Walking Protects Women Against Stroke: WHS Long-Term Follow-Up
Pam Harrison, Hien T. Nghiem, MD

April 13, 2010 Women who walk 2 or more hours a week, especially at a brisk pace, are significantly less likely to experience any type of stroke than women who do not walk, according to long-term follow-up findings from the Women's Health Study (WHS).

Findings were published online April 6 and will appear in the June issue of Stroke. Jacob Sattelmair, MSc, Harvard School of Public Health, Boston, Massachusetts, found that during an average follow-up of 11.9 years, walking time and walking pace were inversely related, either significantly or with borderline significance, to total, ischemic, and hemorrhagic stroke risk among 39,315 healthy US women 45 years and older who participated in the WHS.

Specifically, women who walked 2 hours or more per week had a 30% lower risk for any stroke than women who did not walk, whereas women whose usual walking pace was brisk (> 4.8 km/hour) had a 37% lower risk for any stroke compared with women who did not walk.

Women who walked 2 hours or more per week also had a 57% lower risk for hemorrhagic stroke compared with women who did not walk, whereas women whose usual walking pace exceeded 4.8 km/hour had a 68% lower risk for hemorrhagic stroke than women who did not walk.

Interesting, vigorous physical activity was not related to stroke risk in the same study. There was an inverse association between total leisure-time physical activity and risk for total and ischemic stroke, but the association was of borderline significance. Nevertheless, women who were most active in leisure-time activities were 17% less likely to have any type of stroke than the least active women.

"This was a cohort of female health professionals, predominantly white, so they may not be representative of all middle-aged women in the US, but there really is no obvious reason to suggest that findings would necessarily be different in other populations," Mr. Sattelmair told Medscape Neurology. "I think the overall take-home in terms of stroke prevention is that regular physical activity is essential to minimize the risk of cardiovascular disease."

Observational Study
On scheduled completion of the WHS in March 2004, women participating were invited to continue in a follow-up observational study; 88% of the WHS cohort who were still alive did. At baseline, women were asked to estimate the average time spent on 8 groups of recreational activities during the past year: walking or hiking; jogging; running; bicycling; aerobic exercise; aerobic dance; use of exercise machines; tennis, squash, or racquetball; lap swimming; and lower-intensity exercise, including yoga.

"They also reported their usual walking pace," the investigators added. The cohort was stratified into those who do not walk regularly and those who walk at a pace of less than 3.2 km/hour, 3.2 to 4.7 km/hour (considered to be an average pace), 4.8 to 6.3 km/hour (considered to be brisk pace), or 6.4 or more km/hour (a striding pace). During follow-up, 579 total strokes occurred: 473 ischemic strokes, 102 hemorrhagic strokes, and 4 strokes of unknown type.

"There was no overall linear trend of decreased risk for total stroke across categories of vigorous activity...and findings for ischemic stroke again mirrored those for total stroke," the investigators observe. Neither age nor body mass index modified the relationship between physical activity and stroke risk.

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Single Dose of Aspirin Effective in Relieving Migraine Pain
Lisa Nainggolan, Charles P. Vega, MD

April 19, 2010 A single 1000-mg dose of aspirin is an effective treatment of acute migraine headaches for more than half of people who take it, and the addition of 10 mg of metoclopramide may reduce nausea, according to the findings of a literature review published online April 14 in the Cochrane Database of Systematic Reviews.

"Aspirin plus metoclopramide would seem to be a good first-line therapy for acute migraine attacks in this population," write Varo Kirthi, MD, and colleagues, with the Pain Research and the Nuffield Department of Anaesthetics at the John Radcliffe Hospital, in Oxford, United Kingdom.

The researchers searched Cochrane CENTRAL, MEDLINE, EMBASE, and the Oxford Pain Relief Database for studies through March 10, 2010. The 13 selected studies, including 4222 participants, were randomized, double-blind, placebocontrolled, or active-controlled; evaluated the use of aspirin to treat a single migraine headache episode; and included at least 10 participants per treatment group. In addition, studies compared aspirin 900 mg or 1000 mg (alone or in combination) and metoclopramide 10 mg vs placebo or other active comparators (typically sumatriptan 50 mg or 100 mg).

Compared with placebo, aspirin reduced associated symptoms of nausea, vomiting, photophobia, and phonophobia. A single 1000-mg dose of aspirin reduced pain from moderate or severe to no pain by 2 hours in 24% of people vs 11% taking placebo. Severe or moderate pain was reduced to no worse than mild pain by 2 hours in 52% taking aspirin vs 32% taking placebo. Headache relief at 2 hours was sustained for 24 hours more often with aspirin vs placebo.

In addition, metoclopramide, when combined with aspirin, significantly reduced nausea (P < .00006) and vomiting (P = .002)vs aspirin alone, although it had minimal effect on pain. Fewer participants taking aspirin needed rescue medication vs those taking placebo. Adverse events were reported more often with aspirin vs placebo but were mostly mild and transient.

The review also found that aspirin alone was comparable to the prescription medication sumatriptan 50 mg for 2-hour pain-free relief and headache relief, whereas sumatriptan 100 mg was superior to aspirin plus metoclopramide for 2-hour pain-free, but not headache, relief; no data comparing sumatriptan with aspirin for 24-hour headache relief were available.

"Aspirin plus metoclopramide will be a reasonable therapy for acute migraine attacks, but for many it will be insufficiently effective," noted study author R. Andrew Moore, DSc, in a written release. "We are presently working on reviews of other OTC [over-the-counter] medicines for migraines, to provide consumers with the best available evidence on treatments that dont need a prescription," he said.

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How to succeed in using dopamine agonists in Parkinson's disease

L. M. Shulman

University of Miami School of Medicine, Miami, Florida, USA

Dopamine receptor agonists are assuming increased importance in the treatment of both early and advanced symptoms of Parkinson's disease (PD). However, tolerability of these drugs can be a problem. Identifying patients who are at increased risk of adverse effects is central to using dopamine agonists in PD. The newer agonists, pramipexole and ropinirole, are generally adequate without levodopa for early symptoms and carry the hope for a more acceptable profile of long-term side-effects. In the patient with advanced disease, all four dopamine agonists significantly augment the response to levodopa, which reduces the problems of motor fluctuations and drug related dyskinesia. Understanding the common pitfalls when prescribing these drugs will facilitate their safety and efficacy.

Keywords: dopamine agonists, Parkinson's disease, Therapy

Introduction
The use of dopamine agonists in patients with Parkinson's disease (PD) can be both challenging and time-consuming, yet dopamine receptor agonists are assuming an ever increasing prominence in the management of PD. It is not an overstatement to say that patients with Parkinson's symptoms will be less optimally managed over the course of their illness if agonists are not added to their regimen. Dopamine agonists have rightfully assumed an important role in the management of symptoms of PD. However, the science behind the use of this class of drugs with precision lags significantly behind the needs of clinical practice. It is desirable to identify PD patients who will benefit from the use of dopamine agonists and specifically at what disease stage maximum benefit can be obtained. These are compelling questions given the cost of these medications, the side-effect profile and the presence of therapeutic alternatives.

With the array of antiparkinsonian medications now available it is essential that these medications be used in the right order, in the right doses and in the right combinations to maximize benefit and minimize both short-term and long-term adverse effects. A sound scientific foundation should guide the choice from the four dopamine agonists currently available. Incomplete scientific knowledge, a combination of fragmentary but tantalizing scientific clues and a growing body of clinical experience allow one to make the best possible therapeutic decisions for patients. Strategies that will assist in the successful use of dopamine agonists in patients with PD are the topic of this paper.

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Migraine Treatment With Rizatriptan and Almotriptan: A Crossover Study

Daisy S. Ng-Mak, PhD; X. H. Hu, MD, PhD; Marcelo Bigal, MD, PhD

Abstract
Background: Rizatriptan and almotriptan are effective and well-tolerated triptans that have not been compared directly.

Objective: To evaluate the effectiveness of rizatriptan 10 mg and almotriptan for the acute treatment of migraine, in a real -world setting.

Methods: Of a large, multicenter, open-label , crossover study, we conducted a substudy to contrast the effectiveness of rizatriptan 10 mg and almotriptan 12.5 mg for the acute treatment of 2 migraine attacks in a sequential, crossover manner. Time to outcome was assessed using stopwatches. Mean and median times to onset of pain relief (PR) and pain freedom (PF) for rizatriptan and almotriptan were compared. The effect of rizatriptan on times to onset of PR and PF, adjusting for potential confounding factors (treatment sequence, treatment order, and use of rescue medication), was computed via a Cox proportional hazard model.

Results: Out of the 146 patients taking almotriptan as their usual care medication, 79 used stopwatch for both attacks. Significantly more patients taking rizatriptan achieved onset of PR within 2 hours after dosing than those taking almotriptan (88.6% vs 73.4%, P = .007). A higher proportion of patients taking rizatriptan achieved PF within 2 hours after dosing than those taking almotriptan (55.7% vs 45.6%, P = .10). Times to onset of PR and PF were significantly shorter with those patients taking rizatriptan than with those taking almotriptan (median time to PR: 45 vs 60 minutes, P = .002; median time to PF: 100 vs 135 minutes, P = .004). The adjusted proportional hazard ratios (rizatriptan vs almotriptan) for times to onset of PR and PF were 1.51 (95% confidence interval 1.20 to 1.88) and 1.42 (95% confidence interval 1.15 to 1.76), respectively. More patients were very satisfied when treating their attacks with rizatriptan than with almotriptan. Rizatriptan was preferred by most patients.

Conclusions: Times to achieve PR and PF were significantly shorter for patients using rizatriptan , as compared with those using almotriptan.

Introduction
A wide range of medications are available for the acute treatment of migraine, including both nonmigraine-specific and migraine -specific medications .[1] Among available acute migraine medications , triptans are considered to be the class of choice for patients with attack-related disability.[2,3] The efficacy and safety of triptans have been demonstrated by numerous randomized, placebo-controlled trials ,[4- 7] but few studies have contrasted triptans in head-to-head clinical trials , and most of these studies used sumatriptan as the comparator (eg,[8-10 ]).

Comparative efficacy evidence among oral triptans is scant.[11- 13] The most cited source for comparisons is a large meta-analysis that includes 53 clinical controlled triptan trials . Among its conclusions, it was found that almotriptan 12.5 mg, eletriptan 80 mg, and rizatriptan 10 mg were among the most effective triptans, as measured by 2-hour pain relief (PR).[14 ] Echoing the meta-analysis, Goadsby et al reported that almotriptan 12.5 mg , eletriptan 80 mg , and rizatriptan 10 mg were the top choices for migraine treatment. [15 ] It was suggested that rizatriptan is associated with a better clinical efficacy, while almotriptan is associated with better tolerability.

Despite the differing attributes presented by the various triptans, the relative importance of these attributes from the perspective of the migraine sufferer is not well known. Large randomized clinical trials (RCTs), while helpful , may not capture the clinical nuances that determine patient preferences for medications. For example, it is unknown whether patients' preference for triptans follows a consistent or random pattern. Similarly, it is unknown whether patients' preferences are
reflected in the outcomes measured by clinical trials.[16] Although rizatriptan and almotriptan have never been compared in RCTs, other types of contrasts have been performed . For example, a pharmacy prescription study[17 ] found that more patients treated with rizatriptan 10 mg, compared with almotriptan 12.5 mg , used only 1 tablet for acute migraine treatment (78% vs 58%) and, on average, consumed fewer tablets per attack (1.19 vs 1 .43). In contrast, using the patient's preference as the primary outcome variable, a recent randomized, open-label, crossover clinical trial reported that 9% more patients preferred almotriptan 12.5 mg over rizatriptan 10 mg; [18 ] however , the difference was not found to be statistically significant.

As direct , head-to-head comparisons between rizatriptan and almotriptan have not been performed, and results from observational studies differed, herein we conducted analysis from a large study where patients used rizatriptan 10 mg or almotriptan 12.5 mg in a real-life situation (treating as usual), to measure patients' preference as a function of treatment attributes .

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Obesity and Migraine: The Effect of Age, Gender and Adipose Tissue Distribution

B. Lee Peterlin, DO; Andrea L. Rosso, MPH; Alan M. Rapoport , MD; Ann I. Scher, PhD

Abstract
Objective.To evaluate the prevalence of migraine/severe headaches in those with and without general obesity and abdominal obesity (Abd-O) and the effect of gender and age on this relationship.

Background.General, or total body obesity (TBO), as estimated by body mass index, is a risk factor for migraine chronification. However, there are conflicting data as to whether TBO is associated with migraine prevalence. Abd-O has been shown to be a better predictor of various disease states than TBO, but has not been evaluated in general population studies in association with migraine .

Methods.Data from a general population survey, the National Health and Nutrition Examination Survey, were used to obtain demographics, self-report of migraine/severe headaches and measured body mass indices, including height, weight, and waist circumference. All analyses were stratified by age and gender and multivariate analyses were determined through use of logistic regression models.

Results.A total of 21,783 participants were included in the analysis . Between 2055 years of age, the prevalence of migraine was increased in both men and women with TBO as compared with those without, (P.001). Migraine was also more prevalent in those with Abd-O as compared with those without (men: 20.1% vs 15.9%, P<.001; women: 36.9% vs 28.8 .2%, P<.001). After 55 years of age, the prevalence of migraine in men was no longer associated with either TBO or Abd-O. Similarly, after 55 years of age, the prevalence of migraine in women was no longer associated with TBO. However, in women older than 55 years, the prevalence of migraine was decreased in those with Abd-O as compared with those without Abd-O (14.4% vs 17.4%, P<.05). After adjusting for demographics, cardiovascular risk factors and Abd-O, results were similar for the association between migraine prevalence and TBO in both younger and older men and women. After adjusting for demographics, cardiovascular risk factors and TBO, migraine prevalence was no longer associated with Abd-O in younger men, but remained associated with an increased odds ratio of having migraine in younger women, as well as a decreased odds ratio in older women. Conclusion.The relationship between migraine and obesity varies by age, gender, and adipose tissue distribution (eg, TBO vs Abd-O). In men and women 55 years old,migraine prevalence is increased in those with TBO, independent of Abd-O. In addition, in men and women 55 years old , migraine prevalence is increased in those with Abd-O; and in women this association is independent of TBO. In men older than 55 years , migraine is not associated with either TBO or Abd-O. However, in women older than 55 years , migraine prevalence is decreased in those with Abd-O and is independent of TBO.

Introduction
Migraine is a common and often disabling disorder that occurs more commonly in adult women than men of all ages. Migraine or probable migraine has been estimated to occur in 34.5% of adult women and 20.1% of adult men in the general population. [1] The relationship between migraine or other headache disorders and markers ofcardiovascular disease has been a focus of research interest in recent years. [2] In particular, general obesity or total body obesity (TBO), as
estimated by the body mass index (BMI), has been shown to be related to headache disorders in several clinical and epidemiologic studies.[39] However, there is considerable uncertainty about the nature of the obesity/headache relationship and whether it is specific to migraine, or chronic daily headache, or headache in general.

In a general population study in 2003, individuals with TBO and episodic headache were shown to be at an increased risk of incident chronic daily headache over a 1-year period relative to those without TBO (odds ratio [OR] = 5.3 [1 .4 21.8] ).[3] Yet data relating obesity and episodic migraine have been conflicting. Two clinic-based studies suggested that migraine occurs with a higher relative frequency in those with TBO than those without TBO.[4,5] However, 2 general population-based studies of adults did not find a relationship between migraine and TBO.[6,7] A third study found an association between TBO and headache but not self-reported migraine .[8] Finally, a recent general population study found that TBO was associated with the prevalence of migraine or severe headaches. [9]

Several factors may contribute to these conflicting reports. First, all but one[9] of the prior studies evaluating migraine prevalence and obesity estimated BMI based on self-reported height and weight . Multiple studies in various disorders have shown that BMI is commonly underestimated when self-reported as compared with when it is measured, including in migraineurs .[10 13 ] This measurement error might obscure the true relationship between migraine and obesity if it is differential.

Second, the degree to which anthropometric measurements (such as the BMI and waist circumference [WC]) correlate with adipose tissue mass vs lean body mass varies by both age and gender.[8,12 15] Specifically, aging has been shown to be associated with a progressive increase in the ratio between fat and lean body mass even in those who manage to maintain a constant BMI as they become older. Thus, the degree to which BMI is proxy measurement for total body fat is age-dependent.[1315 ] In addition, adipose tissue distribution patterns are different in women and men, with younger women having more adipose tissue depots in a gluteo-femoral distribution than abdominally, while men of all ages and older women have more abdominal adipose tissue depots then young women.[1618 ]

Third, multiple studies in various disorders , including cardiovascular disease and diabetes, have shown that abdominal obesity (Abd-O) may be a better predictor than general /TBO, as estimated by BMI, for disease risk and all-cause mortality.[18 20 ] Furthermore, although Abd-O is generally present in those with TBO, the presence of Abd-O does not necessitate the presence of TBO. For example , in 20032004, it was estimated that 31% of men and 33% of women in the United States were obese by BMI; however , 42% of men and 61% of women in the United States were estimated to have Abd-O.[18] Notably, one clinic-based study has suggested that Abd-O is a risk factor for chronic daily headache in women. [21 ]

In the present study, we further explore the relationship between migraine and obesity, examining separately the effects of TBO and Abd-O. We hypothesize that migraine prevalence is associated with TBO and Abd-O in an age and gender-dependent manner, and that the association with Abd-O is independent of TBO.

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Modern Management of the Migraine Headache

Kimberly A. Pesaturo, PharmD; Fae G. Wooding, PharmD

Abstract
Migraine headache is a debilitating disorder that affects millions of people in the United States and worldwide. The diagnosis of migraine can significantly affect quality of life, health care costs, and daily productivity. Hundreds of trials and many guidelines have documented various approaches to migraine management, whether via acute treatment or chronic migraine prophylaxis. Acute or abortive migraine managementencompasses specific and nonspecific migraine therapeutics, including nonopioid and opioid analgesics, triptans, and ergotamines. Prophylactic migraine management data span the pharmacological spectrum from antiepileptic and antihypertensive agents to botulinum toxin type A. Special considerations for migraine management also must be applied in various populations, including children, pregnant women, and the elderly. The following review serves as an introduction to current therapeutic approaches for acute migraine treatment and provides an overview of available literature for pharmacological prophylaxis.

Introduction
Over the past 2 decades, an increase in migraine awareness has resulted in the introduction of new pharmacological treatment agents as well as additional indications and data on existing medications for prophylaxis. Migraine is defined as a unilateral headache with pulsating pain of a moderate to severe intensity, often accompanied by photophobia, phonophobia, and/or nausea, and may occur with or without aura.[1] The headaches exhibit a recurrent pattern and can
significantly affect activities of daily living. Approximately 30 million people in the United States suffer from migraines, with 18% of women and 6% of men experiencing at least 1 migraine headache annually. [1]

Because of its significant impact on quality of life and interpatient variability in treatment response, migraine management remains challenging for many health care professionals. Migraine has a significant societal burden resulting in costly medical bills and lost productivity, averaging about 64 to 150 million work days lost each year.[2,3] Consequently , migraine headache has been classified by the World Health Organization as one of the 19 most disabling diseases worldwide .[4] Migraine prevalence varies by age, sex, and ethnicity with the highest prevalence in whites, followed by African Americans and then Asians.[5] In the United States, the prevalence of migraine headache decreases as household income increases.[6] Although hundreds of clinical trials are available regarding migraine treatment modalities, this review serves as an introduction to current accepted therapeutics for migraine treatment and an overview of pharmacological prophylaxis in the modern management of migraine.

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Effectiveness of an Intensive Multidisciplinary Headache Treatment Program
Birgit Gunreben-Stempfle, MS; Norbert Grießinger, MD; Eberhard Lang, MD; Barbara Muehlhans, MS; Reinhard Sittl, MD; Kathrin Ulrich, MD

ABSTRACT

Objective.To investigate if the effectiveness of a 96-hour multidisciplinary headache treatment program exceeds the effectiveness of a 20-hour program and primary care.

Background.When dealing with chronic back pain, low-intensity multidisciplinary treatment yields no significantly better results than standard care and monodisciplinary therapy ; however , high-intensity treatment does. For multidisciplinary headache treatment, such comparisons are not yet available. In a previous study undertaken by our Pain Center, the outcome of a minimal multidisciplinary intervention model (20-hour) did not exceed primary care.

Methods.Forty-two patients suffering from frequent headaches (20 ± 9 headache days/month; range: 8 30) were treated and evaluated in a 96-hour group program. The results were compared with the outcomes of the previous study. Subjects who had undergone either the 20-hour multidisciplinary program or the primary care were used as historical control groups.

Findings.A significant reduction in migraine days (P < .001), tension-type headache days (P < .001), frequency of migraine attacks (P = .004), and depression score (P < .001) was seen at the follow-up after 22 (±2) weeks. Comparing the intensive multidisciplinary program with primary care, repeated measures ANOVAs revealed significant time ×group interactions for migraine days (P = .020), tension -type headache days (P = .016), and frequency of migraine attacks (P = .016). In comparison with the 20-hour multidisciplinary program, the 96-hour program showed significantly better effects only in the reduction of migraine days (P = .037) and depression score (P = .003). The responder-rates (50% improvement) in the 96-hour program were significantly higher than in the 20-hour program (migraine days, P = .008; tension -type headache days, P = .044) and primary care (migraine days, P = .007; tension -type headache days, P = .003; tension -type headache intensity, P = .037). The effect sizes were small to medium in the 96-hour program. Particularly with the reduction of migraine symptomatology , the 96-hour program performed better than the 20-hour program, which produced only negligible or small effects.

Conclusions.Intensive multidisciplinary headache treatment is highly effective for patients with chronic headaches. Furthermore, migraine symptomatology responds especially well to this intensive treatment program, whereaseffects on tension -type headaches were realized by both multidisciplinary programs. Randomized controlled trials and subgroup analysis are needed to find out if these results can be replicated and which patient characteristics allow for sufficient improvements for headache sufferers even with less complex treatment.

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DEXAMETHASONE IN ADULTS WITH BACTERIAL MENINGITIS

JAN DE GANS, PH.D., AND DIEDERIK VAN DE BEEK, M.D., FOR THE EUROPEAN DEXAMETHASONE IN ADULTHOOD BACTERIAL MENINGITIS STUDY INVESTIGATORS

ABSTRACT
Background
Mortality and morbidity rates are high among adults with acute bacterial meningitis, especially those with pneumococcal meningitis. In studies of bacterial meningitis in animals, adjuvant treatment with corticosteroids has beneficial effects.

Methods
We conducted a prospective, randomized, double-blind, multicenter trial of adjuvant treatment
with dexamethasone, as compared with placebo, in adults with acute bacterial meningitis. Dexamethasone (10 mg) or placebo was administered 15 to 20 minutes before or with the first dose of antibiotic and was given every 6 hours for four days. The primary outcome measure was the score on the Glasgow Outcome Scale at eight weeks (a score of 5, indicating a favorable outcome, vs. a score of 1 to 4, indicating an unfavorable outcome). A subgroup analysis according to the causative organism was performed. Analyses were performed on an intention-to-treat basis.

Results
A total of 301 patients were randomly assigned to a treatment group: 157 to the dexamethasone
group and 144 to the placebo group. The baseline characteristics of the two groups were similar.
Treatment with dexamethasone was associated with a reduction in the risk of an unfavorable outcome (relative risk, 0.59; 95 percent confidence interval, 0.37 to 0.94; P=0.03). Treatment with dexamethasone was also associated with a reduction in mortality (relative risk of death, 0.48; 95 percent confidence interval, 0.24 to 0.96; P=0.04). Among the patients with pneumococcal meningitis, there were unfavorable outcomes in 26 percent of the dexamethasone group, as compared with 52 percent of the placebo group (relative risk, 0.50; 95 percent confidence interval, 0.30 to 0.83; P=0.006). Gastrointestinal bleeding occurred in two patients in the dexamethasone group and in five patients in the placebo group.

Conclusions
Early treatment with dexamethasone improves the outcome in adults with acute bacterial meningitis and does not increase the risk of gastrointestinal bleeding. (N Engl J Med 2002;347:1549-56.)

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Chronic Tension-type Headache with Vitamin D Deficiency: Casual or Causal Association?

Sanjay Prakash, DM; Nilima D. Shah, MD

Abstract and Introduction
Abstract
The prevalence of tension-type headache andvitamin D deficiency are both very high in the general population. The inter-relations between the two have not been explored in the literature. We report 8 patients with chronic tension-type headache and vitamin D deficiency (osteomalacia). All the patients responded poorly to conventional therapy for tension headache. The headache and osteomalacia of each of the 8 patients responded to vitamin D and calcium supplementation. The improvement in the headache was much earlier than the improvements in the symptom complex of osteomalacia. We also speculate on the possible mechanisms for headache in the patients with vitamin D deficiency.

Introduction
Tension-type headache (TTH) is the most common type of primary headache. It is a featureless headache that is characterized by nothing more than a pain in the head, and is diagnosed mainly by the absence of features described in other types of headache. [1] Because of the lack of disease specific features, several secondary headaches may mimic TTH. [1,2] However, secondary causes of headache are not well described in the literature.

Vitamin D deficiency constitutes a largely unrecognized epidemic in many populations worldwide . A total of 40 100% US and European elderly men and women may have vitamin D deficiency.[3] Vitamin D deficiency is associated with various types of disorders such as musculoskeletal disorder (rickets, osteomalacia, osteoporosis, myopathy), carcinoma (at least 17 carcinomas, such as carcinoma of the breast, prostate, colon, ovary , pancreas, etc), autoimmune disorders (diabetes mellitus, multiple sclerosis, osteoarthritis, rheumatoid arthritis, Crohn's disease, etc), cardiovascular disorders (hypertension, congestive heart failure, myocardial infarction), kidney disorders, psychiatric disorders (depression, schizophrenia), skin disorders (psoriasis), etc.[3,4]

The inter-relations of vitamin D deficiency with headache have not been explored. Here we report 8 patients in whom chronic tension -type headache (CTTH) was associated with vitamin D deficiency.

Case Reports
We observed 8 patients over a period of 1 .5 years . Three patients are described in detail. Written informed consent was taken from the patients to publish this report.

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Cauda Equina Schwannoma Misdiagnosed as Focal Motor Neuron Disease
Bashar Katirji, MD, FACP

A 40-year-old man had a 4-year history of progressive right thigh weakness. Following a neurological consultation and normal magnetic resonance imaging (MRI) of the lumbar spine, the diagnosis of focal motor neuron disease was made. Recently, he required a kneeanklefoot orthosis for ambulation and experienced slight numbness of the right leg. He had no leg or back
pain. Examination showed severe atrophy with no power in the right quadriceps. Thigh adductors and hip flexors were severely weak (able to overcome gravity but no resistance). The right knee jerk was absent. There were no upper motor signs. Sensory examination showed patchy decreased pinprick and touch of the right leg.

Needle electromyography revealed fibrillation potentials and marked decrease of recruitment of motor unit action potentials (MUAPs) in the right quadriceps, thigh adductors, and iliacus muscles. In addition, there were scattered fibrillations and mildimpairment of MUAP recruitment in the right tibialis anterior,medial gastrocnemius and tibialis posterior, and the left quadriceps, thigh adductors, and iliacus. There were no fasciculation potentials and there were no fibrillation potentials in the lumbar paraspinal muscles. On nerve conduction studies, the right femoral motor response was absent and the left was normal, whereas the saphenous, sural, and superficial peroneal sensory responses were normal bilaterally. The electrodiagnostic findings were consistently severe right L3-L4 radiculopathies, but with additional mild right L5 and S1 and left L3-L4 radiculopathies.

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