Showing papers by "Shuu Jiun Wang published in 2011"

Reversible cerebral vasoconstriction syndrome: current and future perspectives

Abstract: Reversible cerebral vasoconstriction syndromes (RCVS) are characterized by recurrent acute severe headaches, namely thunderclap headaches, and multifocal segmental vasoconstrictions. Interest has arisen in the definitions, clinical presentations, differential diagnoses, risk factors and complications of RCVS. This article will comprehensively review the milestone monographs and the latest research work addressing these issues. Studies that have focused on the relationship between RCVS and thunderclap headache will be detailed. We will also discuss research on the enigmatic pathophysiology and potential therapeutic approaches. Up-to-date information and challenges, undergoing studies and future research directions will be deeply probed.

Sustained visual cortex hyperexcitability in migraine with persistent visual aura

Abstract: Persistent aura without infarction, a rare migraine disorder, is defined by aura symptoms that persist for >1 week without radiological evidence of cerebral infarction. To unveil its pathophysiological mechanisms, this study used magnetoencephalography to characterize the visual cortex excitability in persistent aura by comparison with episodic and chronic migraine. We recruited six patients with persistent visual aura, 39 patients with episodic migraine [12 in ictal phase; 27 in interictal phase (with aura, n = 9; without aura, n = 18)], 18 patients with chronic migraine and 24 healthy controls. Five sequential blocks of 50 neuromagnetic prominent 100 ms responses were obtained, and the dynamic change in visual cortex excitability was evaluated by the percentage changes of individual mean prominent 100 ms amplitudes at blocks 2–5 compared with block 1, with a significant increase indicating potentiation. We found that in patients with persistent aura, there was significant potentiation during ictal periods ( P = 0.009 and 0.006 at blocks 2 and 5, respectively), and the excitability change was inversely correlated with the duration of aura persistence (correlation coefficient −0.812, P = 0.050, block 2). The interictal recordings ( n = 3) also showed potentiation. In terms of the other migraine spectrum disorders, persistent aura differed from episodic migraine in the presence of ictal potentiation. Persistent aura further differed from chronic migraine in the absence of interictal potentiation in chronic migraine. There was a higher percentage change of response amplitude at the end of stimulation (block 5) in persistent aura (43.3 ± 11.7) than in chronic migraine (−7.6 ± 5.5, P = 0.006) and ictal recordings of episodic migraine (−4.9 ± 9.6, P = 0.020). Normal control subjects had no significant response changes. This magnetoencephalographic study showed that the visual cortex in patients with persistent visual aura maintains a steady-state hyperexcitability without significant dynamic modulation. The excitability characteristic supports persistent visual aura as a nosological entity in migraine spectrum disorders and suggests a pathophysiological link to sustained excitatory effects possibly related to reverberating cortical spreading depression.

Persistent ictal-like visual cortical excitability in chronic migraine

Abstract: Episodic migraine (EM) may evolve into the more disabling chronic migraine (CM, monthly migraine days ⩾ 8 and headache days ⩾ 15) with unknown mechanism. Aiming to elucidate the pathophysiology of CM and its relationship with EM, this study characterized the visual cortical responses in CM and EM. Neuromagnetic visual-evoked responses to left-hemifield checkerboard reversals were obtained in patients with EM (interictal or ictal states), CM (interictal) and age-matched controls. For each subject, the 1500 evoked responses were sequentially divided into 30 blocks and percentage changes of P100m amplitude in blocks 2, 9, 16, 23, and 30 compared to the first block were computed to assess habituation. At the end of visual stimulation (block 30), P100m amplitude was decreased (habituated) in the controls (n = 32) (35.2 ± 2.6 nAm vs. 41.9 ± 2.7, p = 0.005) but increased (potentiated) in the interictal state of EM (n = 29) (39.7 ± 3.8 vs. 33.5 ± 3.0, p = 0.007). In CM (n = 25), P100m was habituated (46.5 ± 2.9 vs. 51.6 ± 3.7, p = 0.013) but higher at the initial block than in those of the interictal state of EM (p = 0.001). These CM features also characterized the P100m in the ictal state of EM (n = 9). There was no difference of P100m between CM and ictal state of EM. In conclusion, patients with CM demonstrate a persistent ictal-like excitability pattern of the visual cortex between migraine attacks which may implicate central inhibitory dysfunction.

Brain-derived neurotrophic factor gene Val66Met polymorphism modulates reversible cerebral vasoconstriction syndromes.

Abstract: Background Reversible cerebral vasoconstriction syndrome (RCVS) could be complicated by cerebral ischemic events. Hypothetical mechanisms of RCVS involve endothelial dysfunction and sympathetic overactivity, both of which were reported to be related to brain-derived neurotrophic factor (BDNF). The study investigated the association between functional BDNF Val66Met polymorphism and RCVS. Methods Patients with RCVS and controls were prospectively recruited and genotyped for the BDNF Val66Met polymorphism. Magnetic resonance angiography (MRA) and transcranial color-coded Doppler sonography were employed to evaluate cerebral vasoconstriction. Genotyping results, clinical parameters, vasoconstriction scores, mean flow velocities of the middle cerebral artery (VMCA), and Lindegaard indices were analyzed. Split-sample approach was employed to internally validate the data. Principal Findings Ninety Taiwanese patients with RCVS and 180 age- and gender-matched normal controls of the same ethnicity completed the study. The genotype frequencies did not differ between patients and controls. Compared to patients with Met/Met homozygosity, patients with Val allele had higher mean vasoconstriction scores of all arterial segments (1.60±0.72 vs. 0.87±0.39, p 120 cm/s (p<0.001). Split-sample validation by randomization, age, entry time or residence of patients demonstrated concordant findings. Conclusions Our findings link BDNF Val66Met polymorphism with the severity of RCVS for the first time and implicate possible pathogenic mechanisms for vasoconstriction in RCVS.

Prevalence and impact of migrainous vertigo in mid-life women: A community-based study

Abstract: We surveyed 1436 women aged 40-54 years in the community. Of these, 278 (19.4%) were diagnosed with migraine or probable migraine based on the International Classification of Headache Disorder criteria. The diagnoses of migrainous vertigo (MV) were modified from Neuhauser's criteria. Of the 278 women, 238 (85.6%) underwent an interview and 72 (30.3%) of those with migraine or probable migraine had MV. The 1-year prevalence of MV among mid-life women was 5.0% (95% CI, 4.0-6.3%). The MV subjects had a higher proportion of aura (23.6% vs 9.6%; OR, 2.9), nausea (76.4% vs 55.8%; OR, 2.6) and photophobia (61.1% vs 41.7%; OR, 2.2) compared with the migraine subjects without MV. The migrainous subjects with and without MV had similar Short-Form 36 (SF-36) scores. Our study showed that MV was common in mid-life women. Their health-related quality of life was similar in migrainous subjects with MV and those without MV.

Temporal associations between weather and headache: analysis by empirical mode decomposition.

Abstract: Background Patients frequently report that weather changes trigger headache or worsen existing headache symptoms. Recently, the method of empirical mode decomposition (EMD) has been used to delineate temporal relationships in certain diseases, and we applied this technique to identify intrinsic weather components associated with headache incidence data derived from a large-scale epidemiological survey of headache in the Greater Taipei area. Methodology/Principal Findings The study sample consisted of 52 randomly selected headache patients. The weather time-series parameters were detrended by the EMD method into a set of embedded oscillatory components, i.e. intrinsic mode functions (IMFs). Multiple linear regression models with forward stepwise methods were used to analyze the temporal associations between weather and headaches. We found no associations between the raw time series of weather variables and headache incidence. For decomposed intrinsic weather IMFs, temperature, sunshine duration, humidity, pressure, and maximal wind speed were associated with headache incidence during the cold period, whereas only maximal wind speed was associated during the warm period. In analyses examining all significant weather variables, IMFs derived from temperature and sunshine duration data accounted for up to 33.3% of the variance in headache incidence during the cold period. The association of headache incidence and weather IMFs in the cold period coincided with the cold fronts. Conclusions/Significance Using EMD analysis, we found a significant association between headache and intrinsic weather components, which was not detected by direct comparisons of raw weather data. Contributing weather parameters may vary in different geographic regions and different seasons.

New daily persistent headache: should migrainous features be incorporated?

Abstract: Introduction: International Classification of Headache Disorders (ICHD-2) criteria for new daily persistent headache (NDPH) require tension-type headache features. Many patients with ‘new-onset persistent’ headache fail to fulfil such criteria due to prominent migrainous features.Subjects and methods: We reviewed all NDPH patients in our headache clinic, using the definition of persistent headache 3 months. The patients were dichotomised: patients meeting ICHD-2 criteria (NDPH-S) and patients failing to meet ICHD-2 criteria due to prominent migrainous features (NDPH-M). All patients had completed a structured intake form including demographics, headache profiles, Beck Depression Inventory (BDI), Short Form 36 (SF-36) Health Survey, and Migraine Disability Assessment (MIDAS). A telephone interview was conducted for follow-up.Results: A total of 92 NDPH patients were enrolled (59 (64.1%) NDPH-M, 33 (35.9%) NDPH-S). Between the two subgroups, the sociodemographics were indistinguis...

Connective tissue disorders in patients with spontaneous intracranial hypotension.

Abstract: Objective: Spontaneous intracranial hypotension (SIH) is caused by spinal cerebrospinal fluid (CSF) leakage. An underlying connective tissue disorder has been hypothesized to cause dural weakness and predisposition to CSF leak. We conducted a case-controlled study to investigate the role of connective tissue disorders in SIH patients.Methods: We recruited 55 consecutive SIH patients (38 F, 17 M; mean age, 40.8 ± 9.8 years) and 55 age- and sex-matched control individuals (mean age, 38.0 ± 8.9 years) for this study. The connective tissue disorders were evaluated by: (i) Beighton hypermobility scores and revised diagnostic criteria for benign joint hypermobility syndrome; (ii) skin and skeletal manifestations of Ehlers–Danlos syndrome (EDS); and (iii) skeletal features of Marfan syndrome.Results: The frequencies of joint hypermobility according to Beighton scores >4/9 (SIH 23.6% vs controls 16.4%, P = 0.48) and revised benign joint hypermobility syndrome criteria (SIH 23.6% vs controls 34.5%, P = 0.29) did n...

Morning headache in habitual snorers: frequency, characteristics, predictors and impacts.

Abstract: Objectives: Morning headache has been considered as an accompanying symptom of obstructive sleep apnoea syndrome (OSAS). However the frequency, characteristics, predictors and impacts of morning headache in habitual snorers are not well defined. Methods: We studied consecutive patients with habitual snoring in a sleep laboratory using polysomnography. All patients were interviewed by a physician regarding the presence or absence of morning headache, migraine and insomnia. Each patient completed the Short Form-36 health survey (SF-36) and the Hospital Anxiety and Depression Scale (HADS). Morning headache was defined as headache on awakening � 1 day/week for � 6 months. Results: Of the 268 participants with habitual snoring, 63 (23.5%) had morning headache and 184 (69%) had OSAS. Patients with morning headache reported lower scores in all eight domains of the SF-36 than those without (difference: 10.6 to 29.7 points, all p � 0.005). The independent predictors of morning headache were migraine (adjusted odds ratio (AOR) 6.3), insomnia (AOR 4.2), psychological distress (HADS � 8) (AOR 3.9) and OSAS (AOR 2.6). Morning headache in 12 patients (19%) fulfilled the criteria for migraine attacks. Conclusions: Morning headache was common in habitual snorers and associated with a pervasive impairment of healthrelated quality of life. Migrainous features were not uncommon. Not only OSAS, but migraine, insomnia and psychological distress were also important predictors for morning headache, even in snoring patients.

Cefepime-related encephalopathy in peritoneal dialysis patients.

Abstract: Encephalopathy or neurotoxicity can occur with cefepime use in patients with impaired or relatively normal renal function. However, few articles have examined the relationship between cefepime's adverse effects and peritoneal dialysis. Here, we report the case of an 80-year-old woman with chronic renal failure on peritoneal dialysis that developed agitation, confusion, and dystonia after cefepime administration for 2 days. The clinical and electroencephalographic abnormalities improved after discontinuation the drug. We review the role of peritoneal dialysis in the development of cefepime-induced encephalopathy. Peritoneal dialysis is a less efficient way to eliminate cefepime than hemodialysis. Short-term hemodialysis might be considered to facilitate elimination of the drug in patients who have developed neurotoxicity.

Subcortical hyperexcitability in migraineurs: a high-frequency oscillation study.

Abstract: Objectif: Un niveau anormal d'excitabilite du systeme nerveux central a ete observe chez les patients atteints de migraine. Que ce soit de l'hyper ou de l'hypo excitabilite demeure un sujet de controverse. Le but de cette etude etait de comparer les oscillations somatosensitives a haute frequence (OHF), refletant l'excitabilite sous-corticale (phase precoce) et l'inhibition intra corticale (phase tardive), entre des patients atteints de migraine et des sujets temoins. Methode: Les OHF ont ete enregistrees de C3'-FZ, avec un filtre de frequence 500-1000 Hz apres stimulation du nerf median droit au poignet, et separees en phase precoce et tardive selon le pic N20. Cinquante-neuf patients non traites (n = 24 pendant une crise ; n = 35 entre les crises) et 22 sujets temoins ont complete l'etude. Resultats: En phase precoce d'OHF, les patients, qu'ils soient ou non en periode de crise, avaient des amplitudes maximales (p = 0,039) et une aire sous la courbe (p = 0,029) plus elevees que celles des sujets temoins. Quant a la phase tardive d'OHF, il n'y avait pas de difference entre les groupes. Conclusion: Notre etude suggere qu'il existe un etat d'hyperexcitabilite dans les regions sous-corticales chez les patients atteints de migraine, tant en periode de crise qu'entre les crises.

Treatment guidelines for acute and preventive treatment of cluster headache

Abstract: The Treatment Guideline Subcommittee of the Taiwan Headache Society evaluated both the acute and the preventive treatments for cluster headache now being used in Taiwan, based on the principles of evidence- based medicine. We assessed the quality of clinical trials and levels of evidence, and referred to other treatment guidelines proposed by other countries. Throughout several panel discussions, we merged opinions from the subcommittee members and proposed a consensus on the major roles, recommended levels, clinical efficacy, adverse events and cautions of clinical practice regarding acute and preventive treatments of cluster headache. The majority of Taiwanese patients have episodic cluster headaches, because chronic clusters are very rare. Cluster headache is characterized by severe and excruciating pain which develops within a short time and is associated with ipsilateral autonomic symptoms. Therefore, emergency treatment for a cluster headache attack is extremely important. Within the group of acute medications currently available in Taiwan, the subcommittee determined that high-flow oxygen inhalation has the best evidence of effectiveness, followed by intranasal triptans. Both are recommended as first-line medical treatments for acute attacks. Oral triptans were determined to be second-line medications. For transitional prophylaxis, oral corticosteroids are recommended as the first-line medication, and ergotamine as the second-line choice. As for maintenance prophylaxis, verapamil has the best evidence and is recommended as the first-line medication. Lithium, melatonin, valproic acid, topiramate and gabapentin are suggested as the second-line preventive medications. Surgical interventions, including occipital nerve stimulation, deep brain stimulation, radiofrequency block of the sphenopalatine ganglion, percutaneous radiofrequency rhizotomy and trigeminal nerve section, are invasive and their long-term efficacy and adverse events are still not clear in Taiwanese patients; therefore, they are not recommended currently by the subcommittee. The transitional and maintenance prophylactic medications can be used together to attain treatment efficacy. Once the maintenance prophylaxis achieves efficacy, the transitional prophylactic medications can be tapered gradually. We suggest the corticosteroids be used within two weeks, if possible. The duration of maintenance treatment depends on the individual patient's clinical condition, and the medications can be tapered off when the cluster period is over.

Needling the pain and comforting the brain: Acupuncture in the treatment of chronic migraine

Abstract: Chronic migraine (CM) is a disabling complication of migraine. Prevalence is high, disease-related burden is great, and medical and psychiatric comorbidity is considerable. Treatment has been unsatisfactory and rigorous trials specifically targeting CM are rare. Topiramate and botulinum neurotoxin are the only pharmacological treatments that have been proven effective in randomized, placebo-controlled trials (1–6); however, the therapeutic gain (against placebo) is only modest (Table 1). New or complementary therapeutic modalities for CM treatment are needed. Acupuncture is a widely used, non-pharmacological treatment for migraine. Although its use is still controversial, a recent Cochrane systematic review found acupuncture to be as effective as, or possibly more effective than, preventive migraine agents (7). A beneficial effect of acupuncture in migraine prophylaxis was demonstrated in a prospective randomized trial for CM (8). In a 12-week treatment period, a significantly larger decrease in the mean monthly number of moderate/ severe headache days was observed in the acupuncture group compared with the topiramate group ( 10.5 vs. 7.8 days per 4 weeks, p< 0.01). Significant differences favoring acupuncture across multiple efficacy end points, including mean change of headache days, Migraine Disability Assessment Scores (MIDAS), Hospital Anxiety and Depression Scale (HADS) scores, Short Form 36 (SF-36) scores, Beck Depression Inventory II (BDI-II) scores, mean days of acute medication use, 50% reduction in monthly moderate/severe headache days, 50% reduction in monthly headache days, and safety end points were also observed. In the context of the topiramate studies (1,9) and the Phase III Research Evaluating Migraine Prophylaxis Therapy (PREEMPT) trials (4–6), similar beneficial effects were also observed in patients who were overusing acute medications. Does this study identify an alternative choice for CM patients? Probably yes, but the reasons behind the positive effect could be complex. The study was designed according to the guidelines for trials of the prophylactic treatment of CM (10) and had a clearly defined acupuncture treatment procedure following the Standards for Reporting Interventions in Clinical Trials of Acupuncture (STRICTA) recommendations (11), making it possible to replicate the study and provide a basis for comparisons across disciplines. The acupoints chosen are classic acupuncture sites, which correspond to the dermatomal distribution of trigeminocervical complexes: V1 dermatome [Cuanzhu (BL 2) and Yintang (EX-HN 3)], V2 dermatome [Taiyang (EX-HN 5)], and C2 dermatome [Fengchi (GB-20)]. Traditionally, acupuncture has had its own diagnostic system and the acupoints are individualized and tailored for headaches over different meridians. In this study, the benefits from individualized acupuncture are limited by the fixed-site approach. However, even with this trade-off, the acupuncture arm still outweighed the topiramate group. The positive results of this trial seem to provide a rational mechanism linking the intervention with the pathophysiology of migraine; that is, modulating the trigeminal sensory system. While this hypothesis is possible, a second thought is required to interpret the data. The investigators provided several reasons to justify the choice of topiramate as the active comparator instead of control with sham acupuncture; however, none could offset the putatively higher placebo effect caused by the needling procedure in comparison

Queckenstedt’s Test Headache Response is Associated with Increased Jugular Venous Flow Volume During Migraine Attack

Abstract: Cephalic venous congestion induced by Queckenstedt’s (Q)-test, i.e., transient compression of bilateral internal jugular veins (IJV), can aggravate headache intensity during migraine attacks, especially in patients with throbbing pain. We hypothesized that the IJV flow volume was related to the Q-test response. Ultrasonography was used to measure the flow volume of bilateral IJV in migraine patients during acute attacks and interictal periods and in normal controls. All acute migraine patients underwent Q-test in a supine position. “Q-test headache response” was designated by the changes in headache intensity (0–10 scale) before and 30 s after the Q-test. Thirty-nine acute migraine patients, 20 interictal migraine patients and 23 noxrmal controls completed the study. Acute migraine patients had higher bilateral IJV flow volume than both interictal patients and normal controls (973.4 ± 348.2 vs. 733.8 ± 210.1 vs. 720.3 ± 244.9 mL/min, p = 0.001). In acute migraine patients, bilateral IJV flow volume was the only independent variable related to the Q-test headache response (adjusted R2= 0.422). Thus, the IJV flow volume was increased during migraine attacks and was directly related to the Q-test response. It may be used as a research tool for peripheral sensitization during acute migraine attacks. (E-mail: sjwang@vghtpe.gov.tw )

OnabotulinumtoxinA: Preventive Treatment for Chronic Migraine

Abstract: Aurora SK, Dodick DW, Turkel CC, et al.: OnabotulinumtoxinA for treatment of chronic migraine: results from the doubleblind, randomized, placebo-controlled phase of the PREEMPT 1 trial. Cephalalgia 2010, 30: 793–803. Diener HC, Dodick DW, Aurora SK, et al.: OnabotulinumtoxinA for treatment of chronic migraine: results from the double-blind, randomized, placebo-controlled phase of the PREEMPT 2 trial. Cephalalgia 2010, 30: 804–814. Dodick DW, Turkel CC, DeGryse RE, et al.: OnabotulinumtoxinA for treatment of chronic migraine: pooled results from the double-blind, randomized, placebocontrolled phases of the PREEMPT clinical program. Headache 2010, 50:921–936.