IntroductionCluster headache is perhaps the best defined trigeminal autonomic cephalalgia. Its less frequent form, chronic cluster headache, frequently eludes available medical therapies [1]. Three cases of chronic cluster headaches that were responsive to oral anticoagulation are described. The paucity of effective therapies to treat this condition [1,2], and the puzzling effectiveness of warfarin in the cases described here, justify reporting of this uncontrolled evidence. Case reports Patient 1A 46-year-old white male presented with cluster headache since the age of 32 years, and with chronic cluster headache since the age of 35 years. He was submitted to currently available prophylactic therapies for cluster headache such as prednisone, deflazacort, verapamil, lithium carbonate, methysergide, divalproate, pizotifen, lamotrigine and topiramate, and to several other unconventional therapeutic drugs. He only responded to steroids, which produced a partial and transitory response. He took prednisone for a prolonged period, which may have contributed to the chronification of his cluster headache. A retrogasserian balloon compression led to a transitory remission. In September 2003, after an earlier communication of the case subsequently described by Souza et al. [3], warfarin 2.5 mg/day up to 10 mg/day was prescribed. Cluster headache attacks decreased during the titration period and were followed by a sustained remission in the succeeding two months, allowing him to discontinue prednisone. The attacks recurred when warfarin was withdrawn, but their frequency and intensity decreased again from 6 daily full-blown episodes to a headache-free condition after two mild episodes following J Headache Pain (2005) 6:417-419 DOI 10.1007/s10194-005-0234-6Warfarin as a therapeutic option in the control of chronic cluster headache: a report of three cases Abstract Chronic cluster headache remains refractory to medical therapy in at least 30% of those who suffer from this condition. The lack of alternative medical therapies that are as effective as, or more effective than, lithium carbonate makes new therapies necessary for this highly disabling condition. Based on a previous report, we gave oral anticoagulants to three patients with chronic cluster headache. Two of them remained cluster headachefree while taking warfarin. In the third patient, the use of warfarin for three weeks initially increased the frequency and intensity of cluster headache attacks but subsequently induced a prolonged remission. In spite of the paucity of data available, oral anticoagulation appears to be a promising therapy for chronic cluster headache.
CONTEXT AND OBJECTIVE: Pressure ulcers are lesions caused by inadequate blood flow and tissue malnourishment secondary to prolonged pressure on skin, soft connective tissues, muscle and/or bones. The authors report two distinct clinical situations of severely compromised neurological patients who shared several predisposing factors for pressure ulcers, but with opposite outcomes regarding the development of pressure ulcers. CASE REPORTS: The first case was a young patient in a persistent vegetative state who developed pressure ulcers that resulted in secondary sepsis and death. The second case was a patient with a diagnosis of amyotrophic lateral sclerosis who, in spite of being bedridden for several months with severe immobility, never developed pressure ulcers. These intriguing contrary clinical situations had already been defined by Charcot in the nineteenth century, with his creation of the expression "decubitus ominosus". He indicated that patients with amyotrophic lateral sclerosis usually did not develop this form of complication, as was illustrated by the cases presented here.
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