Neurophysiological Studies in Chronic Paroxysmal Hemicrania and Hemicrania Continua

SYNOPSIS
To explore the possible involvement of the pain control system, pain pressure threshold (PPT), nociceptive flexion reflex (RIll), blink and corneal reflexes have been studied for pain perception assessment in 12 patients with chronic paroxysmal hemicrania (CPH) and 12 patients with hemicrania continua (HC). PPT was found to be reduced in HC and CPH when separately compared to controls. In addition, a significant reduction of subjective pain perception (Tp) which was most marked on the symptomatic side, has been demonstrated after sural nerve stimulation in CPH. The RIll reflex threshold on the symptomatic side was significantly reduced when patients were compared to controls, No major differences between CPH and HC as regards blink reflex latencies were found; nor was any such difference observed when comparing the two headache groups to controls. The corneal reflex thresholds were found significantly reduced bilaterally in CPH, irrespective of whether the treatment was given or not.     

Organic Headaches Mimicking Chronic Paroxysmal Hemicrania

The article describes two women who had headaches that mimicked chronic paroxysmal hemicrania (CPH). The first patient had a collagen vascular disorder; and the second one, a large malignant tumor in the right frontal lobe. The similarity of the headaches of the first patient to CPH included an absolute response to indomethacin. The existence of these cases may lead to a better understanding of the pathophysiology of CPH. At the same time, their existence also calls for caution in the diagnosis of CPH.     

Transcranial Doppler Sonography in Chronic Paroxysmal Hemicrania

SYNOPSIS
Three patients with chronic paroxysmal hemicrania (CPH) (1 M, 2 F) and 9 healthy controls (8 M I F) were studied with transcranial Doppler (TCD) sonography. One patient who was studied during the spontaneous attacks hyperventilated markedly. Middle cerebral artery velocity (V_MCA) was measured in the first attack, and anterior cerebral artery velocity (V_ACA) in the second attack, respectively. V_MCA and V_ACA decreased bi-laterally during attack. V_MCA started to decrease at an early stage of the attack, i.e. prior to the major hyperventilation that was observed during the attack. V_ACA on the symptomatic side decreased less than that on the other side (P<0.05). Cerebral vasomotor reactivity (VMR) was expressed as the percentage change in mean blood flow velocity as a function of end-tidal PCO₂ (P_ETCO₂) reduction induced by voluntary hyperventilation (DV/DP_ETCO₂). In the 3 patients, a slightly lowered VMR was observed in the MCA and posterior cerebral artery on both sides, and in the ACA on the symptomatic side IP>0.05) in comparison with controls. These observations may imply an abnormal vascular reactivity in CPH.     

A Piroxicam Derivative Partly Effective in Chronic Paroxysmal Hemicrania and Hemicrania Continua

Piroxicam beta-cyclodextrin has recently been observed to be equal to, or even possibly to be superior to, indomethacin (mainly with regard to side effects) in a single case of hemicrania continua. Piroxicam beta-cyclodextrin, 20 to 40 mg per day, was, accordingly, tried in six patients with chronic paroxysmal hemicrania and six patients with hemicrania continua with a previously proven response to indomethacin. The study was conducted over a period of 3 weeks and in an open fashion. A placebo effect is considered to be negligible in these disorders. In such a comparison, piroxicam beta-cyclodextrin seemed inferior to indomethacin, in particular in chronic paroxysmal hemicrania.     

Cerebral Blood Flow in Chronic Posttraumatic Headache

Background and Purpose.-Headache is the most common neurologic symptom following minor closed head injury. There is often a lack of objective evidence supporting an organic basis of cerebral pathology in these cases. This pilot study considers the possibility of alterations in cerebral blood flow, indicating evidence of an organic disorder in posttraumatic headache.
Methods.-Regional cerebral blood flow studies of 35 patients with chronic posttraumatic headache (PTH) (International Headache Society criteria), identified retrospectively from our cerebral blood flow data base, were compared with those of 49 nonheadache controls and 92 migraineurs (Ad Hoc Committee criteria). Regional cerebral blood flow (initial slope index method) was measured using the xenon Xe 133 inhalation technique.
Results.-Compared to migraineurs and controls, and after adjusting for differences (analysis of covariance) in baseline variables such as blood pressure, hematocrit, and Pco 2 , patients with PTH had: (1) significantly lower mean initial slope indices (P<0.001, P=0.002, respectively); (2) regional interhemispheric flow differences (rlFD), with higher distribution of regional asymmetrical probe pairs (rIFD≥7%: P[PTH versus control]=0.006, P[PTH versus migraine]=0.016; rIFD≥10%: P[PTH versus control]=0.011, P[PTH versus migraine]=0.003]; and (3) more hemispheric asymmetries (P[PTH versus control]=0.023, P[PTH versus migraine]=0.57). Lower mean initial slope indices and hemispheric asymmetry (mean interhemispheric flow difference ≥3.2%) predicted PTH over control (P=0.023 and 0.002, respectively). Lower mean initial slope indices predicted PTH over migraine (P=0.002).
Conclusions.-Patients with PTH have reduced regional cerebral blood flow, and regional and hemispheric asymmetries. These cerebral hemodynamic alterations support an organic basis to chronic posttraumatic headache.     

Chronic Paroxysmal Hemicrania and Hemicrania Continua: Orbital Phlebography and MRI Studies

SYNOPSIS
Six patients with chronic paroxysmal hemicrania (CPH) and 10 patients with hemicrania continua (HC), two indomethacin-responsive, unilateral, headache syndromes, were investigated with orbital phlebography and magnetic resonance imaging of the brain. Orbital phlebography apparently showed pathological findings more frequently in CPH than in HC. Such abnormalities did not always show preference for the side of headache. MR scans were grossly normal in these headaches.     

Chronic Paroxysmal Hemicrania: A Case Report

SYNOPSIS
Corneal indentation pulse amplitudes and intraocular pressures were obtained from a 51-year-old Danish woman-diagnosed as having chronic paroxysmal hemicrania. During headache attacks, values for both procedures were found to be markedly increased, especially on the symptomatic side. Complete relief of symptoms was obtained by indomethacin, prophylactically.     

Alternatives in Drug Treatment of Chronic Paroxysmal Hemicrania

Indomethacin is the drug of first choice in chronic paroxysmal hemicrania with clear relief of pain as a diagnostic criterion. In a few cases, indomethacin is not tolerated because of side effects. Therefore, the efficacy of carbamazepine, verapamil. sumatriptan. acetylsalicylic acid, and oxygen as drugs in the prophylactic or acute treatment of chronic paroxysmal hemicrania was studied in a prospective open trial with 10 patients suffering from chronic paroxysmal hemicrania. The trial results, in accordance with a review of the literature. suggest that acetylsalicylic acid (and probably naproxen and diclofenac) and verapamil are the most effective drugs of second choice in chronic paroxysmal hemicrania. The efficacy of sumatriptan in this condition needs still to be clarified. although there is evidence for partial efficacy. Carbamazepine and oxygen did not show any significant influence on chronic paroxysmal hemicrania.     

Cerebral Blood Flow Studies in Patients with Cluster Headache

SYNOPSIS
Cerebral blood flow (CBF) has been measured in 26 patients liable to cluster headaches. Of four patients studied during spontaneous attacks CBF fell in three and rose in one. Attacks could not be induced by nitroglycerine, alcohol or histamine except when patients were currently experiencing a bout of cluster headaches. The CBF rose during some induced attacks and fell during others. It is concluded that CBF changes do occur in cluster headache but the pattern is not consistent and does not at present suggest a mechanism for cluster headache.     

Chronic Paroxysmal Hemicrania and Hemicrania Continua. Interval Between Indomethacin Administration and Response

The interval between indomethacin dosage and clinical response was assessed in hemicrania continua (n=12) and chronic paroxysmal hemicrania (n=11) sufferers. The number of trials per patient ranged from I to 30. At the time of testing, the patients had "considerable" pain after discontinuation of the drug. The dosage used was the usual one for that patient at the given pain level; ie, 25 or 50 mg tid. All the patients had a complete, long-term response to treatment. Nevertheless, the average interval between drug intake and pain relief during the present study ranged beween 30 minutes and 48 hours in both disorders. In most patients (10 in both groups), the indomethacin effect was complete within 24 hours, and frequently within 8 hours. It is suggested that interindividual differences in dosage and timing to abolish the headaches may be due to different bioavailability or individual sensitivity. Recommendations on indomethacin testing in unilateral headaches are given.     

Acetazolamide for the Treatment of Chronic Paroxysmal Hemicrania

SYNOPSIS
A 25-year-old patient presented with clinical characteristics of chronic paroxysmal hemicrania which failed to respond to indomethacin 300 mg daily. Total relief of headaches was obtained with acetazolamide 250 mg t.i.d.     

Adolescent Chronic Paroxysmal Hemicrania Responsive to Verapamil Monotherapy

SYNOPSIS
Two teenage girls with chronic paroxysmal hemicrania demonstrated dramatic yet incomplete improvement with indomethacin. Verapamil monotherapy provided nearly complete cessation of headaches.     

Successful Aspirin Prophylaxis in a Child with Chronic Paroxysmal Hemicrania

It is generally recognized that indomethacin prophylaxis is the treatment of choice in adults with chronic paroxysmal hemicrania (CPH). Our case report is the first to demonstrate complete control of CPH in a 9 year-old child using small dose aspirin prophylaxis. This case also represents direct observation of the youngest patient with CPH having the earliest reported onset.     

Hemicrania Continua Evolving From Cluster Headache Responsive to Valproic Acid

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