Thursday, July 14, 2016

Triptan and DHE use in basilar and hemiplegic migraine; no laughing matter

Mathew PG, Krel R, Buddhdev B, Ansari H, Joshi SG, Spinner WD, Klein BC. A
retrospective analysis of triptan and DHE use for basilar and hemiplegic
migraine. Headache. 2016 Apr 8. doi: 10.1111/head.12804. [Epub ahead of print]

Patients with basilar migraine (BM) and hemiplegic migraine (HM) have been excluded from triptan and DHE clinical trials due to a potential risk of ischemic vascular events, and the FDA mandates that package labeling state that they are contraindicated in BM and HM. The objective of this study was to demonstrate that triptans and DHE can be used for the abortive treatment of BM and HM without significant adverse ischemic vascular events.
A retrospective chart review of patients with BM features or HM who received acute abortive treatment with either triptans or DHE was conducted at 4 headache centers to assess the frequency of ischemic vascular events after administration. The diagnoses of BM or HM were made by headache specialists based on The International Classification of Headache Disorders, 2nd edition (ICHD-II). Searchable terms included BM, vertigo, dysarthria, diplopia, hemiplegia/hemiparesis, facial droop, weakness, confusion, altered consciousness, confusion, ataxia, and aphasia, as well as all triptans or DHE.
The study included 67 patients with BM features and 13 patients with HM. Among those receiving triptans, 40 were in the BM group and 5 were in the HM group. Among those receiving DHE, 27 were included in the BM group and 8 were in the HM group. No side effects of stroke or myocardial infarction were reported. In the triptan group, 5 patients reported adverse effects that included GI upset, rash, neck dystonia, nightmares, and flushing. In the DHE group, 5 patients had adverse events that included chest tightness, dystonic reaction, transient asymptomatic anterior T wave inversion, and agitation.
In this retrospective study, triptans and DHE were used with no reported, subsequent acute/subacute ischemic vascular events for the abortive treatment of migraines with basilar and hemiplegic-type features. Although the small sample sizes generated theoretical statistical event rates of 4.5% for BM and 23% for HM, there has been no clear evidence that BM and HM carry an actual elevated risk for vascular events compared with migraine with aura.

Courtesy of :

Mathew PG, Robertson CE. No Laughing Matter: Gelastic Migraine and Other
Unusual Headache Syndromes. Curr Pain Headache Rep. 2016 May;20(5):32.

Primary and secondary headache disorders have established diagnostic criteria in the International Classification of Headache Disorders IIIb, as well as classic findings, which although not part of the formal criteria are often suggestive of a particular diagnosis. At times, headache disorders can involve unusual symptoms that lack an identifiable secondary cause. This review will discuss some of these unusual symptoms, including headache associated auditory and olfactory symptoms, as well as two case reports involving gelastic migraine and migrainous thoracalgia.

From the article:

Gelastic Symptoms
Gelastic epilepsy is a seizure disorder that involves ictal laughter as one of its primary manifestations. The seizures of gelastic epilepsy can be further categorized by the presence or absence of mirth. The term mirth refers to the pleasant or euphoric sensation that can be associated with pathologic laughter. This seizure type has a strong association with hypothalamic hamartomas, but cortical foci have been noted in frontal , temporal , and parieto-occipital lobes. Some of the pathology in these areas of cortical foci have included cavernous angiomas, low-grade gliomas, cortical dysplasia, pleomorphic xanthoastrocytomas], and mixed oligoastrocytomas.  Based on intracranial EEG recording and electrocortical stimulation, it is suspected that the mesial/lateral aspects of the superior frontal gyrus, the cingulate gyrus, and the orbitofrontal gyrus play a role in the semiology of gelastic seizures. Successful surgical excision has been an effective treatment for gelastic epilepsy. Even in cases involving resection in the cingulate gyrus, the preservation of spontaneous laughter maintains the notion of bilateral motor representation.

Case Report

A case report documented a 37-year-old woman with migraine with language aura. She experienced episodes of expressive aphasia that could last up to 30 min. She denied visual, sensory, or motor aura. She also described an uncontrollable urge to laugh that occurred exclusively before some of her migraines. The laughter started as a giggle and became true laughter lasting 5–10 min. During these episodes, she was not thinking of anything funny and was not in an entertaining situation. She denied any loss of consciousness, convulsion, incontinence, or tongue bite. An EEG demonstrated no evidence of epileptiform activity, and MRI of the brain was unremarkable. She started a titration of verapmail, and 80 mg twice a day improved her headache and gelastic frequency. Her response to verapamil suggests that her gelastic episodes without mirth are likely a form of migraine aura or prodrome.

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