Sudden Onset of Vestibular Migraine Complicated with BPPV and Mal de Debarquement Syndrome – a Diagnostic Dilemma

Vestibular migraine is combination of migraine and vestibular symptoms. In clinical examination it can be replaced with benign paroxysmal positional vertigo (BPPV) cupulolithiasis, but also BPPV is common comorbidity in migraine patients. There is also high association between vestibular migraine and Mal de Debarquement syndrome. Patient came to hospital with vertigo that was diagnosed as left PC-BPPV canalolithiasis. After first Epley's maneuver symptoms didn't resolved. Week after, at second Epley's maneuver performed patient developed left PC-BPPV cupulolithiasis. Month after, at third Epley's maneuver BPPV resolved but patient developed Mal de Debarquement syndrome. Laboratory testing showed hyperhomocisteinemia and homozygous MTHFR C677T and PAI, with low vitamin D. After reviewing the vestibular symptoms in the first attack which was misdiagnosed as BPPV canalolithiasis, and history of migraine, patient was diagnosed with vestibular migraine. Patient well responded to migraine diet and supplementation with B complex. Vestibular disorders are similar to each other and they can overlap. More attention in taking detailed medical history should be given to patients with vertigo or dizziness.

Treatment of noncognitive neuropsychiatric disorders in Alzheimer's disease

Alzheimer's disease (AD) is the most common neurodegenerative disease, which is caused by cerebral amyloidosis. Noncognitive neuropsychiatric disorders (NСNPDs) include emotional, behavioral disorders, as well as psychotic symptoms. NСNPDs are almost an obligatory manifestation of this disease, accompany cognitive impairment and are detected at all stages of the disease – from preclinical to the severe dementia stage. As an example, we present a case report of a female patient with mild dementia in AD in whom Akatinol memantine administration resulted in the stabilization of a cognitive defect within one year and a decrease in the severity of emotional and behavioral disorders. The article discusses the indications and contraindications for antipsychotic administration in this disease, NСNPDs treatment in AD, which includes nonpharmacological and pharmacological methods. Accurate analysis of NСNPDs allows to predict the disease course, optimize the treatment, and thereby improve the quality of life of the patient and his relatives and caregivers.

Migraine in children and adolescents: modern principles of diagnostics and treatment

Migraine is a nervous system disorder that affects 7.7% of children and can debut before the age of 3 years. As they get older, the incidence of migraine increases, and among adolescents, its prevalence reaches 15%. The disease can significantly reduce the child's daily activity, school performance. Migraine is the most common cause of headache in children and adolescents, but it is not always diagnosed; it is not uncommon for patients with migraine to be misdiagnosed and given ineffective treatment. An effective approach to the diagnosis of migraine in children is presented, diagnostic criteria for migraine according to the 3rd edition of International Classification of Headache Disorders are described. Special disorders in childhood are described – episodic syndromes in children associated with migraine. Migraine treatment in children includes four main approaches: 1) lifestyle recommendations; 2) migraine attack treatment; 3) nonpharmacological treatment; 4) migraine preventive pharmacotherapy. All of the listed approaches for the treatment of migraine in childhood are discussed in detail.

Post-release of the symposium «How to Deal with Pain in the 21st Century? Expert Opinions» (November 8, 2021, XII Interdisciplinary International Congress «Manage Pain»)

The article presents the chronology of the symposium «How to Deal with Pain in the 21st Century? Experts' opinions», which took place on November 8 during the XII interdisciplinary international congress «Manage Pain». The lectures discussed issues of non-steroidal anti-inflammatory drugs (NSAIDs), including etoricoxib (Atorika tabs), administration on the example of a clinical case, problems of terminology associated with the concepts of «lumbago» and «sciatica», rare clinical syndromes (for example, heavy-purse syndrome) that we need to differentiate nonspecific back pain with, strategies for choosing NSAIDs in patients with osteoarthritis, the importance of timely administration of NSAIDs in the prevention of chronic pain syndromes, the influence of emotional and cognitive factors on the back pain chronization. The benefits of etoricoxib (Atorika) in the treatment of chronic back pain were reviewed, as well as the evidence for its safety.

Meloxicam efficacy and safety in treatment of pain syndromes of different localization according to domestic studies

More than 500 million people worldwide suffer from osteoarthritis (OA). Neck and low back pain (LBP) is one of the most common reasons for visiting a general practitioner to receive primary medical care in different countries. The prevalence of chronic LBP varies from 4% to 20%, and increases linearly from the third decade to 60 years, and stabilizes in the seventh decade of life. According to the latest published clinical guidelines of the Russian Association for the Study of Pain, nonsteroidal anti-inflammatory drugs (NSAIDs) are used in minimally effective doses and a short course to relieve acute musculoskeletal pain. The ratio of the NSAIDs activity associated with cyclooxygenase (COX) – COX-1 / COX-2 – inhibition allows us to evaluate their potential toxicity. The smaller this value, the more selective the drug is against COX-2, and the less toxic it is. Meloxicam belongs to the predominantly selective COX-2 inhibitors. In the Russian market, meloxicam of domestic production - Amelotex® is widely prescribed. Several studies have shown the high efficacy and safety of meloxicam in the treatment of pain syndromes with different localizations (LBP, neck pain of vertebrogenic nature, OA, etc.), it can be recommended for elderly patients, patients with comorbid diseases such as arterial hypertension (AH), diabetes mellitus, gastrointestinal tract pathology. Meloxicam has a good efficacy and safety profile, a pronounced symptom-modifying effect.

Novel approaches to the treatment of cervical dystonia. The concept of dual navigation control

Сervical dystonia (CD) is the most common type of focal dystonia (up to 50% of all dystonia cases). Botulinum neurotoxin (BoNT) injections is the treatment choice for CD. However, the effectiveness and tolerability of botulinum therapy in CD depends on the correct choice of target muscles and the accuracy of the BoNT injection. The publication presents literature data and our own clinical experience regarding the use of navigation in BoNT injections in CD.According to the majority of authors, the use of navigation equipment, such as ultrasound (US) and electromyography (EMG), definitely increases the effectiveness of CD treatment and reduces the likelihood of adverse events. For the first time, an algorithm for the diagnosis and treatment of CD is proposed, based on the use of the method of «double- (EMG and US) guided navigation», a variant for determining the comparative activity of muscles by the intensity of the EMG signal and the design of an individual «passport» of the CD. The possibilities of analyzing the US of muscles, drawing up an accurate treatment regimen, targeted administration of BoNT, and using a non-injectable EMG electrode are shown. We present 4 clinical cases demonstrating the advantages of the double- (EMG+US) guided navigation method over the EMG-guided navigation for injection. The proposed algorithm for the diagnosis and treatment of CD makes it possible to increase the effectiveness of treatment, optimize the costs of BoNT and diagnostic equipment (injection EMG needle).

New in understanding the burden of migraine: semantic analysis of the voice of Russian patients – users of Web 2.0

Migraine is the second leading cause of maladjustment, and the burden of migraine is determined by its impact on work ability, social activity and family relationships.Objective: to identify the patterns of behavior of Russian patients with migraine, factors affecting their quality of life, and the level of awareness of the disease based on a semantic analysis of messages in Web 2.0.Patients and methods. The study is based on the results of semantic processing (automated analysis of natural language texts, taking into account their meaning) of anonymized messages from 6566 unique authors (patients and their relatives) from social networks and forums (over 73 thousand messages over 10 years, 2010–2020). In addition, the study was carried out exclusively according to the data indicated in the messages. In this regard, complete data for several parameters was not available for analysis. No personal data about the authors of the messages was collected or used. The sex was determined based on the text of the analyzed message. For the study, only open data from the Internet from social networks and forums was used.Results and discussion. A landscape of problems of persons complaining of migraine issues was formed. Factors affecting the quality of life were grouped into four main groups (“Lifestyle restrictions by triggers of migraine attacks”, “Loss of opportunity to work”, “Serious psychological problems”, “Family planning issues”); additional, rarer, but acute problems were also identified. The analyzed messages show that the average number of days with migraines is 9.4 per month; 21.8% of patients report daily migraines. Moreover, most patients have been suffering from attacks for 10 years or more, and 9% of patients – for 30 years or more. The analysis of diagnostic patterns showed that in most cases, patients independently resorted to additional examination methods, while only 13.1% of patients had experience of adequate preventive therapy.Conclusion. The study demonstrated the presence of a wide range of unmet needs, quality of life problems both in patients themselves and their caregivers, as well as a significant social and economic burden of this disease (including a long-term burden on the economy, which can be used as arguments for reimbursing the cost of migraine therapy) based on the text messages on migraine in open sources on the Internet.

Changes in retinal structures as markers of multiple sclerosis progression

The involvement of the visual pathway in multiple sclerosis (MS) pathology determines the importance of studying the structures of the retina for earlier diagnosis and monitoring the severity of the neurodegeneration. The introduction of the reference method of optical coherence tomography (OCT) allows high resolution in vivo visualization of the retinal structures.Objective: to identify changes in various retinal structures in remitting (RMS) and secondary-progressive (SPMS) MS phenotypes.Patients and methods. The study included 80 patients with RMS (n=48) and SPMS (n=32); the control group included 20 age- and sex-adjusted healthy individuals. Clinical assessment was carried out using the Expanded Disability Status Scale (EDSS) and the Multiple Sclerosis Severity Score (MSSS). All patients were examined by an ophthalmologist. To assess changes in the retina, OCT was performed using the RTVue XR Avanti apparatus (Optovue, USA).Results and discussion. We found a significant (p<0.001) decrease in the thickness of the retina of the foveal and parafoveal regions, the thickness of the ganglionic cell complex when comparing the parameters of the retina of the control group and patients with RMS. There was also a significant (p<0.01) decrease in the retinal thickness in the perifoveal region, the thickness of the layer of retinal nerve fibers, the magnitude of focal and global losses. During comparation of the retinal OCT data between patients with RMS and SPMS, we revealed significant differences (p<0.001) in the thickness of the retinal nerve fiber layer, the retinal thickness in the parafoveal and foveal regions, and a significant (p<0.01) decrease in the thickness of the peripheral region, the thickness of the ganglionic cell complex, the volume of focal and global losses. Assessment of the correlations of OCT parameters with the EDSS and MSSS scales in both phenotypes showed a single significant (p<0.05) strong negative correlation (r=-0.70) of the EDSS score and retinal thickness in the foveal region in patients with SPMS.Conclusion. As a domain of criteria for the MS course without signs of disease activity (No Evidence of Disease Activity, NEDA), it is advisable to use retinal OCT with analysis of the retinal thickness in the foveal region, the thickness of the retinal nerve fiber layer, the ganglion cell complex for dynamic monitoring of the inflammatory process activity in patients with RMS and assessment of its progression in patients with SPMS.

Drug-induced parkinsonism

Drug-induced parkinsonism (DIP) is the most common drug-induced movement disorder and is most commonly associated with antipsychotic drugs, monoamine reuptake inhibitors, and calcium channel blockers. DIP manifests as a typical movement disorder, which makes it practically indistinguishable from idiopathic Parkinson's disease (PD) and requires differential diagnosis. DIP symptoms develop fairly quickly (hours to weeks) after the antipsychotic is started or after the dose is increased. Therefore, DIP is predominantly a clinical diagnosis that must be kept in mind when a patient develops typical symptoms during treatment onset or increasing the dose of drugs that most often lead to such an adverse reaction (ADR). DIP evaluation includes using the Naranjo algorithm, which helps assess a causal relationship between drug intake and the development of parkinsonism symptoms. The primary DIP treatment is the reduction of the dose of the inducer drug, or its cancellation, or replacement with another drug. In patients with schizophrenia and antipsychotic-induced DIP, dose reduction, replacement with another medication, or prescription of a drug with anticholinergic activity may be possible. The awareness of the doctor and the patient about the possibility of developing this ADR is crucial in the prevention of DIP. Therefore, choosing a drug with the lowest risk of developing DIP is necessary for pharmacotherapy.