Typical cluster headache caused by granulomatous pituitary involvement

Psychedelics in the Treatment of Headache and Chronic Pain Disorders

The therapeutic potential of psychedelics in headache and chronic pain disorders is documented over decades of anecdotal and early investigational reports, which have paved the way for the first controlled studies of psilocybin and lysergic acid diethylamide (LSD) in these disorders. The reported lasting clinical effects after limited dosing with psychedelics present a novel means for disease management, but considerable further study will be required to address disease-specific treatments, uncover mechanism(s) of action, and verify safety. In this chapter, these topics are reviewed with particular attention to the neurobiological systems that offer potential sources of psychedelics' unique clinical effects in headache and pain.

Cluster headache due to structural lesions: A systematic review of published cases

BACKGROUND

Cluster headache (CH) is a severe incapacitating headache disorder. By definition, its diagnosis must exclude possible underlying structural conditions.

AIM

To review available information on CLH caused by structural lesions and to provide better guides in the distinguishing process and to ensure that there is not a potentially treatable structural lesion.

METHODS

We conducted a systematic review of 77 published cases of symptomatic CH and cluster-like headache (CLH) in PubMed and Google Scholar databases.

RESULTS

Structural pathologies associated with CH were vascular (37.7%), tumoral (32.5%) and inflammatory (27.2%). Brain mass-like lesions (tumoural and inflammatory) were the most common diseases (28.6%), among which 77.3% lesions were at the suprasellar (pituitary) region. Cases of secondary CH related to sinusitis rose dramatically, occupying 19.5%. The third most common disease was internal carotid artery dissection, accounting for 14.3%. Atypical clinical features raise an early suspicion of a secondary cause: Late age at onset and eye and retroorbital pains were common conditions requiring careful evaluation and were present in at least one-third of cases. Abnormal neurological examination was the most significant red flag for impaired cranial nerves. CLH patients may be responsive to typical CH treatments; therefore, the treatment response is not specific. CLH can be triggered by contralateral structural pathologies. CLH associated with sinusitis and cerebral venous thrombosis required more attention.

CONCLUSION

Since secondary headache could perfectly mimick primary CH, neuroimaging should be conducted in patients in whom primary and secondary headaches are suspected. Cerebral magnetic resonance imaging scans is the diagnostic management of choice, and further examinations include vessel imaging with contrast agents and dedicated scans focusing on specific cerebral areas (sinuses, ocular and sellar regions). Neuroimaging is as necessary at follow-up visits as at the first observation.

Neuroendocrine Associations Underlying the Persistent Therapeutic Effects of Classic Serotonergic Psychedelics

Recent reports on the effects of psychedelic-assisted therapies for mood disorders and addiction, as well as the effects of psychedelics in the treatment of cluster headache, have demonstrated promising therapeutic results. In addition, the beneficial effects appear to persist well after limited exposure to the drugs, making them particularly appealing as treatments for chronic neuropsychiatric and headache disorders. Understanding the basis of the long-lasting effects, however, will be critical for the continued use and development of this drug class. Several mechanisms, including biological and psychological ones, have been suggested to explain the long-lasting effects of psychedelics. Actions on the neuroendocrine system are some such mechanisms that warrant further investigation in the study of persisting psychedelic effects. In this report, we review certain structural and functional neuroendocrinological pathologies associated with neuropsychiatric disorders and cluster headache. We then review the effects that psychedelic drugs have on those systems and provide preliminary support for potential long-term effects. The circadian biology of cluster headache is of particular relevance in this area. We also discuss methodologic considerations for future investigations of neuroendocrine system involvement in the therapeutic benefits of psychedelic drugs.

Trigemino-autonomic headache and Horner syndrome as a first sign of granulomatous hypophysitis

Objective:

To report a rare case of incipient granulomatous hypophysitis presenting by atypical trigemino-autonomic cephalalgia (TAC) and Horner syndrome.

Methods:

The patient was investigated with repeated brain MRI, CSF examination, thoracic CT, Doppler and duplex ultrasound of the cerebral arteries, and extensive serologic screening for endocrine and autoimmune markers. Written informed consent was obtained from the patient for access to clinical files for research purposes and for publication.

Results:

We present a middle-aged woman with a history of an autoimmune pancreatitis type 2 who had therapy-refractory TAC with Horner syndrome. Initial cerebral MRI showed only indistinct and unspecific signs of a pathologic process. A biopsy revealed a granulomatous hypophysitis. The symptoms disappeared after transsphenoidal subtotal resection of the pituitary mass and anti-inflammatory therapy.

Conclusions:

This case elucidates that inflammatory pituitary diseases must be taken into account in case of atypical and refractory TAC, especially in patients with a history of autoimmune diseases. To our knowledge, the association between TAC accompanied by Horner syndrome and hypophysitis has not yet been described before.

Segmental cavernous carotid ectasia in a patient with cluster-like headache

INTRODUCTION

Cluster headache (CH) is a primary headache with severe, unilateral periorbital or temporal pain lasting 15-180 min, accompanied with various cranial autonomic features. A diagnosis of cluster-like headache can be made whenever underlying cause of CLH is present.

METHODS AND RESULTS

We report a case where an ectatic cavernous segment of the internal carotid artery triggered CHL, most probably due to compression of the ophthalmic nerve within cavernous sinus. The pathological substrate of a vessel ectasia is degeneration of the tunica intima as a consequence of atherosclerosis and hypertension. On the other hand, cavernous sinus is unique space where parasympathetic, sympathetic and nociceptive fibers are in intimate relationship which is of great importance for understanding of CH pathophysiology.

CONCLUSION

Magnetic resonance imaging and MR angiography are mandatory imaging tools used for precise localization of pathological changes in the cavernous sinus, especially in the group of secondary headaches attributed to vascular disorders.

Symptomatic cluster headache: a review of 63 cases

Cluster headache is a primary headache by definition not caused by any known underlying structural pathology. Symptomatic cases have been described, for example tumours, dissections and infections, but a causal relationship between the underlying lesion and the headache is difficult to determine in many cases. The proper diagnostic evaluation of cluster headache is an issue unresolved. The literature has been reviewed for symptomatic cluster headache or cluster headache-like cases in which causality was likely. The review also attempted to identify clinical predictors of underlying lesions in order to formulate guidelines for neuroimaging. Sixty-three cluster headache or "cluster headache-like"/"cluster-like headache" cases in the literature were identified which were associated with an underlying lesion. A majority of the cases had a non-typical presentation that is atypical symptomatology and abnormal examination (including Horner’s syndrome). A striking finding in this appraisal was that a significant proportion of CH cases were secondary to diseases of the pituitary gland or pituitary region. Another notable finding was that a proportion of cluster headache cases were associated with arterial dissection. Even typical cluster headaches can be caused by structural lesions and the response to typical cluster headache treatments does not exclude a secondary form. It is difficult to draw definitive conclusions from this retrospective review of case reports especially considering the size of the material. However, based on this review, I suggest that neuroimaging, preferably contrast-enhanced magnetic resonance imaging/magnetic resonance angiography should be undertaken in patients with atypical symptomatology, late onset, abnormal examination (including Horner’s syndrome), or those resistant to the appropriate medical treatment. The decision to perform magnetic resonance imaging in cases of typical cluster headache remains a matter of medical art.

Necrotizing granulomatous hypophysitis presenting as a sellar mass

We report the case of a 45-year-old Colombian female with a 3-month history of headache, anorexia, fatigue, and diplopia in addition to left facial nerve palsy 2 weeks prior to presentation. On examination, visual fields and fundi were normal, but left abducens and facial nerve palsies were noted. An MRI scan disclosed a sellar mass with suprasellar but neither parasellar nor retrosellar extension. The mass was interpreted as a pituitary tumor and resected via the transsphenoidal approach. Histologic examination revealed necrotizing granulomas in a background of normal pituitary gland tissue. The differential diagnosis includes tuberculosis, sarcoidosis, fungal infection, syphilis, granulomatous autoimmune hypophysitis, Langerhans cell histiocytosis, and Erdheim-Chester disease. Staining for tubercle bacilli (acid fast and fite) as well as for fungi (GMS) was negative and PCR for mycobacteria showed the same result. Postoperative empiric treatment with antituberculous medication resulted in resolution of the cranial nerve palsies within a 1 month. The diagnosis of inflammatory/infectious granulomatous hypophysitis can be difficult to diagnose preoperatively and occasionally even postoperatively. A high index of suspicion should be maintained especially in those patients with a history of a systemic granulomatous disease or in regions endemic in granulomatous infectious diseases.

Diagnostic testing for migraine and other primary headaches

Most primary headaches can be diagnosed using the history and examination. Judicious use of neuroimaging and other testing, however, is indicated to distinguish primary headaches from the many secondary causes that may share similar features. This article evaluates the reasons for diagnostic testing and the use of neuroimaging, electroencephalography, lumbar puncture, and blood testing. The use of diagnostic testing in adults and children who have headaches and a normal neurologic examination, migraine, trigeminal autonomic cephalalgias, hemicrania continua, and new daily persistent headache are reviewed.

Cluster headache: to scan or not to scan

By definition, cluster headache (CH) is not caused by underlying structural pathology. However, patients with CH or CH-like syndromes and an associated structural lesion have been described. In many cases it is difficult to establish a causal relation between the headache syndrome and the lesion. We reviewed the literature for symptomatic CH or CH-like cases in which causality was very likely, and we found that even typical CH with a typical episodic time pattern and a response to typical CH treatment can be caused by underlying structural pathology such as a pituitary tumor. Based on this small retrospective series of case reports, it is impossible to give advice about neuroimaging. If neuroimaging is considered, MRI (not CT) is the investigation of choice.