Breaking the cycle of medication overuse headache

Care of this disorder can be complex-from ruling out another secondary cause of headache to supervising detox from abortives, providing preventives, and educating often-fearful patients.

Secondary Headache Syndromes

PURPOSE OF REVIEW

This article is intended to assist clinicians in distinguishing benign primary headache syndromes from serious headache presentations that arise from exogenous causes.

RECENT FINDINGS

Although most cases of severe headache are benign, it is essential to recognize the signs and symptoms of potentially life-threatening conditions. Patients with primary headache disorders can also acquire secondary conditions that may present as a change in their baseline headache patterns and characteristics. Clinical clues in the history and examination can help guide the diagnosis and management of secondary headache disorders. Furthermore, advances in the understanding of basic mechanisms of headache may offer insight into the proposed pathophysiology of secondary headaches.

SUMMARY

Several structural, vascular, infectious, inflammatory, and traumatic causes of headache are highlighted. Careful history taking and examination can enable prompt identification and treatment of underlying serious medical disorders causing secondary headache syndromes.

Pacemaker implantation for treating migraine-like headache secondary to cardiac arrhythmia: A case report

RATIONALE

Co-occurrence of headache and arrhythmia is not rare. However, their causal relationship remains unclear. Here, we described a case of migraine-like headache relieving with pacemaker implantation. Our case study indicates that arrhythmia is causal for migraine-like headache, which, to our knowledge, has never been reported.

PATIENT CONCERNS

A 63-year-old woman patient suffered from paroxysmal headache with a visual aura presenting like migraine for 2 years. No ophthalmic or neurological disorder was found, but cardiac examination detected bradycardia, which was confirmed by 24-hour dynamic electrocardiogram (DCG) revealing sinus bradycardia mixed with ventricular premature beats and supraventricular tachycardia. Transcranial doppler (TCD) detected an equal echo flat plaque on the anterolateral wall of the common carotid artery (CA) bifurcation.

DIAGNOSIS

Migraine-like headaches secondary to arrhythmia.

INTERVENTIONS

The patient underwent pacemaker implantation.

OUTCOMES

Both visual aura and headache were resolved following pacemaker implantation.

LESSONS

To the best of the authors' knowledge, we are the first to report migraine-like headache as a secondary symptom of arrhythmia. Arrhythmia may aggravate insufficient blood supply to the brain due to CA lesion and induce a migraine-like headache. This case study indicated that pacemaker implantation could be a fundamental treatment for migraine-like headaches caused by cardiac arrhythmia.

[Not Available]

Zusammenfassung. Chronische Kopfschmerzen stellen ein häufiges Problem in der Praxis dar. Die Behandlung beinhaltet eine Kombination von medikamentösen und nichtmedikamentösen Therapieverfahren im Rahmen eines multimodalen Settings. Neben der chronischen Migräne steht der Medikamentenübergebrauchskopfschmerz im Vordergrund. Hierbei ist ein zusätzliches Ziel, die Patienten vorausgehend im ambulanten oder stationären Setting von den übermässig konsumierten Schmerz- und Migränemittel zu entziehen. Mit der Kombination von einem Medikamentenentzug mit der nachfolgenden Optimierung der Migränebehandlung akut und prophylaktisch lässt sich in den allermeisten Fällen eine Verminderung der Kopfschmerzfrequenz und dadurch eine Verbesserung der Lebensqualität erreichen.

Side effects associated with current and prospective antimigraine pharmacotherapies

INTRODUCTION

Migraine is a neurovascular disorder. Current acute specific antimigraine pharmacotherapies target trigeminovascular 5-HT1B/1D, 5-HT1F and CGRP receptors but, unfortunately, they induce some cardiovascular and central side effects that lead to poor treatment adherence/compliance. Therefore, new antimigraine drugs are being explored. Areas covered: This review considers the adverse (or potential) side effects produced by current and prospective antimigraine drugs, including medication overuse headache (MOH) produced by ergots and triptans, the side effects observed in clinical trials for the new gepants and CGRP antibodies, and a section discussing the potential effects resulting from disruption of the cardiovascular CGRPergic neurotransmission. Expert opinion: The last decades have witnessed remarkable developments in antimigraine therapy, which includes acute (e.g. triptans) and prophylactic (e.g. β-adrenoceptor blockers) antimigraine drugs. Indeed, the triptans represent a considerable advance, but their side effects (including nausea, dizziness and coronary vasoconstriction) preclude some patients from using triptans. This has led to the development of the ditans (5-HT1F receptor agonists), the gepants (CGRP receptor antagonists) and the monoclonal antibodies against CGRP or its receptor. The latter drugs represent a new hope in the antimigraine armamentarium, but as CGRP plays a role in cardiovascular homeostasis, the potential for adverse cardiovascular side effects remains latent.

[Situs inversus of the optic nerve. A case report]

INTRODUCTION

Situs inversus of the optic nerve is a congenital anomaly characterised by the emergence of the vessels in the retina towards the nose rather than in a temporal direction. It is caused by an anomalous insertion of the optic stalks into the optic vesicle that gives rise to dysversion of the head of the optic nerve. It is not an isolated condition and usually appears jointly with tilted disc syndrome and in patients with myopia. It is characterised by the presence of inferior conus atrophy, deficiencies in the temporal visual field, refraction defects and ambliopy.

CASE REPORT

A 22 years-old female who attended an ophthalmological examination due to severe frontal headaches accompanied by halos and loss of sharpness in her sight. From the results of the ophthalmetric and ophthalmological examination she was diagnosed as suffering from a condition consistent with this congenital anatomical anomaly.

CONCLUSIONS

Situs inversus of the optic nerve is a rare condition that may appear in isolation or accompanied by other pathologies. Application of the visual field test and new diagnostic techniques, such as optical coherence tomography, facilitates the differential diagnosis of this situation. Its prevalence remains unknown, as it is not included in the register of rare diseases. Moreover, the scant number of patients studied and the scarce literature on this anomaly do not allow us to know whether the defects it causes develop over time. It would therefore be important to perform an ophthalmological follow-up of patients with situs inversus of the optic nerve.

Identification of clinical and paraclinical findings predictive for headache occurrence during spontaneous subarachnoid hemorrhage

OBJECTIVES

Headache is recognized as the main but unwarranted symptom of subarachnoid hemorrhage (SAH). There are no enough findings identified as predictive for headache occurrence in SAH. We evaluated the clinical and paraclinical factors predictive for headache occurrence in SAH.

PATIENTS AND METHODS

We retrospectively analyzed medical records of 431 consecutive non traumatic SAH patients (264 females and 167 males), ages from 19 to 91 years, presenting with headache (70.3%) and without headache (29.7%) during period of 11years.

RESULTS

Among all tested parameters, as negative predictors for headache occurrence were recognized: patients' ages (OR 0.97 [95%CI: 0.96-0.99], p=0.025), persistence of coagulation abnormality (OR 0.23 [95%CI: 0.08-0.67], p=0.006), atrial fibrilation (OR 0.23 [95%CI: 0.09-0.59], p=0.002), chronic renal failure (OR 0.26 [95%CI: 0.09-0.76], p=0.014) and more diseases (OR 0.11 [95%CI: 0.04-0.32], p<0.0001), as higher clinical score (OR 0.94 [95%CI: 0.90-0.99], p=0.018) including positive neurological findings (OR 0.34 [95%CI: 0.21-0.55], p<0.001) and loss of consciousness (OR 0.22 [95%CI: 0.12-0.39], p<0.001) at the SAH onset, while the complaint of neck stiffness was identified as its positive predictor (OR 1.93 [95%CI: 1.19-3.10], p=0.007).

CONCLUSIONS

Although diagnosis based solely on clinical presentation is not reliable and speculative, our findings could provide physicians with evidence to consider SAH not only in conditions of its headache occurrence but also in those with headache absence.

Headache yesterday in Karnataka state, India: prevalence, impact and cost

BACKGROUND

The Global Campaign against Headache has pioneered evaluation of the prevalence and impact of headache on the preceding day ("headache yesterday") as a new approach to the estimation of headache-attributed burden, avoiding recall error. We report its application in Karnataka State, southern India.

METHODS

In a door-to-door survey, biologically unrelated adults (aged 18-65 years) were randomly sampled from urban and rural areas in and around Bengaluru and interviewed by trained researchers using a validated, structured questionnaire. Enquiry into headache applied ICHD-II diagnostic criteria and included questions about headache on the day preceding the interview (headache yesterday [HY]).

RESULTS

There were 2329 participants (participation proportion 92.6 %; males 1141 [49.0 %], females 1188 [51.0 %]; mean age 38.0 [±12.7] years; 1103 [47.4 %] from rural areas, 1226 [52.6 %] urban). HY was reported by 138 participants (males 33 [2.9 %], females 105 [8.8 %]): the 1-day prevalence of headache was 5.9 %. Mean duration of HY was 7.0 ± 8.5 h, so that 1.7 % of the population (5.9 % * 7.0/24), on average, had headache at any moment in time yesterday. Mean intensity on a scale of 1-3 was 2.0 [±0.8]. Lost productivity due to HY was reported by 83.3 % of participants with HY: 37.7 % able to do less than half of what they had planned and 13.0 % able to do nothing. Productivity loss at population level (being the productivity loss within the entire adult population, every single day, attributable to headache) was 3.0 %.

CONCLUSIONS

This method of enquiry, free from recall error, confirmed a very high level of headache-attributed burden in Karnataka: previous estimates based on 3-month recall may even have been too low. Until another study is done in the country, these are the best data for all India. They demonstrate need for action nationwide to mitigate this burden, and correct action will ultimately almost certainly be cost-saving.

Increasing severity of traumatic brain injury is associated with an increased risk of subsequent headache or migraine: a retrospective cohort study of U.S. active duty service members, 2006-2015

Traumatic brain injury (TBI) is a common injury in the U.S. Compared to the general population, military service members can be at increased risk for TBI because of the nature of their work. Sequelae of TBI, such as headache or migraine, can lead to military duty limitations or separation from service. To determine whether the severity of TBI is associated with the risk of these sequelae, this 2006-2015 retrospective cohort study compared the incidence of diagnosed headache or migraine among all service members with a first-time mild or moderate/severe TBI (N=111,018) against a matched sample without any history of TBI. Risk increased according to the severity of TBI. Compared to service members without TBI, those who sustained a mild TBI were 3.99 times more likely to have a headache or migraine, and those with a moderate/severe TBI were 8.89 times more likely. Patients, medical providers, and military leaders can use these results to guide care after a TBI. Early identification of those at higher risk of these sequelae could improve medical management and reduce disability.

Effect of Clopidogrel and Aspirin vs Aspirin Alone on Migraine Headaches After Transcatheter Atrial Septal Defect Closure: The CANOA Randomized Clinical Trial

IMPORTANCE

The occurrence of new-onset migraine attacks is a complication of transcatheter atrial septal defect (ASD) closure. It has been suggested that clopidogrel may reduce migraine attacks after ASD closure.

OBJECTIVE

To assess the efficacy of clopidogrel, used in addition to taking aspirin, for the prevention of migraine attacks following ASD closure.

DESIGN, SETTING, AND PARTICIPANTS

Randomized, double-blind clinical trial performed in 6 university hospitals in Canada. Participants were 171 patients with an indication for ASD closure and no history of migraine.

INTERVENTIONS

Patients were randomized (1:1) to receive dual antiplatelet therapy (aspirin + clopidogrel [the clopidogrel group], n = 84) vs single antiplatelet therapy (aspirin + placebo [the placebo group], n = 87) for 3 months following transcatheter ASD closure. The first patient was enrolled in December 2008, and the last follow-up was completed in February 2015.

MAIN OUTCOMES AND MEASURES

The primary efficacy outcome was the monthly number of migraine days within the 3 months following ASD closure in the entire study population. The incidence and severity of new-onset migraine attacks, as evaluated by the Migraine Disability Assessment questionnaire, were prespecified secondary end points. A zero-inflated Poisson regression model was used for data analysis.

RESULTS

The mean (SD) age of the participants was 49 (15) years and 62% (106) were women. Patients in the clopidogrel group had a reduced mean (SD) number of monthly migraine days within the 3 months following the procedure (0.4 [95% CI, 0.07 to 0.69] days) vs the placebo group (1.4 [95% CI, 0.54 to 2.26] days; difference, -1.02 days [95% CI, -1.94 to -0.10 days]; incident risk ratio [IRR], 0.61 [95% CI, 0.41 to 0.91]; P = .04) and a lower incidence of migraine attacks following ASD closure (9.5% for the clopidogrel group vs 21.8% for the placebo group; difference, -12.3% [95% CI, -23% to -1.6%]; odds ratio [OR], 0.38 [95% CI, 0.15 to 0.89]; P = .03). Among patients with migraines, those in the clopidogrel group had less-severe migraine attacks (zero patients with moderately or severely disabling migraine attacks vs 37% [7 patients] in the placebo group; difference, -36.8% [95% CI, -58.5% to -15.2%]; P = .046). There were no between-group differences in the rate of patients with at least 1 adverse event (16.7% [14 patients] in the clopidogrel group vs 21.8% [19 patients] in the placebo group; difference, -5.2% [95% CI, -17% to 6.6%]; P = .44).

CONCLUSIONS AND RELEVANCE

Among patients who underwent transcatheter ASD closure, the use of clopidogrel and aspirin, compared with aspirin alone, resulted in a lower monthly frequency of migraine attacks over 3 months. Further studies are needed to assess generalizability and durability of this effect.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00799045.

The Great Imitator in Endocrinology: A Painful Hypophysitis Mimicking a Pituitary Tumor

CONTEXT

The incidence of syphilis has been increasing in recent decades in Western countries. Pituitary involvement is very unusual in syphilis. This infectious disease is not often considered in the workup of a patient with hypophysitis.

CASE

We report the case of a 28-year-old man who was admitted for headaches worsening over 1 month that became resistant to paracetamol. A magnetic resonance imaging scan revealed a heterogeneous pituitary mass suggesting a pituitary tumor. Hormonal investigations showed partial corticotropic and thyrotropic deficiencies. Headaches required high doses of morphine. Transsphenoidal surgery was performed, and histological examination revealed an aspect of hypophysitis. One month later, clinical reexamination showed skin and tongue lesions very suggestive of a syphilis infection, which was serologically confirmed. Immunohistochemistry on paraffin sections of the resected pituitary revealed an abundant presence of Treponema pallidum, confirming the diagnosis of a syphilitic hypophysitis. Intravenous therapy by benzylpenicillin for 14 days was rapidly efficient. Headaches stopped within a few days, and the skin and tongue lesions disappeared during the following month. Thyrotropic deficiency resolved in 2 weeks, but partial corticotropic deficiency persisted at 3 months.

CONCLUSION

This is the first case of a pituitary involvement in acquired syphilis, pathologically proven, in a non-HIV-infected patient. In a context of the resurgence of syphilis, this diagnosis should be considered in the case of a pituitary lesion with unusually intense headaches.

Neuroimaging of headaches associated with vascular disorders

Headaches from vascular causes need to be differentiated from primary headaches because a misdiagnosis may lead to dire consequences for the patient. Neuroimaging is critical in identifying patients with vascular headaches and identifying the nature of the pathologic disorder causing these headaches. In addition, the imaging findings guide the physician regarding the optimal treatment modality for these lesions. This review summarizes the nuances of differentiating patients with secondary headaches related to vascular disease and discusses pertinent neuroimaging studies.

Headache in sports

Sports- and exercise-related headaches are not unusual. Despite their frequent occurrence in this context, there are little epidemiologic data concerning sports-related headache. The recent attention of concussive injuries and associated post-traumatic headache has renewed interest in the study of those headaches occurring after head trauma; however, any primary headache type can also occur in the setting of contact and/or collision sports. The nonspecific nature of headaches provides unique challenges to clinicians encountering this complaint. It is, therefore, imperative that physicians treating athletes are able to distinguish the various headache types and presentations often seen in this population.

[Fluctuating headache with personality change in a 63 year old man]

We present a 63 year old man with new onset of fluctuating headache and behavioural changes showing marked inhibition and disorientation. After non invasive and invasive diagnostics an isolated cerebral vasculitis was found. Key results have been found in cerebral MRI and cerebral digital subtraction angiography with irregularities of vessel calibre of the intracerebral arteries. During treatment with high-dose corticosteroid therapy and Cyclophosphamid pulse therapy qualitative disorders and headache rapidly regressed. We discuss differential diagnosis of secondary headache, etiology of cerebral vasculitides, diagnostic challenge and therapy in isolated cerebral vasculitis.

Headache attributed to cranial or cervical vascular disorders

Cranial or cervical vascular disease is commonly associated with headaches. The descriptions may range from a thunderclap onset of a subarachnoid hemorrhage to a phenotype similar to tension type headache. Occasionally, this may be the sole manifestation of a potentially serious underlying disorder like vasculitis. A high index of clinical suspicion is necessary to diagnose the disorder. Prompt recognition and treatment is usually needed for many conditions to avoid permanent sequelae that result in disability. Treatments for many conditions remain challenging and are frequently controversial due to paucity of well controlled studies. This is a review of the recent advances that have been made in the diagnosis or management of these secondary headaches.

Imaging in the evaluation of headache

When deciding to perform imaging for headache, it is important to consider many factors including the pretest probability, prevalence of diseases, sensitivity of imaging, and implications for treatment. For the first presentation of a headache or a change in headache pattern, if the characteristics do not perfectly fit a primary headache type, imaging may be indicated according to the ICHD-2 criteria to exclude a secondary cause before a primary headache is diagnosed. The value of negative imaging should not be underestimated in the cost-benefit analysis, which often only takes into account number needed to treat or likelihood of finding a significant treatable abnormality. One study has shown that some groups of patients are less likely to overuse other parts of the health care system after negative neuroimaging. Further studies with stronger methodologies, finer differentiation of acute and chronic headache presentations, more advanced imaging technology, among other factors, can improve decision making on when to use imaging and assess the impact of imaging on patient satisfaction and quality of life. In addition, functional MRI, MRS, and voxel-based morphometry MRI are only some of the neuroimaging techniques currently used in research to further understand the pathophysiology and mechanisms of headache. In conclusion, although most headaches are a primary headache disorder with a benign course, imaging is an important part of the diagnostic evaluation to exclude the presence of a secondary cause of headache that could cause fatal results or severe neurologic morbidity. In headache patients without focal neurologic examination abnormalities, the yield of neuroimaging for significant intracranial findings is generally low. However, specific subgroups of headache patients and headache presentations can have much higher rates of significant intracranial abnormalities.

Targeted headache history

Armed with information obtained from the targeted headache history, clinicians can almost always make an accurate diagnosis or at least determine sick from well. Through using the information obtained, clinicians can craft a safe and cost-effective treatment plan that has a high likelihood of success.

Medication overuse headaches

“An ounce of prevention is worth a pound of cure” in the management of MOH. Prevention of transformation of primary headache types to their chronic counterparts is necessary to prevent this most troubling transformation. Strict attention to what patients are telling you (and often times not telling you) about their episodic headaches will enable pharmacologic and nonpharmacologic measures to avoid that transformation to chronic daily headache, so often associated with MOH. Once MOH becomes manifest, withdrawal of the overused drug is mandatory; otherwise experience tells us the pattern of overuse will only be perpetuated and no measure will help alleviate the headache. At the same time, as detoxification takes place, measures to ensure that relapse will not take place should begin. These efforts include prophylactic pharmacologic measures as well as psychological support, education, and surveillance to prevent relapses. The rate of relapse is unfortunately high, but these general and specific measures enumerated above will add greatly to the chances of success.

The role of the physical examination in the evaluation of headache

The population of patients suffering with headaches is vast and underserved. The most critical element in headache evaluation is the history. The targeted history not only differentiates primary from secondary headaches but also provides a realistic list of conditions associated with secondary headache. Several of these conditions do present with specific physical findings, such as papilledema, Horner's syndrome, or CN palsy. The targeted physical examination of the patient with headache takes less than 3 minutes. The ability simply to recognize but a few straightforward clinical findings directs the evaluation in the proper direction. If you enjoy seeing patients, feel competent identifying but a few physical findings, and understand the basics of primary and secondary headaches and facial pain, there is urgent need of your services.

The role of laboratory testing in the evaluation of headache

Blood tests have a minor role in headache management and that role is limited to a few secondary headache conditions. In headache, as with any symptom, laboratory tests should be chosen based on solid clues derived from the targeted history and physical examination. A shotgun approach to blood tests that includes rare diseases or those with low local prevalence frequently yields false-positive results, which exposes the patient to the expense, anxiety, and risk inherent in misdiagnosis. Keep it simple and do not forget about spinal fluid.

Factors that cause concern

Headaches can be benign or life threatening but, with careful attention to the details described in this article, the correct diagnosis and treatment can be arrived at in many cases. Modern imaging techniques have taken the guesswork out of many conditions but a high index of suspicion and attention to red flags helps avoid potential adverse outcomes in headache encounters in a high proportion of cases.

A case of spinal epidural haematoma during breath-hold diving

Spinal epidural haematoma (SEH) is a rare condition usually the result of bleeding of the epidural venous plexus that might present with acute spinal cord compression. It is often due to traumatic events, but 'spontaneous' cases have been described, usually related to different predisposing conditions, such as coagulopathies. A 47-year-old male presented with severe frontal headache and intense cervical pain which developed during a protracted breath-hold spearfishing session. A cervical spine MRI performed 12 days after symptom onset showed a small epidural blood collection on the left side of the spinal canal, at the C7-T1 level. One week later, blood was no longer present and the asymptomatic patient was discharged. Protracted minor trauma (neck flexion) and repeated Valsalva manoeuvres might have played a role in the genesis of this event. The role of decompression sickness is discussed as well.

[Chronic migraine: treatment]

We define chronic migraine as that clinical situation in which migraine attacks appear 15 or more days per month. Until recently, and in spite of its negative impact, patients with chronic migraine were excluded of the clinical trials. This manuscript revises the current treatment of chronic migraine. The first step should include the avoidance of potential precipitating/aggravating factors for chronic migraine, mainly analgesic overuse and the treatment of comorbid disorders, such as anxiety and depression. The symptomatic treatment should be based on the use of nonsteroidal anti-inflammatory agents and triptans (in this case < 10 days per month). It is necessary to avoid the use of combined analgesics, opioids and ergotamine-containing medications. Preventive treatment includes a 'transitional' treatment with nonsteroidal anti-inflammatory agents or steroids, while preventive treatment exerts its actions. Even though those medications efficacious in episodic migraine prevention are used, the only drugs with demonstrated efficacy in the preventive treatment of chronic migraine are topiramate and pericranial infiltrations of Onabotulinumtoxin A.

[Chronic migraine: pathophysiology]

Chronic migraine is considered a complication of episodic migraine. Several risk factors, which may be modifiable or non-modifiable, make varying contributions to the progression towards chronification. Every year 2.5% of patients with episodic migraine go on to suffer chronic migraine. Experimental studies point to a dysfunction in the descending pain modulatory system that would facilitate nociceptive afferents, in the absence of damage to tissues, and so chronic migraine would share a pathogenesis that is similar to that of fibromyalgia, irritable bowel syndrome or chronic tension-type headache (conditions that frequently coexist). This paper reviews the risk factors and the scientific evidence of the possible pathogenic mechanisms involved in the progression towards chronification.

[Onabotulinumtoxin A in the treatment of chronic migraine]

INTRODUCTION. Chronic migraine is the most frequent complication of migraine. Its management is complex and difficult, and is based essentially on preventive measures. AIM. To analyse the development of the use of Onabotulinumtoxin A (OnabotA) in migraine, especially in its chronic form, the method of administration, its mechanism of action, its safety profile and its possible indications in clinical practice. DEVELOPMENT. The study conducts a thorough review of all the clinical trials in the literature that have used OnabotA in the prevention of migraine, both in its episodic and its chronic forms, and the outcomes in the chronic form are analysed in detail. CONCLUSIONS. In studies in phase III, OnabotA has proved to be effective in the treatment of patients with chronic migraine, with significant reductions in the mean frequency of days with headaches, the number of headache episodes, the days with migraine or the proportion of patients with severe disability, in addition to other parameters. It is also effective in the subgroup of patients with symptomatic headache due to medication abuse. OnabotA has proved to be safe and well tolerated in this indication, with foreseeable, usually mild or moderate, transitory side effects. In sum, OnabotA is a safe, well-tolerated alternative in the preventive treatment of chronic migraine.

Chronic migraine: current concepts and ongoing treatments

Migraine is an episodic painful disorder occasionally developing into a chronic form. Such disorder represents one of the most common neurological diseases in clinical practice. Chronicization is often accompanied by the appearance of acute drugs overuse. Chronic migraine (CM) constitutes migraine's natural evolution in its chronic form and involves headache frequency of 15 days/month, with features similar to those of migraine attacks. Medication Overuse Headache (MOH) has been defined as a headache present on > or = 15 days/month, with regular overuse for > 3 months of one or more drugs used for acute and/or symptomatic headache management. Subtypes of MOH attributed to different medications were delineated. Misuse of ergots, triptans, opioids or combination analgesics on > or = 10 days/month was required to make the diagnosis of MOH, while > or = 15 days/month were needed for simple analgesic-overuse headache. CM's low prevalence produces an extremely high disability grade. Therefore, special attention should be paid to both control and reduction of risk factors which might favour the migraine chronicization process and/or the outbreak of MOH. In MOH sufferers, the only treatment of choice is represented by drug withdrawal. Successful detoxification is necessary to ensure improvement in the headache status when treating patients who overuse acute medications. Different procedures have been suggested for withdrawal namely at home, at the hospital, with or without the use of steroids, with re-prophylaxis performed immediately or at the end of the washout period. At the moment we have not a total agreement whether prophylactic treatment should be started before, during, or after discontinuation of the overuse drug. Both drugs have been approved for CM treatment in view of their well-defined resistance to previous prophylaxis drugs. Recently, the PREEMPT clinical program has confirmed onabotulinumtoxinA as an effective, safe, and well-tolerated prophylactic treatment for adults with CM.

[Headache--from an ophthalmic point of view]

The authors approach a subject keen to neuroophthalmologists, which is becoming more and more frequent with the overuse of VTU (videoterminal unit). They hope to better understand the headache (from an ophthalmic point of view), and how to diagnose it better and faster.

Secondary chronic cluster headache due to trigeminal nerve root compression

A 50-year-old woman had a gradual onset of chronic headache located in the right temporal region and a burning sensation in the root of the tongue which over a year evolved into chronic cluster headache with a milder chronic headache in-between the severe cluster headache attacks. A cerebral magnetic resonance imaging (MRI) showed vascular compression of the trigeminal nerve root on the pain side. Neurosurgery microvascular decompression relieved the patient's chronic cluster headache, the chronic intermittent headache and the burning tongue sensation. The effect was persistent at a 1 year follow-up. Patients with atypical symptoms of cluster headache should be examined with cerebral MRI angiography of arteries and veins to exclude symptomatic causes.

The diagnosis of brain tumours in children: a guideline to assist healthcare professionals in the assessment of children who may have a brain tumour

BACKGROUND

Brain tumours are the commonest solid tumour in children. Children with brain tumours are frequently unwell for months prior to diagnosis. A prolonged period between symptom onset and diagnosis is associated with increased morbidity.

OBJECTIVE

To develop an evidence-based clinical guideline to support healthcare professionals in the identification, assessment and investigation of children presenting with symptoms and signs that could be due to a brain tumour.

METHODS

A systematic literature review with a meta-analysis and cohort study provided the guideline evidence base. A multi-disciplinary workshop and Delphi consensus voting were used to translate the evidence into a clinical guideline. The results of the literature review and cohort study have been previously published.

RESULTS

20 healthcare professionals and parents participated in the workshop. 77 statements were generated detailing the presenting features of childhood brain tumours, factors that could be used to discriminate brain tumours from other less serious conditions and possible referral pathways for children with brain tumours. 156 healthcare professionals agreed to participate in the Delphi process; 112 completed the first round and 88 completed all three rounds (attrition rate 21%). 64 statements reached consensus. The final guideline comprises 76 recommendations advising on the symptomatology of childhood brain tumours, assessment of children who may have a brain tumour and recommendations for selection for and timing of central nervous system imaging.

CONCLUSION

Implementation of this guideline may support clinicians in the identification and timely imaging of children with brain tumours. This may reduce the morbidity currently experienced by many children with brain tumours.

Cardiac cephalgia

The purpose of this review was to provide a critical evaluation of medical literature on so-called “cardiac cephalgia” or “cardiac cephalalgia”. The 2004 International Classification of Headache Disorders codes cardiac cephalgia to 10.6 in the group of secondary headaches attributed to disorder of homoeostasis. This headache is hardly recognizable and is associated to an ischaemic cardiovascular event, of which it may be the only manifestation in 27% of cases. It usually occurs after exertion. Sometimes routine examinations, cardiac enzymes, ECG and even exercise stress test prove negative. In such cases, only a coronary angiogram can provide sufficient evidence for diagnosis. Cardiac cephalgia manifests itself without a specific pattern of clinical features: indeed, in this headache subtype there is a high variability of clinical manifestations between different patients and also within the same patient. It “mimics” sometimes a form of migraine either accompanied or not by autonomic symptoms, sometimes a form of tension-type headache; on other occasions, it exhibits characteristics that can hardly be interpreted as typical of primary headache. Pain location is highly variable. When the headache occurs as the only manifestation of an acute coronary event, the clues for suspicion are a) older age at onset, b) no past medical history of headache, c) presence of risk factors for vascular disorders and d) onset of headache under stress. Knowledge of cardiac cephalgia is scarce, due to its rare clinical occurrence and to the scant importance given to headache as a symptom concomitantly with an ischaemic cardiac event.

[Ophthalmological causes of headache]

Ophthalmologic causes of headache represent a very complex and extensive problem, and very often differential diagnostic problem too. Many various reasons of headache can be caused by ophthalmologic diseases like those of anterior and posterior eye segments, acute and subacute angle closed glaucoma and orbital diseases. Headache can be caused by no or poor correction of the refraction anomalies. Ophthalmologic causes of headache are quite frequently connected with conditions that affect other body systems apart from the eyes, nervous and/or vascular system in particular. Although ophthalmologic examination very provides the clue in patients with headache, the diagnostic and therapeutic approach to the problem has to be interdisciplinary.

[Cervicogenic headache: etiopathogenesis, characteristics, diagnosis, differential diagnosis and therapy]

The term "cervicogenic headache" (CH) implies a chronic hemicranial pain syndrome caused by upper cervical spine disorders. According to the clinical researches, in 15-20% of the patients with chronic unilateral headache, it is the case of the headache of cervical origin. The sources of the referred pain manifested as CH are the disorders of anatomical structures innervated by the first three cervical spinal nerves and/or direct irritation/lesion of these nerves (spinal nerves C1-C3, intervertebral/i.v. joints C0-C3, i.v. disc C2-C3 muscles, ligaments, bony structures, dura mater, vertebral arteries). Neuroanatomical and neurophysiological researches have proven the convergence of nociceptive afferents from the receptive field of the spinal nerves C1-C3, and nociceptive afferents from the receptive field of the trigeminal nerve which occurs in the trigeminocervical nucleus located in the upper segments of the cervical part of the spinal cord. Because of the convergence of the nociceptive afferents in the trigeminocervical nucleus, the pain from the receptive field of the spinal nerves C1-C3 is referred into the receptive field of the trigeminal nerve (head, face), and the pain from the receptive field of the trigeminal nerve is referred into the receptive field of the spinal nerves C1-C3 (cervico-occipital area). Diagnosis of CH can be made on the basis of history, clinical picture, clinical examination and radiological examinations, and confirmed by anesthetic blockade of the affected structure. It is necessary to rule out the other forms of headache in differential diagnosis, first of all migraine and tension headache because of their great similarity with CH. The following is used in the treatment of the CH: medical therapy, acupuncture, neural therapy, local botulinum toxin injection, cervical epidural corticosteroid injection, physical therapy, massage, kinezitherapy, traction and surgical treatment. It seems that the best results are achieved by a combination of manual therapy, physical therapy and kinezitherapy. Although the CH has been included into International headache classification, this hemicranial pain syndrome has still been unknown to a wider circle of medical practicioners. That is why the purpose of this article is to describe etiopathogenesis, characteristics, diagnosis, differential diagnosis and therapy of CH.

The Acute Hangover Scale: A new measure of immediate hangover symptoms

PURPOSE

No psychometrically established measure of acute hangover symptoms is published and available to use in experimental investigations. The present investigation combined data across three studies of residual alcohol effects to establish the properties of a new Acute Hangover Scale (AHS) based on symptoms supported in previous lab studies.

METHODS

Professional mariners from a Swedish maritime academy (n=54) and young adult students/recent graduates of urban U.S. universities (n=135) participated in one of three within-subjects' studies of residual effects of heavy drinking (M=0.114 g% breath alcohol concentration [BrAC]). All drank placebo one evening and alcoholic drinks another evening followed by an 8-h sleep period before completing the AHS 10-20 min after awakening.

RESULTS

The AHS showed excellent internal consistency reliability the morning after alcohol. The AHS mean score and each item were significantly affected by beverage but not demographics or typical drinking, supporting validity.

CONCLUSIONS

The AHS is a reliable and valid instrument for assessing acute hangover symptoms in experimental investigations of residual alcohol effects.

Recurrent headache as the main symptom of acquired cerebral toxoplasmosis in nonhuman immunodeficiency virus-infected subjects with no lymphadenopathy: the parasite may be responsible for the neurogenic inflammation postulated as a cause of different types of headaches

Headache and/or migraine, a common problem in pediatrics and internal medicine, affect about 5% to 10% children and adolescents, and nearly 30% of middle-aged women. Headache is also one of the most common clinical manifestations of acquired Toxoplasma gondii infection of the central nervous system (CNS) in immunosuppressed subjects. We present 11 apparently nonhuman immunodeficiency virus-infected children aged 7 to 17 years (8 girls, 3 boys) and 1 adult woman with recurrent severe headaches in whom latent chronic CNS T. gondii infection not manifested by enlarged peripheral lymph nodes typical for toxoplasmosis, was found. In 7 patients, the mean serum IgG Toxoplasma antibodies concentration was 189 +/- 85 (SD) IU/mL (range 89 to 300 IU/mL), and in 5 other subjects, the indirect fluorescent antibody test titer ranged from 1:40 to 1:5120 IU/mL (n= <1:10 IU/mL). Some of the patients suffered also from atopic dermatitis (AD) and were exposed to cat and/or other pet allergens, associated with an increased IL-4 and decreased IFN-gamma production. These cytokine irregularities caused limited control of cerebral toxoplasmosis probably because IL-4 down-regulated both the production of IFN-gamma and its activity, and stimulated production of a low NO-producing population of monocytes, which allowed cysts rupture, increased parasite multiplication and finally reactivation of T. gondii infection. The immune studies performed in 4 subjects showed a decreased percentage of T lymphocytes, increased total number of lymphocytes B and serum IgM concentration, and impaired phagocytosis. In addition, few of them had also urinary tract diseases known to produce IL-6 that can mediate immunosuppressive functions, involving induction of the anti-inflammatory cytokine IL-10. These disturbances probably resulted from the host protective immune reactions associated with the chronic latent CNS T. gondii infection/inflammation. This is consistent with significantly lower enzyme indoleamine 2,3-dioxygenase (IDO) activity reported in atopic than in nonatopic individuals, and an important role that IDO and tryptophan degradation pathways plays in both, the host resistance to T. gondii infection and its reactivation. Analysis of literature information on the subjects with different types of headaches caused by foods, medications, and other substances, may suggest that their clinical symptoms and changes in laboratory data result at least in part from interference of these factors with dietary tryptophan biotransformation pathways. Several of these agents caused headache attacks through enhancing NO production via the conversion of arginine to citrulline and NO by the inducible nitric oxide synthase enzyme, which results in the high-output pathway of NO synthesis. This increased production of NO is, however, quickly down-regulated by NO itself because this biomolecule can directly inactivate NOS, may inhibit Ia expression on IFN-gamma-activated macrophages, which would limit antigen-presenting capability, and block T-cell proliferation, thus decreasing the antitoxoplasmatic activity. Moreover, NO inhibits IDO activity, thereby suppressing kynurenine formation, and at least one member of the kynurenine pathway, 3-hydroxyanthranilic acid, has been shown to inhibit NOS enzyme activity, the expression of NOS mRNA, and activation of the inflammatory transcription factor, nuclear factor-kB. In addition, the anti-inflammatory cytokines IL-4 and IL-10, TGF-beta, and a cytokine known as macrophage deactivating factor, have been shown to directly modulate NO production, sometimes expressing synergistic activity. On the other hand, IL-4 and TGF-beta can suppress IDO activity in some cells, for example human monocytes and fibroblasts, which is consistent with metabolic pathways controlled by IDO being a significant contributor to the proinflammatory system. Also, it seems that idiopathic intracranial hypertension, pseudotumor cerebri, and aseptic meningitis, induced by various factors, may result from their interference with IDO and inducible nitric oxide synthase activities, endogenous NO level, and cytokine irregularities which finally affect former T. gondii status 2mo in the brain. All these biochemical disturbances caused by the CNS T. gondii infection/inflammation may also be responsible for the relationship found between neurologic symptoms, such as headache, vertigo, and syncope observed in apparently immunocompetent children and adolescents, and physical and psychiatric symptoms in adulthood. We therefore believe that tests for T. gondii should be performed obligatorily in apparently immunocompetent patients with different types of headaches, even if they have no enlarged peripheral lymph nodes. This may help to avoid overlooking this treatable cause of the CNS disease, markedly reduce costs of hospitalization, diagnosis and treatment, and eventually prevent developing serious neurologic and psychiatric disorders.

Neuropsychiatric lupus in patients with lupus glomerulonephritis

Neuropsychiatric symptoms are recognized to occur in a significant percentage of systemic lupus erythematosus patients and to be a leading cause of morbidity and mortality in lupus. The aim of the present study is to investigate neuropsychiatric symptoms in the patients with lupus nephritis without chronic renal failure. We studied 74 patients (4 male, 70 female) with SLE without chronic renal failure. Disease activity was assessed by the European Consensus Lupus activity Measurement (ECLAM). Renal biopsies disclosed type V lesions in 23 patients, type IV--in 34, type III--in 3, type II--in 11, type I--in 3 patients. Two control groups are used--with rheumatoid arthritis (96 patients) and 63 healthy subjects. The most frequent clinical manifestations are cognitive dysfunction (52.94%), headache (29.41%), psychoses (17.65%), epileptic seizures (20.59%) etc., and the most common cognitive deficit is related to impairment of the memory. The tests for cognitive disorders and nuclear magnetic resonance are the methods of investigation, by which the nervous system injuries are most early detected in the course of the disease. The presented study describes the correlations between the immunologic deviations (antiribosomal P-antibodies, aPL, aSm, aC1q), MMP-9, AT III and the NP injuries.

Acute treatment of headache

Effective acute treatment of headache begins with making an accurate diagnosis and ruling out secondary causes of headache. Once a primary headache is diagnosed, it is important to choose the right combination of behavioural therapy and acute care (abortive and symptomatic) therapy for each patient. Some patients may need preventive medication on a daily basis. If patients overuse acute medications and develop medication overuse headache (previously called analgesic rebound headache), they often seek medical attention due to the chronicity and/or intensity of their pain and resultant disability. For acute care of migraine, physicians should choose a triptan they know and expect to work. They should prescribe the dose and route of administration that will provide the most rapid and complete response to all the associated symptoms of migraine, in addition to the pain. The effectiveness of the 7 available triptans in early, double-blind, controlled trials is more similar than different. How and when to give them will be discussed. Treatment of cluster headache will be presented briefly.