Documentation of cerebrospinal fluid opening pressure and other important aspects of lumbar puncture in acute headache

BACKGROUND

Measuring cerebrospinal fluid (CSF) opening pressure by lumbar puncture (LP) is an essential tool in the investigation of patients with acute headache.

AIM

To assess documentation of opening CSF pressure in those with acute headache undergoing LP. General documentation of the procedure and CSF investigations was also assessed.

METHODS

Retrospective review of medical records of patients admitted to a teaching hospital Acute Medical Admissions Unit over a three-month period with a presenting complaint of headache.

RESULTS

A total of 106 patients presented with headache of whom 48 patients had at least one LP attempted. Only 41 patients (85%, 95% CI 72-94) had their LP documented. Of 47 patients that had a successful LP, 22 (47%) had a recorded opening pressure. Eighteen (32%) of all patients had their position recorded, with seven (15%) patients having had position and opening pressure documented. Twenty patients (43%) had the appropriate results documented. Twelve patients (31%) had paired serum glucose measured.

CONCLUSIONS

Documentation of a LP for headache in the acute setting was generally poor. CSF opening pressure measurement was frequently omitted and no appropriate action taken if high. Paired serum glucose was rarely measured. Acute physicians may benefit from a proposed protocol and documentation sticker.

[Sphenoid arachnoidocele: report of one case]

OBJECTIVES

To define a diagnostic strategy of a sphenoid sinus lesion and the management of CSF fluid leak in the case of a sphenoid arachnoidocele.

MATERIALS AND METHODS

A 70-year-old woman exhibited a sphenoidal sinus opacity which was discovered on the assessment of chronic headaches. It was labelled sphenoid mucocele. A cerebrospinal fluid leak occurred when the marsupialization was made. After an assessment of additional imaging (MRI, CTscan), the diagnosis of sphenoid arachnoidocele was retained.

RESULTS

The leak was repaired by navigated endoscopic endonasal surgery. We used a multilayer reconstructive technique with autologous materials (abdominal fat, fascia of muscle, middle turbinate) and fibrin glue. With a decline of eighteen months no rhinorrhea was noted.

CONCLUSION

Sphenoid arachnoidocele is a rare disease. This case shows that it's essential to know the differential diagnosis sphenoid sinus lesions and how to repair an osteomeningeal leak.

Chordoma presenting as pseudoprolactinoma

Chordomas are relatively rare neoplasms that appear to originate from benign remnants of primitive notochord. They account for about 0.15% of all intracranial neoplasm and are the most common of extradural neoplasms that involve the clivus. Although they present mostly with signs and symptoms of other intracranial lesions they rarely present with high prolactin levels mimicking prolactinomas. We report a case of chordoma presenting as a pseudoprolactinoma. We discuss the presentation, radiological features and treatment of this rare presentation.

Allogeneic epidural blood patch in the setting of persistent spinal headache and disseminated coccidioidomycosis

In most cases of post-dural puncture headache, the positional symptoms will resolve spontaneously within 2 weeks. Conservative therapies include oral analgesics and hydration, bed rest, and abdominal binders. For refractory cases, an autologous epidural blood patch remains the treatment of choice. However, in certain cases the use of autologous blood for the blood patch may place the patient at risk for infectious or malignant contamination of the central nervous system. Coccidioidomycosis results from inhalation of the arthroconidia (spore) stage of the fungal lifecycle. The most common manifestation of coccidioidomycosis is acute pulmonary symptoms, while the most feared complication is meningitis. Immunocompromised patients are at increased risk of fungemia; therefore, introduction of fungal elements into the central nervous system can occur if autologous blood is used for an epidural blood patch. We report a case of persistent dural-puncture headache in the setting of disseminated coccidioidomycosis. An autologous blood epidural blood patch was considered but deferred due to risk of coccidioidomycosis meningitis. Other epidural space interventions such as fibrin glue injection or saline infusions were judged to be too imprecise or ineffective. The patient was successfully treated with allogeneic blood donated by his wife, but only after testing of her blood as is required for any directed blood donation. Allogeneic epidural blood patches are an option for refractory dural puncture headaches when autologous blood may cause meningitis or malignant seeding of the central nervous system.

Diagnosis and management of the primary headache disorders in the emergency department setting

Headache continues to be a frequent cause of emergency department (ED) use, accounting for 2% of all visits. Most of these headaches prove to be benign but painful exacerbations of chronic headache disorders, such as migraine, tension-type, and cluster. The goal of ED management is to provide rapid and quick relief of benign headache, without causing undue side effects, and to recognize headaches with malignant course. Although these headaches have distinct epidemiologies and clinical phenotypes, there is overlapping response to therapy; nonsteroidals, triptans, dihydroergotamine, and the antiemetic dopamine antagonists may play a therapeutic role for each of these acute headaches. This article reviews the diagnostic criteria and management strategies for the primary headache disorders.

[Mitochondrial disorder underlying headache symptoms]

MERRF (myoclonic epilepsy with ragged red fibers) is a rare mitochondrial disorder affecting the function of several distinct organs. Diagnosis of the syndrome has conventionally been made on the basis of the patient's myoclonic epilepsy and the so-called ragged red fibers observed in the patient's muscle biopsy. The diagnosis is confirmed by mutation analysis. Symptoms and findings vary from patient to patient even within one family. A strain-associated headache episode and bout of nausea with deficiency symptoms occurs as the most severe symptom in the young boy of our case report.

Premature birth--Studies on orthodontic treatment need, craniofacial morphology and function

A series of studies have been initiated implying a unique opportunity to evaluate and compare malocclusion traits, orthodontic treatment need, craniofacial morphology, mandibular function, signs and symptoms of temporomandibular disorders (TMD) and headache between extremely preterm (EPT; born before the 29th week of gestation) and very preterm (VPT; born between 29 and 32 weeks of gestation) and full-term born children. THIS THESIS WAS BASED ON FOUR STUDIES: Paper I. A systematic literature review was undertaken to answer the following questions: Does prematurity result in alterations of palatal morphology, dental occlusion, tooth-crown dimensions, tooth maturation and eruption? What role does neonatal oral intubation play in the appearance of the alterations? Are the alterations in morphology permanent or transient? The literature search spanned from January 1966 to November 2002 and was later extended to September 2008. Furthermore, a quality analysis of the methodological soundness of the studies in the review was performed. Paper II-IV. The aims were to compare EPT and VPT 8- to 10-year-old children with matched full-term controls considering: Prevalence of malocclusion traits and orthodontic treatment need (Paper II). Craniofacial morphology (Paper III). Mandibular function, signs and symptoms of TMD and headache (Paper IV). KEY FINDINGS IN PAPER I AND THE SUPPLEMENTARY SEARCH: Moderate scientific evidence existed for more malocclusion traits among premature children. Limited evidence was found for no delay in dental eruption, if corrected age was considered for the premature children. Insufficientwas considered for the premature children. Insufficient evidence was found for altered tooth-crown dimensions and permanent alteration of palatal morphology among prematurely children. Thus, further well-designed controlled studies which should also consider orthodontic treatment need, craniofacial morphology, TMD and headache are needed. KEY FINDINGS IN PAPER II-IV: A higher prevalence of malocclusion traits and the assessed need of orthodontic treatment were higher among the preterm children compared with full-term born children (Paper II). Several craniofacial parameters differed significantly between preterm and full-term born children (Paper III). Preterm children did not differ from full-term born children when considering diagnoses according to the Research Diagnostic Criteria for TMD (RDC/TMD), signs and symptoms of TMD or headache (Paper IV).

KEY CONCLUSIONS AND CLINICAL IMPLICATIONS

The increased survival rate of very preterm and especially the extremely preterm children contribute to a new group of children in society. The dental clinician should, therefore, be aware of the potential for a higher number of malocclusion traits, more malocclusion traits per individual, greater orthodontic treatment need and altered craniofacial morphology in prematurely born children compared with full-term born children. In spite of this, the prematurely born children had not more TMD or headache than full-term born children at the age of 8-10 years.

[Use of anesthesiological technologies in the complex treatment of cervicocranial pain syndromes]

Four hundred and eighty-four patients with pain syndromes of cervicocranial localization, such as migraine, exercise-induced headache, cervicogenic headache, trigeminal neuralgia, trigeminal neuropathy, and occipital neuralgia were observed. The patients were randomized by the type, intensity, and duration of the pain syndrome and subdivided into two subgroups in each of the study nosological entities. The patients from control groups received the conventional complex therapy including drug (nonsteroidal anti-inflammatory drugs, central myorelaxants, anticonvulsants, and antidepressants depending on the type of a pain syndrome) and non-drug (physiotherapy, massage, and therapeutic exercises) ones. The patients were examined before, during, and after a course of therapy and comprised neurological and neuroorthopedic examinations; pain rating by the visual-analogue and the rank scale, and neuroimaging and electrophysiologic techniques. Comparison of the results obtained in the respective subgroups has indicated that anesthetic modes and reflex exposures in the complex therapy is an effective and safe procedure for relieving pain in the head and neck. Medicinal blocks arrest pain at shorter notice, reduce the single and daily doses of the used drugs and, in some cases, avoid their administration, thus, preventing their side effects, improve the quality of life, and increase the social activity of patients with cervicocranial pain syndromes.

[Cervicogenic headaches: aspects of diagnosis and analgesia]

Eighty-six patients with cervicogenic headaches underwent a comprehensive clinical and instrumental studies involving neurological and neuroorthopedic examinations; pain rating by the visual-analogue scale (VAS) and the rank scale, and neuroimaging and electrophysiologic techniques. The patients were divided into two groups: a study group (n = 43) and a control one (n = 43). In the study group, treatment policy was determined by the intensity and duration of the pain syndrome: local anesthetic blocks of the occipital nerve, facet joints, and the trigger points of the cervicocranial area were used to arrest acute pain of a VAS score of 5 or more. With a pain syndrome score of less than 5, treatment was initiated with reflex exposures. All the patients from the study group took nonsteroidal anti-inflammatory drugs (NSAID) and, if required, central myorelaxants. The control group received the conventional therapy, including drug (NSAID, central myorelaxants, and anticonvulsants) and non-drug (physiotherapy and massage) ones. Medicinal blocks and reflex analgesia could relieve the pain syndrome in cervicogenic headaches in shorter periods and reduce the dosage of the drugs used in the study group patients as compared with the controls.

Prevalence of chronic pain after traumatic brain injury: a systematic review

CONTEXT

The Centers for Disease Control and Prevention estimates that approximately 1.4 million US individuals sustain traumatic brain injuries (TBIs) per year. Previous reports suggest an association between TBI and chronic pain syndromes (eg, headache) thought to be more common in patients with mild TBI and in those who have sustained brain injury from violent rather than unintentional trauma. Comorbid psychiatric disorders such as posttraumatic stress disorder (PTSD) may also mediate chronic pain symptoms.

OBJECTIVES

To determine the prevalence of chronic pain as an underdiagnosed consequence of TBI and to review the interaction between chronic pain and severity of TBI as well as the characteristics of pain after TBI among civilians and combatants.

EVIDENCE ACQUISITION

The Ovid/MEDLINE database was searched for articles published between 1951 and February 2008 using any combination of the terms brain injury, pain, headache, blast injury, and combat (combat disorders, war, military medicine, wounds and injuries, military personnel, veterans). The PubMed and MD Consult databases were searched in a similar fashion. The Cochrane Collaboration, National Institutes of Health Clinical Trials Database, Meta-Register of Current Controlled Trials, and CRISP databases were searched using the keyword brain injury. All articles in peer-reviewed journals reporting original data on pain syndromes in adult patients with TBI with regard to pain prevalence, pain category, risk factors, pathogenesis, and clinical course were selected, and manual searches were performed of their reference lists. The data were pooled and prevalence rates calculated.

EVIDENCE SYNTHESIS

Twenty-three studies (15 cross-sectional, 5 prospective, and 3 retrospective) including 4206 patients were identified. Twelve studies assessed headache pain in 1670 patients. Of these, 966 complained of chronic headache, yielding a prevalence of 57.8% (95% confidence interval [CI], 55.5%-60.2%). Among civilians, the prevalence of chronic pain was greater in patients with mild TBI (75.3% [95% CI, 72.7%-77.9%]) compared with moderate or severe TBI (32.1% [95% CI, 29.3%-34.9%]). Twenty studies including 3289 civilian patients with TBI yielded a chronic pain prevalence of 51.5% (95% CI, 49.8%-53.2%). Three studies assessed TBI among 917 veterans and yielded a pain prevalence of 43.1% (95% CI, 39.9%-46.3%). PTSD may mediate chronic pain, but brain injury appears to have an independent correlation with chronic pain.

CONCLUSIONS

Chronic pain is a common complication of TBI. It is independent of psychologic disorders such as PTSD and depression and is common even among patients with apparently minor injuries to the brain.

Idiopathic Headache in Children Under Six Years of Age: A Follow‐Up Study

OBJECTIVE

To assess the evolution of idiopathic headache with early onset and to investigate the influence of early somatic disorders, "life events," and psychiatric disorders on the onset and the course of headache. We also studied the possible prognostic role of gender, headache diagnosis at onset, and history of headache in family members on the course of headache. We also investigated the applicability of the ICHD-II criteria to idiopathic headache in preschool children.

METHODS

Prospective evaluation of 25 consecutive headache patients referred before the age of 6 years. Headache diagnosis was based on the IHS 1988 criteria, on the ICHD-II criteria, and on "alternative" clinical criteria [eg, duration less than 1 hour in migraine without aura (MWA), less than 30 minutes in tension-type headache (TTH)]. All patients were assessed by a structured interview to detect early developmental disorders (eg, feeding difficulties or sleep disorders) and "life events" (eg, parents' separation and others according to DSM-IV). All patients underwent clinical observations and assessment of psychiatric comorbidity (ICD-10) by means of interviews and the Child Behaviour Check List. All the above-mentioned evaluations were performed at recruitment (T0) and at the end of the follow-up period (T1).

RESULTS

A total of 25 children with headache (12 males; 13 females) were monitored through long-term clinical follow-up (mean duration: 4.2 years; range: 2.8 to 6.6 years). The "definite" diagnosis of migraine without aura or TTH at T0 was possible in only 6/25 (24%) and 9/25 patients (36%) applying the IHS 1988 criteria and the ICHD-II criteria respectively, but in 20/25 (80%) applying the "alternative" clinical criteria. Evaluation of headache at T1 revealed: remission in 16/25 (64%) patients and persistence in 9/25 (36%). At T1, the ICHD-II diagnosis was possible in 100% of the children with headache persistence (1/9 migraine without aura and 8/9 TTH) and these diagnoses were found to be perfectly concordant with those obtained applying the "alternative criteria." Early developmental disorders were present in 11/25 children, with a significantly higher prevalence in children with headache persistence compared to children showing headache remission (78% vs. 25%; P < .05). No significant differences were found between patients with headache persistence and patients with headache remission with regard to gender, history of headache in family members, headache diagnosis at onset, psychiatric comorbidity at T0, and with regard to "life events" at both T0 and T1. Conversely, the children presenting psychiatric disorders at T1 were more frequently affected by headache than those without psychiatric disorders (59% vs. 15%; P < .05).

CONCLUSIONS

Our results suggest that the ICHD-II criteria are too restrictive to allow the classification of migraine without aura and TTH in preschool children. Nevertheless, a diagnosis based on these criteria was possible in all the patients with headache persistence at the end of several years' follow-up. We found a significant association between early somatic disorders and persistence of headache and also between the presence of psychiatric disorders at the end of follow-up and the persistence of headache. "Life events," on the other hand, while not showing a statistically significant association with the evolution of the headache, may nevertheless influence the course of the headache in some patients. Our results suggest that environmental and psychological factors play an important role in idiopathic headache with onset in preschool age, and thus that the diagnostic-therapeutic approach must take these factors into account.

Emergency department evaluation of sudden, severe headache

AIM

To assess the clinical management of adults presenting with sudden, severe headache.

METHODS

We retrospectively reviewed the medical records of consecutive adults presenting with sudden, severe headache to the emergency department (ED) or medical admissions unit at one teaching hospital.

RESULTS

Of 12 025 consecutive attendances over 3 months, 91 adults (0.8%, 95% CI 0.6-0.9%) presented with sudden severe headache. Documentation of time to peak headache intensity and headache duration was complete in only 33% of cases. Brain computed tomography was performed in each of the 29 patients (33%) in whom it appeared indicated for the investigation of headaches peaking within 5 min and lasting more than 1 h, as well as 11 patients (13%) who did not meet these criteria. Lumbar puncture was attempted in every patient for whom it appeared indicated (although it was unsuccessful and abandoned on three of 24 patients), as well as one patient in whom it appeared not to be indicated. When subarachnoid haemorrhage was suspected, 81% of patients had spectrophotometry. Of the patients, 52 (60%) were given a specific diagnosis, 17 (33%) of whom were given a diagnosis despite an apparently insufficient history. A further 12 (14%) could have been diagnosed if the International Headache Society classification had been applied to the documented history. Neurological advice was sought for only 20 patients (23%).

CONCLUSION

Patients with sudden, severe headache might benefit if EDs used simple protocols, emphasizing the crucial elements of history and examination, appropriate investigation and targeted consultation with neurologists.

Nocebo as headache trigger: evidence from a sham-controlled provocation study with RF fields

BACKGROUND

A large proportion of the population in Norway has experienced headache in connection with mobile phone use, but several double-blind provocation studies with radiofrequency (RF) and sham exposures have shown no relation between headache and mobile phone RF fields.

AIMS

To investigate the type and location of headache experienced by participants in one provocation study in order to gain insight into possible causes and mechanisms of the headaches.

METHOD

Questionnaire about headache, indication on figure of location of headache after exposure, interview with neurologist about headache features to make headache diagnoses.

RESULTS

The 17 participants went through 130 trials (sham or RF exposure). No significant difference existed in headache type, laterality or location between the headaches experienced with the two exposures types. In most participants, the headache was compatible with tension-type headache.

DISCUSSION

As participants experienced their typical 'mobile phone headache' both with and without RF exposure, and since the experiment did not involve the stress or the arm/head position of mobile phone use, the most likely explanation is that the headache in this situation is caused by negative expectations (nocebo).

CONCLUSION

This and other similar studies indicate that headache occurring in connection with mobile phone use is not related to RF fields, and that a nocebo effect is important for this and possibly other headache triggers.

[Renovascular hypertension: symptoms and signs. Clinical study on 20 patients]

OBJECTIVES

symptoms in renovascular hypertension can be wrong interpreted, which leads to a late diagnostic, after discover the determination disease.

MATERIALS AND METHODS

the study on the renovascular hypertension was made on 20 patients, aged between 2 and 36 years old, diagnosed with reno-ureteral malformations, pyelonephritis, reno-ureteral reflux and renal trauma as a determination disease, leads to manifestation types that guide the diagnostic: neuro-psychiatric signs, weight loss, renal signs and digestive signs. Beginning from these signs the arterial hypertension was diagnosed and the investigations determined the causes.

RESULTS

Periodic postoperative evaluation at 3 months, during a period between 4 months and 7 years, individualised 4 evolutional clinical types: AHT with lumbar pain, AHT with no clinical signs, AHT with ophthalmologic signs and AHT with encephalitis like signs.

CONCLUSIONS

symptoms in renovascular hypertension don't have pathognomonic clues and the identified signs, one type or all together, enforce the evaluation or even the monitoring of the arterial tension at least 30 days. If the values exceed the normal, complex investigations will be made in order to determine the specific cause of the AHT.

[Spontaneous low cerebospinal fluid pressure syndrome. A case report and literature review]

INTRODUCTION

Spontaneous low cerebrospinal fluid pressure syndrome is a spontaneous intracranial hypotension pressure due to a cerebrospinal fluid leak without any known dural effraction. It is clinically characterised by postural headaches relieved by supine position. We report a 38-year-old patient with this syndrome and review the literature.

EXEGESIS

The diagnosis is sometimes difficult in atypical presentation of the syndrome and can lead to incapacitating chronic headache and rarely to complications. Cerebral magnetic resonance imaging has dramatically improved identification, diagnosis and management of this syndrome. Treatment is mainly based on blood patch realisation. Cerebrospinal fluid leak probably due to a spontaneous defect in the dural mater is suspected to be the main mechanism of this syndrome without any history of lumbar puncture or penetrating trauma.

CONCLUSION

Early diagnosis, often easy on the basis of clinical characteristics of the headache may avoid complications.

[Prophylactics of postpuncture syndrome after central neuroaxial blockades]

The article presents data of an analysis of anesthesiologic maintenance of 3410 cesarean sections under conditions of spinal and epidural anesthesia. A detailed examination of 378 women has shown that frequency of the development of postinjection syndrome depends on the area of the defect of dura mater and the volume of lost cerebrospinal fluid. Postinjection syndrome can be prevented by using special needles leaving a less defect in dura mater and by introduction of 10-15 ml of sterile isotonic solution of sodium chloride into the epidural space.

Temporomandibular dysfunction: an often overlooked cause of chronic headaches

OBJECTIVE

To review and discuss the role of temporomandibular dysfunction (TMD) as a cause of chronic headaches and facial pain.

DATA SOURCES AND STUDY SELECTION

A literature review was performed using the PubMed database for English-language articles published between January 1, 1981, and August 31, 2006, using the following keywords: temporomandibular dysfunction, temporomandibular disorder, temporomandibular joint, and chronic headache. Additional information was obtained from a review of current medical texts.

RESULTS

Allergists and immunologists are frequently called on to evaluate patients with chronic headaches and facial pain. TMD is known to cause recurrent facial discomfort and headaches. Many individuals with the disorder present with headache or facial discomfort as their only chief complaint. They mistakenly think it is a "sinus" headache. Nearly 10 million Americans are affected by the disorder, and early studies estimate that TMD pain is the cause of chronic headaches in 14% to 26% of individuals with recurrent headaches.

CONCLUSIONS

TMD is a likely underdiagnosed cause of chronic headache and facial discomfort. As such, many patients with the disorder are routinely mislabeled as experiencing chronic sinusitis and are unnecessarily subjected to multiple courses of broad-spectrum antibiotics and other unnecessary therapy. TMD can be readily diagnosed by a careful history and physical examination. Patients typically respond well to conservative therapy, which includes behavioral modification and nonsteroidal anti-inflammatory drugs. The disorder should be suspected in individuals with a long-standing history of chronic daily headaches and facial pain without objective evidence of sinus, neurologic, or intracranial abnormalities.

Headache attributed to hypothyroidism

Clinical and subclinical hypothyroidisms are common conditions in the population. Clinic-based studies suggest that hypothyroidism may be an exacerbating factor for some primary headaches. Furthermore, hypothyroidism may be a risk factor for incident new daily persistent headache. This article reviews the classification of the headaches attributed to hypothyroidism according to the second edition of the International Classification of Headache Disorders. We also review the prevalence, etiology, and principles of treatment of hypothyroidism. Because hypothyroidism is a treatable cause of secondary headaches, doctors should be aware of this relationship.

Dialysis headache

We describe the various side effects occurring in dialysis sessions and indicate measures for their prevention and/or treatment. Next, we analyze dialysis headache in terms of incidence, prevalence, criteria for its inclusion in the classification of the International Headache Society, and factors related to its triggering, ie, bradykinin and nitric oxide (NO), which have increased plasma levels during dialysis. This permits a critical analysis in comparison with NO donor headache in terms of the pathophysiologic mechanisms that mediate the triggering of both conditions. A similarity is particularly detected in terms of the role of NO as the last link in the chain of events that precedes the onset of headache, which is preceded by a latency period of 3 to 4 hours, much longer than the few seconds needed to inactivate NO. A hypothesis is raised to explain this phenomenon, opening new perspectives for the study of the pathophysiology of headaches, including primary headaches.

Updated overview of pediatric headache and migraine

Headache is a common complaint, occurring in >90% of school age children. The frequency increases with increasing age and the etiologies range from tension to life-threatening infections and brain tumors. Migraine is the most frequent cause of acute and recurrent headaches in children. The overall prevalence of non-migraine headaches is 10-25%. A thorough history, physical and neurological examination, and appropriate diagnostic testing if indicated will enable the physician to distinguish migraine and tension headaches from those of a secondary etiology. In this review, we present an updated overview of childhood headaches. The recently developed International Classification of Headache Disorders, second edition ICHD-II will be summarized. The Quality Standards Subcommittee of the American Academy of Neurology AAN and the Practice Committee of Child Neurology Society CNS recommendations for neuroimaging of children with recurrent headaches concluded that routine neuroimaging is not indicated if the neurological examination is normal. Neuroimaging should be considered in children with recent onset of severe headache, change in the headache type, associated focal neurological features, or seizures. Trends in the management guidelines will be highlighted.

High-altitude headache

High-altitude headache (HAH) is an important public health problem because many of the millions of visitors to locations high above sea level get significant headaches each year. Headache is the most common symptom of acute exposure to high altitude. It may be a manifestation of acute mountain sickness (AMS), as well as of chronic mountain sickness (CMS). This article describes the clinical picture of AMS and CMS. The clinical characteristics of HAH are presented, its pathophysiology is discussed, and the acute and preventive treatment options are reviewed.

[Headache and migraine]

Headaches are one of the most common disorders and symptoms in daily medical practice. There has been dramatic progress of knowledge in the fields of epidemiology, pathophysiology, acute treatment, and preventive therapy over the past 100 years. Triptans have been the breakthrough in the treatment of acute migraine attacks. Beta blockers, calcium antagonists, and neuromodulators are available for preventive migraine therapy. Treatment for chronic tension headache is still unsatisfying. Cluster headache is part of the group of trigemino-autonomic headaches. Headache from medication overuse plays an increasingly important role. New medical care structures such as integrated headache care provide better support for patients with chronic headache disorders.

Association between stress at work and primary headache among nursing staff in Taiwan

BACKGROUND

Stress, one of the most commonly identified triggers for primary headache in the workplace, usually leads to inefficient work during attacks. Stress-related primary headaches in the nursing staff of hospitals have received little attention.

OBJECTIVE

To realize the association between stress and headache, and the means of coping with this kind of headache.

METHODS

A cross-sectional, hospital-based study using a semi-structured questionnaire was administered to 900 nursing staffers in a tertiary medical center in southern Taiwan. Thirty-two items, including basic information, headache- and stress-related questions, work satisfaction, and coping strategies were measured. Headache sufferers with either migraine or episodic tension headache (attacks <15 days per month) based on International Headache Society (IHS) criteria were enrolled for analysis. The Student's t-test, one-way analysis of variance (ANOVA), and chi-square test were used for statistical analysis.

RESULTS

Three hundred eighty-six out of 779 responders (49.6%) had experienced primary headaches in the previous year, and 374 (48.1%) had had episodic-type headaches (<15 days/month). A careful neurological interview of the latter group revealed that 222 (28.5%) had migraine, 104 (13.4%) had tension headache, 37 (4.8%) had mixed migraine and tension headache, and 11 (1.4%) had other causes of headache. There were no demographic differences between the sufferers and nonsufferers, although a statistically significant difference was noted in self-reported sources of stress (individual P values ranged from .021 to < .001). Headache sufferers had more stress at work than non-headache sufferers (P < .001). The youngest and least experienced of the nursing staff, the unmarried, and those with a lower level of education had a higher level of stress. The methods used to deal with headaches were sleep, taking medicine, taking a rest, visiting the doctor, and seeking psychological help. Nurses commonly used acetaminophen (panadol--500 mg) to relieve their pain.

CONCLUSION

These results indicate that stress at work is associated with primary headaches among nursing staff, and that nurses rarely seek help in the beginning. Therefore, nursing staff education aimed at ameliorating the stress and coping with the headaches, thus allowing the nurses to provide better patient care, may be warranted.

Health response of two communities to military antennae in Cyprus

OBJECTIVES

This study investigated concerns that have been raised about past and future health effects caused by high power transmissions of high frequency (7-30 MHz) radio waves from military antenna systems at Akrotiri, Cyprus.

METHODS

A cross-sectional study of three villages (two exposed, one unexposed) collected longitudinal and short-term radiofrequency measurements. Health data were collected using questionnaires containing information on demographic factors, specific illnesses, general health (SF-36 well-being questionnaire), reproductive history, childhood illnesses, risk perception and mortality. Analysis was with SPSS v11.5 using cross tabulations of non-parametric data and tests for significance. Key health outcomes were subjected to logistic regression analysis.

RESULTS

Field strengths within the two "exposed" villages were a maximum of 0.30 (Volts/Vm(-1) metre) from the 17.6 MHz military transmissions and up to 1.4 Vm(-1) from unspecified sources, mainly cell phone frequencies. The corresponding readings in the control village were <0.01 Vm(-1). Compared with the control village there were highly significant differences in the reporting of migraine (OR 2.7, p<0.001), headache (OR 3.7, p<0.001), and dizziness (OR 2.7, p<0.001). Residents of the exposed villages showed greater negative views of their health in all eight domains of the SF-36. There were also higher levels of perceived risk, particularly to noise and electromagnetic "pollution". All three villages reported higher values of risk perception than a UK population. There was no evidence of birth abnormalities or differences in gynaecological or obstetric history. Numbers of cancers were too small to show differences.

CONCLUSION

It was clear that even this close (1-3 km) to powerful transmissions, the dominant sources of radiofrequency fields were cell phone and national broadcast systems. There was no excess of cancer, birth defects or obstetric problems. There was heightened risk perception and a considerable excess of migraine, headache and dizziness, which appears to share a gradient with radiofrequency exposure. The authors report this association but suggest this is unlikely to be an effect of radiofrequency and more likely to be antenna visibility or aircraft noise.

A retrospective, comparative study on the frequency of abuse in migraine and chronic daily headache

OBJECTIVE

To assess and contrast the relative frequency of a past history of physical and/or sexual abuse in patients with chronic daily headache (CDH) versus migraine.

BACKGROUND

A number of risk factors have been identified as risk factors for chronification of headache disorders. Limited data exist regarding the influence of physical and/or sexual abuse on primary headache disorders.

METHODS

This was a retrospective chart review of 183 consecutive new headache patients seen from December 2004 through August 2005 at an outpatient tertiary-care center. Patients were included in the study if they had chronic daily headache (with criteria for medication over-use headache or chronic migraine), or migraine with or without aura. A history of physical and/or sexual abuse was systematically asked of all headache patients at their first visit in the clinic. This information was then transferred to a semi-standardized form and the relative frequency of abuse in both groups contrasted.

RESULTS

Of the 161 patients included in the study, 90.1% were female with a mean age of 36.4 +/- 12.0. A total of 59.0% of the patients were diagnosed with CDH and 41.0% were diagnosed with migraine. Overall, 34.8% of all patients, 40.0% of CDH patients, and 27.3% of migraine patients had a history of physical and/or sexual abuse. The relative frequency of a history of physical and/or sexual abuse was higher in the CDH group as compared to the migraine group (P = .048).

CONCLUSION

The relative frequency of abuse is higher in CDH sufferers than migraineurs, suggesting that physical and sexual abuse may be risk factors for chronification.

Post-traumatic headache: emphasis on chronic types following mild closed head injury

The syndrome known as chronic post-traumatic headache (CPTH) is controversial, particularly when it occurs following mild closed head injury or "whiplash". Problems with the diagnosis include issues related to classification, epidemiology, pathophysiology (psychogenic vs. organic) and treatment. In addition, there are cultural differences that may influence prevalence and diagnosis, as in some countries with little medico-legal recourse the disorder is virtually unknown. In this paper we review some of these controversies clinicians are left to formulate their own understanding based on available evidence and clinical experience. This is perhaps as it should be given that the best practice combines knowledge of the evidence with individual clinical experience.

Headache and spontaneous low cerebrospinal fluid pressure syndrome

We examined 59 consecutive patients presenting between 1993 and 2006 at our centre diagnosed with headache associated with spontaneous intracranial hypotension syndrome (SIH). Thirty-six (61%) patients were women; the mean age was 47 years (range 20-68). Cerebral MRI with contrast confirmed SIH in all patients. Headache characteristics were obtained by direct semistructured interview; in a minority of cases information was completed retrospectively through a phone call. All SIH patients suffered from headache. Early recognition of SIH may avoid dangerous worsening due to delayed diagnosis. Orthostatic headache, the main symptom, suggests the diagnosis.

Spontaneous low-pressure headache complicating bag-piping

We describe an interesting case of a 40-year-old lady who developed a spontaneous low-pressure headache whilst playing the bag-pipes. Playing wind instruments requires the generation of significant intra-thoracic pressure, which may have contributed to this musician's condition.

Topiramate in patients with episodic migraine: reducing the risk for chronic forms of headache

OBJECTIVE

The aim was to evaluate whether preventive treatment with topiramate in patients with episodic migraine reduces the risk of developing chronic forms of headache.

BACKGROUND

Chronic forms of headache, including chronic migraine or medication overuse headache (MOH), are characterized by 15 or more headache days per month. Acute medication overuse has been shown to be a risk factor for developing chronic headache, but it is not known whether preventive treatment can reduce the risk of developing chronic forms of headache or the development of MOH.

METHODS

Pooled data from 3 trials in patients with episodic migraine randomized either to treatment with 100 mg topiramate per day (n = 384) or with placebo (n = 372) were analyzed with regard to the number of headache days during a prospective 4-week baseline period and the individual final 4 weeks of each patient's treatment during the planned 26-week double-blind treatment period.

RESULTS

The number of headache days per month in the topiramate versus the placebo-treated groups was 7.3 +/- 3.0 versus 7.3 +/- 3.1 during baseline and 4.1 +/- 4.2 versus 5.6 +/- 4.9 during the final 4 weeks, respectively (P < .001). At the end of the study, 8 versus 16 patients fulfilled International Headache Society criteria of chronic headache (odds ratio: 2.11, P= .082). Moreover, a significantly lower number of patients receiving topiramate treatment reported an increase in headache days per month by the end of the study when compared to placebo (66 vs 88 patients, respectively; odds ratio: 1.49, P < .05). Finally, the number of days with usage of acute medication was significantly lower in the topiramate arm compared with placebo (3.3 +/- 3.7 vs 4.3 +/- 3.6, respectively; P < .001).

CONCLUSION

Preventive treatment with topiramate in patients with episodic migraine may reduce the risk of developing chronic forms of headache.

Virtual 3-Dimensional Preoperative Planning with the Dextroscope for Excision of a 4th Ventricular Ependymoma

OBJECTIVE AND IMPORTANCE

Advances in computer imaging and technology have facilitated enhancement in surgical planning with a 3-dimensional model of the surgical plan of action utilizing advanced visualization tools in order to plan individual interactive operations with the aid of the dextroscope. This provides a proper 3-dimensional imaging insight to the pathological anatomy and sets a new dimension in collaboration for training and education.

CLINICAL PRESENTATION

The case of a seventeen-year-old female, being operated with the aid of a preoperative 3-dimensional virtual reality planning and the practical application of the neurosurgical operation, is presented. This young lady presented with a two-year history of recurrent episodes of severe, global, throbbing headache with episodes of projectile vomiting associated with shoulder pain which progressively worsened. She had no obvious neurological deficits on clinical examination. CT and MRI showed a contrast-enhancing midline posterior fossa space-occupying lesion.

INTERVENTION

Utilizing virtual imaging technology with the aid of a dextroscope which generates stereoscopic images, a 3-dimensional image was produced with the CT and MRI images. A preoperative planning for excision of the lesion was made and a real-time 3-dimensional volume was produced and surgical planning with the dextroscope was made and the lesion excised.

CONCLUSION

Virtual reality has brought new proportions in 3-dimensional planning and management of various complex neuroanatomical problems that are faced during various operations. Integration of 3-dimensional imaging with stereoscopic vision makes understanding the complex anatomy easier and helps improve decision making in patient management.

Headache and migraine

Headache is the commonest neurological presentation. Most patients have a benign pain disorder. The majority manage themselves with over-the-counter medications. Unfortunately therapeutic strategies in primary and secondary health care remain suboptimal and thus the condition poorly managed.

Psychological risk factors in headache

Headache is a chronic disease that occurs with varying frequency and results in varying levels of disability. To date, the majority of research and clinical focus has been on the role of biological factors in headache and headache-related disability. However, reliance on a purely biomedical model of headache does not account for all aspects of headache and associated disability. Using a biopsychosocial framework, the current manuscript expands the view of what factors influence headache by considering the role psychological (i.e., cognitive and affective) factors have in the development, course, and consequences of headache. The manuscript initially reviews evidence showing that neural circuits responsible for cognitive-affective phenomena are highly interconnected with the circuitry responsible for headache pain. The manuscript then reviews the influence cognitions (locus of control and self-efficacy) and negative affect (depression, anxiety, and anger) have on the development of headache attacks, perception of headache pain, adherence to prescribed treatment, headache treatment outcome, and headache-related disability. The manuscript concludes with a discussion of the clinical implications of considering psychological factors when treating headache.

Cysticercosis Headache: An Important Differential of Childhood Headache Disorder in Endemic Countries

Neurocysticercosis is a common pediatric central nervous system (CNS) disease in endemic areas, presenting usually with seizures but has pleomorphic manifestations, including migraine-like secondary headache. We herein report a pediatric patient with tension-type headache as the sole presenting feature of single cysticercus granuloma.

Acute mountain sickness: medical problems associated with acute and subacute exposure to hypobaric hypoxia

This article summarises the medical problems of travel to altitudes above 3000 m. These are caused by chronic hypoxia. Acute mountain sickness (AMS), a self limiting common illness is almost part of normal acclimatisation--a transient condition lasting for several days. However, in <2% of people staying above 4000 m, serious illnesses related to hypoxia develop--high altitude pulmonary oedema and cerebral oedema. These are potentially fatal but can be largely avoided by gradual ascent. Short vacations, pressure from travel companies and peer groups often encourage ascent to 4000 m more rapidly than is prudent. Sensible guidelines for ascent are outlined, clinical features, management and treatment of these conditions.