Chronic paroxysmal hemicrania-tic syndrome

Primary Headaches

The primary headaches are composed of multiple entities that cause episodic and chronic head pain in the absence of an underlying pathologic process, disease, or traumatic injury. The most common of these are migraine, tension-type headache, and the trigeminal autonomic cephalalgias. This article reviews the clinical presentation, pathophysiology, and treatment of each to help in differential diagnosis. These headache types share many common signs and symptoms, thus a clear understanding of each helps prevent a delay in diagnosis and inappropriate or ineffective treatment. Many of these patients seek dental care because orofacial pain is a common presenting symptom.

Therapeutical approaches to paroxysmal hemicrania, hemicrania continua and short lasting unilateral neuralgiform headache attacks: a critical appraisal

Background

Hemicrania continua (HC), paroxysmal hemicrania (PH) and short lasting neuralgiform headache attacks (SUNCT and SUNA) are rare syndromes with a difficult therapeutic approach. The aim of this review is to summarize all articles dealing with treatments for HC, PH, SUNCT and SUNA, comparing them in terms of effectiveness and safety.

Methods

A survey was performed using the pubmed database for documents published from the 1st January 1989 onwards. All types of articles were considered, those ones dealing with symptomatic cases and non-English written ones were excluded.

Results

Indomethacin is the best treatment both for HC and PH. For the acute treatment of HC, piroxicam and celecoxib have shown good results, whilst for the prolonged treatment celecoxib, topiramate and gabapentin are good options besides indomethacin. For PH the best drug besides indomethacin is piroxicam, both for acute and prolonged treatment. For SUNCT and SUNA the most effective treatments are intravenous or subcutaneous lidocaine for the acute treatment of active phases and lamotrigine for the their prevention. Other effective therapeutic options are intravenous steroids for acute treatment and topiramate for prolonged treatment. Non-pharmacological techniques have shown good results in SUNCT and SUNA but, since they have been tried on a small number of patients, the reliability of their efficacy is poor and their safety profile mostly unknown.

Conclusions

Besides a great number of treatments tried, HC, PH, SUNCT and SUNA management remains difficult, according with their unknown pathogenesis and their rarity, which strongly limits the studies upon these conditions. Further studies are needed to better define the treatment of choice for these conditions.

Electronic supplementary material

The online version of this article (doi:10.1186/s10194-017-0777-3) contains supplementary material, which is available to authorized users.

Tics in TACs: A Step into an Avalanche? Systematic Literature Review and Conclusions

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.

Facial pain in a Neurological Tertiary Care Centre — Evaluation of the International Classification of Headache Disorders

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.

Paroxysmal hemicrania-tic and Chiari I malformation: an unusual association

A 54 year-old female has a clinical diagnosis of chronic paroxysmal hemicrania (CPH) according to IHS-criteria (2004) three years ago. Six months after that, she developed symptoms compatible with trigeminal neuralgia (TN) involving the second and third trigeminal territories also at the left side. Cranial and cervical spine resonance magnetic images showed extensive cervical syringomyelia that included nucleus caudalis (C2 level) region and a posterior fossa Chiari I malformation without hydrocephalus. The association between CPH and TN is called chronic paroxysmal hemicrania-tic syndrome (CPH-tic). This is the first clinical description of a secondary cause of CPH-tic syndrome in the literature.

Management of trigeminal autonomic cephalgias and hemicrania continua

The trigeminal autonomic cephalgias (TACs) are a group of primary headache disorders characterised by unilateral trigeminal distribution pain that occurs in association with ipsilateral cranial autonomic features. This group of headache disorders includes cluster headache, paroxysmal hemicrania and short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT syndrome). Although hemicrania continua has previously been classified amongst the TACs, its nosological status remains unclear. Despite their similarities, these disorders differ in their clinical manifestations and response to therapy, thus underpinning the importance of recognising them. We have outlined the clinical manifestations, differential diagnoses, diagnostic workup and the treatment options for each of these syndromes.

'Side locked' migraine and trigeminal autonomic cephalgias: evidence for clinical overlap

This paper will discuss evidence which supports a link between 'side locked' migraine (SLM) and the trigeminal autonomic cephalgias (TACs). Recent papers brought strictly unilateral primary headaches into focus, proposing new classification and discussing pathophysiological mechanisms. We reviewed those proposals and present evidence that SLM falls in between the well-defined TACs and side shifting migraine (SSM). It is difficult to differentiate SLM from the recently proposed headache subtype called hemicrania generis incerti (i.e. hemicrania continua unresponsive to indomethacin). We also present cases that may exemplify the considerations made in the paper.

The paroxysmal hemicrania-tic syndrome

Two cases of paroxysmal hemicrania (PH) associated with trigeminal neuralgia are reviewed. The paroxysmal hemicrania component in one patient was episodic, while it was chronic in the other. Each headache type responded completely to separate treatment, highlighting the importance of recognizing this association. We review the six other cases of chronic paroxysmal hemicrania-tic (CPH-tic) reported, and suggest that the term paroxysmal hemicrania-tic syndrome (PH-tic) be used to describe this association.

Intractable cluster headaches in a migraineur

Some migraineurs have the additional misfortune of suffering from cluster headaches; this situation can be challenging.

Modular headache theory: a new approach

Many people experience headaches that do not fulfill the International Headache Society's criteria for a specific headache disorder, yet behave biologically like that disorder. Others fulfill criteria for one headache disorder but have features of another. To explain these observations, we propose that groups of neurons, called modules, become activated to produce each symptom of a primary headache disorder, and that each module is linked to other modules that together produce an individual's headache. Headaches develop phenotypic stability through a process referred to as learned stereotypy. This theory has implications for the classification, research, and treatment of primary and secondary headache patients.

Modular headache theory

Many people experience headaches that do not fulfil the International Headache Society's criteria for a specific headache disorder yet behave biologically like that disorder. Others fulfil criteria for one headache disorder and yet have features of another disorder. To explain these observations, we propose that groups of neurones called modules become activated to produce each symptom of a primary headache disorder, and that each module is linked to other modules that together produce an individual's headache. This theory has implications for the classification, research and treatment of primary and secondary headache patients.

Cluster and related headaches

The disorders described in this article are relatively rare, but probably are more common than previously thought. Because these disorders cause significant pain and disability and treatment response differs from that of migraine, tension-type, and cluster headaches, recognition is essential. Table 1 lists the important clinical features of these syndromes and contrasts them with cluster headache, the disorder for which they are often confused.

Effective management of ice pick pains, SUNCT, and episodic and chronic paroxysmal hemicrania

Idiopathic stabbing headaches, the SUNCT syndrome, and the paroxysmal hemicranias are a group of primary headache disorders that are characterized by brief, short-lived attacks of head pain, which recur multiple times throughout the day. These syndromes are much less prevalent than other types of primary headaches such as migraine and tension-type headaches but are significantly more disabling. Recognition of these uncommon disorders is important because their management differs from standard headache therapies.

Prevalência e características da cefaléia idiopática em punhaladas em uma população de migranosos

A cefaléia idiopática em punhaladas (CIP) é desordem insuficientemente conhecida, geralmente caracterizando-se por uma dor penetrante com duração de frações de segundo. Devido a estas características é na maiora das vezes subdiagnosticada. Pacientes com migrânea foram acompanhados por período de 12 meses para determinar a prevalência da CIP e suas principais características, durante os períodos assintomáticos da migrânea. Dos 280 pacientes incluídos no estudo, 233 terminaram: 94 apresentavam CIP (40,4%) sendo 72 do sexo feminino (76,5%). Para o grupo de migranosos portadores de CIP a idade média dos pacientes, a idade de início das crises de migrânea e a duração média desta desordem eram respectivamente de 33, 22.5 e 10.6 anos. A CIP tinha duração média de 1,42 segundos [ 1 segundo em 68 casos (72,4%), 2 segundos em 17 (18,1%), 3 segundos em 6 (6,3%), 4 segundos em 1 (1,05%) e 5 segundos em 2 casos (2,15%)]. A apresentação era unilateral em 86 casos (91,4%) e bilateral em 8 casos (8,6%). As dores localizavam-se sobre a região temporal em 56 casos (60%), occipital em 15 (15,6%), frontal em 8 (8,5%), temporo-occipital em 7 (7,4%), parietal em 5 (5,3%), fronto-temporal em 1 (1,06%), cervical em 1 (1,06%) e ocular em 1 paciente (1,06%). Confirmamos que a CIP é uma desordem que tem alta prevalência em pacientes portadores de migrânea. Suas principais características semiológicas foram determinadas durante os períodos intercríticos das crises de migrânea.