Thunderclap Headache

Thunderclap headache as a first manifestation of acute disseminated encephalomyelitis: case report and literature review

BACKGROUND

Acute Disseminated Encephalomyelitis (ADEM) is an acute demyelinating disorder of the central nervous system, characterize by multiple white matter hyperintensities on T2 MRI. Patients usually present with subacute progressive encephalopathy and polyfocal neurological deficits. Possible treatments are corticosteroids, immunoglobulins and plasma exchange. Full clinical recovery is seen in more than half of the cases.

CASE

We describe a case of a 62-year-old patient presenting with thunderclap headache as the first symptom, two weeks after an upper respiratory tract infection. The clinical course was complicated by progressive coma and intracranial hypertension mandating external ventricular drainage and sedation. Initial treatment with methylprednisolone was unsuccessful but clinical resolution and radiological regression was achieved after plasma exchanges and cyclophosphamide.

CONCLUSION

To our knowledge, this is the first reported case of ADEM presenting with thunderclap headache. Intracranial hypertension with the need for invasive neuromonitoring and pressure management is also a very rare complication of ADEM. In this report, we describe the findings of the literature review concerning ADEM, thunderclap headache and intracranial hypertension.

Protective effects of flavonoids against intracerebral and subarachnoid hemorrhage (Review)

Intracerebral hemorrhage (ICH), known as non-traumatic cerebrovascular rupture and hemorrhage, often occurs in the deep basal brain segment. It is known for its high morbidity and mortality rates. Subarachnoid hemorrhage (SAH) is a clinical syndrome caused by the rupture of blood vessels at the base or surface of the brain that allows blood to flow directly into the subarachnoid space. It progresses quickly and typically manifests at younger ages compared with ICH. ICH and SAH are both devastating events in the category of hemorrhagic strokes and are attracting increasing attention from researchers. Flavonoids, being important natural molecules, have remarkable anti-inflammatory and antioxidant effects. Flavonoids have extensive biological activities in inflammation and oxidative stress (OS), and have protective effects in vascular function associated with cerebrovascular diseases. They have an impact on the onset of ICH and SAH by targeting various pathways, including the suppression of inflammation and OS. Recently, the role of flavonoid compounds in ICH and SAH has also received increasing interest. Thus, to serve as a resource for the prevention and treatment of ICH and SAH, the present review provided an overview of the research on flavonoid compounds in the prevention of brain damage after these two conditions have occurred.

What Are the Predictors for and Psychosocial Correlates of Chronic Headache After Moderate to Severe Traumatic Brain Injury?

OBJECTIVE

Although headache (HA) is a common sequela of traumatic brain injury (TBI), early predictors of chronic HA after moderate to severe TBI are not well established, and the relationship chronic HA has with psychosocial functioning is understudied. Thus, we sought to (1) determine demographic and injury predictors of chronic HA 1 or more years after moderate to severe TBI and (2) examine associations between chronic HA and psychosocial outcomes.

SETTING

Community.

PARTICIPANTS

Participants in the TBI Model System (TBIMS) with moderate to severe TBI who consented for additional chronic pain questionnaires at the time of TBIMS follow-up.

DESIGN

Multisite, observational cohort study using LASSO (least absolute shrinkage and selection operator) regression for prediction modeling and independent t tests for psychosocial associations.

MAIN OUTCOME MEASURES

Chronic HA after TBI at year 1 or 2 postinjury and more remotely (5 or more years).

RESULTS

The LASSO model for chronic HA at 1 to 2 years achieved acceptable predictability (cross-validated area under the curve [AUC] = 0.70). At 5 or more years, predictability was nearly acceptable (cross-validated AUC = 0.68), but much more complex, with more than twice as many variables contributing. Injury characteristics had stronger predictive value at postinjury years 1 to 2 versus 5 or more years, especially sustained intracranial pressure elevation (odds ratio [OR] = 3.8) and skull fragments on head computed tomography (CT) (OR = 2.5). Additional TBI(s) was a risk factor at both time frames, as were multiple socioeconomic characteristics, including lower education level, younger age, female gender, and Black race. Lower education level was a particularly strong predictor at 5 or more years (OR up to 3.5). Emotional and participation outcomes were broadly poorer among persons with chronic HA after moderate to severe TBI.

CONCLUSIONS

Among people with moderate to severe TBI, chronic HA is associated with significant psychosocial burden. The identified risk factors will enable targeted clinical screening and monitoring strategies to enhance clinical care pathways that could lead to better outcomes. They may also be useful as stratification or covariates in future clinical trial research on treatments.

Pediatric Headache in Primary Care and Emergency Departments: Consensus with RAND/UCLA Method

Headache is the most frequent neurological symptom in childhood and the main reason for admission to pediatric emergency departments. The aim of this consensus document is to define a shared clinical pathway between primary care pediatricians (PCP) and hospitals for the management of children presenting with headache. For the purposes of the study, a group of hospital pediatricians and a group of PCP from the Emilia Romagna's health districts were selected to achieve consensus using the RAND/UCLA appropriateness method. Thirty-nine clinical scenarios were developed: for each scenario, participants were asked to rank the appropriateness of each option from 1 to 9. Agreement was reached if ≥75% of participants ranked within the same range of appropriateness. The answers, results, and discussion helped to define the appropriateness of procedures with a low level of evidence regarding different steps of the diagnostic-therapeutic process: primary care evaluation, emergency department evaluation, hospital admission, acute therapy, prophylaxis, and follow-up. The RAND proved to be a valid method to value appropriateness of procedures and define a diagnostic-therapeutic pathway suitable to the local reality in the management of pediatric headache. From our results, some useful recommendations were developed for optimizing the healthcare professionals' network among primary care services and hospitals.

Headache in cerebral venous thrombosis

Headache has been consistently reported as the most common symptom of cerebral venous thrombosis and as the most frequent presenting feature. It is often the heralding symptom, preceding other manifestations of the disease by days or even weeks. This aspect highlights the importance of recognizing headache due to cerebral venous thrombosis, as early recognition of the disease can lead to a rapid diagnosis with appropriate imaging techniques and as early treatment with heparin can dramatically change the course of the disease and alter the prognosis. Unfortunately, although common, the headache has no specific features, and the clinical presentation of CVT is highly variable, making the correct diagnosis in the emergency setting a challenging task for clinicians, even in the case of highly specialized ones such as neurologists. In this review, we will briefly summarize the epidemiology and physiopathology of CVT, and then we will discuss in more details the causes, features, and course of headache, focusing on its relevance for differential diagnosis and on red flags that should suggest the possibility of CVT as the cause of the headache.

An unusual postural headache: a case report

BACKGROUND

This paper presents a case of an evolving unusual thunderclap headache that presented to a chiropractor.

CASE PRESENTATION

The intense "migraine-like" headache was aggravated by standing up and relieved substantially when lying down. This low pressure, orthostatic headache was diagnosed as a spontaneous intracranial hypotension (SIH) secondary to a spontaneous tear of the dura. It was referred to the local hospital for management with autogolous blood injection to form an epidural blood patch of the defect. It resolved substantially within 3 days.

CONCLUSIONS

The significance of key features in the history and examination and how if not recognised and subsequently treated with manual therapy, the dural tear could be attributed to the treatment of the chiropractor, a treatment that would typically involve cervical manipulation. Discussion is provided of the implications of a missed diagnosis and possible subsequent chiropractic management with the evolving SIH being attributed to the chiropractic intervention rather than its true "spontaneous" nature.

Management of Childhood Headache in the Emergency Department. Review of the Literature

Headache is the third cause of visits to pediatric emergency departments (ED). According to a systematic review, headaches in children evaluated in the ED are primarily due to benign conditions that tend to be self-limiting or resolve with appropriate pharmacological treatment. The more frequent causes of non-traumatic headache in the ED include primitive headaches (21.8–66.3%) and benign secondary headaches (35.4–63.2%), whereas potentially life-threatening (LT) secondary headaches are less frequent (2–15.3%). Worrying conditions include brain tumors, central nervous system infections, dysfunction of ventriculo-peritoneal shunts, hydrocephalus, idiopathic intracranial hypertension, and intracranial hemorrhage. In the emergency setting, the main goal is to intercept potentially LT conditions that require immediate medical attention. The initial assessment begins with an in-depth, appropriate history followed by a complete, oriented physical and neurological examination. The literature describes the following red flags requiring further investigation (for example neuroimaging) for recognition of LT conditions: abnormal neurological examination; atypical presentation of headaches: subjective vertigo, intractable vomiting or headaches that wake the child from sleep; recent and progressive severe headache (<6 months); age of the child <6 years; no family history for migraine or primary headache; occipital headache; change of headache; new headache in an immunocompromised child; first or worst headache; symptoms and signs of systemic disease; headaches associated with changes in mental status or focal neurological disorders. In evaluating a child or adolescent who is being treated for headache, physicians should consider using appropriate diagnostic tests. Diagnostic tests are varied, and include routine laboratory analysis, cerebral spinal fluid examination, electroencephalography, and computerized tomography or magnetic resonance neuroimaging. The management of headache in the ED depends on the patient's general conditions and the presumable cause of the headache. There are few randomized, controlled trials on pharmacological treatment of headache in the pediatric population. Only ibuprofen and sumatriptan are significantly more effective than placebo in determining headache relief.

The assessment of headaches on the acute medical unit: is it adequate and how could it be improved?

Neurological emergencies represent 15-25% of the medical take, second only to cardiac and respiratory cases. However, the UK's number of neurologists is lower than that of other developed nations. This quality improvement project aimed to develop a guideline to optimise acute headache management by non-specialists, informed by the findings of a survey and audit of doctors' knowledge and practice. In total, 62 doctors responded to our survey. 53/56 (94.6%) agreed a guideline would be useful. Knowledge of some important causes of headache was high, but was lower for others, including cerebral venous sinus thrombosis and cervical artery dissection. A consultant neurologist deemed 14/27 (51.9%) of acute headache presentations audited pre-guidelines to have had appropriate management. After guideline launch, a re-audit demonstrated this proportion was 18/22 (81.8%) (p=0.04). We conclude the investigation and management of acute headache requires optimisation and a guideline may help to achieve this.

The Longitudinal Course of Pain and Analgesic Therapy Following Aneurysmal Subarachnoid Hemorrhage: A Cohort Study

OBJECTIVE

The purpose of this study was to determine the duration, intensity, location, and usual treatment of pain throughout hospitalization following subarachnoid hemorrhage.

BACKGROUND

Headache following subarachnoid hemorrhage can be sudden and severe. Little is known about the longitudinal course of headache or its analgesic therapy following the initial diagnosis of subarachnoid hemorrhage.

METHODS

A prospectively maintained database of 564 patients diagnosed with cerebral aneurysms collected from 10/2009 to 2/2013 was searched for conscious patients with subarachnoid hemorrhage. Available electronic records were queried for pain scores (0-10/10), location, and analgesic consumption.

RESULTS

Forty-six adults with subarachnoid hemorrhage met eligibility criteria for inclusion. Mean [CI 95] daily pain was 3.8 [3.2, 4.4] and maximal daily pain was 5.8 [5.1, 6.6]. Eighty-nine percent of patients reported severe pain of 7-10/10, and 63% of patients reported 10/10 pain at some point during hospitalization. While mean [CI 95] pain declined over the course of hospital stay at a rate of 0.06 [0.04, 0.07] units/day (P < .001), mean [CI 95] maximal daily pain changed at a rate of -0.03 [-0.06, 0.01] units/day, which is not significantly different than zero (P = .15). Pain was located primarily in the head in 76% of subjects but pain in the back, neck, limbs, and eyes was also reported. All patients received oral acetaminophen with increasing daily doses. All but three patients, received opioids, most commonly intravenous fentanyl and oral oxycodone. The mean [95 CI] intravenous morphine equivalent dose of opioids consumed was 15.7 [10.3, 21.1] mg/day and changed at a rate of -0.11 [-0.37, 0.15] mg/day which is not significantly different than zero (P = .40).

CONCLUSION

Despite steady consumption of analgesics, the pain reported by conscious patients while recovering from subarachnoid hemorrhage in the hospital is often severe and persists throughout hospitalization.

Reversible cerebral vasoconstriction syndrome at the emergency department

Objective

Reversible cerebral vasoconstriction syndrome (RCVS) is an underestimated cause of thunderclap headache that shares many characteristics with subarachnoid hemorrhage (SAH). This fact makes the two easily confused by emergency physicians. This study evaluated the clinical manifestations, radiological features, and outcomes of patients with RCVS.

Methods

The electronic medical records of 18 patients meeting the diagnostic criteria of RCVS at our emergency department between January 2013 and December 2014 were retrospectively reviewed.

Results

The mean patient age was 50.7 years, and 80% were women. Patients with RCVS encountered physicians 4.7 times before receiving an accurate diagnosis. The mean duration of symptoms until diagnosis was 9.3 days. All but one patient experienced severe headache of 8 to 10 on a numerical rating scale. A total of 44% of patients had nausea, and 66% of patients experienced worsening of the headache while gagging, leaning forward, defecating, urinating, or having sexual intercourse. The most frequently affected vessels were the middle cerebral arteries, which demonstrated a characteristic diffuse “string of beads” appearance. Four cases were complicated by SAH.

Conclusion

Patients with RCVS have a unique set of clinical and imaging features. Emergency physicians should have a high index of suspicion for this clinical entity to improve its rate of detection in patients with thunderclap headache when there is no evidence of aneurysmal SAH.

Migraine mimics

The symptoms of migraine are non-specific and can be present in many other primary and secondary headache disorders, which are reviewed. Even experienced headache specialists may be challenged at times when diagnosing what appears to be first or worst, new type, migraine status, and chronic migraine.

A review of episodic and chronic pediatric headaches of brief duration

BACKGROUND

Headaches that last less than an hour in duration are uncommon, except for atypical migraine, and without a practitioner's appropriate knowledge, may result in misdiagnosis. Although most of these headaches are classified as primary headache syndromes, some have secondary etiologies such as structural lesions.

METHODS

This pediatric-specific review updates these headache syndromes. Included are atypical migraine, the trigeminal autonomic cephalgias, idiopathic stabbing headache, cranial neuralgias, occipital neuralgia, thunderclap headache, nummular headache, the red ear syndrome, and the numb-tongue syndrome.

CONCLUSION

Knowledge of the clinical characteristics of these headache patterns in children allows physicians to quickly establish the headache diagnosis and develop the optimal treatment plan.