PRIMERAS JORNADAS FRANCO CHILENAS DE

PRIMERAS JORNADAS FRANCO CHILENAS DE
NEUROLOGIA Valparaiso – Chile 17 y 18 marzo 2006 Dr Claudio Martínez G

Grupo de Cefalea Sonepsyn
CEFALEA Y MEDICINA BASADA EN LA EVIDENCIA: TRATAMIENTOS ALTERNATIVOS Dr. Claudio Martínez G. Hospital San Juan de Dios Clínica Indisa UNAB ¿Qué significa este título? ¿A qué se refiere? Grupo de Cefalea Sonepsyn Dr Claudio Martínez G

Dr Claudio Martínez G

Conventional tablets: Efficacy
Proportion of patients with headache relief after 2 hours (maximum published values) 90 80 Patients (%) 70 60 50 40 30 20 Más del 30% de los pacientes con crisis de migraña no responden al tratamiento farmacológico. Migraine Treatment With Rizatriptan and Non-Triptan Usual Care Medications: A Pharmacy-Based Study . Roger Cady, Headache Vol 44, 9 P900 - October 2004 728 pacientes 693 (95.2%) completaron el diario de tratamiento Rizatriptan (192) y no-triptanes (501) Alivio 30’ post dosis: 25 vs 18% Alivio bien definido 2 hrs post dosis: 71 vs 54% Libre de dolor a las 2 hrs: 32 vs 20% Libre de todo síntoma a las 2 hrs Retorno a la actividad habitual a las 2 hrs: 39 vs 35% Satisfacción con el tratamiento 57 vs 55% (P< .05 en todas las comparaciones excepto retorno a la actividad habitual). ¿Qué hacen ellos? Of the 728 patients who entered the study, 693 (95.2%) completed the treatment diary. Patients treated with rizatriptan (192) and non-triptans (501) reported the following outcomes, respectively onset of headache relief within 30 minutes post-dose: 25% versus 18%; self-defined significant headache relief within 2 hours post-dose: 71% versus 54%; pain free or mild pain at 2 hours post-dose: 58% versus 47%; completely symptom-free within 2 hours of post-dose: 32% versus 20%; return to usual activities within 2 hours post-dose: 39% versus 35%; and satisfied with treatment: 67% versus 55% (P< .05 in all comparisons with exception of returning to usual activities). 10 Sum Sum Nara Zolm Riz 10 Almo Ele 40 100 50 2.5 2.5 12.5 Dowson AJ, Cady RK. Rapid Reference to Migraine, 2002 Dr Claudio Martínez G

Robbins LD, Maides J Headache Clinic Northbrook. Headache May 2003
LONG-TERM EFFICACY OF PREVENTIVE MEDICATIONS FOR Cronic Daily Headache Sólo 46% de los pacientes obtuvieron alivio a largo plazo de medicamentos preventivos. En el largo plazo muchos pacientes discontinúan el tratamiento profiláctico y los estudios de corto plazo pueden sobreestimar el valor de él. *Probablemente sólo para migraña crónica. Para la CCr D, los SSRI y el valproato pueden ser la mejor elección a largo plazo*. Recent data suggest that delay in the treatment of a depressive episode is associated with a more protracted course after therapeutic intervention, and incompletely treated depression frequently is followed by relapse. Interestingly, we now believe the same to be true for migraine. Both disorders may alter the very structure of the brain; unchecked, migraine litters the midbrain with tombstones of iron, whereas chronic depression appears to reduce the volume of the frontal cortex and hippocampus. Robbins LD, Maides J Headache Clinic Northbrook. Headache May 2003 Dr Claudio Martínez G

50% de los que han consultado neurólogo
More than 40% of headache patients have problems managing their headaches, despite receiving advice and treatment from their family doctor, according to a recent study published in Headache Furthermore, almost half of patients who have seen a neurologist for their headaches say they still experience significant headache-related disability. An improvement in headache management, including novel interventions, is called for to improve outcomes for headache sufferers. Dr Claudio Martínez G 50% de los que han consultado neurólogo Informan persistencia e insatisfacción con tratamiento

Richard Lipton, M.D Las barreras para un efectivo diagnóstico y tratamiento de las migrañas están en 2 niveles: La mayoría de las personas no acude al médico por sus cefaleas. Cuando lo hacen, en un % importante la consulta es inefectiva. This is despite that fact that many more people had visited their doctor and talked about their headaches (48 percent in 1999 compared to 16 percent in 1989). (19) These figures lead study author Richard Lipton, M.D., professor of neurology, epidemiology and social medicine at Albert Einstein College of Medicine in New York, to conclude that barriers to effective diagnosis and treatment of migraine exist on two levels: most people don't go to the doctor about their headaches, and even when they do, the medical Dr Claudio Martínez G

Eficacia Tratamiento. Farmacológico de las Migrañas
Más del 30% de los pacientes con crisis de migraña no responden al tratamiento farmacológico.* ¿Qué hacen ellos? * De los que responden probablemente un % pequeño es ordenado, cumple las indicaciones y persevera en un tratamiento efectivo. Más del 30% de los pacientes con cefalea no responden al tratamiento farmacológico. Por esto, y para evitar potenciales efectos adversos, los pacientes comenzaron a adoptar modelos no tradicionales de tratamiento para su cefalea. Recientes estudios han evaluado la utilidad de algunas de estas nuevas opciones como medidas preventivas en migraña. Entre las terapias alternativas se encuentran las conductuales, acupuntura y nutricionales. Dr Claudio Martínez G

Complementary and alternative treatments Kenneth A
Complementary and alternative treatments Kenneth A. Holroyd, PhD; and Alexander Mauskop, MD It is estimated that more than 30% of patients do not respond to pharmacologic interventions for headache. As a result, and to avoid potential side effects, patients have begun seeking nontraditional modes of therapy for the management of headache. Among the alternative therapies are behavioral treatments (relaxation therapy, biofeedback therapy, and cognitive-behavioral therapy), acupuncture, and nutritional therapies (herbal remedies and vitamin or mineral supplementation).. NEUROLOGY 2003;60(Suppl 2):S58–S62 Dr Claudio Martínez G

Why Patients Use Alternative Medicine: Results of a National Study
Astin, John A. PhD From the Stanford Center for Research in Disease Prevention, Stanford University School of Medicine, Palo Alto, Calif. Volume 279(19), 20 May 1998, pp Context: Research both in the United States and abroad suggests that significant numbers of people are involved with various forms of alternative medicine. However, the reasons for such use are, at present, poorly understood Three primary hypotheses were tested. People seek out these alternatives because (1) they are dissatisfied in some way with conventional treatment; (2) they see alternative treatments as offering more personal autonomy and control over health care decisions; and (3) the alternatives are seen as more compatible with the patients' values, worldview, or beliefs regarding the nature and meaning of health and illness. Additional predictor variables explored included demographics and health status. Dr Claudio Martínez G

¿Porqué se busca la medicina “alternativa”, o CAM?
Insatisfacción con el tratamiento convencional.* El tratamiento alternativo ofrece mayor autonomía y control sobre “sus” decisiones de salud. La “CAM” es vista como más compatible con los valores, visión del mundo y creencias acerca de la naturaleza y sentido de la salud y enfermedad. La popularidad de una CAM puede reflejar la ineficacia de un tratamiento. 3. Perkin MR, Pearcy RM, Fraser JS. A comparison of the attitudes shown by general practitioners, hospital doctors, and medical students towards alternative medicine. J R Soc Med. 1994;87: A. Patient preference for nonpharmacologic interventions 1. Dissatisfaction: Patients are dissatisfied with conventional treatment because it has been ineffective, [5,6] has produced adverse effects, [6,7] or is seen as impersonal, too technologically oriented, and/or too costly. [6-15] B. Poor tolerance to specific pharmacologic treatments C. Medical contraindications for specific pharmacologic treatments D. Insufficient or no response to pharmacologic treatment E. Pregnancy, planned pregnancy, or nursing F. History of long-term, frequent, or excessive use of analgesic or acute medications that can aggravate headache problems (or lead to decreased responsiveness to other pharmacotherapies) G. Significant stress or deficient stress-coping skills 2. Need for personal control: Patients seek alternative therapies because they see them as less authoritarian [16] and more empowering and as offering them more personal autonomy and control over their health care decisions. 3. Philosophical congruence: Alternative therapies are attractive because they are seen as more compatible with patients' values, worldview, spiritual/religious philosophy, or beliefs regarding the nature and meaning of health and illness. [19-24] The response rate was 69%.The following variables emerged as predictors of alternative health care use: more education (odds ratio [OR], 1.2; 95% confidence interval [CI], ); poorer health status (OR, 1.3; 95% CI, ); a holistic orientation to health (OR, 1.4; 95% CI, ); having had a transformational experience that changed the person's worldview (OR, 1.8; 95% CI, ); any of the following health problems: anxiety (OR, 3.1; 95% CI, ); back problems (OR, 2.3; 95% CI, ); chronic pain (OR, 2.0; 95% CI, ); urinary tract problems (OR, 2.2; 95% CI, ); and classification in a cultural group identifiable by their commitment to environmentalism, commitment to feminism, and interest in spirituality and personal growth psychology (OR, 2.0; 95% CI, ). Dissatisfaction with conventional medicine did not predict use of alternative medicine. Only 4.4% of those surveyed reported relying primarily on alternative therapies. Complementary therapies and the NHS In the early 20th century, scientific medicine emerged as the dominant model for health care in the West. Yet, despite the successes of scientific medicine, people have continued to seek treatments outside mainstream services.1 In the United Kingdom about one in 10 of the adult population consults a CAM (complementary and alternative medicine) practitioner every year, and 90% of this contact happens outside the NHS.2 Why do people turn to these therapies? Persistent symptoms and the real or perceived adverse effects of conventional treatments are the main reasons.w1 Patients value complementary practitioners viewing their predicament "as a whole" and not through the fragmenting lens of clinical specialisation or within the time pressured environment of primary care.w2 The popularity of a clinical method should not, however, be confused with its value. The popularity of CAM may simply reflect the limitations of conventional treatments. In the past 20 years there has been substantial research on its effectiveness. 34 % of Americans were using at least one type of alternative medicine 425 million visits annually to unconventional providers-40 million more times than visits to primary care physicians. $13.7 billion spent with $10.3 billion coming out of pocket Eisenberg DM, Kessler RC, Foster C. et al. Unconventional Medicine in the United States.NEJM 1993; 328; Dr Claudio Martínez G

Predictores de uso CAM. Astin, John A. PhD JAMA.1998;279:1548-1553
Mayor educación Peor salud Orientación holística en salud. Experiencia de “transformación” que modificó la visión previa (personal) del mundo. Alguno de los siguientes problemas de salud: Ansiedad, Problemas de columna, Dolor crónico, Problemas del tracto urinario y GI. Clasificación en un grupo cultural identificable (grupos ambientalistas, feministas, espirituales o de crecimiento personal). La insatisfacción con la medicina convencional no predice el uso de medicina alternativa. (Sólo 4,4% de los entrevistados confía primariamente en la terapias alternativas). These researchers estimated that Americans made 425 million visits to alternative health care providers in 1990, a Figure that exceeded the number of visits to allopathic primary care physicians during the same period. At present, there is no clear or comprehensive theoretical model to account for the increasing use of alternative forms of health care. Accordingly, the goal of the present study was to develop some tentative explanatory models that might account for this phenomenon. Predictores de uso M.A. more education poorer health status a holistic orientation to health having had a transformational experience that changed the person's worldview any of the following health problems: anxiety back problems chronic pain urinary tract problems and classification in a cultural group identifiable by their commitment to environmentalism, commitment to feminism, and interest in spirituality and personal growth psychology Dissatisfaction with conventional medicine did not predict use of alternative medicine. Only 4.4% of those surveyed reported relying primarily on alternative therapies. Along with being more educated and reporting poorer health status, the majority of alternative medicine users appear to be doing so not so much as a result of being dissatisfied with conventional medicine but largely because they find these health care alternatives to be more congruent with their own values, beliefs, and philosophical orientations toward health and life. JAMA.1998;279: IN 1993 Eisenberg and colleagues [1] reported that 34% of adults in the United States used at least 1 unconventional form of health care (defined as those practices "neither taught widely in U.S. medical schools nor generally available in U.S. hospitals") during the previous year. The most frequently used alternatives to conventional medicine were relaxation techniques, chiropractic, and massage. Although educated, middle-class white persons between the ages of 25 and 49 years were the most likely ones to use alternative medicine, use was not confined to any particular segment of the population. Recent studies in the United States [2] and abroad [3,4] support the prevalent use of alternative health care. For example, a 1994 survey of physicians from a wide array of medical specialties (in Washington State, New Mexico, and Israel) revealed that more than 60% recommended alternative therapies to their patients at least once in the preceding year, while 38% had done so in the previous month. [2] Forty-seven percent of these physicians also reported using alternative therapies themselves, while 23% incorporated them into their practices. Dr Claudio Martínez G

¿Qué tipo de MEDICINA hace Usted?
actice of medicine" to include not only the application of medicine to patients, but any practice of the art of healing disease and preserving the health other than those special branches of the art that were expressly excepted); Ind. Code Ann. [section] (Michie 2001) (practice of medicine includes "the suggestion, recommendation, or prescription or administration of any form of treatment, without limitation"). (Practice of medicine means "(a) holding out of one's self to the public within this state as being able to diagnose, treat, prescribe for, palliate, or prevent any human disease, ailment, pain, injury, deformity, or physical or mental condition, whether by the use of drugs, surgery, manipulation, electricity, telemedicine, the interpretation of tests, including primary diagnosis of pathology specimens, images, or any physical, mechanical, or any means whatsoever; (b) suggesting, recommending, prescribing, or administering any form of treatment, operation, or healing for the intended palliation, relief, or cure of any physical or mental disease, ailment, injury, condition or defect or any person..."); Md. Code Annotated, Health Occupations [section] (2001) Dr Claudio Martínez G

¿Qué tipo de MEDICINA hace Usted?
La práctica de la medicina incluye el diagnóstico, tratamiento, , prevención, prescripción o remoción de una enfermedad con cualquier ayuda física, mental, o emocional o supuesta ayuda a una persona: (1) por procedimientos físicos, mentales, emocionales u otros que son realizados o invocados por el tratante, el paciente o ambos, o… (2) por la administración de test, drogas, procedimientos o tratamientos. Incluye la sugestión, recomendación, y cualquier forma de tratamiento sin limitación. actice of medicine" to include not only the application of medicine to patients, but any practice of the art of healing disease and preserving the health other than those special branches of the art that were expressly excepted); Ind. Code Ann. [section] (Michie 2001) (practice of medicine includes "the suggestion, recommendation, or prescription or administration of any form of treatment, without limitation"). (Practice of medicine means "(a) holding out of one's self to the public within this state as being able to diagnose, treat, prescribe for, palliate, or prevent any human disease, ailment, pain, injury, deformity, or physical or mental condition, whether by the use of drugs, surgery, manipulation, electricity, telemedicine, the interpretation of tests, including primary diagnosis of pathology specimens, images, or any physical, mechanical, or any means whatsoever; (b) suggesting, recommending, prescribing, or administering any form of treatment, operation, or healing for the intended palliation, relief, or cure of any physical or mental disease, ailment, injury, condition or defect or any person..."); Md. Code Annotated, Health Occupations [section] (2001) Algunos piensan en la medicina alternativa como alternativa a las drogas. Algunos ofrecen un tratamiento multidisciplinario incluyendo Biofeedback, manejo del estrés, terapia de relajación, suplemento vitamínico en megadosis, modificación de hábitos alimenticios y estilos de vida. Algunos hacen acupuntura, o terapia sobre puntos gatillo, o prescriben feverfew. Otros son más escépticos y ven todos estos acercamientos como sin base. Many health care consumers think of "alternative therapy" as meaning an alternative to drugs. In fact, many mainstream headache doctors offer multidisciplinary headache treatment that draws on a variety of complementary non-drug approaches, including biofeedback, stress management, relaxation therapy, and mineral and vitamin supplementation, as well as nutrition and lifestyle modification. Some headache doctors also practice acupuncture or trigger point therapy, or prescribe the herb feverfew for headache, while others are more skeptical and view these approaches as still unproven. Dr Claudio Martínez G

Kenneth R Pelletier Focus Altern Complement Ther 2003; 8: 3–6
conventional medical practice and the percentage of common, everyday procedures based on rigorous RCTs (1st percentage) versus ‘non experimental evidence’ (2nd percentage): General medicine in a UK District General Hospital at 53% vs. 29% General medical ‘suburban’ practice in the UK at 30% vs. 51% General psychiatry in the UK at 53% vs. 10% General medicine in Japan at 21% vs. 60% Regional paediatric surgery in the UK at 11% vs. 66% Surgical/vascular unit in a UK teaching hospital at 24% vs. 71% Tertiary referral paediatric surgical unit at 26% vs. 71% Eleven general hospitals in France at 50% vs. 28% Cancer centre in the USA at 24% vs. 21% Twelve community paediatricians in the UK at 39.9% vs. 7% Tertiary cancer surgical centre in the USA at 14% vs. 64% Internal medicine in a Swedish teaching hospital at 50% versus 34%. Focus Altern Complement Ther 2003; 8: 3–6 Conventional and integrative medicine – evidence based? Sorting fact from fiction Kenneth R Pelletier On May 14, 1796, Edward Jenner transferred material from a cowpox lesion on the hand of Sarah Nelms to the arm of James Phipps. What possessed him? He was motivated by the writings of poets who extolled the pock-free complexions of milkmaids by a decade of observing what happened to milkmaids during smallpox outbreaks. Fortunately, the boy showed immunity to smallpox and this bold experiment ushered in the vaccine era, which is today’s foundation for public health vaccinations and inoculations world-wide. Virtually all of conventional and integrative medicine has evolved out of such clinical practice over time and is accepted as a standard of practice or discarded based on perceived efficacy.1 Such a clinical focus is rather like the cumulative case studies forming the tort precedents in the practice of law. All clinical care involves adapting general guidelines, research findings and procedures or pharmaceuticals given to one particular individual, with a specific condition at one point in time. This constitutes the ‘art’ of medicine. Such a clinical approach does not easily lend itself to a randomised clinical trial (RCT), which represents the gold standard of biomedical research. Skilled clinicians virtually always report better patient outcomes than is documented in the research literature. Is this self-deception or testimony to the elegant accuracy of clinical judgement, especially in the clinical applications of alternative or integrative medicine? At the root of this debate is a ubiquitous assertion that conventional medicine is grounded in evidence-based research while integrative medicine is not. That assertion is grossly inaccurate and this brief article is intended to defrock this assertion while challenging both conventional and integrative medicine to a higher standard. To provide a baseline against which to measure complementary and alternative medicine (CAM), it is important to point out that as much as 20–50% of conventional care, and virtually all surgery, has not been evaluated by RCTs. According to Richard Smith, editor of the British Medical Journal, ‘Only about 15% of medical interventions are supported by solid scientific evidence… This is partly because only 1% of the articles in medical journals are scientifically sound and partly because many treatments have never been assessed at all’.2 In 1998, James Dalen, Dean of the University of Arizona and editor of Archives of Internal Medicine focused on the evidence basis for cardiology which is often cited as one of the more empirical medical specialities. According to Dalen, in 1986 the American College of Chest Physicians rated the evidence base of cardiology from ‘A’ (large RCTs with positive results) to ‘C’ (non-randomised, no controls and/or case series). Only 24% of the therapies rated ‘A’ while 45% rated ‘C’.3 When this was repeated in 1998, 44% were rated as ‘A’. Most recently, Brian Berman, coordinator of the Cochrane CAM reviews at the University of Maryland School of Medicine, took a random subset of 159 out of 326 completed Cochrane reviews of conventional medicine only.4 These were sorted into six categories ranging from ‘Evidence of Positive Effect’ at 20.8% to ‘Evidence of Negative Effect’ or the treatment was more harmful than beneficial at 6.9%. Overall, the ‘positive’ to ‘possibly positive’ totalled 38.4% compared with ‘no evidence of effect’ to ‘negative effect’ totalling an alarming 61.6%. Perhaps the most alarming statistic is that in the category of ‘Evidence of Negative Effect’: that figure stands at 6.9%, which represents common medical procedures that are known to have a negative effect and yet remain in common usage. To place that 6.9% in perspective, an article in JAMA in 1994 posited a minimum ‘error rate’ in medicine of 1%.5 In that article, the author quotes the prominent business scholar W E Deming, who stated: ‘If we had to live with about 99.9% (error rate), we would have two unsafe plane landings at O’Hare every day; pieces of mail lost every hour, and bank checks deducted from the wrong account every hour.’ Surely, even 0.5–1% error rate is alarming and a documented 6.9% is intolerable. In addition, a frequently cited report from 1978 by the Office of Technology Assessment found that only an estimated 10–20% of allopathic medical interventions are empirically proven. That figure remains accurate nearly 25 years later. Groucho Marx quipped, ‘Be open minded, but not so open minded that your brains fall out.’ There is probably no other area of research that generates such an acrimonious debate than between advocates versus critics of integrative medicine over ‘evidence-based’ medical practices. For brevity, consider the following findings (based on a January 2002 Medline Search) with regard to conventional medical practice and the percentage of common, everyday procedures based on rigorous RCTs (1st percentage) versus ‘non experimental evidence’ (2nd percentage): General medicine in a UK District General Hospital at 53% vs. 29%6 General medical ‘suburban’ practice in the UK at 30% vs. 51%7 Acute adult psychiatry at 65% vs. no data on non-experimental evidence8 General psychiatry in the UK at 53% vs. 10%9 General medicine in Japan at 21% vs. 60%10 Regional paediatric surgery in the UK at 11% vs. 66%11 Surgical/vascular unit in a UK teaching hospital at 24% vs. 71%12 Haematology at 70% with no estimate on non-experimental evidence13 Tertiary referral paediatric surgical unit at 26% vs. 71%14 Dermatology in a Danish university hospital at 38% vs. 33%15 Internal medicine in Canada at 20.9% vs. no non-experimental estimate16 Eleven general hospitals in France at 50% vs. 28%17 Cancer centre in the USA at 24% vs. 21%18 Anaesthesia in Australia at 32% vs. 64.7%19 Twelve community paediatricians in the UK at 39.9% vs. 7%20 Tertiary cancer surgical centre in the USA at 14% vs. 64%21 General medical care at 34 primary care clinics in Spain at 38% vs. 4%22 Internal medicine in a Swedish teaching hospital at 50% versus 34%.23 Again, the focus here is upon conventional medicine only since advocates of an evidence-based approach consistently cite conventional practice as the gold standard. Therefore, it is entirely appropriate to gauge the standard that is clearly found to be grossly deficient in a rigorous evidence base. Bear in mind that these studies and resulting statistics are compounded in their assertion by the fact that the ‘non supported’ percentages, or those practices that continue despite no evidence or actual evidence of harm, ranges from a low of 3% in a tertiary, paediatric surgical unit14 to an alarming 58% not supported in the study of 34 primary medical care clinics in Spain.22 One review cited many of these same studies but drew the opposite conclusion that, ‘claims that conventional medicine is not widely based on evidence should be rejected, as should logically fallacious arguments based on such claims.’24 Unfortunately, this act-of-faith conclusion is based on two fallacies. One is their faith in ‘self evident interventions’ or the non-experimental percentages that they assert are acceptable in conventional medicine and secondly that such self-evident interventions are ‘probably not in alternative medicine’. Both assumptions are presumptuous at best and erroneously reinforce a double standard that fails the fundamental definition of evidence-based medicine. In contrast, insisting upon equally rigorous evidence-based standards, many alternative medicine interventions actually have a stronger evidence base than many conventional medicine practices:1 in nautical terms, let all boats rise with the tide. This is not to diminish the necessity of rigorous standards in integrative medicine but to urge that both conventional and integrative medicine raise their ‘evidence-based’ standards! One of the most widely accepted definitions of evidence-based medicine is offered by David L Sackett, as the ‘Integration of individual clinical expertise with the best available external clinical evidence from systematic research’ and ‘without clinical expertise, (clinical) practice risks being tyrannised by evidence’.25 This is a delicate and complex balance but is increasingly necessary. As but one instance in conventional medicine, clinicians have argued over the value of Digitalis, a commonly used heart medication for over 200 years! Advocates support its use to treat congestive heart failure (CHF), critics argue that Digitalis is toxic and should be curtailed. After a 200-year scientific and clinical debate, the New England Journal of Medicine published a study of over 7000 patients using Digitalis.26 Although Digitalis did reduce CHF hospitalisations by 8%, it did not reduce CHF death and more patients taking Digitalis died of lethal heart arrhythmias. This study by Milton Packer of the Columbia Medical School may finally relegate Digitalis to a second-tier drug only if newer medications, such as angiotensin-converting enzyme (ACE) inhibitors and/or beta-blockers, prove to be ineffective. In contrast to these ubiquitously cited articles is the rigor of Cochrane reviews which empirical evidence suggests have, on average, greater methodological rigour than individual studies, systematic reviews, or meta-analyses published in peer-review journals according to Alejandro R Jadad and colleagues in a Journal of the American Medical Association article of One frequent misconception of Cochrane reviews is that they exclude qualitative, non-experimental findings; however, that is not accurate. Although the Cochrane Collaboration is primarily a repository of RCTs, the approved protocols have and can include qualitative data and non-experimental case studies. There is growing interest in the contribution of such qualitative research findings to the health and medical care evidence base. Qualitative research is concerned with the subjective world. It offers insight into psychosocial, psycho-neuroimmunological, emotional and experiential phenomena in health care to determine what, how and why such factors influence both health and disease. Therefore, findings from qualitative research may contribute to systematic reviews and reviewers need to consider how to incorporate them. There is potential for findings from qualitative research to enhance both the quality and relevance of systematic reviews and their applications to clinical practice and research. When framing questions, such findings can help to define the intervention more precisely and contribute to the choice of outcome measures. Qualitative research may also generate data on the subjective experience of an intervention to be included in a systematic review on an equal basis with quantitatively measured outcomes. Finally, both conventional, CAM, and integrative RCTs need to fully acknowledge and incorporate the fact that patients, practitioners and procedures are complex, interactive, dynamic systems with other even larger and more complex ethical, philosophical, economic, and spiritual dimensions. It is well beyond the scope of this article to describe the specifics of advanced biostatistical techniques in quantitative research. However, the applications of advanced methods of biostatistical data analysis does enable investigators to evaluate a CAM system as an integrated whole within its own context. According to Iris R Bell and her colleagues at the University of Arizona School of Medicine, ‘Path analysis (an extension of multiple regression), structural equation modelling (analysis that includes latent variables), and confirmatory factor analysis (a systematic analysis of the pattern of relationships among variables that attempts to explain that pattern in terms of a smaller number of underlying hypothetical factors) represent only a few of the examples applicable to this type of healthcare outcomes research. These techniques allow us to look at the complex relationships among many dependent and independent variables at the same time, consistent with the higher level of organisation in a complex systems theory model.’28 By specifying paths by which specific variables affect others, then it becomes possible to demonstrate more explicit causal inferences. Through acknowledging the lack of ‘evidence based’ procedures in both conventional and integrative medicine and implementing RCTs with more innovative designs and biostatistical methodologies, the standards whereby all medicine should be judged will be raised for the benefit of both patients and practitioners. References Pelletier KR. The Best Alternative Medicine: What Works? What Does Not? New York: Simon & Schuster, 2000. Smith R. Where is the wisdom?… The poverty of medical evidence. BMJ 1991; 303: 798–9. Dalen J. Conventional and unconventional medicine: can they be integrated? Arch Intern Med 1998; 158: 1–4. [Abstract] Ezzo J, Bausell B, Moerman DE et al. Reviewing the reviews: how strong is the evidence? How clear are the conclusions? Int J Technol Assess Health Care 2001; 17: 457–66. Leape LL. Error in medicine. JAMA 1994; 272: 1851–7. [Abstract] Ellis J, Mulligan I, Rowe J, Sackett DL. Inpatient general medicine is evidence based. 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Haematologists in district general hospitals practice evidence based medicine. Clin Lab Haematol 1997; 19: 243–8. [Abstract] Baraldini V, Spitz L, Pierro A. Evidence-based operations in paediatric surgery. Paediatr Surg Int 1998; 13: 331–5. [Abstract] Jemec GBE, Thorsteinsdottir H, Wulf HC. Evidence based dermatologic out patient treatment. Int J Dermatol 1998; 37: 850–4. [Abstract] Michaud G, McGowan JL, van der Jagt R et al. Are therapeutic decisions supported by evidence from health care research? Arch Intern Med 1998; 158: 1665–8. [Abstract] Slim K, Lescure G, Voitellier M et al. Is laparoscopic surgery really evidence based in everyday practice? Results of a prospective regional survey in France. Presse Med 1998; 27: 1829–33. Djulbegovic B, Loughran TP Jr, Hornung CA et al. The quality of medical evidence in hematology–oncology. Am J Med 1999; 106: 198–205. [Abstract] Myles PS, Bain DL, Johnson F, McMahon R. Is anaesthesia evidence based? A survey of anaesthetic practice. Br J Anaesth 1999; 82: 591–5. Rudolf MCJ, Lyth N, Bundle A et al. A search for the evidence supporting community paediatric practice. Arch Dis Child 1999; 80: 257–61. Lee JS, Urschel DM, Urschel JD. Is general thoracic surgical practice evidence based? Ann Thorac Surg 2000; 70: 429–31. [Abstract] Suarez-Varela MM, Llopis-Gonzalez A, Bell J et al. Evidence based general practice. Eur J Epidemiol 1999; 15: 815–19. [Abstract] Nordin-Johansson A, Asplund K. Randomized controlled trials and consensus as a basis for interventions in internal medicine. J Intern Med 2000; 247: 94–104. [Abstract] Imrie R, Ramey DW. The evidence for evidence-based medicine. Complement Ther Med 2000; 8: 123–6. [Abstract] Sackett DL, Rosenberg WM, Gray JA et al. Evidence based medicine: what it is and what it isn’t. BMJ 1996; 312: 71–2. Packer M. End of the oldest controversy in medicine. Are we ready to conclude the debate on digitalis? N Engl J Med 1997; 336: 575–6. [Abstract] Jadad AR, Cook DJ, Jones A et al. Methodology and reports of systematic reviews and meta-analyses: a comparison of Cochrane reviews with articles published in paper-based journals. JAMA 1998; 280: 278–80. [Abstract] Bell IR, Caspi O, Schwartz GER et al. Integrative medicine and systematic outcomes research: issues in the emergence of a new model for primary health care. Arch Intern Med 2002; 162: 133–40. [Abstract] Kenneth R Pelletier, PhD, MD(hc) is Chairman of the American Health Association and is based at 1990 North California Boulevard, Suite 830, Walnut Creek, California 94596, USA. He is also Clinical Professor of Medicine at the University of Maryland School of Medicine, and the University of Arizona School of Medicine. Dr Claudio Martínez G Kenneth R Pelletier Focus Altern Complement Ther 2003; 8: 3–6

Tanacetum parthenium BACH Dr Claudio Martínez G
Como estos medicamentos son principalmente supresores de síntomas o paliativos habitualmente fallan en ayudar a los mecanismos adaptativos homeostáticos del cuerpo-mente y espíritu y raramente se dirigen a la raiz que causa la enfermedad. De ahí que su éxito en algunas enfermedades crónicas o recurrentes es pobre. Complementary Medicine (Integrative Medicine) includes any forms of physical, nutritional, mental or spiritual therapy that can address the root causes of disease, and/or substitute for, or improve Dr Claudio Martínez G

Tanacetum parthenium Acupuntura Aromaterapia Flores de Bach
Neuroterapia ayurvédica Biofeedback Rolfing (Dr. Ida Rolf, Ph.D) Terapia respiratoria Quiropraxia Sanación por los colores Osteopatía Medicina holística Qigong Reflexología Chamanismo Terapia cognitivo-conductual Medicna china tradicional Unified Field Therapy Yoga Imaginería Hipnosis Terapia nutricional capsaicina BACH Como estos medicamentos son principalmente supresores de síntomas o paliativos habitualmente fallan en ayudar a los mecanismos adaptativos homeostáticos del cuerpo-mente y espíritu y raramente se dirigen a la raiz que causa la enfermedad. De ahí que su éxito en algunas enfermedades crónicas o recurrentes es pobre. Complementary Medicine (Integrative Medicine) includes any forms of physical, nutritional, mental or spiritual therapy that can address the root causes of disease, and/or substitute for, or improve Intranasal application of capsaicin has been used for patients with cluster headaches and also as rescue medication for migraine headaches. Dr Claudio Martínez G

que visa equilibrar as emoções, restaurar a saúde e harmonizar
Terapia holística que visa equilibrar as emoções, restaurar a saúde e harmonizar os corpos sutis através dos óleos essenciais combinados a radiestesia, cristais e cromoterapia. Dr Claudio Martínez G

What kind of alternative care was used ?

Terapia No Farmacológica
Medicina complementaria. Medicina alternativa. Medicina integrativa Medicina holística* Medicina natural Medicina tradicional Acupunctura Biofeedback Aromaterapia Terapias de ejercicios y movimientos Hierbas y medicina folklórica homeopatía Dietas y cambios de vida masaje Megavitaminas Técnicas de relajación Medicina china o hindú. Osteopatía/quiropraxia CAM Conventional (allopathic) Medicine depends on expensive high-tech diagnostic methods, surgery and synthetic or bioengineered medicinal agents (antimicrobials, analgesics, cytotoxic chemotherapy, mood-altering drugs, tranquillisers, hormones & vaccines, etc.). It is best in emergencies & in cases that have serious infections, metabolic or hormonal conditions. It is essential in cases that genuinely need surgery, but it tends to overuse surgery - many cases can be treated successfully without that. Conventional medicine has a high rate of adverse side-effects, i.e. causes an unacceptable rate of iatrogenic disease. As its medicaments are largely symptom-suppressive or palliative, it usually fails to help the adaptive / homeostatic mechanisms of the body-mind-spirit & rarely addresses the root causes of disease. Therefore its clinical success in many chronic or recurring diseases is poor. La medicina alopática convencional depende de onerosos métodos diagnósticos de alta tecnología, cirugía y medicamentos sintéticos o de bioingeniería (antimicriçobianos, analgésicos, citotóxicos, quimioterapia medicamentos moduladores del ánimo, , tranquilizantes hormonas, vacunas,etc.) Son mejores en emergencias, en casos de serias infecciones, condiciones metabólicas u hormonales. Son esenciales en casos que genuinamente necesitan cirugía. La medicina convencional tiene una alta taza de efectos secundarios adversos causando una inaceptable taza de enfermedad iatrogénica. Como estos medicamentos son principalmente supresores de síntomas o paliativos habitualmente fallan en ayudar a los mecanismos adaptativos homeostáticos del cuerpo-mente y espíritu y raramente se dirigen a la raiz que causa la enfermedad. De ahí que su éxito en algunas enfermedades crónicas o recurrentes es pobre. Complementary Medicine (Integrative Medicine) includes any forms of physical, nutritional, mental or spiritual therapy that can address the root causes of disease, and/or substitute for, or improve, the clinical outcome of conventional medicine and/or alleviate its adverse side-effects. *Holistic medicine is the best medicine for humans or animals. It embraces the best of conventional medicine, plus the best of "complementary medicine". Where necessary, it includes surgery. It attains optimal clinical results with minimal side effects to the patient & at less cost than high-tech conventional medicine. Holistic medicine examines all the interactions between the external environment and the body-mind-spirit of the patient. It does not view the Syndrome (the Lesion-Symptom Complex) as the disease per se. The Syndrome is only the clinical manifestation of the disease, i.e. the Branch, or end-result, of the body's defensive reaction, its attempt to try to correct the Energetic Imbalance, which is the Root cause of the disease. In Chinese Medicine aims to diagnose the predisposing factors (usually energetic and/or genetic) & the precipitating factors (usually external factors, but sometimes internal-emotional factors) that trigger the Syndrome in the weak physical structures, organs or parts of the body or in the psyche / spirit of the patient. It places less importance on the Syndrome (Branch) & the weak physical structures than on the Root causes.Treating the Branch is like taking an analgesic for a headache, or an antibiotic for a bacterial infection. It may be necessary for rapid symptomatic relief, but it does NOT address the Root cause of the headache, or of the suppressed immune status that allowed the bacteria to overcome the body's natural defences. Where possible, holistic medicine Treats the Root, i.e uses whatever methods are needed to remove, neutralise or alleviate the root causes of disease. Its modalities include acupuncture, herbal (especially oriental) medicine, homeopathy, immunostimulation therapy, osteopathy / chiropractic, nutritional supplements, dietary adjustment, advice on lifestyle, physical / mental exercises, stress control / hypnosis / relaxation therapy, etc. When indicated, it also uses conventional physiotherapy, medicine, surgery, nutrition, counselling, etc. If Root Treatment does not give the desired result, and in all syndromes that pose a serious threat to life, it Treats the Branch, i.e. to tackle the symptoms & / or lesions directly. In many cases, for example in severe pain, it combines Branch and Root treatment, including helping the client to attain a more balanced mental-spiritual state. Alternative Medicine: The term is a misnomer. Practitioners of "alternative medicine" provide inferior medical care because there is no good alternative to expert holistic medicine. Those who trust "alternative" medical or veterinary therapy at best trust an illusion, & at worst will know the reality of that illusion in time Holistic medicine is the best medicine for humans or animals. It embraces the best of conventional medicine, plus the best of "complementary medicine". Where necessary, it includes surgery. It attains optimal clinical results with minimal side effects to the patient & at less cost than high-tech conventional medicine. 9.- loan RP, Bagiella E, VandeCreek L, et al. Should physicians prescribe religious activities? N Engl J Med. 2000;342: Critics of the religion and health movement claim that the magnitude of associations between religious practice and better health is actually quite weak and is based on data from methodologically flawed studies.[8] They also argue that, regardless of any potential health benefit that may be gained from increased religiosity, ethical concerns should prevent physicians from integrating religious practice with clinical practice.[9 It is this sort of understanding that is implicated, for example, when researchers recommend that physicians encourage their patients to make use of health-promoting resources from the patient's own religious tradition,[7] insofar as the physician is unconcerned with the exact beliefs and rituals of that particular tradition. TLC -- The Learning Curve Empathy: Lost or Found in Medical Education? Sonal Singh, MD Medscape General Medicine. 2005;7(3) ©2005 Medscape On a more personal level, I had initially hesitated in showing empathy, but the nonverbal cues had shown me the right direction. In the first instance, it had been the sight of a desperate mother crying over her boy's dead body. In the second instance, my patient's eyes seemed to yearn for something more than the medicines. Writing about my patients' stories has been an instrument of healing for me in several instances.[18] "Narrative medicine," which uses instruments, such as reflective writing, is being taught in more and more medical schools.[19] Students can improve their capacity for empathy, reflection, and professionalism through serious narrative training. Although the mechanism by which narrative training benefits doctors and patients is still under investigation, "By bridging the divides that separate physicians from patients, narrative medicine offers opportunities for respectful, empathic, and nourishing medical care.[20]" Although the data suggest that empathy is indeed hard to teach, and may in fact be lost during medical training, it is through narrative, perhaps, that what has been lost can be discovered or regained Sloan and coworkers[8] analogize that physicians do not encourage patients to marry just because marriage is associated with lower mortality. 1.8 Complementary and Alternative Medicine (CAM) is a title used to refer to a diverse group of health-related therapies and disciplines which are not considered to be a part of mainstream medical care. Other terms sometimes used to describe them include 'natural medicine', 'non-conventional medicine' and 'holistic medicine'. However, CAM is currently the term used most often, and hence we have adopted it on our Report. CAM embraces those therapies that may either be provided along side conventional medicine (complementary) or which may, in the view of their practitioners, act as a substitute for it. Alternative disciplines purport to provide diagnostic information as well as offering therapy. BMJ 2005;331 (15 October), doi: /bmj c Complementary medicine in the UK seems cost effective Estimates of cost per quality adjusted life year of acupuncture for headache and of spinal manipulation for back pain compare well with other treatments approved for use in the NHS. Canter and colleagues (p 880) performed a systematic review and assessed cost effectiveness reported in one acupuncture trial and four trials of spinal manipulation. Despite the favourable estimates, the authors warn that complementary treatments could be less cost effective if offered routinely rather than in a setting of a clinical trial. They often erroneously believe that they can do no harm. 7-11% of the UK population have consulted a complementary practitioner over the past year. Whilst it is important to be open minded, any treatment, intervention or medication (whether traditional or alternative, bought over the counter or prescribed by a health professional) should be considered with a healthy degree of scepticism. Complementary or Alternative Medicine (often referred to as CAM) should not be considered in isolation but as part of an overall approach to general well being (including improved control of headache and migraine). CAM practitioners take a holistic view of health (i.e. viewing the whole person not just a particular part of them as often happens in mainstream medicine) taking into account all symptoms, individual preferences, lifestyle and family history; they will spend a long time during the first consultation asking many different questions which you may feel are totally unrelated to your migraine. Complementary techniques are those that lack definitive proof of efficacy and are not accepted by the medical mainstream. While many treatments widely used in modern medicine also lack scientific proof, they are not considered complementary or alternative because of their wide acceptance by the medical establishment. Eisenberg, et al. NEJM 1993; 328: 1990 national telephone survey 1/3 of patients use alternative methods 72% of users did NOT inform their physician According to recent studies (Cherniack, Senzel, & Pan, 2001; Eisenberg et al., 1998), 42.1% of the American population uses some form of CAM, with 39% of the older population using CAM. A more recent study (Williamson et al., 2001) identified an even higher percentage (73%) of older adults using CAM, much higher than the national average. Of the older adults who use CAM, 58% reported that they did not discuss the use of CAM with their medical doctor or health care practitioner (Astin, 1998). In this issue is a report of an interesting study involving a comparison of acupuncture with pharmacologic prophylaxis for suppression of headache. Future issues of the journal will contain scientific reports and invited feature articles related to CAM. For those who have a particular interest in this area, please note that our Society offers a special interest section for CAM (chair, Alexander Mauskop; secretary, Marc Husid) and that the National Institutes of Health has added a center for CAM with its own research budget to match. Headache: The Journal of Head and Face Pain Volume 42 Issue 9 Page 843 - October 2002 The CAM Section was formed with the following goals and objectives in mind: (1) to exchange information among section members, (2) to evaluate the scientific evidence regarding the risks and benefits of different CAM modalities, (3) to support and coordinate research into CAM treatments for headaches, (4) to educate AHS members about the use of CAM for headaches, and (5) to educate headache sufferers through the American Council on Headache Education (ACHE) and through Complementary and alternative practices can be grouped under the categories of alternative medical systems (eg, Asian, Ayurvedic, homeopathy), mind-body interventions (eg, biofeedback), biologically based therapies, manipulative methods (eg, massage or chiropractic), and energy therapies (eg, Qui Gong or magnet application). Individual examples are too numerous to mention. The CAM Section will position as research priorities those therapies that possess a plausible scientific basis for efficacy, along with therapies and supplements that already are widely used but whose health benefits are unproven. As an example of a study seeking to evaluate the utility of a biologically based treatment which already enjoys some (albeit insufficient) scientific support, this Section proposes to investigate the role of oral magnesium supplementation for the prophylactic therapy of migraine. Over the past decade, we have learned much regarding the effects of magnesium on brain neurotransmitters, enzymes, and metabolism. For example, it has been clearly established that both nitric oxide production and serotonin regulation can be modulated by changes in magnesium concentration, and the release of substance P is shown to be regulated by magnesium concentration. Magnesium also has a strong vascular dilating effect, and it inhibits platelet aggregation. And yet, while these effects fit well into the several hypotheses of migraine pathogenesis that have been proposed over the years, the idea of magnesium deficiency as a risk factor for migraine has produced much skepticism. It is important that we evaluate in a convincing way this simple, safe, and inexpensive therapy. Another group of treatments stem from what may be called alternative medical systems. Acupuncture is a popular alternative therapy; a wealth of animal studies have indicated biological effects, but there have been few well-conducted human trials. Research has identified some of acupuncture's potential mechanisms of action these include activation of small nerve fibers in the muscle that is transmitted through the spinal cord to the midbrain and pituitary-hypothalamus. The pain relief mechanisms begin in the spinal cord where enkephalin and dynorphin block incoming pain signals. Enkephalin influences the midbrain center to inhibit pain transmission by its effects on serotonin and norepinephrine. The hypothalamus-pituitary releases -endorphin into the blood and cerebrospinal fluid to cause analgesia at a distance. This mechanism seems to be operating when a low-frequency stimulation is used. Although we may be confident that through basic research we understand important mechanisms of action of this treatment intervention, the challenge of performing a double-blind clinical study to evaluate the efficacy of acupuncture is prodigious. Difficulties of trial design include needle site selection and participant blinding. If no needles are inserted, obviously the patient will know it. Needles inserted in the wrong locations still produce an effect greater than placebo. We believe that we must do more to assess this important treatment, which is not costly and produces almost no side effects while using plausible mechanisms to produce analgesia Both physicians and patients often are surprised to discover a wealth of information where none was initially thought to be available. For example, aromatherapy, at first spurned as a therapy apparently lacking scientific merit, has been subjected to two rigorous blinded trials that found peppermint oil to have analgesic properties both in healthy volunteers and in patients with tension-type headaches There are many other CAM therapies awaiting definitive scientific evaluation. Many do not lend themselves easily to scientific research, and the task of developing innovative protocols will be an exciting and challenging one. The National Institutes of Health (NIH) has established a center for CAM which now possesses a respectable research budget and an appetite for appropriate grant proposals. The timing for CAM research is excellent The number of hospitals that have Biofeedback programs has doubled since 1998 Now 20% of hospitals surveyed with wellness or CAM have Biofeedback, the 7th most commonly offered service >90% of physicians consider Biofeedback a legitimate medical practice and refer for it Biofeedback tied for 4th in hospital administrator priorities for what to add, behind chiropractic, acupuncture, and massage 16 of 18 major health insurance carriers claim to cover biofeedback, yet reimburse about 50% of the time Biofeedback has the lowest risk of 20 CAM therapies Only 1% of people surveyed have used biofeedback in the last 12 months Psychosocial factors frequently overlooked or missed in clinical encounters The majority of physician-patient encounters continue to be fairly narrowly focused on biomedical issues. Mind-body therapies not fully integrated, even despite evidence of their being efficacious The CAM Definition is Ambiguous and Invites Arbitrary and Capricious Application in Violation of Each State's Administrative Procedure Act. The model guidelines define CAM as "a broad range of healing philosophies (schools of thought), approaches, and therapies that mainstream Western (conventional) medicine does not commonly use, accept, study, understand, or make available." That definition is so broad and ambiguous as to encompass nearly all innovation in medicine regardless of its origin, source, nature, scientific validity or provability, or potential usefulness. Lacking definite meaning, the term CAM in the guidelines leads to no epistemologically sound and rational distinguishing principle Kathleen M. Boozang, "Is There Alternative Medicine? Managed Care Apparently Thinks So," 32 Conn. L. Rev., v. 567, (2000). She explains that "confusion abounds as to what currently comprises alternative medicine." Kathleen M. Boozang, "Western Medicine Opens the Door to Alternative Medicine," 24 Am. J. L. and Med. 189, 196 (1998). She finds it "virtually impossible to categorize CAM therapies in any comprehenisve way." 32 Conn. L. Rev. at Professor Kathleen M. Boozang has observed that "alternative medicine.. remains elusive, and most attempted definitions are unhelpful." Lacking definite meaning, the term CAM in the guidelines leads to no epistemologically sound and rational distinguishing principle. It thereby invites arbitrary and capricious application in violation of the administrative procedure acts in the states Because the key term CAM is impermissibly vague, if adopted by any medical board, the model guidelines will be subject to challenge under each state's administrative procedure act as arbitrary, capricious, and an abuse of discretion. Moreover, depending on the circumstances present in each state, adoption of the term may invite constitutional challenge under the void for vagueness doctrine of the Fourteenth Amendment to the United States Constitution. See, e.g., Grayned, supra; Farmer, supra. Q. What are nondrug therapies? A. Most of what I end up talking about has to do with behavioral therapies, which I break into three major categories: relaxation training, biofeedback and cognitive behavioral therapy, and stress management therapy. National Library of Medicine classifies alternative medicine under the term complementary therapies. This is defined as therapeutic practices which are not currently considered an integral part of conventional allopathic medical practice. They may lack biomedical explanations but as they become better researched some, such as physical therapy, diet, and acupuncture, become widely accepted whereas others, such as humors or radium therapy, quietly fade away, yet are important historical footnotes. Therapies are termed as Complementary when used in addition to conventional treatments and as Alternative when used instead of conventional treatment Dr Claudio Martínez G

Cochrane reviews of complementary and alternative therapies: evaluating the strength of the evidence Eric Manheimer, Brian Berman, Heather Dubnick, William Beckner Conclusions: While this exercise suggests strong evidence for the effectiveness of some CAM therapies, further research is required, as demonstrated by the numerous classified as insufficient evidence. Only one review fell into the harmful effect category, suggesting that RCTs of CAM therapies have posed little risk to participants. Eric Manheimer, Brian Berman, Heather Dubnick, William Beckner Background: Complementary and alternative medical (CAM) therapies are widely used by the general public but often criticized for lacking evidence of efficacy from high quality studies. The Cochrane Library, often considered the best source of high quality systematic reviews of CAM healthcare therapies, contained 145 reviews related to CAM as of March Objectives: 1. To identify what Cochrane Reviews reveal about the evidence base for CAM. 2. To examine which CAM therapies have the most Cochrane Reviews and the strongest evidence for effectiveness. 3. To identify which therapies widely used or recognized by the general public, hospitals, or physicians are unsupported by Cochrane Reviews, and which therapies supported by strong evidence remain relatively unused. 4. To discuss efforts being made by the CAM Field to insure the preparation of reviews identified as high priority. Methods: Manual and electronic searches of The Cochrane Library were conducted to identify reviews covering therapies considered CAM according to the US NIH criteria. Two raters trained in RCT and systematic review methodology assigned all CAM-related Cochrane Reviews to one of six categories: positive effect, possibly positive effect, two active treatments are equal, insufficient/inconclusive evidence, no effect, or harmful effect [1]. When the two raters differed, a third rater assigned the final classification. The inter-rater agreement between the initial two raters was 83%. The reviews were classified by therapy type. Therapies with the highest number of reviews and the most positive reviews were identified. Disparities between Cochrane evidence and therapy use by the US general public, physicians, and hospitals were identified. Results: The largest number of reviews were classified as insufficient evidence (n=82, 56.6%); followed by positive effect (n=36, 24.8%); possibly positive effect (n=18, 12.4%); and no effect (n=7, 4.8%). One each was classified in the other two categories. Therapies with the highest number of reviews on The Cochrane Library are dietary supplements (non-herbal) (71 reviews), herbals (23), electrical stimulation (eg, transcutaneous electrical nerve stimulation) (11) and acupuncture (10). Three-tenths of acupuncture reviews were positive or possibly positive, as were 4/71 dietary supplement reviews, 16/23 herbal reviews and 5/11 electrical stimulation reviews. Herbal therapies and electrical stimulation are supported by strong evidence but are not widely used in all settings. There are no reviews of meditation, and only three each of massage and chiropractic, all commonly used therapies. Conclusions: While this exercise suggests strong evidence for the effectiveness of some CAM therapies, further research is required, as demonstrated by the numerous classified as insufficient evidence. Only one review fell into the harmful effect category, suggesting that RCTs of CAM therapies have posed little risk to participants. Efforts underway to insure preparation of Cochrane Reviews identified as high priority include recruiting reviewers; providing funds to applicants proposing high priority reviews; and converting high priority non-Cochrane reviews to Cochrane Reviews. References: 1. Rating system based on Ezzo J, Bausell B, Moerman DE, Berman B, Hadhazy V. Reviewing the reviews. How strong is the evidence? How clear are the conclusions? Int J Technol Assess Health Care. 2001; 17(4): Cochrane reviews of complementary and alternative therapies: evaluating the strength of the evidence Herbal therapies and electrical stimulation are supported by strong evidence but are not widely used in all settings. There are no reviews of meditation, and only three each of massage and chiropractic, all commonly used therapies Ottawa 2004 P-094 Dr Claudio Martínez G

Comprensión incompleta de:
Behavioral Research and the Double-Blind Placebo-Controlled Methodology: Challenges in Applying the Biomedical Standard to Behavioral Headache Research J. Rains, D B. Penzien, Headache: Volume 45 - May 2005 Doble ciego es casi imposible con el proceso activo de aprendizaje de los ejercicios de autorregulación y de tratamientos conductuales. La implementación de placebos psicológicos o pseudoterapias son altamente difíciles. Comprensión incompleta de: componentes activos del tratamiento conductual los procesos de cambio psicológico Fisiopatología de la cefalea The gold standard of pharmacologic research (the double-blind, placebo-controlled trial) cannot readily be emulated by behavioral or psychological headache research. The application of blinding to control for contamination of treatment effects with the patient's and the therapist's biases is inconsistent with the active learning process necessary for acquisition of self-regulation and other headache self-management skills and simply not feasible in behavioral research. Development and implementation of behavioral or psychological placebo controls or "pseudotherapies" has been attempted but has proven highly challenging at least in part owing to our incomplete understanding of the active components of behavioral treatment, the inherent difficulty in sorting out active versus extraneous elements of the patient-therapist interactions and psychological change process, as well as limited understanding of headache pathophysiology itself. In some cases, inappropriate controls have lead to erroneous conclusions. (la interacción paciente terapista y Only rarely is blinding meaningfully achievable in administration of behavioral or psychological therapies. Various "psychological placebo" control conditions have been forwarded in behavioral studies (eg, sham treatments, pseudomeditation), but these controls are incapable of emulating an inert control condition comparable to that of the pill placebo in pharmacologic research, and they are best reserved for studies examining the mechanisms whereby an intervention produces improvement. Administration of a behavioral or psychological intervention necessarily involves complex patient-therapist interactions. Therapists generally introduce, evaluate, and reinforce the patient's acquisition of behavioral skills. Thus, therapists cannot be blinded in the same manner as a clinician administering medication. In an effort to control therapist biases, treatment procedural manuals are often employed that detail the therapist's behaviors and essential therapeutic elements in behavioral headache treatment (ie, "manualized treatment"). The main issues to be discussed in relation to behavioral trials concern the recruitment and selection of subjects; sample size and statistical power; the use of a credible control; and the reproducibility of the interventions studied. Some of the problems described below are specific to trials of behavioral interventions (eg, difficulty of blinding), while others also pertain to drug treatment trials (eg, defining clinically significant improvement); still others might be described as "cultural" problems (eg, the lack of integration of behavioral and medical populations). Table 2 lists methodologic considerations addressed in this critique and provides citations to articles further addressing these issues within a special series of papers addressing headache research methodology published in Headache as a companion to this supplement. Double-blinding is impossible for most behavioral interventions, and effective single-blinding is also difficult to achieve in most cases.19 The use of waitlist controls (rather than credible placebos) and the lack of blinding make behavioral trials more prone to bias than traditionally designed drug trials, and more likely to find a spurious statistically significant result. Reproducibility of the Intervention Behavioral therapies, as described above, are fairly complex interventions. Issues such as therapist training, integrity of treatment, and compliance all serve to complicate the reproducibility and transportability of a behavioral intervention. A few trials have empirically studied different methods of delivering behavioral therapies, testing the importance of home practice,94,103 intensity of therapist contact,104 and booster training.84 However, many aspects of the delivery of therapy remain inadequately studied, and variations in these therapies due to personnel, setting, and other factors may partially determine whether the intervention will work as well in practice as in trials. Since its genesis in the mid-20th century, behavioral headache research has grown, matured scientifically, and despite methodological imperfections has yielded impact on contemporary headache management. The past three decades have amassed a considerable evidence base addressing behavioral headache treatments. This literature exhibited unprecedented growth in the 1970s and early 1980s stimulated by the development of biofeedback treatments for headache. Although the number of psychophysiology and biofeedback studies has declined in recent years, behavioral headache research productivity has continued to grow in both number and breadth of studies. Publication trends show greater proportions of controlled than uncontrolled trials, and assessment of a broadening range behavioral and functional variables pertinent to average headache sufferer. Meta-analytic literature reviews of behavioral interventions (relaxation training, biofeedback, cognitive-behavioral therapy) have consistently shown behavioral therapies to be effective treatments for primary headache. Across studies, behavioral interventions have yielded approximately a 35% to 55% reduction in migraine and tension-type headache parameters. Although direct comparisons of behavioral and pharmacologic treatments for headache are few, the available evidence suggests that the level of headache improvement with behavioral interventions may rival those obtained with widely used pharmacologic therapies in representative patient samples. Despite substantial growth, endorsement, and increasing integration of behavioral headache treatments into headache management, there remain substantial opportunities to strengthen and expand both the research base and clinical application of these therapies. Future directions are discussed in detail elsewhere115 and Guidelines for Trials of Behavioral Treatments for Recurrent Headache96 were published to facilitate production of high-quality research. Likely, current treatments represent only a fraction of what is possible in the application of behavioral and psychological principals to headache. Dr Claudio Martínez G

Candidatos para Tratamiento No Farmacológico
Preferencia del paciente Poca tolerancia a terapia con drogas Contraindicaciones a terapia con drogas Insuficiente respuesta a medicación sola Embarazo Abuso de medicación aguda Gran estrés Costo de medicamentos Motivaciones especiales** Campbell JK, Penzien DB, Wall EM. Evidence-based Guidelines for Migraine Headache: Behavioral and Physical Treatments. [American Academy of Neurology Web Site]. April 23, Available at: http// Accessed September 1, 2000. 1. Dissatisfaction: Patients are dissatisfied with conventional treatment because it has been ineffective, [5,6] has produced adverse effects, [6,7] or is seen as impersonal, too technologically oriented, and/or too costly. [6-15] A. Patient preference for nonpharmacologic interventions B. Poor tolerance to specific pharmacologic treatments C. Medical contraindications for specific pharmacologic treatments D. Insufficient or no response to pharmacologic treatment E. Pregnancy, planned pregnancy, or nursing F. History of long-term, frequent, or excessive use of analgesic or acute medications that can aggravate headache problems (or lead to decreased responsiveness to other pharmacotherapies) G. Significant stress or deficient stress-coping skills ** Pilotos de aeronaves p,e, Dr Claudio Martínez G

Magnesio Riboflavina Botox O2 Dr Claudio Martínez G
Q. What is the connection between magnesium and headaches? A. Studies find that half of all patients with severe headaches don't have enough magnesium. (10) Magnesium is a vital element involved in the regulation of a variety of activities in the brain. For instance, serotonin, a chemical in the brain called a neurotransmitter, is involved in headaches. And serotonin receptors are regulated by magnesium. If you're low in magnesium, they don't work as well. Studies also find that patients with low magnesium levels don't have as much success with sumatriptan (a common medication for headaches). But after researchers gave patients magnesium supplements, the sumatriptan worked better. Magnesium also regulates NMDA receptors in the brain, which are very important in the pain process. Magnesium is also a vasodilator, relaxing blood vessels. In fact, there may also be a connection between stress and magnesium because studies find that stress depletes magnesium, which may trigger the migraine. Riboflavin. Riboflavin, or vitamin B2, also has been studied for the prevention of migraine. One study involved 55 patients who received a daily intake of 400 mg of riboflavin or placebo for 3 months.28 Fifty-nine percent of the patients receiving riboflavin improved by at least 50% vs 15% of placebo-treated patients (p _ 0.002). Furthermore, riboflavin was found to be superior to placebo in reducing attack frequency (p _ 0.005) and number of headache days (p _ 0.012). Relief of migraine headaches was not immediate, however, and could require the use of riboflavin for at least 3 months. The authors concluded that additional research is warranted. Q. How about riboflavin and feverfew? A. Riboflavin is vitamin B2, which has long been suspected to help migraines. In one double blind trial conducted in Belgium, participants headaches improved from an average of four headaches a month to two a month after three months of taking daily 400 mg of riboflavin. (11) I do not recommend this high a dose for pregnant women. In another study, 72 volunteers received either feverfew or a placebo. Those receiving the herb found the severity and frequency of their migraines reduced. (12) Feverfew, like all other herbal supplements, should not be taken by pregnant women or those taking blood thinners, such as Coumadin. Q. What other therapies are available for migraine sufferers? A. Acupuncture helps some people. (14) Botox injections also may help. Botox is the deadliest toxin known to man. But used in very small amounts, it's extremely effective for a variety of conditions, including movement disorders. It's used for cosmetic treatments, and through that use we've discovered that it helps migraines. (15) In my experience, 70 percent of patients with intermittent migraines found relief. Todd D. Rozen, MD The two most effective cluster abortive agents are injectable sumatriptan and inhaled oxygen. Because most cluster headache sufferers are cigarette smokers and at high risk of coronary artery disease, many develop contraindications to triptans. Oxygen, the safest of all cluster therapies, is not effective for every patient. In Kudrow’s landmark study,1 75% of patients responded to 100% oxygen at 7 L/min, although only 57% of older chronic cluster headache patients had relief. A recent study documented a gender difference in response to oxygen because only 59% of female cluster patients responded to oxygen, whereas 87% of men did.2 In most textbooks and articles on cluster headache treatment, patients are instructed to use 100% oxygen via a nonrebreather face mask at 7 to 10 L/min. The rationale behind this prescribed oxygen flow rate is unknown but has become doctrine since the Kudrow1 study. Prescribing higher flow rates of oxygen up to 12 L/min has recently been suggested, but there is no documentation that this may improve efficacy.3 Higher oxygen flow rates (up to 15 L/min) are not known to benefit cluster headache patients refractory to standard oxygen therapy. Three cluster headache patients who demonstrated no response to standard oxygen therapy were exposed to higher flow rates of oxygen (14 to 15 L/min) to assess this primary headache. Oxygen’s vasoconstrictive effect on cerebral vessels may play an important role.4 Why 100% oxygen delivered at variable rates would have disparate effects on cluster headache in different individuals is unknown. One study documented that cluster headache patients with the greatest reduction in cerebral blood flow after oxygen inhalation had the most benefit from oxygen therapy.5 Two of the three presented patients had a considerable smoking history, and it may be in that setting that higher flow rates of oxygen are needed to see an abortive response of cluster headache. In a recent investigation, women responded less to standard oxygen therapy than men, and in that study 75% of the women had a smoking history vs 61% of the men.2 Longterm smokers have been shown to have a decreased cerebral vasoconstrictor response to 100% oxygen compared with nonsmokers.6 If cerebral vessel constriction and subsequent reduction in cerebral blood flow is one of the keys to oxygen’s abortive effect in cluster, cluster headache patients with a more substantial smoking history would theoretically have less vasoconstrictor response to 100% oxygen especially at low flow rates and thus a poor response to standard oxygen therapy. Increasing the flow rate of oxygen could conceivably overcome this deficit in cerebral vasoconstrictor response, leading to headache alleviation. Before exposing Magnesium. Magnesium has been identified as having an integral role in the pathogenesis of migraine. 21 Patients with migraine frequently have low serum and tissue levels of magnesium A study of 40 consecutive patients with migraine found that intravenous treatment with magnesium sulfate provided at least a 50% reduction in pain in 35 patients within 15 minutes of infusion.25 Further analysis showed that 86% of patients who responded to magnesium had low pretreatment serum ionized magnesium levels, in contrast to only 16% of the nonresponders. Two of three double-masked studies found positive results with magnesium supplementation. 24,25 In the third study, the most common adverse event was diarrhea or soft stools, which were reported by 18.6% of patients receiving magnesium therapy.26 Overall, the rate of withdrawal because of side effects was only 7%. A recent report of a doublemasked study of magnesium supplementation in children also showed significantly decreased headache frequency (p ) and severity (p 0.0029).27 Patients can increase their magnesium levels by increasing their intake of nuts; legumes, which are rich in magnesium but can trigger migraines; dark, leafy green vegetables; whole grain cereals and breads; and seafood. investigation. Botanical remedies, in the forms of aromatherapy, oral preparations, and topical applications, also have been examined for the prevention of migraine. Intranasal application of capsaicin has been used for patients with cluster headaches and also as rescue medication for migraine headaches. Aromatherapy with peppermint oil has been shown to produce analgesic effect in experimentally induced pain and in patients with tension-type headaches.30,31 Conclusions. Clinical scientific evidence validating the efficacy of alternative treatments for migraine is variable; behavioral interventions have the most support. These interventions can be used to complement traditional pharmacologic interventions. Clinicians who are familiar with alternative approaches to headache treatment can direct their patients to the techniques that are most likely to be safe and effective. References 1. Astin JA. Why patients use alternative medicine: results of a national study. JAMA 1998;279:1548–1553. Dr Claudio Martínez G

Manejo de MIGRAÑA Tratamiento de crisis Profilaxis NO farmacológico.
Inespecífico específico Profilaxis No farmacológica Identificación de gatillos CAM Meditación Relajación Psicoterapia Farmacológica Dr Claudio Martínez G

Efecto Placebo. % de pacientes responden favorablemente al placebo. ¿Por cuánto tiempo? Este efecto placebo puede dar cuenta que terapias completamente inútiles sean efectivas en algunos pacientes “Si una particular terapia nos parece ser claramente inefectiva pero al mismo tiempo es inofensiva y barata no podemos descorazonar al paciente interesado en usarla, en espera de una repuesta placebo favorable”. (Alex Mauskop, M.D) Dr Claudio Martínez G

4) Trat. no farmacológico inadecuado
Why headache treatment fails Lipton, R.B. MD; Silberstein, S.D. MD, FACP; Saper, J.R. MD, FACP; Bigal, M.E. MD, PhD; Goadsby, P.J. MD, PhD 1) El diagnóstico es incompleto o incorrecto 2) Se han obviado importantes factores exacerbantes 3) Farmacoterapia inadecuada 4) Trat. no farmacológico inadecuado 5) Otros factores, incluyendo expectativas no reales y comorbilidad . They have grouped these treatment failures into five broad categories: Dietary or lifestyle factors may play a significant role in headache. 50 Explore the patient’s marital and family status, education, occupation, outside interests, and friendships. Stressful life events, such as divorce, widowhood, separation, and problems with children, are more likely to be associated with refractory headaches, when compared with controls. 51 Alcohol use, especially red wine, may trigger headaches. 50 A history of multiple sexual partners should prompt a search for a potential infectious cause of the headache. Sleep apnea is common in middle-aged obese men and may cause morning headache. 52 Depression or anxiety may present with difficulty in falling asleep or staying asleep, or with early morning awakening. Careful questioning about possible stressors may uncover a source of conflict or a psychological component to the headache, which can lead to intractability in some patients, especially those with very frequent headaches. Some dietary factors, including aspartame, may trigger headache. 53,54 Vitamin A and D overuse may cause intracranial hypertension. 55 Patients who are tense sometimes need physical medicine or behavioral interventions. Patients with occipital tenderness and trigger points often do not get relief of their headache disorder until they have a nerve block or trigger point injection. 68 Patients with intractable headache disorder sometimes are relieved by the use of trigger point injections into tender areas using a combination of a local anesthetic and a depocorticosteroid. Occasional occipital nerve and facet joint blocks are useful, generally when there are concomitant physical signs, such as sensory abnormality over the C2 distribution on the back of the head. Physical therapy is often a useful adjunct for these patients. Patients who are tense and anxious and have trouble coping with their daily existence can have trouble getting their headaches under control. Cognitive training helps them decrease the stress they impose on themselves and may improve their headaches. 66,67 In patients with intractable headache, it is useful to separate pain and ability to function. If pain does not improve, behavioral strategies should focus on optimizing function. Patients should understand that the most effective preventive agents are 20% to 50% better than placebo and only 10% or less of patients become completely headache-free with preventive therapy.53 The best preventive effects of treatment are usually not achieved after a short trial of therapy; most experts recommend 8 to 12 weeks as a reasonable trial period for preventive migraine medication. Patients who are tense sometimes need physical medicine or behavioral interventions. Patients with occipital tenderness and trigger points often do not get relief of their headache disorder until they have a nerve block or trigger point injection.68 Physical therapy is often a useful adjunct for these patients. Patients who are tense and anxious and have trouble coping with their daily existence can have trouble getting their headaches under control. Patients who are tense and anxious and have trouble coping with their daily existence can have trouble getting their headaches under control. Cognitive training helps them decrease the stress they impose on themselves and may improve their headaches.66,67 Dr Claudio Martínez G Neurology Volume 60(7), 8 April 2003, pp

Objetivos del tratamiento CAM en cefalea
< frecuencia y severidad de crisis < la necesidad de medicación aguda y profiláctica < el estrés y síntomas psicológicos relacionados a la cefalea > control personal de las cefaleas. Objetivos del tratamiento conductual y físico Similares al tratamiento con medicamentos para la crisis y profilaxis,se necesita definir claramente los objetivos con expectativas realistas cuando se incorpora terapia no farmacológica en el plan de tratamiernto. Los objetivos: < frecuencia y severidad de crisis < la necesidad de medicación aguda y profiláctica < el estrés y la ansiedad relacionada a la cefalea. Estas medidas dan al paciente a menudo un aumento del control de las crisis mejorando por consiguiente la satisfacción del tratamiento. Raramente el tratamiento no farmacológico es usado en forma exclusiva, sin embargo, hay ciertos pacientes que prefieren tal acercamiento y otros que tienen significativas contraindicaciones o coexisten condiciones que los hacen malos candidatos para erl tratamiento farmacológico. Campbell JK, Penzien DB, Wall EM. Evidence-based Guidelines for Migraine Headache: Behavioral and Physical Treatments. [American Academy of Neurology Web Site]. April 23, http// Accessed September 1, 2000. Establish a comprehensive migraine management plan that includes long-term goals, tips on when the medication needs to be changed, and a regular office visit schedule. Also included is specific information on adverse reactions that may warrant discontinuing the medication, returning to the clinic, calling the office, or even going to the hospital on an emergency basis. As stress was a trigger, we gave him progressive relaxation exercises and stress management.His headaches responded well to triptans and decreased in frequency, perhaps due to stress management. Had the frequency not declined, we would have re-addressed preventive treatment Principios de manejo cuando se usa tratamiento no farmacológico Comprometer al paciente en el plan de manejo. Manejar las expectativas del paciente en cómo y cuanto puede mejorar. Coordinar el plan de tratamiento con otros profesionales de la salud. Principles of Management When Using Nonpharmacologic Therapies Como con los medicamentos, el paciente debe estar comprometido en la decisión de usar terapia no farmacológica. Como estas técnicas son proactivas en su mayoría de los casos si el paciente no está interesado en ella es improbable el éxito. Nuevamente es importante manejar las expectativas y minimizar las desilusiones con una técnica o un resultado. Como muchos médicos no manejan o enseñan estas técnicas el tratamiento debe ser coordinado con otros profesionales de la salud. Campbell JK, Penzien DB, Wall EM. Evidence-based Guidelines for Migraine Headache: Behavioral and Physical Treatments. [American Academy of Neurology Web Site]. April 23, Available at: http// Accessed September 1, 2000. Dr Claudio Martínez G

Terapia no farmacológica y ensayos clínicos
Tratamientos conductuales Hipnoterapia Biofeedback térmico* Biofeedback EMG* Trat,. Relajación * Terapia cognitivo conductual* *Eficacia probada en trabajos doble ciego. Tratamientos físicos - TENS - Tratamiento de ATM - Manipulación cervical - Acupuntura * Otros Homeopatía yerbas Nonpharmacologic Therapies Tested in Clinical Trials There are many nonpharmacologic treatments used as preventive therapies for migraine; those tested in clinical trials’ settings are listed herein. Most of the treatments can be classified as either behavioral or physical therapies. Relaxation therapy, thermal biofeedback, EMG biofeedback, and cognitive/behavioral management therapy have all reported efficacy as preventive therapy for migraine. Campbell JK, Penzien DB, Wall EM. Evidence-based Guidelines for Migraine Headache: Behavioral and Physical Treatments. [American Academy of Neurology Web Site]. April 23, Available at: http// Accessed September 1, 2000. Dr Claudio Martínez G Adaptado de US Headache Consortium:Headache Guidelines

Recomendaciones de tratamiento
Opciones de tratamiento con grado A de evidencia. Terapia de relajación Biofeedback térmico combinado con terapia de relajación. Biofeedback EMG Terapia cognitivo conductual Acupuntura Treatment Recommendations Relaxation therapy, thermal biofeedback, EMG biofeedback, and cognitive-behavioral therapy are all treatment options for which there is Grade-A evidence of efficacy. Grade-A evidence is defined as having multiple, well-designed, randomized clinical trials with a consistent pattern of findings and direct relevance to the recommendation. Campbell JK, Penzien DB, Wall EM. Evidence-based Guidelines for Migraine Headache: Behavioral and Physical Treatments. [American Academy of Neurology Web Site]. April 23, Available at: http// Accessed September 1, 2000. Evidencia grado A se define como la que tiene múltiples ensayos clínicos de buen diseño aleatorios y doble ciego directamente relevantes a la recomendación con un consistente patrón de resultados. Campbell JK, Penzien DB, Wall EM. Evidence-based Guidelines for Migraine Headache: Behavioral and Physical Treatments. [American Academy of Neurology]. April 23, 2000. Dr Claudio Martínez G

Tratamiento no farmacológico crisis migrañosa
Pocos datos confiables sobre efectividad. Disminución de ruido ambiental Reposo en la oscuridad Aplicación de hielo Dormir Masaje o compresión (si aún no hay alodinia) Hiperventilación y O2 Hielo Other: Some people have also found the following helpful in relieving the symptoms of migraine: cooling applications to the head and neck (there are numerous masks, caps and gel patches available) peppermint to reduce nausea lavender - inhaled or rubbed onto the temples Mientras se obtienen datos más precisos y confiables las siguientes acciones pueden recomendarse como beneficiosas: Dr Claudio Martínez G

Practice parameter: Evidence-based guidelines for migraine headache (an evidence-based review) Report of the Quality Standards Subcommittee of the American Academy of Neurology Neurology 2000;55: Stephen D. Silberstein, MD El tratamiento conductual y la intervención física: más para profilaxis que para crisis. Aunque estas modalidades pueden ser efectivas como monoterapia son usadas preferentemente junto a tratamiento farmacológico. Behavioral and physical interventions are used for preventing migraine episodes rather than for alleviating symptoms once an attack has begun. Although these modalities may be effective as monotherapy, they are more commonly used in conjunction with pharmacologic management Dr Claudio Martínez G

CTTCr: Tratamiento con AD tricíclicos y Terapia antiestrés Holroyd Kenneth A. Cols. JAMA, 2001;285: 203 pacientes. Mujeres 76%. CTT cr. Amitriptilina o nortriptilina: ………..53 pacientes** Placebo …………………………… “ Terapia anti estrés más placebo “ Terapia combinada (AD+ TAest) “ Pacientes que < en más de 50% scores de cefalea: AD %; (P 0.006) Antiestrés % (P 0.003) Placebo % (P0.001) Terapia combinada 64%. Context: Chronic tension-type headaches are characterized by near-daily headaches and often are difficult to manage in primary practice. Behavioral and pharmacological therapies each appear modestly effective, but data are lacking on their separate and combined effects. Objective: To evaluate the clinical efficacy of behavioral and pharmacological therapies, singly and combined, for chronic tension-type headaches. Design and Setting: Randomized placebo-controlled trial conducted from August 1995 to January 1998 at 2 outpatient sites in Ohio. Participants: Two hundred three adults (mean age, 37 years; 76% women) with diagnosis of chronic tension-type headaches (mean, 26 headache d/mo). Interventions: Participants were randomly assigned to receive tricyclic antidepressant (amitriptyline hydrochloride, up to 100 mg/d, or nortriptyline hydrochloride, up to 75 mg/d) medication (n = 53), placebo (n = 48), stress management (eg, relaxation, cognitive coping) therapy (3 sessions and 2 telephone contacts) plus placebo (n = 49), or stress management therapy plus antidepressant medication (n = 53). Main Outcome Measures: Monthly headache index scores calculated as the mean of pain ratings (0-10 scale) recorded by participants in a daily diary 4 times per day; number of days per month with at least moderate pain (pain rating >=5), analgesic medication use, and Headache Disability Inventory scores, compared by intervention group. Results: Tricyclic antidepressant medication and stress management therapy each produced larger reductions in headache activity, analgesic medication use, and headache-related disability than placebo, but antidepressant medication yielded more rapid improvements in headache activity. Combined therapy was more likely to produce clinically significant (>=50%) reductions in headache index scores (64% of participants) than antidepressant medication (38% of participants; P =.006), stress management therapy (35%; P =.003), or placebo (29%; P =.001). On other measures the combined therapy and its 2 component therapies produced similar outcomes. Conclusions: Our results indicate that antidepressant medication and stress management therapy are each modestly effective in treating chronic tension-type headaches. Combined therapy may improve outcome relative to monotherapy. JAMA.2001;285: Dr Claudio Martínez G

Tratamiento conductual
Terapia de relajación Biofeedback Terapia cognitivo conductual (manejo del estrés) Table 3 Relaxation techniques ● Progressive muscle relaxation ● Autogenic training ● Meditation or passive relaxation Dr Claudio Martínez G

Técnicas de Relajación
Relajación muscular progresiva Entrenamiento autogénico Relajación pasiva y/o meditación Relaxation training. The three most widely used forms of relaxation training are progressive muscle relaxation (alternately tensing and relaxing selected muscle groups throughout the body),5 autogenic training (the use of self-instructions of warmth and heaviness to promote a state of deep relaxation),6 and meditation or passive relaxation (the use of a silently repeated word or sound to promote mental calm and relaxation)7 (table 3). Relaxation skills presumably enable headache sufferers to exert control over headache-related physiologic responses and, more generally, to lower sympathetic arousal. Relaxation also may provide a break from daily activities and help patients gain a personal sense of mastery or control over their symptoms. Patients typically are instructed to practice relaxation techniques 20 to 30 minutes a day initially. Then, as they master brief relaxation techniques, they are taught to integrate relaxation into their daily activities to prevent or abort the onset of headache episodes. Dr Claudio Martínez G

Biofeedback Medición de Tº de la piel Cambios en la Tº en manos o pies serían un reflejo del flujo sanguíneo y de algún modo una medida de la respuesta al estrés. Regla básica: Manos y/o pies más calientes indican relajación. Manos y/o pies más fríos indican tensión Biofeedback training. Biofeedback refers to any procedure that provides information about physiologic processes, usually through the use of electronic instrumentation, in the form of an observable display,typically an audio tone or visual display. The patient uses feedback about a particular physiologic function in learning to self-regulate the response being monitored.8 Thermal (hand-warming) feedback (feedback of skin temperature from a finger) is used most frequently in treating migraine, typically in conjunction with electromyographic feedback (feedback of electrical activity from muscles of the scalp or neck, or from relaxation training as described above). As with relaxation training, patients are instructed to practice the self-regulation skills they are learning during biofeedback training for about 20 to 30 minutes a day and, as they master self-regulation skills, to integrate these skills into daily activities to prevent or abort headache episodes. Table 4 lists various biofeedback techniques 2) BIO FEEDBACK El bio-feedback es una técnica que, mediante la utilización de aparatología especializada, el paciente puede aprender a controlar su dolor. Con estos instrumentos el enfermo es capaz de percibir algunas de sus funciones orgánicas; por ejemplo: el grado de contracturas musculares, la temperatura de su piel, el estado de sus arterias cerebrales, etc. Estas funciones le son exhibidas en forma de sonidos o imágenes en pantallas de televisión. En otras palabras, él escucha o puede visualizar el grado de contracción de sus músculos o el diámetro de sus arterias. A continuación el paciente aprender a descifrar estos códigos, y estará en condiciones de efectuar las modificaciones necesarias mediante la ayuda de personal técnico adecuadamente entrenado. En el caso de las MIGRAÑAS la persona logrará modificar la temperatura de su piel ( en su mano) y de esta forma contrarrestará el alterado estado de sus arterias cerebrales, involucrado en la producción de su dolor. A review recently completed by the Association for Applied Psychophysiology and Biofeedback (AAPB) (Yucha & Gilbert, 2004) determined that 6 disorders met the two highest standards of efficacy: anxiety, attention deficit disorder, headaches, hypertension, temporomandibular disorders, and urinary incontinence in women. Q. And what about biofeedback? A. While there are several types of biofeedback, the two that seem to work best and are well validated and most commonly used for headaches are electromyographic (EMG) biofeedback and warming, or temperature biofeedback. (17) 17. Chapman, S.L. (1986) A review and clinical perspective on the use of EMG and thermal biofeedback for chronic headaches. Pain 27(1), 1-43. Q. What is the difference between the two? A. EMG biofeedback is used to help patients learn to better control their muscular tension, because muscular involvement is often an important contributor to migraines. So it helps people learn when their muscles are reacting and how to reduce that muscular tension. We usually focus on the head and neck muscles. Temperature biofeedback is based on the notion that as you become more anxious and uptight, your fingertip temperature falls. The blood vessels in the fingertips are responsive to the sympathetic nervous system activation. So the more aroused you get, the cooler your hands get. We put a temperature biofeedback device on the fingertips and teach people through the feedback they get that if they can learn to warm their hands, they can learn how to reduce that level of arousal and relax. Q. How long does it take to learn this? A. With biofeedback, some people are just naturals at it. They're almost like star athletes and they have it right away. For most, it takes eight to 12 sessions to learn biofeedback. But once you've got the skills, it's like learning to ride a bike. It tends to stay with you and you don't need a lot of additional workups or booster sessions to keep your skills sharp. It's the same with relaxation training. Combining Autogenic Training and Biofeedback Thermal biofeedback and autogenic training combine two self-regulation techniques Autogenic phrases promote changes in the body Biofeedback device gives us a window into the body to see the changes Quickens the learning process Biofeedback makes apparent the changes triggered by AT Adverse Effects/Contraindications Risk for strong emotional response, “Ab reaction” Active psychosis CV status, Physical limitations for active meditations Remember, if people become anxious during a particular exercise they can always open their eyes or stop participating Dr Claudio Martínez G

Terapia cognitivo-conductual
Identificación de gatillos y/o factores que desencadenan o exacerban el estrés. Entrenamiento en técnicas C-C Aplicación de las técnicas en situaciones progresivamente más exigentes. Dr Claudio Martínez G

Terapia Cognitivo- Conductual
Apropiada para CTT crónica Niños y adolescentes Embarazadas o deseo de embarazo o lactancia. Inapropiada para: Migraña crónica Abuso de ergotamínicos, triptanes o analgésicos Trastorno psiquiátrico agregado Cognitive-behavioral (stress management) therapy. The rationale for the use of cognitive-behavioral therapy derives from the observation that the way individuals cope with everyday stressors can precipitate, exacerbate, or maintain headaches. Maladaptive responses to headaches can increase headache-related disability and distress. Cognitive-behavioral interventions alert patients to the role their thoughts and beliefs play in generating stress responses and to relationships between stress, coping efforts, and the occurrence of headaches (table 5). Patients are taught to use more effective strategies for coping with headache-related stresses and headaches themselves. Relaxation skills are typically one of several coping skills that are taught. Homework assignments help patients experiment with new coping skills and evaluate and refine these skills. Treatment formats. Behavioral interventions may require 4 to 12 treatment sessions when administered in the clinic. However, in what is termed a minimalcontact or home-based treatment format, just three or four monthly treatment sessions and two or three brief phone contacts are used to introduce headache management skills and address problems that patients may encounter when using these skills. Written materials and audio tapes that help patients learn headache management skills at home make this possible. Minimal-contact treatment appears to be effective for many patients.9 In contrast, efforts to administer behavioral interventions in a completely self-help treatment format have been plagued by high dropout rates and cannot be recommended Efficacy. The Agency for Healthcare Research and Quality (AHRQ) has reviewed controlled trials of behavioral treatments for migraine.10 The figure presents treatment effect sizes (the standardized Drawing on the AHRQ Evidence Report, the US Headache Consortium formulated clinical guidelines that conclude “relaxation training, thermal biofeedback combined with relaxation training, electromyographic biofeedback, and cognitive-behavioral therapy may be considered as treatment options for the prevention of migraine.”3,15 Dr Claudio Martínez G

Reducción de frecuencia de crisis con:
Acupuncture Treatment No More Effective Than Sham Treatment In Reducing Migraine Headaches JAMA Reducción de frecuencia de crisis con: Acupuntura Falsa acupuntura No acupuntura 302 pacientes The study consisted of a three-group, randomized, controlled trial (April 2002-January 2003) involving 302 patients (88 percent women), average age 43 years, with migraine headaches, based on International Headache Society criteria. Patients were randomized to either acupuncture, sham acupuncture, or waiting list control. Acupuncture and sham acupuncture were administered by specialized physicians and consisted of 12 sessions per patient over 8 weeks. The sham treatment consisted of needles placed at non-acupuncture points. Patients were treated at 18 outpatient centers in Germany. Patients completed headache diaries from 4 weeks before to 12 weeks after randomization and from week 21 to 24 after randomization. Acupuncture Treatment No More Effective Than Sham Treatment In Reducing Migraine Headaches Migraine patients who received true acupuncture had no decrease in headaches as compared with those who received sham acupuncture treatment, according to a study in the May 4 issue of JAMA. Related News Stories Acupuncture Cuts Tension Headache Rates By Almost Half (August 1, 2005) -- Acupuncture is an effective treatment for tension headache, cutting rates for sufferers by almost half, shows a study on bmj.com this ... > full story Acupuncture Better Than Drugs Alone For Osteoarthritis Of The Knee (November 24, 2004) -- Acupuncture, as a complementary therapy to drug treatment for osteoarthritis of the knee, is more effective than drug treatment alone, find researchers from Spain in the latest issue of ... > full story Acupuncture Relieves Pelvic Pain During Pregnancy (April 5, 2005) -- Acupuncture and strengthening exercises help relieve pelvic girdle pain during pregnancy and are effective complements to standard treatment, finds a study published online by the British Medical ... > full story UT Southwestern Researcher Investigates Acupuncture For Treatment Of Patients With Bipolar Disorder (December 18, 2001) -- Dr. Tricia Suppes has long been concerned about the 1.9 million Americans with bipolar disorder, also known as manic-depressive illness. That's why she's investigating a new use for an old ... > full story > more related stories Related sections: Health & Medicine Mind & Brain Migraine is a common and disabling condition that typically includes attacks of severe, pulsating, 1-sided headaches, often accompanied by nausea and sensitivity to sound and light, according to background information in the article. Population-based studies suggest that 6 percent to 7 percent of men and 15 percent to 18 percent of women experience migraine headaches. Many patients require interval treatment as attacks occur often or are insufficiently controlled. Drug treatment with beta-blockers, calcium antagonists, or other agents has been shown to reduce the frequency of migraine attacks; however, the success of treatment is usually modest and tolerability often suboptimal. Acupuncture is widely used for preventing migraine attacks although its effectiveness has not yet been fully established. Klaus Linde, M.D., of the Centre for Complementary Medicine Research, Technische Universität Munich, Germany, and colleagues investigated whether acupuncture reduced headache frequency more effectively than sham acupuncture or no acupuncture in patients with migraines. The study consisted of a three-group, randomized, controlled trial (April 2002-January 2003) involving 302 patients (88 percent women), average age 43 years, with migraine headaches, based on International Headache Society criteria. Patients were randomized to either acupuncture, sham acupuncture, or waiting list control. Acupuncture and sham acupuncture were administered by specialized physicians and consisted of 12 sessions per patient over 8 weeks. The sham treatment consisted of needles placed at non-acupuncture points. Patients were treated at 18 outpatient centers in Germany. Patients completed headache diaries from 4 weeks before to 12 weeks after randomization and from week 21 to 24 after randomization. The researchers found that between baseline and weeks 9 to 12, the average number of days with headache of moderate or severe intensity decreased by 2.2 days from a baseline of 5.2 days in the acupuncture group compared with a decrease to 2.2 days from a baseline of 5.0 days in the sham acupuncture group, and by 0.8 days from a baseline of 5.4 days in the waiting list group. No difference was detected between the acupuncture and the sham acupuncture groups while there was a difference between the acupuncture group compared with the waiting list group (1.4 days). The proportion of responders (reduction in headache days by at least 50 percent) was 51 percent in the acupuncture group, 53 percent in the sham acupuncture group, and 15 percent in the waiting list group. "In conclusion, in our trial, acupuncture was associated with a reduction of migraine headaches compared with no treatment; however, the effects were similar to those observed with sham acupuncture and may be due to nonspecific physiological effects of needling, to a powerful placebo effect, or to a combination of both," the authors write. ### (JAMA. 2005;293: About the Study The researchers recruited 302 patients (88% of whom were women) who suffered from migraine headaches. The participants were randomly assigned to one of three treatment groups: True acupuncture. Twelve 30-minute sessions over a period of eight weeks. Needles were placed at defined acupuncture points. Sham acupuncture. Twelve 30-minute sessions over a period of eight weeks. Needles were placed in at least five out of ten predefined non-acupuncture sites. Waiting list control group. Twelve weeks of no treatment, followed by true acupuncture as described above. Practitioners who were trained and experienced in acupuncture administered both the true and sham acupuncture. Although the practitioners knew whether the patients were receiving true or sham acupuncture, the patients did not. All patients maintained a headache diary from four weeks before the start of treatment, through 12 weeks after the start of treatment, and then at weeks after the start of treatment. They noted all migraine attacks and rated the pain intensity of each one. Finally, patients reported any adverse effects. The Findings Between the four weeks preceding the start of treatment and weeks nine to 12 after the start of treatment, the number of days with a migraine of moderate to severe intensity decreased by an average of 2.2 days in both the true acupuncture and sham acupuncture groups. On the other hand, patients in the waiting list control group experienced a decrease in moderate to severe migraines of only 0.8 days (from a baseline of 5.4 days) during the same time period. This differed significantly from both the true and sham acupuncture groups. The researchers also measured the proportion of responders, or patients whose moderate to severe migraines decreased by more than half. They found that 51% of true acupuncture patients and 53% of sham acupuncture patients were responders, compared to only 15% of patients in the waiting list group. Patients receiving true or sham acupuncture were also significantly less likely than patients in the waiting list group to need medication, experience other symptoms associated with migraines, or have their activities impaired by migraines. There were no significant differences between the true and sham acupuncture groups in these areas. None of the patients receiving true or sham acupuncture reported any serious adverse effects. This study is limited by the fact that subjects were primarily recruited through newspaper advertisements, which means they may have had a more positive attitude towards acupuncture than the average migraine sufferer. How Does This Affect You? This study found no significant differences between true and sham acupuncture in the reduction of moderate to severe migraine headaches. Interestingly, however, both true and sham acupuncture were significantly more beneficial than no treatment at all. But if true acupuncture fared no better than sham acupuncture, then why should both—or either—be more effective than no treatment at all? The study authors speculate that although their sham acupuncture was designed not to elicit a response, it may have stimulated an unintentional physiolologic response that helped prevent migraines. Another possibility is that true and sham acupuncture may have a powerful placebo effect. In medication trials, a person taking a placebo is simply swallowing a pill. But with acupuncture, even the sham acupuncture patient is interacting frequently with a practitioner, and is experiencing the ritual associated with acupuncture. As a result, the benefit of the overall experience, if not the acupuncture itself, may be profound enough to have a clinically important impact. While true acupuncture was no more effective than sham acupuncture in this study, this form of therapy does appear to have some benefit. And, unlike with medications, the risk of adverse effects is minimal. If you decide to try acupuncture, the National Center for Complementary and Alternative Medicine recommends the following: Ask your primary health care provider if he or she can recommend a practitioner. Find out about the practitioner’s license and credentials, and where they received their training. Ask you insurer whether they will cover the cost of therapy. Also, when you meet with the acupuncturist, be sure to discuss his or her treatment plan up front. Like many medications, the effectiveness of acupuncture can only be determined after a trial period. A competent acupuncturist will be able to estimate the number of sessions required during this period. It is also essential that you discuss all migraine treatments you are receiving with both your primary care provider and your acupuncturist. Acupuncture for Patients With Migraine A Randomized Controlled Trial Klaus Linde, MD; Andrea Streng, PhD; Susanne Jürgens, MSc; Andrea Hoppe, MD; Benno Brinkhaus, MD; Claudia Witt, MD; Stephan Wagenpfeil, PhD; Volker Pfaffenrath, MD; Michael G. Hammes, MD; Wolfgang Weidenhammer, PhD; Stefan N. Willich, MD, MPH; Dieter Melchart, MD JAMA. 2005;293: Context Acupuncture is widely used to prevent migraine attacks, but the available evidence of its benefit is scarce. Objective To investigate the effectiveness of acupuncture compared with sham acupuncture and with no acupuncture in patients with migraine. Design, Setting, and Patients Three-group, randomized, controlled trial (April 2002-January 2003) involving 302 patients (88% women), mean (SD) age of 43 (11) years, with migraine headaches, based on International Headache Society criteria. Patients were treated at 18 outpatient centers in Germany. Interventions Acupuncture, sham acupuncture, or waiting list control. Acupuncture and sham acupuncture were administered by specialized physicians and consisted of 12 sessions per patient over 8 weeks. Patients completed headache diaries from 4 weeks before to 12 weeks after randomization and from week 21 to 24 after randomization. Main Outcome Measures Difference in headache days of moderate or severe intensity between the 4 weeks before and weeks 9 to 12 after randomization. Results Between baseline and weeks 9 to 12, the mean (SD) number of days with headache of moderate or severe intensity decreased by 2.2 (2.7) days from a baseline of 5.2 (2.5) days in the acupuncture group compared with a decrease to 2.2 (2.7) days from a baseline of 5.0 (2.4) days in the sham acupuncture group, and by 0.8 (2.0) days from a baseline if 5.4 (3.0) days in the waiting list group. No difference was detected between the acupuncture and the sham acupuncture groups (0.0 days, 95% confidence interval, –0.7 to 0.7 days; P = .96) while there was a difference between the acupuncture group compared with the waiting list group (1.4 days; 95% confidence interval; days; P<.001). The proportion of responders (reduction in headache days by at least 50%) was 51% in the acupuncture group, 53% in the sham acupuncture group, and 15% in the waiting list group. Conclusion Acupuncture was no more effective than sham acupuncture in reducing migraine headaches although both interventions were more effective than a waiting list control. Author Affiliations: Centre for Complementary Medicine Research, Department of Internal Medicine II (Drs Linde, Streng, Hoppe, Weidenhammer, and Melchart and Mrs Jürgens), Institute of Medical Statistics and Epidemiology (Dr Wagenpfeil), and Department of Neurology (Dr Hammes), Technische Universität München, Munich, Germany; Institute of Social Medicine, Epidemiology, and Health Economics, Charité University Medical Center, Berlin, Germany (Drs Brinkhaus, Witt, and Willich); Munich, Germany (Dr Pfaffenrath); and Division of Complementary Medicine, Department of Internal Medicine, University Hospital Zurich, Zurich, Switzerland (Dr Melchart). A 1997 NIH consensus statement supported acupuncture as a legitimate therapy with proven efficacy for adult postoperative and It also suggested possible efficacy as adjunctive therapy or as an acceptable alternative deserving additional investigation for a variety of other painful conditions, including headache. For patients with chronic headaches, acupuncture treatment entails at least 10 weekly 20-minute sessions, frequently with electrical stimulation of the needles rather than the traditional manual twirling. Animal studies indicate endorphin-mediated and serotonin-mediated mechanisms of action. Furthermore, a larger portion of patients who experienced both treatment modalities preferred acupuncture to medical treatment. . Available studies provide suggestive, but not convincing, evidence of the efficacy of acupuncture. Further research is needed to determine the role of acupuncture in migraine treatment. Dr Claudio Martínez G Klaus Linde, M.D., Centre for Complementary Medicine Research, Technische Universität Munich, Germany, and colleagues

Acupuncture Treatment No More Effective Than Sham Treatment In Reducing Migraine Headaches JAMA La proporción de respondedores (< en los días de cefalea al menos 50%) fue: 51º% en el grupo acupuntura 53% en el grupo acupuntura falsa 15% en el grupo de espera. “Esto puede ser debido a un efecto fisiológico inespecífico de los pinchazos, a un poderoso efecto placebo o a una combinación de ambos” The study consisted of a three-group, randomized, controlled trial (April 2002-January 2003) involving 302 patients (88 percent women), average age 43 years, with migraine headaches, based on International Headache Society criteria. Patients were randomized to either acupuncture, sham acupuncture, or waiting list control. Acupuncture and sham acupuncture were administered by specialized physicians and consisted of 12 sessions per patient over 8 weeks. The sham treatment consisted of needles placed at non-acupuncture points. Patients were treated at 18 outpatient centers in Germany. Patients completed headache diaries from 4 weeks before to 12 weeks after randomization and from week 21 to 24 after randomization. Klaus Linde Klaus Linde was born in Munich, Germany, in 1960 and is married, with two children (born 1984 and 1988). After completing 13 (mostly boring) years at school he worked in the civil service (1980–81) with severely handicapped children in Bielefeld. After some travelling, he studied German literature and ethnology at the University of Freiburg (1981–82). Subsequently, after a phase of orientation with travelling and work, he decided to study medicine in Italy. This entailed the study of Italian language at Florence in 1983 and first year of medicine at University of Bologna (1983–84). He became ‘more serious and responsible’ after the birth of a son, with continuation of study of medicine in Munich (1984–89). His MD thesis was on dose-dependent reversal effects. Since 1991 he has worked for the Centre of Complementary Medicine Research (formerly Münchener Modell) in Munich; from 1999 to 2001 he did additional part-time work and completed a PhD thesis in epidemiology at the Institute for Social Medicine, Epidemiology and Health Economics at the Humboldt-University, Berlin. Q Who was your most influential teacher? KL: My grandfather (a Protestant parson) who taught me, among many other things, to doubt and have confidence at the same time. Q What part of your work gives you the most pleasure? KL: When all the data are entered and I run the first analysis. Q If you had not entered your current profession, what would you have liked to do? KL: To write novels or to teach literature. Q What makes a good researcher? KL: Creative uncertainty, experience, patience and reliability. Q Which complementary therapies do you use yourself? KL: If possible, I prefer no treatment to any treatment. However, sometimes I use Hamamelis ointment (figure out for what) or echinacea, and I have been treated with homoeopathy, acupuncture, and Tuina in the past. Q What stimulates your creativity? KL: Talking and discussing with people who have different opinions. Q What is the most treasured possession in your life? KL: My family. Q What is your favourite dream? KL: Writing a good novel. Q What makes you happy? KL: A nice dinner with good wine, being in the mountains when the weather is fine, cycling downhill, if a tune I play on the piano runs really well, when I play football and I hit the ball perfectly…. Q What do you deplore in yourself? KL: That I have great difficulties in conflicts between being too soft and getting angry. Q What do you deplore in others? KL: Depends on who is the other. Q What was the most embarrassing moment in your life? KL: Too private… Q How do you keep fit? KL: Soccer, cycling, walking. Q What is your favourite book/film? KL: Short Cuts, Black Cat, White Cat; Once Upon a Time in the West; Able con ella, Leaving Las Vegas, Casablanca… Der Idiot, Michael Kohlhaas, Du meine Pappel im roten Kopftuch (Aitmatov)… Q If you were invited on the Jerry Springer show – why would this be? KL: Never heard of the Jerry Springer show. Klaus Linde, M.D., Centre for Complementary Medicine Research, Technische Universität Munich, Germany, and colleagues Dr Claudio Martínez G

“Respondedores” (+ de 50% reducción días de cefalea):
Acupuncture in patients with tension-type headache: randomised controlled trial. D.Melchart, A.Streng, A.Hoppe, B. C. Witt, S. Wagenpfeil, V.r,Pfaffenrath, M.Hammes, J.Hummelsberger, D.Irnich,W. Weidenhammer, S.Willich, K.Linde BMJ, 29 July 2005) “Respondedores” (+ de 50% reducción días de cefalea): Acupuntura % Acupuntura mínima % Lista de espera % D.Melchart, A.Streng, A.Hoppe, B. C. Witt, S. Wagenpfeil, V.r,Pfaffenrath, M.Hammes, J.Hummelsberger, D.Irnich,W. Weidenhammer, S.Willich, K.Linde BMJ, 29 July 2005) Participants 270 patients (74% women, mean age 43 (SD 13) years) with episodic or chronic tension-type headache. Interventions Acupuncture, minimal acupuncture (superficial needling at non-acupuncture points), or waiting list control. Acupuncture and minimal acupuncture were administered by specialised physicians and consisted of 12 sessions per patient over eight weeks. Main outcome measure Difference in numbers of days with headache between the four weeks before randomisation and weeks 9-12 after randomisation, as recorded by participants in headache diaries. Results The number of days with headache decreased by 7.2 (SD 6.5) days in the acupuncture group compared with 6.6 (SD 6.0) days in the minimal acupuncture group and 1.5 (SD 3.7) days in the waiting list group (difference: acupuncture v minimal acupuncture, 0.6 days, 95% confidence interval -1.5 to 2.6 days, P = 0.58; acupuncture v waiting list, 5.7 days, 3.9 to 7.5 days, P < 0.001). The proportion of responders (at least 50% reduction in days with headache) was 46% in the acupuncture group, 35% in the minimal acupuncture group, and 4% in the waiting list group. Conclusions The acupuncture intervention investigated in this trial was more effective than no treatment but not significantly more effective than minimal acupuncture for the treatment of tension-type headache. Safety of acupuncture 395 reported cases of complications, 216 definite, in 20 years transmission of infectious diseases penetrating injury pneumothorax, spinal, renal, haemopericardium minor drowsiness, syncope Dr Claudio Martínez G

Acupuncture in patients with tension-type headache: randomised controlled trial. D.Melchart, A.Streng, A.Hoppe, B. C. Witt, S. Wagenpfeil, V.r,Pfaffenrath, M.Hammes, J.Hummelsberger, D.Irnich,W. Weidenhammer, S.Willich, K.Linde BMJ, 29 July 2005) Conclusiones: La acupuntura fue más efectiva que el NO tratamiento pero no significativamente más efectiva que la “acupuntura mínima” para el tratamiento de la CTT. Participants 270 patients (74% women, mean age 43 (SD 13) years) with episodic or chronic tension-type headache. Interventions Acupuncture, minimal acupuncture (superficial needling at non-acupuncture points), or waiting list control. Acupuncture and minimal acupuncture were administered by specialised physicians and consisted of 12 sessions per patient over eight weeks. Main outcome measure Difference in numbers of days with headache between the four weeks before randomisation and weeks 9-12 after randomisation, as recorded by participants in headache diaries. Results The number of days with headache decreased by 7.2 (SD 6.5) days in the acupuncture group compared with 6.6 (SD 6.0) days in the minimal acupuncture group and 1.5 (SD 3.7) days in the waiting list group (difference: acupuncture v minimal acupuncture, 0.6 days, 95% confidence interval -1.5 to 2.6 days, P = 0.58; acupuncture v waiting list, 5.7 days, 3.9 to 7.5 days, P < 0.001). The proportion of responders (at least 50% reduction in days with headache) was 46% in the acupuncture group, 35% in the minimal acupuncture group, and 4% in the waiting list group. Conclusions The acupuncture intervention investigated in this trial was more effective than no treatment but not significantly more effective than minimal acupuncture for the treatment of tension-type headache. Dr Claudio Martínez G

Aproximadamente 4% de los adultos sufren de cefalea crónica diaria.
A Randomized, Controlled Trial of Acupuncture for Chronic Daily Headache Remy R. Coeytaux, MD…., Headache Vol 45 October 2005 Aproximadamente 4% de los adultos sufren de cefalea crónica diaria. La intervención no farmacológica puede ser apropiada debido a que el manejo médico exclusivo (drogas) es a menudo inefectivo. Research Submission. A Randomized, Controlled Trial of Acupuncture for Chronic Daily Headache Remy R. Coeytaux, MD, PhD; Jay S. Kaufman, PhD; Ted J. Kaptchuk, OMD; Wunian Chen, MD; William C. Miller, MD, PhD, MPH; Leigh F. Callahan, PhD; J. Douglas Mann, MD Dr Claudio Martínez G

Objetivo: Método. 74 pacientes
A Randomized, Controlled Trial of Acupuncture for Chronic Daily Headache Remy R. Coeytaux, MD…., Headache Vol 45 October 2005 Objetivo: Evaluar la eficacia de la acupuntura adjunta al tratamiento médico para el manejo de la cefalea crónica diaria. Método. 74 pacientes Estudio aleatorio y controlado: Tratamiento médico (neurólogo) VS tratamiento médico + 10 tratamientos acupuntura, Se midió: severidad diaria del dolor y calidad de vida relacionada a la cefalea (QoL). Research Submission. A Randomized, Controlled Trial of Acupuncture for Chronic Daily Headache Remy R. Coeytaux, MD, PhD; Jay S. Kaufman, PhD; Ted J. Kaptchuk, OMD; Wunian Chen, MD; William C. Miller, MD, PhD, MPH; Leigh F. Callahan, PhD; J. Douglas Mann, MD Dr Claudio Martínez G

A Randomized, Controlled Trial of Acupuncture for Chronic Daily Headache Remy R. Coeytaux, MD…., Headache Vol 45 October 2005 Conclusión: El manejo médico por especialista en cefalea no estuvo asociado con mejoría clínica en nuestra población estudiada. El suplemento de acupuntura resultó en mejoría de calidad de vida (QoL) y en la percepción de los pacientes que tuvieron menos sufrimiento por la cefalea. Headache: The Journal of Head and Face Pain Volume 45 Issue 9 Page 1113 - October 2005 doi: /j x Research SubmissionA Randomized, Controlled Trial of Acupuncture for Chronic Daily HeadacheRemy R. Coeytaux, MD, PhD; Jay S. Kaufman, PhD; Ted J. Kaptchuk, OMD; Wunian Chen, MD; William C. Miller, MD, PhD, MPH; Leigh F. Callahan, PhD; J. Douglas Mann, MD University of North Carolina Results. Patients who received only medical management did not demonstrate improvement in any of the standardized measures. Daily pain severity scores trended downward but did not differ between treatment groups (P= .60). Relative to medical management only, medical management plus acupuncture was associated with an improvement of 3.0 points (95% CI, 1.0 to 4.9) on the Headache Impact Test and an increase of 8 or more points on the role limitations due to physical problems, social functioning, and general mental health domains of the Short Form 36 Health Survey. Patients who received acupuncture were 3.7 times more likely (CI, 1.7 to 8.1) to report less suffering from headaches at 6 weeks (absolute risk reduction 46%; number needed to treat 2). Resultados. Los pacientes que recibieron sólo tratamiento médico no mostraron mejoría en ninguna de las medidas estandarizadas. Los score de severidad de dolor diario tendieron a bajar pero no difirieron entre los grupos e tratamiento (P= .60). En relación al tratamiento médico puro el tratamiento +acupuntura se asoció con una mejoría de 3 puntos (95% CI, 1.0 a 4.9) en el “test de impacto de la cefalea” y una mejoría de 8 o más puntos en calidad de vida (role limitations due to physical problems, social functioning, and general mental health domains of the Short Form 36 Health Survey) Los pacientes que recibieron acupuntura tuvieron 3.7 veces más probabilidad (CI, 1.7 to 8.1) de reportar menos sufrimiento a las 6 semanas (riesgo absoluto de reducción 46%; NNT=2). Dr Claudio Martínez G

Feverfew ¿Mecanismo? Dos de cinco trabajos no detectaron diferencias con el placebo. Tres trabajos detectan ventajas sobre placebo pero tienen algunos problemas de diseño. "data favor feverfew over placebo." But more study is needed to arrive at a definitive answer. Cephalagia 1998;18: Tanacetum parthenium Feverfew (Tanacetum parthenium) is currently the only herbal agent that has been tested in a randomized, doublemasked, treatment of recurrent migraine: a meta-analysis of over fivedozen group outcome studies. placebo-controlled trial.29 It has been shown to afford mild prophylaxis against migraine vs placebo (table 7). Patients receiving feverfew experienced a reduction in the mean number (p _ 0.005) and severity of attacks and in the degree of nausea and vomiting (p _ 0.02). Feverfew, however, had no significant effect on the duration of attacks. Feverfew is a relatively safe remedy and can be recommended to patients interested in herbal approaches. ● Feverfew reduced mean number of attacks (3.6 vs 4.7; p _ 0.005) ● Global assessment of improvement on Visual Analogue Scale (74 vs 60; p _ ) ● Reduced nausea and vomiting (p _ 0.02) ● Tendency toward milder intensity of pain ● No effect on duration of attacks Paper presented at the Association for Advancement of Behavior Therapy Meeting, Houston, Guilford Press, 1985. Feverfew for migraine prophylaxis Dr Claudio Martínez G

Quiropráctica y osteopatía Código 1
Una de las más usadas en USA. Tiene la mayor frecuencia de efectos adversos de la CAM. Su efectividad en tratar cefalea y específicamente migraña no ha sido establecida. Structural imbalances in the neck and spine can cause chronic tension. Although research studies have failed to confirm that manipulation techniques are generally helpful for headaches, if you have obvious tender points in your neck and suspect that they may be contributing to headaches, it may be worth being checked by an osteopath or chiropractor. Cranial osteopathy is a type of very gentle manipulation that is said to help encourage the flow of the spinal fluid. Its effectiveness in treating headaches and migraine has not yet been established by scientific research, although there are anecdotal reports of its usefulness Dr Claudio Martínez G

Manual Therapies in the Management of Tension-Type Headache C Fernández,; Cristina Alonso-Blanco; M Cuadrado,; J Miangolarra,; F Barriga, ; J Pareja, Headache: Vol 45 February 2005 Meta-análisis: No se encuentra evidencia que las terapias manuales sean efectivas en CTT. Se requiere mayores estudios pata considerarlas útiles en CTT. Dr Claudio Martínez G

Homeopatía "Now doctors need to be bold and honest with their patients about homeopathy's lack of benefit, and with themselves about the failings of modern medicine to address patients' needs for personalized care." Lancet 2005;366: , Dr. Matthias Egger, from the University of Berne in Switzerland, and associates searched 19 electronic databases covering the period from 1995 to 2003 to identify randomized, placebo-controlled trials of homeopathy. Trials in conventional medicine were randomly selected from the first issue of the Cochrane Controlled Trials Register in 2003 and matched with the homeopathy trials for disorder and outcome measures Included were 110 trials each of homeopathy and conventional medicine, with a median of 65 subjects in each. The investigators separately analyzed the larger trials (trials with standard error in the lowest quartile) and of high-quality methodological quality (with adequate randomization, masking, and data analysis by intention to treat). They conducted a random-effects meta-analysis to estimate odds ratios, with those below 1.0 indicating a beneficial effect of treatment. Included were eight trials of homeopathy and six trials of conventional medicine. The restricted analysis revealed odds ratio of 0.88 for homeopathy and 0.58 for conventional medicine. Including the largest trials, the corresponding odds ratios were 0.96 and 0.67. En este último estudio, realizado por la Universidad de Berna, los autores señalaban que la eficacia de los remedios homeopáticos es comparable a la de placebo y que los efectos beneficiosos se deben a la autosugestión del paciente. El estudio comparó dos grupos de ensayos clínicos, uno formado por 110 trabajos sobre homeopatía y otro por 110 estudios con fármacos tradicionales. Constitutional treatment is usually recommended especially for chronic headaches and migraine. Specific remedies may be suggested for certain types of headache depending on symptoms. These may include aconite, for headaches that feel as if there is a tight band around the head, belladonna for a throbbing headache with feelings of heat, ruta for a headache with a feeling of pressure and bruising and fatigue that is eased by resting. Homoeopathy: although homoeopathic remedies can be bought over the counter it is advisable to consult a homoeopath as there are over 100 remedies that can be prescribed for headache disorders, according to the needs of each individual. The principle of homoeopathy is treating like with like. Particular substances have been shown to produce certain symptoms in healthy individuals; a heavily diluted form is given to cure a sick person who has these symptoms. The dilutions can range from one drop of the active ingredient in 99 drops of water (1/100 or 1c) or diluted further to by one drop of the 1c solution in anther 99 drops of water (1/1000 or 2c) and still further with one drop of the 2c solution to another 99 drops of water (1/ or 3c). The minimum effective dose is used. Remedies are usually supplied in very small tablets to be dissolved on the tongue. MIGRAINE HEADACHE RELIEF Tablets Made from all-natural ingredients, homeopathic remedies contain no synthetic drugs. Regular Price: $7.95 On Sale Only: $3.97 You Save 50% Buy 3 or more - Save 60% Potency: N/A Quantity: 96 Tablets Product #: 008509 Complementary Therapies in Medicine. 1999; Bandolier One high quality (86%) trial that was both randomised and double blind compared individualised homeopathic treatment with placebo in 98 chronic TTH patients. After 12 weeks of treatment there was no difference between homeopathy and placebo on any outcome measure. Homeopathic prophylaxis for migraineIn a systematic review the three studies with the strongest methods showed no difference between homeopathy and placebo. One methodologically weak study did show a difference, and some de-blinding was reported to have been possible. Safety of homeopathy World literature search Enquiries with regulatory agencies (MCA and FDA), companies Incidence of adverse effects very low mostly minor and transient under-reporting mistaken identity (herbal, not homeopathic Dr Claudio Martínez G

Remedios ofrecidos Although feverfew is usually thought of as a Migraine preventive, in GelStat, feverfew and ginger combine as an abortive, meaning that GelStat works to actually stop the migraine attack at its source. As an OTC product, it's far less expensive than prescription abortives, about $6 for four doses. Other OTC medications merely attempt to mask the pain of Migraine. Dr Claudio Martínez G

Aparatos ofrecidos Nostrafon, made in Germany by Novafon, is a precision-made electric massage appliance. It produces penetrating vibrations that can help to bring temporary relief from aches and pains without the use of drugs. Also helps releive tension headaches brought on by stress. Intensity of vibration can be adjusted as needed. Developed specifically for home use so it's lightweight and easy to handle. Dr Claudio Martínez G

Nostra-II - Price - $169.95 (Plus $12.95 Shipping)

Clínicas ofrecidas The Ontario Migraine Clinic was opened the summer of The goal of this clinic was to raise awareness and promote the use of complementary methods to treat this debilitating health issue. The treatments consist of a range of modalities that are all natural. The main method of treatment is Acupuncture and the success has been nothing short of amazing. Dr Claudio Martínez G

MigraCap This non-drug non-vitamin Migraine relief product is currently being evaluated by MAGNUM. It looks quite promising and we will keep you advised as the evaluation is completed. Migra-Cap® was developed by a sufferer for sufferers, using a combination of cold therapy and complete darkness to give relief from the pain that is associated with Migraine and most types of headaches. This 2 in 1 solution is unique for any Migraine relief product with the added benefit of being a one-off purchase. The Lycra cap covers the whole of the head and eye area and is filled with specially formulated gel packs that are strategically positioned to target the areas of the head affected by the intense pain. Ergonomically designed for maximum comfort the breathable, flexible lycra material enables the cap to fit all head shapes and can be used by a person with both short and long hair. (A 'cut-away' in the material allows users with long hair to pull the hair through for maximum effectiveness. Another first for a Migraine relief product). Migra-Cap® can be stored in a domestic fridge or freezer and the specially formulated gels ensure that Migra-Cap® will not freeze to a solid. It is currently available in 4 colors: black, royal blue, purple and navy. All caps have a black inner lining to ensure exclusion from light. We understand Migra-Cap® has been given an 81% success rate following its trial with members of the Migraine Action Association of the United Kingdom. A group MAGNUM has worked with during WHA (World Headache Alliance) international Migraine medical events. Tune in later to see what how our staff’s internal evaluation of MigraCap turn’s out! For more information, visit the manufacture’s website at Dr Claudio Martínez G

Ocular compression maneuver aborts benign cough-induced headache Gupta VK
Benign cough-induced headache is a short-lasting cranial discomfort. The therapeutic role of lumbar puncture (LP) or indomethacin in benign patients with benign cough-induced headache patients is debatable. Transient ocular compression (OC) raises intraocular pressure (IOP) and can limit the impact of cough-induced choroidal venous congestion. A self-applied maneuver that instantaneously aborts cough-induced headache is described in two patients. The effect of this maneuver supports a recent hypothesis that cough-induced headache may be due to ocular choroidal venous congestion and mechanical antidromic trigeminal nerve activation. The OC maneuver has several potential complications and its self-application in benign cough-induced headache should be regarded as an experimental procedure until more data regarding its efficacy and safety become available. Dr Claudio Martínez G

Conclusiones Estamos lejos de haber solucionado el problema de las cefaleas primarias, El tratamiento Cognitivo –Conductual y el CAM puede (¿debe?) intentarse en todos los pacientes con cefalea primaria. Como primera opción en casos calificados. Como terapia coadyudante a la farmacológica. El médico debe liderar (con ayuda o no de otros profesionales) el manejo de las cefaleas. ¡Ojo con las anécdotas! A more sensible recommendation to NICE would be that, in developing the scope of new guidelines on chronic conditions, the institute pays greater attention to reviewing complementary therapies. Therapists with particular expertise in complementary and alternative treatments for each specific condition should be invited to join guideline development groups. These groups can wrestle with the philosophical and methodological dilemmas over what study designs should be included in the evidence base of the guidelines. Uncertain evidence of effectiveness does not preclude a positive recommendation in a guideline, and original modelling of cost effectiveness can be part of guideline development.12 Lastly, those making decisions about integrated medicine in the NHS should consider each complementary or alternative therapy on its merits, using a broad range of appropriate scientific evidence including data on cost effectiveness. Such decision making, if done transparently, may change the public perception of scientific medicine for the better. They often erroneously believe that they can do no harm. 7-11% of the UK population have consulted a complementary practitioner over the past year. Whilst it is important to be open minded, any treatment, intervention or medication (whether traditional or alternative, bought over the counter or prescribed by a health professional) should be considered with a healthy degree of scepticism. los llamados estudios observacionales; las respuestas a la preguntas planteadas intentan abordarse, siempre que se puede, a través de ensayos clínicos. Y mientras llegan esas respuestas, como los médicos no pueden quedarse cruzados de brazos, van haciendo las cosas lo mejor que saben y pueden. Sin embargo, muchos no acaban de entender este sencillo principio de funcionamiento, y creen erróneamente que la medicina se mueve siempre con certezas, sin darse cuenta de que bajo algunas recomendaciones médicas no hay una evidencia clara sino una acuciante pregunta. Dr Claudio Martínez G

¡Merci Beaucoup! Dr Claudio Martínez G

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