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.

Misdiagnosis of angle closure glaucoma

Be suspicious for angle closure glaucoma in patients with headache, blurred vision, or red eye

Sleep, sleepiness, and behavior problems in children with headache

The purpose of this study was to assess sleep, daytime sleepiness, and behavior problems in children suffering from headaches and in controls, with a special focus on the role of gender. A clinical group of 28 children with persistent headache complaints and a control group of 108 healthy children were included. Sleep was assessed by actigraphy and diaries. Behavior problems were assessed by parental reports. In comparison with the control group, the sleep quality of the clinical group was poorer and they complained more about excessive daytime sleepiness. Children suffering from headache showed higher levels of internalizing behavior problems. Gender was found to be a moderating factor for the relationships between headache and sleep. Compared with control girls, girls suffering from headaches had poorer sleep quality, whereas the opposite was true for the boys. The results highlight the importance of assessing sleep, daytime sleepiness, and psychologic adjustment in children complaining about headaches as an integral part of their routine assessment.

Headaches in older patients: special problems and concerns

Any patient older than 50 years who develops headaches for the first time or who has a change in a chronic headache pattern should be investigated for an underlying cause or exacerbating condition. Several headache syndromes occur almost exclusively in older people. One of these, temporal arteritis, needs to be recognized and promptly treated with corticosteroids to avoid permanent visual loss. Other causes of headache that are more common in older people include subdural hematomas, trigeminal neuralgia, herpes zoster infection, and malignancies.

Idiopathic hypertrophic cranial pachymeningitis successfully treated with weekly subcutaneous methotrexate

Idiopathic hypertrophic cranial pachymeningitis is a very infrequent disorder. Adequate management is still a matter of debate. We describe the use of low-dose pulse methotrexate in treating a 63-year-old woman with idiopathic hypertrophic cranial pachymeningitis. A weekly scheme with subcutaneous methotrexate was tried. Clinical improvement occurred in one week. Total remission of the clinical and neuro-imaging abnormalities was evident 6 months later, with minimal side effects. The patient is in complete remission after one year of follow-up without treatment. Hence, low-dose weekly subcutaneous methotrexate may be safe and effective in inducing complete and sustained remission of this condition. The experience with subcutaneous methotrexate to treat this entity has never been reported.

A Case of Pulsed Radiofrequency Lesioning for Occipital Neuralgia: Table 1

OBJECTIVE

This report describes a case where pulsed radiofrequency lesioning (RFL) of the greater occipital nerve (GON) offered a valuable and safe treatment for the management of greater occipital neuralgia. The case is considered in relation to a review of the medical literature on greater occipital neuralgia and RFL interventions.

CASE REPORT

A 62-year-old man with a 43-year history of left suboccipital pain underwent pulsed RFL of the left GON (20-millisecond bursts at intervals of 0.5 second for 4 minutes at 42 degrees C) after failing to achieve substantial analgesia with naproxen, a transcutaneous electrical nerve stimulator (TENS) unit and a greater occipital nerve blockade (GONB) utilizing local anesthetic and steroid. After obtaining 4 months of 70% pain relief, pulsed RFL was repeated and resulted in an additional 5 months of 70% pain relief.

CONCLUSIONS

Pulsed RFL of the GON is an alternative to continuous RFL with the proposed advantage of mitigating pain, as in continuous RFL, but without the potential risk of causing deafferentation pain. While placebo and other nonspecific analgesic effects cannot be ruled out, the apparent safety profile and potential efficacy of pulsed RFL suggests it may be a compelling option to consider before irreversible neuroablative therapies are applied.

Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) or cranial autonomic features (SUNA)--a prospective clinical study of SUNCT and SUNA

Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) and short-lasting unilateral neuralgiform headache attacks with cranial autonomic features (SUNA) are described, although SUNA is rarely reported. The phenotype of SUNCT and SUNA was characterized from a large series of patients (43 SUNCT, 9 SUNA). Three attack types were identified: stabs, groups of stabs and saw-tooth attacks. The mean duration of stabs was 58 s (1-600 s); stab groups, 396 s (10-1200 s); and saw-tooth, 1160 s (5-12 000s). The attack frequency was a mean of 59 attacks/day (2-600), and this depended largely on the type of attack. The pain was orbital, supraorbital or temporal in 38 (88%) SUNCT and 7 (78%) SUNA, and also occurred in the retro-orbital region, side, top, back of head, second and third trigeminal divisions, teeth, neck and ear. All SUNCT patients had conjunctival injection and tearing. Two SUNA patients had conjunctival injection, four had tearing, but none had both. Other cranial autonomic symptoms included nasal blockage, rhinorrhoea, eyelid oedema, facial sweating/flushing and ear flushing. Cutaneous stimuli triggered attacks in 74% of SUNCT but only in 22% of SUNA patients. The majority (95% SUNCT and 89% SUNA) had no refractory period between attacks. For SUNCT 58% and for SUNA 56% of patients were agitated with the attacks. We propose a new set of diagnostic criteria for these syndromes to better encompass the clinical presentations and which include a wider range of attack length, wider trigeminal pain distribution, cutaneous triggering and lack of refractory period.

Are some people sensitive to mobile phone signals? Within participants double blind randomised provocation study

OBJECTIVE

To test whether people who report being sensitive to mobile phone signals have more symptoms when exposed to a pulsing mobile signal than when exposed to a sham signal or a non-pulsing signal.

DESIGN

Double blind, randomised, within participants provocation study.

SETTING

Dedicated suite of offices at King's College London, between September 2003 and June 2005.

PARTICIPANTS

60 "sensitive" people who reported often getting headache-like symptoms within 20 minutes of using a global system for mobile communication (GSM) mobile phone and 60 "control" participants who did not report any such symptoms.

INTERVENTION

Participants were exposed to three conditions: a 900 MHz GSM mobile phone signal, a non-pulsing carrier wave signal, and a sham condition with no signal present. Each exposure lasted for 50 minutes.

MAIN OUTCOME MEASURES

The principal outcome measure was headache severity assessed with a 0-100 visual analogue scale. Other outcomes included six other subjective symptoms and participants' ability to judge whether a signal was present.

RESULTS

Headache severity increased during exposure and decreased immediately afterwards. However, no strong evidence was found of any difference between the conditions in terms of symptom severity. Nor did evidence of any differential effect of condition between the two groups exist. The proportion of sensitive participants who believed a signal was present during GSM exposure (60%) was similar to the proportion who believed one was present during sham exposure (63%).

CONCLUSIONS

No evidence was found to indicate that people with self reported sensitivity to mobile phone signals are able to detect such signals or that they react to them with increased symptom severity. As sham exposure was sufficient to trigger severe symptoms in some participants, psychological factors may have an important role in causing this condition.

TRIAL REGISTRATION

ISRCTN81432775.

Incidental finding of Chiari I malformation with progression of symptoms after head trauma: Case report

Chiari I malformation (CMI) is a neurologic structural anomaly involving cerebellar herniation through the foramen magnum. It is most commonly diagnosed in adult patients who are often asymptomatic. Although there are several case reports of sudden death and neurologic deficits after minor head trauma in patients with CMI, little is known about the effects of trauma on CMI. This case describes a woman with chronic headaches who had an incidental finding of CMI with obstructive hydrocephalus and progression of symptoms after minor head trauma.

Cerviogenic headache

Cervicogenic headache has historically been misdiagnosed, ultimately leading to misguided therapies. Even with the growing body of literature in the field of headache, this particular entity is still vastly understudied. Efforts should be made to encourage appropriate clinical studies in order to provide evidence based therapeutic modalities for this patient population. The dental professional is provided with the unique opportunity to see these patients on a regular basis without the time constraints now shouldered by our physician colleagues. The goal of any health care provider should be to provide the most comprehensive, multi-modal and/or multidisciplinary care possible in our field of expertise. Expanding our practice model to include a more comprehensive approach to patient care has the potential to not only help an underserved population of pain patients but also provide the practitioner with the reward of heartfelt gratitude when pain relief is provided.

Prevalence and characteristics of recurrent headaches in Turkish adolescents

The objectives of this study were to determine the prevalence and characteristics of recurrent headaches and to investigate the sociodemographic differences between high school students with or without recurrent headaches from Izmir, Turkey. Multistep, stratified, cluster sampling method was used in this analytic, school-based cross-sectional study. Twenty-one schools were selected randomly, and 2384 preparatory, first-, second-, and third-grade high school students from 84 different classrooms constituted the study cohort. The prevalence of recurrent headaches was 45.7% (1090/2384). Female students had a significantly higher headache frequency than males (P = 0.000). No significant relationship was evident between age and headache (P = 0.065). Also, there were no significant differences between the adolescents with or without headache for variables such as parental divorce (P = 0.052), existence of a step parent (P = 0.32), people with whom the students live at home (P = 0.186), number of siblings (P = 0.37), and maternal and paternal educational levels (P = 0.62 and P = 0.15, respectively). Headache frequency was higher when the income level of the student's family was lower (P = 0.016). Among the students who had headaches, 53.3% had a medication, 37.3% were referred to a physician, and in 27.2% of them a diagnosis was established. School absenteeism with a ratio of 26.5% was a common problem among the students with headaches. These results indicate that approximately one half of Turkish high school students have recurrent headaches which reduce the quality of their lives.

Primary headache disorder in the emergency department: perspective from a general neurology outpatient clinic

Over a six month period, 22% of patients with headache seen in general neurology outpatient clinics reported prior attendance at an emergency department because of their headache; 9% of the headache cohort had been admitted to hospital. All had primary headache disorders according to International Headache Society diagnostic criteria. Improved primary care services for headache patients are required to reduce the burden of primary headache disorders seen in emergency departments.

Health consequences of the first Persian Gulf War on French troops

Since 1993, many studies on the health of Persian Gulf War Veterans (PGWV) have been undertaken. These studies have concluded that there has been an increased mortality due to external causes, no excess of recognized diseases, and no effect on PGWV children. When compared with the non-deployed, PGWV have reported a higher frequency of infertility as well as different symptoms, but a specific Gulf War syndrome was not identified. In October 2000, the French government asked an independent working group to analyse the scientific literature on PGWV health. The group concluded that an exhaustive study of French PGWV was to be undertaken. The objectives of this study were to describe the exposures of PGWV in the operations theatre, to report on the symptoms and diseases that occurred in PGWV and their children during and after the military campaign, and to explore the possibility of a Gulf War syndrome. This exhaustive cross-sectional study, which included all civilians and troops who served in the Gulf from August 1990 to July 1991, began in January 2002. Data were collected by postal self-administered questionnaires. A standardized clinical evaluation was performed by 27 clinics of occupational diseases and nine military hospitals. Symptoms and diseases which appeared after the campaign are described. To date, among 20,261 PGWV, 5,666 participated in the study (28%). The most frequent symptoms described since the return from the Gulf were headaches (83%), neurological or psychological symptoms, and back pain. Apart from well-known symptoms associations (respiratory, neurocognitive, psychological and musculo-skeletal syndromes), no other cluster was highlighted by our analysis.

[Spontaneous intracranial hypotension]

Spontaneous intracranial hypotension is an infrequent clinical entity characterized by orthostatic headache, low cerebrospinal fluid pressure, and magnetic resonance imaging findings of diffuse pachymeningeal gadolinium enhancement without previous history of head trauma or lumbar puncture. A 24 year-old healthy woman was referred after having daily headaches for two weeks. She described a headache that occurred soon after assuming an upright position and disappeared after resuming a recumbent position. The cerebrospinal fluid showed pleocytosis primarily lymphocitic, raised protein content and an opening pressure of 20 mm H2O. Magnetic resonance imaging of the head showed diffuse pachymeningeal gadolinium enhancement. Radioisotope cisternography using 99mTc-DTPA confirmed the cerebrospinal fluid leak in the thoracic region. With conservative treatment the patient improved in a few days and the headache disappeared. Radiological findings, together with a compatible clinical condition, help to establish the diagnosis of spontaneous intracranial hypotension and avoid the use of unnecessary clinical investigations.

Intermittent headaches as the presenting sign of subacute angle-closure glaucoma

Subacute angle closure causes intermittent episodes of transiently elevated intraocular pressure. Headache is often the chief complaint, which may lead to misdiagnosis. The authors examined headache characteristics and consequences of delayed diagnosis. Patients presenting with headaches have a substantial delay in diagnosis, contributing to permanent ocular damage and glaucoma. Patients with subacute angle closure misdiagnosed with migraine are older and have shorter-duration headaches than patients with typical migraine.

Malignant Hypertension With Intestinal Ischemia Secondary to Juxtaglomerular Cell Tumor

Malignant hypertension is a well-defined condition associated with high blood pressure and acute target-organ damage. Although 95% of cases are secondary to essential hypertension, its etiological profile is broad. Juxtaglomerular cell tumor is a rare condition, with only approximately 65 cases reported to date. We describe a patient with malignant hypertension with acute renal failure and intestinal ischemia secondary to a juxtaglomerular cell tumor. We believe this is the first case of juxtaglomerular cell tumor causing malignant hypertension. The diagnostic approach and treatment are discussed.

Cervicogenic headache: pathophysiology, diagnostic criteria and treatment

Cervicogenic headache is a relatively common and still controversial form of headache arising from structures in the neck. Cervicogenic headache is a unilateral fixed headache characterised by pain that starts in the neck and spreads to the ipsilateral oculo-fronto-temporal area. The pathophysiology of cervicogenic headache probably depends on the effects of various local pain-producing or eliciting factors, such as intervertebral dysfunction, cytokines and nitric oxide. A reliable diagnosis of cervicogenic headache can be made based on the criteria established in 1998 by the Cervicogenic Headache International Study Group or the International Headache Society's most recent International Classification of Headache Disorders (2004). Various therapies have been used in the management of cervicogenic headache. These range from lowly invasive, drug-based therapies to highly invasive, surgical-based therapies. Unfortunately, the paucity of experimental models for cervicogenic headache and the relative lack of biomolecular markers for the condition mean much is still unclear about cervicogenic headache and the disorder remains inadequately treated.

Headache

Headache can be divided into primary headache and secondary headache. In primary headache the headache syndrome, i.e. the head pain and any associated features, are the disease process. In secondary headache the headache syndrome is a symptom of an underlying disorder. The secondary headache may have the same clinical features as a primary headache disorder.

Serious neurological disorders in children with chronic headache

AIMS

To determine the prevalence of serious neurological disorders among children with chronic headache.

METHODS

All children presenting to a specialist headache clinic over seven years with headache as their main complaint were assessed by clinical history, physical and neurological examination, neuroimaging where indicated, and by follow up using prospective headache diaries.

RESULTS

A total of 815 children and adolescents (1.25-18.75 years of age, mean 10.8 years (SD 2.9); 432 male) were assessed. Mean duration of headache was 21.2 months (SD 21.2). Neuroimaging (brain CT or MRI) was carried out on 142 (17.5%) children. The vast majority of patients had idiopathic headache (migraine, tension, or unclassified headaches). Fifty one children (6.3%) had other chronic neurological disorders that were unrelated to the headache. The headache in three children (0.37%, 95% CI 0.08% to 1.1%) was related to active intracranial pathology which was predictable on clinical findings in two children but was unexpected until a later stage in one child (0.12%, 95% CI 0.006% to 0.68%).

CONCLUSIONS

Chronic headache in childhood is rarely due to serious intracranial pathology. Careful history and thorough clinical examination will identify most patients with serious underlying brain abnormalities. Change in headache symptomatology or personality change should lower the threshold for imaging.

A Pilot Study of Botulinum Toxin A for Headache in Cervical Dystonia

OBJECTIVE

To evaluate the prevalence of associated headache (HA) pain with craniocervical dystonia and the therapeutic effect of BoNT-A injections on the HA component when injected for cervical dystonia.

BACKGROUND

HA associated with craniocervical dystonia is a recent formally codified entity, but has not been systematically studied.

METHODS

We identified 44 subjects from three movement disorder clinics who presented with craniocervical dystonia and concurrent HA pain. The subjects were injected with botulinum toxin type A (BoNT-A) and prospectively evaluated with the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS), headache diaries, Headache Impact Test (HIT-6), and Migraine Disability Assessment Scale (MIDAS), along with HA pain anatomy and adverse events, at baseline, and at 4, 8, and 12 weeks post-injection.

RESULTS

As expected, all aspects of the TWSTRS robustly improved. Headache diaries and the HIT-6 also improved at 4, 8, and 12 weeks post-injection. Sections of the MIDAS improved, and adverse events were minimal.

CONCLUSION

BoNT-A safely improves headache associated with craniocervical dystonia when administered for the primary condition of craniocervical dystonia.