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CME: Idiopathic Intracranial Hypertension Abstract. Idiopathic intracranial hypertension is a pressure-induced secondary headache disorder and optic neuropathy. It primarily affects obese women of childbearing age and poses an interdisciplinary challenge both diagnostically and therapeutically. The most common symptom of this disorder are headaches frequently accompanied by photo- and/or phonophobia, whose semiology often resembles that of migraine, followed by transient visual obscurations and pulsatile tinnitus. While protection of visual acuity and visual fields are of first therapeutical priority, adequate headache treatment also plays a key role. In the majority of cases, conservative treatment including weight loss and pharmacological therapy is sufficient. In case of a fulminant disease course or loss of visual function, interventional strategies can be applied additionally. Headache treatment is guided by the predominant semiology.

Migraine? Arnold Chiari Malformation? Or Just a Migraine? Abstract. In a young woman with a long-time headache in the sense of a migraine, a neurological reassessment including new findings of the existing MRI images of the skull resulted in the diagnosis of a Chiari malformation type 1. After successful operation of the MRI findings, the headache decreased significantly. However, since minor headaches of a different quality persist, a migraine plus malformation as an incidental finding are most likely.

Primary Prevention of Acute Stroke Abstract. Strokes are frequent. Vascular risk factors are increasing the stroke risk. Most vascular risk factors are treatable. Their therapy is important in the primary prevention of stroke. According to the INTERSTROKE study, arterial hypertension, inactivity, overweight, dyslipidemia, smoking, unhealthy diet, cardiac pathologies such as major arrhythmia, diabetes mellitus, stress/depression and overconsumption of alcohol are the most important treatable vascular risk factors. In this article, we will also report on at present less well known treatable vascular risk factors such as sleep apnea, atheromatosis of the aortic arch and of arteries supplying the brain, migraine with aura and chronic inflammatory disorders and infections.

Migraine is a very common primary headache disorder associated with intermittent attacks and great suffering. Despite extensive research efforts in the recent years, many pathophysiological aspects remain unclear. An altered cortical adaptability and the brainstem as a migraine generator are probably involved in the initiation of a (silent) cortical spreading depression and other processes that lead to neurogenic inflammation of the meninges causing the headache. Numerous studies in the last years have examined somatic, especially cerebrovascular and also psychological comorbidities. For attack therapy, CGRP antagonists have emerged as promising non-vasoconstrictive acting alternatives for triptans. However, they were so far not approved due to liver enzyme elevations in safety studies. Another new approach without vasoconstrictive action are the selective 5-HT1F agonists (especially Lasmiditan). Large placebo-controlled and triptan-controlled trials need to be awaited. For migraine prophylaxis, a comparable effect of sports and pharmacological prophylaxis using topiramate could be found. Particularly the combination of drug and non-drug therapies (such as the combination of stress management training with a beta-blocker treatment) achieves high efficacy. Also interdisciplinary, multimodal treatment approaches are important options. Two large multicentre studies have demonstrated the efficacy of botulinum toxin A as a prophylactic treatment for chronic migraine. Neuromodulative and neurostimulative procedures are promising but still experimental treatment options for patients with refractory migraine., (© Georg Thieme Verlag KG Stuttgart · New York.)

Known comorbidities for migraine are affective disorders. Only few studies exist which explore migraine as comorbidity in a given diagnosis. The aim of our study is to determine the frequency of the comorbidity "migraine" subject to a given diagnosis. Out of 2562 observations comorbidity "migraine" was diagnosed with a frequency of 16.2 % when an affective disorder was diagnosed. In multiple sclerosis and epilepsy, migraine as comorbidity was diagnosed in 15 % and 9.6 %, respectively. Migraine in patients with Parkinson's disease is rare. The correlation between affective disorders and epilepsies is known, but the high frequency of migraine in multiple sclerosis should be taken into account when diagnosing central demyelinating disorders., (© Georg Thieme Verlag KG Stuttgart · New York.)

Vestibular migraine (VM) presents with attacks of spontaneous or positional vertigo lasting seconds to days. Headaches are often absent during acute attacks, but other symptoms of migraine, such as photophobia or auras may be present. Like migraine headaches VM triggers may include stress, sleep deprivation and hormonal changes. During acute attacks there may be central spontaneous or positional nystagmus and, less commonly, unilateral vestibular hypofunction. In the symptom-free interval vestibular testing shows mostly minor and non-specific findings. The pathogenesis of VM is uncertain but migraine mechanisms may interfere with the vestibular system at the level of the labyrinth, brainstem and cerebral cortex. Treatment includes vestibular suppressants for acute attacks and migraine prophylaxis for patients with frequent recurrences. Avoidance of triggers, stress management and biofeedback may also play a role. However, treatment efficacy has not been validated by properly controlled clinical trials. VM is not included in the 2004 International Headache Society Classification, where basilar-type migraine must have at least two posterior circulation manifestations so that isolated vertigo would not satisfy this criterion.

Nearly 50% of the patients in general medicine practice suffer from vertigo. In specialized vertigo clinics approximately 50% of the patients have either a primary or secondary somatoform vertigo, which develops after a peripheral vestibular disorder (in nearly 30%). The different subgroups of somatoform vertigo and a pathogenetic model for the two forms of somatoform vertigo are presented. Interesting interactions between neuro-anatomical, neurophysiological and psychological mechanisms concerning anxiety and vertigo are described. Therapeutic principles which are important for the treatment of patients with complex somatoform vertigo disorders are described.

The diagnosis of vertigo syndromes in childhood is considered a difficult challenge. A correct diagnosis, however, makes successful therapy possible, prevents unnecessary investigations and alleviates the worries of parents. Migraine-associated forms of vertigo are very common in children (benign paroxysmal vertigo of childhood, vestibular migraine) and account for about 50% of diagnoses. Acute unilateral vestibular failure in the course of infectious and para-infectious labyrinthitis is also more common in children than in adults. Motion sickness is a frequent and relevant problem in children aged 4-10 years old. A number of rare congenital syndromes can occur with bilateral vestibular failure. Because of the relatively high frequency of brainstem and cerebellar tumors in children, MRI should be considered in all patients presenting with subacute central vestibular signs. In principle, all forms of vertigo known in adult patients can also occur in children; however, they must gradually be included in the diagnostic spectrum of the primary care physician (e.g., vestibular paroxysm).

Recurrent disturbances of vision associated with headaches are typical signs of a migraine. A 15-year-old girl suffered from common migraine. The patient had a headache and nausea five days after a first and proved intake of LSD. Shortly later, a complete blindness of both eyes developed within seconds. These symptoms continued for 48 hours. As the pupillar reactions were intact the findings were consistent with cortical blindness. MRI and MR-angiography of the brain, analysis of the cerebrospinal fluid and blood investigations for thrombophilia were normal. The EEG showed a bilateral symmetrical delta wave slowing over the occipital areas. Within the following three months the girl had three more episodes with complete blindness over a period of 12-36 hours. There have never been any visual disturbances in between the episodes and afterwards. Extended diagnosis with long term blood pressure measurement, Doppler sonography and visual evoked potentials were normal. The occipital slowing in the EEG persisted for 18 months. As the symptoms were unusually long and severe for a complicated migraine it is possible that the temporary blindness was the correlate of flash backs caused by the LSD. LSD intake could trigger additional, local cortical dysfunction (e. g. in the occipital areas) in preexisting migraine.

History and Admission Findings: A 29-year-old man was admitted because of recurrent episodes of vomiting., Diagnosis: The admission diagnosis was acute anuric renal failure. Ultrasound was unremarkable and there had been no history of renal disease. The serum creatinine concentration was 5.48 mg/dl. The urinary findings were normal. The final diagnosis was therefore of prerenal failure with dehydration. Cyclical vomiting syndrome was the working diagnosis, having excluded other possible causes., Treatment: Normal renal functions were re-established with rehydration treatment., Conclusion: Cyclical vomiting syndrome is an illness characterized by recurrent bouts of vomiting, often associated with migraine but of uncertain etiology. Therapeutic options include anti-emetics and anti-migraine medication.

The association of migraine and depression has been confirmed in numerous studies and it has been suggested that both diseases influence each other in a bidirectional way. As the conventional antidepressants mostly aggravate a pre-existing depression, treatment of both is a demanding task and should be planned in an interdisciplinary setting with neurologists and psychiatrists experienced in pain management. The pharmacological therapy is mainly based on a modulation of the serotonergic and noradrenergic systems and non-pharmacological treatment is also incorporated. The number of drugs should be kept to a minimum but drugs effective in the treatment of both migraine and depression should be used. Current data favours the use of amitriptylin, although newer studies justify the use of venlafaxin and fluoxetin as second choice drugs.A combination of several antidepressants with acute acting antimigraine drugs can provoke potentially threatening side effects, however, these possible side effects should not lead to suboptimal treatment of patients with depression and concomitant migraine. The current data on the antimigraine effects of common antidepressants are reviewed and advice for the preventive treatment of migraine with concomitant depression is given. Additionally, hazardous interactions and preferable drug combinations are listed.

Dizziness is not a unique clinical picture, but rather is the unspecific symptom of numerous diseases. Dizziness always develops when the real incoming vestibular, visual and somatosensory information contradict each other and the expected input signals. Disorders of the vestibular apparatus are the most frequent cause of dizziness; in contrast, cervicogenic causes play a secondary role. Dizziness syndromes usually have a favourable prognosis and can be successfully treated.

Background: In the pathophysiology of open-angle glaucoma altered perfusion of the optic nerve head is of importance. Up to now these disturbances were presumed to be the chief cause of glaucomatous damage in patients with normal tension glaucoma showing other vascular disturbances like migraine or tinnitus., Patients and Methods: Peak systolic velocity (PSV) and end-diastolic velocity (EDV) were measured and the resistive index (RI) was calculated by colour Doppler imaging (CDI) in the ophthalmic artery (OA), central retinal artery (CRA) and in the short and long posterior ciliary arteries (SPCA, LPCA) in 18 patients with normal tension glaucoma (NTG), in 18 patients with high tension glaucoma (HTG) and in 18 normal control subjects., Results: In an upright sitting position both glaucoma groups showed statistically significant decreases in PSV and EDV in CRA and SPCA compared to the control subjects. HTG when compared to NTG and normal subjects showed statistically significant decreases of EDV and statistically significant increases of RI in LPCA. In addition, compared to normal subjects, HTG patients showed statistically significant increases of RI in both OA and SPCA., Discussion: Both glaucoma groups showed decreased blood flow velocities in the small retrobulbar vessels in an upright sitting position. Normal tension glaucoma patients with symptoms of vasospasms compared to patients with high tension glaucoma showed only small differences in ocular haemodynamics.

We report on a case of a patient with migraine and depression treated with citalopram and sumatriptan. The drug evaluation is presented using the actual summaries of product characteristics (SPC, "Fachinformationen"). Particular the individual perioperative anaesthesiological risk assessment regarding the pharmacodynamic and pharmacointeractions is discussed.

For a healthy, active person, the chance that new ischemic events will occur up in the mountains is not any higher than in the valley. However, for inactive persons with health risks, there is a chance that the stress at the unaccustomed elevation could provoke a clinically silent coronary insufficiency. People with hypertension or diabetes should be able to monitor and adjust the dosage of their medication themselves. Asthmatic patients are often surprisingly fit even in the mountains. When the medication dosage is well established, they may also go mountain climbing at high elevations. On the other hand, when COPD or pulmonary hypertension is present, a pulmonologist should be consulted to determine whether high elevations could cause problems for the patient. Patients who have a medical history of thromboembolisms also require special preparation and prophylaxis. Migraine sufferers should acclimate themselves particularly conscientiously because migraine symptoms are very difficult to differentiate from that of acute mountain sickness.

Epidemiology: Since both migraine and vertigo are common complaints in clinical practice they may coincide in an individual patient just by chance. There are, however, numerous patients with vestibular symptoms caused by migraine, accounting for 6-8% of diagnoses in specialized dizziness clinics. CLINICAL MANIFESTATION: Migraine-associated vertigo is a vestibular disorder which manifests itself with spontaneous or positional rotational vertigo or dizziness induced by head motion. The vertigo may occur without accompanying headache and may last from seconds to several weeks., Diagnosis: Migraine-associated vertigo can be diagnosed according to the following criteria: 1. recurrent vestibular symptoms, 2. migraine according to the criteria of the International Headache Society, 3. migrainous symptoms during the vertigo such as headache, photophobia, phonophobia, scintillating scotoma or other auras, 4. exclusion of other causes., Pathophysiology: The mechanism of migraine-associated vertigo is still obscure. Several hypotheses relating to the pathophysiology of migraine have been proposed: cortical spreading depression, regional changes in brain perfusion, release of neurotransmitters and paroxysmal dysfunction of ion channels. Clinical findings suggest both central and peripheral vestibular involvement., Therapy: Treatment is based on the repertoire of acute and prophylactic medications that are used for migrainous headaches. Controlled studies on the treatment of migraine-associated vertigo are still lacking.

Profound knowledge of the different activities and side effects of the various types and combinations of HRT regimens is of paramount importance for counseling peri- and postmenopausal women. In this article some practical aspects of different topics concerning HRT such as influence of HRT on blood sugar, diabetes, blood pressure, hypertension, serum lipids, migraine, and progestin intolerance are discussed.

The clinical picture of the "cyclical vomiting syndrome" is discussed in the case of a 5 1/2-year-old child. The core symptom of this recurrent disorder is vomiting that occurs in regular cycles and while the patient is in a state of complete well-being, and which is hard to influence. The symptoms, the differential diagnosis, and the therapy of this disorder, which occurs primarily in childhood, are discussed along with the close etiological relationship to infantile migraine. The diagnosis of "psychogenic vomiting" is addressed critically, since it is frequently applied in Germany to disorder pictures that are similar to cyclical vomiting.

Background: In the diagnosis of retinal and cerebral vascular occlusion and migraine amaurosis fugax may be an important symptom. To evaluate the relation between cardiovascular diseases and amaurosis fugax we investigated the risk factors in patients with amaurosis fugax., Materials and Methods: Twenty-four patients (14 m, 10 f; aged 22 to 84 years; mean: 55 +/- 19 years) with amaurosis fugax were included in this study. All patients underwent a detailed clinical and ophthalmological examination, including video fluorescein angiography shortly after the event., Results: The duration of symptoms ranged from 30 seconds to 30 minutes (median: 3 minutes). Additional acute symptoms were headache in eight patients and tinnitus in one patient. Visual acuity showed no difference between the effected and the fellow eye. Intraocular pressure was normal in all eyes. Video fluorescein angiography revealed normal retinal perfusion times in all cases (arm-retina-time: 12.9 +/- 3.8 s; arteriovenous passage time: 1.8 +/- 0.7 s). Cardiovascular risk factors were present in all patients: 58% of the patients suffered from arterial hypertension, 8% of the patients from diabetes mellitus. Hyperlipidaemia was diagnosed in 17% of the patients, 46% of the patients were smokers. A history of cardiovascular disease (e.g. myocardial infarction, vitium, arrhythmia) was found in 58% of the patients. Cerebrovascular disease was diagnosed in 54% of the patients (migraine: 33%)., Conclusions: The ophthalmologic examination especially the fluorescein angiography revealed no pathologic findings in patients with amaurosis fugax. The risk factor distribution corresponded to data found in patients with retinal artery occlusion.

Vertigo consists of a variety of syndromes and can be due to many etiologies. One of these causes is migraine, which in our experience is often overlooked, although migrainous vertigo is well known in the literature. Vertigo in migraine can occur as aura or during the headache phase, or independent of the attacks as aura without headache. The aim of this retrospective study was to analyze cases with vertigo and migraine: 23 (8%) of 298 patients with migraine examined in a neurological outpatient department also had rotational vertigo. 48% of these patients had vertigo independent from typical migraine headache. Two types of vertigo were found: permanent vertigo, and vertigo with the characteristics of paroxysmal positional vertigo. 57% of the vertiginous attacks lasted hours, 26% even days, and 17% minutes. Most of the patients had several attacks of vertigo, some involving up to 30 episodes. To recognize migraine as a cause of vertigo has therapeutic implications. Most of our patients with vertigo and migraine showed a good response to antimigraine therapy.

Vestibular symptoms can be the predominant feature of migraine both in children and adults. Attacks of spontaneous or positional vertigo lasting from minutes to days may occur with or without concomitant headache. In the literature three syndromes of vestibular migraine have evolved: basilar artery migraine, benign recurrent vertigo and benign recurrent vertigo of childhood. In clinical practice, however, variants seem to be more frequent than the pure syndromes. Diagnosis is based on the individual constellation of typical precipitants and symptoms of migraine and the efficacy of pharmacological migraine prophylaxis. Nine cases are presented.

A 39-year-old woman suffering from migraine took two suppositories of an ergotamine-containing proprietary drug (Cafergot, containing 2 mg ergotamine tartrate) for the first time again after an abstinence of two years. Twenty-four hours later she developed symptoms of decreased peripheral blood flow in all four limbs. Walking distance without pain was reduced to 100 m, but the severest changes affected the right arm, with livid discolorations and complete immobility 16 hours after the onset of symptoms. Despite administration of morphine derivatives the pain progressively increased. Angiography demonstrated spastic narrowing of all arm arteries below the axillary artery. No vessels were visualized below the lower-arm bifurcation. Thereupon 4 mg nifedipine were injected through the angio-catheter within 30 min (five individual doses of 0.8 mg each). This was followed by intravenous infusion of 0.5 mg/h. The pain immediately decreased and the livid discoloration as well as impaired arm movement improved. A residual deficit, incomplete lesion of the median nerve, persisted but gradually regressed during the following two months.

Author intends to unite the part results of the glaucoma research (viz. blood vessel system, blood chemism, chamber angle, vegetative reflexes, psychosomatic factors, central effects) in a synthesis. The outcome of this synthesis is displayed in a schematic table.

Thirty patients with simple or ophthalmic migraine had an otoneurological examination. 13% complained of vertigo during attacks of migraine, 17% of giddiness and 6.7% of tinnitus. The usual tests for equilibrium were normal. On electronystagmographical examination 17% of the patients showed only pathological spontaneous nystagmus, 33% only disturbances of caloric response and 7% a combination of both. Audiological testing was normal. The incidence of vestibular disturbances, particularly sensitivity differences of the labyrinths, was significantly greater in the group of patients with migraine than in a control group of 30 healthy persons (P less than or equal to 0.025). On the average, the sensitivity differences, in terms of duration of reactive nystagmus, were greater for these than for the healthy persons (P less than or equal to 0.01). Patients with vestibular disturbances did not show a greater frequency of pathological EEG readings than patients with normal vestibular function. Some hypotheses concerning the pathogenesis of vestibular symptoms as found in migrainous patients are mentioned.

In the past 11 years 115 patients with complicated migraine were examined at the Neurological University Clinic of Vienna (34 male, 81 female, age range 15-65 years, mean age 32 years). About 80% suffered not only from complicated but also from uncomplicated migraine. 6 cases had ophthalmoplegic migraine, 3 cases typical basilaris migraine and the rest (n = 106) migraine accompagnée. The complicated neurological symptoms consisted in most cases of transient sensory and/or motor deficits (n = 37), 15 of these cases had additional visual field deficits. 36 cases had combination of marked aphasia with sensory and/or motor deficits, 16 were monosymptomatic with severe hemihypaesthesia, 10 cases had only motor deficits. The complicating symptoms (i.e. neurological deficits) occurred before attacks of headache and autonomic symptoms in 85 cases. The man frequency of complicated migraine showed a maximum of 1-2 attacks per year (n = 28), the mean duration of single attacks were 15-45 minutes in most cases (n = 31). Only 3 cases had presistent deficits. All patients were examined with EEG, 24.3% of standard EEG done at an any timepoint within the first 3 month after the last attacke revealed no abnormality, 8.7% cases had diffuse slowing, 14.8% bilateral dyshythmia over tempro-frontal areas, other 19.2% asymmetries of this activity and surprisingly 33.1% foci. The maximum of abnormal activities was over frontal and temporal areas. Marked spikes and sharp waves etc. was observed only in 8%. This is the distribution of abnormal EEGs with regard to the severity of abnormalities.(ABSTRACT TRUNCATED AT 250 WORDS)

Following the exemplification of the clinical symptoms the EEG findings of 10 attacks of hemiplegic migraine in 6 children are reported on. Characteristically most of these are severe unilateral or focal disturbances. Five times these appeared as delta-activity, two times as theta-delta-activity, and in one case as theta-activity or alpha-reduction. Only once, a diffuse slowing of the background-activity over both hemispheres could be shown. With one exception in addition to the foci simultaneous diffuse changes were recorded in all children, (four times slight, twice slight to moderate and three times moderate to severe). A predominance of one hemisphere was not recognizable. The foci were not localized to one particular region of the brain. Most of the changes had subsided after a few days. In one case a slight focal voltage depression was apparent even after three month of a year.

In comparison with 27 similar cases, sampled from literature, 4 observations of amnesic episodes in migraine are presented and discussed. These disturbances known as so-called "Migranedammerattacken" seem to be identical with transient global amnesia in all respects. In most of cases, they occur as migraine-precursors or - equivalents. Headache, vegetative und neurological symptoms are frequent but not necessary companions. It is proposed to look for migraine disposition in all cases of transient global amnesia. Perhaps, this approach might be of some use to understand their enigmatic pathogenesis.

Neurologic hemisyndromes in childhood may be due to congenital or acquired changes in cerebral vessels. Among the congenital vascular malformations, which very rarely become manifest already in children, the arteriovenous angiomata and saccular aneurysms are relatively the most common (in childhood about 4-8% manifest, 1-2% of all diseases). Venous angiomata, micro-angiomata and congenital dissecting aneurysms are very rare. But acquired thrombotic blocks of cerebral arteries are of greater importance as causes of acute neurologic hemisyndromes in childhood. Most often they have an inflammatory or traumatic cause, often the cause is unknown. Rare diseases only very recently described as arterial blocks of cerebral vessels are fibromuscular dysplasia and Moya-Moya-disease, the etiology of which is not yet fully understood. The prognosis of these diseases is generally unfavorable, but the focal signs in migraine as visual, sensory, aphasic and motoric defector irritative signs are as a rule reversible. In order to establish, where possible, the cause of acute neurologic hemisyndromes in childhood, early angiography may-classic migraine accompagnee types excepted-help. But also modern biochemical, immunologic, virologic, serologic, bacteriologic, clotting analytic and, possibly, histologic and histochemical techniques should be employed with particular attention to fat metabolism and to auto-immune disease.

The first attack of hemiplegic migraine occurred in most cases between the 10th and 15th year of life in 14 children (8 boys and 6 girls). Most attacks took place with intervals of 3-6 and 6-12 months. Only rarely did they last longer than 24 hours. Precipitating factors (emotional and physical stress, change of weather, influence of light or heat) were given in 6 cases. As many as 7 children attended higher schools with good or average success. A family history, mainly from the maternal side, existed in 11 cases. Sensory symptoms were demonstrable in all children, motor symptoms in 9 and visual symptoms in 13. Ten children had speech disturbances. Hand, lower arm, cheek and tongue were most frequently involved in sensory and motor symptoms. Out of 9 attacks registered with an EEG severe focal signs (delta or theta-delta foci) were demonstrable contralaterally in all children, in 8 children there were also signs of generalized disturbances.

A thorough neurological diagnostic investigation was carried out in 112 patients with chronic headache existing for an average of 14 years, using a case history questionnaire we had designed for the purpose. Apart from the history and clinical examination, the program included X-ray negatives, angiography, computer tomography, sequence scanning, electroencephalogram and echoencephalogram. Migraine was the most common diagnosis (54.5%). Three cases in which admission to a ward was necessary for more detailed examination are described and demonstrated with reference to neuroradiological illustrative material.

444 children and adolescents (266 boys, 178 girls) were examined because of migraine at the Department of Pediatric Neurology of the University Children's Hospital, Frankfurt/Main between 1967 and 1980. 378 of these had common and/or classical migraine, 66 complicated migraine. Family history, sex and age at onset in these two groups are compared. Based on this material (4 cases of ophthalmoplegic, 49 of hemiplegic and 13 of basilar artery migraine) clinical features, EEG findings angiographic and CAT-findings of these different forms of complicated migraine are discussed and demonstrated by typical case reports. The importance of basilar artery migraine even in childhood and the mainly poor prognosis of its special type of early onset- "alternating hemiplegia" - are stressed.