1/18. Information about migraine disability influences physicians' perceptions of illness severity and treatment needs.OBJECTIVE: To assess physician-patient communication about headache-related disability and to evaluate the influence of information about disability on physicians' perceptions of illness severity and the treatment needs of migraineurs. BACKGROUND: Evidence suggests that migraine is suboptimally treated in clinical practice, partly due to poor communication between physicians and their patients. methods: One hundred five neurologists and primary care physicians with an interest in headache participated in two interactive surveys, one in north america (n=42) and one in europe (n=63). Each survey focused on the evaluation of four videotaped migraine cases. The first case was evaluated twice, initially after a typical symptom history that centered on diagnosis and then following a fuller history of migraine disability. Additional questions assessed the extent of the collection of migraine disability information in clinical practice. RESULTS: physicians reported that they recorded symptoms relating to diagnosis (eg, pain location/intensity, associated symptoms) rather than information on headache-related disability. Only about one third of patients volunteered disability information. When made available to them, physicians rated information on disability as one of the most important factors in assessing treatment needs. In particular, when physicians knew the patient's disability history: (1) the proportion of physicians who rated the patient's illness as "severe" increased by 128% in north america, 27% in europe; (2) the proportion of physicians who recommended immediate treatment increased by 63% in north america, 37% in europe; and (3) the proportion of patients recommended for a follow-up visit increased by 15% in north america, 18% in europe. CONCLUSIONS: physicians and patients often fail to discuss headache-related disability during consultation. This information has a powerful influence on physicians' perceptions of illness severity, treatment choice, and the need for follow-up. Tools to improve communication about headache-related disability, such as the Migraine Disability Assessment questionnaire, may favorably improve migraine management.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
2/18. Triptans in the treatment of basilar migraine and migraine with prolonged aura.OBJECTIVE: To report on the use of triptans in migraine with prominent neurologic symptoms. BACKGROUND: As stated in their package inserts, the triptans are contraindicated in patients with basilar or familial hemiplegic migraine, and physicians are reluctant to prescribe these drugs to other patients with prominent or prolonged aura. methods: We evaluated 13 patients with basilar migraine, familial hemiplegic migraine, or migraine with prominent or prolonged aura who had received triptans. RESULTS: Excellent; no adverse events. CONCLUSION: The contraindication of triptans in basilar migraine should be reconsidered. Similarly, prominent or prolonged aura may not represent a reasonable contraindication to triptan therapy.- - - - - - - - - - ranking = 0.076923076923077keywords = physician (Clic here for more details about this article) |
3/18. Patient perceptions and treatment preferences in migraine management.As the characteristics of migraine vary among patients and between attacks, multiple factors must be considered clinically to ensure that patients receive the most effective treatment strategy. Critical information required from the patient is general medical history, migraine-specific history, and the impact of migraine. Once the strategy of care and the optimal therapeutic plan are decided, the choice of therapeutic delivery must take into account patient preferences, compliance and clinical need. During the symposium, a case review and interview with a patient were conducted to illustrate the complex nature of integrating the assessment of signs, symptoms, disability, comorbidities and patient preferences. At the woman's first clinic visit, her Migraine Disability Assessment Scale (MIDAS) score was 70. Previous acute therapies had been only marginally effective, while previous prophylactic therapies had been discontinued because of adverse events or had also proved to be ineffective. The patient's current acute therapy was zolmitriptan 5mg, which she responds to well. Seven months after her first clinic visit, the patient's MIDAS score had decreased to 25. When asked about the relevance and utility of the MIDAS questionnaire, the patient felt that it asked about things that are important, helped her to understand the impact of migraine on her life, and accurately reflected her improvement. The patient also expressed an interest in trying more rapidly acting formulations of migraine-specific therapies in the future, such as a nasal spray formulation of zolmitriptan. The MIDAS questionnaire facilitates communication between physicians and patients to enable greater understanding of the impact of migraine. MIDAS grades can also be used in the stratification of treatment and for monitoring the course of illness and treatment outcomes. By increasing available treatment options, patient needs and preferences can be matched with specific features of migraine therapies. Taking patient preferences into account is likely to increase patient satisfaction and compliance, hopefully decreasing the degree of undertreatment of migraine that has been reported globally.- - - - - - - - - - ranking = 0.076923076923077keywords = physician (Clic here for more details about this article) |
4/18. Emergency department presentation of pediatric stroke.Pediatric stroke is not a common occurrence. When compared with adults, the pediatric population has a much more diverse group of risk factors, and while numerous rare congenital disorders are possible, most known etiologies are cardiac, vascular, or hematologic. The emergency department (ED) presentation of pediatric stroke does not differ greatly from that of adults, although posterior circulation ischemia is less common, and neurologic findings may be more difficult to recognize. ED treatment is also largely the same, with an attention to resuscitation and avoidance of hypoxia, hypotension, hyperthermia, and changes in blood sugar. Use of specialized agents such as aspirin and heparin should be considered in certain cases. It is important for the emergency physician to recognize acute neurologic events in pediatric patients to minimize complications.- - - - - - - - - - ranking = 0.076923076923077keywords = physician (Clic here for more details about this article) |
5/18. A placebo for the pain: a medico-legal case analysis.OBJECTIVES: The objectives of this medico-legal case report are to consider the current status of the use of placebos in pain medicine from clinical, ethical, and legal perspectives. The focus of the analysis is a particular case in which the deceptive use of placebo pain therapy on an adolescent gave rise to professional grievances filed by the patient's mother against the physician who ordered and several nurses who administered the placebo. The medical board declined to take disciplinary action against the physician, and disciplinary action by the board of registered nursing against the nurses was successfully challenged by two of the charged nurses in an administrative review. While there is a growing literature that challenges the need for or justification of the deceptive use of placebos, the practice continues and, as the case under consideration indicates, retains some influential supporters. DESIGN: This is a case report from a community hospital. The patient, referred to here as KC, was an adolescent with migraine headaches. The substitution of a placebo (saline solution) for an opioid analgesic (morphine) was made during KC's treatment. RESULTS: The patient's pain subsided sufficiently following the administration of a placebo to permit his discharge from the hospital. The subsequent discovery by the patient's mother of the deceptive use of a placebo prompted her to file charges of professional misconduct against the treating physician and three nurses with their respective professional licensing boards. The medical board declined to take disciplinary action against the physician, and the disciplinary action by the board of registered nursing was successfully challenged in a ruling by an administrative law judge following a hearing in which expert witnesses took conflicting positions on the acceptability of the deceptive use of a placebo. CONCLUSION: While there is a developing literature that challenges the ethical legitimacy of the deceptive use of placebos in pain medicine, that literature has yet to be recognized as unqualifiedly setting the standard of care or of professionalism in medicine and nursing.- - - - - - - - - - ranking = 0.30769230769231keywords = physician (Clic here for more details about this article) |
6/18. Treatment of bipolar, seizure, and sleep disorders and migraine headaches utilizing a chiropractic technique.OBJECTIVE: To discuss the use of an upper cervical technique in the case of a 23-year-old male patient with rapid-cycling bipolar disorder, sleep disorder, seizure disorder, neck and back pain, and migraine headaches. CLINICAL FEATURES: The patient participated in a high school track meet at age 17, landing on his head from a height of 10 ft while attempting a pole vault. Prior to the accident, no health problems were reported. Following the accident, the patient developed numerous neurological disorders. Symptoms persisted over the next 6 years, during which time the patient sought treatment from many physicians and other health care practitioners. INTERVENTION AND OUTCOME: At initial examination, evidence of a subluxation stemming from the upper cervical spine was found through thermography and radiography. chiropractic care using an upper cervical technique was administered to correct and stabilize the patient's upper neck injury. Assessments at baseline, 2 months, and 4 months were conducted by the patient's neurologist. After 1 month of care, the patient reported an absence of seizures and manic episodes and improved sleep patterns. After 4 months of care, seizures and manic episodes remained absent and migraine headaches were reduced from 3 per week to 2 per month. After 7 months of care, the patient reported the complete absence of symptoms. Eighteen months later, the patient remains asymptomatic. CONCLUSION: The onset of the symptoms following the patient's accident, the immediate reduction in symptoms correlating with the initiation of care, and the complete absence of all symptoms within 7 months of care suggest a link between the patient's headfirst fall, the upper cervical subluxation, and his neurological conditions. Further investigation into upper cervical trauma as a contributing factor to bipolar disorder, sleep disorder, seizure disorder, and migraine headaches should be pursued.- - - - - - - - - - ranking = 0.076923076923077keywords = physician (Clic here for more details about this article) |
7/18. Reevaluating spells initially identified as cataplexy.BACKGROUND AND PURPOSE: cataplexy, transient episodes of bilateral muscle weakness with areflexia provoked by emotions, is a state highly specific to narcolepsy. cataplexy is diagnosed based on clinical interview. Two screening tools have been developed recently but their usefulness has been limited because of length or current lack of psychometric data. Used effectively even these screening tests require the interpreting physician to have an understanding of the typical features of cataplexy. Most physicians encounter patients with cataplexy fairly infrequently, making it difficult to gain proficiency in detecting cataplexy based on clinical interview alone. Relatively little attention has been given to the differential diagnosis of cataplexy, which increases the likelihood of unnecessary sleep testing or false positive diagnosis. patients AND methods: This case series describes six cases where cataplexy was initially diagnosed. In all cases the weakness spells were eventually not attributed to cataplexy. The presentation and characteristics of these cases will be presented as a means to discuss the differential diagnosis of cataplexy. RESULTS: These cases represent a diverse set of medical disorders including bradycardia, migraine, delayed sleep phase syndrome, conversion disorder, malingering and a chronic psychotic disorder. CONCLUSIONS: A more in-depth understanding of the classic features of cataplexy should improve recognition of this fascinating state. Improved cataplexy recognition will enhance the appropriate usage of sleep tests and eventually increase the timeliness and accuracy of the diagnosis of narcolepsy with cataplexy.- - - - - - - - - - ranking = 0.15384615384615keywords = physician (Clic here for more details about this article) |
8/18. Chronic migraine: diagnosis and management strategy.The case presented underscores the complexities encountered in diagnosing and managing patients with a long-standing history of headache and some of the difficulties in classifying patients according to the new International headache Society (IHS) criteria. A 42-year-old nurse with 4 children whose headaches began at age 24 years developed continuous headaches of varying intensity, regularly so debilitating that she was unable to get out of bed and occasionally so disabling that she required an injection of meperidine from her physician. Management strategies are presented and the revised IHS criteria are discussed.- - - - - - - - - - ranking = 0.076923076923077keywords = physician (Clic here for more details about this article) |
9/18. Post-traumatic migraine: chronic migraine precipitated by minor head or neck trauma.Minor trauma to the head or neck is occasionally followed by severe chronic headaches. We have evaluated 35 adults (27 women, 8 men) with no prior history of headaches, who developed recurrent episodic attacks typical of common or classic migraine following minor head or neck injuries ("post-traumatic migraine"-PTM). The median age of these patients was 38 years (range 17 to 63 years), which is older than the usual age at onset of idiopathic migraine. The trauma was relatively minor: 14 patients experienced head trauma with brief loss of consciousness, 14 patients sustained head trauma without loss of consciousness, and 7 patients had a "whiplash" neck injury with no documented head trauma. Headaches began immediately or within the first few days after the injury. PTM typically recurred several times per week and was often incapacitating. The patients had been unsuccessfully treated by other physicians, and there was a median delay of 4 months (range 1 to 30 months) before the diagnosis of PTM was suspected. The response to prophylactic anti-migraine medication (propranolol or amitriptyline used alone or in combination) was gratifying, with 21 of 30 adequately treated patients (70%) reporting dramatic reduction in the frequency and severity of their headaches. Improvement was noted in 18 of the 23 patients (78%) who were still involved in litigation at the time of treatment. The neurologic literature has placed excessive emphasis on compensation neurosis and psychological factors in the etiology of chronic headaches after minor trauma. physicians must be aware of PTM, as it is both common and treatable.- - - - - - - - - - ranking = 0.076923076923077keywords = physician (Clic here for more details about this article) |
10/18. Saint Anthony's fire revisited. Vascular problems associated with migraine medication.ergotamine and related compounds have been used for many years in the management of migraine. This review highlights the potential for toxic effects upon the arterial system which may arise from the use of ergot medications. Data on four female patients aged from 30 to 49 years were collected retrospectively from in-patient records and out-patient follow-up between 1978 and 1990. All four patients presented with the symptoms and signs of arterial obstruction and all had been prescribed ergot preparations as treatment and prophylaxis of migraine, for periods ranging from three to 12 years. Two patients had an acute arterial obstruction that resolved completely when the migraine medication was withdrawn. Two had chronic obstructions and radiological and surgical examination gave evidence of arterial stenosis. These two patients were treated with bypass surgery. review of the literature indicated that other authors had described similar cases but without specifying the methods of data collection. This report supports the findings of others regarding the toxic effects of ergot preparations upon the arterial system, which may take the form of chronic or acute obstruction. general practitioners and physicians should be aware of the possible complications arising from prolonged or excessive use of ergot medications.- - - - - - - - - - ranking = 0.076923076923077keywords = physician (Clic here for more details about this article) |
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