John F. Rothrock

Migraine trigger factors in a non‐clinical Mexican‐American population in San Diego county: implications for etiology

We conducted an investigation of migraine headache in a general population of Mexican-Americans living in San Diego county. Specific headache triggers were reported and analyzed, the most frequently reported for females with migraine being missing meals (58.9%), weather changes (54.4%), menstruation (53.6%), post-crisis letdown (52.7%), and fatigue (51.8%). The most frequently reported trigger factors for migraines reported by males were fatigue (58.8%), sleep (as a precipitating factor) (56.3%), post-crisis letdown (41.2%), and weather changes (37.5%). Trigger factors were further evaluated using stratification by presence or absence of Raynauds phenomenon (RP), menstrual migraine, family history of migraine, and by migraine type. Odds ratios and 95% confidence intervals were calculated. These results suggest that subjects with migraine and RP (perhaps indicative of a systematic vascular tone disorder) and those with menstrual migraine (indicative of sensitivity to hormonal changes) may overall be more sensitive to certain environmental stimuli, particularly those involving change in the internal environment.

A Practice Guide for Continuous Opioid Therapy for Refractory Daily Headache: Patient Selection, Physician Requirements, and Treatment Monitoring

(Headache 2010;50:1175‐1193)

Assessing the Ability of Topiramate to Improve the Daily Activities of Patients With Migraine

OBJECTIVE To assess the impact of topiramate on the daily activities of patients with migraine. PATIENTS AND METHODS We performed a randomized, double-blind, placebo-controlled multicenter trial Initiated on March 1, 2001, and completed on April 4, 2002. Patient-reported data from the Migraine Specific Questionnaire (MSQ) and the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36) were collected at baseline and at weeks 8, 16, and 26 from an intent-to-treat population receiving either topiramate, 50, 100, or 200 mg/d, or placebo. Two activity-related MSQ domains (role restrictive [MSQ-RR] and role prevention [MSQ-RP]) and 2 activity-related SF-36 domains (role physical [SF36-RP] and vitality [SF36-VT]) were the prospectively designated secondary outcome measures. The changes in MSQ and SF-36 scores for each treatment group were calculated by measuring the area under the curve from week 8 (the beginning of the maintenance period) through week 26 of the double-blind phase, relative to the prospective baseline. A mixed-effect piecewise linear regression model was used to estimate average domain score over time. RESULTS Patients receiving topiramate, 100 or 200 mg/d, had significantly reduced mean monthly (28-day) migraine frequency (P = .008 and P < .001, respectively) compared with placebo, but not patients receiving topiramate, 50 mg/d (P = .48). Topiramate significantly improved mean MSQ-RR domain scores (50 mg/d [P = .02], 100 mg/d [P< .001], and 200 mg/d [P < .001]) and mean MSQ-RP domain scores (50 mg/d [P = .007], 100 mg/d [P = .001], and 200 mg/d [P= .002]) vs placebo. Topiramate, 100 and 200 mg/d, significantly improved mean SF36-RP domain scores vs placebo (P = .02). Topiramate (all doses) improved SF36-VT domain scores, although not significantly vs placebo. Changes in prospectively designated domain scores were significantly correlated with changes in mean monthly migraine frequency (P < or = .001 [MSQ domains], P < or = .002 [SF-36 domains]). CONCLUSION Patient-reported migraine-specific outcomes measured by the MSQ-RR and MSQ-RP domains improved significantly for those receiving topiramate (all doses) vs placebo. The SF36-RP domain scores improved significantly for patients receiving 100 or 200 mg/d of topiramate. Improvements in all 4 prospectively selected MSQ and SF-36 domains were significantly correlated with decreases in mean monthly migraine frequency.

Accuracy of paramedic diagnosis of stroke.

BACKGROUND AND PURPOSE Accurate prehospital diagnosis of acute stroke may lead to fewer delays in hospital presentation. In addition, prehospital personnel soon may be administering therapies to patients with presumed stroke. We sought to determine the sensitivity and positive predictive value (PPV) of paramedic diagnosis of stroke in Mobile, Alabama, and to evaluate the impact of an educational program on paramedic diagnostic capability. METHODS We collected data from all paramedic-diagnosed stroke patients transported to a University of South Alabama hospital by Mobile Fire Medics. Final diagnosis was determined by a neurologist and classified as stroke or nonstroke (i.e., PPV). Paramedic diagnoses for all hospitalized stroke patients transported by Mobile Fire Medics were also reviewed (i.e., sensitivity). Sensitivity and PPV were calculated for the period 6/13/95 to 3/13/97. In addition, both indices were calculated for the period before (6/13/95 to 5/5/96) and after (6/25/96 to 3/13/97) an 8-week intensive educational program. RESULTS Seventy-one hospitalized stroke patients were transported by Mobile Fire Medics during the study period. Paramedics correctly identified 67 patients in total (94% sensitivity), 29 during the pre-education period (91% sensitivity), and 29 during the posteducation period (97% sensitivity; P=.33). Twenty-five patients were incorrectly diagnosed with stroke (73% PPV), 15 during the pre-education period (66% PPV), and 9 during the posteducation period (76% PPV; P=.30). CONCLUSION Although paramedics in Mobile misdiagnose few patients with acute stroke, there is a tendency toward overdiagnosis. An educational intervention resulted in a trend toward improved accuracy of diagnosis, but this did not reach statistical significance.

An Interregional Comparative Study of Headache Clinic Populations

We present a comparative study between headache clinic populations from 2 inherently different regions of the United States. Using standardized methods, 1 of us (JFR) prospectively evaluated 578 new patients attending the headache clinic at the University of California in San Diego. In a similar manner, we subsequently evaluated 115 new patients presenting to the headache clinic at the University of South Alabama in Mobile, Alabama. We found few differences between the 2 populations. These differences more likely reflect regional variations in healthcare delivery or methodologic artifact than intrinsic dissimilarities.

Migrainous stroke causing thalamic infarction and amnesia during treatment with propranolol

We report a case of migraine‐associated ischemic stroke causing amnesia, wherein treatment with propranolol may have been contributory. The possible mechanisms involved in migrainous stroke occurring in association with use of propranolol are discussed.

An Analysis of the “Carry-over Effect” Following Successful Short-term Treatment of Transformed Migraine With Divalproex Sodium

Objective.– To determine whether successful short‐term prophylactic treatment of transformed migraine may be followed by a continued respite from headaches once the treatment has been discontinued (“carry‐over effect”).

Headaches due to vascular disorders

The association between stroke and headache is complex, ranging from highly nonspecific, wherein headache is largely irrelevant to diagnosis and therapeutic management, to highly specific and even causative. In short, acute headache may accompany the acute stroke process, chronically complicate stroke, or, in rare instances, serve as the primary cause of stroke. With the first instance, the incidence of acute headache is highly dependent on the stroke sub-type and etiology. In this article, the headaches accompanying or causing acute stroke are addressed in some detail.

Treatment of Acute Migraine With Intravenous Droperidol

Patients in a general internal medicine practice with complaints of chronic headache and related neck discomfort for at least 6 months were recruited. One percent lidocaine was injected at the tendino-osseous junction at tender unilateral or bilateral occipital areas in the internuchal line space. If temporary relief of headache symptoms resulted, then they were eligible for treatment, Seventeen patients were injected in the same area with dextrose diluted in 1% lidocaine to 12.5% strength according to the method of Hackett.1 Injections were repeated at approximately 2-week intervals up to a maximum of seven sets of injections. Eleven of the 17 patients were improved or relieved of symptoms. At a 2-year follow-up, 9 had sustained complete relief of headache symptoms, 1 was partially improved, and 1 had relapsed. There were no complications.

Low pressure headache and pseudosubdural hematomas

A 49-year-old man presented for evaluation of uncharacteristic headaches and for a second opinion regarding the need for surgical evacuation of bilateral subdural hematomas. Seven weeks prior, he had been working on a ceiling with his head and arms extended for a prolonged period. Immediately afterwards he developed a headache that was much worse when he was upright and was rapidly relieved by recumbency. The positional headache had improved but persisted over the ensuing weeks. He had been seen by a neurosurgeon who ordered magnetic resonance imaging (MRI) and subsequently recommended the surgical evacuation of “bilateral subdural hematomas” that he felt were causing the patient’s new headaches. The patient denied any history of significant headaches. He reported pain with eye movement, but denied intracranial sounds. The findings from his physical examination were normal. Review of the noncontrasted brain MRI (Figure) previously obtained demonstrated confluent signal hyperintensity involving the cerebral meninges and no evidence of subdural fluid collections or brain herniation. Editor’s Note: This individual presumably suffered a dural tear, cerebrospinal fluid leak, and low pressure headache syndrome. The scan demonstrates that contrast administration may not be required to detect the diffuse meningeal reaction that typically occurs with this syndrome.