Defining Refractory Migraine: Results of the RHSIS Survey of American Headache Society Members

To gauge consensus regarding a proposed definition for refractory migraine proposed by Refractory Headache Special Interest Section, and where its use would be most appropriate. Background.— Headache experts have long recognized that a subgroup of headache sufferers remains refractory to treatment. Although different groups have proposed criteria to define refractory migraine, the definition remains controversial. The Refractory Headache Special Interest Section of the American Headache Society developed a definition through a consensus process, assisted by a literature review and initial membership survey. Design.— A 12-item questionnaire was distributed at the American Headache Society meeting in 2007 during a platform session and at the Refractory Headache Special Interest Section symposium. The same questionnaire was subsequently sent to all American Headache Society members via e-mail. A total of 151 responses from AHS members form the basis of this report. The survey instrument was designed using Survey Monkey. Frequencies and percentages of the survey were used to describe survey responses. Results.— American Headache Society members agreed that a definition for refractory migraine is needed (91%) that it should be added to the International Classification of Headache Disorders-2 (86%), and that refractory forms of non-migraine headache disorders should be defined (87%). Responders believed a refractory migraine definition would be of greatest value in selecting patients for clinical drug trials. The current refractory migraine definition requires a diagnosis of migraine, interference with function or quality of life despite modification of lifestyle factors, and adequate trials of acute and preventive medicines with established efficacy. The proposed criteria for the refractory migraine definition require failing 2 preventive medications to meet the threshold for failure. Although 42% of respondents agreed with the working definition of refractory migraine, 43% favored increasing the number to 3 (50%) or 4 (26%) preventive treatment failures. When respondents were asked if they felt that the proposed definition was appropriate to select patients for invasive procedures (patent foramen ovale repair or stimulators) only 44% agreed. Conclusions.— There is a consensus for a need for a definition for refractory migraine and that it should be added to the International Classification of Headache Disorder-2. There was also general agreement by the responders that refractory forms of non-migraine headache disorders should be defined.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/72860/1/j.1526-4610.2009.01370.x.pd

Brachial neuropathy after brachial artery-antecubital vein shunts for chronic hemodialysis

Peripheral mononeuropathies may complicate distal arteriovenous fistulas for chronic renal dialysis. We observed three diabetic patients who developed pain, paresthesias, and weakness in the distribution of the median, ulnar, and radial nerves shortly after construction of proximal brachial artery-antecubital vein fistulas. EMG confirmed multiple distal nerve injuries. All three patients improved after shunt banding or ligation. Twenty additional patients with proximal shunts were examined for risk factors for brachial neuropathy. Although all patients had severe atherosclerosis and many had polyneuropathy, we identified no predictive risk factors other than diabetes

Defining Refractory Migraine and Refractory Chronic Migraine: Proposed Criteria From the Refractory Headache Special Interest Section of the American Headache Society

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/74368/1/j.1526-4610.2008.01132.x.pd