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Treatment of pediatric migraine is challenging and often not evidence-based. Powers and colleagues randomly assigned 135 children and adolescents with chronic migraine to receive 10 sessions of cognitive behavioral therapy (CBT) or headache education—in combination with amitriptyline, a common prophylactic medication for migraine—and found that CBT plus amitriptyline was superior to headache education plus amitriptyline in reducing headache days and migraine-related disability. In an Editorial, Connelly discusses challenges to implementation of CBT in the treatment of chronic migraine in children and adolescents.
Author Video Interview
Animal studies suggest that mobilization of bone marrow progenitor cells improves perfusion of an ischemic limb. To investigate whether progenitor cell mobilization improves exercise capacity in patients with peripheral artery disease, Poole and colleagues randomly assigned 159 patients with intermittent claudication to receive injections of granulocyte-macrophage colony-stimulating factor (GM-CSF) or placebo for 4 weeks. The authors report that compared with placebo, GM-CSF therapy did not improve peak treadmill walking time at a 3-month follow-up.
Gastroparesis is a challenging syndrome with few evidence-based treatments. Tricyclic antidepressants have been prescribed for gastroparesis based on the hypothesis that gastroparesis-associated nausea and pain arise from neuropathic changes in enteric and sensory nerves. In a randomized, placebo-controlled trial involving 130 patients with moderate to severe idiopathic gastroparesis, Parkman and colleagues found that compared with placebo, treatment with nortriptyline (maximum dose, 75 mg/d) for 15 weeks did not result in improvement in gastroparesis symptoms.
Evidence-based treatment of posttraumatic stress disorder (PTSD) in adolescents is not established. In a randomized trial involving 61 adolescent girls with sexual abuse-related PTSD, Foa and colleagues compared counselor-delivered prolonged exposure therapy—an established PTSD treatment in adults—with supportive counseling. The authors report that PTSD symptom severity improved more with prolonged exposure therapy than with supportive counseling. In an Editorial, Perrin discusses the efficacy of prolonged exposure therapy for adolescents with PTSD.
Continuing Medical Education
Familial amyloid polyneuropathy, a rare and lethal genetic disease, is caused by disassociation and misassembly of tetramers of the thyroxine transport protein transthyretin into amyloid fibrils. In a randomized trial involving 130 patients with familial amyloid polyneuropathy, Berk and colleagues found that compared with placebo, use of diflunisal, a nonsteroidal anti-inflammatory agent that stabilizes transthyretin tetramers and prevents amyloid fibril formation in vitro, reduced the rate of progression of neurological impairment.
A 65-year-old woman with a history of fever, night sweats, fatigue, and weight loss, presents with cognitive deterioration and headache. Laboratory abnormalities include an elevated erythrocyte sedimentation rate, anemia, and elevated serum soluble interleukin 2 receptor, lactate dehydrogenase, and β2 microglobulin levels. Cerebrospinal fluid analysis demonstrates a mildly increased leukocyte count and total protein concentration. Magnetic resonance imaging showed multiple cerebral infarctions, cerebral angiography suggests vasculitis; imaging studies of the chest and abdomen and ophthalmologic evaluation were unremarkable. What would you do next?
Highlights. JAMA. 2013;310(24):2587-2589. doi:10.1001/jama.2013.5481