Medication overuse is more than just taking too much.
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Analgesics↗
Biomedical subjects
H-C Diener
Publications and source records attributed to H-C Diener.
Is clopidogrel the antiplatelet drug of choice for high-risk patients with stroke/TIA?: Yes.
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Clinical Trials as Topic↗
Cerebral venous thrombosis--headache is enough.
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Brain↗
Lamotrigine reduces migraine aura and migraine attacks in patients with migraine with aura.
This study examined the efficacy of lamotrigine in the prevention of migraine aura. Fifty nine patients suffering from migraine with aura received lamotrigine in a controlled three year prospective open study. Treatment response was defined as a reduction of aura frequency each month by at least 50%. Primary endpoint was reached by three quarters of the patients. Lamotrigine significantly reduced both frequency of migraine aura (mean, 1.5 (SD, 0.6) each month before v 0.4 (0.7) after treatment; p < 0.001) and aura duration (mean, 27 (SD, 11) minutes before v 8 (14) after treatment; p < 0.001). Furthermore, more than three quarters of those patients with a reduction of aura symptoms experienced a significant reduction of frequency of migraine attacks (mean, 2.1 (SD, 1.0) each month before v 1.2 (1.1) after treatment; p < 0.001). Lamotrigine was highly effective in reducing migraine aura and migraine attacks. The strong correlation between reduction of aura symptoms and migraine attacks stresses the potential role of aura-like events and possibly cortical spreading depression as a trigger for trigeminal vascular activation, and subsequently the development of migraine headaches.
Adult↗
[Recurrent hemispheric symptoms without proof of ischemia].
ANAMNESIS AND CLINICAL FINDINGS: Over the last 6 years, a 48-year-old patient recurrently experienced passing neurological left hemispheric symptoms of varying strength. Because of the patient's distinctive cardiovascular risk profile, these symptoms were diagnosed as transitory ischaemic episodes. On inquiry, the patient now reported frequent headaches in close temporal connection to the events. EXAMINATIONS: Repeated imaging of the neocranium using various techniques (CCT, cMRT, MRT-angiography) revealed no conspicuous features. Duplex sonography of the brain feeding arteries, echocardiography, EEG and 24h-ECG also gave findings within the normal range for the patient's age group. Clinical chemistry showed increased values for cholesterol and triglycerides. Incidentally, a moderate upper airway resistance syndrome was identified during polysomnography. DIAGNOSIS: Suspected migraine with aura in terms of a sporadic hemiplegic migraine. TREATMENT AND COURSE: On administration of ASS and rizatriptane, the neurological hemispheric symptoms disappeared completely over the course of a few hours. Under prophylactic treatment with metoprolol and acetazolamide over two months, no further events have been observed up to now. CONCLUSION: Recurrent, temporary neurological deficits, together with the presence of several cardiovascular risk factors, can easily be misinterpreted to be the result of an underlying cerebral ischemia. Even in cases with typical cardiovascular risk profile, a migraine with aura must be considered as one of the possible causes for hemispheric neurological symptoms.
Acetazolamide↗
Incidence and predictors for chronicity of headache in patients with episodic migraine.
The authors followed 532 consecutive patients with episodic migraine (<15 days/month) for 1 year. Sixty-four patients (14%) developed chronic headache (>/=15 days/month). The odds ratios for developing CH were 20.1 (95% CI 5.7 to 71.5) comparing patients with a "critical" (10 to 14 days/month) vs "low" (0 to 4 days/month) and 6.2 (95% CI 1.7 to 26.6) in patients with an "intermediate" (6 to 9 days/month) vs "low" headache frequency and 19.4 (95% CI 8.7 to 43.2) comparing patients with and without medication overuse.
Adult↗
Population impact of losartan use on stroke in the European Union (EU): projections from the Losartan Intervention For Endpoint reduction in hypertension (LIFE) study.
The Losartan Intervention for Endpoint reduction in hypertension (LIFE) study was designed to compare losartan- vs atenolol-based antihypertensive treatment on cardiovascular morbidity and mortality in a population of 9193 hypertensive patients with left ventricular hypertrophy (LVH). In LIFE, the losartan-based treatment further reduced the primary composite end point (cardiovascular death, myocardial infarction, or stroke) by 13% (risk reduction (RR) 0.87, 95% confidence interval (CI) 0.77-0.98, P=0.021). The further reduction in stroke with losartan (RR 0.75, 95% CI 0.63-0.89, P=0.001) was the major contributing factor to the reduction in the primary end point. Our objective was to project the reduction in stroke observed with a losartan- vs an atenolol-based antihypertensive treatment regimen in the LIFE study to the European Union (EU) population. The number of stroke events averted was estimated by identifying the number of persons in the EU expected to meet the LIFE inclusion criteria, and multiplying this figure by the cumulative incidence risk difference in stroke from LIFE at 5.5 years. The age- and gender-specific prevalence of hypertension, electrocardiographically (ECG)-diagnosed LVH among those with hypertension (inclusion criteria), and heart failure among those with LVH and hypertension (exclusion criteria) were applied to the EU census estimates. We conservatively projected that an estimated 7.8 million individuals aged 55-80 years in the EU are affected by hypertension and ECG-diagnosed LVH. Use of a losartan-based antihypertensive treatment in this population is projected to prevent approximately 125 000 first strokes over a 5.5-year period. A population-wide prevention strategy of using losartan in patients with LVH and hypertension has the potential to have a major public health impact by reducing the morbidity and mortality of stroke in the EU.
Aged↗
Pneumonia and urinary tract infection after acute ischaemic stroke: a tertiary analysis of the GAIN International trial.
The third most common stroke complication is infection. We studied the rates of aspiration pneumonia and urinary tract infection (UTI), their risk factors and their effect on outcome in the 1455 Glycine Antagonist (Gavestinel) in Neuroprotection (GAIN) International patients with ischaemic stroke. Forward stepwise logistic regression and Cox proportional hazards modelling identified baseline factors that predicted events and the independent effect of events up to day 7 on poor stroke outcome at 3 months in patients alive at day 7, after correcting for prognostic factors. Higher baseline National Institute of Health Stroke Scale (NIHSS) and age, male gender, history of diabetes and stroke subtype predicted pneumonia, which occurred in 13.6% of patients. Female gender and higher baseline NIHSS and age predicted UTI, which occurred in 17.2% of patients. Pneumonia was associated with poor outcome by mortality (hazard ratio, 2.2; 95% confidence interval, 1.5-3.3), Barthel index (<60) (odds ratio, 3.8; 2.2-6.7), NIHSS (4.9; 1.7-14) and Rankin scale (>/=2) (3.4; 1.4-8.3). UTI was associated with Barthel index (1.9; 1.2-2.9), NIHSS (2.2; 1.2-4.0) and Rankin scale (3.1; 1.6-4.9). Pneumonia and UTI are independently associated with stroke poor outcome. Patients with identified risk factors must be closely monitored for infection.
Age Factors↗
Differences of anti-nociceptive mechanisms of migraine drugs on the trigeminal pain processing during and outside acute migraine attacks.
The aim of this study was to investigate central anti-nociceptive mechanisms of i.v. acetylsalicylic acid (ASA) and oral zolmitriptan (ZOL) in migraine patients and healthy subjects using the 'nociceptive' blink reflex (nBR). Twenty-eight migraine patients received ASA (n = 14, 1000 mg i.v) or ZOL (n = 14, 5 mg p.o) during the acute migraine attack and interictally. Thirty healthy subjects received either ASA or ZOL vs. placebo using a double blind cross over design. nBR was recorded in all patients and subjects before, 60 and 90 min after treatment. ASA and ZOL did not inhibit nBR responses in healthy subjects. Both ASA and ZOL suppressed nBR responses (ASA by 68%, ZOL by 78%) only during the acute attack but not interictally. The data suggest, that the anti-nociceptive effects of migraine drugs on the trigeminal nociceptive processing are different during and outside an acute migraine attack.
Adult↗
Quantification of acute neck pain following whiplash injury by computer-aided pressure algesimetry.
Until now the clinical investigation of cervical pain due to whiplash injury is mainly based on finger palpation. The present study introduces a PC-interactive pressure algesimetry to standardize cervical pain measurement. Pressure pain scores of the splenius and trapezius muscles of 23 patients with an acute cervical syndrome after whiplash injury were compared to those of 24 healthy subjects. The pressure painfulness of neck and shoulder muscles was significantly increased in whiplash patients. The splenii muscles showed an equally increased muscle pain whereas the trapezii muscles showed a left-sided preponderance of painfulness, possibly due to the seat belt position in this group of motor vehicle drivers. The computer-interactive pressure algesimetry enables a standardized and rater-independent quantification of the cervical syndrome with neck and shoulder pain caused by whiplash injury.
Adolescent↗
CNS effects of sumatriptan and rizatriptan.
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Adult↗
Eletriptan for the acute treatment of migraine: results of bridging a Japanese study to Western clinical trials.
OBJECTIVE: To compare the efficacy, safety and tolerability of eletriptan (20, 40 and 80 mg) to placebo when given to Japanese and Western patients for the acute treatment of migraine. METHODS: A double-blind, randomized, parallel-group trial with the aforementioned therapeutic objectives was conducted in Japan (N = 321). By bridging analysis, data from this study were compared to two migraine trials previously conducted in the US (N = 1190) and Europe (N = 563). RESULTS: The 2-h post-dose headache response rates (i.e., the primary efficacy endpoint) of Japanese migraineurs to eletriptan 20, 40 and 80 mg were 64, 67 and 76%, respectively; European and American migraineurs showed similar trends and, in these studies, eletriptan was significantly superior to placebo (p < 0.05). Japanese patients did demonstrate a higher placebo response than Westerners, possibly due to differences in previous triptan exposure or expectation. Adverse events were generally mild to moderate, were comparable in all three studies, and showed a modest dose-response effect. CONCLUSION: The efficacy and tolerability of eletriptan for the acute treatment of migraine is comparable in Japan, Europe and the US.
Adolescent↗
R1--systemic thrombolysis in German stroke units--the experience from the German Stroke data bank.
BACKGROUND: Systemic thrombolysis with tissue plasminogen activator (t-PA) for treatment of acute ischemic stroke was approved in Germany in 2000. Up to now, only data from single centers have been available for the study of the use of thrombolysis in a hospital-based approach outside controlled trials. We therefore sought to determine the frequency of application and complications as well as the patient outcome after t-PA treatment in clinical routine of specialized stroke centers in Germany. METHODS: Within the German Stroke Data Bank Collaboration, 6234 consecutive patients with ischemic stroke were prospectively documented in 20 stroke centers between 1998 and 1999. The patients were centrally followed via telephone interview after 3 months and 1 year to assess global functional outcome using the Modified Rankin Scale. RESULTS: 250 patients (4 %) received systemic t-PA treatment during the study period. The baseline characteristics of these patients were comparable to large clinical trials and phase IV studies. Symptomatic and asymptomatic parenchymal hemorrhage occurred in 22 patients (8.8 %) and was fatal in 3 patients. Follow-up data after 3 months were obtained in 82.4 % of all patients, of which 35 % had a favorable functional outcome (mRS </= 1), while 23.8 % were severely disabled (mRS >/= 4) and 17 % had died. CONCLUSION: The results of our study agree with the assumption that thrombolytic therapy can be performed safely and effectively in daily clinical practice. Nevertheless, the small proportion of patients receiving thrombolysis even in specialized stroke centers calls for further improvement of acute stroke management in Germany.
Cerebral Hemorrhage↗
RPR100893, a substance-P antagonist, is not effective in the treatment of migraine attacks.
A global, double-blind, randomized, placebo-controlled, dose-finding, parallel-group trial was conducted to compare three oral doses of RPR100893 (1, 5, 20 mg), a substance-P antagonist, and placebo in 139 patients with migraine attacks with moderate or severe headache intensity. Headache intensity and improvement of headache after 2 h were not different in the four treatment groups. Therefore, it is concluded that this oral substance-P antagonist in the doses used here is not effective.
Adolescent↗
Abnormal habituation of 'nociceptive' blink reflex in migraine--evidence for increased excitability of trigeminal nociception.
We studied the habituation of the 'nociceptive' blink reflex (nBR) in 15 healthy subjects and 17 migraine patients interictally as well as during unilateral migraine headache within six hours of onset and after treatment. In healthy volunteers the mean regression coefficient (MRC) was - 3.9 following right sided and - 4.9 left sided stimulation. This equals an amplitude loss of 19.5% (5 x -3.9) and 24.5% (5 x -4.9), respectively, across five consecutive sweeps. An augmentation of nBR responses was found in migraine patients interictally: MRC = 3.3 following stimulation of the headache side (HA) and MRC = 4.0 of the non-headache side (non-HA). The differences were statistically significant (anova: d.f. = 1, F = 25.8, P < 0.001). During the migraine attack MRCs were negative both before (-5.0, HA and - 4.0, non-HA) and after treatment (-2.6, HA and - 1.9 non-HA) and significantly differed from those outside the migraine attack (anova: d.f. = 2, F = 12.4, P < 0.001). The demonstrated lack of habituation of the nBR responses indicates an abnormal trigeminal nociceptive processing in migraine patients outside the migraine attack.
Adult↗
Features of medication overuse headache following overuse of different acute headache drugs.
OBJECTIVE: To investigate pharmacologic features such as mean critical duration until onset of medication-overuse headache (MOH) (MCDO), mean critical monthly intake frequencies (MCMIF), and mean critical monthly dosages (MCMD) as well as specific clinical features of MOH after overuse of different acute headache drugs, with a focus on newly approved triptans. METHODS: In a prospective study 98 patients with MOH according to International Headache Society (IHS) criteria underwent standardized inpatient withdrawal from their medication. Patient diaries and structured interviews were used to calculate the MCDO, MCMIF, and MCMD for each substance group. RESULTS: The MCDO was shortest for triptans (1.7 years), longer for ergots (2.7 years), and longest for analgesics (4.8 years). The MCMIF was lowest for triptans (18 single doses per month), higher for ergots (37), and highest for analgesics (114). Although patients overusing ergots and analgesics typically had a daily tension-type headache, patients with triptan-induced MOH were more likely to describe a (daily) migraine-like headache or an increase in migraine frequency. CONCLUSION: Overuse of triptans leads to MOH faster and with lower dosages compared with ergots and analgesics. Clinical features of MOH depend on the type of overused headache medication. Pharmacologic and clinical characteristics of triptan-induced MOH call for the renewal of the current IHS classification.
Acute Disease↗
[Diagnosis related groups in stroke treatment. An analysis from the stroke data bank of the German Stroke Foundation].
BACKGROUND: The upcoming introduction of diagnosis related groups (DRG) as an exclusive base for future calculation of hospital proceeds in Germany requires a thorough analysis of cost data for various diseases. OBJECTIVE: To compare the resulting combined cost weights of the Australian Refined DRG system (AR-DRG) with the proceeds based on actual per-day rates in stroke treatment. PATIENTS AND METHODS: Between 1998 and 1999, data from 6520 patients (median age 68 years, 43% women) with acute stroke or transient ischemic attack (TIA) were prospectively documented in 15 departments of Neurology with an acute stroke unit, 9 departments of general Neurology and 6 departments of Internal Medicine. Prior to grouping cases into DRGs, all available data were transferred into ICD-10-SGB-V 2.0 or the Australian procedure system (MBS-Extended). Hospital proceeds for the respective cases were calculated based on per-day rates of the documenting hospitals. RESULTS: The resulting cost weights demonstrate a good homogeneity compared to the length of stay. When introducing the AR-DRG with a uniform base rate in Germany, a relative decrease of hospital proceeds can be expected in Neurology Departments and for treatment of TIAs. CONCLUSION: Preservation of the existing structure of acute stroke care in Germany requires a supplement to a uniform base rate in Neurology departments.
Acute Disease↗
Acute migraine headache: possible sensitization of neurons in the spinal trigeminal nucleus?
OBJECTIVE: To investigate trigeminal sensory processing in patients with migraine using a novel "nociception-specific" blink reflex. METHODS: Seventeen patients with unilateral migraine headache were studied within 6 hours of onset. Blink reflexes were elicited with a standard stimulating electrode (standard blink reflex) and concentric stimulating electrode (nociception-specific blink reflex) during the acute migraine attack, after treatment with IV lysine acetylsalicylate (1,000 mg) or oral zolmitriptan (5 mg) and interictally. RESULTS: After standard stimulation, no differences were detected for the R1 and R2 onset latencies and areas under the curve (AUC) between the different time points and the headache and nonheadache side. Nociception-specific stimulation revealed a shortening of R2 onset latencies (44.3 +/- 5.4 ms for headache side vs 48.9 +/- 5.8 ms for nonheadache side) during the acute migraine attack compared with the headache-free interval (49.8 +/- 5.3 vs 49.8 +/- 4.5 ms). The AUC of the R2 increased on the headache side by 680% and on the nonheadache side by 230% compared with the headache-free interval. Drug treatment parallel to pain relief increased the onset latencies (zolmitriptan: 48.0 +/- 8.2 ms for headache side vs 52.3 +/- 7.6 ms for nonheadache side; lysine acetylsalicylate: 48.0 +/- 5.0 ms for headache side vs 51.2 +/- 5.6 ms for nonheadache side) and reduced the AUC of R2 (zolmitriptan by 45% and lysine acetylsalicylate by 48%). CONCLUSION: The data suggest temporary sensitization of central trigeminal neurons during acute migraine attacks.
Acute Disease↗