Migrainelike Headache in a Patient With a Hemorrhagic Pituitary Macroadenoma

A 23-year-old woman presented with a 4-day history of a severe migrainelike headache with a normal neurologica examination. The headache resolved after a ketorolac injection, but recurred a few hours later. An MRI scan of the brain showed a hemorrhagic pituitary macroadenoma for which she underwent transsphenoidal removal of the tumor 1 month later. Although uncommon, pituitary hemorrhage with and without apoplexy should be considered in the differential diagnosis of acute headache. Pituitary hemorrhage can be routinely identified on an MRI scan even without pituitary views. However, the pathology can be overlooked and underimaged on a CT scan for acute headache using 10-mm and even 5-mm slices.     

Pituitary apoplexy masquerading as meningoencephalitis

BACKGROUND: Pituitary apoplexy, a rare but life-threatening disorder, is characterized by the abrupt destruction of pituitary tissue secondary to infarction or hemorrhage of the gland itself. Its clinical features include severe headache, stiff neck, fever, visual disturbances, and symptoms of hypoadrenalism. OBJECTIVES: To assess how pituitary apoplexy may mimic the clinical findings of an infectious meningoencephalitis. METHODS AND RESULTS: We describe 3 individuals whose clinical profile and paraclinical studies were consistent with a diagnosis of presumed infectious meningoencephalitis. With minimal improvement on antimicrobial therapy, however, an extensive clinical and radiographic reevaluation yielded pituitary apoplexy as the etiology of their acute neurologic event. CONCLUSIONS: Pituitary apoplexy is often misdiagnosed as meningitis or subarachnoid hemorrhage due to the presence of leukocytes and erythrocytes in the cerebrospinal fluid. These cases serve to highlight the importance of maintaining a broad differential diagnosis when evaluating patients presenting with an acute headache.     

Ophthalmoplegic Migraine-Like Syndrome Due to Pituitary Apoplexy

SYNOPSIS
A patient with a history of migraine without aura developed a complete left III nerve palsy a day after the onset of bilateral throbbing headache associated with vegetative symptoms. Magnetic resonance imaging showed a hemorrhagic pituitary adenoma as the probable cause of the symptoms, presumably by a compressive mechanism. This case suggests a further possible cause of ophthalmoplegia associated with migraine and confirms the clinical utility of magnetic resonance imaging in the differential diagnosis of ophthalmoplegic migraine and other conditions in which the symptomatology is secondary to intracranial lesions.     

Empty Sella and Headache

SYNOPSIS
Empty sella is an anatomical condition caused by herniation of the subarachnoid space into the pituitary fossa through an incompetent seller diaphragm. Headache seems to be one of the most frequently reported symptoms. We studied 13 headache patients (12 females, 1 male) presenting with primary empty sella (PES) on CT scan. The characteristics of the headache were analyzed and plasma levels of pituitary hormones or cortisol assessed. We confirmed the nonspecific nature of the headache in PES even though the majority of our patients complained of daily headache, mostly localized anteriorly. Hormone plasma levels were within normal range in all the patients assessed. However, four patients reported earlier endocrine disorders and more than half of the patients presented with obesity.
In our opinion, PES should be suspected in middle-aged overweight women with daily headache even in the absence of endocrine symptomatology.     

Symptomatic Hypnic Headache Secondary to a Nonfunctioning Pituitary Macroadenoma

We report the case of a woman whose hypnic headache syndrome ceased following pituitary tumor removal. Symptomatic hypnic headache cases are rare, but are starting to appear in the literature. Until more is known, brain neuroimaging, ideally with magnetic resonance imaging, should be considered when the initial diagnosis of hypnic headache is made.     

Headache associated with pituitary adenomas

The objectives of this study were to analyze the characteristics of headache in patients with pituitary adenoma and to investigate the mechanisms involved. Fifty-one patients (27 females and 24 males) with pituitary adenoma were examined. Nineteen (37.3%) of these patients (13 females and 6 males) had headache preoperatively. Most commonly, the headache was generalized (42.1%); overall headache was more frequent in the anterior half of the head (84.2%). Seventeen (89.5%) patients had bilateral headache. Headache was usually described as head heaviness (57.9%) and continuous (57.9%). Pulsating headache and dull pain were only reported by the female patients and were mostly intermittent. The mean age of patients with headache was younger than that of those without headache. Headache was more prevalent in patients with a prolactin-secreting adenoma (57.1%). There were no correlations between visual disturbances, hypopituitarism, tumor size, or cavernous sinus invasion and headache. Hemorrhagic pituitary adenoma in 4 (57.1%) of 7 patients did not always contribute to headache. The headache was improved after surgery in 14 (73.6%) of the 19 patients. In the male patients who survived postoperatively (5 of 6), headache was improved.     

Headache Associated With Pituitary Adenomas

The objectives of this study were to analyze the characteristics of headache in patients with pituitary adenoma and to investigate the mechanisms involved.
Fifty-one patients (27 females and 24 males) with pituitary adenoma were examined. Nineteen (37.3%) of these patients (13 females and 6 males) had headache preoperatively. Most commonly, the headache was generalized (42.1%); overall headache was more frequent in the anterior half of the head (84.2%). Seventeen (89.5%) patients had bilateral headache. Headache was usually described as head heaviness (57.9%) and continuous (57.9%). Pulsating headache and dull pain were only reported by the female patients and were mostly intermittent. The mean age of patients with headache was younger than that of those without headache. Headache was more prevalent in patients with a prolactin-secreting adenoma (57.1%). There were no correlations between visual disturbances, hypopituitarism, tumor size, or cavernous sinus invasion and headache. Hemorrhagic pituitary adenoma in 4 (57.1%) of 7 patients did not always contribute to headache. The headache was improved after surgery in 14 (73.6%) of the 19 patients. In the male patients who survived postoperatively (5 of 6), headache was improved.     

Pituitary apoplexy presenting atypical time course of ophthalmic symptoms

Pituitary apoplexy is defined as a sudden loss of blood supply to the pituitary gland, leading to tissue necrosis and hemorrhage. Its clinical symptoms are characterized by sudden onset of headache, nausea, vomiting, ophthalmic symptoms and hormonal dysfunction. A 65-year-old woman presented with left-sided ptosis and blurred vision. These ophthalmic symptoms gradually worsened for one month without headache, visual acuity and field deficit. Neuro-ophthalmic examination revealed left oculomotor nerve palsy. Magnetic resonance imaging (MRI) revealed a round mass lesion in the left cavernous sinus, which was initially suspected as thrombosed cerebral aneurysm or hemorrhagic Rathke's cleft cyst. The mass lesion was finally diagnosed as pituitary apoplexy. The patient underwent trans-sphenoidal surgery and oculomotor nerve palsy improved after the surgery. Early diagnosis and treatment including surgical decompression are crucially important in patients with oculomotor nerve palsy in pituitary apoplexy, but the symptoms of pituitary apoplexy may slowly progress. It should be noted that pituitary apoplexy could be misdiagnosed as cerebral aneurysm or Rathke's cleft cyst.     

重症创伤性颅脑损伤后血清垂体前叶激素的变化及相关因素

目的 分析重症创伤性颅脑损伤后血清垂体前叶激素的变化及相关因素.方法 回顾性分析2018年6月至2020年6月晋城市人民医院收治的重症创伤性颅脑损伤患者109例的临床资料,在颅脑损伤后1～3d采取静脉血检测血清垂体前叶激素水平,按照是否出现血清垂体前叶激素分泌异常分为正常组(n=60)与异常组(n=49),对影响血清垂...     

Invasive adenoma of the pituitary gland and chronic migrainous neuralgia. A rare coincidence or a causal relationship?

After 31 years of suffering from headache attacks which in the last five years were indistinguishable from migrainous neuralgia (cluster headache), a 52-year-old man was treated for an invasive adenoma of the pituitary gland. During a two-year follow-up period he has not had one single attack of his usual headache. The case history may suggest a causal relationship between the adenoma and the headache attacks.     

Chronic headache and pituitary tumors

Pituitary tumors come to clinical attention due to endocrine dysfunction, distortion of local structures surrounding the pituitary fossa, or as an incidental finding during neuroimaging for headache. Explanations for pituitary tumor-associated headache include stretching of the dura mater and invasion of pain-producing structures within the cavernous sinus. However, small functional pituitary lesions may present with severe headache without cavernous sinus invasion or suprasellar extension. Prolactinomas and growth hormone-secreting tumors have a high prevalence of rare headache phenotypes with or without autonomic features, suggesting that biochemical abnormalities within the hypothalamo-pituitary axis may play a role in headache. Somatostatin analogues may be highly effective at aborting headache associated with functionally active pituitary lesions, particularly in the case of acromegaly. A proposed mechanism for this is inhibition of nociceptive peptides. This article summarizes the clinical features, pathophysiology, and potential treatment approaches to pituitary tumor-associated headache.     

Clusterlike headache as first manifestation of a prolactinoma

We report a case of cluster headache in a patient with a macroprolactinoma. Symptomatic cluster headache was suspected because of an unsatisfactory response to medications that are usually effective in idiopathic cluster headache. The neurological examination was normal. However, magnetic resonance imaging demonstrated a large pituitary tumor. One year after starting treatment with cabergoline, the patient remains asymptomatic. Symptomatic cluster headache should be suspected when the clinical features of the headache are atypical. By inducing vascular mechanisms, the parasellar lesion may have played a role in initiating the cluster headache.     

Typical cluster headache caused by granulomatous pituitary involvement

A young woman had typical cluster headache attacks and a pituitary mass lesion. The headache attacks resolved after transsphenoidal resection of the tumour, which was diagnosed as a granulomatous inflammation. The association between cluster headache and granulomatous enlargement of the pituitary gland has never been described before. This case reinforces the growing evidence that even in typical cases of cluster headache, neuroimaging is mandatory to exclude structural lesions.     

Secondary headache in children

Headache is one of the common symptoms of fever and headache without fever is also not rare in general pediatric clinics. The common causes of these headaches involve extracranial infection due to viral illness, migraine and trauma. Headache with vomiting, fever and meningeal signs suggests meningitis. Taking blood pressure is necessary, even though headache caused by hypertension is rare in children. Neuroimaging should be performed with abnormal neurological findings, atypical headache pattern, or significant change of preexisting headache. Serious underlying diseases, such as brain tumor or intracranial hemorrhage, are uncommon, however they should be diagnosed immediately using neuroimaging because of their urgency.     

A case of postprandial cluster-like headache with prolactinoma: dramatic response to cabergoline

A 17-year-old boy without a significant past medical history presented with recurrent cluster-like headaches induced by meals for 3 years. Magnetic resonance images showed a pituitary tumor. Just after starting treatment with cabergoline, the headaches resolved completely and the patient has been absolutely free from such headache attacks for 2 years.     

Dramatic headache relief after sumatriptan in a patient with a pituitary macroadenoma

We are reporting an interesting case of pituitary macroadenoma. The patient presented with sudden, bifrontal, pulsating headache; photophobia; and an abducens nerve palsy, due to extension of the tumor into the cavernous sinus region. The headache resolved completely after a subcutaneous injection of sumatriptan.     

Warning headache of subarachnoid hemorrhage and infarction due to vertebrobasilar artery dissection

OBJECTIVES: The authors describe the clinical features of headache in patients with vertebrobasilar artery dissection (VBAD) and emphasize the importance of recognition of warning headaches preceding subarachnoid hemorrhage. Headache in VBAD is already recognized, but the natural history and clinical features of the warning headache have not been well elucidated. METHODS: The clinical features of 30 patients with VBAD were analyzed retrospectively. RESULTS: Of the 30 VBAD patients, 16 presented with subarachnoid hemorrhage and 14 with ischemia. Headache (without any other symptoms or signs) was detected in 70% of patients with subarachnoid hemorrhage and 50% of patients with infarction. The headache started acutely, was localized to the occiput or nape of the neck, was sharp and severe in intensity, and was different from any previously experienced headaches. The interval from onset of headache to diagnosis of subarachnoid hemorrhage or infarction was 1 to 10 days. Three patients had sudden severe warning headaches without any evidence of subarachnoid hemorrhage at initial presentation and deteriorated within 24 hours due to subarachnoid hemorrhage, demonstrated later on computed tomography. Angiographic findings of patients with warning headaches were nonspecific compared with those of patients without headache. CONCLUSIONS: The present study confirms a high frequency of headache in patients with VBAD. Sudden severe occipital and nuchal pain, even without subarachnoid hemorrhage or any neurologic deficit, should be considered as a warning sign of subarachnoid hemorrhage. Computed tomography, magnetic resonance imaging, and magnetic resonance angiography should be performed urgently for screening of patients with a warning headache to prevent resultant life-threatening major vascular events.     

Adrenal and pituitary emergencies

Although loss of normal pituitary function may be silent and asymptomatic, sudden loss of gland function (pituitary apoplexy) typically results in characteristic presentations. Sheehan's syndrome is the development of hypopituitarism after postpartum hemorrhage or shock. Patients with Sheehan's syndrome may have typical or atypical presentations based on the extent of pituitary gland destruction. Patients with typical symptoms fail to lactate after giving birth; subsequently these patients also develop symptoms and signs of hypopituitarism. Measuring the serum prolactin level after giving thyrotropin-releasing hormone is a reasonable first step in the diagnosis of this condition in patients who fail to lactate after giving birth. The diagnosis of hypopituitarism is delayed for up to 7 years in patients with atypical symptoms. Acute symptomatic failure of the pituitary gland (pituitary apoplexy) commonly occurs in patients who have asymptomatic pituitary tumors. Many patients with pituitary tumors do not have signs of abnormal endocrine gland secretion and have a normal appearance. Most patients have the following signs or symptoms: headache; acute disturbances in visual acuity or visual fields; ophthalmoplegia, and changes in the level of consciousness. The syndrome of pituitary apoplexy usually evolves over hours to days. Subarachnoid hemorrhage and acute bacterial meningitis are the two most important mimics of pituitary apoplexy. Intravenous steroids and prompt neurosurgical consultation are mandatory in cases of pituitary apoplexy since both steroids and surgery can improve vision. Testings for acute or chronic hypopituitarism is challenging in the Emergency Department setting; however, carefully chosen tests will aid in the subsequent early correct diagnosis after initial Emergency Department management.     

The Evolution of a Migraine Attack – A Review of Recent Evidence

A migraine attack is an extraordinarily complex brain event that takes place over hours to days. This review focuses on recent human studies that shed light on the evolution of a migraine attack. It begins with a constellation of premonitory symptoms that are associated with activation of the hypothalamus and may involve the neurotransmitter dopamine. Even in the premonitory phase, patients experience sensitivity to sensory stimuli, indicating that central sensitization is a primary phenomenon. The migraine attack progresses to a phase that in some patients includes aura, which involves changes in cortical function, blood flow, and neurovascular coupling. The aura phase overlaps with the headache phase, which is associated with further changes in blood flow and function of the brainstem, thalamus, hypothalamus, and cortex. Serotonin receptors, nitric oxide, calcitonin gene‐related peptide, pituitary adenylate cyclase‐activating polypeptide, and prostanoids are demonstrated specific chemical mediators of migraine based on therapeutic and triggered migraine studies. A number of migraine symptoms persist beyond resolution of headache into a postdromal phase, accompanied by persistent blood flow changes in several brain regions. Although these phases of migraine have substantial temporal, neurochemical, and anatomical overlap, each represents an important window onto the pathophysiology of migraine as well as a target for therapeutic intervention. A comprehensive approach to migraine requires an understanding of the entire range of mechanisms and resultant symptoms that occur throughout the evolution of an attack.     

Spontaneous pneumocephalus and subdural hemorrhage after sneezing

Spontaneous pneumocephalus is defined as the presence of air in the absence of intracranial factors. The management of spontaneous pneumocephalus can be conservative or surgical, and surgical intervention could be urgently required if clinical deterioration is rapid. Here, we report a case of pneumocephalus and subdural hemorrhage after sneezing. A 24-year-old male reported to our emergency department with a chief complaint of headache and dizziness. The patient gave a history of onset of headache and dizziness after 2 episodes of heavy sneezing. There was neither a history of recent traumatic episode or previous surgery, nor any signs and symptoms of recent fever or upper respiratory tract infections. Physical examination showed no specific findings. Computed tomography was performed, which showed subdural hemorrhage and PNC in the left occipital lobe, left hemomastoid, and maxillary hemosinus. A neurosurgeon was consulted, who suggested admission in the intensive care unit. An otolaryngologist was then consulted for the left ear otorrhea and hearing impairment. Otoscopic examination showed hemotympanum of the left ear, for which pain control and conservative treatment was suggested. The patient was transferred to general ward 4?days later, since the following brain computed tomography showed resolution of the hemorrhage, and discharged 6?days later because of the improved signs and symptoms. Pneumocephalus and intracranial hemorrhage can occur without a history of trauma or surgery. Special attention is required if headache, dizziness, or other neurologic signs and symptoms occur immediately after sneezing. Intracranial hemorrhage and penumocephalus should be considered in the differential diagnosis.