Cranial nerve involvement, visual complications and headache syndromes in Lyme disease

PURPOSE OF REVIEW

To provide a summary of the visual manifestations and cranial neuropathies seen in Lyme disease.

RECENT FINDINGS

Lyme facial palsy remains the most common manifestation of Lyme neuroborreliosis. Recent investigations show likely evidence of vagal involvement in Lyme disease.

SUMMARY

The literature on Lyme neuroborreliosis continues to evolve. Lyme disease can affect nearly any cranial nerve in addition to causing various headache syndromes. The most common manifestation is Lyme disease facial palsy, occurring in up to 5-10% of patients with documented Lyme disease. Headache syndromes are common in the context of facial palsy but can occur in isolation, and more specific headache syndromes including trigeminal and geniculate neuralgias can occur rarely. Signs and symptoms indicative of vestibulocochlear nerve involvement are relatively common, although it could be that these represent other vestibular involvement rather than a specific cranial neuropathy. Optic neuritis is a controversial entity within Lyme disease and is likely overdiagnosed, but convincing cases do exist. Physicians who see any cranial neuropathy, including optic neuritis, in an endemic area can consider Lyme disease as a possible cause.

Metaphorical use of "headache" and "migraine" in media: A longitudinal study of 1.3 million articles in major publications

BACKGROUND

Stigmatization and trivialization of headache confront individuals with headache disorders, but the degree to which media may contribute is incompletely understood.

OBJECTIVE

The objective of this study was to quantify the frequency of disparaging metaphorical use of the words "headache" and "migraine" in articles and summaries of major publications.

METHODS

This longitudinal study analyzed a dataset of 1.3 million articles and summaries written by authors and editors of 38 major publications. Data cover written publications from 1998 up to 2017. The use of the words "headache" or "migraine" in articles and summaries by major publications was rated by two authors (P.Z. and A.V.) as either "metaphorical" or "medical" based on their contextual application. Pearson's chi-squared test was applied to assess differences in the frequency of metaphorical use of "headache" in comparison to "migraine." Secondary outcomes were the source of publication and time of publication.

RESULTS

A total of 6195 and 740 articles included the words "headache" or "migraine," respectively; 7100 sentences contained the word "headache" and 1652 sentences contained the word "migraine." Among a random sample of 1000 sentences with the word "headache," there was a metaphorical use in 492 (49.2% [95% CI, 46.1-52.3]) sentences. Among a random sample of 1000 sentences with the word "migraine," there was a metaphorical use in 45 (4.5% [95% CI, 3.2-5.8]) sentences. The five most prevalent sources were CNN, Fox News, The New York Times, The Guardian, and The Washington Post. There was an overall increase in the number of articles containing the words "headache" or "migraine" from database inception until analysis (1998 up to 2017). The database included no articles containing either "headache" or "migraine" in 1998; in 2016, this number was 1480 articles.

CONCLUSIONS

In this longitudinal study, major publications applied a metaphorical use of "headache" about half of the time. The metaphorical use of "headache" is 11-fold greater than the metaphorical use of "migraine" in the same media sample. These depictions may contribute to the trivialization of headache and the stigmatization of individuals with headache disorders. Studies with individuals affected by headache disorders are needed to clarify potential influences.

What Are the Predictors for and Psychosocial Correlates of Chronic Headache After Moderate to Severe Traumatic Brain Injury?

OBJECTIVE

Although headache (HA) is a common sequela of traumatic brain injury (TBI), early predictors of chronic HA after moderate to severe TBI are not well established, and the relationship chronic HA has with psychosocial functioning is understudied. Thus, we sought to (1) determine demographic and injury predictors of chronic HA 1 or more years after moderate to severe TBI and (2) examine associations between chronic HA and psychosocial outcomes.

SETTING

Community.

PARTICIPANTS

Participants in the TBI Model System (TBIMS) with moderate to severe TBI who consented for additional chronic pain questionnaires at the time of TBIMS follow-up.

DESIGN

Multisite, observational cohort study using LASSO (least absolute shrinkage and selection operator) regression for prediction modeling and independent t tests for psychosocial associations.

MAIN OUTCOME MEASURES

Chronic HA after TBI at year 1 or 2 postinjury and more remotely (5 or more years).

RESULTS

The LASSO model for chronic HA at 1 to 2 years achieved acceptable predictability (cross-validated area under the curve [AUC] = 0.70). At 5 or more years, predictability was nearly acceptable (cross-validated AUC = 0.68), but much more complex, with more than twice as many variables contributing. Injury characteristics had stronger predictive value at postinjury years 1 to 2 versus 5 or more years, especially sustained intracranial pressure elevation (odds ratio [OR] = 3.8) and skull fragments on head computed tomography (CT) (OR = 2.5). Additional TBI(s) was a risk factor at both time frames, as were multiple socioeconomic characteristics, including lower education level, younger age, female gender, and Black race. Lower education level was a particularly strong predictor at 5 or more years (OR up to 3.5). Emotional and participation outcomes were broadly poorer among persons with chronic HA after moderate to severe TBI.

CONCLUSIONS

Among people with moderate to severe TBI, chronic HA is associated with significant psychosocial burden. The identified risk factors will enable targeted clinical screening and monitoring strategies to enhance clinical care pathways that could lead to better outcomes. They may also be useful as stratification or covariates in future clinical trial research on treatments.

Headaches during pregnancy and the risk of subsequent stroke

BACKGROUND

Primary headache disorder is a known risk factor for stroke in women and usually improves during the first trimester of pregnancy. However, despite this, some women develop headaches during pregnancy (G-HA), and the effect of this headache on subsequent stroke is unknown. In this study, we evaluated the association between G-HA and stroke after delivery in women.

METHODS

Based on the Korean National Health Insurance Service database, we included women hospitalized for delivery between 2012 and 2013. G-HA was defined as a headache diagnosed during pregnancy. Primary outcome was any stroke that occurred during the observational periods from delivery to December 31, 2020. All diseases were identified based on data registered in the database using the International Classification of Disease-10th Revision-Clinical Modification codes.

RESULTS

Of 906,187 pregnant women, G-HA was found in 56,813 (6.3%). During the observational periods, the G-HA ( +) group had a significantly higher risk of any stroke [adjusted hazard ratio (aHR) = 1.59, 95% confidence interval (CI): 1.30-1.95], ischemic stroke (aHR = 1.50, 95% CI: 1.12-2.01), hemorrhagic stroke (aHR = 1.63, 95% CI: 1.23-2.15), and intracerebral hemorrhage (aHR = 1.63, 95% CI: 1.19-2.23) than the G-HA (-) group. When analyzed considering the interaction with history of headache disorder, G-HA showed a significant association with hemorrhagic stroke, but lost its effect on ischemic stroke.

CONCLUSIONS

We demonstrated that G-HA was associated with subsequent stroke occurrence after delivery. However, the relationship between G-HA and ischemic stroke is mitigated by a history of pre-pregnancy headache disorder.

Proposed general diagnostic criteria for secondary headaches

BACKGROUND

The distinction between a pre-existing primary headache and a secondary headache at the onset of a disorder is important and has not been taken into account in the International Classification of Headache Disorders-3. This study aimed to improve the general diagnostic criteria for secondary headaches using results of our previous studies.

MATERIALS AND METHODS

We analyzed characteristics of headaches including their changes in intensity, duration, frequency, localization and side, development of new accompanying symptoms, and therapeutic response at the onset of transient ischemic attacks (TIA) (n = 120, mean age 56.1, 55% females) and ischemic stroke (n = 550, mean age 63.1, 56% females) compared to the control group (n = 192, mean age 58.7, 64% females).

RESULTS

Headache of a new type occurred in 8.4% of ischemic stroke patients and 5% of TIA patients on the day of admission but did not occur at all in the control group. Pre-existing headache with a change of at least one characteristic occurred significantly more often in stroke (5.4%) and TIA (7.5%) than in the control group (1%) (p = 0.01 and p = 0.003 respectively).

CONCLUSION

The presence of a new type of headache and a pre-existing headache with altered characteristics in close temporal relation to a disorder indicates causality. Based on these data we propose revised general diagnostic criteria for secondary headaches.

Autonomic Function Tests, Heart Rate Variability, and Electrophysiological Evaluation in Patients With a Primary Episodic Headache: An Observational Study

PURPOSE

Cranial autonomic symptoms are typically associated with the trigeminal autonomic cephalalgias and also present in substantial cases of migraine. Autonomic nervous system dysfunctions are also been reported in headache disorders and postulated to promote headache attacks. This study was aimed to evaluate the parasympathetic and sympathetic autonomic functions tests in patients with a episodic primary headache and to investigate, if any, electrophysiological abnormalities in the blink reflex test and sympathetic skin response test in these patients.

METHODS

In this cross-sectional study, a total of 100 patients, 50 patients each of migraine and tension-type headache attending the neurology OPD and fulfilling the diagnostic criteria of headache disorders were enrolled. Autonomic functions tests were performed in the Department of Physiology, whereas electrophysiological tests were powered by the Editorial Manager and ProduXion Manager from Aries Systems Corporation performed in the Department of Neurology.

RESULTS

Significant association ( P < 0.05) was observed in "blood pressure response to sustained handgrip" (sympathetic activity) and "heart rate response to Valsalva maneuver" (parasympathetic activity) among patients with migraine. Although the mean sympathetic skin response latency of patients with migraine was within the normal range, it was significantly prolonged in comparison with the control group. "Blood pressure response to sustained handgrip" and "heart rate variability" were found to be significantly ( P < 0.05) different in patients with a tension-type headache. The blink reflex test was observed to be normal in all patients with a headache. Patients with migraine showed a significant dysautonomia in category three of the Ewing battery for autonomic functional disability.

CONCLUSIONS

Autonomic functional abnormality, both sympathetic and parasympathetic, does exist in patients with a primary episodic headache.

Post-stroke Headache

PURPOSE OF REVIEW

Stroke is a major health concern and a leading cause of long-term disability. Persistent post-stroke headache (PPSH) is a common complication of stroke yet little is known about its specific characteristics or optimal management. The purpose of this review is to discuss the epidemiology, presentation, and hypothesized pathophysiology of PPSH. Acute and preventive treatment options, as well as specific concerns regarding triptans and the newer CGRP antagonists, will be discussed in detail as well.

RECENT FINDINGS

The 2018 International Classification of Headache Disorders, 3rd edition (ICHD-3) was the first headache diagnostic manual to include criteria for PPSH and defines this disorder as an acute headache that develops in close temporal relation to stroke and persists beyond 3 months. Recent literature estimates the prevalence of PPSH to be somewhere between 1 and 23% of patients post-stroke. Presentation is variable, but most often mimics tension-type headache. There are no evidence-based guidelines on the optimal treatment of PPSH. PPSH is a common but poorly understood complication of stroke. Given the significant disability burden that PPSH carries, the epidemiology and pathophysiology of PPSH, as well as the efficacy and safety of potential treatment options, warrant further investigation.

Efficacy of Epidural Blood Patching or Surgery in Spontaneous Intracranial Hypotension: A Systematic Review and Evidence Map

BACKGROUND

Spontaneous intracranial hypotension is an important cause of treatable secondary headaches. Evidence on the efficacy of epidural blood patching and surgery for spontaneous intracranial hypotension has not been synthesized.

PURPOSE

Our aim was to identify evidence clusters and knowledge gaps in the efficacy of treatments for spontaneous intracranial hypotension to prioritize future research.

DATA SOURCES

We searched published English language articles on MEDLINE (Ovid), the Web of Science (Clarivate), and EMBASE (Elsevier) from inception until October 29, 2021.

STUDY SELECTION

We reviewed experimental, observational, and systematic review studies assessing the efficacy of epidural blood patching or surgery in spontaneous intracranial hypotension.

DATA ANALYSIS

One author performed data extraction, and a second verified it. Disagreements were resolved by consensus or adjudicated by a third author.

DATA SYNTHESIS

One hundred thirty-nine studies were included (median, 14 participants; range, 3-298 participants). Most articles were published in the past decade. Most assessed epidural blood patching outcomes. No studies met level 1 evidence. Most were retrospective cohort or case series (92.1%, n = 128). A few compared the efficacy of different treatments (10.8%, n = 15). Most used objective methods for the diagnosis of spontaneous intracranial hypotension (62.3%, n = 86); however, 37.7% (n = 52) did not clearly meet the International Classification of Headache Disorders-3 criteria. CSF leak type was unclear in 77.7% (n = 108). Nearly all reported patient symptoms using unvalidated measures (84.9%, n = 118). Outcomes were rarely collected at uniform prespecified time points.

LIMITATIONS

The investigation did not include transvenous embolization of CSF-to-venous fistulas.

CONCLUSIONS

Evidence gaps demonstrate a need for prospective study designs, clinical trials, and comparative studies. We recommend using the International Classification of Headache Disorders-3 diagnostic criteria, explicit reporting of CSF leak subtype, inclusion of key procedural details, and using objective validated outcome measures collected at uniform time points.

A multicenter, longitudinal survey of headaches and concussions among youth athletes in the United States from 2009 to 2019

OBJECTIVE/ BACKGROUND

Chronic headaches and sports-related concussions are among the most common neurological morbidities in adolescents and young adults. Given that the two can overlap in presentation, studying the effects of one on another has proven difficult. In this longitudinal study, we sought to assess the relationship between chronic headaches and concussions, analyzing the role of historic concussions on chronic headaches, as well as that of premorbid headaches on future concussion incidence, severity, and recovery.

METHODS

This multi-center, longitudinal cohort study followed 7,453 youth athletes who were administered demographic and clinical surveys as well as a total of 25,815 Immediate Post-concussion Assessment and Cognitive Testing (ImPACT) assessments between 2009 and 2019. ImPACT was administered at baseline. Throughout the season concussions were examined by physicians and athletic trainers, followed by re-administration of ImPACT post-injury (PI), and at follow-up (FU), a median of 7 days post-concussion. Concussion incidence was calculated as the total number of concussions per patient years. Concussion severity and recovery were calculated as standardized deviations from baseline to PI and then FU in Symptom Score and the four neurocognitive composite ImPACT scores: Verbal Memory, Visual Memory, Processing Speed, and Reaction Time. Data were collected prospectively in a well-organized electronic format supervised by a national research-oriented organization with rigorous quality assurance. Analysis was preformed retrospectively.

RESULTS

Of the eligible athletes, 1,147 reported chronic headaches (CH) at the start of the season and 6,306 reported no such history (NH). Median age of the cohort was 15.4 ± 1.6 years, and students were followed for an average of 1.3 ± 0.6 years. A history of concussions (OR 2.31, P < 0.0001) was associated with CH. Specifically, a greater number of past concussions (r2 = 0.95) as well as concussions characterized by a loss of consciousness (P < 0.0001) were associated with more severe headache burden. The CH cohort had a greater future incidence of concussion than the NH cohort (55.6 vs. 43.0 per 100 patient-years, P < 0.0001). However, multivariate analysis controlling for demographic, clinical, academic, and sports-related variables yielded no such effect (OR 0.99, P = 0.85). On multivariable analysis the CH cohort did have greater deviations from baseline to PI and FU in Symptom Score (PI OR per point 1.05, P = 0.01, FU OR per point 1.11, P = 0.04) and Processing Speed (OR per point 1.08, P = 0.04), suggesting greater concussion severity and impaired symptomatic recovery as compared to the NH cohort.

CONCLUSION

A history of concussions was a significant contributor to headache burden among American adolescents and young adults. However, those with chronic headaches were not more likely to be diagnosed with a concussion, despite presenting with more severe concussions that had protracted recovery. Our findings not only suggest the need for conservative management among youth athletes with chronic headaches, they also indicate a potential health care gap in this population, in that those with chronic headaches may be referred for concussion diagnosis and management at lower rates than those with no such comorbidity.

Prevalence of headache disorders in patients living with epilepsy in rural region in western part of India

BACKGROUND AND AIMS

Headache disorders cause significant distress in patients living with epilepsy (PWE) and are underreported. This study aimed to evaluate the prevalence of various forms of headache in PWE.

METHODOLOGY

Two hundred and three PWE were evaluated for the presence and type of headache as per the International Classification of Headache Disorders (ICHD)-3 classification criteria. The severity was graded using the Headache Under Response to Treatment (HURT)-3. A subgroup analysis of headache and epilepsy was done. The World Health Organization-5 (WHO-5) questionnaire was used to assess mental well-being. The Mini International Neuropsychiatric Interview (MINI) questionnaire was used to study the psychiatric comorbidities, which were classified according to the Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV classification.

RESULTS

The prevalence of headaches in PWE was 45% [60% females]. Female gender and younger age were significantly associated with migraine (p values of 0.03 and 0.05, respectively). Migraine was the most common type of headache (71%), followed by tension-type headache (TTH) (23%) in PWE. The headache was inter-ictal in 80% of PWE. In PWE with migraine, both juvenile myoclonic epilepsy (JME) and frontal lobe epilepsy (FLE) had a 28% prevalence. In PWE with TTH, FLE was more common (43%). The prevalence of migralepsy in PWE was 4% [n = 4; 2 each of occipital lobe epilepsy (OLE) and idiopathic generalized epilepsy (IGE)]. A psychiatric illness was more than two times more likely in PWE with headache (n = 34; 37%) as compared to PWE without headache (n = 19; 17%). Patients living with epilepsy with headaches and psychiatric comorbidities had significantly lower mental well-being (p = 0.001). Forty five percent of PWE with headaches required acute management, and 35% required prophylactic management for their headache.

CONCLUSION

Headache is frequently ignored in PWE. It can affect their mental health and quality of life. Evaluation and management of headache in PWE is very important.

Do catastrophizing and autonomic-reduced flexibility mediate pain outcomes in chronic headache?

OBJECTIVES

Maladaptive cognitive strategies and reduced autonomic flexibility have been reported in chronic pain conditions. No study to date addressed the effects of maladaptive coping and reduced autonomic flexibility, as indexed by heart rate variability (HRV), in chronic headaches. The present study aimed to assess the mediating role of pain catastrophizing and HRV on pain outcomes in patients with chronic headache.

METHODS

Thirty-two chronic headache patients and 28 healthy controls were recruited. Self-reported pain severity, pain interference on daily activity, and pain catastrophizing were assessed through the Multidimensional Pain Inventory and the Pain-Related Self Statements Scale. HRV was recorded at rest. Correlations and mediation analysis between self-report, HRV, and pain outcomes were run.

RESULTS

Patients with chronic headache reported significantly higher pain severity (p < .001; d =  - 1.98), pain interference on daily activity (p < .001; d =  - 1.81), and pain catastrophizing (p < .001; d =  - 0.96) compared to controls. They also presented significantly lower HRV (p < .05; d = 0.57). Both pain catastrophizing and HRV were associated with pain interference on daily activity. However, from mediation analysis, pain catastrophizing only emerged as the mediator for pain severity (p < .001; b = 0.30) and pain interference (p < .001; b = 0.14).

CONCLUSION

Present results showed that chronic headache patients are characterized by high catastrophizing and lower physiological adaptability. Pain catastrophizing emerged as the only mediator of pain outcomes, suggesting that cognitive factors might have a major influence on the severity of pain and its interference on daily activities. Further studies are needed to evaluate these autonomic-cognitive interactions in chronic pain.

Photophobia in headache disorders: characteristics and potential mechanisms

Photophobia is present in multiple types of headache disorders. The coexistence of photophobia and headache suggested the potential reciprocal interactions between visual and pain pathways. In this review, we summarized the photophobic characteristics in different types of headache disorders in the context of the three diagnostic categories of headache disorders: (1) primary headaches: migraine, tension-type headache, and trigeminal autonomic cephalalgias; (2) secondary headaches: headaches attributed to traumatic brain injury, meningitis, non-traumatic subarachnoid hemorrhage and disorder of the eyes; (3) painful cranial neuropathies: trigeminal neuralgia and painful optic neuritis. We then discussed potential mechanisms for the coexistence of photophobia and headache. In conclusion, the characteristics of photophobia are different among these headache disorders. The coexistence of photophobia and headache is associated with the interactions between visual and pain pathway at retina, midbrain, thalamus, hypothalamus and visual cortex. The communication between these pathways may depend on calcitonin gene-related peptide and pituitary cyclase-activating polypeptide transmission. Moreover, cortical spreading depression, an upstream trigger of headache, also plays an important role in photophobia by increased nociceptive input to the thalamus.

PACAP and Other Neuropeptide Targets Link Chronic Migraine and Opioid-induced Hyperalgesia in Mouse Models

Chronic use of opioids can produce opioid-induced hyperalgesia (OIH), and when used to treat migraine, these drugs can result in increased pain and headache chronicity. We hypothesized that overlapping mechanisms between OIH and chronic migraine occur through neuropeptide dysregulation. Using label-free, non-biased liquid chromatography-mass spectrometry to identify and measure changes in more than 1500 neuropeptides under these two conditions, we observed only 16 neuropeptides that were altered between the two conditions. The known pro-migraine molecule, calcitonin-gene related peptide, was among seven peptides associated with chronic migraine, with several pain-processing neuropeptides among the nine other peptides affected in OIH. Further, composite peptide complements Pituitary adenylate cyclase-activating polypeptide (PACAP), Vasoactive intestinal peptide (VIP) and Secretogranin (SCG) showed significant changes in both chronic migraine and OIH. In a follow-up pharmacological study, we confirmed the role of PACAP in models of these two disorders, validating the effectiveness of our peptidomic approach, and identifying PACAP as a mechanistic link between chronic migraine and OIH. Data are available via ProteomeXchange with identifier PXD013362.

Body Mass Index and Primary Headache: A Hospital-Based Study in China

OBJECTIVE

Primary headache and obesity are highly prevalent disorders in the general population. Although many studies have reported an association between the two, there is still no overall comprehension about this relationship. To gain a more accurate understanding in this regard, we analyzed data from a 2011 cross-sectional study in Chongqing, China.

METHODS

Patients with a chief complaint of headache were administered a headache questionnaire and diagnosed by neurology doctors in accordance with the International Classification of Headache Disorders 2nd Edition (ICHD-II) criteria. Patients aged < 18 years or diagnosed with secondary headache were excluded.

RESULTS

Of 1327 patients who cited headache as the chief complaint, 16 were excluded for missing data, while 396 were diagnosed with chronic headache (177 chronic migraine [CM], 186 chronic tension-type headache [CTTH], and 33 other chronic headache) and 915 with episodic headache (369 episodic migraine [EM], 319 episodic tension-type headache [ETTH], and 227 other episodic headache). Chronic headache patients had a higher number of headache days per month, longer duration of headache history, and greater tendency to overuse analgesics than episodic headache patients. The CM and ETTH patients were more apt to be overweight and had a significantly greater body mass index (BMI; p < 0.05) than the EM and CTTH patients. Overweight (odds ratio [OR] = 3.64; 95% confidence interval (CI), 1.19-8.81) and obesity (OR = 28.63; 95% CI, 2.96-276.6) were independently associated with CM but not with other headaches, and this association was not influenced by other factors such as medication overuse.

CONCLUSIONS

The relationship between headache and overweight/obesity varies depending on the type of primary headache. CM patients are more likely to have a higher body mass index than EM patients, while ETTH patients are more likely to be overweight/obese than CTTH patients.

Frequency and pattern of common primary headache among depressed patients at tertiary care centre, Karachi

OBJECTIVE

To determine the frequency of co-morbid common primary headaches among depressed patients.

METHODS

This study was conducted at the Jinnah Postgraduate Medical Centre, Karachi, from July to December 2014, and comprised depressed patients. Diagnosis of depressive disorder was based on diagnostic criteria of International Classification of Diseases (10th version). For the diagnosis of common primary headaches, International Classification of Headache Disorders (2nd edition) criteria were applied. SPSS 17 was used for data analysis.

RESULTS

Of the 331 participants, 129(39%) were males and 202(61%) were females. The overall mean age was 31.40±8.6 years (range: 18-50 years). Besides, 208(62.83%) participants had no headache and 123(37.16%) had common primary headaches. Of the latter, 18(5.4%) had migraine with aura, 49(14.8%) had migraine without aura and 56(16.9%) had tension-type headache. Common primary headaches were more common in females and among those having severe depressive disorder.

CONCLUSIONS

The primary headache was common among outpatients with depressive disorder, predominantly tension-type headache and migraine without aura.

A case of idiopathic hypertrophic pachymeningitis presenting with chronic headache and multiple cranial nerve palsies: A case report

RATIONALE

Idiopathic hypertrophic pachymeningitis (IHP) is a rare condition, characterized by a chronic fibrosing inflammatory process usually involving either the intracranial or spinal dura mater, but rarely both. Here, we report a rare case of IHP affecting both the intracranial and spinal dura mater. We also discussed the diagnosis, management, and outcome of IHP.

PATIENT CONCERNS

We reviewed the case of a 60-year-old woman presenting with chronic headache, multiple cranial nerve palsies and gait disturbance. Magnetic resonance imaging (MRI) of her head revealed thickened and contrast-enhanced dura in the craniocervical region as well as obstructive hydrocephalus and cerebellar tonsillar herniation. The patient had a suboccipital craniectomy and posterior decompression through C1 plus a total laminectomy. The dura was partially resected to the extent of the bony decompression, and a duroplasty was performed.

DIAGNOSES

Microscopic examination of the surgically resected sample showed chronic inflammatory changes, lymphoplasmacytic cell infiltration, fibrous tissue hyperplasia, and hyaline degeneration. Blood tests to evaluate the secondary causes of hypertrophic pachymeningitis (HP) were unremarkable.

INTERVENTIONS

Steroid was used to treat suspected IHP.

OUTCOMES

Postoperatively, the patient showed gradual improvement in her headache, glossolalia, and bucking. Prior to discharge, a follow-up MRI showed improvement of the dura mater thickening.

LESSONS

IHP is a chronic inflammatory disorder of the dura mater that usually causes neurological deficits. Clinical manifestations of IHP, MRI findings, and laboratory abnormalities are the essential components for making an accurate diagnosis. When the radiological or laboratory evaluation is uncertain, but neurological deficits are present, a prompt surgical approach should be considered. Postoperative steroid therapy and close observation for recurrence are necessary to ensure a good long-term outcome.

Prevalence of Primary Headaches in People with Multiple Sclerosis

The aim was to investigate the lifetime prevalence of headache and primary headache (diagnoses according to International Headache Society criteria) in multiple sclerosis (MS). The relationships between headache and clinical features of MS and MS therapy were also investigated. We studied 137 patients with clinically definite MS; 88 reported headache, 21 of whom developed headache after the initiation of interferon. The prevalence of all headaches in the remaining 116 patients was 57.7%. Migraine was found in 25.0%, tension-type headache in 31.9%, and cluster headache in one patient. A significant correlation ( P = 0.007, Fisher's exact test) between migraine and relapsing-remitting MS was found. Primary headaches are common in MS patients. Further studies are needed to clarify the mechanisms underlying this association, particularly the association between migraine and relapsing-remitting MS, and the role of interferon in the development of new headache.

[Headache and functional symptoms]

INTRODUCTION

Headaches are a common reason for visiting neurology clinics. They have their origin in a variety of causes and their specific diagnosis deteriorates as it overlaps with other chronic painful pathologies. Somatic functional syndromes are characterised by chronic painful conditions that have a negative effect on quality of life, and are accompanied by functional symptoms with no organic cause.

AIMS

The aim of this study is to evaluate the prevalence of functional symptoms in patients who visited due to headaches.

PATIENTS AND METHODS

The sample included all the patients who visited the walk-in neurology clinic because of headaches between March and September 2014. A semi-structured survey was carried out in order to evaluate obsessive personality traits, bruxism, gastrointestinal symptoms, anxiety, depression and sleep disorders.

RESULTS

During the period under study, 125 patients visited due to headache. In all, 68.7% of patients with migraine presented functional symptoms and only 32.7% in the case of other headaches (p = 0.0001).

CONCLUSIONS

Functional symptoms were prevalent in patients with headache, mainly in those with migraine.

Caffeine and headache: specific remarks

Caffeine is the most widely used psychostimulant worldwide. Excessive caffeine consumption induces a series of both acute and chronic biological and physiological changes that may give rise to cognitive decline, depression, fatigue, insomnia, cardiovascular changes, and headache. Chronic consumption of caffeine promotes a pro-nociceptive state of cortical hyperexcitability that can intensify a primary headache or trigger a headache due to excessive analgesic use. This review offers an in-depth analysis of the physiological mechanisms of caffeine and its relationship with headache.

Differential diagnosis of orofacial pain and temporomandibular disorder

When a patient complains of orofacial pain, health care providers must make a correct diagnosis. Doing this can be difficult, since various signs and symptoms may not be specific for 1 particular problem or disorder. One initially should formulate a broad differential diagnosis that can be narrowed after analysis of the history and examination. In this article, orofacial pain is categorized as being caused by: intracranial pain, headaches, neuropathic pain, intraoral pain, temporomandibular disorder, cervical pain, pain related to anatomically associated structures, referred pain, or mental illness.

Elevated blood pressure and analgesic overuse in chronic daily headache: an outpatient clinic-based study from China

BACKGROUND

Many studies have reported that hypertension is common in chronic daily headache (CDH) and its subtype chronic migraine (CM), but the reason is still poorly understood. Our clinical literature review suggested that analgesic overuse may be associated with elevated blood pressure (BP), so we performed the present study to investigate the frequency of elevated BP and its link with analgesic overuse in CDH and its subtypes.

METHODS

A cross-sectional study was conducted in neurology outpatients with a diagnosis of CDH according to International Headache Society criteria. CDH patients were classified into CM and non-CM groups, and subclassified with or without analgesic overuse.

RESULTS

Elevated BP was present in 27.96% of CDH patients. Compared with non-CM patients, patients with CM had a longer duration of headache and more severe pain intensity, and a family history of headache and analgesic overuse were also more common, but the elevated BP frequency was not different between the two groups. Almost one-third of the patients had analgesic overuse; 96.8% of which comprised acetaminophen-containing agents. Those with analgesic overuse had a higher frequency of headache than those without analgesic overuse in both the CM and non-CM groups.

CONCLUSIONS

Although the CM patients had a longer duration of headache, more severe intensity, the frequency of elevated BP wasn't higher than non-CM group. Analgesic overuses maybe the reason of higher frequency of elevated BP in CDH and its subtypes. This may have predictive value for clinicians to improve CDH management.

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.

White matter hyperintensities and self-reported depression in a sample of patients with chronic headache

White matter hyperintensities (WMH) have been associated with mood disorders in psychiatric patients. In the present study, we aimed to assess whether WMHs are associated with depressive symptoms and different sensitivity of the behavioral inhibition (BIS), and activation (BAS) systems in patients with chronic headache. Participants were 85 adult outpatients (16 men and 69 women) with a diagnosis of chronic headache. All of the patients underwent brain magnetic resonance imaging (MRI) and were administered the BIS/BAS scales and the Center for Epidemiologic Studies Depression Scale. Above 40 % of patients had periventricular WMHs (PWMHs) and almost 98 % had deep WMHs (DWMHs). Patients with PWMHs reported fewer depressive symptoms than patients without PWMHs. Patients with more severe DWMHs (compared with patients with mild or without DWMH lesions) were older and reported lower scores on the drive dimension of the BIS/BAS scales. In multivariate analyses, patients with PWMHs were 1.06 times more likely to report fewer depressive symptoms than patients without PWMHs. WMH lesions in patients with chronic headache were associated with less depression severity.

Chronic daily headache in a patient with nasopharyngeal carcinoma

Chronic daily headache (CDH) among nasopharyngeal carcinoma (NPC) patients is a multidisciplinary challenge. Although imaging studies are recommended to identify skull-base invasion, intracranial metastasis or skull-base osteoradionecrosis, a headache diary is also a practical approach. A 42-year-old woman had been bothered with CDH since she was diagnosed with T3N1M0 stage III NPC 2 years earlier. Although the imaging studies did not show any abnormality, the attending doctor informed her that there remained the possibility of an intracranial or skull-base lesion. She was regularly taking painkillers. Eventually, when her headache diary was examined, the diagnosis of chronic migraine superimposed on medication overuse headache was made according to the ICHD-IIR. The CDH abated after 1 week of outpatient detoxification. The following half year was uneventful. In reporting this case, we suggest that it would be of interest to a number of disciplines including otorhinolaryngologists, oncologists and radio-oncologists. By avoiding medication overuse in similar patients, we hope to improve the quality of life of these individuals.

Anxiety disorders and migraine intractability and progression

Comorbid psychopathology has been implicated as a risk factor for the chronification and progression of migraine. Although past research has focused principally on depression and migraine, recent research consistently has confirmed that a disproportionate number of migraineurs suffer from one or more comorbid anxiety disorders. Moreover, this research has implicated anxiety disorders as factors potentially associated with migraine intractability and progression; growing evidence suggests that anxiety disorders may be even more prognostically significant than depression. This article summarizes these recent developments, considers mechanisms underlying this comorbidity, discusses strategies for assessing and managing comorbid anxiety, and notes directions for future clinical and empiric work.

Hemicrania continua evolving from cluster headache responsive to valproic acid

Hemicrania continua (HC) is a rare type of primary headache characterized by a prompt and enduring response to indomethacin. We describe a patient who suffered from cluster headache evolving into ipsilateral HC, who does not tolerate a long-term indomethacin therapy. The case was complex in terms of diagnosis, associated comorbidity, and choice of treatment; after several trials with different therapeutic regimens, we started the patient on a therapy with valproic acid and obtained an improvement of her HC.

Neuropathic orofacial pain in children and adolescents

The field of orofacial pain is broad and includes pain conditions affecting the head, face, neck, and intraoral structures. Much has been written about orofacial pain, specifically chronic pain conditions affecting adults. Little is known, however, about the presentation of orofacial pain in pediatric patients. The objective of this paper was to increase awareness and provide information regarding neuropathic orofacial pain in children and adolescents, as pediatric dentists may be asked to participate in the treatment of these patients. Moreover, an accurate history and examination can lead to on early diagnosis of the pain condition, thus avoiding unnecessary or inappropriate dental procedures.

Predictors of abdominal pain in schoolchildren: a 4-year population-based prospective study

BACKGROUND

Chronic abdominal pain (CAP) is common among schoolchildren, but risk factors for its onset are still largely unknown.

AIMS

To determine the frequency of onset of CAP in schoolchildren and investigate risk factors for its development.

METHODS

1411 schoolchildren aged 11-14 years were recruited from schools in North West England. Information was collected on recent pain symptoms and potential risk factors for developing CAP. Participants were followed up 1 and 4 years later and new episodes of CAP were identified.

RESULTS

22% reported new-onset abdominal pain at 1-year follow-up which persisted at 4-year follow-up (CAP). CAP was almost three times higher in girls than boys (34% vs 13%; chi(2): 26.0; p<0.001). In girls, reporting headache at baseline was the only predictive factor for CAP onset: those reporting headaches experienced a doubling in the risk of symptom onset (relative risk: 2.1; 95% confidence interval: 0.95 to 4.7). In contrast, in boys, development of CAP was independently predicted by daytime tiredness (3.0; 1.2 to 7.6), lack of school enjoyment (2.0; 0.95 to 4.2), adverse psychosocial exposures (2.3; 1.2 to 4.5) and taller stature (1.9; 0.8 to 4.5).

CONCLUSION

Our results suggest that over 20% of adolescent schoolchildren experience new-onset non-self-limiting abdominal pain over a 1-year period. Future abdominal pain is predicted by previous somatic symptom reporting in girls and both somatic symptom reporting and psychosocial factors in boys. These risk factors indicate a possible mechanism for understanding the development of CAP, and might have important implications for both primary and secondary preventive strategies.

Carotidynia: a new case for an old controversy

Whereas International Headache society (IHS) criteria of carotidynia were defined in 1988, its validity as a distinct nosological entity has recently been questioned, leading this entity to be removed from the second IHS classification in 2004. We report the case of a 30-year-old woman who developed a pain located at the left carotid bulb, associated with typical findings on ultrasonography and MRI. We discuss new criteria and denomination of this clinical entity.

Chronic Daily Headache in Hereditary Hemochromatosis Treated by Venesection

Coincidence or causality between iron overload and headaches (e.g., daily headache, migraine, and cluster headache) is still under discussion. Herein we report a patient suffering from hereditary hemochromatosis (homozygous C282Y mutation; OMIM: 235220, Locus 6p21.3) and daily headache fulfilling the IHSD-2 criteria of chronic migraine. Three treatments by venesection improved the headache substantially in frequency, intensity, and duration of attacks. We suggest treatment by venesection for iron depletion in patients suffering from hemochromatois and headache.

Fibromyalgia and Overlapping Disorders: The Unifying Concept of Central Sensitivity Syndromes

OBJECTIVES

To discuss fibromyalgia syndrome (FMS) and overlapping conditions, eg, irritable bowel syndrome, headaches, and chronic fatigue syndrome, within the concept of central sensitivity syndromes (CSS).

METHODS

A critical overview of the literature and incorporation of the author's own views.

RESULTS

The concept of CSS seems viable. It is based on mutual associations among the CSS conditions as well as the evidence for central sensitization (CS) among several CSS members. However, such evidence is weak or not available in other members at this time, requiring further studies. The biology of CSS is based on neuroendocrine aberrations, including CS, that interact with psychosocial factors to cause a number of symptoms.

CONCLUSIONS

CSS is an important new concept that embraces the biopsychosocial model of disease. Further critical studies are warranted to fully test this concept. However, it seems to have important significance for new directions for research and patient care involving physician and patient education. Each patient, irrespective of diagnosis, should be treated as an individual considering both the biological and psychosocial contributions to his or her symptoms and suffering.

Sleep and headache disorders: clinical recommendations for headache management

Clinical practice points were drawn from a review of sleep and headache disorders published in the regular issue of Headache (released in tandem with this supplement). The recommendations include: (1) Sleep as well as psychiatric disorders tend to become prevalent in more complex and severe headache patterns and regulation of sleep and mood may favorably impact headache threshold; (2) Specific headache patterns, irrespective of headache diagnosis, are suggestive of a potential sleep disorder (eg, "awakening" or morning headache, chronic daily headache); (3) Sleep disorders most implicated with headache include obstructive sleep apnea, primary insomnia, and circadian phase abnormalities, and treatment of such sleep disorders may improve or resolve headache; (4) Inexpensive screening tools (eg, sleep history interview, headache/sleep diary, validated questionnaires, prediction equations) aid identification of patients warranting polysomnography; and (5) Pharmacologic and behavioral therapies are effective in the regulation of sleep and are compatible with usual headache care.

Improvement of Chronic Headache After Treatment of Unruptured Intracranial Aneurysms

OBJECTIVE

The objective of this study is to determine the incidence, character, and outcome of headache in patients with unruptured intracranial aneurysms who had been treated to avoid the risk of rupture.

BACKGROUND

There are a variety of clinical manifestations associated with unruptured intracranial aneurysms. Among them, chronic headache is the most common presenting and/or accompanying symptom.

METHODS

Among the 137 patients with unruptured aneurysms who had been treated, we collected 81 patients excluding 30 on the basis of inclusion criteria. Twenty-six patients were lost to follow-up. We collected data by medical record review and a telephone survey. Included in the information collected was the analysis of presenting symptom, location and size of each aneurysm, location, quality, intensity and duration of headaches, associated symptoms, triggering and alleviating factors, and precipitating events.

RESULTS

Forty-nine patients (60.5%) of 81 had chronic headaches before the diagnosis of unruptured intracranial aneurysm. Forty-four patients (89.8%) answered that their headaches were improved slightly (12 patients) or markedly (32 patients) (P <.05). The clinical pattern of the headache worsened in only 1 patient and did not change in 4 patients. When the surgical group (40 patients) and the coil embolization group (41 patients) were compared, there was no significant difference observed in outcome (P >.05).

CONCLUSION

Either by employing the technique of clipping or by coil embolization, treatment of unruptured intracranial aneurysms resulted in relief of headaches in majority of patients who had headaches pre-operatively.

Managing the “difficult” headache patient

This article reviews the challenges in managing the more complicated headache patient. These patients often have chronic daily headache or high-frequency disabling migraine. Some patients have problems adhering to treatment regimens, which may reduce treatment efficacy and in some patients lead to medication misuse and overuse. Medication overuse may transform headache to daily and reduce the effectiveness of acute and preventive therapies. There is an elevated risk of mood and anxiety disorders in migraine, with even greater risk in chronic migraine. Personality disorders may further compromise treatment efforts. Current research is reviewed on these issues and clinical suggestions are provided for more effective management of these challenging patients.

Effect of valproic acid on withdrawal therapy in patients with overuse of chronic daily headache medications

Discontinuation of medication is the treatment of choice for patients with chronic daily headache (CDH) who overuse their medications. This treatment may be difficult due to increased headache severity observed in patients immediately after withdrawal. We retrospectively evaluated the efficacy of valproic acid therapy in 66 patients with overuse of CDH medication during withdrawal therapy. Patients were all withdrawn from medications and valproic acid started at 250 mg or 500 mg daily. Forty-two (63.6%) patients had decreased headache severity, including 27.3% objective responses in the first week. At the last visit in the 12th week, 50 patients were headache-free and only one patient had persistent headache. Fifteen patients withdrew from therapy due to side effects and lost to follow-up within this timeframe. Thus, low dose valproic acid appears to be safe and effective in the management of withdrawal therapy.

Fibrous myopathy as a complication of repeated intramuscular injections for chronic headache

Two cases of fibrous myopathy associated with repeated, long-term intramuscular injections for treatment of chronic temporomandibular joint pain and chronic headache, respectively, are described. Both patients developed severe, function-limiting contractures in upper and lower extremity muscles used as injection sites. In one of the cases, the contractures were painful. Electrophysiological testing, magnetic resonance imaging and muscle biopsy results were all consistent with myopathy and replacement of skeletal muscle with noncontractile fibrous tissue. These cases are presented to increase awareness of fibrous myopathy and to promote surveillance for this serious potential complication of long-term intramuscular injections in chronic headache and other pain patients.

Factors associated with depression in patients referred to headache specialists

OBJECTIVE

To evaluate the relationship between selected demographic characteristics and clinical features in patients with headache and depression.

METHODS

We studied demographic and clinical data collected at the time of consultation for 712 new patients with headache referred to five headache specialty clinics in Canada. Data were analyzed as part of the Canadian Headache Outpatient Registry and Database (CHORD) Project. The Beck Depression Inventory (BDI-II) was used to identify the presence of depression. Multivariable logistic regression analysis was employed to evaluate associations between age, gender, employment status, marital status, diagnosis, headache days per month, medication overuse, headache impact (HIT-6), and headache disability (MIDAS) and the presence of depression as measured by the BDI-II.

RESULTS

Among the sample of patients with headache, 27% (n = 189) had moderate to severe depression. Factors independently associated with depression included age less than 50 years, being unemployed, being on disability pension or welfare, being widowed, separated, or divorced, a diagnosis of transformed migraine or headache associated with head trauma or cervical spine disorder, and showing severe headache impact as measured by the HIT-6, or severe disability as measured by the MIDAS.

CONCLUSIONS

In patients with headache referred for specialist consultation, depression is strongly associated with being on disability or welfare, unemployment, age under 50 years, showing severe headache impact on the Headache Impact Test-6, and receiving a diagnosis of transformed migraine. The possibility of a concomitant depression should be strongly considered in patients with headache with any of these characteristics.

Psychiatric comorbidity of migraine

Migraine affects nearly 12% of the adult population in the United States and causes significant lost productivity and decrements in health-related quality of life. The burden of migraine and the challenge in managing it are increased by the comorbid psychiatric conditions that occur in association with it. Studies in both clinical and community-based settings have demonstrated an association between migraine and a number of specific psychiatric disorders. This review will focus on the relationships between migraine and depression, generalized anxiety disorder, panic disorder, and bipolar disorder. In large scale population-based studies, persons with migraine are from 2.2 to 4.0 times more likely to have depression. In longitudinal studies, the evidence supports a bidirectional relationship between migraine and depression, with each disorder increasing the risk of the other disorder. Migraine is also comorbid with generalized anxiety disorder (Odds Ratio [OR] 3.5 to 5.3), panic disorder (OR 3.7), and bipolar disorder (OR 2.9 to 7.3). A diagnosis of migraine should lead to a heightened level of diagnostic suspicion for these comorbid psychiatric disorders. Similarly, a diagnosis of one of these psychiatric disorders should increase vigilance for migraine. Treatment plans for migraine should be mindful of the comorbid conditions.

An approach to children with chronic daily headache

Chronic daily headache is a condition that affects 2 to 4% of adolescent females and 0.8 to 2% of adolescent males. It is manifested by severe intermittent headaches, as well as a chronic baseline headache. Chronic daily headache is diagnosed when headaches occur for greater than or equal to 15 headache days per month, over a period of 3 consecutive months, and with no underlying pathology. The headaches last for more than 4 hours a day. Patients with chronic daily headache will frequently have sleep disturbance, pain at other sites, dizziness, worsening anxiety and mood, and school absence. Successful approaches to treatment include education, use of preventative medication, avoidance of analgesics, and helping the children work their way back into a functional daily routine.

Coexistence of TACS and Trigeminal Neuralgia: Pathophysiological Conjectures

BACKGROUND

Trigeminal autonomic cephalgias (TACs) and trigeminal neuralgia are short-lasting unilateral primary headaches whose study is providing insights into craniofacial pain mechanisms. We report on 2 patients in whom trigeminal neuralgia coexists with the TACs paroxysmal hemicrania and SUNCT.

CONCLUSION

Coexistence of trigeminal neuralgia with various TAC forms suggests a pathophysiological relationship between these short-lasting unilateral headaches.

Headache disability in orofacial pain patients

OBJECTIVE

To retrospectively examine the reported history of and the disability caused by headaches in patients presenting for evaluation and treatment of orofacial pain.

BACKGROUND

More than 81% of patients with the chief complaint of pain in the orofacial region concomitantly report pain in other body locations. Among the comorbidities frequently reported with orofacial pain are a variety of different headaches types, including migraines, tension type headaches, and chronic daily headaches. The extent of the disability caused by those headache complaints in a large patient population is unknown.

METHODS

The Migraine Disability Assessment (MIDAS) is administered to all patients as a part of the initial assessment at the Orofacial Pain Center. This investigation is retrospectively examined the reported history of and the disability caused by headaches in patients who presented for evaluation and treatment of orofacial pain in the Orofacial Pain Center, National Naval Medical Center, Bethesda, MD, between the dates of 1 September 2003 and 1 December 2004.

RESULTS

In the present study 261 (61.3%) patients reported a headache complaint and 100 (38%) fulfilled the criteria for migraine with or without aura. MIDAS scores were reported by 55.3% of 426 patients with the mean score of 23.68. There were no significant differences in MIDAS scores in relation to the presence or absence of an intracapsular disorder. Patients with masticatory and/or cervical myalgia demonstrated significantly higher MIDAS scores when compared to patients without myalgia.

CONCLUSIONS

These findings clearly demonstrate the necessity for evaluation of headache and related disability in orofacial pain patients.

The prevalence and spectrum of sleep problems in women with transformed migraine

OBJECTIVES

It is our clinical observation that patients with transformed migraine (TM) almost invariably report nonrestorative sleep. In this study we sought first to validate that clinical observation, then to describe the prevalence and spectrum of factors that might contribute to nonrestorative sleep in a TM population.

BACKGROUND

Although headaches have been linked with sleep problems for over a century, there is little information about the spectrum or prevalence of specific sleep problems associated with TM in adults.

METHODS

We conducted a detailed sleep interview on 147 consecutive women with TM. Subjective sleep quality was assessed by asking patients to describe their state upon awakening as "refreshed" or "tired."

RESULTS

None of the 147 patients reported awakening "refreshed," and 83.7% stated that they awakened "tired." Sleep complaints were prevalent and varied in this population.

CONCLUSIONS

Although the relationship between pain and sleep is complex and ill understood, we found a very high prevalence of nonrestorative sleep and a similarly high prevalence of modifiable poor sleep habits in patients with TM. Since behavioral approaches have been found effective in improving sleep quality in patients with poor sleep hygiene, we propose that studies be undertaken to assess the impact of such treatment on TM.

Headache and mood disorders

The aim of the study was to estimate the occurrence of mood, anxiety and disability disorders in 300 patients affected by chronic daily headache and MOH, who were observed for a 16–month period in our centre. We monitored the patients on an interview basis, concerning the anamnestic data collection related to the pre–morbid period, information given by relatives regarding the patient’s behaviour during the day, attitudes towards others, maintenance of previous interests and enjoyments, and modifications of the biological rhythm. Several tests were conducted, underlining a significant correlation between headache and mood disorders, impairment of working activity, social and family life. The study shows that patients affected by chronic daily headache and MOH present high levels of anxiety, a depressive symptomatology associated with alexithymia. Moreover, it has been discovered that anxiety and depression facilitate the onset of headache, while patients suffering from pain persistence were more vulnerable to psychiatric problems. In consideration of these results, more exhaustive evaluations relating to the psychopathological aspects in patients affected by headache are necessary.

What is the impact, prevalence, disability, and quality of life of pediatric headache?

Pediatric headache is a common health problem in children, with a significant headache reported in more than 75% by the age of 15 years. Pediatric migraine occurs in up to 10.6% of children between the ages of 5 and 15 years and in up to 28% of adolescents between the ages of 15 and 19 years. Given this high frequency, the impact of this disease on the lives of these children and their parents can be quite significant. This impact can be assessed with disease-specific disability and impairment as well as disease non-specific effects on quality of life. The goal of evaluation should be recognition of this impact, whereas the goal of management should be effective treatment that minimizes the impact of this disorder in the short term and for the life of the patient.

Pediatric SUNCT Syndrome

This report describes a 5-year-old male with sudden unilateral headache attacks (2-50 seconds) accompanied by conjunctival injection, lacrimation, and nasal congestion. The episodes occurred without a precipitating factor, never during sleep. Brain imaging was normal. The attacks resolved spontaneously within 5 months. This headache syndrome (short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing) was previously described in two other children aged 10 and 11.

Balance disorders in headache patients: evaluation by computerized static stabilometry

OBJECTIVES

The aim of the study was to investigate the occurrence of equilibrium disturbances in headache patients, during the interictal period, by computerized static stabilometry.

MATERIALS AND METHODS

Sixty-seven patients were studied: 35 with migraine without aura (MwoA), 12 with tension-type headache (TTH) in the episodic form (ETTH) + MwoA, and 20 with only TTH [10 ETTH + 10 chronic (CTTH)]. The stabilometric parameters considered were: statokinesigram length (L) and surface (S) in open (EO) and closed (EC) eyes conditions with/without occlusal bite, EC with head retroflexion (ECR), and optokinetic stimulation (OKN).

RESULTS

The alteration of at least one of the stabilometric parameters was observed in 45 patients (67.2%): 21 MwoA, 8 ETTH + MwoA, and 16 TTH (8 ETTH + 8 CTTH).

CONCLUSION

In TTH patients (ETTH, CTTH, ETTH + MwoA), the stabilometric findings show a proprioceptive alteration induced by cervicofacial muscle contraction, which was peripheral in origin. In MwoA patients the alterations appear under OKN and support a control impairment in involuntary oculomotility of central origin.