Focus on the management of thunderclap headache: from nosography to treatment

Update on primary headache associated with sexual activity and primary thunderclap headache

BACKGROUND

This narrative review aims to provide an update on primary headache associated with sexual activity and primary thunderclap headache.

METHODS

We conducted a literature search on PubMed with the keywords "headache associated with sexual activity", "sexual headache", "orgasmic cephalalgia", and "coital cephalalgia" in addition to "thunderclap headache" to assess the appropriateness of all published articles in this review.

RESULTS

Primary headache associated with sexual activity is a "primary" headache precipitated by sexual activity, which occurs as sexual excitement increases (progressive at onset), or manifests as an abrupt and intense headache upon orgasm (thunderclap at onset) or combines these above two features. Primary headache associated with sexual activity is diagnosed after a thorough investigation, including appropriate neuroimaging studies, to exclude life-threatening secondary causes such as subarachnoid hemorrhage. According to the criteria of the third edition of the International Classification of Headache Disorders, primary thunderclap headache is also a diagnosis by exclusion. The pathophysiology of primary headache associated with sexual activity and primary thunderclap headache remains incompletely understood. Treatment may not be necessary for all patients since some patients with primary headache associated with sexual activity and primary thunderclap headache have a self-limiting course.

CONCLUSION

A comprehensive neuroimaging study is needed for distinguishing primary headache associated with sexual activity or primary thunderclap headache from secondary causes. Primary headache associated with sexual activity and primary thunderclap headache are self-limited diseases and the prognoses are good, but some patients with primary headache associated with sexual activity may have a prolonged course.

Menstrually-related stabbing headache in a patient without migraine: case report

Introduction Stabbing headache is considered a primary headache and is a prevalent entity in the general population.  Objective To present an unusual case of stabbing headache associated with menstruation. Method Data collected through complete anamnesis. Case report The authors report a case of a woman suffering from a stabbing headache which features that has not been previously described – a menstrual pattern in the presentation of stabbing headache attacks. Conclusions We conclude that this menstrual pattern of stabbing headache attacks is unusual in patients with primary stabbing headache and that it does not fulfil diagnostic criteria for migraine or tension-type headache.

Fatal reversible cerebral vasoconstriction syndrome

We report four fatal cases of fulminant reversible cerebral vasoconstriction syndrome, all initially diagnosed as primary central nervous system vasculitis and treated with corticosteroids. Although reversible cerebral vasoconstriction syndrome is usually self-limiting without permanent neurologic deficits, rarely it can be fatal and worse outcomes have been associated with corticosteroid treatment.

Headache and Its Approach in Today's NeuroIntensive Care Unit

Headache is a very common symptom in the neurointensive care unit (neuroICU). While headache in the neuroICU can be caused by worsening of a pre-existing primary headache disorder, most are secondary to another condition. Additionally, headache can be the presenting symptom of a number of conditions requiring prompt recognition and treatment including subarachnoid hemorrhage, ischemic and hemorrhagic stroke, central nervous system infection, pituitary apoplexy, and cerebral vasoconstriction. The neuroICU also has a unique postoperative population in which postcraniectomy and postcraniotomy headache, postintravascular intervention headache, hyperperfusion syndrome, ventriculitis, medication overuse or withdrawal headache, and hypercapnia may be encountered. Management varies dramatically depending on the etiology of the headache. Overreliance on opiate analgesics may produce significant adverse effects and lengthen ICU stays. However, nonnarcotic medications are increasingly being recognized as helpful in reducing the pain among various postsurgical and headache patients. Taken together, a multimodal approach targeting the underlying pathology and choosing appropriate systemic and local analgesic medications may be the best way to manage headache in critically ill patients.

Sudden headache, third nerve palsy and visual deficit: thinking outside the subarachnoid haemorrhage box

A 75-year-old lady presented with sudden severe headache and vomiting. Examination was normal, and CT and lumbar puncture not convincing for subarachnoid haemorrhage. Shortly thereafter, she developed painless diplopia. Examination confirmed right third cranial nerve palsy plus homonymous left inferior quadrantanopia. Urgent cerebral MRI with angiography was requested to assess for a possible posterior communicating artery aneurysm, but revealed an unsuspected pituitary mass. Pituitary adenoma with pituitary apoplexy was diagnosed. Pituitary apopolexy is a syndrome comprising sudden headache, meningism, visual and/or oculomotor deficits, with an intrasellar mass. It is commonly due to haemorrhage or infarction within a pituitary adenoma. Treatment includes prompt steroid administration, and potentially surgical decompression. While subarachnoid haemorrhage is an important, well-recognised cause of sudden severe headache, other aetiologies, including pituitary apoplexy, should be considered and sought.

Isolated headache in general practice: determinants for delay in referral in patients with subarachnoid haemorrhage

BACKGROUND

A delay in diagnosing aneurismal subarachnoid haemorrhage (SAH) occurs in a substantial proportion of patients who present with headache as the only symptom.

OBJECTIVE

To identify determinants for a delay in referral in patients with SAH, who present with isolated headache to the general practitioner (GP).

METHODS

For all 112 patients with SAH admitted to the hospital between October 2008 and June 2009, we sent a questionnaire to the GPs asking for details presented during the initial GP visit. In this retrospective study, we included 31 patients with SAH who initially presented with isolated headache. We assessed acuteness of headache onset, history of headaches and a patient delay as determinants for delayed referral (> 2 h after a visit to the GP), by calculating risk ratios (RRs) with corresponding 95% confidence intervals (CIs).

RESULTS

Referral was delayed in 18 of these 31 patients. The delay occurred in all 10 patients in whom the GP was unaware of the acute onset of headache and in 8 of 21 patients in whom the GP was aware of this symptom (RR: 2.6; 95% CI: 1.5-4.5). A history of headaches (RR: 1.8; 95% CI: 1.1-3.0) and a patient delay (RR: 2.1; 95% CI: 1.0-4.5) also increased the probability of delayed referral.

CONCLUSION

In patients with SAH who presented with isolated headache to the GP, GP's unawareness of the acute onset of the headache, a history of headaches and late presentation by the patient increased the probability of delayed referral.

Thunderclap headache triggered by micturition: responsive to nimodipine

Primary thunderclap headache (TCH) is a rare condition, of which the onset can be triggered by coughing, exercise, and sexual activity. Micturition is a recognized trigger of secondary TCH with pheochromocytoma in bladder, but not of primary TCH. We describe a patient with an apparent primary TCH, which repeatedly occurred immediately after micturition until she achieved a therapeutic dosage of nimodipine.