Karl Zeiler

Long-Term Outcome of Patients with Headache and Drug Abuse after Inpatient Withdrawal: Five-Year Follow-Up

Thirty-eight patients with “chronic daily” headache and ergotamine and/or analgesics abuse according to the criteria proposed by the international Headache Society were re-investigated 5 years after inpatient drug withdrawal. At the end of the observation period, 19 patients (50.0%) had their headaches on only 8 days per month or less, 18 patients (47.4%) were free of symptoms or had only mild headaches. A close correlation was found between the frequency of headache and the duration of drug abuse, as well as between the intensity of headache and the number of tablets taken per month. Frequency and intensity of headache had changed within the first 2 years after withdrawal, but remained stable afterwards. Fifteen patients (39.5%) reported on recurrent drug abuse. Patients with migraine showed a tendency towards a better prognosis compared to patients with tension-type headache or with combined migraine and tension-type headache. The results of this study highlight the long-term efficacy of inpatient drug withdrawal in patients with headache and ergotamine and/or analgesics abuse.

Comparison of transesophageal and transthoracic contrast echocardiography for detection of a patent foramen ovale

Abstract Presence of a patent foramen ovale may indicate paradoxic embolism in patients with otherwise unexplained embolie disease.1–3 Transthoracic contrast echocardiography has been used as a simple technique for detecting patent foramen ovale.4–6 However, particularly in patients with poor transthoracic image quality, presence of a patent foramen ovale might be missed. Transesophageal contrast echocardiography provides superior visualization of the atrial septum and therefore is believed to improve diagnostic accuracy. The present study investigates the influence of image quality on the detection of a patent foramen ovale by both transthoracic and transesophageal contrast echocardiography.

Significance of left-sided heart disease for the detection of patent foramen ovale by transesophageal contrast echocardiography

Detection of patent foramen ovale by contrast echocardiography is based on transient inversion (right atrial pressure higher than left atrial pressure) of the interatrial pressure gradient. Therefore, the presence of left-sided heart disease with potential elevation of left atrial pressure might obscure the diagnosis of patent foramen ovale. Accordingly, 150 patients (88 men, 62 women; mean age 51.7 +/- 15.2 years) were evaluated for a patent foramen ovale by transesophageal contrast echocardiography. Additionally, atrial septal motion during normal respiration and during the Valsalva maneuver was analyzed. Patency of the foramen ovale was observed in 20 (27%) of 74 patients without left-sided heart disease and with previous arterial embolism, in none (0%) of 25 patients with left-sided heart disease and embolism, in 7 (39%) of 18 patients without left-sided heart disease and without embolism and in 3 (9%) of 33 patients with left-sided heart disease and without embolism. The detection rate of patent foramen ovale was lower in patients with than without left-sided heart disease (5% vs. 29%, p = 0.0007) but was similar in patients with and without embolism (20% vs. 19.5%, p = NS). Abnormal atrial septal motion was more frequently observed in patients with left-sided heart disease (p = 0.0003) and was inversely correlated to detection of patent foramen ovale (p = 0.0003). Multivariate analysis revealed an independent association between the absence of left-sided heart disease and the detection of patent foramen ovale (p = 0.0003). These data suggest that in patients with left-sided heart disease, patency of the foramen ovale may be missed even by transesophageal contrast echocardiography.

C677T MTHFR Mutation and Factor V Leiden Mutation in Patients with TIA/Minor Stroke: A Case-Control Study

A common C677T mutation in the gene for the enzyme 5,10-methylenetetrahydrofolate reductase (5,10-MTHFR) has been linked to elevated levels of homocysteine and was therefore suspected to be a candidate genetic risk factor for arterial occlusive disease. Another mutation, factor V Leiden, has been established as a common hereditary risk factor for venous thrombosis, but its role in arterial disease remains controversial. We investigated the prevalence of both the C677T MTHFR mutation and the factor V Leiden mutation in 81 patients with transient ischemic attack (TIA) or minor stroke (MS) and in 81 age- and sex-matched control subjects free from clinically manifest vascular disease. We further compared clinical and laboratory data as well as clinical course of patients carrying the factor V Leiden mutation alone or in combination with the C677T MTHFR mutation and mutation-free patients. The prevalence of the MTHFR mutation did not differ between patients and control subjects with 11.1% homozygous carriers in both groups (OR for homozygous carriers 1.0; 95% CI 0.38-2.66). However, there was a trend towards a higher prevalence of carriers of factor V Leiden in patients (12.3%) than in control subjects (4.9%) (OR 2.75; 95% CI 0.83-9.17;p=0.09). Furthermore, we found some evidence that the combined occurrence of the C677T MTHFR mutation and factor V Leiden might unfavorably affect the clinical course of the disease, but the number of respective patients was small. Larger studies with a greater number of carriers of both the C677T MTHFR mutation and factor V Leiden seem therefore warranted.

use and abuse of analgesics in tension-type headache

Eighty patients suffering from tension-type headache for an average of 21 years were asked to report on all drugs they had ever taken (type, dosage, duration of intake, efficacy) or were taking currently. The patients had consumed on average 6.3 different drugs. The cumulative doses of derivatives of para-aminophenol, pyrazolone, and salicylic acid in some cases reached a maximum of several kilograms. Most drugs were classified by the patients as “moderately effective”. The rating “very effective” was assigned primarily to barbiturates; however, barbiturates are no longer used as components of compound analgesic drugs in Austria. At the time of investigation, patients consumed 2.5 (mean) different drugs, primarily as compound preparations. Seventeen patients (21%) showed signs of possible analgesics- or ergotamine-induced headache and were therefore advised to undergo withdrawal therapy. Our results show that patients with tension-type headache are at considerable risk of becoming drug-dependent and of acquiring analgesics-induced headache.

Improvement of Decreased Critical Flicker Frequency (CFF) in Headache Patients With Drug Abuse After Successful Withdrawal

A considerable proportion of headache patients fulfill the criteria of “drug abuse” (definition according to the International Headache Society [IHS] criteria). These patients exhibit markedly reduced vigilance and continuous performance, as shown by the results of critical flicker frequency (CFF) analysis.

MMPI and Critical Flicker Frequency (CFF) Analysis in Headache Patients With and Without Drug Abuse

Sixty‐three headache patients (migraine: n = 28; tension‐type headache: n = 35) who fulfilled the IHS criteria of ‘drug abuse’ were investigated by means of the Minnesota Multiphasic Personality Inventory (MMPI) and the Critical Flicker Frequency (CFF) analysis. The results were compared to those of 63 headache patients without drug abuse (matched‐pair case‐control study).

Tension headache and the cervical spine plain X-ray findings

The aim of the present study was to investigate if there is any causal connection between plain X-ray findings of the cervical spine and tension headache. We evaluated the X-rays of the cervical spine of 243 patients, in 91 of which the diagnosis was “tension headache”, in 102 “headache not fulfilling the criteria of tension headache” and in 50 “spondylogenic complaints without headache”. We compared these three groups with regard to frequency and severity of radiologically assessable changes of the cervical spine and found that patients with tension headache had normal findings significantly more often and significantly less often functional or organic changes or both than patients of the other two groups. The radiologically assessable changes of the cervical spine are unlikely to have an essential role in the cause or mechanism of tension headache.

Weitere Kopf- und Gesichtsschmerzen

Der Hustenkopfschmerz (IHS-Code: 4. 4) kann „idiopathisch“ als belangloses Symptom auftreten, kann sich aber auch im Rahmen verschiedener organischer Erkrankungen symptomatisch manifestieren, wie z. B. bei Prozessen im Bereich der hinteren Schadelgrube bzw. des kraniozervikalen Ubergangs (Arnold-Chia-ri-Malformation, Platybasie, Morbus Paget mit basilarer Impression, subdurales Hamatom, raumfordernder Tumor), bei intermittierendem oder permanentem Hirndruck, bei Nasennebenhohlenaffektionen oder bei arterieller Hypertonie. Die Diagnose „benigner Hustenkopfschmerz“ ist daher erst nach Ausschluss organischer Ursachen zulassig, wobei die Untersuchung der hinteren Schadelgrube und des kraniozervikalen Ubergangs mittels MRT erfolgen sollte.

Diagnostische und therapeutische Aspekte ischämischer zerebraler Durchblutungsstörungen

ZusammenfassungIn der vorliegenden Zusammenstellung werden die klinische Symptomatik, die wichtigsten technischen und Labor-Untersuchungen, die akuttherapeutischen Maßnahmen sowie die Langzeit-Prophylaxe von Patienten mit zerebralen Durchblutungsstörungen auf ischämischer Basis diskutiert.SummaryThe paper deals with the clinical symptomatology, the most important technical and laboratory investigations, treatment in the acute stage, and long term prophylaxis in patients with ischaemic cerebrovascular disease (stroke).