New daily persistent headache after SARS-CoV-2 infection in Latin America: a cross-sectional study

BACKGROUND

Persistent headache is a frequent symptom after coronavirus disease 2019 (COVID-19) and there is currently limited knowledge about its clinical spectrum and predisposing factors. A subset of patients may be experiencing new daily persistent headache (NDPH) after COVID-19, which is among the most treatment-refractory primary headache syndromes.

METHODS

We conducted a cross-sectional study in Latin America to characterize individuals with persistent headache after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and to identify factors associated with NDPH. Participants over 18 years old who tested positive for SARS-CoV-2 infection and reported persistent headache among their symptoms completed an online survey that included demographics, past medical history, persistent headache clinical characteristics, and COVID-19 vaccination status. Based on participants' responses, NDPH diagnostic criteria were used to group participants into NDPH and non-NDPH groups. Participant data was summarized by descriptive statistics. Student's t and Mann-Whitney U tests were used according to the distribution of quantitative variables. For categorical variables, Pearson's chi-square and Fisher's exact tests were used according to the size of expected frequencies. Binomial logistic regression using the backward stepwise selection method was performed to identify factors associated with NDPH.

RESULTS

Four hundred and twenty-one participants from 11 Latin American countries met the inclusion criteria. One in four participants met the NDPH diagnostic criteria. The mean age was 40 years, with most participants being female (82%). Over 90% of the participants reported having had mild/moderate COVID-19. Most participants had a history of headache before developing COVID-19 (58%), mainly migraine type (32%). The most predominant clinical characteristics in the NDPH group were occipital location, severe/unbearable intensity, burning character, and radiating pain (p < 0.05). A higher proportion of anxiety symptoms, sleep problems, myalgia, mental fog, paresthesia, nausea, sweating of the face or forehead, and ageusia or hypogeusia as concomitant symptoms were reported in participants with NDPH (p < 0.05). Palpebral edema as a concomitant symptom during the acute phase of COVID-19, occipital location, and burning character of the headache were risk factors associated with NDPH.

CONCLUSION

This is the first study in Latin America that explored the clinical spectrum of NDPH after SARS-CoV-2 infection and its associated factors. Clinical evaluation of COVID-19 patients presenting with persistent headache should take into consideration NDPH.

Headaches and obesity

Obesity and headache disorders are two very common conditions in the general population that have been increasing in incidence over the last decades. Recent studies have shown a significant relationship between obesity and headaches, particularly migraine, with an important role in whether the disease is chronic. On the other hand, no such association was found with tension-type headaches. Studies showing an overlapping of hunger-control pathways and those involved in the pathophysiology of migraine may justify the close association between obesity and migraine. Moreover, a secondary headache for which obesity is a strong risk factor is idiopathic Intracranial Hypertension (pseudotumor cerebri), with several studies showing the impact of weight reduction/bariatric surgery in the treatment of the disease. In conclusion, since obesity is a modifiable risk factor, it is important for physicians treating patients with headaches, and particularly migraine, to be aware of the association between these two disorders.

Relation of hypertension with episodic primary headaches and chronic primary headaches in population of Rafsanjan cohort study

Headache has a variety of types, such as episodic primary headaches (EPH) and chronic primary headache (CPH) in its primary form. There is a positive correlation between these two types of headaches and hypertension (HTN), but in some works this correlation has been reported negatively. Therefore, we planned to study HTN-CPH as well as HTN-EPH correlation in our population. A sample of Rafsanjan population (10,000 individuals) entered the cohort study, as one of the Prospective Epidemiological Research Studies in Iran (PERSIAN). We compared the frequency of HTN categories in CPH and EPH cases with a normal population. Out of 9933 participants (46.6% males and 53.4% females) about 29% had EPH and 7.5% had CPH. HTN was found in 24.27% of EPH cases and 31.98% of CPH cases. HTN was also found to be associated with EPH and CPH in the crude model. Two Categories of HTN (Long controlled and uncontrolled) were not associated with EPH. On the other hand, CPH showed associations with all of the HTN categories. After included all variables and confounders, EPH and CPH had association with HTN without any considerable changes. There is strong HTN-EPH as well as HTN-CPH correlations in the studied population.

The Relationship of Psychiatric Comorbidities and Their Impact on Trigger Site Deactivation Surgery for Headaches

BACKGROUND

Patients seeking trigger site deactivation surgery for headaches often have debilitating symptoms that can affect their functional and mental health. Although prior studies have shown a strong correlation between psychiatric variables and chronic headaches, their associations in patients undergoing surgery have not been fully elucidated. This study aims to analyze psychiatric comorbidities and their impact on patients undergoing trigger site deactivation surgery for headaches.

METHODS

One hundred forty-two patients were prospectively enrolled. Patients were asked to complete the Patient Health Questionnaire-2 and Migraine Headache Index surveys preoperatively and at 12 months postoperatively. Data on psychiatric comorbidities were collected by means of both survey and retrospective chart review.

RESULTS

Preoperatively, 38 percent of patients self-reported a diagnosis of depression, and 45 percent of patients met Patient Health Questionnaire-2 criteria for likely major depressive disorder (Patient Health Questionnaire-2 score of ≥3). Twenty-seven percent of patients reported a diagnosis of generalized anxiety disorder. Patients with depression and anxiety reported more severe headache symptoms at baseline. At 1 year postoperatively, patients with these conditions had successful surgical outcomes comparable to those of patients without these conditions. Patients also reported a significant decrease in their Patient Health Questionnaire-2 score, with 22 percent of patients meeting criteria suggestive of depression, compared to 45 percent preoperatively.

CONCLUSIONS

There is a high prevalence of depression and anxiety in patients undergoing trigger site deactivation surgery. Patients with these comorbid conditions achieve successful surgical outcomes comparable to those of the general surgical headache population. Furthermore, trigger site deactivation surgery is associated with a significant decrease in depressive symptoms.

Bilateral sphenoid sinus mucocele observed in Yaoundé-Cameroon: a case report

A mucocele is a cystic and expansive lesion of the sinus cavities. It is uncommon in the sphenoid sinus and its management is quite challenging especially in low to middle income countries like Cameroon. A 43-years-old female was referred to us by a neurologist for chronic headache and visual disturbances. The pain was unresponsive to analgesics. Physical examination was non-remarkable and a head CT scan realized showed a cyst-like lesion in the sphenoid sinus cavity. Surgical endoscopic treatment was proposed and realized with basic endoscopic instruments, consisting of opening the cavity with drainage of the mucocele. A large opening was made on the anterior wall of the sphenoid sinus, in order to ensure continuous drainage and prevent a recurrence. Sphenoid sinus mucocele is a rare condition, and its diagnosis can be difficult. Confirmation requires specific imaging and treatment is presently well established, but it can be managed with basic tools.

[Blepharyplasty as treatment of chronic headache]

Hemicrania continua (HC) is a primary chronic headache disorder characterised with a broad range of autonomic symptoms. In this case report a 29-year-old patient was bothered by appearance of a unilateral sharp pain located behind the right eye at the same spot where the headache usually was located. He was diagnosed with HC and treated with indomethacin with good effect. However, due to discomfort and hanging eyelids he underwent bilateral blepharoplasty, and the headache and pain resolved completely.

[Chronic headache caused by spontaneous intracranial hypotension]

Spontaneous intracranial hypotension (SIH) is a secondary headache disorder due to leakage of cerebrospinal fluid without a history of dural trauma. If not diagnosed in time, patients may develop invalidating headaches or even life-threatening complications. SIH diagnosis can be challenging as the presentation of the disease may vary significantly. In this case report of a classic course of disease in a 62-year-old woman, we illustrate challenges according to the diagnosis emphasising the importance to consider SIH as a differential diagnosis in cases of orthostatic but also atypical chronic headache.

Diagnosis and Management of Headache: A Review

IMPORTANCE

Approximately 90% of people in the US experience headache during their lifetime. Migraine is the second leading cause of years lived with disability worldwide.

OBSERVATIONS

Primary headache disorders are defined as headaches that are unrelated to an underlying medical condition and are categorized into 4 groups: migraine, tension-type headache, trigeminal autonomic cephalalgias, and other primary headache disorders. Studies evaluating prevalence in more than 100 000 people reported that tension-type headache affected 38% of the population, while migraine affected 12% and was the most disabling. Secondary headache disorders are defined as headaches due to an underlying medical condition and are classified according to whether they are due to vascular, neoplastic, infectious, or intracranial pressure/volume causes. Patients presenting with headache should be evaluated to determine whether their headache is most likely a primary or a secondary headache disorder. They should be evaluated for symptoms or signs that suggest an urgent medical problem such as an abrupt onset, neurologic signs, age 50 years and older, presence of cancer or immunosuppression, and provocation by physical activities or postural changes. Acute migraine treatment includes acetaminophen, nonsteroidal anti-inflammatory drugs, and combination products that include caffeine. Patients not responsive to these treatments may require migraine-specific treatments including triptans (5-HT1B/D agonists), which eliminate pain in 20% to 30% of patients by 2 hours, but are accompanied by adverse effects such as transient flushing, tightness, or tingling in the upper body in 25% of patients. Patients with or at high risk for cardiovascular disease should avoid triptans because of vasoconstrictive properties. Acute treatments with gepants, antagonists to receptors for the inflammatory neuropeptide calcitonin gene-related peptide, such as rimegepant or ubrogepant, can eliminate headache symptoms for 2 hours in 20% of patients but have adverse effects of nausea and dry mouth in 1% to 4% of patients. A 5-HT1F agonist, lasmiditan, is also available for acute migraine treatment and appears safe in patients with cardiovascular risk factors. Preventive treatments include antihypertensives, antiepileptics, antidepressants, calcitonin gene-related peptide monoclonal antibodies, and onabotulinumtoxinA, which reduce migraine by 1 to 3 days per month relative to placebo.

CONCLUSIONS AND RELEVANCE

Headache disorders affect approximately 90% of people during their lifetime. Among primary headache disorders, migraine is most debilitating and can be treated acutely with analgesics, nonsteroidal anti-inflammatory drugs, triptans, gepants, and lasmiditan.

Facemask headache: a new nosographic entity among healthcare providers in COVID-19 era

BACKGROUND

SARS-CoV-2 is a novel infectious agent causing coronavirus disease 2019, which has been declared as pandemic in March 2020. Personal protective equipment has been mandatory for healthcare workers in order to contain the outbreak of pandemic disease. Mild neurological disturbances such as headache have been related to the extensive utilization of facemask. This study aims to examine headache variations related to the intensive utilization of facemask among a cohort of healthcare professionals in a setting of low-medium risk of exposure to SARS-CoV-2.

METHODS

This is a cross-sectional study among healthcare providers from different hospital and clinics in Italy. Each participant completed a specifically designed self-administered questionnaire. Headache features and outcome measures' change from baseline were evaluated over a 4-month period, in which wearing facemask has become mandatory for Italian healthcare workers.

RESULTS

A total of 400 healthcare providers completed the questionnaire, 383 of them met the inclusion criteria. The majority were doctors, with a mean age of 33.4 ± 9.2 years old. Among 166/383 subjects, who were headache free at baseline, 44 (26.5%) developed de novo headache. Furthermore, 217/383 reported a previous diagnosis of primary headache disorder: 137 were affected by migraine and 80 had tension-type headache. A proportion (31.3%) of these primary headache sufferers experienced worsening of their pre-existing headache disorder, mainly for migraine frequency and attack mean duration.

CONCLUSIONS

Our data showed the appearance of de novo associated facemask headache in previous headache-free subjects and an exacerbation of pre-existing primary headache disorders, mostly experienced by people with migraine disease.

Body site distribution of pediatric-onset morphea and association with extracutaneous manifestations

BACKGROUND

The distribution of pediatric-onset morphea and site-based likelihood for extracutaneous complications has not been well characterized.

OBJECTIVE

To characterize the lesional distribution of pediatric-onset morphea and to determine the sites with the highest association of extracutaneous manifestations.

METHODS

A retrospective cross-sectional study was performed. Using clinical photographs, morphea lesions were mapped onto body diagrams using customized software.

RESULTS

A total of 823 patients with 2522 lesions were included. Lesions were more frequent on the superior (vs inferior) anterior aspect of the head and extensor (vs flexor) extremities. Linear morphea lesions were more likely on the head and neck, whereas plaque and generalized morphea lesions were more likely on the trunk. Musculoskeletal complications were more likely with lesions on the extensor (vs flexor) extremity (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.2-3.4), whereas neurologic manifestations were more likely with lesions on the anterior (vs posterior) (OR, 2.8; 95% CI, 1.7-4.6) and superior (vs inferior) aspect of the head (OR, 2.3; 95% CI, 1.6-3.4).

LIMITATIONS

Retrospective nature and the inclusion of only patients with clinical photographs.

CONCLUSION

The distribution of pediatric-onset morphea is not random and varies with body site and within individual body sites. The risk stratification of extracutaneous manifestations by body site may inform decisions about screening for extracutaneous manifestations, although prospective studies are needed.

Sigmoid Sinus Thrombosis with Cerebellar Tuberculous Abscess: A Rare Case of Chronic Headache with Vision Loss

Cerebral venous sinus thrombosis (CVST) is a rare form of brain stroke which is often misdiagnosed. We present a case of CVST due to cerebellar tuberculous abscess. A 41-year female patient was admitted with chronic occipital headache, diminished vision, and fever. The initial brain CT scan was negative, but subsequent imaging (MRI with MRV) showed cerebellar abscess with sigmoid sinus thrombosis. Fundoscopy revealed bilateral optic atrophy. Marked improvement (subjective and objective) was noted after 4 weeks with anti-tuberculosis chemotherapy and anticoagulants. Vision loss was irreversible due to optic atrophy. The case is extremely rare due to the location, rare causative organism (tuberculosis) and complex clinical presentation (occipital headache with vision loss).

Points & Pearls: Evaluation and management of life-threatening headaches in the emergency department

Headache is the fourth most common reason for emergency department encounters, accounting for 3% of all visits in the United States. Though troublesome, 90% are relatively benign primary headaches --migraine, tension, and cluster headaches. The other 10% are secondary headaches, caused by separate underlying processes, with vascular, infectious, or traumatic etiologies, and they are potentially life-threatening. This issue details the important pathophysiologic features of the most common types of life-threatening headaches, the key historical and physical examination information emergency clinicians must obtain, the red flags that cannot be missed, and the current evidence for best-practice testing, imaging, treatment, and disposition. [Points & Pearls is a digest of Emergency Medicine Practice.]

Assessment of acute headache in adults - what the general physician needs to know

Headache is common. Up to 5% of attendances to emergency departments and acute medical units are due to headache. Headache is classified as either primary (eg migraine, cluster headache) or secondary to another cause (eg meningitis, subarachnoid haemorrhage). Even in the acute setting the majority of cases are due to primary causes. The role of the attending physician is to take a comprehensive history to diagnose and treat benign headache syndromes while ruling out sinister aetiologies. This brief article summarises the approach to assessment of headache presenting in acute and emergency care.

Tracking patients with chronic occipital headache after occipital nerve decompression surgery: A case series

BACKGROUND

The therapeutic benefit of nerve decompression surgeries for chronic headache/migraine are controversial.

AIM

To provide clinical characteristics of headache type and treatment outcome of occipital nerve decompression surgery.

METHODS

A retrospective review of clinical records. Inclusion criteria were evidence of chronic occipital headache with and without migrainous features and tenderness of neck muscles, occipital allodynia, and inadequate response to prophylactic drugs.

RESULTS

Surgical decompression of the greater and lesser occipital nerves provided complete and extended (3-6 years) relief of new daily persistent headache in case 3 (46 year old female), and of chronic post-traumatic headache in cases 4 and 6 (35 and 30 year old females, respectively), partial relief of chronic headache/migraine in cases 1 and 2 (41 year old female and 36 year old male), and no relief of episodic (cases 3 and 4) or chronic migraine (case 5, 52 year old male), or chronic tension-type headache (case 7, 31 year old male).

CONCLUSIONS

As a case series, this study cannot test a hypothesis or determine cause and effect. However, the complete elimination of new daily persistent headache and post-traumatic headache, and the partial elimination of chronic headache/migraine in two patients - all refractory to other treatment approaches - supports and justifies the effort to continue to generate data that can help determine whether decompression nerve surgeries are beneficial in the treatment of certain types of chronic headache.

[Occipital condyle syndrome as the first symptom of a metastatic hepatocellular carcinoma. Two case reports]

INTRODUCTION

Occipital condyle syndrome consists of the presence of unilateral occipital headache exacerbated by moving the head and is accompanied by paralysis of the ipsilateral hypoglossal nerve. One of its causes is infiltration of the base of the skull by bone metastases, especially those affecting the hypoglossal nerve due to infiltration as it passes through the osseous canal.

CASE REPORTS

We report two clinical cases of occipital condyle syndrome secondary to metastatic hepatocarcinoma. The first is that of a 52-year-old male with liver cirrhosis secondary to liver pathology caused by hepatitis C virus with occipital condyle syndrome as the presenting symptom in disseminated hepatocarcinoma. The second case is that of a 56-year-old male after recurrence of hepatocarcinoma following a liver transplant, despite not fulfilling the Milan criteria.

CONCLUSION

Occipital condyle syndrome is an alarm symptom and requires a thorough study by means of imaging tests, since it may be the first symptom of an undetected hepatocarcinoma.

[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.

Temporomandibular disorders in adolescents with headache

BACKGROUND

Headache is a common complaint in all age groups and is a frequent cause of medical consultations and hospitalization.

OBJECTIVES

The aim of this study was to evaluate the prevalence of bite and non-bite parafunctions as well as the signs and symptoms of temporomandibular disorder (TMD) in adolescents presenting with primary headaches.

MATERIAL AND METHODS

Parents of adolescents presented with headaches to the Department of Developmental Neurology within a 12-month period were asked to complete a questionnaire developed by the authors of this study. Of the 1000 patients evaluated, 19 females and 21 males, aged 13 to 17 years, met the inclusion criterion - a confirmed clinical diagnosis of migraine or a tension headache according to the International Classification of Headache Disorders, 2nd edition. The diagnostic algorithm of the study group consisted of a full medical history, an assessment of the occurrence of bite habits and a physical examination based on the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD).

RESULTS

Bite and non-bite parafunctions were found in 36 of the study group patients. A significant difference (p = 0.0003) between the number of bite parafunctions and non-bite parafunctions was found in females but not in males. However, bite parafunctions were more frequent in boys compared to girls (p = 0.01).

CONCLUSIONS

Our findings suggest that it may be useful for pediatricians and neurologists to include TMD dysfunctions as a part of a standard examination of adolescents presenting with persistent headaches.

Life-Threatening Headaches in Children: Clinical Approach and Therapeutic Options

Life-threatening headaches in children can present in an apoplectic manner that garners immediate medical attention, or in an insidious, more dangerous form that may go unnoticed for a relatively long period of time. The recognition of certain clinical characteristics that accompany the headache should prompt recognition and referral to an institution equipped with neuroimaging facilities, pediatric neurosurgeons, and neurologists. Thunderclap headaches, which reach a peak within a very short period of time, may be the presenting feature of conditions such as arterial dissection, venous sinus thrombosis, and reversible cerebral vasoconstriction syndrome, which can be addressed by specific pharmacological options instituted in an intensive care setting. On the other hand, subacute to chronic headaches that are accompanied by focal neurological signs, such as abducens nerve palsy, restriction of upward gaze, or papilledema, may be indicative of the need for urgent imaging and neurosurgical referral. [Pediatr Ann. 2018;47(2):e74-e80.].

Headache in the first manifestation of Multiple Sclerosis - Prospective, multicenter study

Objectives

Multiple sclerosis (MS) is the most frequent immune-mediated inflammation of the central nervous system that can lead to early disability. Headaches have not been considered as MS-related symptoms initially, whereas higher prevalence rates were reported since 2000. Postmortem histological analyses of MS patients' brains revealed lymphoid follicle-like structures in the cerebral meninges which suggest a possible pathophysiological explanation for the high headache prevalence in MS. The aim of this study was to evaluate headache characteristics during the first clinical event of MS.

Methods

In a prospective, multicenter study, 50 patients with the diagnosis of CIS or MS were recruited. All participants were screened for the presence of headache within the last 4 weeks with help of the Rostock Headache Questionnaire (Rokoko).

Results

Thirty-nine of fifty questioned patients (78%) reported headaches within the last 4 weeks. Most patients suffered from throbbing and pulsating headaches (25, 50%), 15 (30%) reported stabbing, 14 (28%) dull and constrictive headaches.

Conclusions

Headaches were prevalent in 78% of patients in our population with newly diagnosed CIS and MS. It is among the highest prevalence rates reported so far in patients with CIS or MS. Thus, headache, especially of a migraneous subtype, is a frequent symptom within the scope of the first manifestation of multiple sclerosis. If it were possible to define a MS-typical headache, patients with these headaches and with typical MRI results would be classified as CIS or early MS instead of radiologically isolated syndrome and treated accordingly with an immunomodulatory therapy.

VITOM 3D: Preliminary Experience in Cranial Surgery

BACKGROUND

Optimal vision and ergonomics are important factors contributing to achievement of good results during neurosurgical interventions. The operating microscope and the endoscope have partially filled the gap between the need for good surgical vision and maintenance of a comfortable posture during surgery. Recently, a new technology called video-assisted telescope operating monitor or exoscope has been used in cranial surgery. The main drawback with previous prototypes was lack of stereopsis. We present the first case report of cranial surgery performed using the VITOM 3D, an exoscope conjugating 4K resolution view and three-dimensional technology, and discuss advantages and disadvantages compared with the operating microscope.

CASE DESCRIPTION

A 50-year-old patient with vertigo and headache linked to a petrous ridge meningioma underwent surgery using the VITOM 3D. Complete removal of the tumor and resolution of symptoms were achieved. The telescope was maintained over the surgical field for the duration of the procedure; a video monitor was placed at 2 m from the surgeons; and a control unit allowed focusing, magnification, and repositioning of the camera.

CONCLUSIONS

VITOM 3D is a video system that has overcome the lack of stereopsis, a major drawback of previous exoscope models. It has many advantages regarding ergonomics, versatility, and depth of field compared with the operating microscope, but the holder arm and the mechanism of repositioning, refocusing, and magnification need to be ameliorated. Surgeons should continue to use the technology they feel confident with, unless a distinct advantage with newer technologies can be demonstrated.

Use of Intraoperative Navigation for Reconstruction of the C1 Lateral Mass After Resection of Aneurysmal Bone Cyst

BACKGROUND

Aneurysmal bone cysts (ABCs) are rare blood-filled cystic lesions that are found in the long bones and spine. Here, we present a case of an ABC found in the lateral mass and lamina of C1. Lesions in this area provide a surgical challenge because of its difficulty to access as well as its need for reconstruction. We describe a novel use of intraoperative navigation (ION) to assist in the placement of a C1 lateral mass titanium cage.

CASE DESCRIPTION

An 18-year-old female patient presented with headaches and progressive neck pain. Imaging revealed a large cystic lesion involving the C1 lamina and right lateral mass. The patient underwent ION-assisted aggressive intralesional resection of the ABC and reconstruction of the C1 lateral mass with a static titanium cage, supplemented with posterior fusion from the occiput to C3. At 2-year follow-up, there was no evidence of recurrence and the hardware remained intact.

CONCLUSIONS

ION is a useful aid in assessing the extent of tumor resection and performing cage reconstruction of the C1 lateral mass.

An Unusually Large Carbuncle of the Temporofacial Region Demonstrating Remarkable Post-debridement Wound Healing Process: A Case Report

Skin carbuncles are debilitating skin infections commonly seen in elderly patients with diabetes. These infections develop when a cluster of adjacent furuncles coalesce to form one inflammatory mass. While they commonly occur on the nape of the neck and back, rarer sites involving the face and head have been noted. Management of these rare sites is urgent because of the potential intracranial complications and the surgical outcome is often unsatisfactory due to associated facial scarring. Intraoral drainage is advocated to avoid this; however, when the carbuncle involves a larger area, debridement from the exterior is necessary. The resultant soft-tissue defect requires a skin graft or a flap for coverage, but this may still lead to an unsatisfactory cosmetic outcome. The authors report a case of a carbuncle involving an extensive area over the right temporofacial region, including its management and the remarkable post-debridement cosmetic outcome despite avoidance of plastic surgery techniques due to the patient's high risk associated with anesthesia.

Effect of exclusion of frequently consumed dietary triggers in a cohort of children with chronic primary headache

BACKGROUND

Although dietary factors are known to trigger headaches, the relationship between food and headache in children remains unclear. This prospective, observational case series aimed to evaluate the effect of exclusion of frequently-consumed foods in a cohort of children with headache.

METHODS

One hundred and fifteen children aged 3-15 (mean 10.5) years with primary headache were followed in a paediatric outpatient clinic. Patients who frequently consumed foods or food additives known to trigger headaches were advised to exclude them for six weeks and to return for follow-up with headache and food diary.

RESULTS

One hundred patients attended follow-up. Of these 13 (13%) did not respond to dietary exclusion; 87 (87%) achieved complete resolution of headaches by exclusion of 1-3 of the identified food(s). Caffeine was the most common implicated trigger (28), followed by monosodium glutamate (25), cocoa (22), aspartame (13), cheese (13), citrus (10) and nitrites (six). One patient was sensitive to tomatoes.

CONCLUSIONS

This study demonstrates the potential scale and significance of seven frequently consumed foods or food additives as triggers for primary headache in children. Also this is the first study to show that headaches can be triggered by the cumulative effect of a food that is frequently consumed, rather than by single time ingestion.

Cervical Spine Joint Hypermobility: A Possible Predisposing Factor for New Daily Persistent Headache

The objective of this study was to suggest that joint hypermobility (specifically of the cervical spine) is a predisposing factor for the development of new daily persistent headache (NDPH). Twelve individuals (10 female, 2 male) with primary NDPH were evaluated by one of two physical therapists. Each patient was tested for active cervical range of motion and for the presence of excessive intersegmental vertebral motion in the cervical spine. All patients were screened utilizing the Beighton score, which determines degree of systemic hypermobility. Eleven of the 12 NDPH patients were found to have cervical spine joint hypermobility. Ten of the 12 NDPH patients had evidence of widespread joint hypermobility with the Beighton score. Based on our findings we suggest that joint hypermobility, specifically of the cervical spine, may be a predisposing factor for the development of NDPH.

Significant improvement of intractable headache after transsphenoidal surgery in patients with pituitary adenomas; preoperative neuroradiological evaluation and intraoperative intrasellar pressure measurement

OBJECT

Headache is the most common symptom of both primary and metastatic brain tumor, and is generally considered the primary symptom in patients with large pituitary adenomas. However, patients with small pituitary adenomas rarely complain of intractable headache, and neurosurgeons are unsure whether such small adenomas actually contribute to headache. If conventional medical treatments for headache prove ineffective, surgical removal of the adenoma can be considered as an alternative management strategy.

METHODS

We conducted a retrospective review of 180 patients who underwent transsphenoidal surgery (TSS) for pituitary adenomas at Kanazawa University Hospital between 2006 and 2014. Patients with acute phase intratumoral hemorrhage were excluded. We identified nine patients with intractable headache as the chief complaint associated with small pituitary adenoma (diameters 15.8 ± 2.6 mm, 11-20 mm), non-functioning in eight, and prolactin-secreting in one. The preoperative neuroradiological studies and headache characteristics were assessed retrospectively, and the intrasellar pressure evaluation was performed during TSS in the last seven patients.

RESULTS

All nine patients had complete or substantial resolution of their formerly intractable headache after TSS. Headaches consisted of ocular pain ipsilateral to the adenoma localization within the sella in four cases and bifrontal headache in five. Magnetic resonance imaging of these patients revealed small diaphragmatic foramen, which were so narrow that only the pituitary stalk could pass. Computed tomography scans showed ossification beneath the sellar floor in the sphenoid sinus, presellar type in six cases, and choncal type in three. The adenomas included cysts in seven cases. There was no cavernous sinus invasion. Intrasellar pressure measurements averaged 41.5 ± 8.5 mmHg, range 34-59, significantly higher than in control patients without headache (n = 12), namely 22.2 ± 10.6 mmHg (16-30).

CONCLUSION

In this study, the authors demonstrated the validity of TSS in the treatment of intractable headache associated with pituitary adenoma. The presence of ocular pain, especially ipsilateral to the adenoma, integrity of the diaphragm sella, and ossification in the sphenoid sinus, cyst or hemorrhage and the absence of cavernous sinus invasion were the indications for TSS for patients complaining of intractable headache and having pituitary adenomas.

rTMS in Alleviating Mild TBI Related Headaches--A Case Series

BACKGROUND

Headache is one of the most common debilitating chronic pain conditions in patients with mild traumatic brain injury. Conventional pharmacological treatments have not been shown to be effective in alleviating debilitating mild traumatic brain injury related headaches (MTBI-HA). Therefore, the development of an innovative non-invasive therapy in managing MTBI-HA is needed in the field of pain management. Repetitive transcranial magnetic stimulation (rTMS) utilizes a basic electromagnetic coupling principle in which a rapid discharge of electrical current is converted into dynamic magnetic flux, allowing the induction of a localized current in the brain for neuromodulation. The treatment is currently FDA approved for treating depression in the United States. Recent meta-analysis studies have implicated its usage in chronic pain management.

OBJECTIVE

The objective of the prospective case series is to assess the potential application of rTMS in alleviating MTBI-HA.

STUDY DESIGN

A prospective evaluation was conducted in patients with established diagnoses of MTBI-HA and treated with neuronavigational guided rTMS.

SETTING

The study was conducted at the Veteran Administration San Diego Healthcare System where over 400 patients with MTBI were being evaluated annually by the Rehabilitation Medicine Service. A fraction of this patient population was referred and evaluated in the Anesthesia Pain Clinic for the consideration of rTMS for their headaches.

METHODS

A prospective case series was conducted with human subject protection committee approval. Patients with established diagnoses of MTBI and constant headaches rated at = 4 on a 0 - 10 Numerical Rating Pain Scale (NRPS), and on stable headache medication regimens were selected to receive the treatment. Four sessions of rTMS were delivered to specific areas of cortices over a 2-month period. Patients' average intensities of lingering constant headaches (defined as duration of headache lasting more than 48 hours), and the average frequency (number of severe headache episodes per day), intensity (NRPS), and duration (hours) of headache exacerbations were assessed before and after the rTMS treatment protocol.

RESULTS

Six men (average age of 50) with MTBI-HA received the rTMS treatment protocol. Average pre and post-rTMS constant headache scores (± SD) on the NRPS were 5.50 (± 1.38) and 2.67 (± 1.75), respectively, with an average post-rTMS headache intensity reduction of 53.05% (± 19.90). The average headache exacerbation frequency (episodes per week) was reduced by 78.97% (±19.88) with 2 patients reporting complete cessation of severe headache episodes. For those (N = 4) with persistent headache exacerbations, the average duration and intensity of these exacerbations were reduced by 50.0% and 31.7%, respectively.

LIMITATIONS

This prospective evaluation provides the initial insight that rTMS may be beneficial in alleviating a debilitating chronic pain condition in patients with MTBI-HA. More controlled randomized studies should be conducted to validate its efficacy. Other co-existing cognitive and mood dysfunction should be assessed as well.

CONCLUSIONS

rTMS offers a non-invasive treatment option for MTBI-HA. The tested treatment protocol was well tolerated by the patients and can be adopted for future randomized controlled studies in further validating the treatment efficacy.

[Pharmacotherapy of headache apart from self-medication]

The pharmacotherapy of headache differentiates between self-medication and prescribed medication. Furthermore, pharmacotherapy has to consider the different headache disorders. In this article, the evidence-based treatment recommendations of the German Migraine and Headache Society for the different idiopathic headache disorders including trigeminal neuralgia are described. In addition, for most headache disorders acute and preventive medication has to be differentiated. It has to be noted that acute mediation against headache should not be taken too frequently and that in chronic headache disorders most often only a multimodal treatment results in a sufficient pain reduction.

Some unusual sports-related neurologic conditions

PURPOSE OF REVIEW

This article reviews some of the unusual sports-related neurologic disorders within the new and rapidly growing field of sports neurology that neurologists may encounter.

RECENT FINDINGS

Surfer's myelopathy is a potentially tragic disorder predominantly affecting novice surfers, leaving many who are affected by this condition with permanent paralysis. Neck-tongue syndrome is a rare primary headache disorder that can occur in athletes and nonathletes, and consists of paroxysmal neck and occipital pain and transient ipsilateral tongue numbness, triggered by sudden rotation of the neck. Athletes are also at risk for cervical arterial dissections, with golfers especially prone to vertebral rather than carotid dissections. Finally, "the yips" likely represents a form of occupational dystonia described in golfers.

SUMMARY

The syndromes described in this article range from relatively minor syndromes that cause discomfort or abnormal movement to potentially devastating cerebrovascular or myelopathic syndromes. Although the disorders described in this article are not common, they can affect individuals involved in sports at all levels, from the novice to the elite athlete, and may present to any neurologist. Neurologists should be aware of the potential for these syndromes to occur as a consequence of athletic activities in order to provide the most appropriate diagnosis, management, and counseling.

Prevalence and clinical hallmarks of primary exercise headache in middle-aged Japanese on health check-up

Objective We examined the prevalence and clinical features of primary exercise headache (PEH) in middle-aged Japanese population. Methods A headache specialist interviewed middle-aged subjects serially on health check-up. The primary headaches were diagnosed according to the International Classification of Headache Disorders (ICHD-III beta). Cardiovascular disease (CVD) risk and radiological findings were analyzed. Prevalence of PEH and clinical features were assessed. Results Among 2,546 subjects (1,588 men and 958 women), thirty subjects (13 men and 17 women) were diagnosed with PEH. The prevalence of PEH was 1.19%, 0.82% in men and 1.77% in women. The mean age [standard deviation (SD)] of the subjects was 44.3 (8.8) years and their mean duration (SD) of PEH was 4.5 (7.0) months. Headache occurred bilaterally (23 patients) or unilaterally (7 patients), and in the occipital (16 patients), frontal (10 patients) or diffuse region (4 patients). The persistent headache time ranged from 5 minutes to 12 hours. The degree of headache severity was classified as mild (13 patients), moderate (5 patients) or severe degree (12 patients). PEH was triggered by gym training (16 patients), swimming (6 patients), running (6 patient) and skiing (2 patients). All patients were exercise beginners or played a sport occasionally. No patients visited physicians for headache consultation. Other primary headaches coexisted in 20 patients (67%). Twenty patients had migraine without aura (MO). Seven patients had headache associated with sexual activity. Five patients had cough headache. Two patients had CVD risk factors. Conclusion The present study of PEH indicated the prevalence of 1.2% and the female/male ratio of 2.1 in middle-aged Japanese. The comorbidity rate of MO was high. PEH may not be an uncommon headache in middle-aged MO sufferers and sport beginners.

A Pediatric Case of Reversible Segmental Cerebral Vasoconstriction

Background:

Reversible segmental cerebral vasoconstriction (RSCV) is a recognizable clinical and radiographic syndrome consisting of thunderclap headache with or without focal neurological symptoms combined with reversible segmental vasoconstriction of proximal cerebral blood vessels.

Methods:

We report a case of reversible segmental cerebral vasoconstriction in a child.

Results:

A healthy 13-year-old boy experienced the sudden onset of a severe, diffuse headache upon surfacing from a deep dive in a swimming pool. Severity was maximal at the onset and improved over several hours. The same headache recurred three times over the next four days and a low baseline headache persisted throughout. Vomiting occurred once and mild photo/osmophobia were reported but throbbing, aura, or autonomic symptoms were absent. Focal neurological signs or symptoms were absent and he denied previous history of headaches, medications, drugs, or trauma. Two normal CT scans were performed within hours of separate headaches. Cerebrospinal fluid study on day 5 was bloody with no xanthochromia. MRI/MRA/MRV of the brain and vasculitic work-up were normal. Cerebral angiography on day 6 demonstrated smooth narrowing of multiple proximal cerebral vessels including supraclinoid internal carotid artery (ICA), M1, and A1 on the right and M1 on the left. By ten days, the patient's headaches had resolved and repeat angiography was normal.

Conclusion:

RSCV should be considered in a child with thunderclap headache.

The use of neuroimaging in the management of chronic headache in children in clinical practice versus clinical practice guidelines

In daily practice, neuroimaging studies are frequently performed for the management of childhood headache. The aim of this study was to determine whether there is significant discrepancy between clinical practice and clinical practice guidelines on the indications for neuroimaging studies. Medical records of children with chronic headache, aged 2 to 18 years and treated at Rijeka University Hospital Center, Kantrida Department of Pediatrics, were retrospectively reviewed. Indications for brain magnetic resonance imaging and computed tomography (MRI/CT) scanning were reviewed and compared with clinical practice guidelines. Brain imaging was performed in 164 (76.3%) of 215 children, MRI in 93 (56.7%) and CT in 71 (43.3%) children. Indications for brain MRI/CT were as follows: anxiety and/or insistence by the child's family (71.3%), presence of associated features suggesting neurologic dysfunction (13.4%), age under 5 years (12.8%) and abnormal neurologic examination (2.4%). The majority of children (71.4%) had normal neuroimaging findings. In the rest of imaging studies (28.1%), MRI/CT revealed different intracerebral/extracerebral findings not influencing changes in headache management. Only one (0.60%) patient required change in headache management after MRI/CT. Study results proved that, despite available evidence-based clinical guidelines, brain imaging in children with chronic headaches is overused, mostly in order to decrease anxiety of the family/patient.

Neuromodulation of the great auricular nerve for persistent post-traumatic headache

Headache is the most frequent reason for referral to an outpatient neurology and pain physician practice, with post-traumatic headache (PTH) accounting for approximately 4% of all symptomatic headaches. Headache following trauma has been reported for centuries. In this unique case report we will discuss the clinical course and successful headache treatment of a 57-year-old man diagnosed with PTHs. He suffered from chronic, intractable headaches resistant to multidisciplinary medical management for 4 years. A trial of electrical neuromodulation of the C2-C3 branches within the great auricular nerve (GAN) distribution was proposed as a potential long-term treatment for his chronic, intractable headaches after having several prior headache attacks successfully aborted with ultrasound-guided GAN blocks. Six months after permanent peripheral neurostimulator implantation, the patient reported a greater than 90% reduction in headache frequency, and was able to wean off all his previous prophylactic and abortive headache medications, with the exception of over-the-counter ibuprofen as needed. Subcutaneous electrode application over the branches of C2-C3-namely greater, lesser, and the least occipital nerves-for the treatment of chronic, intractable headache is not a new concept within pain medicine literature. However, subcutaneous electrode application, specifically over the GAN, is unique. The following case report chronicles the novel application of ultrasound-guided peripheral nerve stimulation of the GAN as an effective and safe long-term treatment for chronic, intractable primary headache. The positive outcome chronicled in this case presentation suggests that peripheral nerve stimulation of the GAN should be considered for highly select cases. To our knowledge, this is the first such case report describing GAN as a target for the management of PTH in the literature.

Chronobiological correlates of headache: three decades on

In 1983 an international symposium entitled "Chronobiological Correlates of Headache" was held in Capri. This meeting provided an opportunity to debate new and stimulating aspects of headache, in particular the temporal pattern of headache and the periodicity of the underlying biological and environmental phenomena. Giuseppe Nappi presented his dyschronic hypothesis of primary headaches, which was based on the observation that these conditions involve not only a dysfunction in pain control systems, but also a vulnerability of the rhythmic physiological organization of the central nervous system. He suggested that the hypothalamus played a key role in this vulnerability. Several decades on, thanks to the advent of new technologies (functional neuroimaging and neurophysiological studies), this hypothesis has been supported by scientific data.

Genetic mechanisms in the intergenerational transmission of health

This paper uses a sample of adoptees to study the genetic mechanisms underlying intergenerational associations in chronic health conditions. I begin by estimating baseline intergenerational models with a sample of approximately 125,000 parent-child pairs, and find that children with a parent who has a specific chronic health condition are at least 100% more likely to have the same condition themselves. To assess the role of genetic mechanisms in generating these strong correlations, I estimate models using a sample of approximately 2400 adoptees, and find that genetic transmission accounts for only 20-30% of the baseline associations. As falsification tests, I repeat this exercise using health measures with externally established levels of genetic determination (height and chicken pox), and the results suggest that comparisons of biological and adopted children are a valid method of isolating genetic effects in this sample. Finally, to corroborate these adoptee-based estimates, I examine health correlations among monozygotic twins, which provide an upper bound estimate of genetic influences, and find a similarly modest role for genetic transmission. I conclude that intergenerational health transmission is an important hindrance to overall socioeconomic mobility, but that the majority of transmission occurs through environmental factors or gene-environment interactions, leaving scope for interventions to effectively mitigate health persistence.

Ultrasound guided greater occipital nerve blocks for post-traumatic occipital neuralgia

Chronic headaches can be debilitating for many patients. They often have a nebulous etiology, unpredictable course, and can be difficult to manage. We describe a post-traumatic headache that began after a motor vehicle collision. The patient sustained multiple injuries including a scalp laceration and bilateral occipital condyle fractures. Oral agents were unable to quell this patient's headaches. The diagnosis of occipital neuralgia was suspected based on history and presentation. Our patient received dramatic relief after ultrasound guided bilateral greater occipital nerve blocks.

A systematic literature review of intracranial hypotension following chiropractic

BACKGROUND

Intracranial hypotension (IH) is caused by a leakage of cerebrospinal fluid (often from a tear in the dura) which commonly produces an orthostatic headache. It has been reported to occur after trivial cervical spine trauma including spinal manipulation. Some authors have recommended specifically questioning patients regarding any chiropractic spinal manipulation therapy (CSMT). Therefore, it is important to review the literature regarding chiropractic and IH.

OBJECTIVE

To identify key factors that may increase the possibility of IH after CSMT.

METHOD

A systematic search of the Medline, Embase, Mantis and PubMed databases (from 1991 to 2011) was conducted for studies using the keywords chiropractic and IH. Each paper was reviewed to examine any description of the key factors for IH, the relationship or characteristics of treatment, and the significance of CSMT to IH. In addition, other items that were assessed included the presence of any risk factors, neck pain and headache.

RESULTS

The search of the databases identified 39 papers that fulfilled initial search criteria, from which only eight case reports were relevant for review (after removal of duplicate papers or papers excluded after the abstract was reviewed). The key factors for IH (identified from the existing literature) were recent trauma, connective tissue disorders, or otherwise cases were reported as spontaneous. A detailed critique of these cases demonstrated that five of eight cases (63%) had non-chiropractic SMT (i.e. SMT technique typically used by medical practitioners). In addition, most cases (88%) had minimal or no discussion of the onset of the presenting symptoms prior to SMT and whether the onset may have indicated any contraindications to SMT. No case reports included information on recent trauma, changes in headache patterns or connective tissue disorders.

DISCUSSION

Even though type of SMT often indicates that a chiropractor was not the practitioner that delivered the treatment, chiropractic is specifically cited as either the cause of IH or an important factor. There are so much missing data in the case reports that one cannot determine whether the practitioner was negligent (in clinical history taking) or whether the SMT procedure itself was poorly administered.

CONCLUSIONS

This systematic review revealed that case reports on IH and SMT have very limited clinical details and therefore cannot exclude other theories or plausible alternatives to explain the IH. To date, the evidence that CSMT is not a cause of IH is inconclusive. Further research is required before making any conclusions that CSMT is a cause of IH. Chiropractors and other health practitioners should be vigilant in recording established risk factors for IH in all cases. It is possible that the published cases of CSMT and IH may have missed important confounding risk factors (e.g. a new headache, or minor neck trauma in young or middle-aged adults).

Management of chronic headache

BACKGROUND

Headache remains the most common cause of neurological consultation in clinical practice for which correct diagnosis and treatment are essential.

OBJECTIVE

This article provides a review of headache presentation and management, with an emphasis on chronic headaches and the differentiation between migraine and tension-type headache (TTH).

DISCUSSION

By far the most important diagnostic tool for proper headache diagnosis is the taking of a concise and representative history of the headaches. Migraine and TTH exist along a continuum and identification of the patient's position on this continuum has important implications for management.

Recurrent headache in children

Headache is a common symptom in paediatric hospital practice, the causes may be primary or secondary. A study was conducted in department of paediatrics from May 2005 to February 2007 in order to find out common causes for recurrent headache in children. A total of hundred children in age range of 3-14 years were included in the study. Children with secondary headache were excluded from the study. Various clinical characteristics were studied and based on these, types of headache were categorised using International Headache Society criteria. The most common type of headache observed was migraine (46%) followed by tension headache (31%), psychogenic headache (8%), mixed migraine and tension headache (7%) and other non-specific recurrent headaches (8%). There was clear cut female preponderance in adolescent patients having migraine. Tension headache is becoming a matter of concern in paediatric age group probably due to more competitive and stressful environment.