Primary systemic amyloidosis presenting with demyelinating features.

PURPOSE: Primary systemic amyloidosis is a rare disorder that has multisystemic manifestations. The most common neuropathy in systemic amyloidosis is a small-fiber axonal polyneuropathy. When the neuropathy is the presenting feature, diagnosis is usually delayed. The diagnosis of systemic amyloidosis may be more difficult when patients present with an atypical polyneuropathy. METHODS: Two cases of primary systemic amyloidosis with a multifocal polyneuropathy with demyelinating features are presented. RESULTS: The patients reported in this series with autopsy proven amyloidosis had evidence of a polyneuropathy with demyelinating features. CONCLUSIONS: Amyloidosis should be considered in the differential when a patients presents with a polyneuropathy that has demyelinating features.

Concomitant administration of antiemetics is not necessary with intramuscular dihydroergotamine.

The influence of concomitant administration of an antiemetic agent on the course of nausea was assessed in a field trial of intramuscular dihydroergotamine for the treatment of acute migraine. Of 311 migraine patients enrolled onto the study, 62% (191 of 311) experienced nausea at the outset; 38% (119 of 311) did not. Of those with nausea at the outset, 54% (103 of 191) received an antiemetic. Of those without nausea at the outset, 25% (30 of 119) received an antiemetic. Thus, a total of 43% (133 of 311) of patients received a concomitant antiemetic, whereas 57% (177 of 311) received dihydroergotamine alone. When changes in the incidence of nausea were compared at 30 and 60 minutes after dihydroergotamine, an antiemetic effect was discerned in patients treated with or without a concomitant antiemetic. Antiemetic treatment yielded no significant difference in the percentage of patients experiencing nausea during the study. At baseline, 50% (88 of 177) of patients who received dihydroergotamine alone experienced nausea compared with 77% (103 of 133) of those who received an antiemetic. At the 30-minute point, 35% (61 of 173) of patients who received dihydroergotamine alone still experienced nausea versus 47% (62 of 133) of patients who received an antiemetic. At the 60-minute point, only 24% (42 of 174) of those given dihydroergotamine alone had nausea, compared with 38% (50 of 132) given concomitant antiemetic. Ongoing nausea seems to be a manifestation of the migraine process rather than an adverse effect associated with intramuscular dihydroergotamine.(ABSTRACT TRUNCATED AT 250 WORDS)

Office-based treatment of acute migraine with dihydroergotamine mesylate.

The Regional Migraine Field Trial assessed the efficacy and safety of dihydroergotamine mesylate (D.H.E. 45) for migraine in the office setting. Patients were admitted to the study provided they met the International Headache Society definition of migraine with or without aura. Thirty-eight neurologists enrolled 311 patients (274 women and 37 men) between the ages of 13 and 70 years in this open-design study. Ninety-five percent of the patients had moderate or severe headache pain at entry, and 62% had nausea. All patients received a single intramuscular injection of D.H.E. 45 1 mg. A second intramuscular injection of 1 mg was given 60 minutes after the first injection, if needed. An antiemetic was administered concomitantly with D.H.E. 45, if needed. Rescue therapy was given at the investigators' discretion. Efficacy was judged by the relief of pain, patients' ability to function, need for a second injection, need for rescue medication, and need for an antiemetic. At 30 and 60 minutes, 46% and 72% of patients had only mild or no head pain, respectively. At 24 hours, 77% of all patients had mild or no head pain. D.H.E. 45 also improved functional ability. At 30 and 60 minutes, 58% and 75% of patients had only mild or no disability, respectively. At 24 hours, 81% had mild or no impairment. Nausea was present in 62% of patients at the outset, 40% of patients at 30 minutes, and 30% at 60 minutes. An antiemetic was given to 43% of patients at the outset. The presence of nausea was similar whether or not patients received an antiemetic.(ABSTRACT TRUNCATED AT 250 WORDS)

Cluster headache following head injury: a case report and review of the literature.

A relation between head trauma and cluster headache is frequently described in the literature. The percentage of cluster patients with a history of head injury is approximately 16.5 when several large studies are reviewed. The present paper reports another case where there is close proximity between head injury and the onset of cluster headache. A review of the literature attempts to document the supposition that there is indeed a causal or precipitous role for head injury in cluster cephalgia pathogenesis.

Self-administration of parenteral ketorolac tromethamine for head pain.

Sixty-one separate self-injections of ketorolac tromethamine (Toradol) by 16 patients diagnosed with episodic migraine with or without aura were evaluated over a 90-day period for safety, efficacy of pain reduction, and the ability of this therapy program to prevent the necessitation of emergency room acute care. Prior to initiation of treatment, patients were formally instructed on intramuscular injection techniques by a member of our nursing staff. Patients were instructed to call upon the onset of a severe headache interfering with daily functioning and, then, were permitted to proceed with the injection. Headache intensity ratings were collected prior to injection and intermittently for the following twenty-four hours. The results demonstrate safety and efficacy of this form of therapy. A significant percent of ketorolac usages (64%) resulted in a good response and significant reduction in head pain. Twenty-three percent of ketorolac usages resulted in a mild response and only 13% of usages provided no relief. Furthermore, 13% of all usages failed to prevent the necessitation for emergency room treatment. The results are discussed in terms of the impact of self-injection on pain relief and substantial cost-reduction by decreasing emergency room utilization.

Phenelzine therapy for headache patients with concomitant depression and anxiety.

Eleven patients with refractory chronic daily headache, associated depression, and generalized anxiety were treated with phenelzine. Ten patients (91%) had a greater than or equal to 50% improvement in headache frequency, seven (64%) had a similar degree of improvement in mood and headache intensity or activity level. Orthostatic hypotension was the most common side effect and necessitated discontinuation of therapy in two patients. One patient suffered a hypertensive crisis which was easily managed and caused no permanent sequelae. Based on these preliminary results, we conclude that phenelzine is effective in the treatment of chronic daily headache with associated depression and anxiety, but further investigations are needed to determine if there is selective efficacy of phenelzine for this subgroup of patients.

Atypical MRI findings of venous sinus thrombosis in pregnancy: clinical significance relating to episodic vascular headache.

Two cases of headache during pregnancy were associated with MRI findings suggestive of venous sinus thrombosis. The findings, however, were atypical, and of uncertain clinical significance. Venous sinus thrombosis typically does not occur during the first and second trimesters (less than 10 percent of reported cases). Thus, these two cases are doubly unusual. The correct significance of these equivocal MRI findings of possible venous sinus thrombosis must be understood so that unnecessary and potentially harmful therapies are not employed, and so that appropriate management of what may otherwise be a typical vascular headache syndrome may be undertaken.