"Are You Talking to Me?" Confronting Behavioral Disturbances in Patients With Headache

The famous question, "Are you talking to me?," was coined by Robert DeNiro in his lead role as Travis Bickle in the Martin Scorsese classic, Taxi Driver . The phrase also characterizes the troubling encounters that many headache-treating professionals confront as they attempt to discuss serious matters of care and compliance with some of their headache patients. Although most headache patients are eager to take professional advice and guidance, there exists a minority of patients whose behavior undermines a collaborative relationship between doctor and patient. In these cases, the physician may need to directly confront this behavior in order to overcome behavioral barriers that interfere with desirable treatment outcomes. This article offers explicit means and strategies to engage difficult patients, increase the likelihood of program adherence and improvement, and develop a more satisfying doctor-patient relationship, based on clinical experience in a national referral center for difficult-to-manage headache patients.     

Personality characteristics before and after treatment of different head pain syndromes

In order to examine whether, in patients with different types of headache and craniofacial pain, MMPI and STAI scores are significantly different before and after treatment, 114 patients with tension-type headache (n = 34), atypical facial pain (n = 20), temporomandibular joint dysfunction (n = 36), migraine (n = 16), cluster headache (n = 4), chronic paroxysmal hemicrania (n = 2), trigeminal neuralgia (n = 2) were examined. A pain index was calculated (0–10) which quantified pattern, duration and frequency of pain. The Italian MMPI (356 item abbreviated version) and the STAI tests were administered before and after treatment. A paired t -test was used to assess pre- and post-treatment differences, and multiple regression analysis was employed to examine whether such differences correlated with the improvement in the pain index. In the total group after treatment, there was a significant reduction of certain MMPI scores (Hs, D, Hy, Pa, Pt, Sc, Si) and of STAI 1 and 2 scores. Separate analysis confirmed this among women but not among men. No relation was found between MMPI and STAI changes and the degree of improvement as assessed through the pain index. Clinical improvement leads to normalization of MMPI profiles and STAI scores in women. The psychometric data before treatment were not predictive for treatment outcome.     

MMPI profiles in patients with headache or craniofacial pain: a comparative study

Our purpose was to examine the MMPI profiles of 157 patients with chronic headache or facial pain. The following diagnostic groups were considered: tension-type headache (n = 44); migraine + cluster headache + chronic paroxysmal hemicrania (20); trigeminal neuralgia (7); atypical facial pain (AFP) (33); temporomandibular joint dysfunction (TMJ) (53). There were two control groups: C1 of 27 healthy individuals and C2 of 18 patients with chronic pain located elsewhere. A "Pain Index" was calculated (0-10) which quantified pattern, duration and frequency of pain. The Italian MMPI abbreviated version was administered to all subjects. One-way Anova, the Duncan test and correlation analysis were performed. Of the diagnostic groups, AFP scored highest and TMJ lowest in all except three scales. In the AFP group, all neurotic scales scored above 70. The Pain Index correlated with higher scores on most scales. Chronic pain may lead to personality alterations, but some features of craniofacial pain correlate with specific personality disturbances.     

Migraine art

An analysis is made of 207 drawings and paintings entered for a migraine art competition. All types of visual disturbances were depicted. One hundred and fifty-four of the paintings showed spectral appearances with fortification or teichopsia in 99. Sixty-two showed either a partial or complete hemianopic loss. Metamorphopsia was seen in 32 and pain was depicted in some form or another in 80. Situational or trigger factors were shown in 23.     

Outcomes of visual disturbances after methanol poisoning

Introduction.?Methanol poisoning and toxic optic neuropathy is still seen worldwide. Little attention has been paid to the persistent visual disturbances following methanol poisoning. We aimed to evaluate the outcomes of visual disturbances in methanol-poisoned patients referred to us with visual disturbances. Methods.?This retrospective observational case series evaluated the outcomes of visual disturbances in patients with methanol poisoning hospitalized in Loghman Hakim and Hazrat Rasoul Akram hospitals between March 2003 and October 2009. Medical charts were evaluated for age, gender, time between consumption and hospital presentation, gastrointestinal symptoms, abnormal neurological findings at presentation and during hospital admission, arterial blood gas results, treatment modalities, history of chronic diseases, and status of vision at presentation and discharge from the hospital. The patients or their relatives were contacted 1 year after the admission date of the last patient and questioned about the status of the patients' vision at the time of hospital discharge, after discharge, and at the time of phone contacts. Results.?A total of 50 patients with methanol poisoning and visual disturbances at presentation survived. Thirty-seven cases were followed; 16 showed visual disturbance improvement before hospital discharge, and 21 had visual disturbance after discharge. Visual disturbances were classified into two groups: severe to total blindness and blurred/snowfield vision. Patients were also grouped into one of four categories: group I: patients whose blurred or snowfield vision completely recovered within up to a maximum of 2 weeks after discharge (n?=?7); group II, the patients who were blind at the time of discharge (n?=?5) and partially recovered within a maximum of 3–4 weeks; group III, the patients who were blind at the time of discharge and gained no improvement in their vision (n?=?5); group IV, who were blind at the time of discharge, partially recovered within few days to approximately 1 month and experienced reduced vision and blindness after about a maximum of 9 months (n?=?4). Patients whose visual disturbances improved with treatment and the patients in group I were considered as transient (n?=?23) and groups II, III, and IV as permanent visual disturbance cases (n?=?14). Significant difference was not seen in age, sex, elapsed time to presentation, gastrointestinal symptoms, abnormal neurological and CT findings, and arterial blood gas results at presentation between the transient and permanent visual disturbance groups. No association existed between the visual disturbance and abnormal neurological and CT findings.

Conclusion.?Blurred or snowfield vision in methanol poisoning resolved. However, outcomes of the blindness cannot be predicted. Insome patients, blindness improves but these patients eventually experience reduced vision afterwards.     

Nonpharmacologic Interventions for Improving Sleep Disturbances in Patients With Lung Cancer: A Systematic Review and Meta-analysis

Context

Lung cancer patients experience higher levels of sleep disturbances compared to other cancer patients, and this leads to greater distress, poorer function, and lower quality of life. Nonpharmacologic interventions have demonstrated improvements in the context of breast cancer, but their efficacy in the lung cancer population is unclear.

Clinical presentations of the Tourette syndrome diathesis

Psychiatric disturbances are frequent in Tourette syndrome (TS) patients but their relationship to the tic disorder is controversial. The report of a high prevalence of psychiatric disorders in TS relatives with or without tics compared with controls supports the hypothesis that neuropsychiatric disturbances are variant expressions of the TS gene. This combined with the report of a high prevalence of the tic disorder suggests that TS may contribute significantly to the etiological heterogeneity of a wide array of psychiatric disorders. The following is a report of patients who sought treatment because of disabling psychiatric symptoms and in whom the diagnosis of a TS diathesis was made for the first time as an incidental observation during the evaluation. The histories of the patients and their families provide clinical support for the hypothesis of a significant relationship between TS and psychiatric disorders and suggests that clinicians should be alert to the presence of an underlying TS diathesis in their patients.     

Use of sodium concentration and anion gap to improve correlation between serum chloride and bicarbonate concentrations

Although most acid-base disorders cause opposite and equal changes in serum chloride and bicarbonate concentrations, this inverse relationship can be distorted by changes in the anion gap and/or water balance. Therefore, we examined the relationship between chloride and bicarbonate before and after adjusting for anion gap and serum sodium concentration. Patients with abnormal electrolytes were grouped by chloride and bicarbonate concentrations (low, normal, and high). Then, chloride and anion gap-adjusted bicarbonate were adjusted for water excess (or deficit), manifesting as hyponatremia (or hypernatremia), after which patients were reclassified. Classification by chloride and bicarbonate changed in 82% of the 135 patients after adjustment for anion gap and sodium. Serum chloride and bicarbonate were each low (concordant) in 23 patients, while 18 had discordant chlorides and bicarbonates (9 low/high, 9 high/low). After adjustments, chloride and bicarbonate were discordant in 40 patients (31 low/high, 9 high/low) and concordant in none. The correlation between serum chloride and bicarbonate improved from -0.459 to -0.998 after adjustments for sodium and anion gap. A very close inverse relationship between serum chloride and bicarbonate concentrations is commonly distorted by concomitant water disturbances and anion gap acidoses in internal medicine patients admitted with electrolyte disorders.     

Post–traumatic headache from moderate head injury

The onset of post-traumatic headache occurs frequently in children, where it is often caused by severe head injuries, therefore, it is part of a post–traumatic syndrome, rather than of an independent headache and in this case no cause is clearly evident. The problem, conversely, arises in post–traumatic headache after a light trauma, since it is difficult to establish the cause–effect link. We have studied PTH incidence for one year in the patients of the emergency ward of the Saint Charles of Nancy Hospital, compared to the activity of 4 Italian headache centres. At the Saint Charles of Nancy Hospital of 98 patients with PTH after a moderate head trauma, 18 had acute and 26 chronic PTH, the majority ceased after six months. In the Italian headache centres 1,656 patients were examined, of these 3.2% suffered from PTH: 25 acute, 29 chronic. These data confirm the poor evidence of PTH after a light trauma and lead to doubt of the existence of this nosological entity.     

Risk factors related to poor outcome after methanol poisoning and the relation between outcome and antidotes – a multicenter study

Introduction. Thorough prognostic and metabolic studies of methanol poisonings are scarce. Our aims were to evaluate the factors associated with sequelae and death from methanol poisoning, to develop a simple risk-assessment chart to evaluate factors associated with sequelae and death from methanol poisoning, and to compare the antidotes ethanol and fomepizole. Patients and methods. We present a retrospective observational case series of methanol-poisoned patients from Norway (1979 and 2002–2005), Estonia (2001) and Tunisia (2003/2004), and patients from two different centers in Iran (Teheran 2004–2009 and Mashhad 2009–2010) who were identified by a positive serum methanol and had a blood acid-base status drawn on admission. The patients were divided into different groups according to their outcome: Survived, survived with sequelae, and died. Results. A total of 320 patients were identified and 117 were excluded. Of the remaining 203 patients, 48 died, and 34 were discharged with neurological sequelae. A pH <?7.00 was found to be the strongest risk factor for poor outcome, along with coma (Glasgow Coma Scale (GCS) <?8) and a pCO₂ ≥?3.1 kPa in spite of a pH <?7.00. More patients died despite hyperventilation (low pCO₂) in the ethanol group. Conclusions. Low pH (pH <?7.00), coma (GCS <?8), and inadequate hyperventilation (pCO₂ ≥?3.1 kPa in spite of a pH <?7.00) on admission were the strongest predictors of poor outcome after methanol poisoning. A simple flow-chart may help identify the patients associated with a poor outcome.     

新疆地区卵巢早衰相关因素分析

目的调查了解新疆地区卵巢早衰(POF)发病的相关影响因素,从而为其预防提供依据。方法对70例POF患者及70例正常妇女进行调查问卷,了解其详细的基本情况、生活社会环境及精神心理情绪状态,并对相关因素进行分析。结果盆腔手术史(OR=4.244、P=0.001)、精神创伤(OR=3.115、P=0.019)、腮腺炎(OR=14.276、P=0.012)、抑郁情绪(OR=2.400、P=0.012)、经常感到压力史(OR=3.692、P=0.001)、经常熬夜(OR=2.944、P=0.003)、接触有害物质(OR=3.414、P=0.042)为POF的危险因素,经常锻炼(OR=0.419、P=0.012)为其保护因素。结论尽早治疗月经紊乱、科学健康的生活习惯、良好的精神心理状态、减少有毒物质的接触、坚持锻炼是有效预防卵巢功能过早衰退的基本保障。     

老年高血压中医证候分型的粘附分子表达与血微循环的关系

目的 探讨老年高血压中医证候分型细胞间黏附分子（ICAM-1）、单核细胞趋化因子-1（MCP-1）表达水平和全血粘度与血微循环相关性。方法对156例老年高血压患者进行中医证候分型，采用双抗体夹心KIISA法检测技术测定ICAM-1、MCP-1水平；以全自动血流变仪锥板稳态测量技术检测全血粘度、红细胞变形性，从微循环角度观察血液流变学、ICAM-1表达与中医证候各型关系。结果三组ICAM-1、MCP-1明显高表达（P〈0．01），全血粘度依次为正常对照组〈肝火亢盛组〈痰湿壅盛组〈阴虚阳亢组。红细胞变形指数与正常人比较差异显著（P〈0．05）。结论老年高血压中医不同证候型与血微循环之间存在一定关系，ICAM-1、MCP-1水平高表达、血液流变异常可作为高血压早期血微循环障碍时检测指标。     

An Investigation of the Neurological and Neuropsychiatric Disturbances in Adults with Undiagnosed and/or Untreated Phenylketonuria in Poland

Background The aim of the study was to determine neurological and neuropsychiatric manifestations in a group of patients with previously undiagnosed or untreated phenylketonuria (PKU) in the south‐eastern part of Poland. Methods The study was conducted among 400 adults with severe intellectual disability who were born prior to neonatal screening and who resided in Social Welfare Homes in south‐eastern Poland. Participants were aged between 27 and 89 years (mean 51 years). The screening for PKU was performed by blood test using tandem mass spectrometry method (MS/MS) and analysis of organic acids in urine. Among all new identified untreated individuals, neurological symptoms were recorded and neuropsychiatric disturbances were assessed with The Neuropsychiatric Inventory‐Nursing Home Version (NPI‐NH). Results We found 10 previously undiagnosed and one previously diagnosed but untreated individuals with PKU (four women and seven men). The most commonly exhibited neurological manifestations included the following: profound speech disturbances, balance disturbances, muscular hypertonicity, muscular tremors and seizures. The most frequent behaviours included the following: aberrant/troublesome motor behaviour, agitation/aggression and euphoria/elation. Conclusion Data from the present study indicate that future treatment of these individuals should combine a dietary intervention with individual behavioural therapy and neurorehabilitation to improve general health and quality of life.     

Migraine and idiopathic narcolepsy--a case-control study

In order to evaluate a possible association between migraine and idiopathic narcolepsy, we performed a multicentre case-control study on the comorbidity of narcolepsy and different headaches. In total, 96 patients with idiopathic narcolepsy were enrolled. The migraine frequency in the patients and in the control group was 21.9% and 19.8%, respectively (P = 0.722). The migraine features did not differ significantly between both groups. However, headache fulfilling the criteria for tension-type headache was significantly more often reported by narcolepsy patients than by the control group (60.3% vs. 40.7%, P= 0.006). We conclude that there is no association between migraine and narcolepsy but that patients with narcolepsy show more unspecific headache, probably due to sleep disturbances.     

儿童睡眠及睡眠障碍影响因素的调查研究

目的了解乌鲁木齐市不同年龄儿童睡眠时间及睡眠障碍的发生情况，探讨其可能的影响因素。方法于2002年6月-2003年6月在乌鲁木齐市随机抽取2个行政区4000名2—12岁儿童，对其睡眠状况进行统一问卷调查。结果（1）我市各年龄儿童平均睡眠时间均低于国际标准，其主要影响因素为儿童的年龄、睡眠比和入睡时间以及父母的年龄、文化程度。（2）我市儿童睡眠障碍的总发生率为39．70％，不同年龄儿童睡眠障碍的类型有所不同。影响儿童睡眠障碍的主要因素依次为父母一方或双方睡眠障碍的存在、孩子患扁桃体炎的次数、夜问哺患发作的次数和入睡时间。结论乌鲁木齐市2-12岁儿童的睡眠时间普遍较少，睡眠障碍的发生率较高，其影响因素与孩子的年龄、睡眠习惯、健康状况及遗传等多方面因素有关，故应引起大家的共同关注，减少睡眠问题带来的健康隐患。     

Oculomotor disturbances in patients with tension headache treated with acupuncture or physiotherapy

Forty-eight female patients with chronic tension headache were randomized into two treatment groups--acupuncture and physiotherapy. The patients were examined using oculomotor tests. Intensity of the headache and tenderness of the trapezius muscles were assessed in accordance with graded scales. The mean velocity gain for smooth pursuit eye movements improved for all target velocities both in the physiotherapy group and in the acupuncture group. The latency was reduced for all three gaze angles in the physiotherapy group while no improvement occurred in the acupuncture group. There was a reduction of headache intensity in both groups while tenderness of the trapezius muscles was reduced in the physiotherapy group but unchanged in the acupuncture group. A significant correlation was found between average of the mean velocity gain and tenderness of the trapezius muscles.     

The Relationship Between Headaches and Sleep Disturbances

The relationship between headaches and sleep disturbances is complex and difficult to analyze. Both symptoms may have casual relations, or may be associated in the same patient with mutual reinforcements.
We studied 25 patients presenting with morning or nocturnal headaches. Standard headache diagnosis and polysomnography were performed. After polysomnography, the diagnoses were reevaluated.
The main headache entities were cluster, chronic paroxysmal hemicrania, migraine, tension, combined headache, and chronic substance abuse headache.
For each group, headache, sleep data, and changes in diagnosis are discussed. The diagnosis was changed in 13 patients; the final diagnoses were periodic movements of sleep, fibromyalgia syndrome, and obstructive sleep apnea. The diagnoses of cluster headache and chronic paroxysmal hemi-crania were not modified by polysomnography.
The migraine and tension headache groups had a relative male preponderance, and the diagnosis was changed in approximately half of the patients. This was also observed in combined headaches. Patients who had chronic substance abuse headaches had mainly insomnia, which in some cases, was relieved by stopping medication.
Data were also analyzed in terms of simple models linking headache and sleep disturbances. Such an approach allowed the identification of several modes of mutual interaction.
In summary, morning or nocturnal headaches are frequent indicators of a sleep disturbance and their presence might justify polysomnography, and the use of simple clinical models may be useful for understanding the complex relationship between headache and sleep.