Primary Headaches

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

Chronic Paroxysmal Hemicrania in a Patient with a Macroprolactinoma

We report a patient with headaches meeting the criteria of chronic paroxysmal hemicrania, as defined by the International Headache Society classification. Headaches were fully responsive to indomethacin during the first 3 months of treatment but recurred when daily doses were lowered. Investigations revealed a macroprolactinoma. Headaches stopped after cabergoline treatment. This report further suggests that patients with paroxysmal hemicrania should be investigated for pituitary abnormalities.

Primary headache disorders

Primary headache disorders include migraine, tension-type headaches, and the trigeminal autonomic cephalgias (TACs). "Primary" refers to a lack of clear underlying causative pathology, trauma, or systemic disease. The TACs include cluster headache, paroxysmal hemicrania, and short-lasting neuralgiform headache attacks with conjunctival injection and tearing; hemicrania continua, although classified separately by the International Headache Society, shares many features of both migraine and the TACs. This article describes the features and treatment of these disorders.

Paroxysmal hemicrania responding to topiramate

Chronic paroxysmal hemicrania (CPH) is a rare primary headache syndrome, which is classified along with cluster headache and short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) as a trigeminal autonomic cephalalgia. CPH is exquisitely responsive to indomethacin so much so that the response is one of the current diagnostic criteria. The case of a patient with CPH, who had marked epigastric symptoms with indomethacin treatment and responded well to topiramate 150 mg daily, is reported. Cessation of topiramate caused return of episodes, and the response has persisted for 2 years. Topiramate may be a treatment option in CPH.

Update on the diagnosis and management of Trigemino-Autonomic Headaches

Severe shortlasting headaches are rare but very disabling conditions with a major impact on the patients' quality of life. Following the IHS criteria, these headaches broadly divide themselves into those associated with autonomic symptoms, so called trigeminal autonomic cephalgias (TACs), and those with few autonomic symptoms. The trigeminal-autonomic cephalgias include cluster headache, paroxysmal hemicranias, and a syndrome called SUNCT (short lasting unilateral neuralgic cephalgias with conjunctival injection and tearing). In all of these syndromes, hemispheric head pain and cranial autonomic symptoms are prominent. The paroxysmal hemicranias have, unlike cluster headaches, a very robust response to indomethacin, leading to a notion of indomethacin-sensitive headaches. Although TACs are, in comparison with migraine, quite rare, it is nevertheless very important to consider the clinical factor that they are easy to diagnose and the treatment is very effective in most patients.

[Headache induced by oral intake of metoprolol in a patient with chronic and limited cardiac tamponade]

The papers describing the secondary headache attributed simultaneously to vascular disorder beyond the head and neck and use of drug are lacking. There is no adequate position for that type of headache in the current classification of headache, either. The case of secondary headache induced by metoprolol in a 57-year-old patient with superior vena cava syndrome (SVCS) is reported. He suffered from chronic paroxysmal headache with accompanying rash and the superficial jugular veins were over-flown about 30 minutes after an intake of 25 mg of metoprolol. At the seventh day of hospital stay, the sudden death occurred. Postmortem examination showed the limited cardiac tamponade caused by aortal perforation and adhesive pericarditis SVCS produced by chronic, limited cardiac tamponade revealed after oral intake of metoprolol can be the cause of secondary headache that might be defined as "headache attributed to vascular disorder beyond the head and neck and related to medication for other indications".

Chronic paroxysmal hemicrania, hemicrania continua and SUNCT: the fate of the three first described cases

The first patient with chronic paroxysmal hemicrania has been followed for 45 years, and for 33 years with indomethacin treatment. The headache became less severe with time; there was no indomethacin tachyphylaxis. The first patient with SUNCT was followed for 28 years, until his demise at 89. Pain became worse with time. No adequate therapy was found. The first patient with Hemicrania continua was followed for 19 years, until her demise at 81. She was treated with indomethacin during the whole observation time. There was no tachyphylaxis. Both patients treated with indomethacin developed gastric ulcer. And both had gastric surgery. Indomethacin therapy may be a life-long affair. The risk of gastric complications may be substantial.