Migraine prevention

Preventive medications reduce migraine frequency and severity, and improve migraine-specific quality of life. Recent evidence also suggests that these same medications enhance the patient's response to acute migraine therapies, and may also reduce the likelihood of developing chronic daily headache. However, many patients who should receive or be offered preventive treatment are not. Most patients can be successfully managed when patient and physician expectations are realistic and aligned, the selection of preventive medications is individualised, and the initiation and titration strategy is appropriate and carefully followed. Rational combinations of preventive medications may also be useful. This review provides an evidence and experience-based approach to the preventive treatment of migraine.     

Stroke prevention

Stroke prevention is a crucial issue because (i) stroke is a frequent and severe disorder, and (ii) acute stroke therapies that are effective at the individual level have only a little impact in term of public health. Stroke prevention consists of the combination of 3 strategies: an optimal management of vascular risk factors, associated when appropriate with antithrombotic therapies, carotid surgery, or both. Primary prevention trials have shown that reducing blood pressure in hypertensive subjects reduces their vascular risk, including stroke. The association of perindopril plus indapamide reduces the vascular risk in patients who have had a stroke or TIA during the last 5 years, irrespective of their baseline blood pressure. Lowering serum cholesterol with statins or gemfibrozil in patients with hypercholesterolemia or coronary heart disease (CHD), reduces the risk of stroke. However, no trial of cholesterol-lowering therapy has been completed in stroke patients. A strict control of high cholesterol levels should be encouraged, because of benefits in terms of CHD. Statins should be prescribed for stroke patients with CHD, or increased cholesterol levels. Cigarette smoking is associated with an increased risk of stroke and should be avoided. Careful control of all risk factors, especially arterial hypertension in type 1 and type 2 diabetics is recommended, together with a strict glycemic control to reduce systemic microvascular complications. Estrogens prescribed in hormone replacement or oral contraceptive therapies are not recommended after an ischemic stroke. It is also recommended to reduce alcohol consumption and obesity, and to increase physical activity in patients at risk for first-ever or recurrent stroke. An optimal management of risk factors for stroke is crucial to reduce the risks of first-ever stroke, recurrent stroke, any vascular event after stroke and vascular death. One of the major public health issues for the coming years will be to focus more on risk factor recognition and management. Received: 29 November 2001, Accepted: 7 December 2001     

Polypill strategy vs. prevention clinics for stroke prevention

Thirty years of clinical trials have demonstrated that stroke can be prevented by reducing blood pressure to less than 140/90 mm Hg or by a further decrease of 10/5 mm Hg when blood pressure is controlled, by reducing LDL cholesterol by at least 1 mmol/l (39 mg/dl), and by inhibiting platelet aggregation. The (too simplistic) concept of the polypill strategy combining pharmacologic agents to achieve these goals is supposed to reduce the risk by 80% overall. However, reducing general salt and sugar intake, giving up smoking, developing prevention clinics with prevention nurses to improve adherence to preventive treatments, as well as decreasing poverty and malnutrition, increasing the level of hygiene, fighting against infectious diseases and financially helping developing countries are all combined necessary approaches to decrease the worldwide burden of stroke and other vascular diseases.     

Starting prevention work

This article provides basic, practical guidelines for starting prevention work; it draws upon ten years' experience of professional staff members at a community mental health center. Difficulties that stand in the way of prevention are first discussed. The difficulties include professional habits, defenses, and taboos, as well as lack of theory, training, and institutional support. The main body of the article provides examples of effective and ineffective ways of starting prevention, that is, promoting mental health in the community. Recommendations are made for using a normal developmental life-crisis framework, and starting small action models that can later be generalized to diverse settings and have potential for long-lasting effects in the community.The article is based on the author's experience as Clinical Psychologist, San Mateo County Mental Health Services, Daly City, California.     

Primary stroke prevention

Stroke is one of the leading causes of death and disability worldwide. Although important advances in therapeutic approaches have been made, treatment is still far from satisfactory. Thus, major efforts should be made on stroke prevention. We present evidence-based recommendations for primary stroke prevention. Changes to modifiable risk factors, the role of drugs and surgery are discussed. New markers may help identification of subjects at high risk.     

The correlation between general disease prevention and prevention of HIV-contagion among adolescents

A representative group of young persons (N = 745), who used the youth clubs in Copenhagen were asked to fill in a structured questionnaire. A large group of the young had had their sexual debut (N = 367). In respect of this group we found no correlation between prevention regarding general health risk factors vs. prevention against HIV contraction. It is discussed as to whether this difference can be accepted as an expression of the fact that adolescents do not consider the risk of AIDS as something that can affect them. Similarly, current problems in the chain of knowledge, attitude and behaviour in relation to intervention programmes are also discussed, including ethical aspects.     

Nutrition and stroke prevention

Nutrition is much more important in prevention of stroke than is appreciated by most physicians. The powerful effects of statin drugs in lowering the levels of fasting cholesterol, combined with an unbalanced focus on fasting lipids (as opposed to postprandial fat and oxidative stress), have led many physicians and patients to believe that diet is relatively unimportant. Because the statins can lower fasting lipids by &50% to 60%, and a low-fat diet only lowers fasting cholesterol by &5% to 10%, this error is perhaps understandable. However, a Cretan Mediterranean diet, which is high in beneficial oils, whole grains, fruits, and vegetables and low in cholesterol and animal fat, has been shown to reduce stroke and myocardial infarction by 60% in 4 years compared with the American Heart Association diet. This effect is twice that of simvastatin in the Scandinavian Simvastatin Survival Study: a reduction of myocardial infarction by 40% in 6 years. Vitamins for lowering of homocysteine may yet be shown to be beneficial for reduction of stroke; a key issue is the high prevalence of unrecognized deficiency of vitamin B(12), requiring higher doses of vitamin B(12) than have been used in clinical trials to date. Efforts to duplicate with supplementation the evidence of benefit for vitamins E, C, and beta carotene have been largely fruitless. This may be related to the broad combination of antioxidants included in a healthy diet. A Cretan Mediterranean diet is probably more effective because it provides a wide range of antioxidants from fruits and vegetables of all colors.     

The prevention of schizophrenia

Preventive strategies can be divided into universal, selective and indicated prevention and early intervention. Universal interventions are directed to the general population. Selective approaches are targeted at people who have risk factors for an illness, but who do not show any current signs. Indicated approaches target high risk individuals with minimal signs or symptoms foreshadowing mental disorder, but who do not meet diagnostic levels at the current time. Early intervention involves treating those with already diagnosable disorder in a timely and optimal manner aiming to decrease the severity of the illness, and reduce secondary morbidity. Although universal and selective interventions are not yet viable strategies, indicated prevention and early intervention are now realistic possibilities in schizophrenia. Development of methods to identify those at risk of psychosis continues to evolve. Promising results in the prevention and delay of transition to psychotic disorder from high risk state have been found. Early intervention in schizophrenia, including promotion of early help-seeking, has been shown to reduce the duration of untreated psychosis, which is known to be associated with poor outcome in schizophrenia. Early intervention programmes which optimise the care of the first episode have been shown to produce better outcomes than routine management.