Neurology
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Review Historical Article
Treatments for Parkinson disease--past achievements and current clinical needs.
Although idiopathic Parkinson disease (PD) remains the only neurodegenerative disorder for which there are highly effective symptomatic therapies, there are still major unmet needs regarding its long-term management. Although levodopa continues as the gold standard for efficacy, its chronic use is associated with potentially disabling motor complications. Current evidence suggests that these are related to mode of administration, whereby multiple oral doses of levodopa generate pulsatile stimulation of striatal dopamine receptors. ⋯ So far, clinical trial evidence regarding 5-HT agonists, glutamate antagonists, adenosine A(2) antagonists and alpha-adrenergic receptor antagonists, has been inconsistent, but trials with cholinesterase inhibitors and atypical antipsychotics to treat dementia and psychosis, have been successful. However, the ultimate goal of PD medical management is modifying disease progression, thereby delaying the evolution of motor and nonmotor complications of advanced disease. As understanding of preclinical markers for PD develops, there is new hope for neuropreventive strategies to target "at risk" populations before clinical onset of disease.
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Migraine attacks sometimes increase in frequency over time. Headache experts conceptualize this process with a model that envisions transition into and out of four distinct states: no migraine, low-frequency episodic migraine (<10 headaches per month), high-frequency episodic migraine (10-14 headaches per month), and chronic migraine (CM, >or=15 headaches per month). Transitions may be in the direction of increasing or decreasing headache frequency and are influenced by specific risk factors. ⋯ The influence of medication is modified by both headache attack frequency and frequency of medication use. Although depression and anxiety are associated with an increased risk of new-onset CM, the influence of depression is accounted for by migraine disability assessment scale score, whereas the effect of anxiety may be independent of migraine disability assessment scale score. Emerging data on the longitudinal risk of CM suggest that, in a population at risk, CM may be a preventable disorder.