Current pain and headache reports
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Initially described more than 40 years ago, basilar-type migraine has posed diagnostic and therapeutic dilemmas for medical practitioners. Defined by the coexistence of migraine headache with neurological symptoms emanating from either the brainstem or simultaneously from both cerebral hemispheres, basilar-type migraine has been categorized as "atypical" or "complicated" and has been considered more akin to hemiplegic migraine than to migraine with typical aura. Despite the absence of any data convicting basilar-type migraine as a vasospastic condition, the use of triptans in such patients has been considered prohibited. This review focuses on the diagnosis, clinical presentation, available genetic information, and treatment considerations in patients with basilar-type migraine.
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Curr Pain Headache Rep · Jun 2009
ReviewRole of skin biopsy in the diagnosis of peripheral neuropathic pain.
Evaluation of epidermal nerve fiber density (ENFD) allows objective, pathologic, and minimally invasive assessment of small myelinated and unmyelinated cutaneous axons. In addition to providing diagnostic confirmation of neuropathies affecting these "small fibers," this procedure has advanced clinical care by dramatically increasing awareness of the role of small myelinated and unmyelinated axons in disorders of peripheral nerve and in neuropathic pain. This review highlights the technical aspects of skin biopsy for ENFD determination, the role of skin biopsy in the diagnosis of small-fiber neuropathy and ganglionopathy, and the diagnostic approach to the patient with peripheral neuropathic pain.
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Curr Pain Headache Rep · Jun 2009
ReviewPatent foramen ovale and migraine: association, causation, and implications of clinical trials.
Patent foramen ovale (PFO) appears to be associated with migraine with aura (MA), probably through cardiac shunting. PFOs may also be comorbid with cryptogenic strokes. ⋯ MIST did demonstrate an association between MA and severe PFO shunts prospectively. Difficulty with recruitment closed the MIST II and ESCAPE trials; the PREMIUM and PRIMA randomized controlled trials are ongoing at the time of this writing.
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Curr Pain Headache Rep · Jun 2009
ReviewNewest aspects on the association between migraine and cardiovascular disease: the role of modifying factors.
Migraine has been established as a risk factor for ische-mic stroke. Further evidence suggests that migraine is also associated with other ischemic vascular events, including myocardial infarction and cardiovascular death. However, these associations appear to be limited to the subgroup of patients with migraine with aura (MA). ⋯ These include vascular risk factors, migraine attack frequency, and genetic variants. In addition, there appear to be differential effects with regard to ischemic stroke and myocardial infarction. These new findings await confirmation in independent patient populations and are currently not sufficient to argue for a change in diagnostic testing or treatment.
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Although medication costs make up one of the smallest portions of the overall expense of headache care, it is the segment of expense that often impacts the patient most directly. The advent of triptans marked a major advance in migraine therapy, but their high cost has limited their widespread use. ⋯ These include compulsory licensing, exclusive contracting, over-the-counter -availability, and the introduction of generic triptans. Each method impacts the consumer, third-party payer, or pharmaceutical company in a different manner.