higher accuracy of Simpson's rule for the determination of right ventricular ejection fraction.

Angioscintigraphic assessment of arterial and portal liver blood flow: comparison with splanchnic angiography.

In order to validate an angioscintigraphic method for the evaluation of the components of hepatic blood flow, the results of angioscintigraphy were compared with splanchnic angiography in 25 cirrhotics. Two indices of hepatic portal perfusion and a splenohepatic arterial index were calculated. These were correlated with portal diameter and hepatic artery diameter, respectively. No correlation was found between grades of portal perfusion according Nordlinger's criteria and these indices. The method is very simple and could be applied to evaluate the changes of liver hemodynamics induced by drugs or shunt surgery.

[Dissecting aneurysm of the thoracic aorta with paraplegic onset. Diagnosis using computerized tomography]. / Aneurisma dissecante dell'aorta toracica ad inizio paraplegico. Diagnosi mediante tomografia computerizzata.

A case of dissecting aneurysm of the thoracic aorta (De Bakey type III) which first presented as paraplegia of the lower extremities, and the diagnosis of which was confirmed by computerised tomography, is reported. Examination of the literature confirms the rarity of neurological complications especially as an initial symptom. The ischaemia involving areas supplied by the intercostal arteries must be the pathogenetic mechanism of both the paraplegia and the significant increase in sero-enzymes (CPK-MB). The case observed confirms the opinion of other authors that computerised tomography permits rapid diagnosis. As it is also easily performed and not invasive it represents an alternative to conventional angiography.