Sinus venous stenosis, intracranial hypertension and progression of primary headaches

The recently advanced hypothesis that idiopathic intracranial hypertension without papilledema (IIHWOP) is a powerful risk factor for the progression of pain in individuals prone to episodic primary headache implies that IIHWOP is much more prevalent than it is believed to be in the general population and that it can run almost asymptomatic in most of the affected individuals. In this review, we discuss the evidence available supporting that: (a) sinus venous stenosis-associated IIHWOP is much more prevalent than believed in the general population and can run without symptoms or signs of raised intracranial pressure in most of individuals affected, (b) sinus venous stenosis is a very sensitive and specific predictor of intermittent or continuous idiopathic intracranial hypertension with or without papilledema, even in asymptomatic individuals, (c) in primary headache prone individuals, a comorbidity with a hidden stenosis-associated IIHWOP represents a very common, although largely underestimated, modifiable risk factor for the progression and refractoriness of headache.

Magnitude, impact, and stability of primary headache subtypes: 30 year prospective Swiss cohort study

OBJECTIVE

To determine the prevalence, impact, and stability of different subtypes of headache in a 30 year prospective follow-up study of a general population sample.

DESIGN

Prospective cohort study.

SETTING

Canton of Zurich, Switzerland.

PARTICIPANTS

591 people aged 19-20 from a cohort of 4547 residents of Zurich, Switzerland, interviewed seven times across 30 years of follow-up.

MAIN OUTCOME MEASURES

Prevalence of headache; stability of the predominant subtype of headache over time; and age of onset, severity, impact, family history, use of healthcare services, and drugs for headache subtypes.

RESULTS

The average one year prevalences of subtypes of headache were 0.9% (female:male ratio of 2.8) for migraine with aura, 10.9% (female:male ratio of 2.2) for migraine without aura, and 11.5% (female:male ratio of 1.2) for tension-type headache. Cumulative 30 year prevalences of headache subtypes were 3.0% for migraine with aura, 36.0% for migraine without aura, and 29.3% for tension-type headache. Despite the high prevalence of migraine without aura, most cases were transient and only about 20% continued to have migraine for more than half of the follow-up period. 69% of participants with migraine and 58% of those with tension-type headache manifested the same predominant subtype over time. However, the prospective stability of the predominant headache subtypes was quite low, with substantial crossover among the subtypes and no specific ordinal pattern of progression. A gradient of severity of clinical correlates and service use was present across headache subtypes; the greatest effect was for migraine with aura followed by migraine without aura, and then tension-type headache and unclassified headaches.

CONCLUSIONS

These findings highlight the importance of prospective follow-up of people with headache. The substantial longitudinal overlap among subtypes of headache shows the developmental heterogeneity of headache syndromes. Studies of the causes of headache that apply diagnostic nomenclature based on distinctions between discrete headache subtypes may not capture the true nature of headache in the general population.

Cerebral infarct presenting with thunderclap headache

A 73-year-old man presented with a thunderclap headache (TCH), suggesting a subarachnoid haemorrhage. Neurological examination, computer tomography of the head, and cerebrospinal fluid examination were normal. Magnetic resonance imaging of the brain revealed a supratentorial cerebral infarct. No cerebral aneurysm could be detected. A TCH can be the presenting feature of many conditions. A formula for the diagnostic assessment of TCH should be established. The management of this type of headache is controversial. Articles differ in their conclusions and recommendations. An expansion of routine investigations should be performed in cases where the neurological examination, cerebrospinal fluid analysis, and computer tomography are normal. A TCH can be the primary clinical feature of a supratentorial cerebral infarct.

[Anatomical and neurochemical bases accounting for the frequent association between headaches and sleep: the hypnic headache paradigm]

INTRODUCTION

The relationship between headache and sleep is complex and runs in two directions. Headache may be the consequence of a (primary or secondary) sleep disorder or its cause (in chronic tension-type headache and/or chronic migraine with or without painkiller abuse). It can also be related to sleep in an intrinsic way, as in the case of hypnic headache (which only appears during sleep) or other primary headaches, such as migraine and certain trigeminal-autonomic cephalgias (which can appear during the waking state or during sleep); this type of headache occurs mostly during REM sleep.

DEVELOPMENT

The neural pathways that control sleep and pain are anatomically, physiologically and neurochemically cross-linked. These neural systems are located in the brain stem, the hypothalamus and the basal brain. Such cross-links are produced on two different levels. On the one hand, they occur in the serotoninergic nuclei of the brain stem, whose activity in physiologically diminished during REM sleep and which are involved in antinociceptive control. On the other hand, they are also to be found in the hypothalamus, where serotoninergic terminals have been detected in the suprachiasmatic nucleus (SCN). As cells in the SCN are lost with age, their circadian and homeostatic functioning fails, the activity of the hypothalamus-pineal axis is reduced and the endogenous melatonin rhythm is altered. This results in a disorder affecting the control of the sleep-waking cycle and antinociceptive control.

CONCLUSIONS

Dysfunctions in these neuronal networks in the brain stem (especially in the serotoninergic nuclei) or the hypothalamus (SCN) can account for headaches that begin in the REM phase of sleep and affect biologically predisposed subjects.