Dewey K. Ziegler

Prognosis in Patients with Transient Ischemic Attacks

The prognosis on 144 patients with transient ischemic attacks was determined over a minimum period of three years by quantitating, at intervals, the number of attacks and also the neurological disability by means of a disability score. No patients had neurological disability at the initiation of the study. Total cervicocephalic angiography was performed on 93 patients. Seven of the 144 patients were deceased at the end of the three-year period, five of them due to strokes. Seventeen patients (15.6%) developed persistent neurological disability during the three years, with the mean disability score being much higher for the patients with carotid attacks than those with basilar attacks. The cumulative number of attacks in both carotid and basilar groups rose steadily in the first 18 months, with a much larger number of attacks occurring in the basilar group. The attack rate leveled off after 18 months in the carotid group. Attacks tended to be consistent in nature over a period of time. Twenty-eight percent of those patients with basilar attacks and 12.5% of those patients with carotid attacks showed carotid stenosis on angiography. Study of carotid stenosis associated with subsequent neurological disability revealed that increased risk occurred only when carotid stenosis was more than 70%

Migraine in Twins Raised Together and Apart

History of headache and migraine diagnosed by structured interview utilizing International Headache Society criteria was obtained in two samples of female twin pairs—154 raised together and 43 raised apart since infancy. Zygosity was determined by standard methods. Probandwise concordance rates were determined. Assuming that liability to migraine has a multifactorial etiology involving a number of genetic and environmental risk factors acting additively, tetrachoric correlations in the four groups of twins (monozygotic raised together, monozygotic raised apart, dizygotic raised together, and dizygotic raised apart) were then calculated. The genetic and environmental influences in the liability to migraine were estimated using biometrical model‐fitting methods.

Stroke In China, 1986 Through 1990

BACKGROUND AND PURPOSE Incidence of stroke varies markedly in different world populations. In seven Chinese cities, the effect of a program of risk factor modification on the incidence and mortality of stroke was studied and compared with a control population. This article describes the incidence of stroke in the control populations for the years 1986 through 1990. METHODS Incidence (first-ever strokes only) for 1986 was obtained by door-to-door interview with heads of households with subsequent verification on examination by a neurologist and review of medical and/or hospital records. In subsequent years, cases were ascertained with a three-tier monitoring system: by community health workers, local medical centers, and the Beijing Neurosurgical Institute. RESULTS Average annual age-adjusted incidence per 100,000 was 215.6 (261.5 for males, 174.5 for females; P < .001). There was a significant drop in the total number of cases from 137 in 1986 to 106 in 1990, but the age-adjusted rate showed a significant drop for males only (322.3 to 182.5, P < .001). Marked differences in average annual age-adjusted rates existed among the seven cities, from 486.4 for Harbin to 80.9 for Shanghai. This difference in rate among cities was found for both sexes but was more pronounced in males. CONCLUSIONS The stroke incidence rates in China, like those in Japan, are among the higher ones in the world. In recent years, there has been an apparent decline in stroke incidence. Marked differences in rates were found between males and females with decline in incidence occurring almost exclusively in males. There were also marked differences in stroke incidence among the cities studied. These differences may result in part from differences in diet, alcohol and cigarette consumption, or prevalence of hypertension.

Evaluation of the relationship between migraine headache and depression.

MIGRAINE HEADACHE and depression are both common disorders. There have been many suggestions of a relationship between them1-4 but few systematic studies have been done. Kashiwagi et al 1 using rigid criteria for depression, found that 50% of a series of 100 patients with various types of headaches were depressed including 36 with unipolar affective disorders, 3 with bipolar affective disorder and 11 with secondary depression. Vascular headaches or combination of tension and vascular headaches are present in 69 of these patients of whom 22 were depressed. Comparing patients with tension headaches, vascular headaches or a combination of both however, they found no increase in the incidence of depression in the group with vascular headaches over the others.

Headache syndromes suggested by factor analysis of symptom variables in a headache prone population

THE STUDY of headache, one of the most universal and anciently described of human afllictions, has been plagued by problems of defining homogeneous patient groups. The Ad Hoc Committee of the National Institute of Neurological Diseases and Blindness in 1962, recognizing this problem, summarized the consensus at that time by naming several entities of symptom patterns of recurrent headache not due to specific local causes: classic migraine, common migraine, cluster headache, hemiplegic and ophthalmoplegic migraine, lower-half headache, muscle contraction headache, and combined headache (vascular and muscle contraction) [l]. Although the common features of migraine are well known, as are those of ‘tension headache’, all who deal with headache patients, however, are aware of the uncertainty of how commonly each specific headache characteristic occurs in association with another. Segments of ‘migraine’ and ‘tension’ headache syndromes, for example, seem to be more commonly mingled in the pattern of headache of the individual patient than the pure symptom complex. Attempts to find a single defining criterion for migraine have been productive of disagreement. The extent and importance of the difficulty encountered by clinicians in identifying identical or even closely similar populations among headache patients can scarcely be overemphasized. Gowers stressed the ‘paroxysmal’ nature (episodic nature) of the headaches, mentioned the frequent occurrence of nausea, visual disturbance and unilaterality of headache [2]. Wolff stressed the response to ergotamine, the autonomic dysfunction features, the presence of scalp blood vessel dilatation and of scalp tenderness, and the psychogenic aspects of precipitation of attacks [3]. Ostfeld recognized the problems in diagnosis created by ‘patients’ expectations and skills in communicating and the doctor’s biases’. To isolate a homogeneous patient population he defined migraine as those patients whose headache responded rapidly and well to intramuscular ergotamine and not placebo [4]. Lance et al, however, in one of the largest recent series, uses as criteria for migraine ‘recurrent severe headache with

Magnetic resonance image abnormality in migraine with aura.

Cerebral magnetic resonance imaging (MRI) was performed on 18 patients with migraine characterized by aura consisting of both visual symptoms and paresthesias. Fifteen headache-free individuals of the same age range were used as controls. Records were randomized and read in blind fashion by two neuroradiologists. Small subcortical white matter lesions were seen in three migraine cases and two controls. In one migraine case cortical infarctions were seen. In two controls, small areas of increased density similar to those in migraine were seen. No consistent correlation of migraine or its duration with cerebral atrophy was found. It is concluded that identification of both these MRI findings (small subcortical white lesions and cerebral atrophy) as significantly associated with migraine is doubtful.

Opiate and Opioid Use in Patients With Refractory Headache

Opiate and opioid analgesics are commonly used for pain in general and presumably for headache. Codeine, oxycodone and propoxyphene, among the most commonly prescribed, do carry some risk of abuse, and their efficacy in headache patients has not been well studied. In many patients with other kinds of pain, however, both of neoplastic and non-neoplastic origin, chronic opiate use has been demonstrated to be of benefit without adverse side effects. The type of headache patient with intractable pain who needs frequent opiate analgesic and who does not develop addiction or drug abuse is an important subject for research.

Headache: Public Health Problem

Headache is, and apparently always has been, a frequent pain syndrome. It is reported in American and Western European societies in very high percentages of the population. Headache, and specifically severe headache, have also been reported as prevalent from a variety of societies worldwide, although prevalence rates have varied (they are very low, for example, in the Peoples Republic of China). Whether prevalence varies with different socioeconomic groups remains uncertain. Severe headache and specifically migraine is, for reasons still unknown, much more common in women, and, in most studies, is reported to decrease in prevalence in older age groups. Positive family histories are common, but the precise role of genetics is unknown. A major problem in the epidemiologic studies remains the difficulty of uniform definition of headache syndromes.

Discrepancies in recorded results from duplicate neurological history and examination in patients studied for prognosis in cerebrovascular disease.

Histories were taken and neurological examinations performed according to a carefully standardized protocol by two neurologists on 28 patients with histories of probable transient cerebrovascular insufficiency. Duplicate examinations were performed within a short interval of the initial examinations. Comparison of the findings on the two examinations showed extreme discrepancies in recording of presence or absence of specific symptoms and of signs on the neurological examination, including signs considered “objective”—for example, reflex asymmetry. Discussion between the examiners followed by another set of duplicate examinations reduced the discrepancies on the findings of neurological examination, but did very little to the discrepancies in the history. The necessity of realizing the variability of the history and examination in evaluating the course of, and therapy for, transient cerebrovascular ischemic attacks is emphasized.

Headache syndromes suggested by statistical analysis of headache symptoms

Statistical study of the correlation between 49 variables concerning characteristics of headache and of headache patients was carried out on 1,198 sequential patients complaining of severe or disabling headaches and attending a headache clinic. Factor analysis was the statistical method employed, 17 factors accounting for 64% of total variation emerged. The most prominent factor contained descriptors of neurological dysfunction associated with headache. Another factor contained variables of nausea and vomiting, only associated with inability to work. Other factors, contained separately, the following variables: (a) Time of headache, (b) time of week of headache, (c) unilateral nature of headache, (d) visual phenomena associated with headache. Relation of these findings to headache taxonomy is discussed.