Nancy A. Melville

SCOTTSDALE, ARIZ. – Medications have their rightful place in headache treatment, but a strong dose of some key coping and behavioral tools can go a long way toward helping patients manage their own headaches, Alvin E. Lake III, Ph.D., said at a symposium sponsored by the American Headache Society.

The placebo effect has long shown how powerful an influence perception can be in how patients experience pain, and research shows that effect to be particularly important in headaches, he said.

In fact, nearly every published headache study comparing drugs alone with a combination of drugs and behavior therapy has shown the combined treatment to be superior, said Dr. Lake, who is director of the division of behavioral medicine at the Michigan Head-Pain & Neurological Institute in Ann Arbor, Mich.

“We can emphasize the power of drugs in our interventions, or we can emphasize the coping skills, but it doesn't have to be either/or because there are ways to think of them together,” he said.

An important starting point in teaching patients self-efficacy in headache control is to convey the sense of confidence that they can indeed prevent and control headaches, and that they can remain calm and continue to function, Dr. Lake said.

Establishing those core beliefs gives patients a critical sense of control over pain; research has shown that people's beliefs that they can accomplish something are better predictors of their actually accomplishing it than are most other factors, including past performance, he said.

Clinicians can help build up those beliefs by presenting examples of people who had similar obstacles and overcame them. “What often inspires us the most and changes our behavior is seeing someone else who overcame it,” Dr. Lake said.

In addition to noting others' experiences, clinicians can suggest that patients look to their own experiences and think of an obstacle that they overcame. “Urge patients to consider how they overcame it and think about how they could use those same skills in managing or preventing their pain,” Dr. Lake said.

Patients should, however, also work to try to raise their level of pain tolerance. This effort is especially important among patients who are trying to decrease excessive use of analgesics and who will likely have to deal with some pain in the process. “These patients need to learn to tolerate some level of pain without reaching for a painkiller,” Dr. Lake said.

Deep breathing skills and other relaxation methods can be useful tools in pain tolerance, and optimal health behavior, including nutrition and sleep regulation, should be encouraged to further control headaches.

Finally, Dr. Lake emphasized that a clinician's enthusiastic reinforcement of adaptive behavior can make a bigger difference to patients than some doctors may realize. “Reinforcement is a huge factor in our relationships with patients,” he said. “I think we sometimes don't recognize how important our relationship is with patients.”

SCOTTSDALE, ARIZ. – Medications have their rightful place in headache treatment, but a strong dose of some key coping and behavioral tools can go a long way toward helping patients manage their own headaches, Alvin E. Lake III, Ph.D., said at a symposium sponsored by the American Headache Society.

The placebo effect has long shown how powerful an influence perception can be in how patients experience pain, and research shows that effect to be particularly important in headaches, he said.

In fact, nearly every published headache study comparing drugs alone with a combination of drugs and behavior therapy has shown the combined treatment to be superior, said Dr. Lake, who is director of the division of behavioral medicine at the Michigan Head-Pain & Neurological Institute in Ann Arbor, Mich.

“We can emphasize the power of drugs in our interventions, or we can emphasize the coping skills, but it doesn't have to be either/or because there are ways to think of them together,” he said.

An important starting point in teaching patients self-efficacy in headache control is to convey the sense of confidence that they can indeed prevent and control headaches, and that they can remain calm and continue to function, Dr. Lake said.

Establishing those core beliefs gives patients a critical sense of control over pain; research has shown that people's beliefs that they can accomplish something are better predictors of their actually accomplishing it than are most other factors, including past performance, he said.

Clinicians can help build up those beliefs by presenting examples of people who had similar obstacles and overcame them. “What often inspires us the most and changes our behavior is seeing someone else who overcame it,” Dr. Lake said.

In addition to noting others' experiences, clinicians can suggest that patients look to their own experiences and think of an obstacle that they overcame. “Urge patients to consider how they overcame it and think about how they could use those same skills in managing or preventing their pain,” Dr. Lake said.

Patients should, however, also work to try to raise their level of pain tolerance. This effort is especially important among patients who are trying to decrease excessive use of analgesics and who will likely have to deal with some pain in the process. “These patients need to learn to tolerate some level of pain without reaching for a painkiller,” Dr. Lake said.

Deep breathing skills and other relaxation methods can be useful tools in pain tolerance, and optimal health behavior, including nutrition and sleep regulation, should be encouraged to further control headaches.

Finally, Dr. Lake emphasized that a clinician's enthusiastic reinforcement of adaptive behavior can make a bigger difference to patients than some doctors may realize. “Reinforcement is a huge factor in our relationships with patients,” he said. “I think we sometimes don't recognize how important our relationship is with patients.”

SCOTTSDALE, ARIZ. – Medications have their rightful place in headache treatment, but a strong dose of some key coping and behavioral tools can go a long way toward helping patients manage their own headaches, Alvin E. Lake III, Ph.D., said at a symposium sponsored by the American Headache Society.

The placebo effect has long shown how powerful an influence perception can be in how patients experience pain, and research shows that effect to be particularly important in headaches, he said.

In fact, nearly every published headache study comparing drugs alone with a combination of drugs and behavior therapy has shown the combined treatment to be superior, said Dr. Lake, who is director of the division of behavioral medicine at the Michigan Head-Pain & Neurological Institute in Ann Arbor, Mich.

“We can emphasize the power of drugs in our interventions, or we can emphasize the coping skills, but it doesn't have to be either/or because there are ways to think of them together,” he said.

An important starting point in teaching patients self-efficacy in headache control is to convey the sense of confidence that they can indeed prevent and control headaches, and that they can remain calm and continue to function, Dr. Lake said.

Establishing those core beliefs gives patients a critical sense of control over pain; research has shown that people's beliefs that they can accomplish something are better predictors of their actually accomplishing it than are most other factors, including past performance, he said.

Clinicians can help build up those beliefs by presenting examples of people who had similar obstacles and overcame them. “What often inspires us the most and changes our behavior is seeing someone else who overcame it,” Dr. Lake said.

In addition to noting others' experiences, clinicians can suggest that patients look to their own experiences and think of an obstacle that they overcame. “Urge patients to consider how they overcame it and think about how they could use those same skills in managing or preventing their pain,” Dr. Lake said.

Patients should, however, also work to try to raise their level of pain tolerance. This effort is especially important among patients who are trying to decrease excessive use of analgesics and who will likely have to deal with some pain in the process. “These patients need to learn to tolerate some level of pain without reaching for a painkiller,” Dr. Lake said.

Deep breathing skills and other relaxation methods can be useful tools in pain tolerance, and optimal health behavior, including nutrition and sleep regulation, should be encouraged to further control headaches.

Finally, Dr. Lake emphasized that a clinician's enthusiastic reinforcement of adaptive behavior can make a bigger difference to patients than some doctors may realize. “Reinforcement is a huge factor in our relationships with patients,” he said. “I think we sometimes don't recognize how important our relationship is with patients.”

SCOTTSDALE, ARIZ. – The incidence of pseudotumor cerebri is rising among the obese, so physicians should keep this relatively uncommon condition in mind when obese patients present with symptoms resembling brain tumor or intracranial pressure, said Deborah Friedman, M.D., at the American Headache Society's 2004 Headache Symposium.

Pseudotumor cerebri is primarily seen in obese women of childbearing age, and although the condition affects only 1 in 100,000 people in the United States, the rate for obese women between the ages of 20 and 44 is about 19 per 100,000.

In areas with higher levels of obesity, however, pseudotumor cerebri is being seen more frequently.

In Mississippi, called the most overweight state in the nation because a quarter of its population is considered obese by BMI criteria, the incidence of pseudotumor cerebri in the overall population is double, at 2 per 100,000, and among obese women aged 20-44, the rate is about 25 per 100,000. Large increases in pseudotumor cerebri incidence rates have also been noted in men in the region, said Dr. Friedman of the University of Rochester (N.Y.).

The most common symptom, headache, occurs in about 90% of patients. Descriptions of the pain range from headache behind the eyes that feels like pressure to headache in the morning, said Dr. Friedman.

Visual symptoms, seen in about three-quarters of patients, are the second most common symptom, and papilledema is also very common.

“Patients will often describe blurriness or say that if they bend over, their vision goes out for a few seconds when they straighten up again,” Dr. Friedman said. “It's usually a sign that the optic nerve is swollen.”

About 60% of patients also experience the third most common symptom of intracranial noises, usually described as a whooshing in the ear or the sound of their heartbeat in the ear.

In diagnosing the disease, imaging and mental status are typically normal, and a lumbar puncture should show increased cranial pressure with otherwise normal spinal fluid content.

Dr. Friedman underscored the need for a lumbar puncture. “You have to do a spinal tap to make a diagnosis,” she stressed. “It's disheartening how many people I see who come in without having an LP.”

There are no evidence-based guidelines for treating pseudotumor cerebri, and not all patients even require treatment. But with the possibility of vision loss, the most important goal of treatment should be to preserve a patient's vision, she said.

An ophthalmologist needs to be brought in for such cases, but it's essential that the physicians collaborate on care, Dr. Friedman noted.

“Most of the time, there's no captain of the ship in management, and the doctors aren't working as a team,” she said. “It's crucial to have an ophthalmologist and a neurologist who are both following the patient and talking to each other about how to manage the patient.”

SCOTTSDALE, ARIZ. – The incidence of pseudotumor cerebri is rising among the obese, so physicians should keep this relatively uncommon condition in mind when obese patients present with symptoms resembling brain tumor or intracranial pressure, said Deborah Friedman, M.D., at the American Headache Society's 2004 Headache Symposium.

Pseudotumor cerebri is primarily seen in obese women of childbearing age, and although the condition affects only 1 in 100,000 people in the United States, the rate for obese women between the ages of 20 and 44 is about 19 per 100,000.

In areas with higher levels of obesity, however, pseudotumor cerebri is being seen more frequently.

In Mississippi, called the most overweight state in the nation because a quarter of its population is considered obese by BMI criteria, the incidence of pseudotumor cerebri in the overall population is double, at 2 per 100,000, and among obese women aged 20-44, the rate is about 25 per 100,000. Large increases in pseudotumor cerebri incidence rates have also been noted in men in the region, said Dr. Friedman of the University of Rochester (N.Y.).

The most common symptom, headache, occurs in about 90% of patients. Descriptions of the pain range from headache behind the eyes that feels like pressure to headache in the morning, said Dr. Friedman.

Visual symptoms, seen in about three-quarters of patients, are the second most common symptom, and papilledema is also very common.

“Patients will often describe blurriness or say that if they bend over, their vision goes out for a few seconds when they straighten up again,” Dr. Friedman said. “It's usually a sign that the optic nerve is swollen.”

About 60% of patients also experience the third most common symptom of intracranial noises, usually described as a whooshing in the ear or the sound of their heartbeat in the ear.

In diagnosing the disease, imaging and mental status are typically normal, and a lumbar puncture should show increased cranial pressure with otherwise normal spinal fluid content.

Dr. Friedman underscored the need for a lumbar puncture. “You have to do a spinal tap to make a diagnosis,” she stressed. “It's disheartening how many people I see who come in without having an LP.”

There are no evidence-based guidelines for treating pseudotumor cerebri, and not all patients even require treatment. But with the possibility of vision loss, the most important goal of treatment should be to preserve a patient's vision, she said.

An ophthalmologist needs to be brought in for such cases, but it's essential that the physicians collaborate on care, Dr. Friedman noted.

“Most of the time, there's no captain of the ship in management, and the doctors aren't working as a team,” she said. “It's crucial to have an ophthalmologist and a neurologist who are both following the patient and talking to each other about how to manage the patient.”

SCOTTSDALE, ARIZ. – The incidence of pseudotumor cerebri is rising among the obese, so physicians should keep this relatively uncommon condition in mind when obese patients present with symptoms resembling brain tumor or intracranial pressure, said Deborah Friedman, M.D., at the American Headache Society's 2004 Headache Symposium.

Pseudotumor cerebri is primarily seen in obese women of childbearing age, and although the condition affects only 1 in 100,000 people in the United States, the rate for obese women between the ages of 20 and 44 is about 19 per 100,000.

In areas with higher levels of obesity, however, pseudotumor cerebri is being seen more frequently.

In Mississippi, called the most overweight state in the nation because a quarter of its population is considered obese by BMI criteria, the incidence of pseudotumor cerebri in the overall population is double, at 2 per 100,000, and among obese women aged 20-44, the rate is about 25 per 100,000. Large increases in pseudotumor cerebri incidence rates have also been noted in men in the region, said Dr. Friedman of the University of Rochester (N.Y.).

The most common symptom, headache, occurs in about 90% of patients. Descriptions of the pain range from headache behind the eyes that feels like pressure to headache in the morning, said Dr. Friedman.

Visual symptoms, seen in about three-quarters of patients, are the second most common symptom, and papilledema is also very common.

“Patients will often describe blurriness or say that if they bend over, their vision goes out for a few seconds when they straighten up again,” Dr. Friedman said. “It's usually a sign that the optic nerve is swollen.”

About 60% of patients also experience the third most common symptom of intracranial noises, usually described as a whooshing in the ear or the sound of their heartbeat in the ear.

In diagnosing the disease, imaging and mental status are typically normal, and a lumbar puncture should show increased cranial pressure with otherwise normal spinal fluid content.

Dr. Friedman underscored the need for a lumbar puncture. “You have to do a spinal tap to make a diagnosis,” she stressed. “It's disheartening how many people I see who come in without having an LP.”

There are no evidence-based guidelines for treating pseudotumor cerebri, and not all patients even require treatment. But with the possibility of vision loss, the most important goal of treatment should be to preserve a patient's vision, she said.

An ophthalmologist needs to be brought in for such cases, but it's essential that the physicians collaborate on care, Dr. Friedman noted.

“Most of the time, there's no captain of the ship in management, and the doctors aren't working as a team,” she said. “It's crucial to have an ophthalmologist and a neurologist who are both following the patient and talking to each other about how to manage the patient.”

SCOTTSDALE, ARIZ. – Headache management in the elderly involves consideration of factors not often seen in younger patients, Jerry W. Swanson, M.D., said at a symposium sponsored by the American Headache Society.

The possibility of secondary headache is greater in older patients, who often experience polypharmacy and drug interactions, said Dr. Swanson, professor and chair of the division of neurology at the Mayo Clinic Medical School in Rochester, Minn.

Headache ranks as the 10th most common symptom among elderly women and the 14th among elderly men.

Secondary headaches represent one-third of headaches in the elderly, compared with 10% in the general population (Headache 1990;30:273-6).

Typical causes of secondary headaches in the elderly include lesional headaches or cerebrovascular disease–both of which are more common in the elderly–as well as medication-induced headaches.

Giant cell arteritis, a necrotizing, granulomatous arteritis rarely seen before age 50, also should be considered. “New-onset headache is the key with giant cell arteritis,” Dr. Swanson said. Other common symptoms of giant cell arteritis include jaw claudication (which occurs in about 40% of cases), fatigue, and fever.

When elderly patients present with a headache, it is important to obtain a detailed history. It's especially important to get a detailed medication history. Why? “Because patients have more medical conditions as they age, you're much more likely to encounter polypharmacy, which increases the risk of drug interactions and side effects,” Dr. Swanson said.

Elderly patients are also prone to have a reduced tolerance to those side effects, he pointed out.

Headaches that are associated with medication are often generalized and of mild to moderate severity, and they may be throbbing.

The list of drugs that could be etiologic includes antibiotics, such as tetracycline; bronchodilators; cardiovascular drugs, such as vasodilators and antihypertensives; sedatives and stimulants; antidepressants, such as selective serotonin reuptake inhibitors; and reproductive drugs, such as estrogen.

With secondary headache ruled out, diagnosing and managing primary headaches in the elderly can pose unique challenges and atypical twists. Migraine headaches, for instance, peak in prevalence at about age 40 and are thus less common in the elderly.

That means migraines make up about 8% of headaches in women over age 60 and 3% in men. However, the literature indicates that migraines develop in about 2% of patients over age 50.

In the elderly, migraine headaches can present with reduced severity and frequency than in younger patients. But there can also be what neurologist C. Miller Fisher, M.D., described as “late-life migraine accompaniments”–including new onset of focal neurologic symptoms, positive visual displays, gradual buildup of visual and sensory symptoms, and serial progression.

Tension-type headaches, though also less common in older age, are more prevalent than migraines, with rates beyond age 65 varying between 27% and 44.5% and higher rates reported among women.

Treatment of migraine or tension-type headaches in older patients can be difficult. It is important to keep in mind that if a prophylactic approach is used with elderly patients, the starting dose should be low and with slow increases, Dr. Swanson said.

Cluster headaches, though also infrequent, are more common among men.

“Virtually all patients for whom a [cluster headache] diagnosis is being entertained should undergo MRI and [magnetic resonance angiography],” he said.

Another type of primary headache, the hypnic headache, has been reported specifically in the elderly and not in younger age groups, he said.

First described in 1988 and still rare, the hypnic headache is a dull one that develops only during sleep, yet with “clocklike regularity.” In addition, the hypnic headache is not attributed to any other disorder.

Treatments for the hypnic headache include sleep rationing, lithium, caffeine, or indomethacin, Dr. Swanson noted.

SCOTTSDALE, ARIZ. – Headache management in the elderly involves consideration of factors not often seen in younger patients, Jerry W. Swanson, M.D., said at a symposium sponsored by the American Headache Society.

The possibility of secondary headache is greater in older patients, who often experience polypharmacy and drug interactions, said Dr. Swanson, professor and chair of the division of neurology at the Mayo Clinic Medical School in Rochester, Minn.

Headache ranks as the 10th most common symptom among elderly women and the 14th among elderly men.

Secondary headaches represent one-third of headaches in the elderly, compared with 10% in the general population (Headache 1990;30:273-6).

Typical causes of secondary headaches in the elderly include lesional headaches or cerebrovascular disease–both of which are more common in the elderly–as well as medication-induced headaches.

Giant cell arteritis, a necrotizing, granulomatous arteritis rarely seen before age 50, also should be considered. “New-onset headache is the key with giant cell arteritis,” Dr. Swanson said. Other common symptoms of giant cell arteritis include jaw claudication (which occurs in about 40% of cases), fatigue, and fever.

When elderly patients present with a headache, it is important to obtain a detailed history. It's especially important to get a detailed medication history. Why? “Because patients have more medical conditions as they age, you're much more likely to encounter polypharmacy, which increases the risk of drug interactions and side effects,” Dr. Swanson said.

Elderly patients are also prone to have a reduced tolerance to those side effects, he pointed out.

Headaches that are associated with medication are often generalized and of mild to moderate severity, and they may be throbbing.

The list of drugs that could be etiologic includes antibiotics, such as tetracycline; bronchodilators; cardiovascular drugs, such as vasodilators and antihypertensives; sedatives and stimulants; antidepressants, such as selective serotonin reuptake inhibitors; and reproductive drugs, such as estrogen.

With secondary headache ruled out, diagnosing and managing primary headaches in the elderly can pose unique challenges and atypical twists. Migraine headaches, for instance, peak in prevalence at about age 40 and are thus less common in the elderly.

That means migraines make up about 8% of headaches in women over age 60 and 3% in men. However, the literature indicates that migraines develop in about 2% of patients over age 50.

In the elderly, migraine headaches can present with reduced severity and frequency than in younger patients. But there can also be what neurologist C. Miller Fisher, M.D., described as “late-life migraine accompaniments”–including new onset of focal neurologic symptoms, positive visual displays, gradual buildup of visual and sensory symptoms, and serial progression.

Tension-type headaches, though also less common in older age, are more prevalent than migraines, with rates beyond age 65 varying between 27% and 44.5% and higher rates reported among women.

Treatment of migraine or tension-type headaches in older patients can be difficult. It is important to keep in mind that if a prophylactic approach is used with elderly patients, the starting dose should be low and with slow increases, Dr. Swanson said.

Cluster headaches, though also infrequent, are more common among men.

“Virtually all patients for whom a [cluster headache] diagnosis is being entertained should undergo MRI and [magnetic resonance angiography],” he said.

Another type of primary headache, the hypnic headache, has been reported specifically in the elderly and not in younger age groups, he said.

First described in 1988 and still rare, the hypnic headache is a dull one that develops only during sleep, yet with “clocklike regularity.” In addition, the hypnic headache is not attributed to any other disorder.

Treatments for the hypnic headache include sleep rationing, lithium, caffeine, or indomethacin, Dr. Swanson noted.

SCOTTSDALE, ARIZ. – Headache management in the elderly involves consideration of factors not often seen in younger patients, Jerry W. Swanson, M.D., said at a symposium sponsored by the American Headache Society.

The possibility of secondary headache is greater in older patients, who often experience polypharmacy and drug interactions, said Dr. Swanson, professor and chair of the division of neurology at the Mayo Clinic Medical School in Rochester, Minn.

Headache ranks as the 10th most common symptom among elderly women and the 14th among elderly men.

Secondary headaches represent one-third of headaches in the elderly, compared with 10% in the general population (Headache 1990;30:273-6).

Typical causes of secondary headaches in the elderly include lesional headaches or cerebrovascular disease–both of which are more common in the elderly–as well as medication-induced headaches.

Giant cell arteritis, a necrotizing, granulomatous arteritis rarely seen before age 50, also should be considered. “New-onset headache is the key with giant cell arteritis,” Dr. Swanson said. Other common symptoms of giant cell arteritis include jaw claudication (which occurs in about 40% of cases), fatigue, and fever.

When elderly patients present with a headache, it is important to obtain a detailed history. It's especially important to get a detailed medication history. Why? “Because patients have more medical conditions as they age, you're much more likely to encounter polypharmacy, which increases the risk of drug interactions and side effects,” Dr. Swanson said.

Elderly patients are also prone to have a reduced tolerance to those side effects, he pointed out.

Headaches that are associated with medication are often generalized and of mild to moderate severity, and they may be throbbing.

The list of drugs that could be etiologic includes antibiotics, such as tetracycline; bronchodilators; cardiovascular drugs, such as vasodilators and antihypertensives; sedatives and stimulants; antidepressants, such as selective serotonin reuptake inhibitors; and reproductive drugs, such as estrogen.

With secondary headache ruled out, diagnosing and managing primary headaches in the elderly can pose unique challenges and atypical twists. Migraine headaches, for instance, peak in prevalence at about age 40 and are thus less common in the elderly.

That means migraines make up about 8% of headaches in women over age 60 and 3% in men. However, the literature indicates that migraines develop in about 2% of patients over age 50.

In the elderly, migraine headaches can present with reduced severity and frequency than in younger patients. But there can also be what neurologist C. Miller Fisher, M.D., described as “late-life migraine accompaniments”–including new onset of focal neurologic symptoms, positive visual displays, gradual buildup of visual and sensory symptoms, and serial progression.

Tension-type headaches, though also less common in older age, are more prevalent than migraines, with rates beyond age 65 varying between 27% and 44.5% and higher rates reported among women.

Treatment of migraine or tension-type headaches in older patients can be difficult. It is important to keep in mind that if a prophylactic approach is used with elderly patients, the starting dose should be low and with slow increases, Dr. Swanson said.

Cluster headaches, though also infrequent, are more common among men.

“Virtually all patients for whom a [cluster headache] diagnosis is being entertained should undergo MRI and [magnetic resonance angiography],” he said.

Another type of primary headache, the hypnic headache, has been reported specifically in the elderly and not in younger age groups, he said.

First described in 1988 and still rare, the hypnic headache is a dull one that develops only during sleep, yet with “clocklike regularity.” In addition, the hypnic headache is not attributed to any other disorder.

Treatments for the hypnic headache include sleep rationing, lithium, caffeine, or indomethacin, Dr. Swanson noted.

SCOTTSDALE, ARIZ. — Radiofrequency tissue tightening using Thermage's ThermaCool TC system has gained favor for wrinkle reduction with the standard use of a single pass of the device, but better results and greater tolerance are seen with a multiple-passes approach using reduced treatment-level settings, said Bill H. Halmi, M.D., at a meeting sponsored by the Skin Disease Education Foundation.

The ThermaCool system, which has received Food and Drug Administration approval for smoothing wrinkles and sagging skin around the face, has yielded only modest results, and subtle changes were often not even noticeable, said Dr. Halmi, a dermatologist and owner of Arizona Advanced Dermatology in Phoenix.

Furthermore, the treatment was not without some discomfort, and early safety observations showed a 6% rate of scarring or texture change 6 months post treatment.

In a new technique introduced last year by Brian Zelickson, M.D., however, use of multiple passes in a single treatment with lower frequency showed the achievement of greater deep-collagen denaturation. In addition, the already rare risk of surface tissue damage was further decreased, as was patient discomfort.

Dermatologists including Dr. Halmi have picked up on the multiple-passes approach and report much improved results. "The newer treatment paradigm is much better tolerated, reduces the risks, and appears so far to offer better results," Dr. Halmi said.

With the multiple-passes approach, frequency should be reduced and as many as four or five passes can be used. "One pass is made over the entire surface area, then on the second pass you concentrate on the areas of interest, and you can go on to four or five passes on the face to reach a clinical point of physical tightening," Dr. Halmi said.

Since there is immediate collagen contraction, visible results are seen right away, but this response usually lasts only a matter of hours or days. It typically takes about 2 months, however, to see the maximum results of the more important secondary response showing collagen remodeling and tightening.

While radiofrequency (RF) waves have long been used in dermatology for purposes such as electrocoagulation and skin resurfacing, the ThermaCool system is unique in that it uses a patented capacitive coupling to give greater uniformity in heating and tightening deeper tissue, Dr. Halmi explained.

The device also uses cooling before, during, and after the delivery of the RF energy to protect the epidermis.

Slides presented from Dr. Halmi's practice showed dramatic improvement in areas including the nasolabial fold, the jowls, and especially the neck.

"It turns out neck tightening is probably the area this [treatment] does the best in," Dr. Halmi said. "Using the 'traditional' protocol of one pass usually achieves at least subtle results, but multiple passes appear to be yielding much better results."

The SDEF and this newspaper are wholly owned subsidiaries of Elsevier.

SCOTTSDALE, ARIZ. — Radiofrequency tissue tightening using Thermage's ThermaCool TC system has gained favor for wrinkle reduction with the standard use of a single pass of the device, but better results and greater tolerance are seen with a multiple-passes approach using reduced treatment-level settings, said Bill H. Halmi, M.D., at a meeting sponsored by the Skin Disease Education Foundation.

The ThermaCool system, which has received Food and Drug Administration approval for smoothing wrinkles and sagging skin around the face, has yielded only modest results, and subtle changes were often not even noticeable, said Dr. Halmi, a dermatologist and owner of Arizona Advanced Dermatology in Phoenix.

Furthermore, the treatment was not without some discomfort, and early safety observations showed a 6% rate of scarring or texture change 6 months post treatment.

In a new technique introduced last year by Brian Zelickson, M.D., however, use of multiple passes in a single treatment with lower frequency showed the achievement of greater deep-collagen denaturation. In addition, the already rare risk of surface tissue damage was further decreased, as was patient discomfort.

Dermatologists including Dr. Halmi have picked up on the multiple-passes approach and report much improved results. "The newer treatment paradigm is much better tolerated, reduces the risks, and appears so far to offer better results," Dr. Halmi said.

With the multiple-passes approach, frequency should be reduced and as many as four or five passes can be used. "One pass is made over the entire surface area, then on the second pass you concentrate on the areas of interest, and you can go on to four or five passes on the face to reach a clinical point of physical tightening," Dr. Halmi said.

Since there is immediate collagen contraction, visible results are seen right away, but this response usually lasts only a matter of hours or days. It typically takes about 2 months, however, to see the maximum results of the more important secondary response showing collagen remodeling and tightening.

While radiofrequency (RF) waves have long been used in dermatology for purposes such as electrocoagulation and skin resurfacing, the ThermaCool system is unique in that it uses a patented capacitive coupling to give greater uniformity in heating and tightening deeper tissue, Dr. Halmi explained.

The device also uses cooling before, during, and after the delivery of the RF energy to protect the epidermis.

Slides presented from Dr. Halmi's practice showed dramatic improvement in areas including the nasolabial fold, the jowls, and especially the neck.

"It turns out neck tightening is probably the area this [treatment] does the best in," Dr. Halmi said. "Using the 'traditional' protocol of one pass usually achieves at least subtle results, but multiple passes appear to be yielding much better results."

The SDEF and this newspaper are wholly owned subsidiaries of Elsevier.

SCOTTSDALE, ARIZ. — Radiofrequency tissue tightening using Thermage's ThermaCool TC system has gained favor for wrinkle reduction with the standard use of a single pass of the device, but better results and greater tolerance are seen with a multiple-passes approach using reduced treatment-level settings, said Bill H. Halmi, M.D., at a meeting sponsored by the Skin Disease Education Foundation.

The ThermaCool system, which has received Food and Drug Administration approval for smoothing wrinkles and sagging skin around the face, has yielded only modest results, and subtle changes were often not even noticeable, said Dr. Halmi, a dermatologist and owner of Arizona Advanced Dermatology in Phoenix.

Furthermore, the treatment was not without some discomfort, and early safety observations showed a 6% rate of scarring or texture change 6 months post treatment.

In a new technique introduced last year by Brian Zelickson, M.D., however, use of multiple passes in a single treatment with lower frequency showed the achievement of greater deep-collagen denaturation. In addition, the already rare risk of surface tissue damage was further decreased, as was patient discomfort.

Dermatologists including Dr. Halmi have picked up on the multiple-passes approach and report much improved results. "The newer treatment paradigm is much better tolerated, reduces the risks, and appears so far to offer better results," Dr. Halmi said.

With the multiple-passes approach, frequency should be reduced and as many as four or five passes can be used. "One pass is made over the entire surface area, then on the second pass you concentrate on the areas of interest, and you can go on to four or five passes on the face to reach a clinical point of physical tightening," Dr. Halmi said.

Since there is immediate collagen contraction, visible results are seen right away, but this response usually lasts only a matter of hours or days. It typically takes about 2 months, however, to see the maximum results of the more important secondary response showing collagen remodeling and tightening.

While radiofrequency (RF) waves have long been used in dermatology for purposes such as electrocoagulation and skin resurfacing, the ThermaCool system is unique in that it uses a patented capacitive coupling to give greater uniformity in heating and tightening deeper tissue, Dr. Halmi explained.

The device also uses cooling before, during, and after the delivery of the RF energy to protect the epidermis.

Slides presented from Dr. Halmi's practice showed dramatic improvement in areas including the nasolabial fold, the jowls, and especially the neck.

"It turns out neck tightening is probably the area this [treatment] does the best in," Dr. Halmi said. "Using the 'traditional' protocol of one pass usually achieves at least subtle results, but multiple passes appear to be yielding much better results."

The SDEF and this newspaper are wholly owned subsidiaries of Elsevier.

SCOTTSDALE, ARIZ. — The tissue adhesive Dermabond has gained popularity, especially for use in children and emergent situations, because of its short application time and improved cosmesis over older adhesives, and despite its limitations, the product can be ideal for many uses, said Bari Cunningham, M.D., at a meeting sponsored by the Skin Disease Education Foundation.

Although studies have shown that Dermabond offers no significant improvement in cosmesis over traditional suturing, its benefits are reflected in substantially higher pain scores and shorter procedure time (JAMA 1997;277:1527-30; J. Pediatr. 1998;132:1067-70).

“It's a few seconds versus the time it takes for stitches, which with children can take upward of half an hour. So the benefit is obvious,” said Dr. Cunningham of Children's Hospital, San Diego, and the University of California, San Diego.

Another advantage of Dermabond over suturing is that a follow-up visit is not needed, which is convenient for patients needing to travel a long distance. In addition, wounds treated with Dermabond can withstand wetness, which is indispensable for patients who want to swim.

The product also is especially beneficial for the commonly problematic diaper region.

“Usually, when you stitch the diaper region, you worry about postop infection, but this is far superior,” Dr. Cunningham said.

Dermabond's maker, Ethicon Inc., says the product seals out most infection-causing bacteria, such as certain staph, pseudomonas, and Escherichia coli species. Although it's not yet certain whether that will translate into fewer postop infections, the possible antibacterial properties are intriguing, Dr. Cunningham said.

Dermabond is a relatively new tissue adhesive about three times as strong as the old cyanoacrylates, which were too weak for widespread use. The old adhesives also tended to be brittle and prone to cracking, Dr. Cunningham said.

The product has evolved in response to physicians' preferences, with newer formulations being more viscous and featuring better applicator tips.

Dr. Cunningham and her colleagues conducted a study comparing suturing with tissue adhesive. In a 2-month follow-up, they found significantly better cosmesis with suturing than with the skin glue (Arch. Derm. 2001;137:1177-80).

The adhesive is ideal for incisions such as low-tension closures for cysts but is not appropriate for high-tension areas, Dr. Cunningham said.

She urged care in the eye area; there have been cases of doctors accidentally gluing a patient's eye shut. In such instances, avoid trying to pry the eye open or using water, which can make the situation worse. Instead, apply a petrolatum-based product to gently ease the eye open.

For the same reason, doctors should avoid placing Neosporin (neomycin) ointment or other petrolatum-based products on an incision that needs to be closed, because such products can cause the Dermabond to dissolve.

And then there's the price; at about $30 a vial, some question whether Dermabond is worth the cost. Dr. Cunningham argued that the savings in time make up for the cost. “If you factor in the cost of time taken for a postoperative visit, suture removal, and nursing, it is often more cost effective to use the Dermabond,” she said.

The SDEF and this newspaper are wholly owned subsidiaries of Elsevier.

SCOTTSDALE, ARIZ. — The tissue adhesive Dermabond has gained popularity, especially for use in children and emergent situations, because of its short application time and improved cosmesis over older adhesives, and despite its limitations, the product can be ideal for many uses, said Bari Cunningham, M.D., at a meeting sponsored by the Skin Disease Education Foundation.

Although studies have shown that Dermabond offers no significant improvement in cosmesis over traditional suturing, its benefits are reflected in substantially higher pain scores and shorter procedure time (JAMA 1997;277:1527-30; J. Pediatr. 1998;132:1067-70).

“It's a few seconds versus the time it takes for stitches, which with children can take upward of half an hour. So the benefit is obvious,” said Dr. Cunningham of Children's Hospital, San Diego, and the University of California, San Diego.

Another advantage of Dermabond over suturing is that a follow-up visit is not needed, which is convenient for patients needing to travel a long distance. In addition, wounds treated with Dermabond can withstand wetness, which is indispensable for patients who want to swim.

The product also is especially beneficial for the commonly problematic diaper region.

“Usually, when you stitch the diaper region, you worry about postop infection, but this is far superior,” Dr. Cunningham said.

Dermabond's maker, Ethicon Inc., says the product seals out most infection-causing bacteria, such as certain staph, pseudomonas, and Escherichia coli species. Although it's not yet certain whether that will translate into fewer postop infections, the possible antibacterial properties are intriguing, Dr. Cunningham said.

Dermabond is a relatively new tissue adhesive about three times as strong as the old cyanoacrylates, which were too weak for widespread use. The old adhesives also tended to be brittle and prone to cracking, Dr. Cunningham said.

The product has evolved in response to physicians' preferences, with newer formulations being more viscous and featuring better applicator tips.

Dr. Cunningham and her colleagues conducted a study comparing suturing with tissue adhesive. In a 2-month follow-up, they found significantly better cosmesis with suturing than with the skin glue (Arch. Derm. 2001;137:1177-80).

The adhesive is ideal for incisions such as low-tension closures for cysts but is not appropriate for high-tension areas, Dr. Cunningham said.

She urged care in the eye area; there have been cases of doctors accidentally gluing a patient's eye shut. In such instances, avoid trying to pry the eye open or using water, which can make the situation worse. Instead, apply a petrolatum-based product to gently ease the eye open.

For the same reason, doctors should avoid placing Neosporin (neomycin) ointment or other petrolatum-based products on an incision that needs to be closed, because such products can cause the Dermabond to dissolve.

And then there's the price; at about $30 a vial, some question whether Dermabond is worth the cost. Dr. Cunningham argued that the savings in time make up for the cost. “If you factor in the cost of time taken for a postoperative visit, suture removal, and nursing, it is often more cost effective to use the Dermabond,” she said.

The SDEF and this newspaper are wholly owned subsidiaries of Elsevier.

SCOTTSDALE, ARIZ. — The tissue adhesive Dermabond has gained popularity, especially for use in children and emergent situations, because of its short application time and improved cosmesis over older adhesives, and despite its limitations, the product can be ideal for many uses, said Bari Cunningham, M.D., at a meeting sponsored by the Skin Disease Education Foundation.

Although studies have shown that Dermabond offers no significant improvement in cosmesis over traditional suturing, its benefits are reflected in substantially higher pain scores and shorter procedure time (JAMA 1997;277:1527-30; J. Pediatr. 1998;132:1067-70).

“It's a few seconds versus the time it takes for stitches, which with children can take upward of half an hour. So the benefit is obvious,” said Dr. Cunningham of Children's Hospital, San Diego, and the University of California, San Diego.

Another advantage of Dermabond over suturing is that a follow-up visit is not needed, which is convenient for patients needing to travel a long distance. In addition, wounds treated with Dermabond can withstand wetness, which is indispensable for patients who want to swim.

The product also is especially beneficial for the commonly problematic diaper region.

“Usually, when you stitch the diaper region, you worry about postop infection, but this is far superior,” Dr. Cunningham said.

Dermabond's maker, Ethicon Inc., says the product seals out most infection-causing bacteria, such as certain staph, pseudomonas, and Escherichia coli species. Although it's not yet certain whether that will translate into fewer postop infections, the possible antibacterial properties are intriguing, Dr. Cunningham said.

Dermabond is a relatively new tissue adhesive about three times as strong as the old cyanoacrylates, which were too weak for widespread use. The old adhesives also tended to be brittle and prone to cracking, Dr. Cunningham said.

The product has evolved in response to physicians' preferences, with newer formulations being more viscous and featuring better applicator tips.

Dr. Cunningham and her colleagues conducted a study comparing suturing with tissue adhesive. In a 2-month follow-up, they found significantly better cosmesis with suturing than with the skin glue (Arch. Derm. 2001;137:1177-80).

The adhesive is ideal for incisions such as low-tension closures for cysts but is not appropriate for high-tension areas, Dr. Cunningham said.

She urged care in the eye area; there have been cases of doctors accidentally gluing a patient's eye shut. In such instances, avoid trying to pry the eye open or using water, which can make the situation worse. Instead, apply a petrolatum-based product to gently ease the eye open.

For the same reason, doctors should avoid placing Neosporin (neomycin) ointment or other petrolatum-based products on an incision that needs to be closed, because such products can cause the Dermabond to dissolve.

And then there's the price; at about $30 a vial, some question whether Dermabond is worth the cost. Dr. Cunningham argued that the savings in time make up for the cost. “If you factor in the cost of time taken for a postoperative visit, suture removal, and nursing, it is often more cost effective to use the Dermabond,” she said.

The SDEF and this newspaper are wholly owned subsidiaries of Elsevier.

SCOTTSDALE, ARIZ. — The tissue adhesive Dermabond has gained popularity, especially in pediatric and emergency settings, because of its short application time and improved cosmesis over older adhesives, and despite its limitations, the product has many uses, said Bari Cunningham, M.D., at a meeting sponsored by the Skin Disease Education Foundation.

Although studies have shown that Dermabond offers no significant improvement in cosmesis over traditional suturing, its benefits are reflected in substantially higher pain scores and shorter procedure time, which have made the product ideal in emergency department and pediatric settings (JAMA 1997;277:1527-30; J. Pediatr. 1998;132:1067-70).

"It's a few seconds versus the time it takes for stitches—which with children can take upward of half an hour. So the benefit is obvious," said Dr. Cunningham of Children's Hospital, San Diego, and the University of California, San Diego.

Another advantage of Dermabond over suturing is that a follow-up visit is not needed, which is convenient for patients needing to travel a long distance. In addition, wounds treated with Dermabond can withstand wetness, which is indispensable for patients who want to swim.

Dermabond's maker, Ethicon Inc., says the product seals out most infection-causing bacteria, such as certain staph, pseudomonas, and Escherichia coli. Although it's not yet certain whether that will translate into fewer postop infections, the possible antibacterial properties are intriguing, Dr. Cunningham said.

Dermabond is a relatively new tissue adhesive about three times as strong as the old cyanoacrylates, which were too weak for widespread use and tended to be brittle and prone to cracking, Dr. Cunningham said.

The product has evolved in response to dermatologists' preferences, with newer formulations being more viscous and featuring better applicator tips.

Most studies that have shown benefits to Dermabond looked at uses in incisional surgery, whereas a majority of dermatologists work more with excisional surgery. To determine the adhesive's benefits in that context, Dr. Cunningham and her colleagues conducted a study comparing suturing with tissue adhesive. In a 2-month follow-up, they found significantly better cosmesis with suturing than with the skin glue (Arch. Derm. 2001;137:1177-80).

The adhesive is ideal for incisions such as low-tension closures for cysts but is not appropriate for high-tension areas. She urged care in the eye area; there have been cases of doctors accidentally gluing a patient's eye shut. In such instances, avoid trying to pry the eye open or using water, which can make the situation worse. Instead, apply a petrolatum-based product to gently ease the eye open.

In addition to Dermabond's inappropriateness for high-tension areas, another disadvantage is that the adhesive doesn't obviate sutures altogether, because subcutaneous sutures are still required.

And then there's the price; at about $30 a vial, some question whether Dermabond is worth the cost. But, Dr. Cunningham argued, "if you factor in the cost of time taken for a postoperative visit, suture removal, and nursing, it is often more cost effective to use the Dermabond."

The SDEF and this newspaper are wholly owned subsidiaries of Elsevier.

SCOTTSDALE, ARIZ. — The tissue adhesive Dermabond has gained popularity, especially in pediatric and emergency settings, because of its short application time and improved cosmesis over older adhesives, and despite its limitations, the product has many uses, said Bari Cunningham, M.D., at a meeting sponsored by the Skin Disease Education Foundation.

Although studies have shown that Dermabond offers no significant improvement in cosmesis over traditional suturing, its benefits are reflected in substantially higher pain scores and shorter procedure time, which have made the product ideal in emergency department and pediatric settings (JAMA 1997;277:1527-30; J. Pediatr. 1998;132:1067-70).

"It's a few seconds versus the time it takes for stitches—which with children can take upward of half an hour. So the benefit is obvious," said Dr. Cunningham of Children's Hospital, San Diego, and the University of California, San Diego.

Another advantage of Dermabond over suturing is that a follow-up visit is not needed, which is convenient for patients needing to travel a long distance. In addition, wounds treated with Dermabond can withstand wetness, which is indispensable for patients who want to swim.

Dermabond's maker, Ethicon Inc., says the product seals out most infection-causing bacteria, such as certain staph, pseudomonas, and Escherichia coli. Although it's not yet certain whether that will translate into fewer postop infections, the possible antibacterial properties are intriguing, Dr. Cunningham said.

Dermabond is a relatively new tissue adhesive about three times as strong as the old cyanoacrylates, which were too weak for widespread use and tended to be brittle and prone to cracking, Dr. Cunningham said.

The product has evolved in response to dermatologists' preferences, with newer formulations being more viscous and featuring better applicator tips.

Most studies that have shown benefits to Dermabond looked at uses in incisional surgery, whereas a majority of dermatologists work more with excisional surgery. To determine the adhesive's benefits in that context, Dr. Cunningham and her colleagues conducted a study comparing suturing with tissue adhesive. In a 2-month follow-up, they found significantly better cosmesis with suturing than with the skin glue (Arch. Derm. 2001;137:1177-80).

The adhesive is ideal for incisions such as low-tension closures for cysts but is not appropriate for high-tension areas. She urged care in the eye area; there have been cases of doctors accidentally gluing a patient's eye shut. In such instances, avoid trying to pry the eye open or using water, which can make the situation worse. Instead, apply a petrolatum-based product to gently ease the eye open.

In addition to Dermabond's inappropriateness for high-tension areas, another disadvantage is that the adhesive doesn't obviate sutures altogether, because subcutaneous sutures are still required.

And then there's the price; at about $30 a vial, some question whether Dermabond is worth the cost. But, Dr. Cunningham argued, "if you factor in the cost of time taken for a postoperative visit, suture removal, and nursing, it is often more cost effective to use the Dermabond."

The SDEF and this newspaper are wholly owned subsidiaries of Elsevier.

SCOTTSDALE, ARIZ. — The tissue adhesive Dermabond has gained popularity, especially in pediatric and emergency settings, because of its short application time and improved cosmesis over older adhesives, and despite its limitations, the product has many uses, said Bari Cunningham, M.D., at a meeting sponsored by the Skin Disease Education Foundation.

Although studies have shown that Dermabond offers no significant improvement in cosmesis over traditional suturing, its benefits are reflected in substantially higher pain scores and shorter procedure time, which have made the product ideal in emergency department and pediatric settings (JAMA 1997;277:1527-30; J. Pediatr. 1998;132:1067-70).

"It's a few seconds versus the time it takes for stitches—which with children can take upward of half an hour. So the benefit is obvious," said Dr. Cunningham of Children's Hospital, San Diego, and the University of California, San Diego.

Another advantage of Dermabond over suturing is that a follow-up visit is not needed, which is convenient for patients needing to travel a long distance. In addition, wounds treated with Dermabond can withstand wetness, which is indispensable for patients who want to swim.

Dermabond's maker, Ethicon Inc., says the product seals out most infection-causing bacteria, such as certain staph, pseudomonas, and Escherichia coli. Although it's not yet certain whether that will translate into fewer postop infections, the possible antibacterial properties are intriguing, Dr. Cunningham said.

Dermabond is a relatively new tissue adhesive about three times as strong as the old cyanoacrylates, which were too weak for widespread use and tended to be brittle and prone to cracking, Dr. Cunningham said.

The product has evolved in response to dermatologists' preferences, with newer formulations being more viscous and featuring better applicator tips.

Most studies that have shown benefits to Dermabond looked at uses in incisional surgery, whereas a majority of dermatologists work more with excisional surgery. To determine the adhesive's benefits in that context, Dr. Cunningham and her colleagues conducted a study comparing suturing with tissue adhesive. In a 2-month follow-up, they found significantly better cosmesis with suturing than with the skin glue (Arch. Derm. 2001;137:1177-80).

The adhesive is ideal for incisions such as low-tension closures for cysts but is not appropriate for high-tension areas. She urged care in the eye area; there have been cases of doctors accidentally gluing a patient's eye shut. In such instances, avoid trying to pry the eye open or using water, which can make the situation worse. Instead, apply a petrolatum-based product to gently ease the eye open.

In addition to Dermabond's inappropriateness for high-tension areas, another disadvantage is that the adhesive doesn't obviate sutures altogether, because subcutaneous sutures are still required.

And then there's the price; at about $30 a vial, some question whether Dermabond is worth the cost. But, Dr. Cunningham argued, "if you factor in the cost of time taken for a postoperative visit, suture removal, and nursing, it is often more cost effective to use the Dermabond."

The SDEF and this newspaper are wholly owned subsidiaries of Elsevier.

SCOTTSDALE, ARIZ. — The incidence of pseudotumor cerebri is rising among the obese, so physicians should keep this relatively uncommon condition in mind when obese patients present with symptoms resembling brain tumor or intracranial pressure, said Deborah Friedman, M.D., at the American Headache Society's 2004 Headache Symposium.

Pseudotumor cerebri is primarily seen in obese women of childbearing age, and although the condition affects only 1 in 100,000 people in the United States, the rate for obese women between the ages of 20 and 44 is about 19 per 100,000.

In areas with higher levels of obesity, however, pseudotumor cerebri is being seen more frequently.

In Mississippi, called the most overweight state in the nation because a quarter of its population is considered obese by BMI criteria, the incidence of pseudotumor cerebri in the overall population is double, at 2 per 100,000, and among obese women aged 20–44, the rate is about 25 per 100,000.

Large increases in pseudotumor cerebri incidence rates have also been noted in men in the region, said Dr. Friedman of the University of Rochester (New York).

The most common symptom, headache, occurs in about 90% of patients. Descriptions of the pain range from headache behind the eyes that feels like pressure to headache in the morning, said Dr. Friedman.

Visual symptoms, seen in about three-quarters of patients, are the second most common symptom, and papilledema is also very common.

“Patients will often describe blurriness or say that if they bend over, their vision goes out for a few seconds when they straighten up again,” Dr. Friedman said. “It's usually a sign that the optic nerve is swollen.”

About 60% of patients also experience the third most common symptom of intracranial noises, usually described as a whooshing in the ear or the sound of their heartbeat in the ear.

In diagnosing the disease, imaging and mental status are typically normal, and a lumbar puncture should show increased cranial pressure with otherwise normal spinal fluid content.

Dr. Friedman underscored the need for a lumbar puncture.

“You have to do a spinal tap to make a diagnosis,” she stressed. “It's disheartening how many people I see who come in without having a lumbar puncture.”

There are no evidence-based guidelines for treating pseudotumor cerebri, and not all patients even require treatment.

However, with the possibility of vision loss, the most important goal of treatment should be to preserve a patient's vision, Dr. Friedman said.

An ophthalmologist needs to be brought in for such cases, but it's essential that the physicians collaborate on care.

“Most of the time, there's no captain of the ship in management, and the doctors aren't working as a team,” said Dr. Friedman, adding that an ophthalmologist and a neurologist should both follow the patient and communicate about management.

SCOTTSDALE, ARIZ. — The incidence of pseudotumor cerebri is rising among the obese, so physicians should keep this relatively uncommon condition in mind when obese patients present with symptoms resembling brain tumor or intracranial pressure, said Deborah Friedman, M.D., at the American Headache Society's 2004 Headache Symposium.

Pseudotumor cerebri is primarily seen in obese women of childbearing age, and although the condition affects only 1 in 100,000 people in the United States, the rate for obese women between the ages of 20 and 44 is about 19 per 100,000.

In areas with higher levels of obesity, however, pseudotumor cerebri is being seen more frequently.

In Mississippi, called the most overweight state in the nation because a quarter of its population is considered obese by BMI criteria, the incidence of pseudotumor cerebri in the overall population is double, at 2 per 100,000, and among obese women aged 20–44, the rate is about 25 per 100,000.

Large increases in pseudotumor cerebri incidence rates have also been noted in men in the region, said Dr. Friedman of the University of Rochester (New York).

The most common symptom, headache, occurs in about 90% of patients. Descriptions of the pain range from headache behind the eyes that feels like pressure to headache in the morning, said Dr. Friedman.

Visual symptoms, seen in about three-quarters of patients, are the second most common symptom, and papilledema is also very common.

“Patients will often describe blurriness or say that if they bend over, their vision goes out for a few seconds when they straighten up again,” Dr. Friedman said. “It's usually a sign that the optic nerve is swollen.”

About 60% of patients also experience the third most common symptom of intracranial noises, usually described as a whooshing in the ear or the sound of their heartbeat in the ear.

In diagnosing the disease, imaging and mental status are typically normal, and a lumbar puncture should show increased cranial pressure with otherwise normal spinal fluid content.

Dr. Friedman underscored the need for a lumbar puncture.

“You have to do a spinal tap to make a diagnosis,” she stressed. “It's disheartening how many people I see who come in without having a lumbar puncture.”

There are no evidence-based guidelines for treating pseudotumor cerebri, and not all patients even require treatment.

However, with the possibility of vision loss, the most important goal of treatment should be to preserve a patient's vision, Dr. Friedman said.

An ophthalmologist needs to be brought in for such cases, but it's essential that the physicians collaborate on care.

“Most of the time, there's no captain of the ship in management, and the doctors aren't working as a team,” said Dr. Friedman, adding that an ophthalmologist and a neurologist should both follow the patient and communicate about management.

SCOTTSDALE, ARIZ. — The incidence of pseudotumor cerebri is rising among the obese, so physicians should keep this relatively uncommon condition in mind when obese patients present with symptoms resembling brain tumor or intracranial pressure, said Deborah Friedman, M.D., at the American Headache Society's 2004 Headache Symposium.

Pseudotumor cerebri is primarily seen in obese women of childbearing age, and although the condition affects only 1 in 100,000 people in the United States, the rate for obese women between the ages of 20 and 44 is about 19 per 100,000.

In areas with higher levels of obesity, however, pseudotumor cerebri is being seen more frequently.

In Mississippi, called the most overweight state in the nation because a quarter of its population is considered obese by BMI criteria, the incidence of pseudotumor cerebri in the overall population is double, at 2 per 100,000, and among obese women aged 20–44, the rate is about 25 per 100,000.

Large increases in pseudotumor cerebri incidence rates have also been noted in men in the region, said Dr. Friedman of the University of Rochester (New York).

The most common symptom, headache, occurs in about 90% of patients. Descriptions of the pain range from headache behind the eyes that feels like pressure to headache in the morning, said Dr. Friedman.

Visual symptoms, seen in about three-quarters of patients, are the second most common symptom, and papilledema is also very common.

“Patients will often describe blurriness or say that if they bend over, their vision goes out for a few seconds when they straighten up again,” Dr. Friedman said. “It's usually a sign that the optic nerve is swollen.”

About 60% of patients also experience the third most common symptom of intracranial noises, usually described as a whooshing in the ear or the sound of their heartbeat in the ear.

In diagnosing the disease, imaging and mental status are typically normal, and a lumbar puncture should show increased cranial pressure with otherwise normal spinal fluid content.

Dr. Friedman underscored the need for a lumbar puncture.

“You have to do a spinal tap to make a diagnosis,” she stressed. “It's disheartening how many people I see who come in without having a lumbar puncture.”

There are no evidence-based guidelines for treating pseudotumor cerebri, and not all patients even require treatment.

However, with the possibility of vision loss, the most important goal of treatment should be to preserve a patient's vision, Dr. Friedman said.

An ophthalmologist needs to be brought in for such cases, but it's essential that the physicians collaborate on care.

“Most of the time, there's no captain of the ship in management, and the doctors aren't working as a team,” said Dr. Friedman, adding that an ophthalmologist and a neurologist should both follow the patient and communicate about management.

PHOENIX, ARIZ. — Pregnancies achieved using donor-egg in vitro fertilization can present a higher risk of pregnancy-induced hypertension than those achieved through standard IVF, according to the results of a retrospective study.

Investigators compared 50 oocyte-donation pregnancies with 50 standard IVF pregnancies at three private practice medical groups at the California Pacific Medical Center in San Francisco. The rate of pregnancy-induced hypertension (PIH) was more than three times higher in the donor-egg IVF group than in the standard IVF group (27% vs. 8%), said Donna Wiggins, M.D., the study's lead investigator and a San Francisco ob.gyn.

PIH was defined as a systolic blood pressure (BP) of at least 140 mm Hg or a diastolic BP of at least 90 mm Hg occurring after 20 weeks' gestation in a woman with previously normal BP.

In looking separately at nulliparous patients, the researchers found greater PIH rates in the donor-egg IVF group (37% vs. 8%), she said at the annual meeting of the Pacific Coast Obstetrical and Gynecological Society.

Among women who had twins, 58% of those in the donor-egg IVF group and 17% of the standard IVF group developed PIH.

The women were between the ages of 30 and 50 years, and the average maternal age in the donor-egg IVF group was 42, compared with 38 in the standard IVF group. But Dr. Wiggins explained that when age stratifications were applied, there was not an increasing incidence with advancing age. And when the multiple logistic regression was applied, age fell out as an indicator of significance with regard to PIH.

Aside from the PIH rates, the two groups showed similar results in most other categories. The cesarean-section rate was 43% in the donor-egg group and 45% in the standard IVF group.

First-trimester bleeding occurred in 12% of the donor-egg group and 14% in standard IVF. And the most common postpartum complications of “lactation difficulties” and postpartum depression occurred in both groups at about the same rate of 10%.

Birthweight was an average of 3,044 g in the donor-egg group and 3,017 g in standard IVF group, and premature labor occurred in the donor-egg group at a rate of 16%, compared with 10% in the standard IVF group.

“In looking at donor-egg and [standard] IVF pregnancies, there aren't that many differences, aside from the significant difference in hypertensive disorders,” said Dr. Wiggins. “All things considered, however, the women for the most part had good outcomes.”

The reasons for the higher PIH rates in donor-egg IVF may have to do with the fact that the donor egg is foreign, Dr. Wiggins speculated. “Unlike any other pregnancy, a donor-egg pregnancy is 100% allogeneic, and this may affect the adequacy of trophoblast invasion and hence hypertensive disorders,” she said at the meeting, cosponsored by the American College of Obstetricians and Gynecologists.

When initially introduced in 1984, donor-egg IVF was primarily indicated for premature ovarian failure, defined as menopause occurring before the age of 40. But the primary indication for egg donation at most IVF centers is now diminished ovarian reserve in women with functioning ovaries, Dr. Wiggins said.

PHOENIX, ARIZ. — Pregnancies achieved using donor-egg in vitro fertilization can present a higher risk of pregnancy-induced hypertension than those achieved through standard IVF, according to the results of a retrospective study.

Investigators compared 50 oocyte-donation pregnancies with 50 standard IVF pregnancies at three private practice medical groups at the California Pacific Medical Center in San Francisco. The rate of pregnancy-induced hypertension (PIH) was more than three times higher in the donor-egg IVF group than in the standard IVF group (27% vs. 8%), said Donna Wiggins, M.D., the study's lead investigator and a San Francisco ob.gyn.

PIH was defined as a systolic blood pressure (BP) of at least 140 mm Hg or a diastolic BP of at least 90 mm Hg occurring after 20 weeks' gestation in a woman with previously normal BP.

In looking separately at nulliparous patients, the researchers found greater PIH rates in the donor-egg IVF group (37% vs. 8%), she said at the annual meeting of the Pacific Coast Obstetrical and Gynecological Society.

Among women who had twins, 58% of those in the donor-egg IVF group and 17% of the standard IVF group developed PIH.

The women were between the ages of 30 and 50 years, and the average maternal age in the donor-egg IVF group was 42, compared with 38 in the standard IVF group. But Dr. Wiggins explained that when age stratifications were applied, there was not an increasing incidence with advancing age. And when the multiple logistic regression was applied, age fell out as an indicator of significance with regard to PIH.

Aside from the PIH rates, the two groups showed similar results in most other categories. The cesarean-section rate was 43% in the donor-egg group and 45% in the standard IVF group.

First-trimester bleeding occurred in 12% of the donor-egg group and 14% in standard IVF. And the most common postpartum complications of “lactation difficulties” and postpartum depression occurred in both groups at about the same rate of 10%.

Birthweight was an average of 3,044 g in the donor-egg group and 3,017 g in standard IVF group, and premature labor occurred in the donor-egg group at a rate of 16%, compared with 10% in the standard IVF group.

“In looking at donor-egg and [standard] IVF pregnancies, there aren't that many differences, aside from the significant difference in hypertensive disorders,” said Dr. Wiggins. “All things considered, however, the women for the most part had good outcomes.”

The reasons for the higher PIH rates in donor-egg IVF may have to do with the fact that the donor egg is foreign, Dr. Wiggins speculated. “Unlike any other pregnancy, a donor-egg pregnancy is 100% allogeneic, and this may affect the adequacy of trophoblast invasion and hence hypertensive disorders,” she said at the meeting, cosponsored by the American College of Obstetricians and Gynecologists.

When initially introduced in 1984, donor-egg IVF was primarily indicated for premature ovarian failure, defined as menopause occurring before the age of 40. But the primary indication for egg donation at most IVF centers is now diminished ovarian reserve in women with functioning ovaries, Dr. Wiggins said.

PHOENIX, ARIZ. — Pregnancies achieved using donor-egg in vitro fertilization can present a higher risk of pregnancy-induced hypertension than those achieved through standard IVF, according to the results of a retrospective study.

Investigators compared 50 oocyte-donation pregnancies with 50 standard IVF pregnancies at three private practice medical groups at the California Pacific Medical Center in San Francisco. The rate of pregnancy-induced hypertension (PIH) was more than three times higher in the donor-egg IVF group than in the standard IVF group (27% vs. 8%), said Donna Wiggins, M.D., the study's lead investigator and a San Francisco ob.gyn.

PIH was defined as a systolic blood pressure (BP) of at least 140 mm Hg or a diastolic BP of at least 90 mm Hg occurring after 20 weeks' gestation in a woman with previously normal BP.

In looking separately at nulliparous patients, the researchers found greater PIH rates in the donor-egg IVF group (37% vs. 8%), she said at the annual meeting of the Pacific Coast Obstetrical and Gynecological Society.

Among women who had twins, 58% of those in the donor-egg IVF group and 17% of the standard IVF group developed PIH.

The women were between the ages of 30 and 50 years, and the average maternal age in the donor-egg IVF group was 42, compared with 38 in the standard IVF group. But Dr. Wiggins explained that when age stratifications were applied, there was not an increasing incidence with advancing age. And when the multiple logistic regression was applied, age fell out as an indicator of significance with regard to PIH.

Aside from the PIH rates, the two groups showed similar results in most other categories. The cesarean-section rate was 43% in the donor-egg group and 45% in the standard IVF group.

First-trimester bleeding occurred in 12% of the donor-egg group and 14% in standard IVF. And the most common postpartum complications of “lactation difficulties” and postpartum depression occurred in both groups at about the same rate of 10%.

Birthweight was an average of 3,044 g in the donor-egg group and 3,017 g in standard IVF group, and premature labor occurred in the donor-egg group at a rate of 16%, compared with 10% in the standard IVF group.

“In looking at donor-egg and [standard] IVF pregnancies, there aren't that many differences, aside from the significant difference in hypertensive disorders,” said Dr. Wiggins. “All things considered, however, the women for the most part had good outcomes.”

The reasons for the higher PIH rates in donor-egg IVF may have to do with the fact that the donor egg is foreign, Dr. Wiggins speculated. “Unlike any other pregnancy, a donor-egg pregnancy is 100% allogeneic, and this may affect the adequacy of trophoblast invasion and hence hypertensive disorders,” she said at the meeting, cosponsored by the American College of Obstetricians and Gynecologists.

When initially introduced in 1984, donor-egg IVF was primarily indicated for premature ovarian failure, defined as menopause occurring before the age of 40. But the primary indication for egg donation at most IVF centers is now diminished ovarian reserve in women with functioning ovaries, Dr. Wiggins said.

PHOENIX, ARIZ. — About one-quarter of a diverse group of pregnant women would not consider a pregnancy termination for a fetus with Down syndrome, according to a study presented at the annual meeting of the Pacific Coast Obstetrical and Gynecological Society.

The prospective study of 1,038 pregnant women who were participating in research at the University of California, San Francisco, department of obstetrics, gynecology, and reproductive sciences showed that 24% said they would not consider a termination if testing showed the fetus had Down syndrome.

Among the 76% of women who said they would consider an abortion under such circumstances, half said they would do so only in the first trimester, 36% said they would do so only in the first or second trimester, and 14% said they would at any point in the pregnancy, said lead author Lee A. Learman, M.D., of the UCSF department.

The women were interviewed before 20 weeks' gestation and were of diverse socioeconomic backgrounds.

When asked about their attitudes regarding abortion in general, 23% said that they thought abortion should be available only in cases of rape or incest, and 8% said abortion should not be available under any circumstances.

Seventy-two percent of the women answered yes to the question of whether they would ever consider having an abortion, and 52% reported that they had had an abortion in the past.

With adjustment for various factors, women were more likely to consider an abortion if they were older, had a previous abortion, or expressed distrust in the health care system. Conversely, they were less likely to consider an abortion if they had at least two prior births, were married, were fatalistic about the outcome of their pregnancy, or were not white.

“The overarching goal of the project is to help understand the tradeoffs involved in screening and testing strategies and to help patients make decisions that are consistent with their personal values and feelings,” Dr. Learman said.

In a commentary on the study, Anita Nelson, M.D., medical director of Women's Health Care Programs at Harbor-UCLA Medical Center in Torrance, Calif., brought up the possibility that patients' actions may not always be consistent with their declared beliefs. Dr. Learman agreed, saying his lab is working on research to track discrepancies between actions and beliefs.

Dr. Nelson added that efforts to better prepare women for the many possible outcomes of a pregnancy should also extend to the preconception period to prevent unrealistic expectations.

“When women expect perfect outcomes, we can find ourselves in a bit of a legal jam, and it's therefore important to lay on the table all the risks of pregnancy while all options are still open—including the option to not become pregnant,” she said during the meeting.

PHOENIX, ARIZ. — About one-quarter of a diverse group of pregnant women would not consider a pregnancy termination for a fetus with Down syndrome, according to a study presented at the annual meeting of the Pacific Coast Obstetrical and Gynecological Society.

The prospective study of 1,038 pregnant women who were participating in research at the University of California, San Francisco, department of obstetrics, gynecology, and reproductive sciences showed that 24% said they would not consider a termination if testing showed the fetus had Down syndrome.

Among the 76% of women who said they would consider an abortion under such circumstances, half said they would do so only in the first trimester, 36% said they would do so only in the first or second trimester, and 14% said they would at any point in the pregnancy, said lead author Lee A. Learman, M.D., of the UCSF department.

The women were interviewed before 20 weeks' gestation and were of diverse socioeconomic backgrounds.

When asked about their attitudes regarding abortion in general, 23% said that they thought abortion should be available only in cases of rape or incest, and 8% said abortion should not be available under any circumstances.

Seventy-two percent of the women answered yes to the question of whether they would ever consider having an abortion, and 52% reported that they had had an abortion in the past.

With adjustment for various factors, women were more likely to consider an abortion if they were older, had a previous abortion, or expressed distrust in the health care system. Conversely, they were less likely to consider an abortion if they had at least two prior births, were married, were fatalistic about the outcome of their pregnancy, or were not white.

“The overarching goal of the project is to help understand the tradeoffs involved in screening and testing strategies and to help patients make decisions that are consistent with their personal values and feelings,” Dr. Learman said.

In a commentary on the study, Anita Nelson, M.D., medical director of Women's Health Care Programs at Harbor-UCLA Medical Center in Torrance, Calif., brought up the possibility that patients' actions may not always be consistent with their declared beliefs. Dr. Learman agreed, saying his lab is working on research to track discrepancies between actions and beliefs.

Dr. Nelson added that efforts to better prepare women for the many possible outcomes of a pregnancy should also extend to the preconception period to prevent unrealistic expectations.

“When women expect perfect outcomes, we can find ourselves in a bit of a legal jam, and it's therefore important to lay on the table all the risks of pregnancy while all options are still open—including the option to not become pregnant,” she said during the meeting.

PHOENIX, ARIZ. — About one-quarter of a diverse group of pregnant women would not consider a pregnancy termination for a fetus with Down syndrome, according to a study presented at the annual meeting of the Pacific Coast Obstetrical and Gynecological Society.

The prospective study of 1,038 pregnant women who were participating in research at the University of California, San Francisco, department of obstetrics, gynecology, and reproductive sciences showed that 24% said they would not consider a termination if testing showed the fetus had Down syndrome.

Among the 76% of women who said they would consider an abortion under such circumstances, half said they would do so only in the first trimester, 36% said they would do so only in the first or second trimester, and 14% said they would at any point in the pregnancy, said lead author Lee A. Learman, M.D., of the UCSF department.

The women were interviewed before 20 weeks' gestation and were of diverse socioeconomic backgrounds.

When asked about their attitudes regarding abortion in general, 23% said that they thought abortion should be available only in cases of rape or incest, and 8% said abortion should not be available under any circumstances.

Seventy-two percent of the women answered yes to the question of whether they would ever consider having an abortion, and 52% reported that they had had an abortion in the past.

With adjustment for various factors, women were more likely to consider an abortion if they were older, had a previous abortion, or expressed distrust in the health care system. Conversely, they were less likely to consider an abortion if they had at least two prior births, were married, were fatalistic about the outcome of their pregnancy, or were not white.

“The overarching goal of the project is to help understand the tradeoffs involved in screening and testing strategies and to help patients make decisions that are consistent with their personal values and feelings,” Dr. Learman said.

In a commentary on the study, Anita Nelson, M.D., medical director of Women's Health Care Programs at Harbor-UCLA Medical Center in Torrance, Calif., brought up the possibility that patients' actions may not always be consistent with their declared beliefs. Dr. Learman agreed, saying his lab is working on research to track discrepancies between actions and beliefs.

Dr. Nelson added that efforts to better prepare women for the many possible outcomes of a pregnancy should also extend to the preconception period to prevent unrealistic expectations.

“When women expect perfect outcomes, we can find ourselves in a bit of a legal jam, and it's therefore important to lay on the table all the risks of pregnancy while all options are still open—including the option to not become pregnant,” she said during the meeting.

SCOTTSDALE, ARIZ. — Fluctuating hormones are believed to be the key culprit behind menstrual migraines, so low-dose monophasic oral contraceptives are generally the best alternative to help such patients, Christine Lay, M.D., said at a symposium sponsored by the American Headache Society.

Physicians often turn to biphasic contraception instead of monophasic pills in the belief that varying the hormone dosage will help alleviate menstrual migraines, but the dosage schedule can in fact make the problem worse, said Dr. Lay, a neurologist with the Headache Institute at Roosevelt Hospital, New York.

Dr. Lay gave the example of Mircette, which contains 21 days of 0.15-mg desogestrel/0.02-mg ethinyl estradiol, followed by 2 days of placebo pills and 5 days of 0.01-mg ethinyl estradiol. She noted that numerous physicians prescribe Mircette thinking it might help patient's menstrually related migraines.

Instead, the method introduces another level of fluctuation of estrogen, and it is that fluctuation that is believed to trigger the migraines in the first place, said Dr. Lay. “It's not whether the estrogen is present or absent, but [it's] the change in estrogen and I find many patients don't do well on Mircette because of fluctuations in estrogen.”

Even worse for menstrual migraines are triphasic pills, which cause greater fluctuation in hormone levels and often are high-dose pills, Dr. Lay said.

“The triphasic pills are the worst for migraine patients,” she said. “Invariably, you will have a patient track her calendar and over a month's period of time she will report that within a day or two of switching to a new dose of pill, the woman will experience a migraine attack.”

Migraine patients generally fare much better when using monophasic low-dose (20-mcg) birth control pills, which offer a more uniform hormone level, Dr. Lay said. She added that the estrogen patch is another effective way of providing a more steady level of estrogen.

Newer noncycling methods such as Seasonale (ethinyl estradiol and levonorgestrel) are also good alternatives for migraineurs, she said. “With a 91-day regimen, including 84 days of real pills and then the placebo pills, women skip perhaps three out of every four menstrual migraine attacks, because they're not having a menstrual cycle,” Dr. Lay said in an interview.

Estrogen use in patients who suffered from migraines was frowned upon for many years, but the International Headache Society Task Force on Combined Oral Contraceptives and HRT determined more recently that it was safe for migraineurs, provided that there are no other risk factors for coronary heart disease or vascular disease.

In addition, the migraine should be without aura and patients should be given the lowest effective hormone dose.

In the ebb and flow of hormone levels, it is the withdrawal of estrogen, specifically, that experts believe contributes to menstrual migraines. The withdrawal is believed not only to affect trigeminal pain pathways and have vasculature effects, but it may modulate neurotransmitters and magnesium, Dr. Lay said at the meeting.

The release of prostaglandin also plays a role in migraines, sensitizing peripheral nociceptors to pain and mediating hyperalgesia, and prostaglandin is known to increase during migraine attacks.

A key approach to treatment is having patients maintain a diary in which they track their menses and headache days, Dr. Lay said. The journal can help guide treatment options and determine the role of oral contraceptive use.

Since menstrual migraines can occur in young, otherwise healthy women, Dr. Lay strongly recommended using caution in approaching contraceptive issues.

“This is a critical time to discuss with patients pregnancy planning and medication contraindications in pregnancy because, invariably, some of these patients could wind up getting pregnant” unintentionally.

“Physicians may have the patient go off the pill in order to observe the migraine pattern over time. However, the migraine pattern may not improve for at least 3-6 months. In such cases, it's essential to talk about pregnancy issues if the patient is on the pill for contraceptive purposes,” she said.

SCOTTSDALE, ARIZ. — Fluctuating hormones are believed to be the key culprit behind menstrual migraines, so low-dose monophasic oral contraceptives are generally the best alternative to help such patients, Christine Lay, M.D., said at a symposium sponsored by the American Headache Society.

Physicians often turn to biphasic contraception instead of monophasic pills in the belief that varying the hormone dosage will help alleviate menstrual migraines, but the dosage schedule can in fact make the problem worse, said Dr. Lay, a neurologist with the Headache Institute at Roosevelt Hospital, New York.

Dr. Lay gave the example of Mircette, which contains 21 days of 0.15-mg desogestrel/0.02-mg ethinyl estradiol, followed by 2 days of placebo pills and 5 days of 0.01-mg ethinyl estradiol. She noted that numerous physicians prescribe Mircette thinking it might help patient's menstrually related migraines.

Instead, the method introduces another level of fluctuation of estrogen, and it is that fluctuation that is believed to trigger the migraines in the first place, said Dr. Lay. “It's not whether the estrogen is present or absent, but [it's] the change in estrogen and I find many patients don't do well on Mircette because of fluctuations in estrogen.”

Even worse for menstrual migraines are triphasic pills, which cause greater fluctuation in hormone levels and often are high-dose pills, Dr. Lay said.

“The triphasic pills are the worst for migraine patients,” she said. “Invariably, you will have a patient track her calendar and over a month's period of time she will report that within a day or two of switching to a new dose of pill, the woman will experience a migraine attack.”

Migraine patients generally fare much better when using monophasic low-dose (20-mcg) birth control pills, which offer a more uniform hormone level, Dr. Lay said. She added that the estrogen patch is another effective way of providing a more steady level of estrogen.

Newer noncycling methods such as Seasonale (ethinyl estradiol and levonorgestrel) are also good alternatives for migraineurs, she said. “With a 91-day regimen, including 84 days of real pills and then the placebo pills, women skip perhaps three out of every four menstrual migraine attacks, because they're not having a menstrual cycle,” Dr. Lay said in an interview.

Estrogen use in patients who suffered from migraines was frowned upon for many years, but the International Headache Society Task Force on Combined Oral Contraceptives and HRT determined more recently that it was safe for migraineurs, provided that there are no other risk factors for coronary heart disease or vascular disease.

In addition, the migraine should be without aura and patients should be given the lowest effective hormone dose.

In the ebb and flow of hormone levels, it is the withdrawal of estrogen, specifically, that experts believe contributes to menstrual migraines. The withdrawal is believed not only to affect trigeminal pain pathways and have vasculature effects, but it may modulate neurotransmitters and magnesium, Dr. Lay said at the meeting.

The release of prostaglandin also plays a role in migraines, sensitizing peripheral nociceptors to pain and mediating hyperalgesia, and prostaglandin is known to increase during migraine attacks.

A key approach to treatment is having patients maintain a diary in which they track their menses and headache days, Dr. Lay said. The journal can help guide treatment options and determine the role of oral contraceptive use.

Since menstrual migraines can occur in young, otherwise healthy women, Dr. Lay strongly recommended using caution in approaching contraceptive issues.

“This is a critical time to discuss with patients pregnancy planning and medication contraindications in pregnancy because, invariably, some of these patients could wind up getting pregnant” unintentionally.

“Physicians may have the patient go off the pill in order to observe the migraine pattern over time. However, the migraine pattern may not improve for at least 3-6 months. In such cases, it's essential to talk about pregnancy issues if the patient is on the pill for contraceptive purposes,” she said.

SCOTTSDALE, ARIZ. — Fluctuating hormones are believed to be the key culprit behind menstrual migraines, so low-dose monophasic oral contraceptives are generally the best alternative to help such patients, Christine Lay, M.D., said at a symposium sponsored by the American Headache Society.

Physicians often turn to biphasic contraception instead of monophasic pills in the belief that varying the hormone dosage will help alleviate menstrual migraines, but the dosage schedule can in fact make the problem worse, said Dr. Lay, a neurologist with the Headache Institute at Roosevelt Hospital, New York.

Dr. Lay gave the example of Mircette, which contains 21 days of 0.15-mg desogestrel/0.02-mg ethinyl estradiol, followed by 2 days of placebo pills and 5 days of 0.01-mg ethinyl estradiol. She noted that numerous physicians prescribe Mircette thinking it might help patient's menstrually related migraines.

Instead, the method introduces another level of fluctuation of estrogen, and it is that fluctuation that is believed to trigger the migraines in the first place, said Dr. Lay. “It's not whether the estrogen is present or absent, but [it's] the change in estrogen and I find many patients don't do well on Mircette because of fluctuations in estrogen.”

Even worse for menstrual migraines are triphasic pills, which cause greater fluctuation in hormone levels and often are high-dose pills, Dr. Lay said.

“The triphasic pills are the worst for migraine patients,” she said. “Invariably, you will have a patient track her calendar and over a month's period of time she will report that within a day or two of switching to a new dose of pill, the woman will experience a migraine attack.”

Migraine patients generally fare much better when using monophasic low-dose (20-mcg) birth control pills, which offer a more uniform hormone level, Dr. Lay said. She added that the estrogen patch is another effective way of providing a more steady level of estrogen.

Newer noncycling methods such as Seasonale (ethinyl estradiol and levonorgestrel) are also good alternatives for migraineurs, she said. “With a 91-day regimen, including 84 days of real pills and then the placebo pills, women skip perhaps three out of every four menstrual migraine attacks, because they're not having a menstrual cycle,” Dr. Lay said in an interview.

Estrogen use in patients who suffered from migraines was frowned upon for many years, but the International Headache Society Task Force on Combined Oral Contraceptives and HRT determined more recently that it was safe for migraineurs, provided that there are no other risk factors for coronary heart disease or vascular disease.

In addition, the migraine should be without aura and patients should be given the lowest effective hormone dose.

In the ebb and flow of hormone levels, it is the withdrawal of estrogen, specifically, that experts believe contributes to menstrual migraines. The withdrawal is believed not only to affect trigeminal pain pathways and have vasculature effects, but it may modulate neurotransmitters and magnesium, Dr. Lay said at the meeting.

The release of prostaglandin also plays a role in migraines, sensitizing peripheral nociceptors to pain and mediating hyperalgesia, and prostaglandin is known to increase during migraine attacks.

A key approach to treatment is having patients maintain a diary in which they track their menses and headache days, Dr. Lay said. The journal can help guide treatment options and determine the role of oral contraceptive use.

Since menstrual migraines can occur in young, otherwise healthy women, Dr. Lay strongly recommended using caution in approaching contraceptive issues.

“This is a critical time to discuss with patients pregnancy planning and medication contraindications in pregnancy because, invariably, some of these patients could wind up getting pregnant” unintentionally.

“Physicians may have the patient go off the pill in order to observe the migraine pattern over time. However, the migraine pattern may not improve for at least 3-6 months. In such cases, it's essential to talk about pregnancy issues if the patient is on the pill for contraceptive purposes,” she said.