Fayyaz Ahmed

Retrospective Evaluation of the Dose of Dysport and BOTOX in the Management of Cervical Dystonia and Blepharospasm: The REAL DOSE Study

The purpose of this study is to evaluate the real‐world dose utilization of Dysport and BOTOX for cervical dystonia and blepharospasm. Six investigational sites (five countries) were identified. Investigators abstracted utilization data for patients who received Dysport before switching to BOTOX or BOTOX before switching to Dysport. Patients were identified during scheduled clinic visits and selected if they met study criteria, which included treatment for at least 2 consecutive years (at least 1 year with Dysport or BOTOX, then switched and maintained on BOTOX or Dysport for at least another year). A total of 114 patients were included in the assessment. Ratios of mean dose for Dysport to BOTOX ranged from a low of 2:1 to a high of 11:1. Thirty‐one percent of patients fell into the Dysport‐to‐BOTOX ratio grouping of 5:1 to less than 6:1; 30% of patients had a mean ratio of Dysport to BOTOX of 4:1 to less than 5:1; and only 21% of all patients evaluated fell into the Dysport‐to‐BOTOX ratio grouping of 3:1 to less than 4:1. Results are consistent with United Kingdom labeling for botulinum toxins stating that units of different serotype A toxins are not interchangeable and simple dose‐conversion factors are not applicable.

EHMTI-0102. Prospective analysis of the use of onabotulinumtoxina (botox®) In the treatment of chronic migraine; real-life data in 299 patients from hull, UK

BackgroundChronic migraine affects 2% of the population. It results in substantial disability and reduced quality of life. Medications used for prophylaxis in episodic migraine may also work in chronic migraine. The efficacy and safety of OnabotulinumtoxinA (BOTOX) in adults with chronic migraine was confirmed in the PREEMPT programme. However, there are few real-life data of its use.Method254 adults with chronic migraine were injected with OnabotulinumtoxinA BOTOX as per PREEMPT Protocol between July 2010 and May 2013, their headache data were collected using the Hull headache diary and analysed to look for headache, migraine days decrements, crystal clear days increment in the month post treatment, we looked at the 50% responder rate as well.ResultsOur prospective analysis shows that OnabotulinumtoxinA, significantly, reduced the number of headache and migraine days, and increased the number of headache free days. OnabotulinumtoxinA Botox also improved patients’ quality of life. We believe that these results represent the largest post-marketing cohort of patients treated with OnabotulinumtoxinA in the real-life clinical setting.ConclusionOnabotulinumtoxinA is a valuable addition to current treatment options in patients with chronic migraine. Our results support findings of PREEMPT study in a large cohort of patients, we believe, is representative of the patients seen in an average tertiary headache centre. While it can be used as a first line prophylaxis its cost may restrict its use to more refractory patients who failed three oral preventive treatments.

Imaging patients with suspected brain tumour: guidance for primary care.

The number of referrals by primary care practitioners to secondary care neurology services, particularly for headache, may be difficult to justify. Access to imaging by primary care practitioners could avoid referral without compromising patient outcomes, but the decision to refer is based on a number of complex factors. Due to the paucity of rigorous evidence in this area, available data are combined with expert opinion to offer support for GPs. The study suggests management for three levels of risk of tumour: red flags>1%; orange flags 0.1-1%; and yellow flags<0.1% but above the background population rate of 0.01%. Clinical presentations are stratified into these three groups. Important secondary causes of headache where imaging is normal should not be overlooked, and normal investigation does not eliminate the need for follow-up or appropriate management of headache.

Non-invasive vagus nerve stimulation for the acute treatment of episodic and chronic cluster headache: A randomized, double-blind, sham-controlled ACT2 study

Background Clinical observations and results from recent studies support the use of non-invasive vagus nerve stimulation (nVNS) for treating cluster headache (CH) attacks. This study compared nVNS with a sham device for acute treatment in patients with episodic or chronic CH (eCH, cCH). Methods After completing a 1-week run-in period, subjects were randomly assigned (1:1) to receive nVNS or sham therapy during a 2-week double-blind period. The primary efficacy endpoint was the proportion of all treated attacks that achieved pain-free status within 15 minutes after treatment initiation, without rescue treatment. Results The Full Analysis Set comprised 48 nVNS-treated (14 eCH, 34 cCH) and 44 sham-treated (13 eCH, 31 cCH) subjects. For the primary endpoint, nVNS (14%) and sham (12%) treatments were not significantly different for the total cohort. In the eCH subgroup, nVNS (48%) was superior to sham (6%; p < 0.01). No significant differences between nVNS (5%) and sham (13%) were seen in the cCH subgroup. Conclusions Combing both eCH and cCH patients, nVNS was no different to sham. For the treatment of CH attacks, nVNS was superior to sham therapy in eCH but not in cCH. These results confirm and extend previous findings regarding the efficacy, safety, and tolerability of nVNS for the acute treatment of eCH.

OnabotulinumtoxinA for chronic migraine: a critical appraisal.

Chronic migraine (CM) is a severe disabling condition with a few available evidence-based management options. OnabotulinumtoxinA (onaBoNTA) is approved for use in a number of disorders. Its benefits and potential use in migraine were observed incidentally while treating patients cosmetically for wrinkles. The mechanism of action of onaBoNTA in CM is not fully understood, but there is evidence that this involves axonal transport via sensory fibers. The Phase III REsearch Evaluating Migraine Prophylaxis Therapy trials have established the efficacy as well as the long-term safety and tolerability of onaBoNTA in CM. This review will discuss the evidence behind its use in this setting.

Current Understanding on Pain Mechanism in Migraine and Cluster Headache

Context Migraine and cluster headache are undoubtedly painful conditions. The respective pathogenesis of these two conditions is incompletely understood. In both cases, the treatments used have largely been empirical and have relied to a much lesser extent on our understanding of the mechanisms causing pain. We hereby review the pain mechanisms in migraine and cluster headache, two of the commonest primary headache disorders. Evidence Acquisition A review of the English literature was conducted by searching PubMed for studies on pain mechanism in migraine and cluster headache. We entered [migraine] and [pain mechanism] in Pubmed and 488 articles were obtained. Articles were then included according to their relevance to the topic. Similarly, [cluster headache] and [pain mechanism] revealed 79 search results. Results There is evidence that the trigeminovascular system and neurogenic inflammation play important roles, together with certain areas of the brain, leading to these conditions being termed ‘neurovascular headaches’. Functional imaging findings suggest a possible role of the dorsolateral pons in generating migraine attacks while the role of the hypothalamus in cluster headache is more firmly established. Conclusions Migraine and cluster headache have complex pathophysiologies. The exact mechanism causing pain in both conditions is incompletely understood and more research needs to be undertaken in this area.

Hemicrania Continua Responsive to Botulinum Toxin Type A: A Case Report

Hemicrania continua (HC) is a primary headache disorder with full response to indomethacin as one of its diagnostic criteria; however, indomethacins side effects could limit its use in HC.

Evidence-based treatments for cluster headache.

Cluster headache (CH), one of the most painful syndromes known to man, is managed with acute and preventive medications. The brief duration and severity of the attacks command the use of rapid-acting pain relievers. Inhalation of oxygen and subcutaneous sumatriptan are the two most effective acute therapeutic options for sufferers of CH. Several preventive medications are available, the most effective of which is verapamil. However, most of these agents are not backed by strong clinical evidence. In some patients, these options can be ineffective, especially in those who develop chronic CH. Surgical procedures for the chronic refractory form of the disorder should then be contemplated, the most promising of which is hypothalamic deep brain stimulation. We hereby review the pathogenesis of CH and the evidence behind the treatment options for this debilitating condition.

Cluster-like headache heralding inflammatory orbital pseudotumour.

A 33-year-old woman presented with a 3-week history of left periorbital pain. There was continuous background pain with intermittent severe exacerbations occurring three to four times a day, each time lasting for an hour accompanied by lacrimation but no rhinorrhoea, conjunctival injection or ptosis. There was early morning awakening. She gave a history of a similar event 1 year previously lasting 1 week. On examination there were no neurological signs. Cluster headache was diagnosed and she was commenced on steroids for 10 days and also verapamil. She responded dramatically within 48 h and remained well 1 month later and the verapamil was stopped. Three weeks later she returned with double vision and continuous stabbing pain in her left eye, worse on eye movements. Examination showed a proptosed left eye with conjunctival injection and periorbital swelling. There was restricted adduction of the left eye with double vision in that direction. A computed tomography scan showed an enlarged lateral rectus with thickening of both tendon and muscle belly (Fig. 1). Thyroid functions were normal, but thyroglobulin and thyroid microsomal antibody levels were elevated. Orbital pseudotumour was diagnosed and she was treated with a high dose of oral steroids with gradual reduction of the dose, on which she responded well with complete resolution of symptoms.

Chronic daily headaches.

Chronic Daily Headache is a descriptive term that includes disorders with headaches on more days than not and affects 4% of the general population. The condition has a debilitating effect on individuals and society through direct cost to healthcare and indirectly to the economy in general. To successfully manage chronic daily headache syndromes it is important to exclude secondary causes with comprehensive history and relevant investigations; identify risk factors that predict its development and recognise its sub-types to appropriately manage the condition. Chronic migraine, chronic tension-type headache, new daily persistent headache and medication overuse headache accounts for the vast majority of chronic daily headaches. The scope of this article is to review the primary headache disorders. Secondary headaches are not discussed except medication overuse headache that often accompanies primary headache disorders. The article critically reviews the literature on the current understanding of daily headache disorders focusing in particular on recent developments in the treatment of frequent headaches.