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INTRODUCTION. Flunarizine, with level of evidence A, and nadolol, with evidence level C, would be indicated as preventive treatment of migraine. Yet, no previous studies have been conducted to compare the effectiveness of the two drugs. AIM. To compare the effectiveness parameters in independent groups of patients treated preventively with one of the pharmaceuticals from the study, the same protocol being applied in both cases. PATIENTS AND METHODS. The subjects selected for the study were patients with episodic migraine (according to 2004 International Headache Society criteria) who had undergone preventive treatment for the first time, with flunarizine (5 mg/day) or nadolol (20-40 mg/day). The main effectiveness variables (reduction in the number of seizures at four months of treatment and responder rates) were analysed. RESULTS. The study included 227 patients who intended to receive treatment: 155 with flunarizine (80.5% females; mean age: 38.3 ± 12.1 years) and 72 with nadolol (63.8% females; mean age: 37.1 ± 12.0 years). The mean number of seizures prior to treatment was 6.09 ± 2.6 in the flunarizine group and 5.1 ± 1.7 in the nadolol group (p = 0.0079); at four months of treatment it was 2.61 ± 2.4 in the flunarizine group and 2.77 ± 2.4 in the nadolol group (p = NS). Percentage of reduction of migraines: 55.2% with flunarizine and 50.4% with nadolol (p = NS). The responder rate was 69% with flunarizine and 67% with nadolol (p = NS). The excellent response rate (reduction in the number of seizures by 75% or more) was 52.2% with flunarizine and 36.1% with nadolol (p = 0.0077). Percentage of adverse side effects: 48.3% with flunarizine and 25% with nadolol (p = 0.0009). The satisfaction rate was similar in both groups, 68%. CONCLUSIONS. Both flunarizine and nadolol proved to be effective in the preventive treatment of episodic migraine. Flunarizine is used more often in our milieu and was less well tolerated.

Chronic daily headache (CDH) includes primary headaches that last more than four hours with a frequency equal or superior to 15 days a month over the last three months. It has a prevalence of 4-5% in the general population and is a frequent reason for visiting the physician in headache units.To evaluate the effectiveness of topiramate, as the primary drug, in CDH due to probable chronic migraine with or without medication abuse.From the 447 patients with migraine in our database, we selected those: a) satisfying Silberstein criteria for CDH; b) that had not followed prior prophylactic treatment; and c) who were treated with topiramate as the primary drug. The mean number of days with headache and bouts of severe migraine in the fourth month of treatment using topiramate as compared to the month preceding treatment, as well as the percentage of responses and the rate of respondents in the fourth month were all analysed.Eighty-three patients (88% females) with a mean age of 38.0 +/- 14.13 years were selected. Medication abuse was reported in 44% of cases. At the fourth month of treatment, the mean number of days with headache dropped significantly from 20.8 to 7.9 (p0.0001) and the mean number of bouts of severe migraine diminished from 4.4 to 1.7 (p0.0001). The rate of respondents was 72%. Medication abuse continued in 14% of cases. Side effects were produced in 58% of patients and the dropout rate was 24%.Topiramate proved to be effective in the treatment of CDH due to probable chronic migraine and with probable medication abuse in de novo migraine patients.

Introduccion. Los pacientes con migrana cronica (MC) y abuso de medicacion son dificiles de tratar y tienen peor calidad de vida que otros pacientes con migranas. Objetivo. Valorar si la presencia de abuso de farmacos disminuye la efectividad del topiramato. Pacientes y metodos. Una serie de pacientes con MC fueron agrupados segun presentasen criterios de abuso o no abuso de farmacos. Se les aconsejo la supresion del farmaco del cual abusaban. Se ajusto el tratamiento de sus crisis y se inicio tratamiento preventivo desde el principio con topiramato. Se valoro el numero dias con cefalea y migranas intensas en el mes previo y al cuarto mes de tratamiento. Resultados. Fueron seleccionados 262 pacientes con criterios de MC, y de ellos 167 (63,7%) cumplieron criterios de abuso. En ambos grupos hubo una reduccion significativa del numero de dias con cefalea/mes y numero de crisis de migrana/mes al cuarto mes de tratamiento con topiramato. Porcentaje de reduccion de dias con cefalea/mes en MC sin abuso, 59,3 ± 36,1%; y con abuso, 48,7 ± 41,7% (p = 0,0574). Porcentaje de reduccion de migranas intensas/mes en MC sin abuso, 61,2%; y con abuso, 50% (p = 0,0224). Tasa de respondedores segun numero de dias con cefalea/mes en MC sin abuso, 69%; y con abuso, 57%. Tasa de respondedores segun numero de migranas intensas/mes en MC sin abuso, 76,8%; y en MC con abuso, 61% (p = 0,0097). Conclusiones. El topiramato fue efectivo en pacientes con MC sin y con abuso de farmacos, aunque con menor efectividad en estos ultimos.

Introduccion. El topiramato y la onabotulinumtoxina A han mostrado ser eficaces en la migrana cronica con o sin abuso de farmacos segun los criterios recientes de la Clasificacion de Cefaleas de la Sociedad Internacional de Cefaleas. Objetivo. Demostrar que la flunaricina es tan efectiva como el topiramato en la migrana cronica sin abuso de farmacos. Pacientes y metodos. Estudio prospectivo, no aleatorizado, comparativo de dos grupos de pacientes con similar edad y sexo, con migrana cronica sin abuso, tratados preventivamente por primera vez con topiramato o flunaricina. Resultados. A 40 pacientes tratados con flunaricina se les asigno un paciente del mismo sexo y edad tratado con topiramato. La media de reduccion de las migranas intensas en el grupo del topiramato fue del 59% y en el grupo de la flunaricina, del 58,5% (p = 0,9444); la tasa de respondedores al cuarto mes de tratamiento tampoco mostro diferencias significativas, ya que fue del 75% para el topiramato y del 70% para la flunaricina (p = 0,6236). La media de reduccion de otras cefaleas en el grupo del topiramato fue del 57%, y en el grupo de la flunaricina, del 64% (p = 0,4261); la tasa de respondedores al cuarto mes de tratamiento fue del 76%, similar en ambos grupos. El porcentaje de abandonos del tratamiento fue mayor con el topiramato (19,5%) que con la flunaricina (10%) (p = 0,3493). En ninguno de los dos grupos hubo efectos adversos graves. Un 78,9% de los pacientes que tomo topiramato presento satisfaccion con el farmaco frente al 75% del grupo de la flunaricina (p = 0,7903). Conclusion. La flunaricina mostro ser tan efectiva como el topiramato en el tratamiento de la migrana cronica sin abuso de farmacos.

Introduccion. Los pacientes con cefalea y abuso de medicacion (CAM) son dificiles de tratar, presentan mayor tendencia a la cronificacion y peor calidad de vida que los que cursan con otras cefaleas. Objetivo. Valorar los indicadores de respuesta de estos pacientes al tratamiento ambulatorio. Pacientes y metodos. De una serie de pacientes con migrana, seleccionamos aquellos con criterios de CAM segun el apendice de la International Classification of the Headache Disease (ICHD-2) de 2006 y que nunca habian llevado previamente tratamiento. Ambulatoriamente, se les aconsejo la supresion del farmaco del que abusaban. Se ajusto el tratamiento de sus crisis con los farmacos mas eficaces y se inicio tratamiento preventivo desde el principio, con topiramato o flunaricina. Se agrupo a los pacientes segun persistieran con CAM o no. Se valoro el numero dias con cefalea en el mes previo y al cuarto mes de tratamiento y la persistencia de abuso. Resultados. Cumplieron criterios de CAM 178 pacientes (edad media: 40,9 anos; 88,7% mujeres). El 68,5% (122 pacientes) respondio y dejo de cumplir criterios de CAM tras el tratamiento. En ambos grupos, los tratamientos de sus crisis (triptanes, antiinflamatorios no esteroideos, analgesicos) y preventivos utilizados (topiramato o flunaricina) fueron similares. La media de dias con cefalea previa al tratamiento fue de 18,52 en el grupo que respondio y de 20,87 (p = 0,0263) en el grupo que no respondio al tratamiento. Un 7,3% abandono el tratamiento preventivo en el grupo de respondedores frente al 35% (p = 0,0001) en los no respondedores. Conclusiones. El mayor numero de dias con cefalea en el mes previo al tratamiento y el abandono del tratamiento preventivo fueron indicadores de mala evolucion.

Introduccion. La migrana cronica es una cefalea primaria dificil de tratar que produce gran afectacion de la calidad de vida del paciente. La clasificacion internacional de cefaleas modifico los criterios de migrana cronica recientemente, por lo que existen pocos trabajos que analicen grupos con estos nuevos criterios. Objetivo. Analizar un grupo de pacientes con migrana cronica remitidos a una consulta de neurologia general. Pacientes y metodos. Se seleccionaron los primeros 100 pacientes con migrana. Se establecieron y analizaron subgrupos de pacientes con migrana episodica, cronica o cronica con probable cefalea por abuso de farmacos segun la clasificacion de cefaleas de la Sociedad Internacional de Cefaleas (IHS) y su revision del ano 2006. Resultados. Del total de 738 nuevos pacientes, 100 (13,5%) sufrieron migranas. De estos 100 nuevos pacientes con migrana, 42 (el 5,6% de la serie total) cumplieron los criterios de migrana cronica, y 15 pacientes con migrana cronica, los criterios de probable cefalea por abuso de farmacos. Antes de acudir a la consulta de neurologia, solo al 41% se le habia diagnosticado migrana, un 38% no habia recibido informacion sobre esta entidad, solo el 17% tomaba triptanes como tratamiento sintomatico, y un 23% habia seguido tratamiento preventivo. Conclusiones. Destacamos la importancia de la migrana episodica y cronica en una consulta general de neurologia, aplicando los criterios recientes de la IHS. Los pacientes con migrana cronica enviados a la consulta de neurologia siguen, en un alto porcentaje, sin haber sido diagnosticados, ni informados, ni tratados correctamente, con un alto grado de automedicacion y abuso frecuente de farmacos. Los tratamientos preventivos y triptanes en migranas intensas se siguen utilizando poco en atencion primaria.

Introduccion. La flunaricina y recientemente el topiramato han mostrado su eficacia en la profilaxis de la migrana. Objetivo. Comparar dos grupos independientes de pacientes con similares caracteristicas clinicas y demograficas tratados con flunaricina o topiramato como primer farmaco en la prevencion de sus migranas y valorar la eficacia y tolerabilidad segun el farmaco recibido. Pacientes y metodos. Todos los pacientes presentaban mas de cuatro crisis al mes y/o migrana transformada segun los criterios de Silberstein y nunca habian recibido tratamiento profilactico. Se determino: numero y media de crisis en el mes previo y al cuarto mes de tratamiento y tasa de respondedores. Resultados. Se incluyo a 125 pacientes en cada grupo. No hubo diferencias significativas entre ambos grupos en edad media y media de crisis en el mes previo. Con ambos farmacos hubo un descenso significativo (0,0001) de la media de crisis en el cuarto mes de tratamiento, aunque sin diferencias significativas: topiramato (5,88 ± 3,7 a 2,1 ± 2,5) y flunaricina (5,24 ± 3,2 a 2,3 ± 2,7). La reduccion media de crisis al cuarto mes fue del 58,2 ± 38,2% con topiramato y del 55,4 ± 37,5% con flunaricina. La tasa de respondedores fue del 71% con topiramato y 67% con flunaricina. El porcentaje de abandonos con topiramato (28%) fue superior que con flunaricina (11%) (0,0013). Con topiramato 69 pacientes refirieron efectos adversos y 53 pacientes con flunaricina (0,0427). Conclusiones. Ambos farmacos mostraron una alta efectividad cuando se usaron como primer farmaco en el tratamiento preventivo de la migrana. El topiramato mostro mejores resultados de efectividad, pero mas efectos adversos, aunque ninguno grave

Introduccion. La migrana representa el 10% de las primeras consultas neurologicas en Espana, y mas de la mitad de las nuevas consultas en las unidades de cefaleas (UC); de ahi la importancia de esta patologia. Objetivo. Valorar si existen diferencias entre los pacientes con migrana enviados a una consulta general de neurologia (CGN) o a una UC. Pacientes y metodos. Se comparan dos grupos de pacientes con migrana: unos enviados por primera vez a CGN y otros enviados directamente a una UC. Resultados. En la CGN, el 10,7% (374 pacientes) del total de nuevas consultas fueron por migrana; se compararon con 107 migranas (64%) del total de cefaleas atendidas por primera vez en la UC durante el ano 2000. La edad media y el sexo fueron similares en ambos grupos. En el grupo de migranas de la UC se solicitaron mas TAC/RM (20%); el 77,5% de los pacientes llevaba tratamiento previo, se puso tratamiento preventivo al 71%, triptanes al 51% y preciso revision el 44,8%. En el grupo de migrana de la consulta general se solicitaron menos TAC/RM (14%), solo el 20% llevaba tratamiento previo, se instauro tratamiento preventivo al 45%, triptanes al 6% y preciso revision el 25%. Conclusiones. El grupo de pacientes con migrana enviados a la UC presento una patologia mas grave, preciso mas tratamientos preventivos, mayor utilizacion de triptanes y mayor control posterior que el grupo de pacientes con migrana enviados a la CGN.

Introduction. Migraine is a very common disorder and frequent cause of consultation of the neurologist. The triptanes have been a great advance in the treatment of migraine attacks. At present it is the treatment of choice in severe attacks of migraine, but it is more expensive than the other drugs used for this. Taking into account the greater efficacy and the saving in direct and indirect costs which may be due to treatment with triptanes, its use may not only be effective but also efficient. Objective. To analyze the cost-effectiveness of the triptanes sold in Spain (sumatriptan, naratriptan, zolmitriptan, rizatriptan, almotriptan). Material and methods. We analyzed the efficacy, therapeutic gain and number of different triptanes needed for treatment. We evaluated the cost of multiplying the result of the number needing treatment by the price of each unit of the drug. The results are expressed in pesetas and in euros. Results. Rizatriptan gave the best results and was the cheapest triptan, followed by sumatriptan and zolmitriptan. When criteria of efficacy were used, naratriptan was the most expensive triptan, in spite of being the cheapest per unit. Conclusions. In chronic, recurrent disorders such as migraine, when the cost of treatment using triptans is assessed, one has not only to evaluate the cost per unit but also to introduce other parameters such as the efficacy of the drug, which is one of the most important.

Introduction. There is some controversy concerning the need to perform neuroimaging studies in patient complaining of headache. 90% of the people had a complaint of headache during their life, and it is impossible to perform neuroimaging studies in all of them. Objective. The aim of this study is knowing the reasons for indications neuroimaging studies in the evaluation of primary headaches and the effectiveness at the diagnosis. Patients and methods. The clinical records of patients who a neuroimaging study was performed for headache during 1998 were retrospectively studied. We analysed in all patients: the age, sex, diagnosis of headache, suspicion of diagnosis, reason and time for indication the neuroimaging study, and if the study modified the diagnosis. Results. During 1998, were performed 107 neuroimaging studies in 96 patients. The mean age were 38 years. 60% were females. The suspicion of diagnosis was primary headache in 71% patients. Only one patient had an abnormality. The reasons for applying a neuroimaging study were: in 20 of the patients the migraine was more frequent and they didn 't relieve with abortive drugs, in 20 there was a migraine aura, in 11 because the migraine turned to daily headache, in 17 the family asked for a neuroimaging study, there was a 17 of patients seemed to have an organic disease, in 2 the headache appeared daily, and in 7 of the cases weren't any reasons. Conclusions. Headache is the most frequent reason for asking a neuroimaging study. Primary headache is the type of headache that justifies most of indications. The most frequent reasons for performing a study were common changes in characteristics of migraine.

OBJECTIVE To analyze the patients sent to Neurology Clinics for headache and to investigate the differences in epidemiology, clinical findings and therapeutics as compared with those consulting for other neurological disorders. PATIENTS AND METHODS Eighteen neurologists from all the Outpatient Departments of the Community of Aragon Health Service were analysed using a specially designed questionnaire for all the patients who attended the Neurology Clinics for the first time during a period of three months. RESULTS Of 3,489 patients assessed, 25.5% complained of headache. Of these, 70% were women of an average age of 41.2 +/- 18.8 years. In 42% the consultation was for migraine followed by chronic tension headache in 30.1%. Family doctors sent 86.7% of the patients and requested complementary tests for 31.1%. Cerebral TAC (12.4%) and EEG (7.6%) were the investigations most often requested. Treatment was given to 68.6% of the patients with headache. Calcium-antagonists and anti-depressants were the drugs most used. CONCLUSIONS Headache is the commonest cause for consulting a neurologist. It affects young adults, with marked predominance of the female sex. There are significative differences in clinical attention (fewer complementary tests are requested and less follow-up is necessary, although more treatment is given) than for other neurology patients.

We studied 56 patients, 30 women and 26 men ranging from 30 to 79 years of age (average age 64.5 +/- 10.4), who were admitted to our hospital between 1982 and August 1995 with clinical features compatible with occlusion at the level of the bifurcation of the basilar artery. The patients were selected following clinical and neuro-radiological criteria. All patients included in the study had two or more recent infarcts in the vertebro-basilar territory, related to involvement of the rostral region of the basilar artery. The diagnosis was confirmed by CT or MR scanning. The infarcts were in the thalamus, brain-stem, cerebellum and parieto-occipital lobe. A thalamic infarct associated with an infarct in another region was the most frequent lesion. The CT-MR findings in the 56 cases were: 29 patients presented with a unilateral thalamic infarct associated with another infarct (23 occipital, 8 parietal, 6 brain-stem and 2 cerebellum). There were eight patients with bilateral thalamic infarcts and seven with bilateral occipital infarcts. In six patients the occipital infarct was associated with another infarct at a different level (parietal or cerebellar) and six patients had cerebellar infarcts together with an infarct of the mid-brain. In 22 of the patients, lesions were found in three or more areas. The commonest clinical findings were: Motor deficit (69.6%), abnormal eye movements (44.5%), cerebellar dysfunction (42.8%), altered level of consciousness (32.1%), visual field defects (28.5%), pupil anomalies (19.6%). The most frequently associated risk factors were: Arterial hypertension (58.9%), a history of ACV (32.1%) and atrial fibrillation (21.4%). Mortality was 5.7%. In contrast to the classical descriptions, motor defecit was the commonest symptom in our series.

Patients with headache and medication abuse (HMA) are difficult to treat, have a greater tendency towards chronification and a poorer quality of life than those with other types of headache. AIM. To evaluate the indicators showing that these patients are responding to ambulatory treatment.From a series of patients with migraine, we selected those who satisfied HMA criteria according to the appendix of the 2006 International Classification of the Headache Disease (ICHD-2) and who had never previously undergone treatment. As outpatients, they were advised to stop taking the drug that they were abusing. The treatment of their seizures was adjusted with the most efficient drugs and preventive treatment was started from the outset with topiramate or flunarizine. Patients were grouped according to whether they continued with HMA or not. Comparisons were made between the number of days with headache during the previous month and after four months of treatment and the persistence of abuse.HMA criteria were met by 178 patients (mean age 40.9; 88.7% females). Results showed that 68.5% (122 patients) responded and no longer met HMA criteria after treatment. The treatment used for their seizures (triptans, nonsteroidal antiinflammatory drugs, analgesics) and preventive treatment (topiramate or flunarizine) were similar in both groups. The average number of days with headache prior to treatment was 18.52 in the group that responded and 20.87 (p = 0.0263) in the group that did not respond to treatment. In the group of responders 7.3% dropped out of preventive treatment compared with 35% (p = 0.0001) in the group of non-responders.A higher number of days with headache during the previous month and withdrawing from preventive treatment were indicators of a bad progression.

Patients with chronic migraine (CM) and medication abuse are difficult to treat, and have a greater tendency towards chronification and a poorer quality of life than those with other types of headache.To evaluate whether the presence of medication abuse lowers the effectiveness of topiramate.A series of patients with CM were grouped according to whether they met abuse criteria or not. They were advised to stop taking the drug that they were abusing. Treatment was adjusted to match their crises and preventive treatment with topiramate was established from the beginning. The number of days with headache and intense migraine in the previous month and at four months of treatment was evaluated.In all, 262 patients with CM criteria were selected and 167 (63.7%) of them fulfilled abuse criteria. In both groups there was a significant reduction in the number of days with headache/month and number of migraine attacks/month at the fourth month of treatment with topiramate. The percentage of reduction in the number of days with headache/month in CM without abuse was 59.3 ± 36.1%, and with abuse, 48.7 ± 41.7% (p = 0.0574). The percentage of reduction in the number of days with intense migraine/month in CM without abuse was 61.2%, and with abuse, 50% (p = 0.0224). Response rate according to the number of days with headache/month in CM without abuse was 69%, and with abuse, 57%. Response rate according to the number of intense migraines/month in CM without abuse was 76.8%, and in CM with abuse, 61% (p = 0.0097).Topiramate was effective in patients with CM with and without medication abuse, although effectiveness is lower in the latter case.El abuso de farmacos en pacientes con migraña cronica influye en la efectividad del tratamiento preventivo con topiramato?Introduccion. Los pacientes con migraña cronica (MC) y abuso de medicacion son dificiles de tratar y tienen peor calidad de vida que otros pacientes con migrañas. Objetivo. Valorar si la presencia de abuso de farmacos disminuye la efectividad del topiramato. Pacientes y metodos. Una serie de pacientes con MC fueron agrupados segun presentasen criterios de abuso o no abuso de farmacos. Se les aconsejo la supresion del farmaco del cual abusaban. Se ajusto el tratamiento de sus crisis y se inicio tratamiento preventivo desde el principio con topiramato. Se valoro el numero dias con cefalea y migrañas intensas en el mes previo y al cuarto mes de tratamiento. Resultados. Fueron seleccionados 262 pacientes con criterios de MC, y de ellos 167 (63,7%) cumplieron criterios de abuso. En ambos grupos hubo una reduccion significativa del numero de dias con cefalea/mes y numero de crisis de migraña/mes al cuarto mes de tratamiento con topiramato. Porcentaje de reduccion de dias con cefalea/mes en MC sin abuso, 59,3 ± 36,1%; y con abuso, 48,7 ± 41,7% (p = 0,0574). Porcentaje de reduccion de migrañas intensas/mes en MC sin abuso, 61,2%; y con abuso, 50% (p = 0,0224). Tasa de respondedores segun numero de dias con cefalea/mes en MC sin abuso, 69%; y con abuso, 57%. Tasa de respondedores segun numero de migrañas intensas/mes en MC sin abuso, 76,8%; y en MC con abuso, 61% (p = 0,0097). Conclusiones. El topiramato fue efectivo en pacientes con MC sin y con abuso de farmacos, aunque con menor efectividad en estos ultimos.

We studied 56 patients, 30 women and 26 men ranging from 30 to 79 years of age (average age 64.5 +/- 10.4), who were admitted to our hospital between 1982 and August 1995 with clinical features compatible with occlusion at the level of the bifurcation of the basilar artery. The patients were selected following clinical and neuro-radiological criteria. All patients included in the study had two or more recent infarcts in the vertebro-basilar territory, related to involvement of the rostral region of the basilar artery. The diagnosis was confirmed by CT or MR scanning. The infarcts were in the thalamus, brain-stem, cerebellum and parieto-occipital lobe. A thalamic infarct associated with an infarct in another region was the most frequent lesion. The CT-MR findings in the 56 cases were: 29 patients presented with a unilateral thalamic infarct associated with another infarct (23 occipital, 8 parietal, 6 brain-stem and 2 cerebellum). There were eight patients with bilateral thalamic infarcts and seven with bilateral occipital infarcts. In six patients the occipital infarct was associated with another infarct at a different level (parietal or cerebellar) and six patients had cerebellar infarcts together with an infarct of the mid-brain. In 22 of the patients, lesions were found in three or more areas. The commonest clinical findings were: Motor deficit (69.6%), abnormal eye movements (44.5%), cerebellar dysfunction (42.8%), altered level of consciousness (32.1%), visual field defects (28.5%), pupil anomalies (19.6%). The most frequently associated risk factors were: Arterial hypertension (58.9%), a history of ACV (32.1%) and atrial fibrillation (21.4%). Mortality was 5.7%. In contrast to the classical descriptions, motor defecit was the commonest symptom in our series.