The Painful Truth of Migraine

A World Federation of Neurology and International Headache Society collaboration.

By Tissa Wijeratne, Wolfgang Grisold, David Dodick, Mohammad Wasay, and William Carroll

The Global Burden of Diseases Collaborators confirmed that neurological disorders are the leading cause of disability worldwide1. Globally in 2016, neurological disorders were the leading cause of disability-adjusted life years (276 million [uncertainty interval 247-308] and the second leading cause of deaths at 9.0 million [8.8-9.4]).

The world map printed on top of the hemispheres in the brain. The gold color denotes the World Federation of Neurology. The navy blue denotes the International Headache Society. The red denotes the pain.

Migraine is the most burdensome illness in people under the age of 50 (the group who contributes most to society through the workforce) and, in females2-4. Among people with migraine who experience more than 15 days per month with headache, 20 percent are occupationally disabled. Migraine with aura is associated with a 20 percent increased risk of mortality, and the suicide rate among people with cluster headache is 20 times the national average.

Lack of research support for and publications in the field of migraine from low-to-middle-income countries is disappointing and alarming5. The situation in high-income countries is still in tremendous need of progress. For example, in the United States, migraine and headache disorders are the least funded research area disproportionate to its disease burden compared to other diseases. Migraine is responsible for 46 percent of the U.S. disability burden due to neurological diseases and stroke, but migraine research comprises just 0.6 percent of federal funding.

In Australia (despite being a high income country) the estimated lost productivity in 2018 along with it was nearly 40 billion Australian dollars6,7. The national research funder of Australia—National Health and Medical Research Council (NHMRC)—allocated only less than 0.09 percent of total annual research budget during the 2007-2017 decade toward migraine, despite migraine being the highest cause of disability in Australia7,8.

It is indeed time for the World Federation of Neurology (WFN) to partner with International Headache Society (IHS) with a view to taking this important issue head-on with an energetic global campaign. We are determined to dedicate 2019 to raising awareness for the most common brain disorder in the world.

Key Messages

  • World Brain 2019 jointly with International Headache Society.
  • WFN will provide educational and promotional material.
  • Get on board now; let’s spread the news through mainstream media, social media platforms, and national and international meetings throughout the year.
  1. Migraine: The Painful Truth
  2. Prevalence: Migraine is the most common brain disease in the world, affecting one in seven people worldwide.
  3. Disability: Migraine is one of the leading causes of disability in the world and can severely impact every aspect of life.
  4. Education: Migraine is underrecognized, underdiagnosed, and undertreated.
  5. Research: Migraine receives less research funding than all of the world’s most burdensome diseases.
  6. Standard of Care: Migraine is a disease in which the majority of sufferers do not get the help they need.

In September 2017, the historic first Global Patient Advocacy Summit was convened, bringing together all stakeholders, including patients and patient advocates (IHS-GPAC). After a full day of presentations from all stakeholders and a robust discussion, a series of consensus statements that reflect the priorities and advocacy goals for the future were developed and presented as the Vancouver Declaration on Global Headache Patient Advocacy 20189.

The main outcomes of the summit included:

  1. It is important to understand and promote global, regional, and local interests of people with headache disorders as well as challenge their pervasive stigma.
  2. All patients affected by headache should have reliable access to competent medical care.
  3. All health care professionals should have adequate access to adequate training in headache medicine.
  4. A global benchmark should be established to ensure that all patients affected by headache disorders receive an accurate diagnosis and evidence-based treatment.
  5. Information is needed about consultation, diagnosis, treatment of headache disorders, and patient-reported outcomes (e.g. quality of life, satisfaction with treatment).

People who have a migraine or a headache disorder have a right to receive appropriate, evidence-based, and safe care.

  1. Correct diagnosis so that treatment is appropriate (as per IHCD classification)10,11.
  2. Access to the standard of care treatment regardless of financial situation, gender, culture, or place that your patient lives.
  3. Receive treatment by educated clinicians at all stages of your patient’s journey (acute treatment as well as preventive treatment).
  4. Receive treatment that is personalized and takes into consideration age, gender, culture, goals, and the patient’s changing needs over time (acute treatment and preventive treatment).

Behind these numbers are real lives

We will soon be able to share a series of educational and promotional materials that can be used in your country to advocate for better care for your patients.

The World Brain Day | Migraine: The Painful Truth is an important priority. The educational and promotional material from the WFN-IHS collaboration will help neurologists to be the best advocates for your patients with migraine and other headache disorders. •

References

  1. Collaborators , G.B.D.N.D.C., Global, regional, and national burden of neurological disorders during 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet Neurol, 2017. 16(11): p. 877-897.
  2. Steiner, T.J., et al., Migraine is first cause of disability in under 50s: will health politicians now take notice? J Headache Pain, 2018. 19(1): p. 17.
  3. Collaborators, G.B.D.H., Global, regional, and national burden of migraine and tension-type headache, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurol, 2018. 17(11): p. 954-976.
  4. Reuter, U., GBD 2016: still no improvement in the burden of migraine. Lancet Neurol, 2018. 17(11): p. 929-930.
  5. Mateen, F.J., et al., Headache disorders in developing countries: research over the past decade. Cephalalgia, 2008. 28(11): p. 1107-14.
  6. Lynne, P., Migraine in Australia Whitepaper. 2018. https://www2.deloitte.com/au/en/pages/economics/articles/migraine-australia-whitepaper.html, accessed 20th March 2019
  7. Wijeratne T, Crewther .D., Crewther S. Migraine: The Greatest Disability of All in Australia. in Neuroepidemiology. 2018.
  8. Wijeratne , T., Out of sight, out of mind, Migraine the hidden cost of disability 2018. https://www.youtube.com/watch?v=1UzdkECbNDo, accessed 19th March 2019
  9. Dodick, D., et al., Vancouver Declaration on Global Headache Patient Advocacy 2018. Cephalalgia, 2018. 38(13): p. 1899-1909.
  10. Li, D., A.F. Christensen, and J. Olesen, Field-testing of the ICHD-3 beta/proposed ICD-11 diagnostic criteria for migraine with aura. Cephalalgia, 2015. 35(9): p. 748-56.
  11. Olesen, J., From ICHD-3 beta to ICHD-3. Cephalalgia, 2016. 36(5): p. 401-2.

Aging Through the Ages

By Peter J. Koehler

In an era of increasing mean age of the general population and the resulting burden of degenerative disease—with respect to neurology, in particular dementia and Parkinson’s disease—studies on aging may provide interesting insights. Genomic stability in cancer and aging are popular areas of study today. Preventive lifestyle campaigns with respect to cardiovascular diseases resulted in favorable effects, at least for a part of the community. One might wonder whether our predecessors were engaged with this subject.

Resignation

Despite the much lesser mean age in the past, partly due to child mortality and lack of urban hygiene, a few persons became quite old then as well. Therefore, it is of no surprise to find texts and studies on aging centuries ago. One of the early authors on the subject was the Roman statesman and philosopher Marcus Tullius Cicero (106 BCE-43 BCE), who wrote an essay on the subject (Cato Maior de Senectute) in the year 44 BCE, when he was 63 years old. It is considered literature of consolation for elderly people. Cicero has Cato the elder (234-149 BCE) say:

Figure 1. Arnaldus de Villa Nova’s (c. 1240-1311) 1480 printed edition of the Regimen Sanitatis.

“He does not do what young men do; nevertheless he does what is much more important and better … to each part of our life there is something specially seasonable; so that the feebleness of children, as well as the high spirit of youth, the soberness of maturer years, and the ripe wisdom of old age—all have a certain natural advantage which should be secured in its proper season … I frequently attend the Senate and bring motions before it on my own responsibility, prepared after deep and long reflection. And these I support by my intellectual, not my bodily forces.”

But he also wrote about old age, “We must fight it as we should an illness” and “Senectus ipsa morbus est” [old age itself is a disease].

Early Lifestyle Advice

The medieval Regimen Sanitatus (of Salerno, Italy, where an early medical school was founded in the ninth century) of which 240 printed editions have been published (first in the late 12th century) in Latin, Hebrew, Persian, and European languages, contained a number of regimens, including exercise, hygiene, diet, and moderation in everything. In fact, it was a didactic poem in hexameter verse. (See Figure 1.)

Figure 2. Fountain of Youth (1546), Lucas Cranach the Elder (public domain).

The idea of eternal youth, often depicted by the Fountain of Youth, originating from Hindu tradition, was often seen in the western world during the Middle Ages and already described by the Greek historian Herodotus (c 484-c 425 BCE). A 16th century painting by Lucas Cranach the Elder (1472-1553) provides a nice example of the legendary spring. (See Figure 2.)

In terms of humoral medicine, a (patho)physiological doctrine that reigned from Ancient Greek medicine up to around 1800, health and disease were considered to be the result of balanced or unbalanced mixtures of four body fluids: blood, phlegm, yellow, and black bile. Old age was associated with dryness and cold; in particular, it was caused by loss of warmth. Therefore, warmth of younger people, living or sleeping with them, could restore warmth. Alchemists tried to find the “elixir vitae” or elixir of life that would provide eternal life. (See Figure 3.)

Figure 3. (right) Elixir Vitae by Fra Donato d’Eremita.

The English Franciscan friar and philosopher Roger Bacon (1214-1294) wrote a book The Cure of Old Age and Preservation of Youth that was translated into English and published in 1683. In the subtitle, we find “shewing how to cure and keep off the accidents of old age; and how to preserve the youth, strength, and beauty of body, and the senses of all the faculties of both body and mind.” (See Figure 4.)

Figure 4. Roger Bacon’s Cure of Old Age (posthumous English translation of 1683).

The Venetian nobleman and patron of arts Luigi Cornaro (1464-1566) wrote his Discorsi della Vita Sobria (Discourses on the Temperate Life; 1591) probably at age 83. Fifty editions appeared up to the 18th and 19th century. Moderation in life, he believed, would lead to conservation of vital energy. Ages up to 100 or 120 could be reached in that way.

French philosopher René Descartes (1596-1650) wrote on old age as well. He searched for ways to avoid old age by prevention and cure based upon scientific knowledge (Discours de la Méthode, 6th part, 1637).

“And this is a result to be desired, not only in order to the invention of an infinity of arts, by which we might be enabled to enjoy without any trouble the fruits of the earth, and all its comforts, but also and especially for the preservation of health, which is without doubt, of all the blessings of this life, the first and fundamental one; for the mind is so intimately dependent upon the condition and relation of the organs of the body, that if any means can ever be found to render men wiser and more ingenious than hitherto, I believe that it is in medicine they must be sought for. It is true that the science of medicine, as it now exists, contains few things whose utility is very remarkable: but without any wish to depreciate it, I am confident that there is no one, even among those whose profession it is, who does not admit that all at present known in it is almost nothing in comparison of what remains to be discovered; and that we could free ourselves from an infinity of maladies of body as well as of mind, and perhaps also even from the debility of age, if we had sufficiently ample knowledge of their causes, and of all the remedies provided for us by nature.”

Figure 5. Descartes’ Discours de la Méthode (1637).

Figure 6. Title page of Gerard van Swieten’s Oratio (1763, published posthumously in 1778).

About a century later, Dutch physician Gerard van Swieten (1700-1772), who became the personal physician of Austrian Empress Maria Theresa and reformer of academic medical teaching in Vienna, held a foundation day speech, “Oratio de senum valetudine tuenda” [Address on protecting the health of the elderly] (1763), in which he presented a positive view of old age. He believed serious conditions in old age could be prevented by keeping the right balance of bodily fluids (blood, phlegm, yellow bile, and black bile) by temperance all one’s life. He advised against quacks and their elixirs. He used a nice metaphor: “The old experienced steersman quietly keeps course from the afterdeck, while the young climb the rigging on his command to adjust the sails.”

His German colleague Christian Wilhelm Hufeland (1762-1836), professor of pathology and therapeutics in Jena and Berlin, published his Kunst das menschliche Leben zu verlängern [Art to extend human life; 1797]. The book was translated into several languages. He took a special interest in the preservation of vital energy. Being a friend of the German writer and poet Wolfgang von Goethe (1749-1832), he added one of his aphorisms (from his play Egmont (1788), to which Ludwig van Beethoven composed music in 1810) on the title page. “Süsses Leben! Schöne freundliche Gewohnheit des Daseins und Wirkens!—von dir soll ich scheiden!“ [Sweet life! Sweet, pleasant habitude of existence and of activity! from thee must I part!]

In 1879, the English antiquary and writer William John Thoms (1803-1885) wrote The Longevity of Man. Its Facts and Its Fictions. With a prefatory letter to Prof. Owen, C.B., F.R.S. on the limits and frequency of exceptional cases. He investigated claims of “ultra-centenarianism,” advised a critical attitude with this respect, and concluded that most cases were not proven.

Charcot on Diseases of Old Age

French pioneer in neurology Jean-Martin Charcot (1825-1893) had an interest in diseases of old people, particularly in his early career, which is understandable when looking at the population of the Salpêtrière hospice at the time. His pupil Benjamin Ball (1833-1893; became psychiatrist at St. Anne, Paris) collected Charcot’s lectures on the subject and published them in 1868, Leçons sur les Maladies des Vieillards et les Maladies chroniques [Lectures on diseases of the elderly and chronic diseases].

Charcot provided the general phenomena of senile pathology, gave information on fever in these patients, and discussed gout and chronic articular rheumatism. The first of the 18 lectures is from Charcot’s early days at the Salpêtrière (1862). He explained what type of patients were living at the Salpêtrière, next to the insane and epileptic patients, a category he did not have to take care for. As for the rest “la population de cet asile se compose d’environ 2,500 femmes qui, pour la plupart, appartiennent aux classes les moins favorisées de la société, mais dont quelques-unes cependant ont connu des jours meilleurs » [the population of the asylum consists of approximately 2,500 women, who, for the main part, belong to the category of less favored by the society, but of whom nevertheless some have known better days].

Figure 7. Title page of Hufeland’s Die Kunst das menschliche Leben zu verlängern (1797).

He distinguished two categories, the first consisting of women older than the age of 70, usually in good health, but who were living in misery and abandon. “C’est ici, messieurs, que nous trouverons les matériaux qui nous serviront à faire l’histoire clinique des affections de l’âge sénile”. [It is here, gentlemen, where we will find the material serving us to make a clinical history of affections of the senile age].

The second category consisted of women of all ages, suffering from chronic incurable diseases, leaving them with a permanent handicap.

Figure 8. From Charcot’s 1868 Leçons sur les Maladies des Vieillards et les Maladies chroniques depicting articular rheumatism and cardiac valvular disease.

Rejuvenation in the 19th and 20th Century

One of Charcot’s contemporary colleagues in Paris tried to find a solution to disorders of old age. Better known by his experiments on spinal cord hemisections and the eponymous syndrome associated with the resulting signs, Charles-Edouard Brown-Séquard (1817-1894), during the last period of his career, investigated the effects of subcutaneous injections of liquid obtained from the testicles of animals. (See for instance Lancet 1889, July 20, p.105).

As happened so often in those days (self-experimentation), he administered the injections also to himself and believed to measure increased muscle strength among other effects. Although he tried to keep a strict scientific attitude, the popularity of the experiments finally harmed his reputation. Nevertheless, he was considered one of the pioneers of endocrinology.

The scientific reports were picked up by non-medical persons and used in novels, for instance by French writer Emile Zola (1840-1902), founder of the literary school of naturalism, who, in the last novel of his 20-volume Rougon-Macquart series, Le Docteur Pascal (1893), presents country physician Pascal Rougon, who made a genealogical tree of his own family with the purpose of studying heredity. He noted all kinds of interesting details about his family members, proving that degenerative taints are inherited (a popular subject in late 19th century medicine and society).

Zola staged Rougon not just as a physician, but also as a scientist. He extracted sheep brains and injected the extracts into patients. “Il croyait avoir découvert la panacée universelle, la liqueur de vie destinée à combattre la débilité humaine, seule cause réelle de tous les maux, une véritable et scientifique fontaine de Jouvence… ». [He believed to have discovered the universal panacea, the vital liquor destined to combat human debility, sole real cause of all ailments, a veritable and scientific fountain of youth… Zola, 1893, p.54]. Although considering himself to be successful at the beginning, Rougon finally turned to the injection of water, recognizing the placebo effect. One day, experimenting with organ extracts, he is criticized by his family members: “. . . il est encore a` sa cuisine du diable!” [. . . he is still in his devilish kitchen . . .], referring to his home laboratory.

Additional Reading

Koehler PJ. Charcot, la Salpêtrière, and hysteria as represented in European literature. Prog Brain Res. 2013;206:93-122.

Thane P. Geriatrics. In: Bynum WF, Porter R. Companion Encyclopedia of the History of Medicine. London, Routledge, 1997, pp. 1092-1115.

Zola E. Le Docteur Pascal (1984 edition by Livre de poche, first published in 1893). Paris: Fasquelle; 1893.

Around that time, Louis-Henry Goizet published his book La Vie Prolongée au Moyen de la Méthode Brown-Séquard [Life extended by the Brown-Séquard method;1891]. One of the chapters has the title, “Sénilité simple. Des effets du suc testiculaire employé dès les premières manifestations de la sénilité. – Retour rapide à l’âge virile. – Observations personelles de l’auteur » [Simple senility. Effects of testicular fluid applied from the first manifestations of senility. – Rapid return to the virile age. – Personal observations of the author]. The ideas were well carried into the 20th century.

French surgeon Serge Voronoff (1866-1951) applied testicular (and thyroid gland) tissue transplantations since about 1920 and published his Étude sur la Vieillesse et le Rajeunissement par la Greffe [Study of Old Age and Rejuvenation by Grafting, 1925]. While popular in the 1920s, he fell out of favor later after criticism from the scientific community and change of public opinion.

Old age and its problems have always led to resignation, preventive measures against associated disease, and even questionable interventions. •

Prof. James Waldo Lance (1926-2019)

Prof. Jim Lance was a pioneer in the field of headache, and a teacher who drew many students to neurology

By Tissa Wijeratne, Alessandro Zagami, and William Carroll

This In Memoriam is reprinted COURTESY of InSight+.

The neurological world, and Australian neurology in particular, lost an outstanding leader Feb. 20, 2019, with the death of Prof. James (Jim) Waldo Lance in Sydney, at the age of 92.

His contribution to neurology, neurological training, and headache medicine, in particular, together represent an outstanding legacy of a life experienced to the full.

James Lance was born in Wollongong, NSW, in 1926. On his mother’s side, his forbears were veterinarians who came to Australia from Edinburgh in about 1840. His maternal grandfather studied veterinary science and founded the School of Veterinary Science at the University of Sydney in roughly 1909. (The J.D. Stewart building at University of Sydney is named after him.)

Growing up in Wollongong, Jim had asthma as a young child. His parents felt it was better to send him to a boarding school near Moss Vale, NSW, at the age of 7, which settled his asthma. Tudor House, the boarding school, had a famous headmaster, John Medley, who was later Sir John Medley, the vice chancellor of the University of Melbourne and chair of the Australian Broadcasting Corporation.

Dr. Cotter Harvey, a respected respiratory physician from Sydney, visited the school to give a talk on breathing problems.

“Why do people yawn?” Jim asked afterward.

Dr. Harvey replied: “Well, I don’t know that I can give you an answer to that question.” This was a revelation to Jim; grown-up specialists could not answer all questions.

At the beginning of World War II in 1939, Jim went to Geelong Grammar School in Victoria. In 1944, he had to change to the King’s school in Parramatta, NSW, due to difficulties in interstate travel at that time. He was enthused by chemistry there and entered the University of Sydney Medical School in 1944, completing his degree in 1950.

Research

There was no formal research component to the undergraduate curriculum at that time. The professor of bacteriology, the late Dr. Hugh Ward, introduced Henry Harris and Jim Lance to Howard Florey, of penicillin fame, who advised them on a potential research career. They both flew to Melbourne to embark on research experience. Harris adopted the advice so well to the extent that he replaced Florey when he retired and became the Regius professor of medicine with a distinguished scientific career.

Jim chose to return to Sydney and met with Peter Bishop, an experimental neurophysiologist, and then embarked on research into the pyramidal tract. He also began clinical work as a resident medical officer at the Royal Prince Alfred Hospital (1950–1951). Cutting his residency short, Prof. Lance took up a National Health and Medical Research Council fellowship at the University of Sydney (1952–1953) to work toward his Doctor of Medicine degree, which he was awarded in 1955. He became firmly engrossed in neurology and with research. He produced five articles from this period, including an article on an attempt to regenerate the pyramidal tract.

The articles were:

  • Origin of the Pyramidal Tract in the Cat
  • Properties of Pyramidal Tract
  • Pyramidal and Extrapyramidal Control of Tonic Mechanisms in the Cat
  • Pyramidal Tract in Spinal Cord of Cat
  • Supraspinal Control of Tonic Vibration Reflex

In 1954, he traveled to London to train as a neurologist. At that time, the fastest way was a three-day journey in a propeller-driven aircraft. This was prohibitively expensive for Jim so he signed up as a ship’s surgeon on a shilling a month for a return trip to England.

After a month-long voyage, he arrived in London and accepted a position as assistant house physician at the National Hospital in Queen Square. He became houseman to Sir Francis Walshe, an outstanding neurologist, and learned to master the art of neurology, realizing that physiology was the basis of clinical neurology. While at Queen Square, he developed a keen interest in headache.

He returned to Sydney and met his wife-to-be, Judith, for the second time at a dance at St. Paul’s College. He had first met her when she took a post in physiology as a medical student. Following their second meeting, the relationship blossomed, and the marriage produced five children.

Headache Medicine

At work, Jim combined teaching and clinical practice with appointments as tutor at St. Paul’s College (1956-1960), visiting lecturer at the University of Sydney (1956-1962), superintendent at the Northcott Neurological Center (1956-1957) and honorary assistant physician at Sydney Hospital (1956-1961) and St. Luke’s Hospital (1957-1961).

The late Dr. George Selby reignited Jim’s interests in headache medicine in Australia with the large number of patients with headache attending his clinic. The two studied 500 patients with headache in great detail, resulting in a landmark article that identified many features of migraine that had not been previously appreciated, such as the frequent onset of migraine in childhood, the presence of allodynia in many patients with migraine, reflecting the presence of central sensitisation, and the major impact of emotional factors on the migraineur.

In 1960, Jim Lance again left Australia to follow his passion for research work at the Massachusetts General Hospital in Boston, where he became interested in myoclonic epilepsy and described the Lance–Adams syndrome in “The Syndrome of Intention or Action Myoclonus as a Sequel to Hypoxic Encephalopathy” and “The Falling Attacks of Myoclonus.” He returned to Australia as the founder of the first academic Department of Neurology in Australia in the newly established medical school at UNSW. He remained at UNSW from then, starting as a senior lecturer (1961-1963), then associate professor (1964-1974), professor of neurology—personal chair (1975-1992) and, most recently, as emeritus professor.

Along with his active research program, Prof. Lance continued his busy clinical practice at the Prince Henry and Prince of Wales Hospitals where he was chair of the department of neurology (1961-1992) and foundation director of the Institute of Neurological Sciences from 1990 until his retirement. He was a former president of the Australian and New Zealand Association of Neurologists, a founding director of the Australian Brain Foundation, inaugural president of the Australian and New Zealand Headache Society and president of the International Headache Society (1987-1989).

In Practice

Jim was a mentor to many neurology trainees in Australia and many other parts of the world. Together with Prof. Jim McLeod, they provided a beacon for Australian neurologists and clinician scientists. Through the 1970s and 1980s, they were regarded as the most influential neurologists in Australia. Almost all neurology trainees in those times would have had the good fortune to have been exposed to their skill and expertise, and a good number of them have gone on to carve their own places in Australian neurology.

Jim had a remarkable power of observation, which enabled him to collect unusual symptoms and signs, collate them, and describe them in detail as new entities, ranging from benign coital headache to the Harlequin syndrome.

He was a prolific publisher, contributing 33 articles to the Medical Journal of Australia alone from 1959 to 2003, with the last being an invited autobiography. He was the undoubted leader of headache medicine in Australia and greatly influential in headache medicine worldwide. This was recognized when he was honored with numerous awards from the American Association for the Study of Headache, the British Migraine Association and, in 2015, the International Headache Society Special Recognition Award, presented to him by Peter Goadsby.

Jim was actively involved in the World Federation of Neurology (WFN) and served as a vice president from 1989-1997. He was delighted to hear that the WFN would be dedicating the year 2019 to migraine and headache medicine through its World Brain Day initiative July 22.

Jim Lance was a gentleman, in the true sense of the word, always courteous, and kind. Despite his numerous achievements, he was always humble and was the first to acknowledge the contributions of others. He was passionate about teaching and drew more than the occasional medical student listening to his lectures to a career in neurology. He was the embodiment of the clinician scientist. He had boundless enthusiasm, which was infectious, and was a great mentor to many neurological trainees.

We will all miss him.

Jim Lance is survived by his wife Judy, his five children, 19 grandchildren, one great grandchild and another on the way. •

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.

Prof. Wijeratne is chair of advocacy and public awareness for the World Federation of Neurology, chair of the SIG-Migraine for the World Federation of Neurology, chair of the Annual Lance-Goadsby Migraine Symposium and Oration, director of the department of neurology at Sunshine Hospital, and research scholar at the School of Psychology and Public Health, and the College of Science, Health, and Engineering at La Trobe University.

Zagami is associate professor at the Institute of Neurological Sciences  at the Prince of Wales Hospital and the Prince of Wales Clinical School, UNSW.

Prof. Carroll is president of the World Federation of Neurology, professor in the department of neurology at Sir Charles Gairdner Hospital and the Centre for Neuromuscular and Neurological Disorders, Perron Institute, University of Western Australia.

James Waldo Lance

By David Burke

This In Memoriam is reprinted COURTESY of The Australia & New Zealand Association of Neurologists Newsletter.

Australia and the world have lost a true giant of neurology with the passing of James Waldo Lance, CBE, AO, MD, FRCP, FRACP, FAA.

Following is the eulogy that was delivered at Jim’s funeral service by Prof. David Burke, past presidentof ANZAN.

We are here today to pay our respects to the doyen of Australian neurology. Jim Lance was the complete physician, a man who covered all fields and was an exemplar clinician-scientist. He was the academic father and intellectual inspiration for many of us. We will not see his like again.

  • He was the first person appointed as a neurologist in Australia.
  • He set up the first academic department of neurology in Australia and founded the Institute of Neurological Sciences of the Prince Henry and Prince of Wales Hospitals.
  • He was the first professor of neurology in Australia.
  • He was the first practicing clinician elected as a Fellow of the Australian Academy of Science.
  • He was president of the Australian Association of Neurologists, and one of the founding fathers and a lifelong supporter of the Brain Foundation.
  • He was the foundation president of the Australian Headache Society and president of the International Headache Society.

His service to the community has been recognized by the Governor General.

  • He was appointed commander of the order of the British Empire in 1977.
  • He was appointed officer in the order of Australia in 1991.
  • He was awarded the Centenary Medal of Federation in 2001.
  • He was recognized nationally and internationally.
  • He won the Lilly Foreign Education Fellowship at Massachusetts General Hospital in Boston in 1960.

The British Migraine Association awarded him the Gold Medal in 1975.

The American Association for the Study of Headache recognized him four times: the Harold G. Wolff Memorial Award in 1967 and again in 1983, the Arnold Friedman Distinguished Clinician/Researcher Award in 1989, and the John Graham Senior Clinician Award in 1991.

Under the presidency of Geoff Donnan, the Australian Association of Neurologists created an annual award: The James Lance Young Investigator Award, in recognition of his lifelong role in training the next generation.

When Michael Halmagyi was president, the Brain Foundation created the James Lance Award for research into migraine and other headaches. These achievements and this recognition do not tell you much about Jim Lance as we knew him. He has contributed so much to our lives that it is difficult to know where to begin.

James Waldo Lance was born in Wollongong in 1926 and graduated in medicine in 1950 from the University of Sydney. Influenced by Nobel Laureate Howard Florey, he cut short a residency at Royal Prince Alfred Hospital to undertake full-time research for the degree MD with Peter Bishop at the newly established Brain Research Institute at the University of Sydney. A fellow student was Jim McLeod, undertaking research for the BSc (medicine), and the two became lifelong friends, spending time in the U.K. and later in Boston at much the same time. The two Jims became known as the “Gentleman Jims,” a legendary twosome in Australian neurology, running complementary departments at our two premier institutionssetting a high bar for others to emulate elsewhere in the country.

He spent a couple of years in London, first at the Royal Postgraduate Medical School at Hammersmith Hospital, and then at Queen Square, where he was influenced by eminent clinicians and great teachers. After he returned to Australia, an opportunity to develop a neurological career arose when the University of New South Wales set up a new medical school at The Prince Henry Hospital under Ralph Blacket, the foundation professor of medicine. After a year in Boston honing his academic skills, Jim took up the appointment as chair of the department of neurology, an appointment that he held for 30 years.

During that time, he worked tirelessly to develop the specialty, at Prince Henry and throughout the country. And now, we can see the fruits of his labor: Neurology is arguably the most exciting field in which to work as a physician.

Our unit was blessed by its leadership, with Jim running neurology, Alec Gonski running neurosurgery, and Jo Loder running Ward 4. Prince Henry became a beacon in neuroscience in Australia, culminating in the formation of the Institute of Neurological Science, with Jim as the first director, and then the Prince of Wales Medical Research Institute. Now renamed NeuRA, this was the first medical research institute devoted exclusively to neuroscience in Australia.

He formally retired from the hospital service at the obligatory age of 65, but he continued a neurological practice until his late 80s. He maintained a weekly presence at our Grand Rounds, where he shared clinical insights and taught our trainees the art of neurology.

Throughout his life, Jim championed the scientific basis of medicine, always inquiring, always interested in evidence, but always humble and ready to change his mind when the evidence dictated that. He was a man of enthusiasms and unquenchable work ethic, that stimulated his colleagues and staff to work harder to emulate the standards he had set. If one questioned a task, Jim’s response was typical of the man: That’s OK: I’ll do it myself.

He believed in people whether colleagues or patients, and his support was unwavering. He actively nurtured the careers of junior colleagues, and took pride in their achievements. He treated his patients as people—intelligent and capable of understanding if the right language was used. He was unfailingly honest in his appraisals, but did not have a bad word for people: If a reference consisted of two paragraphs the thumb was down; if it consisted of two pages, the thumb was up. And his influence extended beyond those who worked directly with him, and beyond Australia.

A quote from a senior colleague from Melbourne typifies responses received from all over the country, and from overseas:

“Jim was an inspiration to me while training in the early 1980s. He always had encouraging and kind words for me as a trainee and junior neurologist, and I feel a great debt both to his leadership in our profession and in shaping my own development as a clinician-scientist.”

He loved nothing more than teaching, and his Grand Rounds and lectures on Mondays in Ward 4 at The Prince Henry Hospital attracted young aspiring clinicians from all over the city. His clinical consultations were incisive, instructive, and an opportunity to teach. The referring physician inevitably learned not only what to do, but why to do it.

We have benefitted from his leadership, his wisdom, his generosity, and his support. Jim may have gone, but his legacy will continue to grow not just through his direct family, but through those clinicians and scientists who count themselves as part of his extended family.

We thank Jim for a life well spent. More particularly we thank Judy, Fiona, Sarah, Jenny, Robert, and Sophie and their families for allowing us to share his life. •

Prof. Jagjit S. Chopra, DCH, FRCP, PhD, FAMS, FIAN

(1935-2019)

By Prof. Inder M.S. Sawhney, MD, DM, FRCP, MNAMS, FIAN; Prof. Vijay K. Kak, MS, FRCS, FRCSE, FAMS, FIAMS, FIHE and Prof. Sudesh PrabhakarMD, DM, FIAN

The World Federation of Neurology (WFN) honored Prof. Jagjit Singh Chopra (JSC) with the Lifetime Achievement Award in September 2017 at Kyoto, Japan. His achievements were applauded on the world stage in his absence, as he could not attend the meeting due to a disabling stroke.

Prof. Chopra displaying the latest edition of the book, “Neurology in Tropics,” edited by him.

He was selected as Secretary General of the World Congress of Neurology (WCN), which was organized successfully in 1989 at New Delhi. He has the distinction of being associated with the WFN since 1985 in various capacities, including co-chair of the Finance Committee, vice chair of the research group on organization and delivery of neurological services and editor-in-chief of World Neurology from 1999-2009.

Prof. Chopra was the first Indian neurologist to be nominated for the post of WFN president in 2005. He breathed his last Jan. 18, 2019, in Chandigarh, India, plunging the neurology community worldwide, his friends, and colleagues into gloom with the loss of a distinguished neurologist.

JSC was born June 15, 1935, in Lahore (now Pakistan). He received his early school education in Fazilka and completed his medical degree at the Government Medical College, Patiala (Punjab University) in 1959. He proceeded to the U.K. after one year’s house job at Rajindra Hospital in Patiala, and worked at the Royal Belfast Hospital for Sick Children, Belfast, and later in the departments of medicine and neurology at the Royal Victoria Hospital in Belfast.

He was trained under neurology stalwarts such as Drs. R.S. Allison, JHD Miller, L.J. Hurwitz and M.W. Swallow. He passed the examination for diploma in child health from Royal College of Physicians in 1962 in London, and obtained MRCP (Edinburgh) with specialization in neurology in 1963. He was the youngest Indian to be awarded FRCP (Edinburgh) in 1969. He was awarded a PhD by the Queen’s University in 1967 in Belfast for extensive research on diabetic neuropathy.

Toward the end of his U.K. sojourn, JSC met his former teacher, Dr. P.N. Chuttani, in an elevator in London. In the brief encounter, JSC expressed his desire to return to India.

“Boy, go and pack your bags. I have given you the job,” said Dr. Chuttani to his bright student. That is how Dr. Chopra joined the Postgraduate Institute of Medical Education and Research (PGIMER) in Chandigarh, in 1968, as assistant professor of neurology, and gradually rose to professor of neurology until his superannuation in June 1995.

Neurology Department

JSC was instrumental in setting up a world-class department of neurology and research laboratory at PGIMER and dedicated his life to establishing model clinical, teaching, and research facilities in the department. He started the DM (neurology) training program at PGIMER and trained several super-specialists in neurology, most of whom are heading departments at various establishments in India and abroad. He also trained many specialists in neurology for the Armed Forces of India.

Neurology training during his tenure was rigorous. None of his trainees can forget the teaching at Saturday grand rounds, where the emphasis used to be on clinical neurology. He was a man who appeared tough in his professional and academic dealings, but was endowed with a kind heart and always went the extra mile to help everyone, especially his students. He had the reputation of being a hard taskmaster, a strict disciplinarian, and an immaculate clinician.

Prof. Chopra retired in 1995 but continued as professor emeritus at PGIMER. He was also selected as national lecturer by University Grants Commission, and lectured at various medical institutions across the country. The National Academy of Medical Sciences (India), New Delhi, also honored him with emeritus professorship. He was awarded the Dr. B.C. Roy National Award as an eminent medical teacher.

Research

JSC has contributed immensely in the field of neurosciences research and education. He has conducted research in muscle diseases, peripheral nerves, young strokes, and infections of the nervous system, and has guided over a dozen PhD theses. He has published nearly 250 scientific research papers in journals of national and international repute.

He was editor-in-chief for “Text Book of Neurology,” and “Neurology India,” a publication of the Neurological Society of India, for six years. He has written about 50 chapters in various books and monographs, published in India and abroad. He served on the editorial board of several journals. Age did not dampen his enthusiasm for neurology. He had a firm belief that there was no limit to gaining knowledge and giving it back to the world. He co-edited “Neurology in Tropics” in his 80s and was a force behind meeting the deadlines for its publication.

JSC was the founder president of Indian Academy of Neurology (1993-1994), his brainchild, and past president of the Neurological Society of India (2003). He had been a member of the executive committee of the International Federation of Clinical Neurophysiology, selected as an honorary member of the American Academy of Neurology and the American Neurological Association, member of the London Medical Society, Association of British Neurologists, and Ulster Medical Society. He was elected fellow of the Medical Society of London and the National Academy of Medical Sciences (India), New Delhi.

JSC has been a member of the advisory groups/panels of medical education and training of National Board of Examinations; Indian Council of Medical Research; NIHMANS, Bangalore; Indian Council of Child Welfare, Chandigarh; and the department of biotechnology for the government of India. He had been a member of several international scientific program advisory committees. He was nominated as a senator to the Baba Farid University of Health Sciences, Faridkot, Punjab, by the governor of Punjab.

Awards

JSC had been the recipient of several awards and orations, including the Ninth Amrut Modi Research Award, Pelipu Perindevi Suriya Award of Pharmacological Society of India, MN Sen Oration Award of ICMR, Life Time Achievement Award in Neurosciences, Madras Neuro Trust, Dr. M.S. Sanjeev Rao Oration, Dr. R.S. Allison Oration, Belfast, U.K., Baldev Singh Orations, NSI and National Academy of Medical Sciences, New Delhi, Vishist Chikitsha Gold Medal by Association of Chest Physicians of India, award by Pan Arab Union of Neurological Societies, Emirates Medical Association and Emirates Neurological Society and Emirates League Against Epilepsy, and awards from Pakistan Neurological Society and Epilepsy Association of Pakistan. He was awarded the Parman Patra by S. Prakash Singh Badal, chief minister, Punjab in 2007, and Padma Bhushan (the third highest national award) by the president of India in 2008.

JSC was happily married to Amarjit Chopra, who passed away over a year ago. They have a daughter and a son. Dr. Brinder Chopra received her MD in clinical biochemistry from Punjab University, and is currently working as associate professor of biochemistry at Gian Sagar Institute of Medical Sciences, Patiala. She is married to Dr. Sukhpreet Singh, MS (general surgery), and they have two children.

Their son, Dr. Harvin Chopra, is trained in radiodiagnosis with an MD from Medical University of Innsbruck, Austria, and an MD from MMU, Mullana. He is married to Natasha.

JSC was a brilliant organizer, an excellent clinician, and mentor to a large number of neurologists all over the world. Prof. Chopra will be immensely missed in the world of neurology and will live forever in the hearts of his students and colleagues. We owe him a debt of gratitude for his contribution to neurosciences and for his never-ending faith in the potential of his students. •

Prof. Sawhney is the honorary professor of neurology at Swansea University, and consultant neurologist and clinical director neurosciences at the ABM University Health Board, Morriston Hospital Swansea, U.K. Prof. Kak is emeritus professor of neurosurgery at PGIMER in Chandigarh, former director-principal of Government Medical College in Chandigarh, and secretary medical education and research at the Chandigarh Administration, India. Prof. Prabhakar is the former professor and head of the department of neurology, Postgraduate Institute of Medical Education & Research in Chandigarh, India.

References
Kak VK, Sawhney IMS. In Memorium – Prof. JS Chopra. Neurology India 2019; 67(1): 346-349.
Sawhney IMS, Kak VK. In Memorium – Prof JS Chopra. Annals of Indian Academy of Neurology 2019; 22 (2): 259-260.

Istanbul University Cerrahpasa Faculty of Medicine

By Dr. Cyril Oshomah Erameh

Thank you to the WFN and the Turkish Neurological Society for this privileged academic opportunity to visit one of the most established neurological centers in Turkey.

This wonderful experience commenced with the receipt of my acceptance for this program from Jade Levy of the WFN. She explained my travel details and made introductions to Burak Tokdermir, the Turkish Neurological Society contact. Tokdermir was helpful in planning my trip and linking me up with the professor at Cerrahpasa.

On my arrival at the neurology department in Cerrahpasa, I was warmly welcomed by Dr. Melih Tutuncu. Dr. Melih took me on a tour and introduced me to the department chair, Prof. Sabahattin Saip and Prof. Aksel Siva, renowned for MS management. My weekly schedule was drafted in accordance to my particular interest areas in neurology. These areas were epilepsy, movement disorders, neuromuscular, and neuroinflammatory diseases. This schedule was further finetuned by Prof. Derya Uluduz, my contact professor.

The weekly schedule I followed during the visit was:

Monday

  • Morning: Epilepsy unit with EEG reporting, outpatient clinics, and inpatient case management.
  • Afternoon: EMG lab.

Tuesday

  • Morning: Epilepsy unit with EEG reporting, outpatient clinics, and inpatient case management.
  • Afternoon: Movement disorders clinic.

Wednesday: MS clinic.

Thursday

  • Morning: Movement disorders.
  • Afternoon: EMG lab.

Fridays: Free time to view the sights and sounds of Istanbul.

During this period, I learned more about epilepsy, movement disorders, and MS. My EEG reporting skills have also improved following this visit.

The highpoint of the visit was the 54th National Neurology Congress of the Turkish Neurological Society, which took place Nov. 30-Dec. 6, 2018, in Antalya. I enjoyed this academic week. It was powerfully packed with lectures delivered by erudite neurology scholars. I learned a great deal about current trends in neurology. Rixos Hotel, the conference site, was beautiful and serene with a wonderful seaside view.

I also networked, met young neurologists from all over Turkey, and made new friends. It was indeed a wonderful experience for me.

This department was apt for me. As a young neurologist with a wide future and from a developing country in Africa [Nigeria], this visit highlighted how care of neurological case are in developed countries, giving me insight into how to make improvements in my home country. My plan following this visit is to improve neurodiagnosis in my center and also seek additional training.

Finally, I would like to again thank the WFN and Turkish Neurological Society for this visit, with special thanks to Jade Levy, Burak Tokdermir, Prof. Derya Uluduz, Dr. Melih Tutuncu, Prof. Aksel Silva, Dr. Aysegul Gunduz, Prof. Gunes Kiziltan, Dr. Uygur, Dr. Bade Gulec, Prof. Sabahattin Saip, and the entire Noroloji Department of Istanbul University Cerraphasa Tip Fakultesi. •

Calling All MS Researchers

MSIF offers grants for researchers from low- and middle-income countries

By Anne Helme

The Multiple Sclerosis International Federation (MSIF) is inviting applications for McDonald Fellowships and Du Pré grants for researchers or clinicians working in a low- or middle-income country, who would like funding to expand their expertise and build partnerships with other countries. The deadline for application is July 21, 2019.

Members of the MSIF Research Alumni Network at ECTRIMS 2018.

McDonald Fellowships enable young researchers from low- and middle-income countries to work in a research institution outside their own country, with a view to returning to their country to establish a program of MS research that involves the application of the newly learned techniques, to help transform the MS landscape in their home country. The fellowship consists of a two-year grant of £30,000 GBP per year, to cover travel and living costs, and an additional contribution of £2,000 GBP per year to the host institution. Find out more at https://www.msif.org/research/awards-grants-and-fellowships/mcdonald-fellowships/.

Du Pré grants fund short visits by researchers and clinicians from low- and middle-income countries to established MS research centers outside their own country, either to learn from each other or to carry out parts of joint research projects. Visits generally last between two and six months. Each grant is up to a maximum of £6,000 GBP. The funds are intended to go toward travel and living costs, or to supplement an existing grant to extend a visit. Find out more at https://www.msif.org/research/awards-grants-and-fellowships/du-pre-grants/. •

Helme is the head of research and access at the Multiple Sclerosis International Federation.

CNC: Meeting in Cairo

Prof. Maged Abdel Naseer

The Egyptian Society of Neurology was founded in 1955. It serves as a minaret of neurological education, brainstorming of new ideas and sharing of updates.

Speakers for the opening ceremony.

Gunther Deuschl, from Germany, provides his introductory remarks

Since 1999, members of the society have been holding an annual conference in the capital city under the name of the Cairo International Neurology Conference (CNC).

More than 700 attendees enriched the 2019 conference with their participation in various pre-conference workshops, including epilepsy, EEG in the ICU, headache, stroke medicine and neurointervention, neuromuscular ultrasound, and movement disorders. This was followed by conference symposia and sessions showing a mosaic attendance from all over Egypt.

This year’s 20th CNC was a special one because it was honored by the presence of neurology experts from different parts of the world in addition to different Arab countries including Libya, Sudan, Jordan, Tunisia, and Kingdom of Saudi Arabia. Interesting, for the first time in many years, Iraqi experts were able to make it to the CNC.

The story that began with the pharaohs will never end. •

Prof. Maged Abdel Naseer is the WFN delegate from Egypt.

Tropical Neurology: INTROPICON 2018

BY PROF. CHANDRASHEKHAR MESHRAM, NAGPUR, INDIA, AND PROF. RAAD SHAKIR, LONDON.

The second International Tropical and Geographical Neurology Conference (INTROPICON) was held in conjunction with the 28th Brazilian Congress of Neurology and the 15th Pan American Congress of Neurology Oct. 11-14, 2018, in Sao Paulo, Brazil. The congress was huge and was attended by more than 3,800 delegates from all over Latin America and across the world.

The Tropical and Geographical Neurology Applied Research Group of the World Federation of Neurology (WFN) is the oldest group, established in 1961, and has had many meetings over the years. This congress was decided following the reconstruction of the research group in Mumbai during INTROPICON in 2017. The chair of the research group is Dr. Chandrashekhar Meshram from Nagpur, India. This second congress was co-chaired by Dr. Meshram and the late Prof. Amilton Barreira, Sao Paulo, Brazil. It is with great sadness that the whole world of neurology, and in particular tropical and Latin American neurology, will sorely miss Prof. Barreira. His contributions were immense.

INTROPICON 2018 covered the field with fascinating presentations on a variety of topics. The congress featured an in-depth look at cysticercosis, amebic encephalomyelitis, cerebral malaria, Chagas disease, schistosomiasis, toxoplasmosis, trypanosomiasis, cerebral venous thrombosis in India, paracoccidioidomycosis, arboviruses, Zika virus status, congenital Zika virus, chikungunya, dengue status in Latin America and Asia, yellow fever, and vaccinations for arboviruses. Videos of live cysticerci floating in the third and lateral ventricles seen on endoscopy were mesmerizing.

INTROPICON 2018 also discussed the status of meningitis across the world. The current human T-lymphotropic virus type 1 (HTLV1) status and HIV were presented and discussed. Poliomyelitis and post-polio syndrome are still ongoing problems, which was addressed. Cytomegalovirus infection and Ebola were issues affecting individuals, and their current statuses were presented. Fungal disease received its share of discussion and time. Snakebites still kill thousands in many countries. Their management remains challenging and, at times, difficult.

Amilton Barreira

In addition, major issues such as stroke, dementia, epilepsy, and Parkinson’s disease were discussed. Their unique management and long-term care in resource-poor settings were the main points of discussion. The availability of simple drugs for epilepsy and Parkinson’s disease was a major hindrance to neurological care. The lack of manpower and funding remains a major obstacle to neurological service provision. It is astounding that drugs as cheap as simple anticonvulsants, levodopa, and warfarin, among others, are still not available to billions of individuals living in low- and middle-income countries.

There remains a huge discrepancy in the provision of care in various parts of the tropics. In all, neurological expertise is concentrated in major cities, and in some of those, advanced imaging, genetic testing, and management (including interventional procedures) is available. However, this is by and large in fee-paying settings, which is not accessible to the majority of those who need the service.

Neurology training for young doctors is a priority, and it is heartening to see the increasing numbers of budding training programs across the world. There is nothing like training locally to master the vast number of conditions discussed, but just as important is exposure to training in more advanced settings. The Tropical and Geographical Neurology Applied Research Group of the WFN is working hard toward these goals. The meeting of this research group is biennial, and the next meeting is planned to be with the African Academy of Neurology in 2021. •

World Stroke Day 2018: BEYINDER

BY DERYA ULUDUZ

The Turkish Stroke Patient Society (BEYINDER), a member of the Stroke Alliance for Europe (SAFE), organized the first symposium for stroke survivors and their caregivers in Turkey on World Stroke Day 2018, acknowledging the importance of acute management in stroke, long-term commitment, and attention to the needs and rights of stroke patients for better outcomes. The full day symposium was titled “İnme Hasta ve Hasta Yakınları Sempozyumu,” which is Turkish for the “Symposium of the Stroke Survivors and Their Caregivers.”

BEYINDER was founded in 2017 and became a member of SAFE shortly after. We have strong collaborations with SAFE to raise awareness with respect to strokes. Every year, 15 million people suffer strokes worldwide, and it is the leading cause of disability. BEYINDER also publishes a stroke magazine for patients every three months.

The symposium, organized at the Altunizade Event Center in Istanbul, was attended by stroke survivors and their caregivers with the participation of health directors and heads of emergency services. The most important target of this event was the public; we created simple messages to promote via social media, newspapers, and press. The event relevance and the topics of the sessions (importance of primary prevention, emergency management interventions, and life after stroke for better outcome) were appraised by the TV channels, social media, news agencies, and newspapers. They focused on our activity on their main bulletins.

Social media

The main aim of this symposium was to provide close collaborations between stroke survivors, stroke neurologists, and policymakers to solve the main problems. In one of the sessions, we gave the microphone to the patients and discussed the problems they experienced and the needs of those patients. The second important target for this event was policymakers and the Ministry of Health. BEYINDER is now working to prepare a report about the conclusion of the symposium and the tribulations of those patients, and will contact the Ministry of Health to discuss and facilitate the solutions.

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