Abortive Headache Therapy in the Office With Intravenous Dihydroergotamine Plus Prochlorperazine

Over two years, 92 patients were treated in the office for 146 severe headache episodes. Headaches were aborted using four different intravenous regimens containing 0.5 or 1 mg. of dihydroergotamine and 3.5, 5, or 10 mg. of prochlorperazine. The speed and rate of response were directly proportional to the prochlorperazine dose used. High prochlorperazine doses (10 mg.) aborted the most headaches (95%) in the shortest time, but caused more sedation and akathesia. Low doses (3.5 mg.) aborted less headaches (89%) and responses were delayed; but, on the other hand, sedation was minimal and akathesia mild and uncommon. Dihydroergotamine given alone caused intolerable side effects; but, when it was given with prochlorperazine, efficacy was enhanced and side effects were greatly reduced. Aborting headaches in the office can be reliably achieved with minimal side effects by administering an intravenous mixture containing 1 mg. of dihydroergotamine and 3.5 mg. of prochlorperazine.     

Prostaglandin Inhibition and Cerebrovascular Control in Patients with Headache

SYNOPSIS
Effects of aspirin and indomethacin on cerebral blood flow (CBF) and cerebral vasomotor responsiveness (VMR) to 5% CO₂ and 100% O₂ inhalation were compared in patients with vascular and non-vascular headaches. Indomethacin was 60 times as potent as aspirin in inhibiting cerebrovascular prostacyclin (PGI₂) synthesis in humans, as judged by CBF and VMR effects. 972 mgs of aspirin, a dose known to inhibit thromboxane synthesis and platelet aggregation had minimal effects on CBF (−3.8%), attributed to partial PGI₂ inhibition, since there was no effect on VMR to 5% CO₂. Indomethacin (25–50 mgs) reduced CBF (−17.8%), VMR to 5% CO₂ (−72%) and VMR to 100% O₂ (−75%). PGI₂ plays an important role in cerebrovascular control of human subjects. Inhibition of PGI₂ synthesis by indomethacin relieves cluster-type headaches more consistently than other headaches. Evidence is offered that 100% O₂ inhalation causes cerebral vasoconstriction by inhibiting cerebrovascular PGI₂ synthesis, thereby benefitting cluster headaches. Migraineurs appear to have excessive PGI₂ synthesis. Patients with hemicephalalgia show asymmetric hemispheric responses to indomethacin, ascribed to asymmetric neurogenic influences on PGI₂ synthesis.     

Frequency of Chronic Headaches in Japanese Patients With Multiple Sclerosis: With Special Reference to Opticospinal and Common Forms of Multiple Sclerosis

Background.— Headache is common in Western patients with multiple sclerosis (MS), but its frequency has not been reported in Asian patients. In Asians, the opticospinal form of MS, showing similar characteristics to relapsing neuromyelitis optica in Westerners, is regarded as a different subtype from conventional MS. Objectives.— The aim of this study was to clarify the frequency of primary and chronic secondary headaches in Japanese patients with MS and the factors associated with the emergence of such headaches. Methods.— We investigated 127 consecutive patients with clinically definite MS. Frequencies of primary and chronic secondary headaches were compared according to clinical subtype, administration of interferon beta, and anti‐aquaporin‐4 antibody status. Results.— The frequency of patients with primary and chronic secondary headaches at the time of interview was 64/127 (50.4%); the frequency of migraine was 26/127 (20.4%) and that of tension‐type headache was 38/127 (29.9%). The frequencies of patients with primary and chronic secondary headaches and migraine without aura after the onset of MS were higher in patients undergoing interferon beta therapy than in those not on the therapy (42.4% vs 23.4%, P < .05 and 15.1% vs 4.3%, P = .05, respectively). There were no significant differences in the frequency of primary and chronic secondary headaches based on clinical subtype of MS. However, among patients not receiving interferon beta, the occurrence of migraine with aura after the onset of MS was significantly higher in patients with anti‐aquaporin‐4 antibody than in patients without the antibody (13.3% vs 0.0%, P < .05). Conclusions.— In Japanese patients with MS, the frequency of primary and chronic secondary headaches, especially migraine, was higher than in the general Japanese population. Administration of interferon beta was related to a higher frequency of primary and chronic secondary headaches, especially migraine without aura, irrespective of clinical subtype of MS.     

Headaches Associated With Nasal Obstruction Due to Deviated Nasal Septum

A deviated nasal septum not only can cause a blocked nose, but may also be associated with headaches. This study evaluates the nature of these headaches, the effect of submucous resection of the nasal septum, and the factors associated with postoperative headache relief. Deviated nasal septa were corrected by submucous resection in 99 men and 17 women. Patients were studied at 4 to 48 months (mean 18 months) postoperatively. Fifty-five of the 116 patients studied (47.4%) had preoperative recurring headaches. Thirty-five of the 55 patients with headaches (63.6%) experienced relief (complete or partial) of their headaches at a mean follow-up period of 18 months. Patients were more likely to be relieved of their headaches following submucous resection if the headaches were most intense over the frontal region, pressure like in nature, and if the submucous resection resulted in relief of nasal obstruction. It is possible that headaches recur in the long term, and it is postulated that central mechanisms play a role.     

Abortive Headache Therapy With Intramuscular Dihydroergotamine

During a six month period, intramuscular dihydroergotamine mesylate (1 mg.) was given to 43 patients (75 headache episodes) who presented to the office after oral medications failed to abort their headaches. Headaches were successfully aborted in 71%, with most responses occurring between 30-minutes and 4-hours after injection. Side effects were common (61%) but not serious; sedation developed in 25%, nausea in 24%, transient worsening of headaches in 15%, body aches in 11%, diarrhea in 5%, and in 13%, headaches that were successfully aborted relapsed within 24 hours. Intramuscular dihydroergotamine, although under-used, is cost effective, practical, and well suited for busy medical offices. Its appropriate use can reduce the need for narcotic analgesics and emergency room visits.     

A Double-Blind, Randomized Comparison of Aztreonam Plus Clindamycin with Tobramycin Plus Clindamycin in Abdominal Infections

Seventy patients with intraabdominal infections were randomly assigned in double-blinded fashion to receive either the combination of tobramycin plus clindamycin (TM/C) or aztreonam plus clindamycin (AZ/C). Thirty-four patients received AZ/C and 36 were given TM/C. Average ages were 62 years (TM/C) and 66 years (AZ/C). In approximately one-half of both groups, the source of infection was perforated colon or perforated appendix. There were no significant differences in demographic factors between these groups, although those given AZ/C had a more serious long-term prognosis due to underlying diseases. The average lengths of treatment were 10 days (TM/C) and 9 days (AZ/C). Clinical response to therapy did not differ, as 84% of the TM/C patients and 78% of the AZ/C patients had satisfactory clinical responses. The two regimens differed in adverse effects, as an elevated PT/PTT was more frequently (p < 0.05) observed in AZ/C. All PT/PTT elevations responded to injections of vitamin K, and no serious bleeding occurred. Choice between these regimens depends on differences in cost and the risk of adverse effects, as both regimens appear equally effective for treatment of abdominal infections in conjunction with appropriate surgical intervention.     

Management of pain in patients with myocardial infarction

A survey of analgesics used for pain relief in patients suffering with myocardial infarction was carried out for a duration of one month. Forty-eight patients were studied regarding pain relief prior to transfer to hospital and on admission to the Coronary Care Unit (CCU), out of 48, only three patients did not require any analgesic. It was found that the management of pain in the community and the CCU was variable. Intravenous diamorphine 5 mgs was found to be most effective practice for pain relief. Out of twenty-six patients who received IV diamorphine 5 mgs initially 16 patients (62%) had adequate pain relief, in contrast to 21% (3) of those who received only 2.5 mgs. In 14 patients who received this lower dose it was found only to be effective in three patients.     

Improvement in Headaches With Continuous Positive Airway Pressure for Obstructive Sleep Apnea: A Retrospective Analysis

Objective.— We aimed to identify clinical features in patients with severe headaches that predicted obstructive sleep apnea (OSA) and determine clinical and sleep study characteristics that predicted headache improvement with continuous positive airway pressure (CPAP). Background.— Many patients with headaches complain of sleep symptoms and have OSA. There is often improvement of headaches with CPAP treatment. Methods.— We conducted a retrospective chart review of all patients referred to adult neurology clinic for headaches and sent for polysomnography between January 2008 and December 2009. Follow‐up ranged from 18 to 42 months. Results.— Eighty‐two headache patients (70 females, 12 males) were studied. Mean age was 45 ± 13 years (females 45 ± 13, males 43 ± 11) and mean body mass index was 32 ± 9. Headache types included 17% chronic migraine without aura, 22% episodic migraine without aura, 32% migraine with aura, 21% tension‐type headache, 6% chronic post‐traumatic headache, 11% medication overuse headache, and 7% other types. All patients were receiving standard treatment for their headaches by their neurologist. Fifty‐two patients (63%) had OSA. Increasing age, female gender, and chronic migraine without aura were predictive of OSA. Of the patients with OSA, 33 (63%) used CPAP and 27 (82%) were adherent to CPAP. Headache improvement was reported by 40 patients (49%) due to either standard medical therapy or CPAP. Patients with OSA who were CPAP adherent (21/27) were more likely to have improvement in headaches than patients intolerant of CPAP (2/6), those that did not try CPAP (8/19), and those who did not have OSA (16/30) (P = .045). Of the 33 patients who used CPAP, 13 reported improvement in headaches specifically due to CPAP therapy and 10 additional patients noted benefit in sleep symptoms. The presence of witnessed apneas (P = .045) and male gender (P = .021) predicted improvement in headaches due to CPAP. Conclusions.— Headache patients should be evaluated for the presence of OSA. Treating OSA improves headaches in some patients.     

A 22-Year-Old Woman With Chronic Daily Headaches

Tension-type headache is a common clinical complaint occurring in 78% of the general population. Chronic tension-type headache in adult patients is defined as attacks of headaches occurring on at least 15 days per month over a period of at least 3 consecutive months. The association between headaches and psychological factors represents a significant clinical problem that leads to a broader discussion about whether primary headaches could lead to anxiety or whether anxiety symptoms may precipitate primary headaches. This case highlights the positive outcomes associated with the appropriate identification and treatment of a comorbid psychiatric condition.     

A History of Cigarette Smoking Is Associated With the Development of Cranial Autonomic Symptoms With Migraine Headaches

(Headache 2011;51:85‐91) Objective.— To look at the smoking history of migraine patients and to determine if a history of cigarette smoking is associated with the development of cranial autonomic symptoms with migraine headaches. Background.— It has recently been noted that a significant number of migraine patients may develop autonomic symptoms during their attacks of headache. Why some headache patients activate the trigeminal autonomic reflex and develop cranial autonomic symptoms while others do not is unknown. Cluster headache occurs more often in patients with a history of cigarette smoking, suggesting a link between tobacco exposure and cluster headache pathogenesis. Could cigarette smoking in some manner lead to activation of the trigeminal‐autonomic reflex in headache patients? If cigarette smoking does lower the threshold for activation of the trigeminal autonomic reflex then do migraine patients who have a history of cigarette smoking more often develop cranial autonomic symptoms than migraineurs who have never smoked? Methods.— Consecutive patients diagnosed with migraine (episodic or chronic) who were seen over a 7‐month time period at a newly established headache center were asked about the presence of cranial autonomic symptoms during an attack of head pain. Patients were deemed to have positive autonomic symptoms along with headache if they experienced at least one of the following symptoms: eyelid ptosis or droop, eyelid or orbital swelling, conjunctival injection, lacrimation, or nasal congestion/rhinorrhea. A smoking history was determined for each patient including was the patient a current smoker, past smoker, or had never smoked. Patients were deemed to have a positive history of cigarette smoking if they had smoked continuously during their lifetime for at least at 1 year. Results.— A total of 117 migraine patients were included in the analysis (96 female, 21 male). Forty‐six patients had a positive smoking history, while 71 patients had no smoking history. Some 70% (32/46) of migraineurs with a positive history of cigarette smoking had cranial autonomic symptoms along with their headaches, while only 42% (30/71) of the nonsmoking patients experienced at least 1 autonomic symptom along with headaches and this was a statistically significant difference (P < .005). In total, 74% of current smokers had autonomic symptoms with their headaches compared with 61% of past smokers and this was not a statistically significant difference. There was a statistically significant difference between the number of current smokers who had autonomic symptoms with their headaches compared with the number of patients who never smoked and had autonomic symptoms (P < .05). Overall, 52% of the studied migraineurs had autonomic symptoms. There was a statistically significant difference between autonomic symptom occurrence in male and female smokers vs male and female nonsmokers. Each subtype of cranial autonomic symptoms was all more frequent in smokers. Conclusion.— A history of cigarette smoking appears to be associated with the development of cranial autonomic symptoms with migraine headaches.     

替扎尼定与非甾体抗炎药联合治疗急性痉挛性疼痛的临床研究

目的:替扎尼定是具有解痉作用的α2肾上腺能受体激动剂,并具有一定的胃肠道保护作用,适用于单一治疗或与非甾体消炎药(NSAIDs)联合治疗急性痉挛性疼痛。通过替扎尼定和非甾体类抗炎药物的联合应用,临床观察和评估联合用药能否增强疗效和增加安全性。方法:急性痉挛性疼痛70例,随机分为两组,一组服用替扎尼定2mg,bid 双氯芬酸50mg,bid,一组服用双氯芬酸50mg,bid 安慰剂2mg,bid。观察药物疗效和不良反应。结果:联用组的总有效率为70%,胃肠道不良反应发生率为12%,中枢神经系统不良反应发生率为18%;单用组的总有效率为56%,胃肠道不良反应发生率为32%,中枢神经系统不良反应发生率为10%。结论:替扎尼定和非甾体类药物联用具有更好的疗效以及更高的药物耐受性。     

Psychosocial Functioning in Schoolchildren With Recurrent Headaches

The psychosocial functioning of 113 schoolchildren (8 to 15 years old) reporting headaches at least once a month was compared to a group of headache-free control subjects matched for sex and age. Thirteen percent of the headache sufferers had migraine headaches, 28% had episodic tension-type headaches, 30% had chronic tension-type headaches, and 29% had migraine coexisting with tension-type headaches.
Overall, the headache sufferers experienced more somatic complaints, stress, and psychological symptoms, in addition to being absent from school (due to illness), more often and reported fewer caring persons as compared to headache-free controls. Although few differences between the four headache groups emerged in the children's psychosocial functioning levels, children with migraine coexisting with tension-type headaches had significantly more frequent somatic complaints than those having episodic tension-type headaches. In addition, children with migraine or migraine coexisting with tension-type headaches were more often absent from school than those having tension-type headaches only. A significant but weak relationship between children's headache severity and their somatic complaints was noted.     

Randomized Study Comparing a Basal-Bolus With a Basal Plus Correction Insulin Regimen for the Hospital Management of Medical and Surgical Patients With Type 2 Diabetes: Basal Plus Trial

OBJECTIVE

Effective and easily implemented insulin regimens are needed to facilitate hospital glycemic control in general medical and surgical patients with type 2 diabetes (T2D).

RESEARCH DESIGN AND METHODS

This multicenter trial randomized 375 patients with T2D treated with diet, oral antidiabetic agents, or low-dose insulin (≤0.4 units/kg/day) to receive a basal-bolus regimen with glargine once daily and glulisine before meals, a basal plus regimen with glargine once daily and supplemental doses of glulisine, and sliding scale regular insulin (SSI).

RESULTS

Improvement in mean daily blood glucose (BG) after the first day of therapy was similar between basal-bolus and basal plus groups (P = 0.16), and both regimens resulted in a lower mean daily BG than did SSI (P = 0.04). In addition, treatment with basal-bolus and basal plus regimens resulted in less treatment failure (defined as >2 consecutive BG >240 mg/dL or a mean daily BG >240 mg/dL) than did treatment with SSI (0 vs. 2 vs. 19%, respectively; P < 0.001). A BG <70 mg/dL occurred in 16% of patients in the basal-bolus group, 13% in the basal plus group, and 3% in the SSI group (P = 0.02). There was no difference among the groups in the frequency of severe hypoglycemia (<40 mg/dL; P = 0.76).

CONCLUSIONS

The use of a basal plus regimen with glargine once daily plus corrective doses with glulisine insulin before meals resulted in glycemic control similar to a standard basal-bolus regimen. The basal plus approach is an effective alternative to the use of a basal-bolus regimen in general medical and surgical patients with T2D.Inpatient hyperglycemia in patients, with or without diabetes, is associated with poor hospital outcomes, including prolonged hospital stay, infections, and disability after hospital discharge, and death (1–3). Several clinical trials in critically ill patients have reported that improvement of glycemic control reduces hospital complications (4–6), hospital stay, and mortality (6–8). In patients with T2D admitted to general medicine and surgery services, recent randomized, controlled trials have shown that treatment with a basal-bolus regimen results in significantly lower mean daily blood glucose (BG) and in a higher percentage of BG within target range than does treatment with sliding scale regular insulin (SSI) (9,10). In addition, in general surgical patients, the basal-bolus approach results in a significant reduction in the frequency of composite complications, consisting of postoperative wound infection, pneumonia, bacteremia, and acute renal and respiratory failure (10). On the basis of these results, clinical practice guidelines have recommended the use of the basal-bolus approach as the preferred insulin regimen for the management of patients with diabetes not in the intensive care unit (ICU) (11–13).Despite the benefits of a basal-bolus regimen in improving glycemic control in non-critically ill patients (2,7,9,10,14), many health care providers and hospitalists are reluctant to integrate this approach into their clinical practice, probably because of its complexity and a fear of hypoglycemia (15–18). Because most patients in the hospital have reduced caloric intake as a result of medical illness or surgical procedures, we hypothesized that a single daily dose of basal insulin might result in similar glucose control and lower the rate of hypoglycemia relative to a basal-bolus regimen. Accordingly, we tested the efficacy and safety in general medical and surgical patients with T2D of a daily dose of basal insulin plus corrective doses with a rapid-insulin analog given by sliding scale (basal plus regimen) with a basal-bolus insulin regimen with glargine once daily and fixed doses of glulisine before meals and also with SSI (no basal insulin) given four times.     

Comparing Diazepam Plus Fentanyl With Midazolam Plus Fentanyl in the Moderate Procedural Sedation of Anterior Shoulder Dislocations: A Randomized Clinical Trial

BackgroundThe reduction of shoulder dislocation requires adequate procedural sedation and analgesia. The mixture of midazolam and fentanyl is reported in the literature, but long-acting benzodiazepines in conjunction with fentanyl are lacking.Study ObjectiveOur aim was to compar e IV diazepam with IV midazolam in moderate procedural sedation (based on the classification of the American Society of Anesthesiologists) for the reduction of shoulder dislocation.MethodsThis was a randomized controlled clinical trial conducted from April 2019 to December 2019 in the emergency department of a university-affiliated hospital in Tehran, Iran. Participants were adult patients (aged 18–65 years) with anterior shoulder dislocation. Group A (n = 42) received diazepam 0.1 mg/kg plus fentanyl 1 μg/kg IV and group B received midazolam 0.1 mg/kg plus fentanyl 1 μg g/kg IV. Main outcomes measured were onset of muscle relaxation, time taken to reduction, total procedure time, number of the reduction attempts, patient recovery time, the occurrence of the adverse effects, amount of the pain reported by the patients using visual analog scale, and patients and physicians overall satisfaction with the procedure using a Likert scale question.ResultsEighty-one patients were included. The mean ± standard deviation time of the onset of the muscle relaxation and time taken to reduction was shorter in the diazepam plus fentanyl group (p = 0.016 and p = 0.001, respectively). Adverse effects and pain relief were not statistically different between the two groups. Patient recovery time and total procedure time was shorter in the midazolam plus fentanyl group (p = 0.008 and p = 0.02, respectively). The overall satisfaction of patients and physicians was higher in the diazepam plus fentanyl group.ConclusionsAs compared with midazolam plus fentanyl, diazepam plus fentanyl was superior in terms of the onset of the muscle relaxation, patient and physician satisfaction, and time taken to reduction.     

Sustained Headache Syndrome Associated with Tender Occipital Nerve Zones

SYNOPSIS
A sustained headache syndrome can develop from headaches of diverse etiologies. Over seven years,112 patients with such a syndrome received 188 sets of injections in the occipital nerve regions andtwo-thirds had prolonged relief. In such headaches, interrupting the pain cycle with occipital injectionscontaining 1% lidocaine plus betamethasone may be a useful adjunct to other preventive and abortivemedical therapies.     

Flunarizine Is Effective in Prophylaxis of Headache Associated With Scleroderma

Migraine-like headaches may occasionally be seen in patients with scleroderma. The mechanism of these headaches is not well established but may be secondary to central "Raynaud's phenomenon". We report a patient with such headaches that responded dramatically to the centrally acting calcium channel blocker, flunarizine. We suggest that flunarizine should be considered in the management of patients with scleroderma and migraine-like headaches.     

Headaches in Patients With Traumatic Lesions of the Cervical Spinal Cord

We established the occurrence of headache in a group of 20 patients with traumatic transections of the cervical spinal cord. All but two patients had complete sensory lesions at levels varying from C2-3 to C7-8. Only three patients claimed to have no headaches at all although one of them had nuchal pains with fever. Twelve patients had "bladder" or "bowel headaches" or had had them in the past. These headaches were mostly generalized, throbbing or pounding in nature and severe in intensity. They were caused by obstruction of urinary flow and fecal impaction, respectively, and were associated with autonomic dysreflexia. Otherwise the headaches reported by the patients were mild although frequent in four, i.e once per week or more. These headaches were also mostly bilateral and lasted a relatively short time, i.e. less than one or two hours. The causes of these headaches were nonspecific for the group studied except for stimulation of the body which, however, probably depended on a mechanism similar to that of the bladder and bowel headaches. Migraine, either classic or common, was not reported by any of the patients.     

Effect of Pegylated Interferon Plus Tenofovir Combination on Higher Hepatitis B Surface Antigen Loss in Treatment-naive Patients With Hepatitis B e Antigen -positive Chronic Hepatitis B: A Real-world Experience

PurposeThe loss of serum hepatitis B surface antigen (HBsAg) in patients with chronic hepatitis B (CHB) is considered an ideal clinical outcome but rarely achieved with current standard of care. We evaluated the effectiveness in inducing HBsAg seroclearance in a real-world clinical cohort of Chinese patients with CHB treated with a combination of pegylated interferon (Peg-IFN) with tenofovir disoproxil fumarate (TDF) or monotherapy with each agent.MethodsA total of 330 patients with CHB were assigned to receive Peg-IFN plus TDF for 48 weeks (Peg-IFN plus TDF group), Peg-IFN alone for 48 weeks (Peg-IFN group), or TDF alone for 144 weeks (TDF group). The primary end point was the percentages of patients who achieved HBsAg seroclearance at week 72. Differences from the baseline characteristics and treatment data were compared using the χ² test for categorical variables or 1-way ANOVA for continuous variables. A Kaplan–Meier test was performed to compare the HBsAg loss among the 3 groups. Discrimination of responders versus nonresponders was quantified using AUC curves. Optimal cut-offs were selected based on Youden's J statistic defined as J = sensitivity + specificity-1.FindingsAt week 72, the Kaplan–Meier cumulative HBsAg loss was 11.5% in the Peg-IFN plus TDF group, 5.7% in the Peg-IFN group, and 0% in the TDF group. The percentage of patients with HBsAg loss was comparable in the Peg-IFN plus TDF and Peg-IFN groups (P = 0.143), but both were significantly higher than that in the TDF group (P = 0.000 and P = 0.010). In addition, a significantly higher percentage of patients in the combination group and Peg-IFN group had serum HBsAg of <100 IU/mL compared with the TDF group (32.7% vs 23.6% vs 9.2%; P < 0.001) but no significant differences in the percentages of patients with HBsAg <1000 IU/mL, the undetectable serum HBV DNA and hepatitis B e antigen seroconversion. Our model predicted serum HBsAg loss at week 72 (AUC = 0.846) if the HBsAg level was reduced by > 1.5 log₁₀ IU/mL from baseline at treatment week 24, an optimal timepoint for prediction of HBsAg loss in this cohort.ImplicationsA 48-week course of Peg-IFN and TDF combination therapy led to profound reduction in serum HBsAg level, resulting in a significantly higher rate of HBsAg loss compared with TDF monotherapy. Patients with steep HBsAg decline >1.5 log₁₀ IU/mL at week 24 well signaled a higher probability of achieving HBsAg loss at week 72.     

Application of the ICHD-II criteria to the diagnosis of primary chronic headaches via a computerized structured record

BACKGROUND: The authors recently developed a software program designed to analyze clinical data from patients affected by primary headache. The program is based exclusively on the International Classification of Headache Disorders 2nd edition (ICHD-II) criteria. This software examines all the diagnoses of primary headaches on the basis of the variables needed to fulfill these mandatory criteria. METHODS: We tested the software, Primary Headaches Analyser 1.0 INT (PHA), by entering and analyzing clinical data from 200 consecutive patients affected by primary chronic headaches and evaluating the corresponding output diagnoses. RESULTS: The diagnosis of chronic migraine (1.5.1) was obtained in 68 cases (34 %) and that of probable chronic migraine (1.6.5) plus probable medication-overuse headache (8.2.8) in 46 (23%). Chronic tension-type headache (2.3) and probable chronic tension-type headache (2.4.3) plus probable medication-overuse headache (8.2.8) were diagnosed in 24 (12%) and 2 (1%) patients, respectively. Moreover, 4 and 12 patients, respectively, received both the diagnosis of chronic migraine (1.5.1) plus chronic tension-type headache (2.3) and of probable migraine (1.6.1) without aura plus chronic tension-type headache (2.3). In the remaining 44 cases (22%), none of the chronic primary headaches disorders defined by ICHD-II received an output diagnosis from the program. This was due mainly to the fact that the criteria fulfilled were insufficient for the diagnoses of migraine without (1.1) aura plus chronic migraine or, more infrequently, chronic tension-type headache. CONCLUSIONS: Our software program permitted diagnoses of chronic migraine, chronic tension-type or their probable forms (with or without MOH) in 78% of 200 patients with headache 15 or more days per month. In the remaining cases the inability to provide a specific diagnosis may be explained in part by the fact that the criteria for both diagnoses are too stringent and do not accurately reflect variations of the headache pattern in these chronic forms.     

The Hospital Management of Severe Migrainous Headache

In a two year period, 47 patients with migraine were hospitalized for the management of severe headache; 18 had acute migraine (duration less than 72 hours), 17 had status migrainosus (duration by definition more than 72 hours), and 12 had chronic daily headaches qualitatively of a migraine type. Treatment in all comprised cessation of all previous medication, plus one of the following: intravenous DHE, intravenous lidocaine, a combination of lidocaine + DHE, or subcutaneous sumatriptan. Improvement from DHE, lidocaine, or both was slow and often incomplete. Sumatriptan was not used in patients with chronic daily headaches; in the 8 cases of acute migraine or status migrainosus in which it was used, improvement was rapid and complete in seven.