Faculty Bibliography

AIMS: To examine the effectiveness and tolerability of acute treatment with frovatriptan in women experiencing menstrual migraine (MM) vs. female migraineurs with non-MM. METHODS: This was an open-label postmarketing surveillance study (n = 7107) conducted in Germany to assess acute treatment with frovatriptan in one to three migraine attacks. This retrospective subanalysis evaluated acute frovatriptan treatment in women who experienced >or=1 MM attack vs. those women with non-MM attacks. Effectiveness and tolerability were graded using a 4-point scale (1 = very good, 2 = good, 3 = satisfactory, 4 = poor). RESULTS: Demographics were similar in MM (n = 1931) and non-MM patients (n = 2080), except that mean age (38.3 vs 45.3 years, respectively) and number of migraine attacks per month were less in the MM group than in the non-MM group (both p < 0.001). Although 98% of women reported that their previous migraines were moderate or severe, only one third in each treatment group previously used triptans. Prestudy medications were rated as good or very good for effectiveness by 20.3% and 19.2% of the MM and non-MM groups, respectively. In contrast, the effectiveness of frovatriptan was rated as very good or good by 92.7% and 90.9% of women in the MM and non-MM groups, respectively. Forty-three percent and 96% of all women rated their previous medication and frovatriptan, respectively, as having good or very good tolerability. Among women rating their previous medication as poor or satisfactory, most (94%) rated frovatriptan as very good or good. CONCLUSIONS: Acute frovatriptan treatment improved patient ratings of treatment effectiveness and tolerability in women with migraine associated with menses.

Abdominal migraine usually has its onset during childhood or adolescence and resolves in adulthood, often being replaced by typical migraine headaches. Rarely, migraine headache and recurrent abdominal pain coexist in some patients during adulthood. We report a patient who developed abdominal migraine without headaches beginning for the first time at the age of 22 years. The abdominal symptoms increased in frequency coincident with medication overuse and resolved after the overuse was treated. Analgesic overuse may cause a worsening of noncephalic pain in patients with extra-cephalic variants of migraine.

Menstruation increases the risk of migraine in susceptible women. In a subpopulation of women with menstrual migraine, headaches occurring in association with onset of menses may be more severe and of longer duration than headaches experienced by the same woman at other times of her menstrual cycle. Although menstrual migraines share many clinical characteristics of other types of migraines, their occurrence is predictable provided that the patient has regular menstrual cycles. Therefore, short-term prevention regimens can be considered for women whose headaches are not adequately managed with acute therapies.

Hemicrania continua (HC) is an uncommon, primary headache disorder characterized by a continuous unilateral headache of moderate intensity with superimposed exacerbations of more severe pain. HC exists in two temporal subtypes, a continuous form in which headaches persist continuously without remission periods, and a less common remitting form in which bouts of continuous headaches are separated by pain-free remissions. There have been more than 100 prior reports of HC; in the majority of which the headache is strictly unilateral and without side shift. We now report the third patient in whom headaches alternated sides during different attacks.

The headache disorders described here are relatively rare, but probably are more common than previously thought. These disorders cause significant pain and disability, so recognition is essential as treatment response differs from that of migraine, tension-type, and cluster headaches. Table 4 reviews the important clinical features of these syndromes and contrasts them with cluster headache, the disorder for which they are often confused.

Opioids elicit antinociception in mammals through three distinct types of receptors designated as mu, kappa and delta. However, it is not clear what type of opioid receptor mediates antinociception in non-mammalian vertebrates. Radioligand binding techniques were employed to characterize the site(s) of opioid action in the amphibian, Rana pipiens. Naloxone is a general opioid antagonist that has not been characterized in Rana pipiens. Using the non-selective opioid antagonist, [3H]-naloxone, opioid binding sites were characterized in amphibian spinal cord. Competitive binding assays were done using selective opioid agonists and highly-selective opioid antagonists. Naloxone bound to a single-site with an affinity of 11.3 nM and 18.7 nM for kinetic and saturation studies, respectively. A B(max) value of 2725 fmol/mg protein in spinal cord was observed. The competition constants (K(i)) of unlabeled mu, kappa and delta ranged from 2.58 nM to 84 microM. The highly-selective opioid antagonists yielded similar K(i) values ranging from 5.37 to 31.1 nM. These studies are the first to examine opioid binding in amphibian spinal cord. In conjunction with previous behavioral data, these results suggest that non-mammalian vertebrates express a unique opioid receptor which mediates the action of selective mu, kappa and delta opioid agonists.

Headache is an extremely common complaint in the Emergency Department, accounting for up to 16% of all visits. Although there are more than 300 medical conditions which can produce headache, the vast majority of headache disorders are benign. This article outlines an orderly approach for evaluating patients who present with headaches; in addition, the authors discuss the emergency treatment of the more common types of headache.