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Prakash S, Dave A, Joshi H. Herpes zoster ophthalmicus evolving into headache characterised as hemicrania continua. BMJ Case Rep 2018; 2018:bcr-2018-224235. [PMID: 29574434 DOI: 10.1136/bcr-2018-224235] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Postherpetic neuralgia (PHN) is the most common chronic complication of herpes zoster infection. However, a few patients may develop different types of pain after herpetic lesions. We are reporting two patients who developed postherpetic hemicrania continua (HC). Case 1: a 54-year-old woman had a 10-month history of continuous left-sided pain with superimposed exacerbations. The pain started with the onset of herpetic lesions in the ophthalmic division. The lesions subsided in a few weeks. However, the pain persisted and it responded exclusively to indomethacin. Case 2: a 61-year-old woman developed clinical features pertinent to PHN. However, later on, the pattern and associated clinical features changed. The patient fulfilled the criteria of HC and showed a complete response to indomethacin. We suggest that every patient with PHN should be asked for cranial autonomic features and a trial of indomethacin should be given in refractory herpes zoster neuropathy.
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Affiliation(s)
- Sanjay Prakash
- Department of Neurolgy, Smt BK Shah Medical Institute and Research Centre, Vadodara, India
| | - Ankit Dave
- Department of Neurolgy, Smt BK Shah Medical Institute and Research Centre, Vadodara, India
| | - Hemant Joshi
- Department of Neurolgy, Smt BK Shah Medical Institute and Research Centre, Vadodara, India
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2
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Sokolov AY, Murzina AA, Osipchuk AV, Lyubashina OA, Amelin AV. Cholinergic mechanisms of headaches. NEUROCHEM J+ 2017. [DOI: 10.1134/s1819712417020131] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Wöber C. Tics in TACs: A Step into an Avalanche? Systematic Literature Review and Conclusions. Headache 2017; 57:1635-1647. [PMID: 28542727 DOI: 10.1111/head.13099] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Accepted: 04/04/2017] [Indexed: 01/03/2023]
Abstract
BACKGROUND Trigeminal autonomic cephalalgias (TACs) comprise cluster headache, paroxysmal hemicrania, short-lasting unilateral neuralgiform headache attacks, and hemicrania continua. In some cases, trigeminal neuralgia (TN, "tic douloureux") or TN-like pain may co-occur with TACs. AIM This article will review the co-occurrence and overlap of TACs and tics in order to contribute to a better understanding of the issue and an improved management of the patients. METHODS For performing a systematic literature review Pubmed was searched using a total of ten terms. The articles identified were screened for further articles of relevance. SUMMARY TACs are related to tics in various ways. TN or TN-like paroxysms may co-occur with CH, PH, and HC, labeled as cluster-tic syndrome, PH-tic syndrome, and HC-tic syndrome. Such co-occurrence was not only found in the primary TACs but also in secondary headaches resembling TACs. The initial onset of TAC and tic may be simultaneous or separated by months or years. In acute attacks, tic and TAC may occur concurrently or much more often independently of each other. The term "cluster-tic syndrome" was also used in patients with a single type of pain in a twilight zone between TACs and TN fulfilling none of the relevant diagnostic criteria. Short-lasting neuralgiform headache attacks overlap with TN in terms of clinical features, imaging findings, and therapy.
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Affiliation(s)
- Christian Wöber
- Department of Neurology, Medical University of Vienna, Vienna, Austria
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Maarbjerg S, Wolfram F, Heinskou TB, Rochat P, Gozalov A, Brennum J, Olesen J, Bendtsen L. Persistent idiopathic facial pain – a prospective systematic study of clinical characteristics and neuroanatomical findings at 3.0 Tesla MRI. Cephalalgia 2016; 37:1231-1240. [DOI: 10.1177/0333102416675618] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Introduction Persistent idiopathic facial pain (PIFP) is a poorly understood chronic orofacial pain disorder and a differential diagnosis to trigeminal neuralgia. To address the lack of systematic studies in PIFP we here report clinical characteristics and neuroimaging findings in PIFP. Methods Data collection was prospective and standardized in consecutive PIFP patients. All patients underwent 3.0 MRI. Results In a cohort of 53 PIFP patients, the average age of onset was 44.1 years. PIFP was found in more women 40 (75%) than men 13 (25%), p < 0.001. There was a high prevalence of bilateral pain 7 (13%), hypoesthesia 23 (48%), depression 16 (30%) and other chronic pain conditions 17 (32%) and a low prevalence of stabbing pain 21 (40%), touch-evoked pain 14 (26%) and remission periods 10 (19%). The odds ratio between neurovascular contact and the painful side was 1.4 (95% Cl 0.4–4.4, p = 0.565) and the odds ratio between neurovascular contact with displacement of the trigeminal nerve and the painful side was 0.2 (95% Cl 0.0–2.1, p = 0.195). Conclusion PIFP is separated from trigeminal neuralgia both with respect to the clinical characteristics and neuroimaging findings, as NVC was not associated to PIFP.
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Affiliation(s)
- Stine Maarbjerg
- Danish Headache Center, Department of Neurology, Rigshospitalet, Faculty of Health and Medical Sciences, University of Copenhagen, Nordre Ringvej 67, 2600 Glostrup, Denmark
| | - Frauke Wolfram
- Department of Diagnostics, Rigshospitalet, Faculty of Health and Medical Sciences, University of Copenhagen, Nordre Ringvej 57, 2600 Glostrup, Denmark
| | - Tone Bruvik Heinskou
- Danish Headache Center, Department of Neurology, Rigshospitalet, Faculty of Health and Medical Sciences, University of Copenhagen, Nordre Ringvej 67, 2600 Glostrup, Denmark
| | - Per Rochat
- Department of Neurosurgery, Rigshospitalet, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Aydin Gozalov
- Danish Headache Center, Department of Neurology, Rigshospitalet, Faculty of Health and Medical Sciences, University of Copenhagen, Nordre Ringvej 67, 2600 Glostrup, Denmark
| | - Jannick Brennum
- Department of Neurosurgery, Rigshospitalet, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Jes Olesen
- Danish Headache Center, Department of Neurology, Rigshospitalet, Faculty of Health and Medical Sciences, University of Copenhagen, Nordre Ringvej 67, 2600 Glostrup, Denmark
| | - Lars Bendtsen
- Danish Headache Center, Department of Neurology, Rigshospitalet, Faculty of Health and Medical Sciences, University of Copenhagen, Nordre Ringvej 67, 2600 Glostrup, Denmark
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Affiliation(s)
- M Vikelis
- Department of Neurology, Athens Naval Hospital, Athens, Greece.
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Affiliation(s)
- A S Cohen
- Headache Group, Institute of Neurology, Queen Square, London, UK
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Zebenholzer K, Wöber C, Vigl M, Wessely P, Wöber-Bingöl C. Facial pain in a Neurological Tertiary Care Centre — Evaluation of the International Classification of Headache Disorders. Cephalalgia 2016; 25:689-99. [PMID: 16109050 DOI: 10.1111/j.1468-2982.2004.00936.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
The aim of this study was to examine the diagnostic spectrum of facial pain and to evaluate the clinical features relevant to the differential diagnosis in a neurological tertiary care centre. This is the first investigation comparing the first with the second edition of the International Classification of Headache Disorders (ICHD-I, ICHD-II) in consecutively referred patients comprising a broad spectrum of disorders without restricting the inclusion to certain diagnoses. Studying 97 consecutive patients referred for facial pain, we found trigeminal neuralgia or other types of cranial neuralgia in 38% and 39% according to ICHD-I and ICHD-II, respectively; persistent idiopathic facial pain was diagnosed in 27% and 21%, respectively. The proportion of patients who could not be classified was 24% in ICHD-I and 29% in ICHD-II. Six per cent of the patients had cluster headache or chronic paroxysmal hemicrania, the remaining 5% had various other disorders. The agreement between ICHD-I and ICHD-II was very good to perfect. In ICHD-II, sensitivity and specificity were similar to ICHD-I, the specificity and negative predictive value were imrpoved in single features of trigeminal neuralgia, but were widely unchanged in persistent idiopathic facial pain. The number of patients who could not be classified was larger in ICHD-II than in ICHD-I. Modifying the diagnostic criteria for different types of facial pain, in particular changes in the criteria of persistent idiopathic facial pain, might be helpful in reducing the number of patients with unclassifiable facial pain.
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Affiliation(s)
- K Zebenholzer
- Department of Neurology, University of Vienna, Vienna, Austria
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Pego-Reigosa R, Vázquez-López ME, Iglesias-Gómez S, Martínez-Vázquez FM. Association between Chronic Paroxysmal Hemicrania and Primary Trochlear Headache: Pathophysiology and Treatment. Cephalalgia 2016; 26:1252-4. [PMID: 16961797 DOI: 10.1111/j.1468-2982.2006.01202.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- R Pego-Reigosa
- Neurology Department, Complejo Hospitalario Xeral-Calde, C/Severo Ochoa sn, Lugo, Spain.
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Calvo JF, Bruera OC, de Lourdes Figuerola M, Gestro D, Tinetti N, Leston JA. SUNCT Syndrome: Clinical and 12-Year Follow-up Case Report. Cephalalgia 2016; 24:900-2. [PMID: 15377323 DOI: 10.1111/j.1468-2982.2004.00755.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- J F Calvo
- Headache and Pain Unit, Department of Neurology, Hospital de Clínicas, José De San Martín, Buenos Aires, Argentina
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Putzki N, Nirkko A, Diener HC. Trigeminal Autonomic Cephalalgias: A Case Of Post-Traumatic SUNCT Syndrome? Cephalalgia 2016; 25:395-7. [PMID: 15839855 DOI: 10.1111/j.1468-2982.2004.00860.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- N Putzki
- Neurology, University of Essen, Essen, Germany.
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Abstract
Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) is a rare type of primary headache. In this report we describe the occurrence of SUNCT in a family. Unfortunately, one of the siblings was already dead. However, clear and detailed information from close relatives and her general practitioner confirmed the diagnosis of SUNCT. It is likely that genetic factors contribute to all types of trigeminal autonomic cephalalgias.
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Affiliation(s)
- A R Gantenbein
- Headache Group, Institute of Neurology, London WC1N 3BG, UK
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Köseoglu E, Karaman Y, Kücük S, Arman F. SUNCT Syndrome Associated with Compression of Trigeminal Nerve. Cephalalgia 2016; 25:473-5. [PMID: 15910575 DOI: 10.1111/j.1468-2982.2005.00875.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- E Köseoglu
- Medicine Faculty, Department of Neurology, Erciyes University, 38039 Kayseri, Turkey.
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Selekler HM, Efendi H, Alemdar M. Short-Lasting Unilateral Neuralgiform Headache with Severe Lacrimation and Mild Conjunctival Injection. Cephalalgia 2016; 25:317-20. [PMID: 15773832 DOI: 10.1111/j.1468-2982.2004.00854.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- H M Selekler
- Kocaeli University Medical Faculty, Deparment of Neurology, Derince 41900, Kocaeli, Turkey.
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Matharu MS, Goadsby PJ. Bilateral Paroxysmal Hemicrania or Bilateral Paroxysmal Cephalalgia, Another Novel Indomethacin-Responsive Primary Headache Syndrome? Cephalalgia 2016; 25:79-81. [PMID: 15658943 DOI: 10.1111/j.1468-2982.2005.00904.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Abstract
Short-lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT) is a primary headache syndrome that has been reported to be resistant to treatment with intravenous lidocaine. We report four cases of SUNCT in whom intravenous lidocaine (1.3-3.3 mg kg−1 h−1) completely suppressed the headaches for the duration of the infusion. The headache returned after cessation of treatment. Two patients went on to have their symptoms controlled on topiramate (50-300 mg daily). One patient had typical migrainous aura in association with some of the attacks of pain but never migrainous headaches. These cases suggest that treatment with lidocaine can be considered when acute intervention is required to suppress a severe exacerbation of SUNCT, and further broaden the therapeutic and clinical background of this syndrome.
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Affiliation(s)
- M S Matharu
- Headache Group, Institute of Neurology and The National Hospital for Neurology and Neurosurgery, London, UK
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Abu Bakar N, Matharu M, Renton T. Pain Part 9: Trigeminal Autonomic Cephalalgias. DENTAL UPDATE 2016; 43:340-352. [PMID: 29148687 DOI: 10.12968/denu.2016.43.4.340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
The trigeminal autonomic cephalalgias are a group of rare, highly disabling, primary headache syndromes distinctly characterized by the unilaterality of their attacks and presence of cranial autonomic symptoms. Although pain is often localized to the peri-orbital and temporal regions, it is not uncommon for pain to radiate to tooth-bearing areas and mimic toothache or jaw pain. Hence, dental practitioners should be aware of these syndromes to enable appropriate referral and avoid unnecessary, and often irreversible, dental treatments. Many dentists will not have heard of these conditions but must remain vigilant, and ensure that they are not confused with trigeminal neuralgia, so that their patients are appropriately advised and referred. Clinical relevance: The dental practitioners may be the first line of healthcare providers consulted by these patients in the hope of obtaining pain relief. Lack of familiarity with an uncommon condition may lead to poor patient management.
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Tic versus TAC: differentiating the neuralgias (trigeminal neuralgia) from the cephalalgias (SUNCT and SUNA). Curr Pain Headache Rep 2015; 19:473. [PMID: 25501956 DOI: 10.1007/s11916-014-0473-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Trigeminal neuralgia, short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) and short-lasting unilateral neuralgiform headache attacks with autonomic symptoms (SUNA) are classified as distinct disorders in the International Classification of Headache Disorders 3 beta (ICHD-3 beta). SUNCT and SUNA are primary headache disorders included among the trigeminal autonomic cephalalgias. Trigeminal neuralgia is classified under painful cranial neuropathies and other facial pains. The classification criteria of these conditions overlap significantly which could lead to misdiagnosis. The reported overlap among these conditions has called into question whether they should be considered distinct entities or rather a continuum of the same disorder. This review explores the known overlap and how other features not included in the ICHD-3 beta criteria may better differentiate the "Tics" (trigeminal neuralgia) from the "TACs" (SUNCT and SUNA).
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Haviv Y, Khan J, Zini A, Almoznino G, Sharav Y, Benoliel R. Trigeminal neuralgia (part I): Revisiting the clinical phenotype. Cephalalgia 2015; 36:730-46. [DOI: 10.1177/0333102415611405] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Accepted: 06/27/2015] [Indexed: 12/16/2022]
Abstract
Aims We conducted a cross-sectional study to re-examine the clinical profile of patients with a clinical diagnosis of classical trigeminal neuralgia (CTN). Methods Inclusion criteria consisted of the International Headache Society’s published classification of CTN. For the specific purposes of the study, features such as autonomic signs, persistent background pain, attack durations of >2 minutes and reports of pain-related awakening were included. The demographic and clinical phenotype of each patient were carefully recorded for analysis. Results The study cohort consisted of 81 patients and based on reported attack duration these were divided into short (≤ 2 minutes, n = 61) and long (> 2 minutes, n = 20) groups for further analysis. The group with short attack duration neatly fit most of the criteria for CTN while the long attack group presents a more challenging diagnosis. There were no significant differences in pain severity, quality and location between the short and long attack groups. The frequency of persistent background pain was significantly higher in the long (70%) compared to the short attack group (29.5%, p = 0.001). There were significantly more reports of pain-related awakenings in the long (55%) than in the short attack groups (29.5%, p = 0.04). There were no significant differences in the frequency of autonomic signs between the short (21.3%) and long attack groups (40%, p = 0.1). In the short attack group, the presence of autonomic signs was significantly associated with longer disease duration, increased pain-related awakenings, and a reduced prognosis. Conclusion There are clear diagnostic criteria for CTN but often patients present with features, such as long pain attacks, that challenge such accepted criteria. In our cohort the clinical phenotype of trigeminal, neuralgiform pain with or without autonomic signs and background pain was observed across both short and long attack groups and the clinical implications of this are discussed.
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Affiliation(s)
- Y Haviv
- Department of Oral Medicine, The Faculty of Dentistry, Hebrew University-Hadassah, Israel
| | - J Khan
- Rutgers School of Dental Medicine, Rutgers State University of New Jersey, USA
| | - A Zini
- Department of Community Dentistry, The Faculty of Dentistry, Hebrew University-Hadassah, Israel
| | - G Almoznino
- Department of Oral Medicine, The Faculty of Dentistry, Hebrew University-Hadassah, Israel
- Department of Oral Medicine, Oral and Maxillofacial Center, Medical Corps, Israel Defense Forces, Israel
| | - Y Sharav
- Department of Oral Medicine, The Faculty of Dentistry, Hebrew University-Hadassah, Israel
| | - R Benoliel
- Rutgers School of Dental Medicine, Rutgers State University of New Jersey, USA
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Role of trigeminal microvascular decompression in the treatment of SUNCT and SUNA. Curr Pain Headache Rep 2013; 17:332. [PMID: 23564233 DOI: 10.1007/s11916-013-0332-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Short-lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT) and short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms (SUNA) are primary headache disorders. Evidence suggests that SUNCT/SUNA have similar pathophysiology to the trigeminal autonomic cephalalgias and involves the trigeminal autonomic reflex. This review provides an overview of microvascular decompression of the trigeminal nerve and other surgical therapeutic options for SUNCT/SUNA. We have undertaken a mini-meta-analysis of available case reports and case series with the aim of providing recommendations for the use of such therapies in SUNCT/SUNA. There is some evidence supporting microvascular decompression of the trigeminal nerve in selected patients who have medically refractory SUNCT/SUNA and a demonstrable ipsilateral aberrant vessel on magnetic resonance imaging (MRI). We also consider what further investigations could be undertaken to assess the role of surgical interventions in the treatment of these often debilitating conditions.
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Rodgers SD, Marascalchi BJ, Strom RG, Huang PP. Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing syndrome secondary to an epidermoid tumor in the cerebellopontine angle. Neurosurg Focus 2013; 34:E1. [PMID: 23452266 DOI: 10.3171/2013.1.focus12233] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) syndrome is classified under trigeminal autonomic cephalalgias. This rare headache syndrome is infrequently associated with secondary pathologies. In this paper the authors report on a patient with paroxysmal left retroorbital pain with associated autonomic symptoms of ipsilateral conjunctival injection and lacrimation, suggestive of SUNCT syndrome. After failed medical treatment an MRI sequence was obtained in this patient, demonstrating an epidermoid tumor in the left cerebellopontine angle. The patient's symptoms completely resolved after a gross-total resection of the tumor. This case demonstrates the effectiveness of resection as definitive treatment for SUNCT syndrome associated with tumoral compression of the trigeminal nerve. Early MRI studies should be considered in all patients with SUNCT, especially those with atypical signs and symptoms.
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Affiliation(s)
- Shaun D Rodgers
- Department of Neurosurgery, New York University Langone Medical Center, New York, New York, USA
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Wilbrink LA, Weller CM, Cheung C, Haan J, Ferrari MD. Cluster-Tic Syndrome: A Cross-Sectional Study of Cluster Headache Patients. Headache 2013; 53:1334-40. [DOI: 10.1111/head.12161] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2013] [Indexed: 11/30/2022]
Affiliation(s)
| | - Claudia M. Weller
- Department of Human Genetics; Leiden University Medical Centre; Leiden; The Netherlands
| | - Carlo Cheung
- Department of Neurology; Leiden University Medical Centre; Leiden; The Netherlands
| | | | - Michel D. Ferrari
- Department of Neurology; Leiden University Medical Centre; Leiden; The Netherlands
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Lambru G, Matharu M. Management of Trigeminal Autonomic Cephalalgias in Children and Adolescents. Curr Pain Headache Rep 2013; 17:323. [DOI: 10.1007/s11916-013-0323-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Abstract
INTRODUCTION Cluster headache (CH) is a primary headache by definition not caused by any known underlying structural pathology. However, symptomatic cases have been described. The evaluation of CH is an issue unresolved. CASE REPORT A 41-year-old man presented with a 3-month history of side-locked attacks of excruciating severe stabbing and boring right-sided pain located in the temple and the orbit. The attacks were associated with conjunctival injection and restlessness and migrainous features. The duration of attacks was about 30 minutes and the frequency 4 to 5 per 24 hours. His vital signs and physical and neurological examination were normal. A previous unenhanced brain computed tomography had been normal. A diagnosis of CH was made. The patient responded partially to treatment. Enhanced magnetic resonance imaging after 3 weeks displayed a right-sided parietal glioma with a surrounding edema and mass effect. After debulking, the headache attacks resolved completely. CONCLUSIONS Contrast-enhanced magnetic resonance imaging should always be considered in patients with CH despite earlier normal head computed tomography/examinations. Late-onset CH represents a condition that requires careful evaluation. Parietal glioblastoma multiforme can present as CH.
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Lambru G, Matharu MS. Trigeminal autonomic cephalalgias: A review of recent diagnostic, therapeutic and pathophysiological developments. Ann Indian Acad Neurol 2012; 15:S51-61. [PMID: 23024564 PMCID: PMC3444219 DOI: 10.4103/0972-2327.100007] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2011] [Revised: 09/16/2011] [Accepted: 11/24/2011] [Indexed: 11/25/2022] Open
Abstract
The trigeminal autonomic cephalalgias (TACs) are a group of primary headache disorders that are characterized by strictly unilateral trigeminal distribution pain occurring in association with ipsilateral cranial autonomic symptoms. This group includes cluster headache, paroxysmal hemicrania and short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing. These disorders are very painful, often considered to be some of the most painful conditions known to mankind, and consequently are highly disabling. They are distinguished by the frequency of attacks of pain, the length of the attacks and very characteristic responses to medical therapy, such that the diagnosis can usually be made clinically, which is important because it dictates therapy. The management of TACs can be very rewarding for physicians and highly beneficial to patients.
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Affiliation(s)
- Giorgio Lambru
- Institute of Neurology, The National Hospital for Neurology and Neurosurgery, Queen Square, London, UK
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Schwartz DP, Robbins MS. Primary headache disorders and neuro-ophthalmologic manifestations. Eye Brain 2012; 4:49-61. [PMID: 28539781 PMCID: PMC5436189 DOI: 10.2147/eb.s21841] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Headache is an extraordinarily common complaint presenting to medical practitioners in all arenas and specialties, particularly primary care physicians, neurologists, and ophthalmologists. A wide variety of headache disorders may manifest with a myriad of neuro-ophthalmologic symptoms, including orbital pain, disturbances of vision, aura, photophobia, lacrimation, conjunctival injection, ptosis, and other manifestations. The differential diagnosis in these patients is broad and includes both secondary, or symptomatic, and primary headache disorders. Awareness of the headache patterns and associated symptoms of these various disorders is essential to achieve the correct diagnosis. This paper reviews the primary headache disorders that prominently feature neuro-ophthalmologic manifestations, including migraine, the trigeminal autonomic cephalalgias, and hemicrania continua. Migraine variants with prominent neuro-ophthalmologic symptoms including aura without headache, basilar-type migraine, retinal migraine, and ophthalmoplegic migraine are also reviewed. This paper focuses particularly on the symptomatology of these primary headache disorders, but also discusses their epidemiology, clinical features, and treatment.
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Affiliation(s)
- Daniel P Schwartz
- Department of Neurology, Montefiore Headache Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Matthew S Robbins
- Department of Neurology, Montefiore Headache Center, Albert Einstein College of Medicine, Bronx, NY, USA
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Whiplash Injury-induced Atypical Short-lasting Unilateral Neuralgiform Headache With Conjunctival Injection and Tearing Syndrome Treated by Greater Occipital Nerve Block. Clin J Pain 2012; 28:342-3. [DOI: 10.1097/ajp.0b013e318234ec39] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Role of greater occipital nerve blocks and trigger point injections for patients with dizziness and headache. Neurologist 2012; 17:312-7. [PMID: 22045281 DOI: 10.1097/nrl.0b013e318234e966] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The trigeminocervical system is integral in cervicogenic headache. Cervicogenic headache frequently coexists with complaints of dizziness, tinnitus, nausea, imbalance, hearing complaints, and ear/eye pain. Controversy exists as to whether this constellation of symptoms may be cervically mediated. OBJECTIVES To determine whether a wider spectrum of cervically mediated symptoms exist, and to investigate a potential role of greater occipital nerve blocks (GON) and trigger point injections (TPI) in these patients. METHODS Retrospective review of GON/TPI performed in a tertiary otoneurology/headache clinic from May 2006 to March 2007 for suspected cervically mediated symptoms. Data included chief complaint, secondary symptoms, response to injection, pre-GON/TPI posterior vertex sensation changes to pinprick, cervical spine examination, and response to vibration of cervical and suboccipital musculature. RESULTS Total number of 147 patients were included. Chief complaints in decreasing frequency: dizziness (93%), tinnitus (4%), headache (3%), and ear discomfort (0.7%). Overall symptoms in decreasing frequency: dizziness (97%), headache (88%), neck pain (63%), tinnitus (23%), and ear discomfort (22%). Improvements after GON/TPI: neck range of motion (71%), headache (57%), neck pain (52%), ear discomfort (47%), dizziness (46%), and tinnitus (30%). Dizziness responders had neck position asymmetries (84%), reproducible dizziness by cervical and suboccipital musculature vibration (75%), and preinjection posterior vertex sensory changes (60%). CONCLUSIONS A wider spectrum of cervically mediated symptoms may exist by influence of trigeminocervical and vestibular circuitry through cervical afferent neuromodulation. Certain examination findings may help to predict benefit from GON/TPI.
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Abstract
Object
Autonomic symptoms can occur in association with the facial pain of trigeminal neuralgia (TN). The distinction between first division (V1) TN and trigeminal autonomic cephalgias, particularly short-lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT), can be difficult. The goal in this study was to investigate the frequency of autonomic symptoms with TN and to determine their effect on surgical outcome.
Methods
The authors sent questionnaires and reviewed the records of 92 patients who underwent surgical procedures for TN to obtain visual analog scale scores for pain before and after surgery and to determine the location of the pain and the presence of autonomic symptoms.
Results
Sixty-seven percent of patients had at least 1 autonomic symptom, and 14% had 4 or more autonomic symptoms associated with their pain. With V1 pain, the most common autonomic symptoms were conjunctival injection, ptosis, and excessive tearing. With pain involving the second division (V2), facial swelling was the most common autonomic symptom. Excessive salivation occurred most often when the pain involved the third division (V3). In patients who underwent microvascular decompression (MVD), visual analog scores for pain showed significantly greater improvement postoperatively in those who had no preoperative autonomic symptoms than in those who reported autonomic symptoms. There was also a significantly greater number of patients who were pain free postoperatively in the group without autonomic symptoms. There were 3 patients with V1 facial pain associated with conjunctival injection and tearing who, in retrospect, fulfilled all the current diagnostic criteria for SUNCT. These patients underwent MVD, during which a vessel was found to compress the trigeminal nerve. Postoperatively, the 3 patients experienced complete and long-lasting pain relief.
Conclusions
The presence of autonomic symptoms in TN correlated with a worse prognosis for pain relief after MVD. First division TN with autonomic symptoms can present identically to SUNCT but can respond to MVD if there is a compressive vessel. Neurosurgeons should be aware of SUNCT, especially in patients with V1 TN and autonomic symptoms, to ensure that all potential medical therapies have been tried prior to surgical treatment.
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Bartsch T, Falk D, Knudsen K, Reese R, Raethjen J, Mehdorn HM, Volkmann J, Deuschl G. Deep brain stimulation of the posterior hypothalamic area in intractable short-lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT). Cephalalgia 2011; 31:1405-8. [DOI: 10.1177/0333102411409070] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background: SUNCT (short-lasting unilateral neuralgiform headache with conjunctival injection and tearing) is a rare syndrome characterized by the sudden onset of excruciating unilateral periorbital pain that is accompanied by conjunctival injection and lacrimation or further autonomic signs. Similar to patients with chronic cluster headache, Leone and Lyons showed a beneficial effect of deep brain stimulation of the posterior hypothalamic region in two patients with a chronic SUNCT. Case: Here, we present the case of a man with a chronic SUNCT responding to deep brain stimulation of the posterior hypothalamic area. Conclusion: This case supports the idea of a central origin of SUNCT and shows that deep brain stimulation of the hypothalamic region can be effective in the treatment of the chronic form of this rare disorder.
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Affiliation(s)
- T Bartsch
- University Hospital Schleswig-Holstein, Germany
| | - D Falk
- University Hospital Schleswig-Holstein, Germany
| | - K Knudsen
- University Hospital Schleswig-Holstein, Germany
| | - R Reese
- University Hospital Schleswig-Holstein, Germany
| | - J Raethjen
- University Hospital Schleswig-Holstein, Germany
| | - HM Mehdorn
- University Hospital Schleswig-Holstein, Germany
| | - J Volkmann
- University Hospital Schleswig-Holstein, Germany
| | - G Deuschl
- University Hospital Schleswig-Holstein, Germany
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Vesza Z, Várallyay G, Szőke K, Bozsik G, Manhalter N, Bereczki D, Ertsey C. Trigemino-autonomic headache related to Gasperini syndrome. J Headache Pain 2010; 11:535-8. [PMID: 20803228 PMCID: PMC3476227 DOI: 10.1007/s10194-010-0251-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2010] [Accepted: 08/12/2010] [Indexed: 12/19/2022] Open
Abstract
We report the association of ipsilateral trigemino-autonomic headache to a case of right-sided nuclear facial and abducens palsy (Gasperini syndrome), ipsilateral hypacusis and right hemiataxia, caused by the occlusion of the right anterior inferior cerebellar artery. Short-lasting attacks of mild to moderate ipsilateral fronto-periorbital head pain, accompanied by lacrimation and mild conjunctival injection during more severe attacks, were present from the onset of symptoms, with a gradual worsening over the next few months and remitting during naproxen therapy. Magnetic resonance imaging showed an infarct in the right cerebellar peduncle, extending toward the pontine tegmentum, also involving the ipsilateral spinal trigeminal nucleus and tract and the trigeminal entry zone. Gasperini syndrome may be accompanied by ipsilateral trigemino-autonomic head pain.
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Affiliation(s)
- Zsófia Vesza
- Department of Neurology, Semmelweis University, Balassa u. 6., 1083 Budapest, Hungary
| | - György Várallyay
- MR Research Center, Szentágothai Knowledge Center, Semmelweis University, Balassa u. 6., 1083 Budapest, Hungary
| | - Kristóf Szőke
- Department of Neurology, Semmelweis University, Balassa u. 6., 1083 Budapest, Hungary
| | - György Bozsik
- Department of Neurology, Semmelweis University, Balassa u. 6., 1083 Budapest, Hungary
| | - Nóra Manhalter
- PhD Programme, Semmelweis University, Budapest, Hungary
- Department of Neurology, Nyírő Gyula Hospital, Lehel u. 59., 1135 Budapest, Hungary
| | - Dániel Bereczki
- Department of Neurology, Semmelweis University, Balassa u. 6., 1083 Budapest, Hungary
| | - Csaba Ertsey
- Department of Neurology, Semmelweis University, Balassa u. 6., 1083 Budapest, Hungary
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Matharu MS, Zrinzo L. Deep brain stimulation in cluster headache: hypothalamus or midbrain tegmentum? Curr Pain Headache Rep 2010; 14:151-9. [PMID: 20425205 DOI: 10.1007/s11916-010-0099-5] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Functional and structural neuroimaging studies have provided pivotal insights into the pathophysiology of trigeminal autonomic cephalalgias (TACs), particularly cluster headache (CH). Functional imaging studies using positron emission tomography (PET) and functional magnetic resonance imaging (fMRI) in TACs have reported activation of the posterior hypothalamus. A structural neuroimaging study using voxel-based morphometry in CH reported increased volume of the hypothalamic gray, although another larger study failed to reproduce this finding. These studies in CH prompted the use of stereotactic stimulation of the target point identified by functional and structural neuroimaging. The precise anatomical localization of the deep brain stimulation (DBS) target places it at the midbrain tegmentum rather than the posterior hypothalamus. A comparison of the PET and fMRI studies in TACs reveals that the diencephalic/mesencephalic activation is more posteroinferior in the PET studies, straddling the hypothalamus and midbrain tegmentum, whereas the activation is centered on the hypothalamus in the higher spatial resolution fMRI studies. To optimize the outcomes from DBS, it is likely that patients will need to be studied individually using functional imaging techniques that have high spatial and temporal resolution to enable targeting of the appropriate locus with stereotactic stimulation.
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What has functional neuroimaging done for primary headache … and for the clinical neurologist? J Clin Neurosci 2010; 17:547-53. [DOI: 10.1016/j.jocn.2009.09.030] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2009] [Revised: 09/22/2009] [Accepted: 09/23/2009] [Indexed: 11/20/2022]
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Antonaci F, Sances G, Loi M, Sandrini G, Dumitrache C, Cuzzoni MG. SUNCT syndrome with paroxysmal mydriasis: Clinical and pupillometric findings. Cephalalgia 2010; 30:987-90. [DOI: 10.1177/0333102409357478] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
SUNCT syndrome (short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing) is a primary headache characterised by a high frequency of attacks associated with marked autonomic periocular signs and symptoms. Activation of the hypothalamus via the superior salivary nucleus is probably responsible for some of the autonomic involvement observed during SUNCT attacks. We describe a case of SUNCT with unusual autonomic features (e.g., mydriasis) and early onset. Pupillometric studies were performed both in a basal condition (without anisocoria) and after instillation of phenylephrine (a drug with direct sympathomimetic activity) and pilocarpine (a parasympathetic agonist). The findings in this patient seem to indicate involvement of the ocular sympathetic supply in SUNCT, responsible for the mydriasis, and seem to strengthen the possibility that the autonomic phenomena in this syndrome vary with different levels of pain severity.
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Affiliation(s)
- F Antonaci
- University Centre for Adaptive Disorders and Headache, Italy
- Headache Medicine Centre, Polyclinic of Monza, Italy
| | - G Sances
- Mondino Institute of Neurology Foundation, Italy
| | - M Loi
- Headache Medicine Centre, Polyclinic of Monza, Italy
| | - G Sandrini
- University Centre for Adaptive Disorders and Headache, Italy
| | - C Dumitrache
- University Emergency Hospital of Bucharest, Romania
| | - MG Cuzzoni
- University Centre for Adaptive Disorders and Headache, Italy
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De Cesaris F, Fanciullacci M, Pietrini U, Anselmi B, Del Bene E. Defining neuralgiform headache with ipsilateral autonomic symptoms: case report in a headache center. Intern Emerg Med 2008; 3:413-4. [PMID: 18566758 DOI: 10.1007/s11739-008-0168-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2007] [Accepted: 05/26/2008] [Indexed: 10/21/2022]
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Jacob S, Saha AR, Rajabally YA. Post-Traumatic Short-Lasting Unilateral Headache With Cranial Autonomic Symptoms (SUNA). Cephalalgia 2008; 28:991-3. [DOI: 10.1111/j.1468-2982.2008.01622.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) syndrome is a rare headache syndrome classified among the trigeminal autonomic cephalalgias. It is usually idiopathic, although infrequent secondary forms have been described. Recently the term short-lasting unilateral headache with cranial autonomic symptoms (SUNA) has been defined by the International Headache Society (ICHD-2) as similar to SUNCT with less prominent or absent conjunctival injection and lacrimation. We report two patients with paroxysmal orbito-fronto-temporal pains, phenotypically suggesting SUNA, occurring after traumatic head injury.
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Affiliation(s)
- S Jacob
- Department of Neurology, University Hospitals of Leicester, Leicester General Hospital, Leicester
| | - AR Saha
- Department of Neurology, The Royal Sussex County Hospital, Brighton, UK
| | - YA Rajabally
- Department of Neurology, University Hospitals of Leicester, Leicester General Hospital, Leicester
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38
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39
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40
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Functional and structural neuroimaging in trigeminal autonomic cephalalgias. Curr Pain Headache Rep 2008; 12:132-7. [DOI: 10.1007/s11916-008-0025-2] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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41
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Camarda C, Camarda R, Monastero R. Chronic paroxysmal hemicrania and hemicrania continua responding to topiramate: Two case reports. Clin Neurol Neurosurg 2008; 110:88-91. [DOI: 10.1016/j.clineuro.2007.09.002] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2007] [Revised: 08/29/2007] [Accepted: 09/10/2007] [Indexed: 11/27/2022]
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Rocha Filho PAS, Rabello GD, Galvão ACR, Fortini I, Calderaro M, Carrocini D. Uso de gabapentina no tratamento da Síndrome SUNCT. ARQUIVOS DE NEURO-PSIQUIATRIA 2007; 65:503-5. [PMID: 17665024 DOI: 10.1590/s0004-282x2007000300027] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2006] [Accepted: 02/22/2007] [Indexed: 05/16/2023]
Abstract
Relatamos o caso clínico de duas mulheres com quadro compatível com síndrome SUNCT (cefaléia de curta duração, unilateral, neuralgiforme com hiperemia conjuntival e lacrimejamento). As duas apresentavam exames clínico e neurológico normais e RM com sinais de microangiopatia. A primeira apresentava cefaléia há três anos, que ocorria várias vezes por dia, sempre que mastigava ou bocejava. Havia feito uso várias medicações sem melhora. A dor foi controlada após o uso de 600 mg de gabapentina ao dia. A segunda paciente referia cefaléia há seis meses. A dor era diária, ocorrendo de 20-40 vezes por dia. Na ocasião da primeira avaliação no ambulatório, já fazia uso 600 mg de carbamazepina ao dia e 15 mg de clorpromazina, com melhora parcial. Após introdução de gabapentina- 1200 mg/ dia, a paciente evoluiu sem dor, porém com episódios de hiperemia conjuntival.
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Goadsby PJ. Neuromodulatory approaches to the treatment of trigeminal autonomic cephalalgias. ACTA NEUROCHIRURGICA. SUPPLEMENT 2007; 97:99-110. [PMID: 17691295 DOI: 10.1007/978-3-211-33081-4_12] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
The trigeminal autonomic cephalalgias (TACs) are a group of primary headache syndromes characterised by intense pain and associated activation of cranial parasympathetic autonomic outflow pathways out of proportion to the pain. The TACs include cluster headache, paroxysmal hemicrania and SUNCT (short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing). The pathophysiology of these syndromes involves activation of the trigeminal-autonomic reflex, whose afferent limb projects into the trigeminocervical complex in the caudal brainstem and upper cervical spinal cord. Functional brain imaging has shown activations in the posterior hypothalamic grey matter in TACs. This paper reviews the anatomy and physiology of these conditions and the brain imaging findings. Current treatments are summarised and the role of neuromodulation procedures, such as occipital nerve stimulation and deep brain stimulation in the posterior hypothalamus are reviewed. Neuromodulatory procedures are a promising avenue for these highly disabled patients with treatment refractory TACs.
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Affiliation(s)
- P J Goadsby
- The National Hospital for Neurology and Neurosurgery, Institute of Neurology, Queen Square, London, UK.
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45
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Leone M, Mea E, Genco S, Bussone G. Coexistence of TACS and Trigeminal Neuralgia: Pathophysiological Conjectures. Headache 2006; 46:1565-70. [PMID: 17115989 DOI: 10.1111/j.1526-4610.2006.00537.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Trigeminal autonomic cephalgias (TACs) and trigeminal neuralgia are short-lasting unilateral primary headaches whose study is providing insights into craniofacial pain mechanisms. We report on 2 patients in whom trigeminal neuralgia coexists with the TACs paroxysmal hemicrania and SUNCT. CONCLUSION Coexistence of trigeminal neuralgia with various TAC forms suggests a pathophysiological relationship between these short-lasting unilateral headaches.
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Affiliation(s)
- Massimo Leone
- Departments of Neurology and Headache, Istituto Nazionale Neurologico Carlo Besta, Milano, Italy
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46
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May A, Leone M, Afra J, Linde M, Sándor PS, Evers S, Goadsby PJ. EFNS guidelines on the treatment of cluster headache and other trigeminal-autonomic cephalalgias. Eur J Neurol 2006; 13:1066-77. [PMID: 16987158 DOI: 10.1111/j.1468-1331.2006.01566.x] [Citation(s) in RCA: 269] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Cluster headache and the other trigeminal-autonomic cephalalgias [paroxysmal hemicrania, short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) syndrome] are rare but very disabling conditions with a major impact on the patient's quality of life. The objective of this study was to give evidence-based recommendations for the treatment of these headache disorders based on a literature search and consensus amongst a panel of experts. All available medical reference systems were screened for any kind of studies on cluster headache, paroxysmal hemicrania and SUNCT syndrome. The findings in these studies were evaluated according to the recommendations of the European Federation of Neurological Societies resulting in level A, B or C recommendations and good practice points. For the acute treatment of cluster headache attacks, oxygen (100%) with a flow of at least 7 l/min over 15 min and 6 mg subcutaneous sumatriptan are drugs of first choice. Prophylaxis of cluster headache should be performed with verapamil at a daily dose of at least 240 mg (maximum dose depends on efficacy or tolerability). Although no class I or II trials are available, steroids are clearly effective in cluster headache. Therefore, the use of at least 100 mg methylprednisone (or equivalent corticosteroid) given orally or at up to 500 mg i.v. per day over 5 days (then tapering down) is recommended. Methysergide, lithium and topiramate are recommended as alternative treatments. Surgical procedures, although in part promising, require further scientific evaluation. For paroxysmal hemicranias, indomethacin at a daily dose of up to 225 mg is the drug of choice. For treatment of SUNCT syndrome, large series suggest that lamotrigine is the most effective preventive agent, with topiramate and gabapentin also being useful. Intravenous lidocaine may also be helpful as an acute therapy when patients are extremely distressed and disabled by frequent attacks.
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Affiliation(s)
- A May
- Department of Systems Neuroscience, University of Hamburg, Hamburg, Germany.
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Truini A, Barbanti P, Galeotti F, Leandri M, Cruccu G. Trigeminal sensory pathway function in patients with SUNCT. Clin Neurophysiol 2006; 117:1821-5. [PMID: 16807094 DOI: 10.1016/j.clinph.2006.04.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2005] [Revised: 04/14/2006] [Accepted: 04/18/2006] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Short-lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT) is a rare primary headache whose origins are unclear. To seek information on its pathophysiology, we studied the trigeminal Abeta and Adelta pathways by recording trigeminal reflexes and laser evoked potentials (LEPs) in patients with SUNCT. METHODS Trigeminal reflexes and LEPs were recorded in 11 consecutive patients. Ten patients had neuroimaging evidence documenting idiopathic SUNCT and one had a posterior fossa tumour that compressed the trigeminal nerve thus causing symptomatic SUNCT. RESULTS Whereas the patients with idiopathic SUNCT had normal trigeminal reflex and LEP responses, the patient with symptomatic SUNCT had abnormal responses. CONCLUSIONS Our neurophysiological findings show that idiopathic SUNCT spares the trigeminal sensory pathways whereas symptomatic SUNCT does not. SIGNIFICANCE Neurophysiological testing can easily differentiate the idiopathic and symptomatic forms of SUNCT. It also suggests that the two forms are pathophysiologically distinct entities.
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Affiliation(s)
- A Truini
- Department of Neurological Sciences, University La Sapienza, Rome, Italy.
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48
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Matharu MS, Cohen AS, Frackowiak RSJ, Goadsby PJ. Posterior hypothalamic activation in paroxysmal hemicrania. Ann Neurol 2006; 59:535-45. [PMID: 16489610 DOI: 10.1002/ana.20763] [Citation(s) in RCA: 161] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Paroxysmal hemicrania (PH) is a severe, strictly unilateral headache that lasts 2 to 30 minutes, occurs more than five times daily, is associated with trigeminal autonomic symptoms, and is exquisitely responsive to indomethacin. The purpose of the study was to determine the brain structures active in PH. METHODS Seven PH patients were studied using positron emission tomography (PET). Each patient was scanned in three states: (1) acute PH attack-off indomethacin; (2) pain-free-off indomethacin; and (3) pain-free after administration of intramuscular indomethacin 100 mg. The scan images were processed and analyzed using SPM99. RESULTS The study showed no significant activations during state 1 compared with state 2, but there was relative activation of the pain neuromatrix in both states 1 and 2 compared with state 3. This suggests that there is persistent activation of the pain neuromatrix during acute PH attacks and during interictal pain-free states off indomethacin that is deactivated by the administration of indomethacin. In addition, the untreated PH state was associated with significant activation of the contralateral posterior hypothalamus and contralateral ventral midbrain, which extended over the red nucleus and the substantia nigra. INTERPRETATION These activated subcortical structures may play a pivotal role in the pathophysiology of this syndrome.
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Affiliation(s)
- Manjit S Matharu
- Headache Group, Institute of Neurology, Queen Square, London, UK
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49
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Matharu MS, Goadsby PJ. Functional brain imaging in hemicrania continua: implications for nosology and pathophysiology. Curr Pain Headache Rep 2005; 9:281-8. [PMID: 16004846 DOI: 10.1007/s11916-005-0038-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Hemicrania continua is a strictly unilateral, continuous headache of mild to moderate intensity, with superimposed exacerbations of moderate to severe intensity that are accompanied by trigeminal autonomic features and migrainous symptoms. The syndrome is exquisitely responsive to indomethacin. Its clinical phenotype overlaps with that of the trigeminal autonomic cephalalgias and migraine, in which the hypothalamus and the brain stem, respectively, have been postulated to play central pathophysiologic roles. A recent positron-emission tomography study of a cohort of patients with hemicrania continua demonstrated significant activation of the contralateral posterior hypothalamus and ipsilateral dorsal rostral pons in association with the headache of hemicrania continua. In addition, there was activation of the ipsilateral ventrolateral midbrain, which extended over the red nucleus and the substantia nigra and bilateral pontomedullary junction. No intracranial vessel dilatation was obvious.
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Affiliation(s)
- M S Matharu
- Institute of Neurology, Queen Square, London WC1N 3BG, UK
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Abstract
Trigeminal Autonomic Cephalalgias (TACs) is a grouping of headache syndromes that includes cluster headache, paroxysmal hemicrania and short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT). They are recognized clinically by their episodic, stereotypic attack profile and very often prominent cranial autonomic symptoms, such as lacrimation, conjunctival injection or rhinorrhea. They involve afferent activation of the trigeminal innervation of intracranial pain-producing structures, or the perception of that activation, and reflex activation of the facial, seventh cranial, nerve outflow pathway. This excess reflex trigeminal-autonomic activation seems to be permitted by dysfunction in the brain, specifically in the posterior hypothalamic gray matter. Understanding the anatomy and physiology of these disorders has greatly facilitated their management and the development of exciting new strategies such as neuromodulatory approaches to the management of the more intractable cases.
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Affiliation(s)
- P J Goadsby
- Headache Group, Institute of Neurology and The National Hospital for Neurology and Neurosurgery, London, United Kingdom.
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