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A 65-year-old woman was referred with confusion, strange behaviour, sinus tachycardia, hypertension and hyperthermia. She had been taking sumatriptan and paroxetine and recovered completely after discontinuation of these agents. The diagnosis was 'serotonin syndrome', a result of overstimulation of 5-HT(1A) receptors in the raphe nuclei of the brainstem. It is a complication of the use of serotonergic agents and is associated with the rapid onset of mental, autonomic and neurological symptoms. Treatment consists of discontinuation of the suspected medication and, in severe cases, providing symptomatic relief. Given the frequent prescription of (combinations of) serotonergic agents, one should be aware of this complication.

Atrial fibrillation (AF) is the most common sustained rhythm disorder observed in clinical practice and predominantly associated with cardiovascular disorders such as coronary heart disease and hypertension. However, several classes of drugs may induce AF in patients without apparent heart disease or may precipitate the onset of AF in patients with preexisting heart disease. We reviewed the literature on drug-induced AF, using the PubMed/Medline and Micromedex databases and lateral references. Successively, we discuss the potential role in the onset of AF of cardiovascular drugs, respiratory system drugs, cytostatics, central nervous system drugs, genitourinary system drugs, and some miscellaneous agents. Drug-induced AF may play a role in only a minority of the patients presenting with AF. Nevertheless, it is important to recognize drugs or other agents as a potential cause, especially in the elderly, because increasing age is associated with multiple drug use and a high incidence of AF. This may contribute to timely diagnosis and management of drug-induced AF.

In recent years several new treatments have been introduced in neurology, sumatriptan in migraine, riluzole in amyotrophic lateral sclerosis, interferon-beta in multiple sclerosis and rivastigmine in Alzheimer's disease. Doubts exist on the effects on functional outcome of these new treatments. Hardly effective drugs are not forced on physicians by the pharmaceutical industry, since physicians are involved in decisions from phase I studies to the final approval of the drugs. The problem is, however, that in clinical studies emphasis is still on statistically significant differences rather than on meaningful differences in the functional status of patients. In conclusion, in clinical studies outcome measures should be chosen more carefully and there is a need for sensitive linear functional scales.

Cluster headache is a rare but very typical disease. Too often, however, the correct diagnosis is made only after several years of patient suffering, while adequate treatment is readily available. Two patients, men aged 29 and 45 years, showed a good picture of the typical features: excruciating, unilateral headache occurring in attacks and associated among other aspects with conjunctival redness, swelling of nasal mucosa and motor restlessness.

Sumatriptan (Imigran), an effective drug against symptoms of migraine may cause a sensation of thoracic oppression. In some patients, this is accompanied by ECG alterations. In such cases, the underlying mechanism is probably coronary spasm, although this has never been demonstrated angiographically. The case is described of a young woman who was hospitalized after resuscitation because of ventricular fibrillation. One week previously, after subcutaneous administration of sumatriptan, she had had chest pains for half an hour. A spasm provocation test during coronary angiography gave a positive result. The patient was treated with a calcium antagonist following which she remained free of symptoms. In patients with chest pain after administration of sumatriptan, it is necessary to use this drug cautiously; spasm of the coronary arteries as a cause should be excluded.

Since the registration of sumatriptan (Imigran) in May 1991, the Netherlands Centre for Monitoring of Adverse Reactions to Drugs received 13 reports of substernal chest tightness or pain attributed to its use. These concerned 11 women and two men with an average age of 41 years, who developed angina-like symptoms mostly within one hour after oral or subcutaneous administration. Electrocardiography (in three patients) and echocardiography (in one patient), performed after resolution of the symptoms, were normal. With the exception of one patient, none had experienced such symptoms before. Although sumatriptan is an effective anti-migrainous drug, cautious use is strongly advised. Sumatriptan is contraindicated in patients with coronary artery disease or variant angina pectoris.