Joel Saper - Academia.edu (original) (raw)
Papers by Joel Saper
Neurology, 2003
Cluster headache, although relatively uncommon, is one of the most painful primary headache disor... more Cluster headache, although relatively uncommon, is one of the most painful primary headache disorders. Approximately 90% of affected individuals experience daily attacks for several weeks to months (cluster periods) separated by attack-free intervals lasting for months to years (remission periods). The other 10% of sufferers exhibit a more chronic pattern marked by attacks that persist for longer than 1 year with no remission or only short periods of remission. The most striking feature of cluster headache is its circadian and circannual periodicity, which has implicated the hypothalamic pacemaker (the suprachiasmatic nucleus) in the pathogenesis of the disorder. The unique attack profile of cluster headache mandates the use of rapid-acting symptomatic therapy, such as oxygen or subcutaneous sumatriptan. Preventive treatment is two-pronged and consists of transitional treatment, usually with prednisone, to produce rapid suppression of attacks, and maintenance treatment (typically wi...
Clinical Therapeutics, 2020
PURPOSE The Prevention of Migraine via Intravenous ALD403 Safety and Efficacy 1 (PROMISE-1) study... more PURPOSE The Prevention of Migraine via Intravenous ALD403 Safety and Efficacy 1 (PROMISE-1) study was a phase III, randomized, double-blind, placebo-controlled study designed to evaluate the efficacy, tolerability, and pharmacokinetic properties of repeat intravenous (IV) doses of the calcitonin gene-related peptide‒targeted monoclonal antibody eptinezumab (ALD403) for migraine prevention in adults with episodic migraine. Here we present the results of PROMISE-1 through 1 year of treatment (up to 4 doses). METHODS Patients received up to 4 IV administrations of eptinezumab 30 mg, 100 mg, 300 mg, or placebo every 12 weeks. Patients recorded migraine and headache in an electronic diary daily. Additional assessments, including the patient-reported outcomes, were performed at regularly scheduled clinic visits throughout the 56-week study period. FINDINGS A total of 888 adults (mean age, 39.8 years; 84.3% female; 83.8% white) received treatment: eptinezumab 30 mg, n = 219; eptinezumab 100 mg, n = 223; eptinezumab 300 mg, n = 224; and placebo, n = 222. During the primary 12-week study evaluation period, single doses of eptinezumab 100 mg and 300 mg led to significant reductions in mean monthly migraine-days versus placebo, beginning as early as the first day after the initial dose. The reduction in mean monthly migraine-days was maintained throughout the study (100 mg, -3.9, -4.5, -4.7, and -4.5 days; 300 mg, -4.3, -4.8, -5.1, and -5.3 days; and placebo, -3.2, -3.8, -4.0, and -4.0 days during weeks 1-12, 13-24, 25-36, and 37-48, respectively). Overall, the number of patients with a ≥50% or ≥75% reduction in migraine for each 12-week interval during the entire study was consistently numerically higher in the eptinezumab groups than in the placebo group. The proportions of patients with ≥50% reduction in migraine were similar across the eptinezumab groups. Eptinezumab was well tolerated throughout the study. Adverse events were similar across dosing periods, and there were no serious tolerability signals identified with continued dosing. IMPLICATIONS IV eptinezumab administered every 12 weeks for up to 4 doses was associated with early and sustained migraine-preventive effects and a favorable safety profile in adults with episodic migraine. ClinicalTrials.gov identifier: NCT02559895.
Advances in applied neurological sciences, 1988
This short introduction will emphasize the approach to chronic recurring daily or almost daily he... more This short introduction will emphasize the approach to chronic recurring daily or almost daily headache and it will consider the phenomenon of “migraine transformation” in which episodic and typical primary headache conditions appear to be transformed into chronic daily headache patterns. In 1962, the Ad Hoc Committee on Classification of Headache offered what was to become the standard classification for head pain disorders for the next 20 years. This report was based upon the premise of a clear distinction between migraine and tension headache (TH) and emphasized system-specific etiologies: vasculature in migraine, musculature in tension headache. But, despite its many citations and its traditional acceptance by researchers and clinicians alike, many authorities have been unable to reconcile the myriad of events and phenomena of migraine, TH, and cluster headache with the basic foundations of this classification. During the past few years, the emphasis on peripheral phenomena (blood vessels and muscles) and separateness between migraine and TH disorders has been challenged, and with it has come a change views on the treatment of these disorders.
Neurologia, neurochirurgia i psychiatria polska
Hospital practice (Office ed.), Jan 30, 1987
Primary Care Case Reviews, 2001
Neurologic Clinics, 1999
This article addresses headache-related topics in which medicolegal issues have occurred or in wh... more This article addresses headache-related topics in which medicolegal issues have occurred or in which they are likely to occur. Where possible, an actual case has been presented. Most sections of this article are divided into three parts: principle of care, case history, and discussion and recommendations. When appropriate, American Academy of Neurology guidelines have been noted.
The Journal of Pain, 2002
Headache: The Journal of Head and Face Pain, 2000
Headache: The Journal of Head and Face Pain, 1995
We studied transnasal butorphanol (Stadol NS·) for pain relief during acute migraine in a multice... more We studied transnasal butorphanol (Stadol NS·) for pain relief during acute migraine in a multicenter, randomized, double‐blind, placebo controlled trial using ambulatory patients at 10 geographically diverse headache centers. Patients were volunteer adults diagnosed with migraine with or without aura by International Headache Society criteria. One hundred fifty‐seven patients completed the study. We treated the pain of one headache in each patient with either transnasal butorphanol (n=107) or transnasal placebo (n=50). Pain relief, pain intensity, nausea, vomiting, and effect on function were measured periodically. Adverse experiences were documented. Global assessments were made at follow‐up. With butorphanol, migraine pain was reduced from moderate, severe, or incapacitating to slight or absent for 35 patients (33%) within 30 minutes, for 50 patients (47%) within 1 hour, and for 76 (71%) within 6 hours, compared to 2 (4%) 8 (16%) and 15 (30%) respectively for placebo. Side effect...
Headache: The Journal of Head and Face Pain, 1987
SYNOPSISErgotamine tartrate has been recognized as the drug of first choice for the treatment of ... more SYNOPSISErgotamine tartrate has been recognized as the drug of first choice for the treatment of acute attacks of migraine. This paper draws attention to a common but poorly delineated state of addiction that can develop when ergotamine tartrate usage exceeds two or three days per week. This syndrome is characterized by a self‐sustaining, rhythmic headache/medication cycle, with daily or almost daily migraine headaches and the irresistible and predictable use of ergotamine tartrate as the only means of alleviating the headache attacks. This report further delineates the clinical features, criteria for recognition, and treatment alternatives for this syndrome. In order to avoid this condition, usage should be restricted to 2 days per week.
Headache: The Journal of Head and Face Pain, 2002
Certain features of chronic daily headache, namely, increased headache frequency, expansion of he... more Certain features of chronic daily headache, namely, increased headache frequency, expansion of headache area, and cutaneous allodynia, may imply sensitization of central nociceptive neurons in the trigeminal pathway. Repetitive activation of the trigeminal nerve can lead to a biologic and functional change in trigeminal nucleus caudalis neurons, characterized by a decrease in nociceptive threshold and receptive field expansion. Suppression of the endogenous pain control system can facilitate the process of central sensitization. Evidence of such suppression in patients with chronic daily headache includes decreased platelet serotonin, up‐regulation of 5‐HT2A receptors, increased platelet nitric oxide production, and increased levels of substance P and nerve growth factor in the cerebrospinal fluid. Results from a number of animal experiments have indicated that chronic analgesic exposure leads to changes in serotonin content and density of 5‐HT2A receptors in the central nervous sys...
Headache: The Journal of Head and Face Pain, 1982
Headache: The Journal of Head and Face Pain, 2007
Wade Cooper, MD St. John Chronic headache and Migraine Institute, Madison Height, Michigan A 38-y... more Wade Cooper, MD St. John Chronic headache and Migraine Institute, Madison Height, Michigan A 38-year-old female with history of rheumatoid arthritis and asthma presented to a headache clinic with persistent headache. She developed intermittent headache episodes beginning at age 12, with gradual increase in frequency and severity through age 20. She would experience frequent headaches, at times preceded by visual aura and associated with nausea, photophobia, and phonophobia. By age 30, her headaches were much improved, and she would experience a headache only once every 2 to 3 months. At age 35 her headaches substantially worsened, culminating in a daily low-grade headache with escalation to severe disabling headache 3 times per week. Her pain was typically located in occipital regions bilaterally with radiation to the periorbital regions. The patient did not have aura symptoms. She had associated nausea with photophobia and phonophobia. Her headache would worsen with exertion. She did not experience autonomic features such as ptosis, lacrimation, or rhinorhea. Her headaches were refractory to multiple prevention and acute medications. Past Medical History.—Rheumatoid arthritis, diagnosed at age 33, asthma, depression, frequent sinus infections, 3 generalized seizures in the remote past, and a motor vehicle accident age 33, which did not cause direct head trauma. Family History.—Multiple family members with migraine; no rheumatologic illness. Social History.—Noncontributory Medications.—Tizanadine 8 mg qhs, topiramate 200 mg BID, Sulfasalazine 500 mg daily, etanercept 25 mg twice weekly, fluoxetine 40 mg daily, albuterol inhaler prn, and isometheptine compound prn. Physical Exam.—Normal, including head and neck examination and neurological examination. Her initial temperature was 97.9 F. She remained afebrile throughout her treatment course. Her neck was supple and no areas of erythema or tenderness were appreciated in the head or face. Diagnosis and Treatment.—Her serum studies were normal. ESR = 25 and WBC = 5.3 at initial evaluation with platelets of 189. There were no other markers of inflammation identified. MRI of the cervical spine revealed a mild protrusion of the C5-C6 disc with minimal extension into the right neural foramen, with the remainder of the study unremarkable. Previously obtained cervical spine radiographs including flexion/extension views were normal. MRI of the brain revealed increased signal on axial T2 (Figs. 1 and 2) and coronal T1 (Fig. 3) weighted images in the left sphenoid and posterior ethmoid sinuses suggestive of sinusitis. The patient was started on amoxicillin 1000 mg/clavulanate 62.5 mg (Augmentin 1000 mg XR) taken 2 po BID for 10 days. She experienced substantial pain improvement days after starting the antibiotics. A CT of the sinus was obtained 4 weeks later, revealing persistent inflammation of the left sphenoid and ethmoid sinuses (Fig. 4). The patient then had a clinical worsening of her headaches, and she received another course of antibiotic therapy that provided no significant improvement, as evidenced by continued inflammatory changes on sinus CT (Fig. 5). She had sinus surgery including drainage of the left sphenoid followed by significant improvement in her headaches. At 6 months follow-up, the patient stated that she has had no migraine headaches, and has rare low-grade headaches that respond to low-dose ibuprofen. Retrospective review of a head CT for headache obtained 2 years prior to presentation revealed increased density within the left sphenoid sinus (Fig. 6). Final Diagnosis.—Chronic sphenoid sinusitis
Clinical Neuropharmacology, 1986
Based on our clinical experience and the data reviewed and presented in this report, we propose t... more Based on our clinical experience and the data reviewed and presented in this report, we propose that a state of physical dependency to ergotamine tartrate exists. This dependency state is characterized by the irresistible and dependable use of ergotamine tartrate and is contingent upon a self-sustaining, rhythmic headache/medication cycle that reflects the dependency. The headache and accompaniments (withdrawal headache?) represent the primary withdrawal symptoms. The presence of this state appears to render patients refractory to other forms of preventative therapy, which can be effective only when ergotamine is discontinued and the cycle broken. If the condition is left untreated, it is likely though by no means certain that the more traditional aspects of ergotism will evolve, although variable susceptibility and tolerance to ergotamine tartrate have been demonstrated. The mechanism of this disorder remains uncertain but might be related to the influence of ergotamine tartrate on the limbic-hypothalamic-pituitary-adrenal axis and other aminergic centers (locus ceruleus), areas considered by some as the central loci for the pathogenesis and associated symptoms of migraine.
The Clinical Journal of Pain, 1986
Archives of Neurology, 1974
A 17-year-old girl was examined because of recurrent bilateral facial palsy. Skull roentgenograms... more A 17-year-old girl was examined because of recurrent bilateral facial palsy. Skull roentgenograms demonstrated cranial metaphyseal dysplasia. This unusual hereditary disorder, which is due to defective bone remodeling and absorption, is associated with many neurological disabilities, including multiple cranial neuropathies, hemiplegia, and medullary compression. Cranial metaphyseal dysplasia has been incorrectly diagnosed as osteopetrosis. Although similarities between these two disorders exist, differences in the clinical course, roentgenographic findings, and pathophysiology distinguish the two entities.
Archives of Neurology, 1996
To assess the efficacy and tolerability of subcutaneous dihydroergotamine mesylate (DHE-45) vs su... more To assess the efficacy and tolerability of subcutaneous dihydroergotamine mesylate (DHE-45) vs subcutaneous sumatriptan succinate (Imitrex) for the treatment of acute migraine with or without aura. Double-blind, randomized trial with parallel treatment arms. Clinics and private neurology practices. Patients of either sex, with migraine with or without aura, between the ages of 18 and 65 years. Patients with moderate or severe head pain were randomized to receive either 1 mg of subcutaneous dihydroergotamine mesylate or 6 mg of subcutaneous sumatriptan succinate. Patients rated head pain, functional ability, nausea, and vomiting at baseline and at 0.5, 1, 2, 4, and 24 hours after the injection. Presence or absence of headache at 3 hours was calculated from collected data. If pain persisted after 2 hours, a second injection of the same study medication was allowed, and self-ratings were repeated 30 and 60 minutes later. Follow-up data were collected at 24 hours. Relief of head pain and recurrence of successfully treated headache. There were 295 evaluable patients. At 2 hours, 73.1% of the patients treated with dihydroergotamine and 85.3% of those treated with sumatriptan had relief (P = .002). There was no statistical difference in headache relief between the groups at 3 or 4 hours. Headache relief was achieved by 85.5% of those treated with dihydroergotamine and by 83.3% of those treated with sumatriptan by 4 hours. By 24 hours 89.7% of dihydroergotamine-treated patients and 76.7% of sumatriptan-treated patients had relief (P = .004). Headache recurred within 24 hours after treatment in 45% of the sumatriptan-treated patients and in 17.7% of the dihydroergotamine-treated patients (P < or = .001). Both sumatriptan and dihydroergotamine were effective in aborting migraine headaches. Headache recurrence was two and a half time as likely with sumatriptan as with dihydroergotamine.
Neurology, 2003
Cluster headache, although relatively uncommon, is one of the most painful primary headache disor... more Cluster headache, although relatively uncommon, is one of the most painful primary headache disorders. Approximately 90% of affected individuals experience daily attacks for several weeks to months (cluster periods) separated by attack-free intervals lasting for months to years (remission periods). The other 10% of sufferers exhibit a more chronic pattern marked by attacks that persist for longer than 1 year with no remission or only short periods of remission. The most striking feature of cluster headache is its circadian and circannual periodicity, which has implicated the hypothalamic pacemaker (the suprachiasmatic nucleus) in the pathogenesis of the disorder. The unique attack profile of cluster headache mandates the use of rapid-acting symptomatic therapy, such as oxygen or subcutaneous sumatriptan. Preventive treatment is two-pronged and consists of transitional treatment, usually with prednisone, to produce rapid suppression of attacks, and maintenance treatment (typically wi...
Clinical Therapeutics, 2020
PURPOSE The Prevention of Migraine via Intravenous ALD403 Safety and Efficacy 1 (PROMISE-1) study... more PURPOSE The Prevention of Migraine via Intravenous ALD403 Safety and Efficacy 1 (PROMISE-1) study was a phase III, randomized, double-blind, placebo-controlled study designed to evaluate the efficacy, tolerability, and pharmacokinetic properties of repeat intravenous (IV) doses of the calcitonin gene-related peptide‒targeted monoclonal antibody eptinezumab (ALD403) for migraine prevention in adults with episodic migraine. Here we present the results of PROMISE-1 through 1 year of treatment (up to 4 doses). METHODS Patients received up to 4 IV administrations of eptinezumab 30 mg, 100 mg, 300 mg, or placebo every 12 weeks. Patients recorded migraine and headache in an electronic diary daily. Additional assessments, including the patient-reported outcomes, were performed at regularly scheduled clinic visits throughout the 56-week study period. FINDINGS A total of 888 adults (mean age, 39.8 years; 84.3% female; 83.8% white) received treatment: eptinezumab 30 mg, n = 219; eptinezumab 100 mg, n = 223; eptinezumab 300 mg, n = 224; and placebo, n = 222. During the primary 12-week study evaluation period, single doses of eptinezumab 100 mg and 300 mg led to significant reductions in mean monthly migraine-days versus placebo, beginning as early as the first day after the initial dose. The reduction in mean monthly migraine-days was maintained throughout the study (100 mg, -3.9, -4.5, -4.7, and -4.5 days; 300 mg, -4.3, -4.8, -5.1, and -5.3 days; and placebo, -3.2, -3.8, -4.0, and -4.0 days during weeks 1-12, 13-24, 25-36, and 37-48, respectively). Overall, the number of patients with a ≥50% or ≥75% reduction in migraine for each 12-week interval during the entire study was consistently numerically higher in the eptinezumab groups than in the placebo group. The proportions of patients with ≥50% reduction in migraine were similar across the eptinezumab groups. Eptinezumab was well tolerated throughout the study. Adverse events were similar across dosing periods, and there were no serious tolerability signals identified with continued dosing. IMPLICATIONS IV eptinezumab administered every 12 weeks for up to 4 doses was associated with early and sustained migraine-preventive effects and a favorable safety profile in adults with episodic migraine. ClinicalTrials.gov identifier: NCT02559895.
Advances in applied neurological sciences, 1988
This short introduction will emphasize the approach to chronic recurring daily or almost daily he... more This short introduction will emphasize the approach to chronic recurring daily or almost daily headache and it will consider the phenomenon of “migraine transformation” in which episodic and typical primary headache conditions appear to be transformed into chronic daily headache patterns. In 1962, the Ad Hoc Committee on Classification of Headache offered what was to become the standard classification for head pain disorders for the next 20 years. This report was based upon the premise of a clear distinction between migraine and tension headache (TH) and emphasized system-specific etiologies: vasculature in migraine, musculature in tension headache. But, despite its many citations and its traditional acceptance by researchers and clinicians alike, many authorities have been unable to reconcile the myriad of events and phenomena of migraine, TH, and cluster headache with the basic foundations of this classification. During the past few years, the emphasis on peripheral phenomena (blood vessels and muscles) and separateness between migraine and TH disorders has been challenged, and with it has come a change views on the treatment of these disorders.
Neurologia, neurochirurgia i psychiatria polska
Hospital practice (Office ed.), Jan 30, 1987
Primary Care Case Reviews, 2001
Neurologic Clinics, 1999
This article addresses headache-related topics in which medicolegal issues have occurred or in wh... more This article addresses headache-related topics in which medicolegal issues have occurred or in which they are likely to occur. Where possible, an actual case has been presented. Most sections of this article are divided into three parts: principle of care, case history, and discussion and recommendations. When appropriate, American Academy of Neurology guidelines have been noted.
The Journal of Pain, 2002
Headache: The Journal of Head and Face Pain, 2000
Headache: The Journal of Head and Face Pain, 1995
We studied transnasal butorphanol (Stadol NS·) for pain relief during acute migraine in a multice... more We studied transnasal butorphanol (Stadol NS·) for pain relief during acute migraine in a multicenter, randomized, double‐blind, placebo controlled trial using ambulatory patients at 10 geographically diverse headache centers. Patients were volunteer adults diagnosed with migraine with or without aura by International Headache Society criteria. One hundred fifty‐seven patients completed the study. We treated the pain of one headache in each patient with either transnasal butorphanol (n=107) or transnasal placebo (n=50). Pain relief, pain intensity, nausea, vomiting, and effect on function were measured periodically. Adverse experiences were documented. Global assessments were made at follow‐up. With butorphanol, migraine pain was reduced from moderate, severe, or incapacitating to slight or absent for 35 patients (33%) within 30 minutes, for 50 patients (47%) within 1 hour, and for 76 (71%) within 6 hours, compared to 2 (4%) 8 (16%) and 15 (30%) respectively for placebo. Side effect...
Headache: The Journal of Head and Face Pain, 1987
SYNOPSISErgotamine tartrate has been recognized as the drug of first choice for the treatment of ... more SYNOPSISErgotamine tartrate has been recognized as the drug of first choice for the treatment of acute attacks of migraine. This paper draws attention to a common but poorly delineated state of addiction that can develop when ergotamine tartrate usage exceeds two or three days per week. This syndrome is characterized by a self‐sustaining, rhythmic headache/medication cycle, with daily or almost daily migraine headaches and the irresistible and predictable use of ergotamine tartrate as the only means of alleviating the headache attacks. This report further delineates the clinical features, criteria for recognition, and treatment alternatives for this syndrome. In order to avoid this condition, usage should be restricted to 2 days per week.
Headache: The Journal of Head and Face Pain, 2002
Certain features of chronic daily headache, namely, increased headache frequency, expansion of he... more Certain features of chronic daily headache, namely, increased headache frequency, expansion of headache area, and cutaneous allodynia, may imply sensitization of central nociceptive neurons in the trigeminal pathway. Repetitive activation of the trigeminal nerve can lead to a biologic and functional change in trigeminal nucleus caudalis neurons, characterized by a decrease in nociceptive threshold and receptive field expansion. Suppression of the endogenous pain control system can facilitate the process of central sensitization. Evidence of such suppression in patients with chronic daily headache includes decreased platelet serotonin, up‐regulation of 5‐HT2A receptors, increased platelet nitric oxide production, and increased levels of substance P and nerve growth factor in the cerebrospinal fluid. Results from a number of animal experiments have indicated that chronic analgesic exposure leads to changes in serotonin content and density of 5‐HT2A receptors in the central nervous sys...
Headache: The Journal of Head and Face Pain, 1982
Headache: The Journal of Head and Face Pain, 2007
Wade Cooper, MD St. John Chronic headache and Migraine Institute, Madison Height, Michigan A 38-y... more Wade Cooper, MD St. John Chronic headache and Migraine Institute, Madison Height, Michigan A 38-year-old female with history of rheumatoid arthritis and asthma presented to a headache clinic with persistent headache. She developed intermittent headache episodes beginning at age 12, with gradual increase in frequency and severity through age 20. She would experience frequent headaches, at times preceded by visual aura and associated with nausea, photophobia, and phonophobia. By age 30, her headaches were much improved, and she would experience a headache only once every 2 to 3 months. At age 35 her headaches substantially worsened, culminating in a daily low-grade headache with escalation to severe disabling headache 3 times per week. Her pain was typically located in occipital regions bilaterally with radiation to the periorbital regions. The patient did not have aura symptoms. She had associated nausea with photophobia and phonophobia. Her headache would worsen with exertion. She did not experience autonomic features such as ptosis, lacrimation, or rhinorhea. Her headaches were refractory to multiple prevention and acute medications. Past Medical History.—Rheumatoid arthritis, diagnosed at age 33, asthma, depression, frequent sinus infections, 3 generalized seizures in the remote past, and a motor vehicle accident age 33, which did not cause direct head trauma. Family History.—Multiple family members with migraine; no rheumatologic illness. Social History.—Noncontributory Medications.—Tizanadine 8 mg qhs, topiramate 200 mg BID, Sulfasalazine 500 mg daily, etanercept 25 mg twice weekly, fluoxetine 40 mg daily, albuterol inhaler prn, and isometheptine compound prn. Physical Exam.—Normal, including head and neck examination and neurological examination. Her initial temperature was 97.9 F. She remained afebrile throughout her treatment course. Her neck was supple and no areas of erythema or tenderness were appreciated in the head or face. Diagnosis and Treatment.—Her serum studies were normal. ESR = 25 and WBC = 5.3 at initial evaluation with platelets of 189. There were no other markers of inflammation identified. MRI of the cervical spine revealed a mild protrusion of the C5-C6 disc with minimal extension into the right neural foramen, with the remainder of the study unremarkable. Previously obtained cervical spine radiographs including flexion/extension views were normal. MRI of the brain revealed increased signal on axial T2 (Figs. 1 and 2) and coronal T1 (Fig. 3) weighted images in the left sphenoid and posterior ethmoid sinuses suggestive of sinusitis. The patient was started on amoxicillin 1000 mg/clavulanate 62.5 mg (Augmentin 1000 mg XR) taken 2 po BID for 10 days. She experienced substantial pain improvement days after starting the antibiotics. A CT of the sinus was obtained 4 weeks later, revealing persistent inflammation of the left sphenoid and ethmoid sinuses (Fig. 4). The patient then had a clinical worsening of her headaches, and she received another course of antibiotic therapy that provided no significant improvement, as evidenced by continued inflammatory changes on sinus CT (Fig. 5). She had sinus surgery including drainage of the left sphenoid followed by significant improvement in her headaches. At 6 months follow-up, the patient stated that she has had no migraine headaches, and has rare low-grade headaches that respond to low-dose ibuprofen. Retrospective review of a head CT for headache obtained 2 years prior to presentation revealed increased density within the left sphenoid sinus (Fig. 6). Final Diagnosis.—Chronic sphenoid sinusitis
Clinical Neuropharmacology, 1986
Based on our clinical experience and the data reviewed and presented in this report, we propose t... more Based on our clinical experience and the data reviewed and presented in this report, we propose that a state of physical dependency to ergotamine tartrate exists. This dependency state is characterized by the irresistible and dependable use of ergotamine tartrate and is contingent upon a self-sustaining, rhythmic headache/medication cycle that reflects the dependency. The headache and accompaniments (withdrawal headache?) represent the primary withdrawal symptoms. The presence of this state appears to render patients refractory to other forms of preventative therapy, which can be effective only when ergotamine is discontinued and the cycle broken. If the condition is left untreated, it is likely though by no means certain that the more traditional aspects of ergotism will evolve, although variable susceptibility and tolerance to ergotamine tartrate have been demonstrated. The mechanism of this disorder remains uncertain but might be related to the influence of ergotamine tartrate on the limbic-hypothalamic-pituitary-adrenal axis and other aminergic centers (locus ceruleus), areas considered by some as the central loci for the pathogenesis and associated symptoms of migraine.
The Clinical Journal of Pain, 1986
Archives of Neurology, 1974
A 17-year-old girl was examined because of recurrent bilateral facial palsy. Skull roentgenograms... more A 17-year-old girl was examined because of recurrent bilateral facial palsy. Skull roentgenograms demonstrated cranial metaphyseal dysplasia. This unusual hereditary disorder, which is due to defective bone remodeling and absorption, is associated with many neurological disabilities, including multiple cranial neuropathies, hemiplegia, and medullary compression. Cranial metaphyseal dysplasia has been incorrectly diagnosed as osteopetrosis. Although similarities between these two disorders exist, differences in the clinical course, roentgenographic findings, and pathophysiology distinguish the two entities.
Archives of Neurology, 1996
To assess the efficacy and tolerability of subcutaneous dihydroergotamine mesylate (DHE-45) vs su... more To assess the efficacy and tolerability of subcutaneous dihydroergotamine mesylate (DHE-45) vs subcutaneous sumatriptan succinate (Imitrex) for the treatment of acute migraine with or without aura. Double-blind, randomized trial with parallel treatment arms. Clinics and private neurology practices. Patients of either sex, with migraine with or without aura, between the ages of 18 and 65 years. Patients with moderate or severe head pain were randomized to receive either 1 mg of subcutaneous dihydroergotamine mesylate or 6 mg of subcutaneous sumatriptan succinate. Patients rated head pain, functional ability, nausea, and vomiting at baseline and at 0.5, 1, 2, 4, and 24 hours after the injection. Presence or absence of headache at 3 hours was calculated from collected data. If pain persisted after 2 hours, a second injection of the same study medication was allowed, and self-ratings were repeated 30 and 60 minutes later. Follow-up data were collected at 24 hours. Relief of head pain and recurrence of successfully treated headache. There were 295 evaluable patients. At 2 hours, 73.1% of the patients treated with dihydroergotamine and 85.3% of those treated with sumatriptan had relief (P = .002). There was no statistical difference in headache relief between the groups at 3 or 4 hours. Headache relief was achieved by 85.5% of those treated with dihydroergotamine and by 83.3% of those treated with sumatriptan by 4 hours. By 24 hours 89.7% of dihydroergotamine-treated patients and 76.7% of sumatriptan-treated patients had relief (P = .004). Headache recurred within 24 hours after treatment in 45% of the sumatriptan-treated patients and in 17.7% of the dihydroergotamine-treated patients (P < or = .001). Both sumatriptan and dihydroergotamine were effective in aborting migraine headaches. Headache recurrence was two and a half time as likely with sumatriptan as with dihydroergotamine.