Headache associated with changes in intracranial pressure

The prevalence of papilledema in patients with migraine: a crucial cooccurrence of migraine and idiopathic intracranial hypertension

OBJECTIVE

We aimed to investigate the prevalence of idiopathic intracranial hypertension (IIH) in patients with migraine by screening for papilledema.

MATERIALS AND METHODS

We have included all the patients with migraine who applied to our neurology clinic during December 2019 and accepted to participate in the study. The demographic and clinical characteristics including migraine subtype (episodic/chronic), headache frequency per month, and headache characteristics of all patients were interrogated. Besides, the presence of fibromyalgia (FM) and chronic fatigue syndrome (CFS) was noted. Fundus examination was performed in all of the patients and the presence of papilledema was noted.

RESULTS

Overall, 158 consecutive migraineurs were included in this study. The mean age of the group was 35.9 ± 9.9 and the female/male ratio was 134/24. Papilledema was determined in 10 (6%) patients. There was a past medical history of having IIH in one of these patients. In four of the patients, the diagnosis of IIH was newly established. Comparative analyses between episodic migraineurs and chronic migraineurs revealed that female gender was more prevalent in chronic migraineurs (p = 0.00) and the comorbidities of FM and CFS were more common in chronic migraineurs. Remarkably, papilledema was found to be more common in chronic migraineurs. The results of the logistic regression analyses revealed that obesity was the only predictor for the presence of papilledema (p = 0.014).

CONCLUSION

Our results may suggest that IIH should be kept in mind as a notable comorbidity in migraineurs, particularly in the subgroup of obese patients with chronic migraine.

Low-pressure/spinal fluid leak headache

Low cerebrospinal fluid (CSF) pressure results in neurologic deficits, of which the most common manifestation is headache. Typically, the headache is postural - and specifically, orthostatic - in presentation. There are three hypotheses to explain the occurrence of headache associated with low CSF fluid. The first is traction on pain-sensitive intracranial and meningeal structures; the second is CSF hypovolemia; and the third is spinal loss of CSF resulting in increased compliance at the caudal end of the CSF space. Spontaneous intracranial hypotension (SIH), once believed to be rare, is now more commonly recognized. It is typically associated with orthostatic headache (although initially it may not be) and one or more other symptoms such as alterations in hearing, nausea, vomiting, neck stiffness, diplopia, and visual field cuts. Magnetic resonance imaging (MRI) of the brain with gadolinium is the first study of choice, which typically reveals diffuse pachymeningeal enhancement and, frequently, cerebellar tonsillar descent and posterior fossa crowding. Epidural blood patch (EBP) is the treatment of choice. Surgery and epidural fibrin glue injection are options for those who fail conservative therapy and/or EBP.

Headache related to brain tumors

Headache is one of the most common somatic complaints of patients seeking medical care. Most headaches are not of serious cause and can be diagnosed easily with a good history and physical examination. The challenges to the physician are to determine when underlying intracranial pathology may be causing the symptoms and signs, and to identify the few patients in whom a tumor is the cause of the headache. The subject of headache in patients with brain tumors has been reviewed in neurologic textbooks and in several investigations before, as well as after, modern imaging diagnostic techniques became available. Headache can also manifest as an acute or chronic complication of radiation treatment and/or chemotherapy in patients with intracranial neoplasm, but there are few data in the literature specifically addressing this subject. This article provides an overview of headache in patients with primary and secondary brain tumor, including headache characteristics, the putative mechanism for these headaches, the role of diagnostic testing, and the general principles of management.

Dor pós-operatória em craniotomia

No pós-operatório, 47 a 75% dos pacientes relatam algum grau de dor. O objetivo deste trabalho foi avaliar a dor no pré e pós-operatório de pacientes submetidos a craniotomia. Estudo prospectivo, realizado na unidade de neurocirurgia do Hospital São Paulo. Para avaliação quantitativa de dor, foi utilizada a escala numérica verbal, graduada de 0 a 10. Foram avaliados 40 pacientes, com idade mediana de 36 anos. No pré-operatório, 34 (85%) pacientes relataram cefaléia como a principal causa de dor. No pós-operatório, 37 (93%) pacientes queixaram-se de dor e 3 (7%) pacientes referiram ausência de dor. O pico da dor foi observado no 2º pós-operatório, quando 16 (40%) dos pacientes referiram dor intensa e 11 (28%) queixaram-se de dor moderada. Ausência de dor intensa ocorreu após 6º pós-operatório. Concluí-se que há necessidade de protocolos de analgesia em craniotomia, como treinamento para os enfermeiros para melhor avaliação e manejo da dor.

Secondary headache and head pain emergencies

The vast majority of patients presenting to primary care physicians complaining of headache have primary headaches, such as migraine,tension, or cluster. Secondary or organic headaches, however,always need to be considered, because when present they require prompt diagnosis and intervention. Approximately 10%of patients presenting to the emergency department complaining of headache have a secondary headache, and as many as one in three sudden severe headaches in patients presenting to a general practitioner's office can be attributed to an urgent neurologic condition that requires rapid evaluation and management.

Headache with focal neurological signs or symptoms: a complicated differential diagnosis

Headache syndromes can be associated with focal neurological symptoms or signs. Good knowledge of primary headaches, a detailed history and a thorough clinical examination are prerequisites for their differential diagnosis. The neurological symptoms produced by the migraine aura are the most characteristic and recognisable. However, structural lesions, such as vascular malformations, can produce similar symptoms to migraine with aura, which highlights that paraclinical investigations are necessary in most patients with headache and focal neurological symptoms. In this review, we provide an overview of the differential diagnosis of the most common headache disorders with focal neurological symptoms or signs to refresh the practising neurologist's differential diagnostic knowledge for the clinical situation and to aid the teaching of neurology residents.

Spontaneous low cerebrospinal pressure/volume headaches

The majority, if not all, of the cases of spontaneous intracranial hypotension result from spontaneous cerebrospinal fluid (CSF) leaks. The disorder has a broad clinical and imaging spectrum with substantial variability in clinical and imaging features, in CSF findings, and in response to treatment. Headache is the most common symptom and is typically orthostatic, but with chronicity the orthostatic features may blur into a chronic, lingering headache. Other clinical features include neck pain, nausea, emesis, interscapular pain, diplopia, dizziness, change in hearing, visual blurring, radicular upper extremity symptoms, and a variety of other, but much less common, manifestations. The most common imaging feature is diffuse pachymeningeal gadolinium enhancement. Other manifestations include imaging evidence of sinking of the brain, subdural fluid collections, enlargement of the pituitary, engorgement of venous sinuses, and engorgement of epidural venous plexus. CSF opening pressure is typically low and CSF analysis may be normal or show increased protein concentration and a primarily lymphocytic pleocytosis. No longer can the entity be simply equated with post-spinal puncture headaches. The pathogenetic core and the independent variable is decrease in CSF volume, whereas clinical imaging and CSF findings, including CSF opening pressures, are all variables dependent on the loss of CSF volume. Many patients respond well to treatment, but some present stubborn therapeutic challenges. A subgroup of patients with orthostatic headaches is gradually recognized who have disorders other than CSF leaks.

Low Cerebrospinal Fluid Pressure Headache

Alterations in cerebrospinal fluid (CSF) pressure lead to neurologic symptoms, the most common clinical manifestation of which is headache. Typically, the headache is orthostatic and related to traction on pain-sensitive intracranial and meningeal structures, distention on periventricular pain-sensitive areas, and direct pressure on pain conveying cranial nerves. Low CSF headache is a distinct and familiar syndrome that is seen most frequently following lumbar puncture. In this clinical scenario, the diagnosis and proposed plan of treatment are obvious. Over the past decade, however, an emerging syndrome of spontaneous intracranial hypotension (SIH) is being recognized with increasing frequency. Most of these patients are found to have spontaneous CSF leaks and have unique, clinically distinct imaging findings, which confirm the diagnosis leading to appropriate treatment. Spontaneous intracranial hypotension is a relatively benign and usually self-limiting syndrome of orthostatic headache in association with one or more of numerous symptoms including nausea, vomiting, horizontal diplopia, unsteadiness or vertigo, altered hearing, neck pain/stiffness, interscapular pain, and occasionally visual field cuts. The headache itself, while often orthostatic, may initially be non-positional, may lose its orthostatic features, or rarely or never be orthostatic. It may be gradual, subacute, or thunderclap in onset. There may be a history of minor, antecedent trauma. By very definition, the opening CSF pressure is low, below 60 mm H(2)O, and often a "dry" tap is encountered. However, the pressure may be normal, especially with intermittent leaks and may vary tap to tap. Fluid analysis is normal. Brain (and occasionally spinal) MRI studies, with gadolinium enhancement should be undertaken. In patients with SIH, studies typically reveal diffuse pachymeningeal enhancement, frequently in association with "sagging"of the brain, tonsilar descent, and posterior fossa crowding. Spinal MRI is an up and coming investigational technique, which may be helpful even in the case of a normal brain MRI. Computed tomography myelography is the diagnostic study of choice and may follow radiocisternography, which often shows absence of activity over the convexities and early appearance of activity in the renal/urinary tract. Although conservative measures are often undertaken first, epidural blood patch (EBP) is the treatment of choice. For those who fail EBP, surgery may need to be undertaken in those cases with clearly identified leaks.

Idiopathic intracranial hypertension headache

Idiopathic intracranial hypertension (IIH) is a disorder of increased intracranial pressure that may have papilledema with normal imaging study results. Headache is the most frequent symptom. Although the headache characteristics are indistinguishable from the symptoms of migraine headache, accompanying symptoms of increased intracranial pressure, such as pulsatile tinnitus, transient visual obscurations, and radicular neck pain, may aid in the diagnosis. Magnetic resonance imaging, including venography, is essential for the diagnosis of the primary idiopathic intracranial hypertension. Medical treatment for the headache includes weight loss for obese patients, diuretic therapy, and migraine preventive medications. If medical therapy does not abolish the headache, surgical options should be considered. Because patients with IIH have a poor quality of life, patient education and supportive materials are important.

Spontaneous intracranial hypotension

Spontaneous intracranial hypotension (SIH) is typically manifested by orthostatic headaches that may be associated with one or more of several other symptoms, including pain or stiffness of the neck, nausea, emesis, horizontal diplopia, dizziness, change in hearing, visual blurring or visual field cuts, photophobia, interscapular pain, and occasionally face numbness or weakness or radicular upper-limb symptoms. Cerebrospinal fluid (CSF) pressures, by definition, are quite low. SIH almost invariably results from a spontaneous CSF leak. Only very infrequently is this leak at the skull base (cribriform plate). In the overwhelming majority of patients, the leak is at the level of the spine, particularly the thoracic spine and cervicothoracic junction. Sometimes, documented leaks and typical clinical and imaging findings of SIH are associated with CSF pressures that are consistently within limits of normal. Magnetic resonance imaging of the head typically shows diffuse pachymeningeal gadolinium enhancement, often with imaging evidence of sinking of the brain, and less frequently with subdural fluid collections, engorged cerebral venous sinuses, enlarged pituitary gland, or decreased size of the ventricles. Radioisotope cisternography typically shows absence of activity over the cerebral convexities, even at 24 or 48 hours, and early appearance of activity in the kidneys and urinary bladder, and may sometimes reveal the level of the leak. Although various treatment modalities have been implemented, epidural blood patch is probably the treatment of choice in patients who have failed an initial trial of conservative management. When adequate trials of epidural blood patches fail, surgery can offer encouraging results in selected cases in which the site of the leak has been identified. Some of the spontaneous CSF leaks are related to weakness of the meningeal sac, likely in connection with a connective tissue abnormality.

Spontaneous intracranial hypotension

Spontaneous intracranial hypotension (SIH) is typically manifested by orthostatic headaches that may be associated with one or more of several other symptoms, including pain or stiffness of the neck, nausea, emesis, horizontal diplopia, dizziness, change in hearing, visual blurring or visual field cuts, photophobia, interscapular pain, and occasionally face numbness or weakness or radicular upper-limb symptoms. Cerebrospinal fluid (CSF) pressures, by definition, are quite low. SIH almost invariably results from a spontaneous CSF leak. Only very infrequently is this leak at the skull base (cribriform plate). In the overwhelming majority of patients, the leak is at the level of the spine, particularly the thoracic spine and cervicothoracic junction. Sometimes, documented leaks and typical clinical and imaging findings of SIH are associated with CSF pressures that are consistently within limits of normal. Magnetic resonance imaging of the head typically shows diffuse pachymeningeal gadolinium enhancement, often with imaging evidence of sinking of the brain, and less frequently with subdural fluid collections, engorged cerebral venous sinuses, enlarged pituitary gland, or decreased size of the ventricles. Radioisotope cisternography typically shows absence of activity over the cerebral convexities, even at 24 or 48 hours, and early appearance of activity in the kidneys and urinary bladder, and may sometimes reveal the level of the leak. Although various treatment modalities have been implemented, epidural blood patch is probably the treatment of choice in patients who have failed an initial trial of conservative management. When adequate trials of epidural blood patches fail, surgery can offer encouraging results in selected cases in which the site of the leak has been identified. Some of the spontaneous CSF leaks are related to weakness of the meningeal sac, likely in connection with a connective tissue abnormality.

Intracranial hypotension: the nonspecific nature of MRI findings

We present three patients who complained of postural headache related to different types of intracranial hypotension: spontaneous or primary, and secondary, but presenting the same findings on brain magnetic resonance imaging. Diffuse pachymeningeal gadolinium enhancement supports the belief that the enhancement is a nonspecific meningeal reaction to low pressure.

Cerebrospinal fluid volume depletion and its emerging clinical/imaging syndromes

Cerebrospinal fluid (CSF) volume depletion, due to CSF leakage or CSF shunt overdrainage, is typically indicated when patients present with orthostatic headaches, with or without several other symptoms: neck or interscapular pain, nausea, emesis, diplopia, changes in hearing, visual blurring, facial numbness or weakness, and radicular upper-limb symptoms. Cerebrospinal fluid pressures typically are quite low and head magnetic resonance images typically reveal diffuse pachymeningeal gadolinium enhancement, with or without evidence of sagging of the brain and less frequently with subdural fluid collections, enlarged cerebral venous sinuses or pituitary gland or decreased ventricular size. Magnetic resonance imaging has revolutionized detection of spontaneous CSF leaks, leading to identification of far more cases and recognition of several clinical/imaging forms of presentation of the disorder. These forms, which are different from the "typical" presentation, include a group with consistently normal CSF pressures (normal pressure), another group without abnormal meningeal enhancement (normal meninges), and a group without headache (acephalic). Each of these forms can be seen in a setting of documented and ongoing CSF volume depletion. Awareness of CSF volume depletion is increasing, and its clinical and imaging spectrum is broadening.

Response properties of trigeminal brain stem neurons with input from dura mater encephali in the rat

The responsiveness of trigeminal brain stem neurons to selective local mechanical and chemical stimulation of the cranial dura mater was examined in a preparation in the rat. The dura mater encephali was exposed and its surface stimulated with electrical pulses through bipolar electrodes. Extracellular recordings were made from neurons in the subnucleus caudalis of the spinal trigeminal nucleus. Single neurons driven by meningeal input were identified by their responses to electrical stimulation and to probing their receptive fields on the dura. Facial receptive fields were defined mechanically. Chemical stimuli (a combination of inflammatory mediators, bradykinin, prostaglandin E2, serotonin, capsaicin and acidic Tyrode's solution) were applied topically to the dura and by injection through a catheter into the superior sagittal sinus. All neurons with input from the parietal dura mater had convergent input from the facial skin, with preponderance of the periorbital region. Proportions of units were activated by the combination of inflammatory mediators (55%), bradykinin (64.5%), acidic Tyrode's solution (64.1%) and capsaicin (78.6%). We conclude that, among the chemical mediators of inflammation, bradykinin and low pH are the most effective chemical stimuli in activating meningeal nociceptors. These stimuli may be important during meningeal inflammatory processes that lead to the generation of headaches.

Medicolegal issues: headache

This article addresses headache-related topics in which medicolegal issues have occurred or in which they are likely to occur. Where possible, an actual case has been presented. Most sections of this article are divided into three parts: principle of care, case history, and discussion and recommendations. When appropriate, American Academy of Neurology guidelines have been noted.

Evaluation of the patient with nontraumatic headache: an evidence based approach

This article reviews the literature on the diagnostic tools available to make a cost-effective yet appropriate diagnosis in the patient with an atraumatic headache in the emergency setting. The tools addressed include a good history and physical examination alone, third-generation CT, lumbar puncture, and MR imaging. The epidemiology and characteristics of the more common primary and secondary causes of headache are also reviewed, allowing the clinician to develop a better pretest probability of disease, and make a more educated decision as to when additional diagnostic testing is needed.

Dural arteriovenous fistulas as a cause of intracranial hypertension due to impairment of cranial venous outflow

OBJECTIVES

A retrospective study was carried out on 13 patients with intracranial dural arteriovenous fistulas (DAVFs) who presented with isolated or associated signs of intracranial hypertension.

METHODS

Nine patients presented with symptoms of intracranial hypertension at the time of diagnosis. Ocular fundoscopy available in 12 patients showed bilateral papilloedema in eight and optic disk atrophy in four. Clinical evolution was particularly noticeable in five patients because of chronic (two patients) or acute (after lumbar shunting or puncture: three patients, one death) tonsillar herniation.

RESULTS

Two patients had a type I fistula (drainage into a sinus, with a normal antegrade flow direction). The remaining 11 had type II fistulas (drainage into a sinus, with abnormal retrograde venous drainage into sinuses or cortical veins). Stenosis or thrombosis of the sinus(es) distal to the fistula was present in five patients. The cerebral venous drainage was abnormal in all patients.

CONCLUSION

Type II (and some type I) DAVFs may present as isolated intracranial hypertension mimicking benign intracranial hypertension. Normal cerebral angiography should be added as a fifth criterion of benign intracranial hypertension. The cerebral venous drainage pattern must be carefully studied by contralateral carotid and vertebral artery injections to correctly evaluate the impairment of the cerebral venous outflow. Lumbar CSF diversion (puncture or shunting) may induce acute tonsillar herniation and should be avoided absolutely. DAVF may induce intracranial hypertension, which has a poor long term prognosis and may lead to an important loss of visual acuity and chronic tonsillar herniation. Consequently, patients with intracranial hypertension must be treated, even aggressively, to obliterate the fistula or at least to reduce the arterial flow and to restore a normal cerebral venous drainage. The endovascular treatment may associate arterial or transvenous embolisation and/or surgery. Patients in whom the fistula is not obliterated after an endovascular therapeutic procedure, need continuous clinical and angiographical follow up.

Complications of lumbar puncture

This article reviews historical aspects and the following complications of lumbar puncture: cerebral and spinal herniation, postdural puncture headache, cranial neuropathies, nerve root irritation, low back pain, stylet associated problems, infections, and bleeding complications. The incidence of postdural puncture headache can be greatly reduced by pointing the face of the bevel in the direction of the patient's side, replacing the stylet and rotating the needle 90;dg before withdrawing the needle, and using the Sprotte atraumatic needle, especially in high risk patients.

The forgotten lumbar puncture

Lumbar puncture is crucial in two distinct clinical situations in the diagnosis of the headache patient. The first is the patient who is suspected of having a symptomatic headache; the second is the patient with a chronic intractable or atypical headache disorder. This review discusses the usefulness of the lumbar puncture in the diagnosis of headache secondary to subarachnoid hemorrhage, meningitis, and intracranial hypotension and hypertension. The value of lumbar puncture in the presence of a normal CT/MRI scan is discussed.