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M. Ashina. L. Bendtsen, R. Jensen, J. Olescn, Dept of Neurology, Glostrup Hospital, L'niv of Copenhagen, DK-2600 Glostrup, Copenhagen, Denmark.

Background: We have recently demonstrated that inhibition of nitric oxide synthase has an analgesic effect in chronic tension-type headache (Ashina et al.. Lancet 1999,353:287-89). Aim of Investigation: To examine whether the nitric oxide donor nitroglyccrin (NTG) may induce headache in patients with chronic tension-type headache and to compare NTG induced headache between patients and controls.

Materials and Methods: Sixteen patients with chronic tension-type headache and 16 healthy volunteers were included in a randomized double-blind, crossover trial. Patients and controls received intravenous infusion of NTG (0.5 m g/kg mm for 20 mm) or placebo on 2 days separated by at least 1 week in a randomized Cider. All subjects were examined on days without headache and they had not suffered from any type of headache for at least 12 hours prior to examination. The subjects were not allowed to take any kind of analgesics 12 hours prior to examination. The patients had never had migraine. Headache intensity was measured on a 10 point verbal rating scale during the observation (2 hours) and for the next 10 hours after the discharge. The primary endpoint was the difference between the area under the headache curve (AUC, duration times intensity) recorded on an active day and on a placebo day in patients.

Results: In patients, the median AUC on a NTG day, 2221 (1572-3704), was significantly higher than on a placebo day, 730 (60-1678), (p=0.008). Peak pain intensity occurred 8 hours after infusion of NTG. On a NTG day, the median AUC in patients, 2221 (1 572-3704), was also significantly higher than in controls, 43 (0-972), (pO.0001).

Conclusions: The present study provides further evidence that nitric oxide may paly an important role in the pathophysiology of chronic tension-type headache.


Rami Burstein. Itay Goor-Aryeh, David Yamitsky and Zahid Bajwa (Sponsor), Dept. of Anesthesia, Beth Israel Deaconess Medical Center; Dept. ofNeurobiology, Harvard Medical School, Boston, MA 02115.

Aims of Investigation: Recent studies in an animal model of migraine showed that intracranial pain is accompanied by increased skin sensitivity. These findings suggest that the pathophysiology of migraine involves not only irritation of peripheral pain fibers that supply intracranial blood vessels but also transient increase in the responsiveness (i.e., sensitization) of central neurons that process information arising from intracranial structures and skin. The purpose of the present study was to determine whether a similar increase in skin sensitivity develops in migraineurs during attacks. Methods: In 41 migraine patients we used quantitative sensory testing to study changes in mechanical and thermal pain thresholds ofperiorbital and forearm skin areas (bilaterally) in the absence of and during migraine.

Results: During migraine, 25% of the patients showed no sign of cutaneous allodynia and 75% exhibited cutaneous allodynia. In most cases, the distribution of cutaneous allodynia exceeded the referred pain area.

Conclusions: By describing patients who exhibit allodynia and patients who don't, this study suggests that the pathophysiology of migraine can involve not only peripheral but also central brainstcm and thalamic neurons. Because central scnsiti/.ation is not addressed by traditional antimigrainc therapies, it is likely that drugs that reduce central sensiti/ation benefit those exhibiting cutaneous allodynia.

Acknowledgments: Supported by NIH grants DE-10904 and NS-35611 -01.


David Yamitsky (Sponsor). Itay Goor-Aryeh, Zahid Bajwa and Rami Burstcin, Dept. of Anesthesia, Bclh Israel Deaconess Medical Center; Dept. of Neurobiology, Harvard Medical School, Boston, MA 021 15; Dept. of Neurology. Rambam Medical Center, Technion Medical School, Haifa, Israel.

Aims of Investigation: Signs ofhypcractivity in the parasympa-thetic inncrvation of the head and intracranial blood vessels arc common during migraine attacks. The purpose of the present study was to better understand the role of the intracranial parasympa-thetic innervation in the pathophysiology of migraine.

Methods: In 30 migraine patients we studied changes in pain intensity and mechanical and thermal pain thresholds ofperiorbital and forearm skin areas (bilaterally) in the absence of migraine, during migraine and after SPG block obtained by intranasal lidocame.

Results: SPG block reduced migraine pain intensity and throbbing by >60% in 11 patients, by 30-60% in 8, and by <30% in 1 1. In most cases, reduced pain intensity was noticed m the pcriorbital but not occipital region of the head. Unexpectedly, reduction in pain intensity was not accompanied by reversal of cutaneous allodynia.

Conclusions: Parasympathetic components contribute to the ongoing activation and sensiti/ation of intracranial nociccptors. The continuous state of cutaneous allodynia suggests that the maintenance of central sensitization is independent.

Acknowledgments: Supported by NIH grants DE-10904 and NS-35611-01.


MSB Florendo-Sarfati*. RM Canlas, ZG Bagabaldo*, CC Dio-quino*, MCT Lu*, UP-PGH Medical Center, Makati Medical Center, Baguio Medical Center, Philippines

Aim of Investigation: To characterize pcricranial muscle activity and pressure pain threshold among Filipino patients with tension-type headache.

Methods: This multi-center study included patients diagnosed to have tension-type headaches based on the International Headache Society criteria. Pressure pain threshold algomctry was recorded at the right and left frontalis, tcmporalis and nuchalis muscles. The amplitudes of the motor unit action potentials of the same muscles recorded by surface electromyogram were measured in the resting and contracted state. Pencranial muscle tenderness was determined by recording the total tenderness score. Similar measurements were taken among thirty age and sex matched controls.

Results: Pressure pain threshold was found to be significantly lower in patients with tension-type headache compared to controls. The amplitudes of the motor unit action potentials recorded during the resting state were also significantly higher among patients compared to controls. Only fifteen patients were noted to have pericrania] muscle tenderness.

Conclusion: Pressure pain threshold is decreased while pericranial muscle activity is increased among Filipino patients with tension-type headache. These may be factors contributing to nociception in this group of patients. Algometry and surface electromyography may be more useful than total tenderness scoring when evaluating patients with tension-type headaches. Acknowledgment: Funded by Eisai Co., Ltd.


BM Fusco. O Colantoni*, P Geppetti*', A Bianchi*2, Dcpt. Pharmac. Sciences, Un. of Salcmo, Headache Ctr Un. of Ferrara, 1st. of Pharmacol Un. of Catania

Introduction: A possible hercditability of the so-called "vasomotor" headaches has been proposed. A frequent familiar distribution of migraine has been shown and genes identified as possibly being involved in its origin,. A familiarity for migraine has been described also in some subjects affected by cluster headache (CH), even though this form seems to be a sporadic pathology. We describe two family groups where CH cases re-occurred along with a family history of migraine.

Case Description: A 54-year-old man is affected by CH from the age of 1 8. The cluster period occurred once every 2 years. His sister, mother and grandmother suffered from frequent migraines; the wife and her sister suffered from migraine too. Both his daughters, at the present aged 3 1 and 33 years, arc affected by CH. The youngest reported the onset at the age of 16 years, an occurrence of twice a year, a duration of 20-30 days; the oldest reported the onset at the age of 18: an occurrence of once every 1-2 years. A duration of about a month (during the first 15 days with the pain localised on the right side, then in the left side). The second family group includes a 50-year-old man reporting to be affected by CH during the last 15 years with an average occurrence of once a year. One uncle was affected by an analogous form. The wife suffered from severe migraine as well as her mother and brother. Their son started to suffer (at age 16) from CH-like attacks twice a day for a period of a week. One year and then again 2 1 2 years later the same attacks occurred (during a 20 days period).

Conclusion: These two familiar groups arc peculiar in two aspects:

  1. CH surprisingly re-occurred in the second and third generation;
  2. There is a significant frequency of migraine in all branches of the families. This evidence indicates that a common genetic substrate could support the "vasomotor" headache. Genetic investigation is currently in progress in these two families.


Julia Gattig. Gerhard Hege-Scheumg; Sektion Schmerztherapie. Univ fur Anasthesiologie, D-89070 Ulm, Germany

Aim of Investigation: To investigate factors that may promote the development towards an analgesic induced headache in headache patients.

Methods: We developed a written questionnaire containing 26 detailed questions on the availability of analgesics at home, use of over-the-countcr (OTC) analgesics, source of analgesics and family history of analgesic consumption. We investigated three groups: headache patients (HF.ADACHE), patients with chronic pain of other origin (OTHER) and a control group (CONTROL) with no major pain problem. Statistics: Chi-square test with Bonferroni's correction.

Results: 170 HEADACHE, 120 OTHER and 100 CONTROL completed the questionnaire. High drug availability (having always a pain killer at home) was the main factor determining use of analgesics in all three groups with a trend towards headache patients (HEADACBE/OTHER7CONTROL: 82%/73%/60%; p= 0,01; n.s.). Important factor for choosing a specific brand of analgesic in all three groups was doctor's prescription (72%'79%,'39%; n.s.) or proposals from pharmacists (54%/30%/55%: n.s.). Public advertisement, in Germany restricted to OTC-prcparations, was a minor factor for the use ofOTC-analgesics (30,6% / 12,5%/ 33%, n.s.). Family history of analgesic use was unimportant (13,5% / 4,2% / 10%, n.s.).

Conclusion: We found no specific factors for analgesic use in headache patients that differ from the two other groups. Availability of analgesics at home, doctor's prescription, pharmacists and perhaps advertising seem to determine most of the consumption characteristics of analgesics. Public health strategies to change analgesic abuse should be tailored to these factors.


D. Gharbi. 1. Fennira, V. Abdelmoula, W. Haddad, Pain Center of Rabta Junis - Tunisia.

Aim of Investigation: This work is the primary prospective study in Tunisia about clinical aspects and management of migraine. Methods: We have realized a descriptive and statistical study about a population of 50 patients who have consulted on a period of 2 years from November 1996. date of the opening of the Center, to November 1998.

Results: Such as in occidental countries, migraine in Tunisia appears to be a young woman pathology, 70% of them have a favorable evolution after a classical antimigramous treatment for a period of 6 months at less.

Conclusion: Profile of migraine in Tunisia appears to be the same as in occidental countries.


R. .Jensen. M. Ashina, L. Bendtsen, R. Ekman J. Olesen1, Dept. of Neurology, Glostrup Hospital, Univ of Copenhagen. DK.-2600 Glostrup, Denmark; Dept. of Psychiatry and Neurochemistry, Hospital, Goteborg Univ, S-41 180, Sweden.

Aim of Investigation: To compare plasma levels of substance P (SP), ncuropcptide Y (NPY) and vasoactivc intestinal polypeptide (VIP) in chronic tension-type headache patients and in healthy controls and to examine plasma levels of these neuropeptides in relation to headache state.

Methods: Blood from the peripheral circulation (antccubiial vein) and the cranial circulation (external jugular vein) was drawn from 20 patients with chronic tension-type headache and 20 healthy controls. The patients were examined on two days, one with a typical episode of tension-type headache and one without headache. Results: Plasma SP in patients, 2.0 (1.4 - 2.2) pmol liter. did not differ significantly from plasma SP in controls, 1.7(1.1 -2. 1) pmol liter, (p^O.44). SP levels were slightly but significantly lower on days with headache, 1.4 (0 - 1.9) pmol liter, than on days without headache, 1.6 (1.4 - 2.2) pmol liter, (pO.03). Plasma NPY in patients, 118=3 pmol liter, did not differ significantly from plasma NPY in controls. 1 13 ± 5 pmol liter, (p 0.40). There was no difference between NPY levels on days with headache, 120 = 3 pmol. liter, and on days without headache, 1 1 8 a- 3 pmol liter. (p =0.73). V1P levels in patients, 6 (4 - 7) pmol liter, did not differ significantly from VIP levels in controls. 5 (5 - ~) pmol liter. (p=0 50) VIP levels measured on days with headache, 5 (4 - 6) pmol/liter, did not differ significantly from VIP levels measured on days without headache, 6 (4 - 7) pmol/liter, (p=0 81) Plasma levels ofSP, NPY and VIP did not significantly differ between peripheral and cranial (external Jugular vein) circulation neither in patients or in controls (p>0 05)

Conclusions The present study indicates that plasma levels of SP, NPY and VIP are normal in chronic tension-type headache patients and largely unrelated to headache state Acknowledgments Supported by the Foundation of Jacob Madsen and his wife Olga Madsen, by the Foundation for Research in Neurology, and by the Danish Headache Society


Koji Kawai. Yuka Mori*, Kenichirou Uchida*, Yoko Morishige*, Takefumi Sakabe* (SPON: K. Kawai), Dept. of Anesthesiology-Resuscitology, Yamaguchi Univ School of Medicine, Ube, Yama-guchi, 755-8505, Japan

Aim of Investigation: Various nerve blocks have been used for the treatment ofcervicogenic headache The aim of this study is to evaluate the efficacy and safety of C2 medial rami block and C2 spinal ganglion block

Methods: Sixteen patients (eleven males and five females, 22 to 80 years of age, average 50) with cervicogemc headache were enrolled in this study The diagnosis was made on the basis of Sjaastad's criteria. In twelve patients who had no sensory disturbance on C2 area, C2 medial rami block was selected, injecting a mixture of 2 ml ofmepivacame (1%) and 1ml ofiohexol to the lateral area of the C2 spmous process In four patients who had sensory disturbance on C2 area, C2 spinal ganglion block was selected, injecting a mixture of 1 ml ofmepivacame (1%), 2mg of betamethasone and 0.5ml ofiohexol Effects were assessed by using visual analogue scale

Results: The effect of C2 medial rami block was "marked" in six patients, "moderate" in four, and "poor" in two The effect of C2 spinal ganglion block was "marked" in two patients and "moderate" in two No adverse effect was observed

Conclusions: C2 medial rami block and C2 spinal ganglion block are extremely useful therapeutic measures for cervicogenic headache


John Claude Krusz. Virginia Scott*, Jeanne Belanger*, Anodyne PamCare, 5446 Glen Lakes Dr, Dallas, TX 75231, USA

Aim of Investigation: This is the first known study using propofol (2,6 diisopropylphenol), an intravenous anesthetic agent, to treat refractory migraines and other headaches in patients treated in a headache center

Methods: 75 patients were treated for severe migraines refractory to usual therapy. Propofol was given IV in 20-30 mg doses every 3 to 4 minutes to maximum headache reduction. Propofol did not induce sleep in any patient treated Headaches were greater than 7 out of 10 (VAS) No other agents were used on the day of treatment prior to use of Propofol

Results: Average reduction in headache intensity was 95 1% (on a 0 to 10 scale) 58 of 75 patients stated their migraine was completely abolished Time to maximal reduction was 15-30 minutes and the average dose of Propofol was 95 mg Interestingly, virtually none of treated patients reported return of migraine on the day following treatment The neuropharmacology of Propofol includes agonism at GABA-A receptor subtypes, reduction in synaptic firing rates, inhibition of human platelet aggregation in vivo, stimulation of nitric oxide release, depression of spinal nociceptive neurotransmission and depression ofNMDA receptor excitation.

Conclusions: We have observed that propofol is highly effective in abolishing refractory migraine headaches. It is more effective than any other abortive agent known It works rapidly, is cost-effective and represents a new approach in headache treatment, particularly in clinic settings Moreover, its effectiveness raises many questions about the role ofGABA in headache pathophysiology


Ralph Lange* (SPON:I. Loose), Bayer AG, D-51368 Leverkusen, Joachim A Schwarz*, Michael Hohn*, Qumtiles GmbH, D-63236 Neu-Isenburg, Germany

Aim of Investigation: To generate basic data on the efficacy of 1,000 mg (2 x 500 mg) of effervescent acetylsalicylic acid in resolving acute migraine attacks and on the recurrence rate of any further attacks within 24 hours after drug administration as compared to placebo

Methods: 36 study centers in Germany recruited male or female outpatients who required oral treatment for an acute migraine attack according to the classification of the International Headache Society Pain intensity was recorded on a four-point verbal rating scale at baseline (hour 0) and 0 5, 1, 1 5, 2, 3, 4, 5, and 6 hours after mgestion of medication The number of recurrent attacks within 24 hours was recorded, as well This data was used to calculate the number ofresponders in both treatment groups, a patient was defined to be a responder when showing pain reduction from severe or moderate to mild or no pain at 2 hours after drug intake

Results: A total of 374 patients were randomised Of 368 patients completing the study 351 were evaluable One not related serious adverse event was reported Efficacy results will be presented

Conclusions: Effervescent acetylsalicylic acid 1,000 mg is a safe drug when applied to patients with acute migraine attacks

Acknowledgments: The study was supported by a grant of Bayer AG Dr Schwarz and M Hohn are consultants to Bayer AG Dr Lange is a company employee of Bayer AG


Kenneth R. Lofland. Lon A Rokicki*, Elizabeth M Semenchuk*, Lisa Garner*, & E Richard Blonsky, Pain & Rehabilitation Clinic of Chicago, 640 N LaSalle, Suite 610, Chicago, IL 60610

Aim of Investigation: To evaluate the quality of health care provided to headache sufferers

Methods: Headache sufferers (N-612) from a community sample received a free, comprehensive headache history and evaluation.

Results: Headache patients visited an average of over three health care professionals each, resulting in 2,124 recorded office visits Primary findings included 1) less than 20% of headache sufferers saw a headache specialist, 2) non-headache specialists spent half as much time with patients as headache specialists, usually 10 minutes or less, 3) 50% of patients were not informed of their headache diagnosis, 4) 20% of doctors did not recommend any form of treatment, 5) approximately 80% of health care professionals recommending treatment offered medication as the only treatment option, and 6) less than 2% of doctors recommended a combination of medication and biofeedback, irrespective of patient age Regarding outcomes. 1) 20% resulted in a treatment that had a lasting positive effect, 2) 20% resulted in a temporary positive effect, and 3) 60% resulted in a treatment that had no reported positive effect

Conclusions: Data on over 2,000 office visits demonstrated that the majority of headache sufferers are not appropriately evaluated or treated by most health care professionals, based on guidelines from the scientific literature, as well as the NIH, ACHE, NHF, and other organizations.


Yueshi Mao*. Xin Wang*, Wenbin Zhu* (Spon: Yang Joseph C S) Dept of Neurology, Zhong Shan Hospital of Shanghai Medical Univ, Shanghai 200032, P R China

Aim of Investigation: To investigate the morphological changes in 1 5T MRI and MRA of long-term migrameurs and the value of MR] and MRA in these patients.

Methods: The study consists of two groups One group was composed of 53 migrameurs without aura (according to IHS criteria) and with a history of more than 20 years, the other group was 48 healthy controls which was frequency matched in age and sex 1 5T MRI and MRA were performed in every patient during the headache-free period Signal intensities of the brain were quantita-tively measured

Results: Fifteen patients and two controls showed hypenntensity foci on T2-weighted imaging (p<0 05). The lesions were distributed in the parietal lobe, frontal, penventncular white matter and basal ganglion, with an average size of 2mm in diameter General signal intensities did not differ between the two groups Brain MRA were all normal

Conclusions: The nature of the lesions is discussed It is suggested that the long term impaired regional cerebral blood flow, abnormality of vascular tone, blood velocity and rheology may lead to thrombosis in the patients These lesions are ofischemic origin, somewhat like lacunar mfarction Whether these patients will have higher risk of stroke and the association of migraine and stroke is discussed, which we suggest that abnormal vasoconstnction may play a primary role. It is worth studying with new MR methods in migraine patients


Mongini F, Ibertis F , Poma M , Negro C , Unit for Headache and Facial Pain., Dept of Clinical Pathophysiology, Univ of Turin

Aims of investigation: 1) To assess the prevalence of accompanmg symptoms, somatic and behavioral, in patients with migraine, 2) to determine whether patient clusters can be defined, and 3) to investigate if these symptoms are related to the patient personology

Methods: In two groups of migraine patients (62 and 78, respectively) record was taken of 26 symptoms, somatic or behavioral In group 2 two psychometric tests, the MMPI and the STAI questionnaire were also administered The data were processed through a Self-Organizing Map (SOM) system, that is, a data-driven multidimensional scaling method which projects data from input space (usually high dimensional) to a lower dimensional output-space Since SOM analysis showed in both groups a potential two cluster distribution of the patients K-means cluster analysis was employed and two patient clusters were obtained in both groups Data relative to symptom prevalence and, for group 2, to MMPI and STAI scores were then assessed for each patient cluster (Student t and Chi-square analysis).

Results: In both groups one cluster had significantly higher prevalence respect to the other of the majority of the symptoms and, in particular, of weariness, sleep disorders, mood changes, anxiety, phobias, back pain, vertigo, palpitations, panic attacks, bulimia, gastritis, hair and nail fragility. In group 2 the cluster with higher symptom prevalence had significantly higher mean score of hypochondria, depression and hysteria and of State and Trait Anxiety. Headache characteristics were similar in the two groups and in all patient clusters

Conclusions: It is concluded that a distinction may be drawn between two types of migraine patients, with high and low prevalence of accompanying symptoms, respectively, and that the prevalence of these symptoms is related to the patient personology characteristics


Bemd Nagel*. Sven Khmpe, H. U Gcrbershagen, DRK-Schmerz-Zentrum, Aufder Steigl4-16, D-55131 Mainz, Germany

Aim of Investigation: This study evaluated the therapeutic outcome of 100 inpatients who took part in a comprehensive multimodal headache program (MHP) The effect of the MHP was investigated in relation to pain chronicity and headache diagnosis

Methods: 100 patients with chronic headache were evaluated before and three months after a MHP at the DRK-Pam-Center Mainz. Improvement in Health Related Quality of Life (SF-36), disability (PDI) and depression (CES-D) and a patient outcome self- assessment were used as outcome variables The pain chronicity was measured with the Mamzer Pain Staging System (MPSS I low to MPSS III high pain chronicity) (Pain Suppi, 5, 1990 328)

Results: Diagnoses were chronic tension type headache (CTTH) in 64 patients, episodic tension type headache (ETTH) in 14, migraine (Ml) in 7 and somatoformc headache disorders (SDH) in 14 patients 15 patients had a disorder of low chronicity (MPSS 1), 42 and 43 patients a MPSS score of II and 111 Before treatment patients in the MPSS groups 11 and III had significantly higher scores in the PDI, CES-D and lower scores in most of the SF-36 scales Follow-up was available in 82 patients Overall 59,8% rated the effect of the MHP as very good, good or satisfactory The self assessment was significantly different in the MPSS groups (80,0 %, 60,0 % and 54,1 % very good, good or satisfactory results for MPSS I to MPSS III) Improvement in most of the SF-36 scales, CES-D and PDI was markedly less in the MPSS groups II and III Patients with MI had had a better outcome than patients with TTH, patients with SHD reported the poorest outcome

Conclusions: The MPSS is a valuable tool in assessing the pain chronicity of a headache disorder The outcome of a MHP is influenced not only by diagnosis but even more by pain chronicity


Anke Pielsticker. Gunther Haag, Michael Zaudig, Stefan Lautenbacher (SPON H. Fruhstorfer), Psychosomatic Hospital, Windach, Germany, EIztal Klinik, Elzach, Germany, Dept of Psychiatry and Psychotherapy, Univ of Marburg, Germany

Aim of Investigation: Deficiencies in endogenous pain modulation systems, i e , in diffuse noxious inhibitory controls (DNIC) like mechanisms might be responsible for the development of chronic pain The aim of the present study on 29 patients suffering from chronic tension-type headache and on 25 healthy controls was to search for such deficiencies in headache patients

Methods: To determine detection and pain thresholds, electrical stimuli were administered either to the forearm or to the temple, using a multiple staircase procedure. Intensities varied from non-perceptible to moderately painful After baseline assessment, tonic thermal stimuli were applied concurrently by a thermode to the thigh to induce pain inhibition Tonic thermal stimuli were either slightly above (pain condition) or below pain threshold (heat condition)

Results: The increases in electrical pain thresholds induced by concurrent tonic thermal stimulation were significantly bigger in the healthy controls than in the headache patients Unexpectedly, this effect was stronger at the forearm than at the temple The electrical detection thresholds were not affected in either group

Conclusions: The results confirm previous findings that showed almost no DNIC-like pain inhibition-in fibromyalgia patients The same finding in headache patients suggests that chronic headache is also associated with deficient pain inhibitory mechanisms It has to be clarified in future studies why this deficiency was not limited to cranial sites in the headache sufferers


R Pothmann.G Bollig W Thoiss, I Vormbaum, T Vogtmann, B Kroner-Herwig, J Mau Dept of Neuropedlatncs/ Headache Project Ev Hospital, Oberhausen, Inst of Statistics, Heinnch-Heine-Univ, Dusseldorf2, Inst of Clinical Psychology, Georg-August Univ, Gottmgen3

Aim of Investigation: To investigate whether a short temporal muscle acupuncture stimulation is good clinical practice for pain-reduction compared to a nonspecific needle stimulation

Methods: Patients with acute headache got an i v -line and were randomised in three groups 1) needle at point Ex 2 bitemporally 2) needle at two nonspecific "Placebo-points" 3) needle at non-specific "Placebo-points" plus 500mg ASS mtravenously The results were rated four times within one hour after treatment by the Visual Analog Scale Surface-EMG and pressure-algometry were earned out before and after treatment.

Results: After acupuncture at Ex 2 performed 18 times in 16 patients in a pilot study, 15 patients were completely headache-free after 16 minutes The randomised placebo-controlled study with 224 included patients will be finished in 1999

Conclusion: The first results are very encouraging A simple trig-gerpomt linked acupuncture seems to fulfill the expectations for a non-medical as well as clinical additive acute headache management

Acknowledgments: Supported by a grant of the ministry of research and technology of Germany


Tamuna Saria*. Tsotne Chkhikvishvili*, Tbilisi State Medical Academy, Dept of Neurology, Tbilisi, Georgia 380079

Aim of Investigation: Statistical study of preferable treating methods of tension-type headache (As it is known, there are two approaches of curing such aches, a) medication, b) relaxation procedures; massage, water procedures, etc )

Methods: McGill Pain Questionnaires translated and adapted Georgian version was used to control and measure the intensity of tension-type headache before and after treatment.

Results: 185 patients whose diagnosis was proved by helping the diagnostic criteria, accepted by the Headache classification committee of the International Headache Society, were divided into two groups 1 First group-100 patients, using medication treatment (amitnptiline, anapnhne, benzodiazepms, etc) 2 Second group - 85 patients, using relaxation procedures Both groups were tested by McGill Pain Questionnaire before and after treatment The final investigation shows that 75% of patients in second group had low indicators of pain intensity after treatment The same result was observed in only 35% of patients of the first group

Conclusions: Taking into consideration these results it can be concluded that preferable method of curing the tension-type headache are various relaxation procedures

Acknowledgments All financial matters were arranged independently by working group (the author Tamuna Sana and Proff Tsotne Chkhikvishvili)


P.T Schmidt-Hansen. P Svensson, T S Jensen,T Graven-Nielsen, L Arendt-Nielsen, F. W. Bach, Dept of Neurology and Danish Pain Research Center, Univ Hospital ofAarhus, DK.-8000, Center for Sensory Motor Interaction, Univ ofAalborg, DK-9220

Aim of Investigation: To investigate patterns of referred pain after induction of pain in six different pericranial muscles

Methods: Twenty healthy volunteers were injected with intramuscular hypertonic saline Afterwards the extension of referred pain was drawn by subjects on standardised figures Pressure pain detection thresholds (PPT) were measured before and after injection The side-localisation, as well as the order of muscles injected were randomised

Results: The masseter muscle and anterior part of the temporal muscle showed a convincing homogenicity of the referred pain areas, whereas the other 4 examined pericrania) muscles showed less reproducible areas PPT was lowest in the stemocleid and highest in the posterior part of the temporal muscle No effect of saline injections were seen on PPT (2-way ANOVA)

Conclusion: This method of estimating referred pain following hypertonic saline induced pain in pericranial muscles is reproducible m the masseter and anterior part of the temporal muscles and may be used in further investigations of referred pain in patients with headache

Acknowledgment: Supported by Danish Pain Research Center, Aarhus Univ Hospital


Supratik Sen. Santanu Tnpathi*, Ramakrishna Mission Seva Pra-tishthan & Vivekananda Inst of Medical Sciences, 99 Sarat Bose Road, Calcutta-700003, India

Aim of Investigation: The study was aimed to assess the effect of Amitnptyline Hydrochlonde in Postdural Puncture Headache (PDPH) in a randomised, double-blind, placebo-controlled.clmical tnal Informed consent was obtained, and the Institutional Ethics Committee approved the protocol for the study

Methods: 205 consenting, consecutive, healthy (ASA1), non-depressed adult in-patients undergoing planned surgery were given Spinal Anaesthesia (SpA), with 22 gauge Qumcke's needle and 4ml heavy Bupivacame (0.5%) The intervention consisted of Amitnptyline 25mg or an inert matching placebo as a single nightly dose starting 2 days prior to the day of operation and continuing till 3rd post-operative day (5 days) The patients were closely observed and monitored by the same investigator The main end point was headache or neck pain assessed with Visual Analogue Scale (VAS) and Investigators Global Rating Scale However, complaints of headache, other associated symptoms or presence of any adverse events were recorded and treated

Result: Groups (A=102, MeanAge=48 89, M'F=46 15 53 85, Average duration=60iDin ), and (B=103, MeanAge=49 04, M F=52 48, Average duration=62.35mm) were administered either Amitnptyline or a matching placebo respectively 7 patients (A=2,B=5) were excluded as they developed other complications PDPH occurred in 3 patients in Group A (3%), while Group B had 12 patients (12 25%) There was a positive correlation in either group between VAS rating by patient (lOOwno pain) and Global rating by investigator (Oano pain) Reduction in pain intensity was significantly greater in patients randomised to Amitnptyline (/2 Test significant). Subgroup analyses of study completers supported the intention to treat.

Conclusion: The result suggests noradrenergic and serotonergic mechanisms are important in PDPH. The outcome of the study strongly recommends an alternative therapy in the management of PDPH.


HF Shien, TY Lin. C. Altien, MJTeixeira, RO Rocha, HFG Barboza. Pain Clinic and Physical Medicine & Rehabilitation Division, 10T, Hospital das Clinicas, Univ Medical School, Rua. Conselheiro Brotero 1539, cj 12, Cep 01232-010, Sao Paulo, Brazil.

Aim of Investigation: The objective of the study was the evaluation of the clinical findings and the results of a multidisciplinary approach of 20 patients with the diagnosis ofcervicogenic headache.

Methods: All patients underwent neurological and physiatnc examination, blood tests and image examination of the cervical spine skull and brain. Special attention was focused to the presence of neurological abnormalities, myofascial pain syndromes (MPS) and other abnormalities of the upper cervical spine. The pain intensity was measured by VAS and the pressure pain threshold, with a do-lorimeter, before and after the treatment. All were treated with NSAIDS and psychotropics, physical therapy and, when necessary, acupuncture and/or infiltration of the trigger points with local anesthetics.

Results: MPS was present in all of the patients. The average of VAS before the treatment was 6.5, and after, 2.9 (p< 0,001). The mean pressure pain threshold was 3.5 kg/cm2 before the treatment, and after, 4.4 kg/cm2 (not statistically significant). In 67.6% of the cases, the result of the multidisciplinary treatment was considered excellent (relief > 75% of the initial pain).

Conclusion: A multidisciplinary management is necessary for the correct diagnosis and treatment ofcervicogenic headache. The improvement of postural abnormalities and the correction of perpetuating factors of neck pain is necessary for the treatment. The dolorimetry did not reflect the improvement of symptoms in the patients.


JA Smuts*. MK Baker*, HM Smuts*, JMM Stassen*, E Rossouw*, PWA Bamard*, (SPON: D. Niv), Dept of Neurology, Univ of Pretoria, PO Box 25098, Gezina, 0031 Pretoria, South Africa; Dept of Neurology I, Military Hospital; A Central Bureau of Statistics; Private Consultants, Gezina, Pretoria, South Africa

Aim of Investigation: To evaluate BTX-A injections in the treatment of patients with CTTH.

Methods: We conducted a double-blind, placebo-controlled, randomised study involving 40 patients who fulfilled the International Headache Society criteria for chronic muscle tension headache. In addition, only patients previously treated unsuccessfully with either amitriptyline or sodium valproate were included. Eligible patients received either BTX-A (BOTOX* 100 U in 2 mL saline) or placebo (2 mL saline) as intramuscular injections at predefined areas in the neck and temporal muscles. Clinical outcome was monitored by headache diaries, chronic pain index score and monthly clinical follow-up over a period of 4 months.

Results: After 3 months' follow-up, 54% of patients in the BTX-A group responded favourably to treatment (25% response) compared with 11% in the placebo group. Furthermore, statistically significant decreases in the average pain score (p=0.0002), the average headache score (p=0.0002) and in the number of headache-free days (X2-tsst = 0.001) were achieved in the third month after BTX-A treatment compared with placebo. No serious adverse events were reported.

Conclusions: Intramuscular injections of BTX-A are an effective prophylactic treatment in CTTH and can be considered as an alternative when standard therapy has failed. Acknowledgments: Supported in part by Allergan Ltd, L'K.


George J. Urban. Seymour Diamond, Fredenck Freitag*, Merle Diamond*, Diamond Headache Clinic, Chicago, IL, 60614, USA

Aim of Investigation: To analyze the outcome of difficult headache patients.

Methods: Assessment was performed on 383 consecutive patients of the Diamond Headache Clinic.

Results: During the first 4 months of 1998, we examined and treated 383 patients, 273 (71.3%) females and 110 (28.7%) males. The average age was 39.2 years, with mean length of headache suffering of 13.7 years, that is 34% of their life. The average frequency of headache was 18.9 days per month, headache intensity 8.3 on pain scale from 0 to 10 and mean duration of 30.4 hours. Prior to initial evaluation, patients had seen an average of 2.9 physicians, and were treated with 15 different headache medications. Family history of headache was present in 67% of patients, and depression was reported in 28.2%. Hospitalization was required in 46.7% of patients. Of all patients, 27.7% dropped out of treatment and 79.1% of remaining patients improved. Analgesic dependence was diagnosed in 98 patients (25.6%), migraine headache in 329 (86%), tension-type headache in 225 (58.7%), cluster headache in 31 (8.1%), posttraumatic headache in 11 (2.9%), and other headache types in 8 (2.1%). Of 139 hospitalized patients, 78% improved within 1 month of subsequent follow up.

Conclusions: The outcome in the outpatient as well as the inpatient setting is significant improvement. Appropriate treatment should be initiated without delay to avoid the prolonged duration and disability of headache.


Hans A. van Suijlekom. Hennca C.W. de Vet*, Suzanne G.M. van den Berg*, Wilhelm E.J. Weber. Pain Management and Research Centre, dept. ofAnesthesiology, Univ Hospital Maastricht, P.O. Box 5800, 6202 AZ Maastricht, The Netherlands

Aim of the investigation: To assess interobserver reliability in distinguishing cervicogenic headache (CH) from migraine without aura and tension-type headache we conducted a study which approached daily clinical practice as close as possible.

Methods: Eighteen headache patients and five physicians participated in our 'in vivo' design experiment which we divided in three sessions with six patients and five physicians. During a session each physician queried six patients in succession using a semi-structured interview and a physical examination of the cervical spine. Physicians were then asked to reach a diagnosis according to IHS criteria and the criteria from Sjaastad and coworkers. Kappa statistics were used as a measure of interobserver agreement.

Results: Agreement in headache diagnosis showed a group kappa of 0.56. The kappa values for headache diagnosis between the different pairs of observers ranged from 0.43-0.83 (Table 1).

Table 1 Kappa values for agreement between pairs of observers

4(A) 5(A+)

(N+) = expert headache neurologist, (N) = general neurologist, (A) = expert anesthesiologist in pain treatment, (A+) = expert anesthesiologist in head pain treatment

Conclusion The results of our 'in vivo' design study showed that the reliability in diagnosing CH, when strictly applying the criteria from Sjaastad et al , is similar to the reliability in diagnosing migraine and tension-type headache according the IHS criteria


Vein A M , Solovieva A D , Filatova E G , Moscow Medical Academy, Neurology Dept

Background DHE-5-HTld receptor agonist - has marked vaso-constnctive effect in migraine (M) DHE Nasal Spray is the most convenient form for self-treatment in M subjects Aim of Investigation was to study the efficacy of DHE Nasal Spray in the treatment of M&CH attacks

Material & Methods: DHE was used for acute therapy in 45 M subjects (aged 20 - 60, 38 - F, 7 - M, 38 patients - M without aura (MO), 7 - V with aura (MA)) and 5 males with cluster headache (CH) with total amount of attacks - 68 Methods included clinical neurological examination, VAS% for pain seventy evaluation, Beck Depression Inventory, State-Trait-Anxiety-Inventory The efficacy of DHE was evaluated using 5-point verbal scale The application of DHE one injection in each nostril (equivalent to DHE 0,5 mg) m the beginning of headache attack, the additional dose was allowed in 20 mm, in case of pain resistance the procedure could be repeated in 8 hours

Results: DHE treatment was effective in 85% of cases (51 from 60 attacks were aborted) In 72% of cases pain has relieved in 45 mm (dose equivalent 1,0-2,0 mg) Al cases of MA were stopped in phase of aura CH patients have demonstrated more rapid response in 15 mm (1,0 mg) with no headache recurrence during the day Non-responders (15% - 9 MO attacks) either have broken the regime of treatment or have high levels of anxiety & depression Mild adverse events were observed in 28% of patients & included tachycardia, throat ticking, blocked nose, allergic reactions & myalgias. Only in 3 patients have stopped they treatment due to adverse events

Conclusion: Nasal Spray of DHE was show to be effective and well tolerated in the acute treatment of migraine & cluster attacks The efficacy was related to the time of application & the dosage High levels of anxiety & depression are predictors of low efficacy


Semenin Vitaly, Yuny Gorgo, Ukrainian Inst Psychiatry and Kiev State Univ, Kiev, Ukraine

The purpose of the research consisted in investigation of therapeutics possibility of different forms ofpsychogenic headache in medical influence process by means of formation and activations complexes of brain ASFRs Given method is based on the new revealed property of human brain Under the conditions of activations ofsubcortical structures and impulsive stimulation a complex of stable selective mtra-cerebral function relations is formed Curative activations courses of ASFRs were tested on 30 patients suffering from psychogenic headache Formation and curative activations of ASFR were carried out with complete or long-lasting abolition of analgesic agents In order to form ASFR 30 mg of etymisol (bis-metylamide-I-etylmidasol-4,5 ofdicarbonic acid) were made intramuscular injections After 20 mm photic impulsive stimulation with certain frequency (10-35 Hz) with 3-10 sec exposure was carried out Total number of stimulations from 5 to 10 In all cases of such photo-stimulation a considerable lowering or disappearance of headache were noted

Conducted research showed that curative activations ASFR allow to reach reproducted and quite pronounced effect in psychogenic headache treatment


MS Weaver*. D R Mehlisch. P Brown, C Hafner*, SCIREX Corporation, 3200 Red River, Austin, TX 78705, USA

Aim of Investigation: Data indicate that 78% of the general population suffer from tension-type headaches (TTH) and 16% from migraine headaches (MH) Clinical trial methodology utilized in headache models should effectively evaluate efficacy, safety, quality of life, and work productivity in an efficient time-cost manner Since research standards dictate improving state-of-the-art methodology, the present objective was to investigate innovative techniques that could improve current methodology in this model

Methods: To address time-cost issues, innovative methodology includes techniques (e g , data base, media recruitment, telephone screening, referrals and a study "run-in" phase) to identify re-sponders that are likely to demonstrate high study compliance This compliance correlates with study success rates Those meeting IHS/protocol criteria are screened in the clinic where the study is outlined, informed consent obtained, patient training provided, and examinations completed The "run-in" phase occurs prior to study drug randomization and the patient uses their headache medication under study like conditions

Results: Successful study results, coupled with reduced time-cost factors, confirm the effectiveness of this innovative methodology The results of five recent studies confirm the validity of this recruitment and screening methodology, which are summarized be-

Enrollment Period
Patients Screened Phone/Clinic
Patients Entered
Patients Evaluable
7 months
4 months
6 months
5 months
5 months

Conclusions: Advertising and patient databases are effective methods for recruiting subjects in clinical trials Results indicate that compliance is enhanced by a "run-in" phase Telephone screening procedures allow for the identification of fewer qualified patients This results in more rapid completion of studies with reduced data variation providing greater statistical power to detect treatment effects Better results, fewer sites with fewer patients, is time-cost efficiency


K.Yamada. Y. Ishihara, S. Shimada, M Matsumoto and M. Yoshioka , Dept of Anesthesiology, Otolaryngology, Neurosurgery and General Surgery, Nippon Medical School, Tama-Nagayama Hospital, Tokyo 206-8512, Japan

Aim of Investigation: This study evaluated the role of nerve blocks in the management ofcervicogenic headache in 24 patients (14 female and 10 male, 20-73 years)

Methods: When the specific pain site was localized, the patients were treated with a series of nerve blocks The blocks with local anesthetic (0 25% bupivacame) were performed with the stellate ganglion block, the greater occipital nerve block, the C2 spinal ganglion block and/or an infiltration of the trigger points

Results: Twelve patents had each an evidently past history of a whiplash injury Abnormalities of the upper cervical spine were recognized in 2 female cases. One was an os odontoideum, another was an unilateral congenital hyperplastic anomaly in which the articular process of the atlas In all cases, the pain was relieved as good (relief >50% of the initial pain) or excellent (>75% of the initial pain) by any nerve block treatment Although in two patients with congenital disorders, the temporary pain relief was obtained by nerve blocks, but the adequate pain relief was not attained for the sudden attack pain An os odontoideum was treated by surgical procedure of an atlant-axial fusion. The hyperplasia of an articular process was operated with an excision of a process and a ligature of an unilateral vertebral artery

Conclusions: Nerve block with local anesthetic is an effective method for the relief of cervicogenic headache But the satisfactory result is not obtained in the cervicogenic headache caused by structural disorders of the upper cervical spine In these cases, the surgery is indicated The correct diagnosis is important for the treatment ofcervicogenic headache


Adnan A Shakir, Jamal A Palani, Sherwan A Muhyddin, Dept of Medicine Psychiatric Unit, Medical College, Erbil, Iraq

Aim of Investigation: Is to elucidate the role of different types of Endogenous Opioids. In this study we block the receptor activity by giving pure opioid antagonist "Naloxone" to the patient who has get relieve of chronic pain "Headache" after (CS)

Methods: Fifty-four patients suffering from chronic headache first group (20 patients) where regarded as control group injected intra-venously normal saline, the next group (20 patients) injected different doses of Naloxone half an hour before (CS), third group (14 patient) injected different doses ofnaloxone after getting relieve from the headache by (CS)

Results Revealed that Naloxone in different doses (0 1, 0 2, 0 4, 08,2 mg) has no any significant effect on the reported pain level before and after (CS)

Conclusion In this study we have chosen low and moderate doses ofnaloxone since these doses can block the opioid receptor farther more high doses ofnaloxone may exert non-specific effects The administration of opioid antagonist naloxone might expected to alter the action of endogenous opioid peptides, however the detectable effect is non there appear to be several explanation for this apparent paradox. First There may be opposability of non opioid system involved in the pathology of chronic Pain Second Endogenous opioid both enhances and inhibit receptor of pain, if naloxone interfere with both to the same degree there may be little or no change, however in some other cases when the endogenous opioid system is activated by pain, stress and exercise then the effect ofnaloxone on endogenous peptides become detectable

Acknowledgment: To Dr Sherwan A Muhyddin, Dept of Pharmacology who imported the naloxone ampoule from England


Jutta Weidmann-Ahrens. Detlef Blumenberg, Dept of Anaeshesiology, Klinikum Osnabruck, Osnabruck, Academic Teaching Hosp Univ of Munster, Germany

Aim or Investigation: To investigate a step-by-step-thcrapy corresponding to the claim of maximal effectiveness and safety for a PDPH-patient

Methods: A medline research from 1960-1998 according to the content of predispositions, reasons, clinical aspects and treatments was used to create an algorithm for the diagnosis and therapy of PDPH

Results: Predispositions unintentionally dural puncture, thick needles, women and the 3rd life decade Important clinical aspects body-position-depended frontal and/or occipital headache, neck/shoulder ache Associated symptoms nausea, vomiting, dizziness, auditive and visual symptoms, cranial nerve dysfunctions and depression The spontaneous recovery rate in 5 days is 80% The aim of therapy is to reduce/stop the cerebrospmal fluid leakage Positioning (bed rest), epidural saline- and blood-placement are recommended because of good results The success rate of conservative treatment is 80%, of saline-patch 73% and of blood-patch 98% Side effects of the blood-patch neuropathic pain, meningitis, pareses, haematoma, coma, cerebral hypertension, paralysis and epidural abscess Normally these side effects are temporary but very serious

Conclusions: A principle invasive treatment cannot be justified because of the high spontaneous recovery-rate of PDPH and serious side effects of the blood-patch Therefore we recommend an algorithm for diagnosis and therapy of PDPH according to pain intensity and duration of symptoms (Fig 1)


E Cosofret, R Ailioale*. P Figueredo*, Student's Hospital, Univ of Medicine and Pharmacy, "Carol Davila", 7000 Bucharest, Romania

Aim of Investigation: To determine the specific pattern ofcepha-lalgia in the case of students from Bucharest Universitary Centre who asked medical assistance for their headache

Methods: 410 students coming from different Universities of Bucharest, capital of Romania, were investigated They were at their first referral for the evaluation and treatment of headache All the patients were interviewed by a neurologist specialized in cephalal-gia who asked them about their.general health, pain characteristics, and who determined the type ofcephalalgid We completed a pain-evaluation questionnaire and all results were included in a database with the following fields: Name, Sex, Faculty, Year of study. Type ofcephalea, Period of study (classes, examinations, holidays), Pain characteristics, Influence on their intellectual activity.

Results: The distribution by sex was 53% females and 47% males. The student during their first three years of faculty are the most affected - 67.4% of cases (19.8% in the first year, 27.8% in the second year and 19.8% in the third year). In the case of males, cephalagia was more frequent for the students at the Scientific ' Faculties-32.4% tensional cephalea and 23.5% neurasthenic cephalea. In the case of females cephalagia was more frequent for the students at the Technical Faculties-51 % tensional cephalea. The ; intensity of pain was mild to moderate in 68.9% of cases. 62% reported more than 3 attacks per month, but frequency and inten; sity of pain increased in 55.9% of cases during the school-examination period. Cephalea has decreased intellectual performances (83%), has diminished attention, ability of concentration and memory (73%). Moreover, in 24.3% of cases, the patient cannot attend classes or even exams.

Conclusions: The patient suffering from cephalalgia is a student in his/her first three years of Faculty, undergoes frequent attacks of mild to moderate intensity, which are exacerbating during the periods of school-examinations; both sexes are equally affected. Cephalea determines a decrease of the intellectual performances and even the impossibility to attend classes or school-examinations.

9th WORLD CONGRESS ON PAIN, 1999, Vienna, Austria, p. 419 - 427


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