Submited on: 29 Dec 2010 02:33:40 PM GMT
Published on: 30 Dec 2010 03:38:08 PM GMT
 
Constipated and a bit stuffed?
Posted by Dr. Karl Alstadhaug on 20 Jan 2011 03:19:31 PM GMT

1 Is the subject of the article within the scope of the subject category? Yes
2 Are the interpretations / conclusions sound and justified by the data? Partly
3 Is this a new and original contribution? Yes
4 Does this paper exemplify an awareness of other research on the topic? Yes
5 Are structure and length satisfactory? Yes
6 Can you suggest brief additions or amendments or an introductory statement that will increase the value of this paper for an international audience? No
7 Can you suggest any reductions in the paper, or deletions of parts? Yes
8 Is the quality of the diction satisfactory? Yes
9 Are the illustrations and tables necessary and acceptable? No
10 Are the references adequate and are they all necessary? Yes
11 Are the keywords and abstract or summary informative? Yes
  • Other Comments:

     

    This article is undoubtedly creative, unorthodox, and a bit provocative. I applaud the author for this – controversial opinions are needed.  However, scientifically the paper has several limitations. A major concern is the premises for the argumentation that are inaccurate. Controversial issues are discussed superficially, and conclusions are only partly justified by the data. Besides, the immodest criticism of a very large body of neuroscientists may seem a bit stuck-up.

     

    Starting with the diagnosis, the author describes 5 episodes with acute (within 5-10 seconds), predominantly mild to moderate, migraine-like headache associated with mild nausea and dizziness after the Valsalva maneuver (VM). Is this migraine? It might be, but the acute start and the mild pain make the attacks atypical. It is true that neuro-imaging is not a diagnostic requirement for typical migraine, but this is not true for migraine-like headaches in general.

    Should not potential secondary cause always be ruled out, especially when headache attacks occur acute and are triggered by VM? If the headache represents exertional headache or something else, the discussion about migraineous mechanisms falls on stony ground. Nor is the hypothesis testing described very convincing. To test the effect of intervention is demanding, and as stated by the author himself: Trigger factors are rarely predictable and migraine patients identify such factors in only a minority of attacks. It is worth noticing that constipation may also be a prodromal symptom of migraine, and perhaps the VM only aggravated a minor pre-existing headache? The discussion of VM-mechanisms and their potential role in headache is for that matter opportune and interesting. However, track is lost when the author uses his own visual aura, atypical monocular and unrelated to the constipation or the VM , in the discussion part to argue against a role of cortical spreading depression (CSD) and a cortical origin of the scintillating scotoma (SS) in migraine. An alternative explanation of the SS is given: A pressure-mediated transient and localized distortion/dimpling at the posterior pole of the eye with mechanical rather than electrical “retinal chaos” probably underlies migraineous SS.  In the introduction of the article the author starts to state that CSD is currently believed to underlie migraine attacks. Well, most researchers believe that it underlies the aura. Later, according to the author a single description by Lashely has effectively blunted the critical thinking of a very large body of neuroscientists…, and continues: …migraine research has itself got lost hopelessly in the woods. With these strong statements it will be difficult to convince a scientific community that self-experience, including 5 migraine-like attacks and 2 atypical scintillating scotomas (retinal origin), could make much of the basis for such controversial opinions. Let me remind the reader that detailed descriptions of the scintillating scotoma were published long before Lashley (Parry, Ruete, Airy, Charcot, Jolly, Bäumler…), and that monocular visual aura, occurs much less frequently than typical homonymous visual disturbances as described in the International Classification of Headache Disorders (ICHD-2). I agree that descriptions of the SS from unbiased migraineurs with appropriate medical background are highly valuable, but I can’t see that the author here is less biased than Alvarez, Hare, Richards, Pöppel, Ekbom, Grüsser and several others.

     

  • Competing interests:
    No
  • Invited by the author to review this article? :
    No
  • Have you previously published on this or a similar topic?:
    No
  • References:
    None
  • Experience and credentials in the specific area of science:

    A few years with clinical practice and research in the field of headache.  

  • How to cite:  Alstadhaug K .Constipated and a bit stuffed?[Review of the article 'Constipation-related Migraine Is Linked To The Effect Of The Valsalva Maneuver On The Eye: A Case Report And A Mechanistic Review ' by Gupta V].WebmedCentral 2011;2(1):WMCRW00394
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He who rides a tiger cannot dismount

Karl Alstadhaug's surgically precise analysis of my article is sheer courage in prose and an intellectual delight to read. Before I respond to the issues raised, I would like to underscore that science and Nature dwarfs us all, lay or professional. Leaving aside the other languages, the literature of migraine in the English language itself is inexhaustible. An adversary so protean or chameleon-like such as migraine -- that frequently dishes out lessons in humility to pretenders daring to unwrap its mystery or hoping to manage its victims -- is best approached with awe and reverence rather than being "stuck-up" or "stuffed". With a little care, a review need not ever be disparaging. I am myself a reviewer for over fifty leading medical periodicals, and, have always used my words with deliberate discretion - even in disagreement. Every review has two parts: a gut-reaction or instinctive response and a more carefully thought-out intellectually stimulating or inspirational component. Ideally, reviewers should suppress their gut reaction and analyse the submission dispassionately. The hallmark of intellect of a higher degree is the ability to hold contrasting opinions or evidences with perfect equanimity. For articles at or beyond the borders of conventional wisdom, matters are nebulous to all -authors / investigators/trialists/ therapists, members of sanctioning ethical committees, editors, reviewers - the exchange is between equals with one individual or a group having being granter a brief glimpse of scientific truth by Nature. Initially, translation of such truth into the double-blind mathematical statistical pattern is not always possible. Novelty in science is a form of "stress" and always strikes surprise, disquiet, and disbelief as entrenched or established knowledge/thinking is sought to be erased. Dissent, in science at least, merits a little more care in choice of words and mutual respect. Review carries in its folds the obligation to read articles referenced in any paper under review - to comment without such reading amounts to surreptitious below-the-belt blows. Sharp or catchy bits and bytes or one-liners as headers are best left to the entertainment industry or to the political fraternity. I quote from my book, Adaptive Mechanisms in Migraine, Nova Science Publishers, Inc., New York, 2008: "As if it had a life of its own, migraine reckons carefully the motive of both its seeker as well as the healer...Beyond knowledge lies wisdom, and beyond wisdom lurks faith. The slow dance between migraine-related knowledge, wisdom, and faith that began over two millennia ago appears to have quickened its pace...While it has given me a measure of intellectual pleasure in unfolding the concept of migraine adaptive mechanisms, nothing could delight me more than a sustained and devastating challenge to the concept by an individual or a school of experts." Unless sheathed in reflection, intellectual courage can and usually does go haywire.


(i)"Controversial issues are discussed superficially, and conclusions are only partly justified by the data. Besides, the immodest criticism of a very large body of neuroscientists may seem a bit stuck-up."

My perspective article on cortical spreading depression (CSD) in Expert Review of Neurotherapeutics[2009;9(11):1595-1614] has exhaustively dissected the mythical Holy Grail-like aura surrounding the experimental concept of CSD; this review has been referenced in the index article. Scientific discovery, generally, has nothing to do with a "very large body of (neuro)scientists". The work of "very large bodies of (neuro)scientists" is to codify and regiment knowledge by arbitrary or contemporary consensus of nosology and therapeutics for day-to-day clinical practices and for satisfying statutory/legal obligations and authoritative bodies. Every scientific discovery mandates that "a very large body of (neuro)scientists" will be proven to have held incorrect notions or mythical concepts life-long. Truth is truth - it is neither modest nor immodest but can certainly be inconvenient to the herd as it demolishes concepts held dear and tears at scientific statures and research careers. If sheer repetition is the absolute truth, yes, CSD underlies migraine. Repetition is a political weapon, but, medical research is also not free from politics. "...since nausea and/or vomiting is a cardinal feature of migraine, it would be invaluable to know how CSD could possibly stimulate the vomiting centre in the medulla...CSD has permeated and dominated ("enraptured") the psyche of most primary headache researchers and captured their imagination, making them both unwilling as well as incapable of entertaining any alternative explanation." (Gupta, 2008). Karl rides the tiger of CSD along with the "large body" of his peers.


(ii)While pre-publication review exists to keep egg off (established) author's faces (Drummond Rennie, JAMA), post-publication review can - and will - be (mis)used to publically or openly and stoutly defend medical myths and assumptions. Karl's overemphasis on "conclusions" and "data" is stock-in-phrase for reviewers of the anonymous era. Both features, while undoubtedly being very important, must not detract from the heart-of-the-matter or the essence of the article under review. "Form" and "format" are far less important (see previous comment). Data are a terminal facet of human cogitation, observation, and experimentation that, dressed with statistics, have evolved the accountant-mentality in medical research. Data cannot (or at least, should not) precede or supplant a careful reflection of the problem. Currently, we gather data and then set about trying to make sense of our results; logic, necessarily, must go out of the window. The extant data bank of migraine is simply mind boggling - equivalent to not one, but, several Gordian knots -- but remains a "heap of junk" that has not allowed migraine research to take-off (Gupta - Expert Review of Neurotherapeutics 2010;10(9): 1409-1422 - open access). Far less important than the conclusions in my article (on constipation-related migraine) is the template that I have provided for future observations in other individuals, especially those with comprehension of the mechanics and consequences of the Valsalva maneuver (see below).


(iii)"If the headache represents exertional headache or something else, the discussion about migraineous mechanisms falls on stony ground".


The fallacies of the "new" "splitting" classification of migraine have been discussed in several of my comments in the BMJ as well as JNNP in the last decade. The walls between migraine, migraine-like headache, exertional headache, and even cluster headache are far, far from robust and are not even paper-thick. "To maintain that a distinct pathophysiologic mechanism will ultimately be discovered for each of the nosologic entities currently delineated by the new version of the classification of the International Headache Society appears to be nothing but a form of irrational scepticism" - (Gupta, 2008). Accepting Karl's premise that my constipation-related headache attacks could be "exertional" in nature or a simple aggravation of the underlying migraine attacks, I underscore that nothing is also known about the pathophysiologic basis of both of the alternative explanations. One cannot set off the unknown against (to disprove) the unknown. "Contemporary migraine research stands where cardiovascular medicine stood before the discovery of the atheromatous plaque. The atheromatous plaque underlies all expression of coronary heart disease, including sudden death, pump failure, ventricular arrhythmias, atrioventricular blocks, acute myocardial infarction, unstable angina, effort-induced angina, and angina at rest -- Gupta, 2008. The "atheromatous plaque-like" bio-marker for migraine will emerge sooner or later. Knowledge of the biology of migraine is at its infancy. Even the term "biological" is misunderstood in migraine. Biology of any illness is not synonymous with "physiological", "organic" or "non-environmental" or what is discovered at the laboratory bench. The biology of an illness is the elucidation of the forces that push an individual towards disease or the disease-free state." (Gupta, 2008). These are very powerful conceptual tools that have yet to permeate into mainstream migraine research. There is an ocean of nihilism in the "stony ground" stance of Karl. To a degree, nihilism is a wise touchstone. If the migraine code is to be eventually cracked, nihilism is to be used carefully, not blankly or blandly. A few tottering steps in this direction have been taken in my book on migraine Adaptive Mechanisms.

(iv)"Let me remind the reader that detailed descriptions of the scintillating scotoma were published long before Lashley (Parry, Ruete, Airy, Charcot, Jolly, Baumler...), and that monocular visual aura, occurs much less frequently than typical homonymous visual disturbances as described in the International Classification of Headache Disorders (ICHD-2). I agree that descriptions of the SS from unbiased migraineurs with appropriate medical background are highly valuable, but I can't see that the author here is less biased than Alvarez, Hare, Richards, Poppel, Ekbom, Grusser and several others."

Karl has completely missed one of the major features of the article while stressing the "lost track" of my line of thinking. I have clearly acknowledged the possibility of personal bias in the article prominently. Most importantly, I have presented a template for all subsequent observations of the migrainous SS - covering the eyes alternately, digitally displacing the phenomenon, and closing the eyes. I have also clearly mentioned that my observations need to be confirmed or refuted by the observations of others according to this template. I am not aware of a previous description of the migrainous SS on these lines - perhaps Karl can enlighten me. Also, while others may have described their migraine aura previously, the slow progression described by Lashley was linked unthinkingly to CSD by pure imagination and sheer fascination (for animal experimental physiology) of the "very large body of neuroscientists". Unfortunately, falsehood flies, and truth comes limping in much later, if at all. Let me remind Karl that even all RCT are conducted with a positive or a negative bias or assumption(s) or a working hypothesis. Under the sun of the solar system galaxy, there is nothing like a purely objective observation; all observation is selective and subjective (Medawar PB, The Art of the Soluble. London: Metheun, 1967; Gupta VK, Cardiovascular Drugs and Therapy, 1996;10(3): 303-305) (see previous Comment also). Research is re-search - a search for what is already known to Nature. RCTs and meta-analyses have ripped reverence out of medical research through the battering-ram of statistics. I also thank Karl for the cautious and rather muted applause in the first pass. Nevertheless, I refuse to be cowed down by or "play" to the "very large body of the scientific community". While some of the best intellects are involved in migraine research, in the absence of a clear research vision for migraine, there is much fence-sitting and fear of publically grappling with the unknown for fear of ridicule by peers. Karl, like other neuroscientists including neuro-ophthalmologists, has mixed-up in his mind SS with other manifestations of the visual aura. Unless simultaneous nasal spread of SS from the para-macular region in one eye and temporal spread from the para-macular region in the other eye is established, SS cannot be regarded as being of visual cortical origin (Gupta. Editorial, 2011 (CORTICAL-SPREADING DEPRESSION: AT THE RAZOR'S EDGE DOI: 10.1007/s10194-010-0287-z). J Headache Pain. Science is nothing but a simplification of observed phenomena. Current migraine research is nothing but increasing mystification of observed phenomena. "Once the sound and the fury and the swirling clouds of doubt have settled, migraine will be demystified and prove to be ... as simple in nature as the microscope, the television, the motor-car, the airplane, the submarine, or the space module ... (Gupta, 2008)". As for the "very large body of (neuro)scientists", the following quote is very apt: "A work of art has never been produced by a committee of artists, nor a great discovery made by a committee of scholars. The syntheses needed for the progress of our knowledge of man should be elaborated in a single brain" - Alexis Carrel.


I have started the process of decoding migraine in order to clear the mists enveloping the disorder and to create a defensible overarching research vision for migraine simply because someone had to undertake this gigantic and himalyan or herculean task. Perhaps, others will complete this sisyphean task. Certainly, no one "stuffed-up" is going to unravel migraine. Had I been busy in conducting trials or (brain) hardwiring patients of primary headaches for treatment, I would not even have got to the first base. Where you start is very important because it determines where you will finish. -- Vinod K Gupta


Responded by Dr. Vinod K Gupta on 27 Jan 2011 09:23:45 AM
Appreciable effort
Posted by Prof. Prasunpriya Nayak on 20 Jan 2011 05:15:27 AM GMT

1 Is the subject of the article within the scope of the subject category? Yes
2 Are the interpretations / conclusions sound and justified by the data? Partly
3 Is this a new and original contribution? No
4 Does this paper exemplify an awareness of other research on the topic? No
5 Are structure and length satisfactory? Yes
6 Can you suggest brief additions or amendments or an introductory statement that will increase the value of this paper for an international audience? No
7 Can you suggest any reductions in the paper, or deletions of parts? No
8 Is the quality of the diction satisfactory? Yes
9 Are the illustrations and tables necessary and acceptable? Yes
10 Are the references adequate and are they all necessary? Yes
11 Are the keywords and abstract or summary informative? Yes
  • Other Comments:

    Though the question of biasness or at least the possibilities of undermininig some points are always crucial for a study/publication on self, the paper is well presented.

  • Competing interests:
    Nil
  • Invited by the author to review this article? :
    No
  • Have you previously published on this or a similar topic?:
    No
  • References:
    None
  • Experience and credentials in the specific area of science:

    Nil

  • How to cite:  Nayak P .Appreciable effort[Review of the article 'Constipation-related Migraine Is Linked To The Effect Of The Valsalva Maneuver On The Eye: A Case Report And A Mechanistic Review ' by Gupta V].WebmedCentral 2011;2(1):WMCRW00392
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Review
Posted by Prof. José M Pumar on 18 Jan 2011 04:23:17 PM GMT

1 Is the subject of the article within the scope of the subject category? Yes
2 Are the interpretations / conclusions sound and justified by the data? No
3 Is this a new and original contribution? No
4 Does this paper exemplify an awareness of other research on the topic? No
5 Are structure and length satisfactory? Yes
6 Can you suggest brief additions or amendments or an introductory statement that will increase the value of this paper for an international audience? No
7 Can you suggest any reductions in the paper, or deletions of parts? No
8 Is the quality of the diction satisfactory? Yes
9 Are the illustrations and tables necessary and acceptable? Yes
10 Are the references adequate and are they all necessary? Yes
11 Are the keywords and abstract or summary informative? Yes
  • Other Comments:

    This article reports the author's own experience, which describes the onset of migraine attack after performing a Valsalva maneuver induced constipation and the disappearance of these episodes of headache after the completion of a maneuver.

    The Valsalva maneuver causes increased intrathoracic pressure, and may be a trigger and an aggravating factor in some types of headache, but its relationship with the onset of migraine is not completely clear. Some authors believe that the Valsalva maneuver induced migraine in cases of massive right-to-left shunt (J Headache Pain 2007, 8:7-12). A theory that tries to explain this association is that when there is a right-to-left shunt, a number of chemicals that are normally eliminated in the lung, would pass from the right atrium to the left to reach the systemic circulation and therefore triggering a migraine. In this scenario, the Valsalva maneuver favours the passage of blood from the right atrium into the left atrium, by causing an increase in intrathoracic pressure, which could determine the onset of a migraine. However, the association between PFO and migraine remains controversial; recent studies support this association (Cephalalgia 2010, 30:535-42) and others reject it (Circulation 2010; 121:1406-12

    Another theory discussed by the author tries to explain this association between the Valsalva maneuver and migraine would be the increased pressure in the orbit that determines a congestion of the choroidal veins, being responsible for the headache. However, it is difficult to justify a hemicranial headache as migraine by this mechanism, and looks like it could play a greater role in other types of headaches.

    The author explains that performing a maneuver that involves opening the mouth and pressure on the eyes to avoid the appearance of migraine attacks related to the Valsalva maneuver. The opening of the mouth during the Valsalva maneuver gets lower the intrathoracic pressure, which could decrease the occurrence of migraine. On the other hand, to make pressure on the eyes limits the increase in intraocular pressure and congestion of the choroidal veins. However, these findings are based on the author's personal experience, and as he says, is one of the major limitations of the study.

    To confirm these results should be a study that included more patients with migraine and subject to the completion of a Valsalva maneuver with and without opening the mouth and eye pressure. It would also be desirable to determine whether these cases there is a right-to-left shunt, which could help further understanding of the role it can play the foramen ovale in triggering migraine attacks.

  • Competing interests:
    None
  • Invited by the author to review this article? :
    No
  • Have you previously published on this or a similar topic?:
    No
  • References:
    None
  • Experience and credentials in the specific area of science:

    I worked in similar studies

  • How to cite:  Pumar J M.Review[Review of the article 'Constipation-related Migraine Is Linked To The Effect Of The Valsalva Maneuver On The Eye: A Case Report And A Mechanistic Review ' by Gupta V].WebmedCentral 2011;2(1):WMCRW00385
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dangerous practices
Posted by Dr. Frederick G. Freitag on 15 Jan 2011 06:21:50 PM GMT

1 Is the subject of the article within the scope of the subject category? Yes
2 Are the interpretations / conclusions sound and justified by the data? Partly
3 Is this a new and original contribution? Yes
4 Does this paper exemplify an awareness of other research on the topic? Yes
5 Are structure and length satisfactory? Yes
6 Can you suggest brief additions or amendments or an introductory statement that will increase the value of this paper for an international audience? Yes
7 Can you suggest any reductions in the paper, or deletions of parts? No
8 Is the quality of the diction satisfactory? Yes
9 Are the illustrations and tables necessary and acceptable? No
10 Are the references adequate and are they all necessary? Yes
11 Are the keywords and abstract or summary informative? Yes
  • Other Comments:

    While I appreiciate we as clinicians are "are own best doctor" this is also a dangerous practice. The failure to be diagnosed and examined by a qualified physician represents a dangerous practice and one that any reasonable organization such as WEBMD should avoid and discourage. Without adequate examination this self diagnosed and possibly self treating clnician may have missed potnetial dangeroius sources for exertional migraine. If it was not for the issues that surround this and the likelihood that this article will fall into the hands of the lay public let alone physicians who may because of this article fail to take appropriate steps in their evaluation and treatment of patients makes this an article which should not be published to the site. Not in its present form. The only part that can be kept is the excellent discussion of the entire process involved by which valsalva maneuver may play a role in headache, however if that part is published then the author needs to do further research looking at the entire role of and connection thjat exisits between the vagal nerve and the trigeminal nucelus anbd its role in migraine. let alone aoutline the appropriate steps in the evaluaiton of apatient with exerrtional headache.

  • Invited by the author to review this article? :
    No
  • Have you previously published on this or a similar topic?:
    No
  • References:
    None
  • Experience and credentials in the specific area of science:

    over 30 years of clinical and research involvement in the field of headache. by the way stupid program you have here that fails to allow a query to go unaswered when it has no relevance

  • How to cite:  Freitag F .dangerous practices[Review of the article 'Constipation-related Migraine Is Linked To The Effect Of The Valsalva Maneuver On The Eye: A Case Report And A Mechanistic Review ' by Gupta V].WebmedCentral 2011;2(1):WMCRW00372
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1 Is the subject of the article within the scope of the subject category? Yes
2 Are the interpretations / conclusions sound and justified by the data? Yes
3 Is this a new and original contribution? Yes
4 Does this paper exemplify an awareness of other research on the topic? Yes
5 Are structure and length satisfactory? Yes
6 Can you suggest brief additions or amendments or an introductory statement that will increase the value of this paper for an international audience? No
7 Can you suggest any reductions in the paper, or deletions of parts? No
8 Is the quality of the diction satisfactory? Yes
9 Are the illustrations and tables necessary and acceptable? Yes
10 Are the references adequate and are they all necessary? Yes
11 Are the keywords and abstract or summary informative? Yes
  • Other Comments:

    None.

  • Competing interests:
    No
  • Invited by the author to review this article? :
    No
  • Have you previously published on this or a similar topic?:
    No
  • References:
    None
  • Experience and credentials in the specific area of science:

    Some experience in clinical practice.

  • How to cite:  Jaseja H .Constipation-related Migraine Is Linked To The Effect Of The Valsalva Maneuver On The Eye: A Case Report And A Mechanistic Review. [Review of the article 'Constipation-related Migraine Is Linked To The Effect Of The Valsalva Maneuver On The Eye: A Case Report And A Mechanistic Review ' by Gupta V].WebmedCentral 2011;2(1):WMCRW00345
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