Babur Dora

A randomized prospective placebo‐controlled study of intravenous magnesium sulphate vs. metoclopramide in the management of acute migraine attacks in the Emergency Department

The objective of this randomized, placebo-controlled, double-blind study was to determine the effectiveness of intravenous magnesium sulphate and intravenous metoclopramide in the treatment of acute migraine attacks in the Emergency Department when compared with placebo. Adult patients who presented to the Emergency Department with a headache that met International Headache Society (IHS) criteria for acute migraine were infused with either 10 mg of intravenous metoclopramide, 2 g of intravenous magnesium sulphate or normal saline over 10 min. At 0, 15, and 30 min, patients were asked to rate their pain on a standard visual analogue scale. At 30 min, patients were asked in a standard manner about the need for rescue medication. Adverse affects were also recorded. Patients were followed up by telephone within 24 h for any recurrence after discharge. The primary endpoint of the study was the difference in pain relief between the groups at 30 min. Of the 120 patients who met IHS criteria, seven were excluded from the study due to insufficient data. The number of patients, gender, age and initial visual analogue scale (VAS) scores were comparable between groups. Each group experienced more than a 25-mm improvement in VAS score at 30 min. However, there was no significant difference detected in the mean changes in VAS scores for pain. The rescue medication requirement was higher in the placebo group. The recurrence rate in 24 h was similar between the groups. Although patients receiving placebo required rescue medication more than the others, metoclopramide and magnesium have an analgesic effect similar to placebo in migraine attacks.

Utility of transcranial doppler ultrasonography for confirmatory diagnosis of brain death: two sides of the coin.

Background. Although the clinical examination and documentation of the clinical signs of brain death are very uniform, there are significant differences in the guidelines for using technical confirmatory tests to corroborate the clinical signs. The current study examined the utility of transcranial Doppler ultrasonography (TCD) for confirmation of brain death. Methods. After 19 patients were excluded from the study because of lack of bone window or because an apnea test could not be performed because of desaturation, 100 patients (61 patients with clinical brain death, and 39 control patients with Glasgow Coma Score<5) were included in the study. The following TCD findings were accepted as confirmatory of brain death when they were found bilaterally or in at least three different arteries for at least 3 minutes within the same examination: (1) brief systolic forward flow or systolic spikes and diastolic reverse flow, (2) brief systolic forward flow or systolic spikes and no diastolic flow, or (3) no demonstrable flow in a patient in whom flow had been clearly documented in a previous TCD examination. Results. The sensitivity and specificity of the first TCD examination for confirmation of brain death were 70.5% and 97.4%, respectively. Eighteen patients with clinical brain death required repeat TCD examinations because of detection of forward systolo-diastolic flow or a diastolic to-and-fro flow pattern, which were not confirmatory for the diagnosis of brain death. Brain death was confirmed ultrasonographically in 12 of 18 patients in a second examination after 12.6±8.3 hours of clinical brain death, in 2 patients in a third TCD examination, and in 1 patient in a fourth examination. Three clinically brain-dead patients had died before the diagnosis was confirmed by repeat TCD examinations. The sensitivity of TCD reached 100% in our study population after the fourth examination. Conclusion. The sensitivity of TCD is increased with repeat examinations and should be repeated in cases in which systolo-diastolic forward flow is demonstrated after the first TCD. TCD may prolong or shorten the time to declaration of brain death. The necessity of demonstrating cerebral circulatory arrest in patients with clinical brain death is debatable.

Validity and Reliability of the Turkish Migraine Disability Assessment (MIDAS) Questionnaire

Objectives.—The aim of this study is to assess the comprehensibility, internal consistency, patient‐physician reliability, test‐retest reliability, and validity of Turkish version of Migraine Disability Assessment (MIDAS) questionnaire in patients with headache.

SUNCT syndrome with dramatic response to oxcarbazepine.

Short-lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT) is a syndrome characterized by very brief unilateral orbital or periorbital attacks of pain of moderate to severe intensity, which are accompanied by simultaneous ipsilateral cranial autonomic symptoms, mainly conjunctival injection and lacrimation (1, 2). The frequency of attacks can range from one to >100 crises per day and pain may be precipitated by manoeuvres of the neck or from cutaneous trigger zones mainly in a trigeminal topography (1, 3, 4). Various treatments have been tried for SUNCT syndrome with no or only slight to moderate benefit. Of the antineuralgic drugs, carbamezapine has been tried with only half of patients having a slight to moderate response (5–17). Oxcarbazepine has never been reported in the treatment of SUNCT syndrome (3). We present a patient with SUNCT who responded dramatically to treatment with low-dose oxcarbazepine.

Exaggerated interictal cerebrovascular reactivity but normal blood flow velocities in migraine without aura

Interictal cerebrovascular reactivity and blood flow velocities were tested in 23 patients with migraine without aura and 10 age- and sex-matched healthy controls by using the breath holding index (BHI). The mean systolic, diastolic and mean velocities and pulsatility indices were not different in the controls and patients. The BHI was found to be significantly greater (P = 0011) in the patients (1.64 ± 0.33) compared with the controls (1.26 ± 0.37), showing an exaggerated reactivity to hypercapnia in migraineurs. Reactivity to pCO2 theoretically depends on pre-existing arteriolar tone and thereby on baseline velocity. Our finding of similar blood flow velocities in controls and patients suggests that the underlying cause for this high reactivity may not be an increased vasotonus but an increased sensitivity to changes in blood CO2 levels.

Effect of the menstrual cycle on standard achromatic and blue-on-yellow visual field analysis of women with migraine

BACKGROUND It has been postulated that migraine and glaucoma may have common vascular causative factors. Significant sex-based differences in the incidence of many important ocular conditions raise the possibility that estrogens may have direct effects on the eye. We performed a study to determine the effect of the menstrual cycle on standard achromatic automated perimetry (SAP) and short-wavelength automated perimetry (SWAP) (blue-on-yellow perimetry) of women with migraine. METHODS Both eyes of 73 normally menstruating women (31 subjects with migraine and 42 healthy control subjects) were included in the study. Subjects underwent a complete ocular examination including SAP and SWAP in both the follicular phase (12th to 13th day of the cycle) and the luteal phase (1 to 2 days before the onset of bleeding) of two consecutive menstrual cycles.We performed visual field analysis using the Humphrey Field Analyzer II with the full-threshold central 30-2 program. Mean sensitivity was calculated for the superior temporal, inferior temporal, superior nasal and inferior nasal regions separately. RESULTS Thirteen subjects were lost to follow-up (5 in the migraine group and 8 in the control group), leaving 26 subjects and 34 subjects respectively. There was no significant difference in mean age between the two groups (33.9 years [standard deviation (SD) 3.4 years] vs. 35.1 years [SD 3.3 years]). The mean duration of migraine was 7.6 (SD 3.1) years (range 3-14 years). In both groups, serum estradiol levels were significantly lower (p = 0.001) and serum progesterone levels were significantly higher (p < 0.001) in the luteal phase than in the follicular phase. In the control group, the mean sensitivity values with SWAP were significantly lower in the luteal phase than in the follicular phase (p = 0.04). A similar decrease was observed for the subjects with migraine with both SAP and SWAP (p = 0.01). There was no difference in regional mean sensitivity between the two phases with either perimetric test in the control group. For the subjects with migraine, there was no difference in regional mean sensitivity between the two phases with SAP. However, with SWAP, the mean sensitivity for the nasal visual field locations was significantly lower in the luteal phase than in the follicular phase (p = 0.01). INTERPRETATION Our study provides further evidence of an effect of sex hormones on the visual field of women with migraine. In addition to assessment of intraocular pressure, menstrual cycle phases should be considered in women with migraine at risk for glaucomatous optic neuropathy.

Migraine with cranial autonomic features and strict unilaterality

Although migraine and cluster headache are two distinct and different entities, occasionally some patients can present with characteristics of both headache disorders occurring simultaneously during attacks (1–3). Either migrainous features can be seen in a patient with cluster headache (1, 3), or unilateral cranial autonomic symptoms can be seen in a patient with typical migraine headache (2, 3), or features of both can be mixed together without one being predominant (3). We present a case with migraine and cluster-like features such as cranial autonomic symptoms and strict unilaterality.

Transient partial ophthalmoplegia and Horner’s syndrome after intraoral local anesthesia

Local neurological symptoms and signs are infrequent after intraoral anesthesia for dental procedures, thus diagnosis may be challenging for a neurologist unfamiliar with this benign phenomenon. Unnecessary diagnostic procedures may be performed and can be associated with complications. We present a 19-year old woman with transient diplopia, miosis, partial enophthalmia and lacrimation on the side of injection after intraoral anesthesia with prilocaine.

Normalization of high interictal cerebrovascular reactivity in migraine without aura by treatment with flunarizine.

Background.—Modification of migraine‐associated cerebrovascular reactivity may provide insight into the mechanism of action of a given therapeutic intervention.

The Effect of the Menstrual Cycle on the Optic Nerve Head Analysis of Migrainous Women

Purpose: To determine the effect of the menstrual cycle on the optic nerve head topographic analysis of normally menstruating migrainous women.Material and Methods: Randomly selected one eye of 44 migrainous and 49 healthy control women with regular menstrual cycles were included in the study. All subjects underwent complete ocular examination. Optic nerve head topographic analysis were performed using a confocal scanning laser ophthalmoscope, HRT II (Heidelberg Retinal Tomograph II, software version 1.6; Heidelberg Engineering, Heidelberg, Germany). They were repeated for two times during the menstrual cycle: in follicular phase (7th to 10th day of the cycle) and in the luteal phase (days 3 to 4 before the menstrual bleeding). Serum estradiol, progesterone, and luteinizing hormone measurements were repeated at each menstrual phase. Results: The mean age of migrainous and control subjects were 31.5 ± 5.1 years and 33.4 ± 3.7 years, respectively (P > 0.05). Their mean disc areas were 2.26 ± 0.46 mm2 and 1.95 ± 0.39 mm2, respectively (P < 0.05). Control subjects did not demonstrate any difference in the disc topography (P > 0.05). The parameter rim volume decreased, while the parameters cup volume and cup shape measure increased significantly in the luteal phase of the migrainous women (all P values < 0.05). Mean intraocular pressure of the migrainous women decreased significantly in luteal phase (P < 0.05). Conclusion: Significant differences exist in the optic rim and cup parameters during the menstrual cycle of the migrainous women. Further clinical trials on ocular blood flow changes during the menstrual cycle of the migrainous women may highlight the role of sex steroids in the optic nerve head of the migrainous women.