Early Responses in Randomized Clinical Trials of Triptans in Acute Migraine Treatment. Are They Clinically Relevant? A Comment

(Headache 2010;50:1198‐1200) One can question the clinical relevance of early headache responses after oral and intranasal triptans. Thus, for pain‐free the early responses were significant but in absolute values they were only a few percentages: the therapeutic gains (TGs) were 1.8% (95% CI = 0.3‐3%) for oral almotriptan 12.5 after 30 minutes and 1.0% (95% CI = 0‐2%) after intranasal zolmitriptan 5 mg after 15 minutes. These results are compared with subcutaneous sumatriptan 6 mg which has TGs of 11% (95% CI = 7‐15%) to 14% (95% CI = 11‐17%) for pain‐free after 30 minutes. Subcutaneous sumatriptan has a 2 times higher response rate than intranasal zolmitriptan and is 5 times more effective than oral almotriptan at these early time points. It is concluded that if a very early and clinically relevant effect is desired then the migraine patient should use the subcutaneous administration form of sumatriptan.     

Exercise in Migraine Therapy—Is There Any Evidence for Efficacy? A Critical Review

Background.— Some migraine patients find that regular exercise helps in reducing the frequency of headache attacks. In addition, exercise in migraine is recommended from many headache experts. However, most of these recommendations refer to some anecdotal reports or observational studies in literature stating that regular exercise can reduce the frequency and severity of migraine.
Objective.— The purpose of this review is to investigate whether recommendations for exercise in migraine are based on sufficient data to cope with requirements of an evidence-based modern migraine therapy. The review summarizes and discusses all available trials on this topic.
Results.— Eight studies und 4 case reports investigated the therapeutic role of aerobic exercise on migraine headache. Some results are controversial regarding the efficacy of sports intervention in migraine. The majority of studies did not find a significant reduction of headache attacks or headache duration and only indicate a reduction of pain intensities in migraine patients due to regular exercise. The grade of recommendation of exercise in migraine based on evidence based medicine (EBM)-criteria is presently B-C. But due to methodological limitations, the available data are insufficient for a final statement on this topic.
Conclusions.— To further recommend exercise in migraine based on EBM-criteria, more studies are imperative. Future studies should adhere to the rules for randomized clinical trials in pharmacological migraines prophylaxis. Implications for further studies are given.     

Selecting Patients for Rehabilitation After Acute Stroke: Are There Variations in Practice?

Ilett PA, Brock KA, Graven CJ, Cotton SM. Selecting patients for rehabilitation after acute stroke: are there variations in practice?

Objective

To investigate whether there were variations in practice in selection for rehabilitation after stroke, after adjustment for case mix.

Design

Prospective multicenter audit.

Setting

Seven acute stroke units in metropolitan and regional Victoria, Australia.

Participants

Consecutive acute stroke admissions (N=616).

Interventions

None.

Main Outcome Measures

Mobility Scale for Acute Stroke Score and Modified Barthel Index (MBI) scores for continence at day 3 poststroke, discharge destination from the acute hospital.

Results

Data were analyzed for 616 stroke survivors. Considerable variability in the percentage of cases accessing inpatient rehabilitation was observed in severe stroke (27%-67%) and mild stroke (27%-73%). To assess adjustment for case mix, a multinomial logistic regression was conducted with the outcome variable being discharge destination (home, rehabilitation, or nursing home), and the predictors being Mobility Scale for Acute Stroke Score, MBI continence scores, age, and social situation. The overall amount of variability explained in discharge destination by the predictors was 63% (Nagelkerke pseudo R²). The regression analysis was repeated, adding unit code as a predictor. Unit code was a significant contributor to the model (P<.01).

Conclusion

The results of the study indicate that, after adjusting for case mix, there may be variations in practice in selection for rehabilitation leading to inequities of access.     

Are There Differences in Arteriovenous Fistulae Created for Hemodialysis between Nephrologists and Vascular Surgeons?

ObjectiveMany studies have reported insufficient support from surgical services, resulting in nephrologists creating arteriovenous fistulas in many centers. The aim of this study was to compare risk factors of arteriovenous fistula dysfunction in patients whose fistulas were created by nephrologists versus vascular surgeons.MethodsThis was a retrospective, analytical study of interventions by nephrologists and vascular surgeons during a period of 15 years. Out of a total of 1,048 fistulas, 764 (72.9%) were created by nephrologists patients, while vascular surgeons were responsible for 284 (27.1%) fistulae. Laboratory, demographic, and clinical parameters which might affect functioning of these arteriovenous fistulae were analyzed.ResultsPatients whose arteriovenous fistula was formed by nephrologists differed significantly from those created by vascular surgeons in relation to the preventive character of the arteriovenous fistula (p = 0.011), lumen of the vein (p < 0.001) and systolic blood pressure (p = 0.047). Multivariate logistic regression of arteriovenous fistula dysfunction showed that risk factors were female gender (odds ratio [OR] = 1.56, 95% CI 1.16–2.07), whether the fistulae were created by vascular surgeons or nephrologists (OR = 1.38; 95% CI 1.01–1.89) and the site of the arteriovenous fistula (OR = 0.64; 95% CI 0.48–0.85).ConclusionsArteriovenous fistulae created by vascular surgeons, female gender, and the location are risk factors of dysfunction.     

What Are We Missing in the Diagnostic Criteria for Migraine?

Purpose of Review

This review is intended to examine how the diagnostic criteria for migraine have evolved over the past 45 years and to evaluate the strengths and weaknesses of the current diagnostic criteria promulgated by the International Classification of Headache Disorders (ICHD).

Recent Findings

The ICHD is a comprehensive and systematic classification system for headache disorders. As the pathophysiology of migraine is more fully elucidated and more sophisticated diagnostic technologies are developed (e.g., the identification of biomarkers), the current diagnostic criteria for migraine will likely be further refined. The ICHD has allowed for more precise research study design in the field of headache medicine.

Summary

The current diagnostic criteria for migraine outlined in the 3rd version of the ICHD are far more sensitive and specific than the clinical criteria proposed in 1962. In future iterations, dividing episodic and chronic migraine into subtypes based on frequency (i.e., low frequency vs high frequency; near-daily vs daily) potentially could assist in guiding clinical management. In addition, a better understanding of aura, vestibular migraine, migrainous infarction, and hemiplegic migraine likely will lead to more refined diagnostic criteria for those entities.

     

Are There Sex Differences in Affective Modulation of Spinal Nociception and Pain?

Sex differences in the processing and experience of emotion exist. The present study examined whether sex differences in emotion lead to sex differences in affective modulation of pain and spinal nociception (assessed by nociceptive flexion reflex, NFR). Participants were healthy men (n = 47) and women (n = 73). Prior to affective modulation testing, electrocutaneous pain sensitivity was assessed (NFR threshold, pain threshold, pain tolerance). Affective modulation of pain and NFR was then assessed by presenting pictures that vary in emotional valence and arousal (mutilation, attack, death, neutral, families, adventure, erotica) during which suprathreshold electrocutaneous stimulations were delivered. Subjective emotional reactions were assessed after every picture, and nociceptive reactions were assessed after every suprathreshold stimulus. Results indicated women had greater pain sensitivity and also responded more negatively to attack pictures and less positively to erotic pictures. But despite these differences, affective modulation of pain/NFR was not moderated by sex: erotic pictures inhibited pain/NFR and mutilation pictures enhanced pain/NFR. Together, this implies subjective emotional experience does not completely mediate picture-evoked modulation of pain/NFR, a supposition that was further supported by exploratory analyses that demonstrated picture-evoked modulation of pain/NFR was present even after controlling for intra- and inter-individual differences in emotional reactions to pictures. Implications and limitations of these findings are discussed.     

Are Antiepileptic Drugs Used in the Treatment of Migraine Associated with an Increased Risk of Suicidality?

Three antiepileptic drugs (AEDs), valproic acid, gabapentin, and topiramate (TPM), are used frequently in the prophylactic treatment of migraines. In December 2008, the US Food and Drug Administration issued a warning suggesting that the use of all AEDs is associated with an increased risk of suicidal ideation and behavior. This warning has been received by the medical community with great skepticism, and the validity of the findings of the meta-analysis that led to its publication has been questioned because of various methodological problems. Yet, migraine by itself is associated with an increased risk of suicidal ideation and behavior as well as with an increased risk of psychiatric disorders that facilitate the development of suicidal behavior. Furthermore, TPM has been associated with psychiatric adverse events that potentially could result in suicidal ideation and behavior. In this article, we review data to determine whether the AEDs used in the prevention of migraine are associated with an increased risk of suicidality.     

Are Live Instructors Replaceable? Computer vs. Classroom Lectures for EFAST Training

Background: The EFAST (extended focused assessment with sonography for trauma) is part of the recommended curriculum for Emergency Medicine and Surgery residents. Computer-based lectures may represent a time-efficient alternative to traditional lectures. Objectives: Our hypothesis was that computer lectures in basic ultrasound and the EFAST are not inferior to classroom lectures in test score improvement for residents with or without prior training. Methods: First-year Emergency Medicine and Surgery residents were enrolled and completed a pre-test. Subjects were then randomized into a classroom group, which attended traditional lectures, and a computer group, which listened to narrated lectures on computers. After the didactic training, all subjects completed a post-test. Results: Forty-four subjects completed the study: 64% were General Surgery residents, 66% were male. Overall, mean test score improvements were higher in the classroom than in the computer group (28.0% vs. 18.4%). In 25 residents without prior training, mean improvements in the computer and classroom groups were 25% and 27%, respectively. The 95% confidence limit around the difference was 9%, falling within the a priori non-inferiority range of 10%, and consistent with non-inferiority of computer-based lectures. In 19 residents with prior training, mean test score improvements for the computer and classroom groups were 13% and 29%, respectively. The 95% confidence limit of 24% exceeded the non-inferiority range, consistent with inferiority of computer-based lectures. Conclusions: Computer-based lectures are not inferior to classroom lectures and may represent a worthwhile substitution in subjects without prior ultrasound education. Our data suggest that didactic ultrasound training through classroom lectures is more effective than computer-based lectures in individuals with prior training.     

Did Going North Give Us Migraine? An Evolutionary Approach on Understanding Latitudinal Differences in Migraine Epidemiology

This commentary discusses a recent publication by evolutionary biologists with strong implications for migraine experts. The Authors showed that a gene polymorphism associated with migraine gave our ancestors an evolutionary advantage when colonizing northern, and thus colder, territories. They then highlight that the prevalence of migraine may differ among countries because of climatic adaptation. These results may prove useful in planning both epidemiological and physiological studies in the field of migraine.     

A Narrative Review of Sex Differences in Eating Disorders: Is There a Biological Basis?

PurposeEating disorders and their core symptoms (eg, binge eating, body weight/shape concerns) disproportionately affect females, and these sex-differentiated effects become prominent during and after puberty. Although psychosocial influences such as heightened sociocultural pressures for thinness in girls and women contribute to this sex imbalance, biological factors could also play an important role.MethodsThis narrative review summarizes evidence of biological factors underlying the sex-differentiated prevalence of eating pathology as well as within-sex variability in risk.FindingsThere are sex differences in the pubertal emergence of genetic effects on eating pathology (adrenarche in males; gonadarche in females), and at least some genetic contributions to eating pathology seem to vary between the sexes. Furthermore, sex steroid hormones (eg, testosterone, estradiol, progesterone) are leading contributors to differential risk for eating pathology in males and females across the life span. Emerging data suggest that between-sex and within-sex variability in risk might occur via hormone-driven modulation (activation/deactivation) of genetic influences and neural responsiveness to food-related cues.ImplicationsThere is a biological basis to heightened risk for eating pathology in females, relative to males, as well as unique biological influences within each sex. Findings from this review highlight the importance of studying both sexes and considering sex-specific biological mechanisms that may underlie differential risk for eating pathology     

Hepatitis C in 2019: Are We There Yet?

Chronic hepatitis C is the most common blood-borne pathogen worldwide. Upwards of half of the individuals infected with hepatitis C have not been diagnosed, and rates of screening remain low. Incidence, which had been declining, began increasing in 2011, mirroring the current opioid epidemic. Once infected, people with chronic hepatitis C are at risk for developing complications including end-stage liver disease and hepatocellular carcinoma, leading to morbidity and mortality. These public health consequences of the hepatitis C epidemic are expected to increase over the coming decade. Innovation has resulted in highly tolerable medications of 8 to 16 weeks’ duration with over 90% efficacy. Experts have determined that the eradication of hepatitis C would be feasible and have laid out strategies to move us toward that goal. Significant and disparate barriers remain, including access to treatment and an increase in incidence related to the opioid epidemic. An underresourced approach to surveillance and screening, provider shortages, and payer restrictions are among the obstacles to eliminating hepatitis C as a public health problem in the United States.     

Is There Gender Discrimination in Acute Renal Colic Pain Management? A Retrospective Analysis in an Emergency Department Setting

BackgroundPain is a widespread problem, affecting both men and women; studies have found that women in the emergency department receive analgesic medication and opioids less often compared with men.AimsThe aim of this study was to examine the administration and management of analgesics by the medical/paramedical staff in relation to the patients' gender, and thereby to examine the extent of gender discrimination in treating pain.DesignThis is a single-center retrospective cohort study that included 824 patients.SettingsEmergency department of tertiary hospital in Israel.Participants/SubjectsThe patients stratified by gender to compare pain treatments and waiting times between men and women in renal colic complaint.MethodsAs an acute pain model, we used renal colic with a nephrolithiasis diagnosis confirmed by imaging. We recorded pain level by Visual Analog Scale (VAS) scores and number of VAS examinations. Time intervals were calculated between admissions to different stations in the emergency department. We recorded the number of analgesic drugs administered, type of drugs prescribed, and drug class (opioids or others).ResultsA total of 824 patients (414 women and 410 men) participated. There were no significant differences in age, ethnicity, and laboratory findings. VAS assessments were higher in men than in women (6.43 versus 5.90, p = .001, respectively). More men than women received analgesics (68.8% versus 62.1%, p = .04, respectively) and opioids were prescribed more often for men than for women (48.3 versus 35.7%, p = .001). The number of drugs prescribed per patient was also higher in men compared with women (1.06 versus 0.93, p = .03). A significant difference was found in waiting time length from admission to medical examination between non-Jewish women and Jewish women.ConclusionsWe found differences in pain management between genders, which could be interpreted as gender discrimination. Yet these differences could also be attributed to other factors not based on gender discrimination but rather on gender differences.