Surgical management of contact point headaches

INTRODUCTION: Contact point headaches are caused by contact between the nasal septum and the lateral nasal wall by a mechanism of referred pain involving the trigeminal nerve. Our goal was to investigate headaches caused by the contact between the septum and the superior turbinate or medial wall of the ethmoid sinuses and not the middle turbinate. MATERIALS AND METHODS: A retrospective chart review was performed on patients who underwent septoplasty and sinus surgery for headache. The total number of patients who opted for surgery was 23. Only 12 patients met the criteria of having a contact point between the septum and medial wall of the ethmoid sinus, or septum and superior turbinate, which were demonstrated via CT scan of the sinuses. These patients underwent surgical intervention in order to relieve the contact points. RESULTS: According to the same pain questionnaire given pre- and postoperatively, 83% no longer complained of headaches, while 8% had significant relief. Forty-one percent of our patients were previously diagnosed with migraines; 80% of these patients were successfully treated by surgery. DISCUSSIONS: Contact point headaches and migraine without aura (MWOA) have similar symptoms (eg, photophobia, phonophobia, nausea and vomiting, pulsating nature). We believe contact point headaches should be considered in the patient with a diagnosis of MWOA headaches.     

Aspects psychologiques des migraines et céphalées

Résumé  Les facteurs psychologiques jouent un r?le important dans la genèse et l'évolution des céphalées, plus particulièrement dans les céphalées chroniques. Ces facteurs sont envisagés successivement dans le cadre de la migraine, des céphalées de tension, des céphalées posttraumatiques et céphalées iatrogènes.

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Summary  The psychological factors play an important role in the genesis and evolution of headaches, espacially concerning chronic headaches. Those factors are successively considered relatively to the migraine, tension type headaches, post-traumatic headaches and iatrogenic headaches.

     

Recurrent and chronic headaches in children below 6 years of age

The objective was to determine the frequency of headache subtypes, according to International Headache Society (IHS) criteria, in a population of children below 6 years visiting a Center for Diagnosis and Treatment of Headache in Youth. Medical records of the children below 6 years at their first visit, admitted for headache between 1997 and 2003, were studied. Headache was classified according to the IHS criteria 2004. Children with less than three headache attacks or less than 15 days of daily headache were excluded. We found 1598 medical records of children who visited our Headache Center in the study period. One hundred and five (6.5%) were children younger than 6 years. The mean age at the first medical control was 4.8±1.3 years (range 17–71 months). There were 59 males (56.1%) and 46 females (43.9%). The mean age at onset of headaches was 4.3 years (range 14–69 months). According to the IHS criteria we found 37 cases (35.2%) with migraine, 19 cases (18%) with episodic tension headache, 5 cases (4.8%) with chronic daily headache, 13 cases (12.4%) with primary stabbing headache, 18 cases (17.1%) with post–traumatic headache, 7 cases (6.6%) with other non–dangerous secondary headaches (otorhinolaryngological diseases, post–infectious headaches), 3 cases (2.85%) with dangerous headaches (Arnold–Chiari type 1 malformation, brain tumour) and 9 cases (8.6%) with unclassifiable headaches. Six children (5.7%) reported more than one headache subtype. The prevalence of dangerous headaches was higher than those in school age (χ²=4.70, p<0.05). Our study shows some differences in headaches in this population vs. school children. In fact at this age migraine is the most common headache, but we also found an increase of secondary causes among the chronic/recurrent and daily headaches, especially posttraumatic disorders and potentially dangerous headaches. Finally our study shows the highest prevalence of the idiopathic stabbing headache in pre–school children in comparison with other ages.     

La DREZotomie microchirurgicale pour Douleurs après traumatisme radicello-médullaire—Plexique ou tronculaire du membre supérieur: A propos de 11 cas opérés versus 8 cas non opérés

Résumé  Sur une série de dix neuf patients souffrant de douleur par désafférentation du membre supérieur d’origine traumatique, pris en charge dans le cadre du Centre d’Evaluation de la Douleur. Onze patients ont été opérés par DREZotomie Microchirurgicale (DMC) et les huit autres ont eu une prise en charge médicale et/ou cognitivo-comportementale. Cette étude tend à confirmer l’efficacité de la DMC dans le traitement des douleurs neurogènes par traumatisme de la jonction radiculomédullaire cervico-thoracique, particulièrement dans leur composante paroxystique, permenttand d’arrêter le plus souvent la consommation médicamenteuse antalgique et améliorer notamment le statut psychologique des patients. Ces données sont vérifiées de manière éloquente lorsqu’on les étudie en comparant les patients opérés aux patients non-opérés. Les résultats post-opératoires sont exposés et comparés à ceux de la littérature récente. II est par ailleurs posé le problème de l’indication de la DMC lorque les lésions neurologiques initiales sont situées uniquement à distance et en périphérie par rapport à la jonction radiculo-médullaire.

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Summary  Neneteen patients with pain resulting from deafferentation of an upper limb due to trauma were treated in the pain centre. Eleven patients were operated by microsurgical DREZotomy (MSD), and eight others had medical and/or cognitivo-behevioural treatment. This study tends to confirms the efficacy of MSD in the treatment of neurogenic pain resulting from injury to the cervico-thoracic dorsal root entry zone (particularly the paroxysmal component), which generally allows discontinuation of antalgic drugs and notably improves the psychological status of patients. These results are clearly confirmed when operated patients are compared with non-operated ones. The postoperative results are presented and compared with those recently reported in the litterature. The indication for MSD is also considered when the initial neurological lesions are located only at some distance and peripherally with respect to the radicello-medullary junction.

     

Prise en charge des céphalées chroniques

Résumé  Il s’agit d’un problème important de Santé Publique puisque 30% de la population fran?aise se plaint de céphalées répétitives. La prise en charge comporte trois étapes successives qui ont chacune leur importance. Le diagnostic correct, dépassant les approximations énoncées, repose avant tout sur l’interrogatoire et un examen clinique soigneux. On peut ainsi individualiser trois groupes d’importance différente: Pathologie migraineuse et affections apparentées (cluster headache), céphalées de tension et céphalées sympt?matiques dont la fréquence est souvent surestimée. Une compréhension pysiopathologique fine est nécessaire pour aborder une thérapeutique adaptée mais elle servira aussi de base aux explications données au malade. Celles-ci sont essentielles pour lever la nosophobie si fréquente chez les céphalalgiques. Lorsque les céphalées ne sont pas fréquentes, on privilégiera le traitement symptomatique. Les traitements de fond choisis en fonction du diagnostic et du terrain seront également explicités afin d’obtenir une bonne observance thérapeutique, dans une relation de confiance, gage indispensable d’une prise en charge correcte.

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Summary  It is an important Public wealth problem since 30% of french population complain about recurrent headaches. A correct diagnosis, overstepping wrong approximations, is built on questionning and a careful clinical examination. Three nosologic entities may be specified: Migraine, Tension-type headaches and symptomatic headaches whose the frequency is often overvalued. A subtle physiopathologic understanding is necessary to approach suitable therapeutics. It will be data to explain the patient’s disease. It is essential to break, frequent nosophobia. When headaches are not frequent, symptomatic treatment will be privileged. Preemptive therapeutics will be explained to obtain a good therapeutic observance, with a confident relation, essential for a good cure.

     

Acute and interictal allodynia in patients with different headache forms: an Italian pilot study

OBJECTIVE: To investigate allodynia in patients with different primary headaches. BACKGROUND: Many migraineurs have allodynia during headache attacks; some may have allodynia outside attacks; allodynia may also be associated with other primary headaches. METHODS: A total of 260 consecutive primary headache patients presenting for the first time at a headache center, and 23 nonheadache controls answered written questions (subsequently repeated verbally) to determine the presence of acute and interictal allodynia. RESULTS: We divided the patients into: episodic migraine (N = 177), subdivided into only migraine without aura (N = 114) and those sometimes or always reporting migraine with aura (N = 63); episodic tension-type headache (N = 28); chronic headaches (headache > or = 15 days/month, N = 52), including chronic migraine, chronic tension-type headache, and medication-overuse headache; and other headache forms (N = 3). Acute allodynia was present in 132 (50.7%), significantly more often in patients sometimes or always suffering migraine with aura, and those with chronic headache forms, compared to patients with migraine without aura and episodic tension-type headache. Interictal allodynia was present in 63 (24.2%) patients, with significantly higher frequency in those having migraine with aura attacks than controls and common migraine patients. CONCLUSIONS: Allodynia is not specific to migraine but is frequent in all headache patients: acute allodynia was reported in half those interviewed and in over a third of patients in each headache category; interictal allodynia was reported by nearly 25%.     

Céphalées psychogènes

Résumé  Le syndrome douloureux constitue le plus souvent un syndrome somato-psychique où s'associent de fa?on variable des facteurs somatiques et psychiques. Parmi ces derniers, on reconnait des composantes affectives, cognitives et comportementales. Dans certains cas, les composantes psychologiques de la douleur paraissent jouer un r?le étio-pathogénique déterminant, délimitant le cadre des céphalées psychogènes, ne constituant qu'une partie des céphalées de tension. L'anxiété, la dépression, certaines névroses et de rares psychoses peuvent générer des céphalées nécessitant des approches diagnostiques et thérapeutiques spécifiques.

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Summary  The painful syndrome most frequently constitutes a somatic-psychic syndrome. Among others, we may recognise affective, cognitive and behavioural components. In some cases, the psychological components of the pain seem to play a determining etio-pathogenic role. They also delimit the frame of the psychogenic headaches and finally constitute only a part of the tension type headaches.

     

Headache Spectrum in Arnold-Chiari Malformation

Exertional headaches in patients with Arnold-Chiari malformation (ACM) are well described. We report four patients with Type I ACM and recurrent headaches. These patients presented, respectively, with low spinal fluid pressure headache, migraine without aura, migraine with aura, and migraine with prolonged aura. This report suggests the need for observing patients with recurrent headaches for any physical stigmata of craniovertebral junction anomalies, and the need to exclude ACM in such patients. Possible implications of the association between ACM and different types of headaches are discussed.     

SUNCT Syndrome. A Clinical Review

The clinical features of SUNCT syndrome have been reviewed in 21 patients. There were 17 men and 4 women, rendering a clear male preponderance (ratio of 4.25). The mean age at onset was around 51 years. Attacks were experienced mostly in the orbital/periorbital area and always recurred on the same side, with an erratic temporal pattern and remissions of varying lengths. Most attacks were moderate to severe in intensity and burning, electrical, or stabbing in character. The attacks were regularly accompanied by prominent, ipsilateral, conjunctival injection, tearing; and rhinorrhea or nasal obstruction. There were many precipitating mechanisms. Exclusively spontaneous attacks were described in 3 patients. The usual duration of paroxysms ranged from 10 to 60 seconds, whereas the longest duration varied from 60 to 300 seconds. The frequency of attacks during the symptomatic periods varied from less than I attack daily to more than 30 per hour. hi the majority of patients, supplementary examinations failed to show any notable abnormality. However, 2 patients were documented to have a symptomatic form of SUNCT, with a vascular malformation in the ipsilateral cerebellopontine angle. A variety of drugs and local anesthetic blockades. inclusive of tic douloureux drugs, were tried, but a persistent, convincingly beneficial effect was generally lacking SUNCT syndrome is in the differential diagnosis when encountering unilateral, orbital/periorbital headache syndromes.     

Nummular headache: a prospective series of 14 new cases

OBJECTIVE: To study the clinical features of nummular headache (NH) and get an approach to its epidemiology. BACKGROUND: NH has been recently described as a primary disorder characterized by head pain exclusively felt in a small rounded area typically 2-6 cm in diameter. METHODS: Through a 1-year period we have studied all patients referred to our neurologic clinic because of head pain exclusively felt in a small-circumscribed area, and not attributed to another disorder. All the patients had normal neurological, analytical, and neuroimaging examinations. All the patients belonged within the same regional care system comprising 220,000 inhabitants. RESULTS: A total of 11 females and 3 males were studied. Based in our hospital series, the incidence was 6.4/100,000/year. The mean age at the onset was 38 years (range: 13-72). Only three patients had another concurrent headache: migraine (n = 2), and trigeminal neuralgia (n = 1) which proved to have an independent course. All the patients reported head pain exclusively felt in either a rounded (n = 12) of 1-6 cm diameter, or an oval area (n = 2) of 5 x 3 cm, and 2 x 3 cm, respectively. Both size and shape of the painful area remained constant since the onset of symptoms. The location of the symptomatic area was mostly parietal (n = 7) or temporal (n = 5), but also frontal (n = 1) and in occiput (n = 1). The background pain was mostly mild-to-moderate, but also moderate-to-severe pain was reported. Exacerbations-either spontaneous or precipitated by combing hair or touching the symptomatic area-were reported by 8 patients. The temporal pattern was chronic-continuous (n = 7) and episodic (n = 7). Ten patients reported a variable combination of sensory disturbance (tenderness, hypoesthesia, hyperalgesia, and allodynia) in the symptomatic area. There were no autonomic accompaniments. Treatment was generally not necessary. When needed, standard oral doses of paracetamol usually sufficed. CONCLUSIONS: NH emerges as a clear-cut clinical picture. It is a noninfrequent primary headache. The particular topography suggests the pain has a probable epicranial source conveyed by, or originated in, one/a few terminal branch(es) of the cutaneous nerves of the scalp.     

Effectiveness of amitriptyline in the prophylactic management of childhood headaches

OBJECTIVE: To study the effectiveness of a standardized dose of amitriptyline, 1 mg/kg, for childhood headaches. BACKGROUND: Amitriptyline has been shown to be effective for the prophylaxis of migraine in adults. Studies in children, however, have been quite limited. In adults, the suggested effective dose range is 10 to 150 mg. In children, a standardized dosage is often not used, resulting in a dosage range in clinical practice that often varies from a very low dose to a dose equivalent to that used in adults. METHODS: Children with more than three headaches per month were treated with amitriptyline, slowly increasing the dose to 1 mg/kg per day. The frequency, severity, and duration of their headaches were initially evaluated and subsequently measured at each follow-up evaluation. Two hundred seventy-nine children had headaches occurring frequently enough to indicate prophylactic treatment. Of these children, 192 (68.8%) were treated with amitriptyline. The average age at presentation was 12.0 (+/- 3.0) years. The ratio of boys to girls was 1:1.74. The average frequency of headaches was 17.1 (+/- 10.1) days per month. The average severity was 6.84 (+/- 1.67) on a 10-point pain scale. The average duration was 11.5 (+/- 15.0) hours. The most frequent diagnoses using International Headache Society criteria were migraine (60.6%), migraine with aura (7.9%), and tension-type headache (10.4%). Of these children, 146 have been seen for at least one follow-up examination, occurring on average 67.3 (+/- 32.3) days after beginning prophylactic treatment. RESULTS: A total of 84.2% of the children reported an overall perception of being better, while 11.6% reported being the same. The frequency of headaches improved to 9.2 (+/- 10.0) days per month. The average severity was reduced to 5.1 (+/- 2.1), and the average duration was reduced to 6.3 (+/- 11.1) hours. If daily or continuous headaches were excluded, the improvements were more marked. Minimal side effects were reported from these children and their families. Long-term evaluation (156 to 415 days) showed continued sustained improvement. CONCLUSIONS: Amitriptyline is an effective prophylactic medication for children with frequent headaches. A standardized dosing regimen results in a significant number of children responding with minimal side effects. The children are able to tolerate this dosing scheme and demonstrate good adherence to a dosing schedule of once a day.     

Frequency of Headaches in Children is Influenced by Headache Status in the Mother

(Headache 2010;50:973‐980) Background.— Migraine aggregates within families. Nonetheless the familial aggregation of chronic daily headaches (CDH) and of episodic headaches of different frequencies has been very poorly studied. Accordingly herein we test the hypothesis that frequency of primary headaches aggregates in the family. Methods.— Sample consisted of 1994 children (5‐12 years) identified in the population. Validated questionnaires were used to interview the parents. Crude and adjusted prevalences of low‐frequency (1‐4 headache days/month), intermediate‐frequency (5‐9 days/month), high‐frequency (10‐14 headache days/month), and CDH (15 or more headache days/month) in children were calculated as a function of headaches in the mother. Results.— Frequency of headaches in the mother predicted frequency of headaches in the children; when the mother had low frequency headaches, the children had an increased chance to have low or intermediate headache frequency (relative risk = 1.4, 1.2‐1.6) but not CDH. When the mother had CDH, risk of CDH in the children was increased by almost 13‐fold, but the risk of infrequent headaches was not increased. In multivariate models, headaches in the children were independently predicted by headaches in the mother (P < .001); headache frequency in the children was also predicted by frequency in the mother (P < .001). Conclusions.— Frequency of headaches in children is influenced by frequency of headaches in the mother and seems to aggregate in families. Future studies should focus on the determinants of headache aggregation, including genetic and non‐genetic factors.     

Osmophobia in juvenile primary headaches

This study was planned to investigate the prevalence of osmophobia in juvenile headache sufferers and to analyse the diagnostic utility of osmophobia in order to distinguish migraine without aura from episodic tension-type headache. We examined 305 consecutive patients presenting at our Paediatric Headache Centre. A semistructured questionnaire was given to 275 selected patients affected by migraine or tension-type headache. The prevalence of osmophobia during attacks was 18.5%, mainly in migraine patients (25.1%) vs. those with tension-type headache (8.3%). Osmophobia showed more specificity than phonophobia or photophobia in the differential diagnosis between migraine and tension-type headache. In conclusion, this study demonstrates that osmophobia resulted in a symptom with poor sensitivity (27.1%) but high specificity (92%) that could become a supportive diagnostic criterion even in children for the differential diagnosis between migraine without aura and tension-type headache.     

Diagnoses and Symptom Patterns in Children Presenting to a Pediatric Headache Clinic

SYNOPSIS
The diagnosis of migraine headache in children and adolescents is complex and not well understood. This study was conducted to compare diagnostic rates, using various criteria for pediatric migraine, and specific symptom characteristics in a sample of children referred for care to a specialized pediatric headache clinic. A structured interview was used at the patient's initial assessment visit to elicit symptom patterns and therapies attempted for headache. Clinical diagnoses were based on consensus agreement reached by a multidisciplinary team. Statistically derived diagnostic rates based on International Headache Society (IHS), Prensky, Vahlquist and our own criteria were significantly lower than clinical diagnostic rates. IHS diagnostic rates were differentially distributed as a function of race, but no other effects were found for demographic variables on diagnostic rates. Specific symptom patterns, however, varied as a function of race, gender and age of the child. The results underscore the need for comprehensive, developmentally based models of the evolution of migraine headache as a foundation for future research and the further development of clinically sensitive diagnostic criteria for pediatric migraine.     

Motor Vehicle Accidents, Headaches and Post-Traumatic Stress Disorder: Assessment Findings in a Consecutive Series

Results of 20 consecutive cases referred for post-traumatic headache (PT-HA) to a psychological practice were assessed for both psychiatric and neurological diagnoses. Nineteen of the 20 cases (95%) had a diagnosable psychiatric disorder, with 15 presenting with a post-traumatic stress disorder. Prior headache history was reported for only 25% of the referred patients, while a prior psychiatric disorder was found for 7 (35%) of the cases. Findings suggest that consideration of a psychiatric disorder should be made for PT-HA patients.     

Céphalées quotidiennes chroniques

Résumé  Les céphalées quotidiennes chroniques sont souvent méconnues des médecins bien qu'une partie notable de la population en souffre (2 à 5% de la population). Le plus souvent, il s'agit de migraineux dont la maladie s'est dégradée à l'occasion de perturbations psychologiques en relation avec la personnalité des patients et/ou les circonstances de la vie. Dans la plupart des cas, on note également l'utilisation abusive des antalgiques. Le sevrage de ceux-ci, un traitement prophylactique englobant les différents facteurs permettent d'améliorer considérablement ces malades.

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Summary  Daily chronic headaches are often unknown by physicians, although a quite important part of the population suffers because of it (from 2 to 5% of the population). The most frequent situation concerns migrainers whose disease was aggravated on the occasion of psychological disturbance connected with the personality and life of the patients. Most of the time, an abusive use of antalgics is noticed. A wearning of them, and a prophylactic treatment, including these different factors can considerably ameliorate the state of these patients.

     

L-5HTP treatment in primary headaches: an attempt at clinical identification of responsive patients

The therapeutic response to L-5HTP, a serotonin precursor, was studied in an attempt to identify clinical subgroups of primary headache patients. The results at the 4th month control in 100 patients under L-5HTP treatment at the dose of 300 mg/day confirm previous observations on the activity profile of the drug, the effects of which are equally distributed between recurrent and daily forms as well as among clinical subtypes. The emerging profile of the responsive patients is characterized by such peculiar traits as prevalence of previous major mood disturbances and minor frequency of anxiety, longer duration of the illness and higher occurrence of some associated symptoms, lower incidence of exogenous and hormonal trigger factors, and previously positive response to pizotifen treatment.