Modafinil is not the new caffeine

In the quest to improve quality of life, physicians are often challenged by their patients to improve ill-defined symptoms such as fatigue and sleepiness. Sometimes these complaints are in isolation from any clear medical condition, sometimes they are a direct consequence (e.g., excessive daytime sleepiness resulting from obstructive sleep apnea), and sometimes they are only associated with a medical or psychiatric condition. Having a Class I level of evidence helps define a treatment protocol with a symptom and its associated condition. This is still no guarantee for success, but a nice prerequisite in today's complex medical environment. Fatigue and sleepiness affect everyone (patients and healthy subjects), and the search for a universal tonic seems never-ending. Modafinil was identified as one such candidate, and when tightly targeted for a specific disease such as narcolepsy, was successful in reducing daytime sleepiness (but not fatigue). However, when used off-label and indiscriminately, both clinical practice and the medical literature found it wanting. Studies that suggested it for other uses tended to be imprecise in their methodologic approach. In this issue of Neurology ®, Kaiser et al.1 present an exceedingly …