Thunderclap Headache with Orgasm: A Case of Basilar Artery Dissection Associated with Sexual Intercourse

Background: Headaches associated with sexual intercourse (coital cephalgia) have many different causes and are often divided in the literature into pre-orgasmic and orgasmic headaches. Objective: To present a case of orgasmic headache caused by a basilar artery dissection and to present a literature-based guide to the diagnosis and management of patients presenting with headaches related to sexual activity. Case Report: We report the case of a 34-year-old man without significant past medical history who presented to the Emergency Department with two episodes of orgasmic headache caused by basilar artery dissection. Conclusions: The cause of headaches related to sexual activity range from the benign to the life-threatening. Due to the dynamics of cerebral blood flow during sexual intercourse, basilar artery dissections and aneurysms should be considered in patients with sudden-onset headaches during orgasm. Appropriate brain imaging and, possibly, lumbar puncture may assist in identifying potentially life-threatening causes of coital headaches.     

Reversible Cerebral Vasoconstriction Syndrome

Reversible cerebral vasoconstriction syndrome (RCVS) is a cerebrovascular disorder with a clinical picture that continues to be refined. It has presented to multiple subspecialties over the past several decades, bringing with it many questions regarding risk factors, diagnosis, and management. Answers have been forthcoming but many questions remain. RCVS presents with recurrent, secondary thunderclap headaches and predominantly affects young women. The mechanism of vasoconstriction is unclear, but there has been speculation regarding a hyperadrenergic state. Diagnosis requires physician awareness, vascular imaging, and knowledge of the differential. The hallmark of its diagnosis is reversibility. Management is empiric, usually with calcium‐channel blockers, as there are no controlled treatment trials for RCVS. Randomized controlled trials are needed.     

Migraine prophylaxis: who, why, and how

If a patient has frequent, severely debilitating migraine headaches, prophylactic treatment may help. Beta-blockers, tricyclic antidepressants, and anticonvulsants have the best evidence of efficacy; calcium channel blockers and nonsteroidal anti-inflammatory drugs are also popular because they are well tolerated and inexpensive. We review migraine treatment with emphasis on prophylaxis.     

Clues in the Differential Diagnosis of Primary vs Secondary Cough,Exercise, and Sexual Headaches

Activity‐related headaches can be provoked by Valsalva maneuvers (“cough headache”), prolonged exercise (“exertional headache”) and sexual excitation (“sexual headache”). These entities are a challenging diagnostic problem as can be primary or secondary and the etiologies for secondary cases differ depending on the headache type. In this paper we review the clinical clues which help us in the differential diagnosis of patients consulting due to activity‐related headaches. Cough headache is the most common in terms of consultation. Primary cough headache should be suspected in patients older than 50 years, if pain does not predominate in the occipital area, if pain lasts seconds, when there are no other symptoms/signs and if indomethacin relieves the headache attacks. Almost half of cough headaches are secondary, usually to a Chiari type I malformation. Secondary cough headache should be suspected in young people, when pain is occipital and lasts longer than one minute, and especially if there are other symptoms/signs and if there is no response to indomethacin. Every patient with cough headache needs cranio‐cervical MRI. Primary exercise/sexual headaches are more common than secondary, which should be suspected in women especially with one episode, when there are other symptoms/signs, in people older than 40 and if the headache lasts longer than 24 hours. These patients must have quickly a CT and then brain MRI with MRA or an angioCT to exclude space‐occupying lesions or subarachnoid hemorrhage.     

Efficacy, Side Effects and Tolerance Compared During Headache Treatment With Three Different Calcium Blockers

SYNOPSIS
Experiences gained in this laboratory during long-term, separate prophylactic trials utilizing three different calcium channel blockers among patients with common migraine, classic migraine, mixed and chronic cluster headaches are reviewed. Nifedipine provided symptomatic improvement among 65% of patients with common migraine and among 77% of patients with classic migraine. Forty-one percent of patients with mixed headache reported some relief of head pain. Sixty percent of patients with chronic cluster reported improved control of their headaches. Verapamil produced improved control of symptoms in 81% of patients with common migraine, 72% of those with classic, 67% of those with mixed and 79% of those with cluster. Nimodipine was reported to be beneficial among 84% of patients with common migraine, among 73% of those with classic migraine and among 53% with chronic cluster. Only 33% of patients treated with nimodipine for mixed headache reported improvement. Side effects were more common with nifedipine (71%) than with verapamil (41%) and were least common with nimodipine (20%). Tolerance developed in 42% of those treated with nifedipine and in 49% of those treated with verapamil. Development of tolerance with nimodipine was rare (4%). Each of these three calcium channel blockers showed different and specific therapeutic efficacies which differed according to the clinical classification of the different types of vascular head pain undergoing treatment.     

Cough, exertional, and other miscellaneous headaches

We have discussed several miscellaneous headache disorders not associated with structural brain disease. The first group included those headaches provoked by "exertional" triggers in various forms. These include benign cough headache, BEH, and headache associated with sexual activity. The IHS diagnostic criteria were discussed. Benign exertional headache and cough headache were discussed together because of their substantial similarities. In general, BEH is characterized by severe, short-lived pain after coughing, sneezing, lifting a burden, sexual activity, or other similar brief effort. Structural disease of the brain or skull was the most important differential diagnosis for these disorders, with posterior fossa mass lesions being identified as the most common organic etiology. Magnetic resonance imaging with special attention to the posterior fossa and foramen magnum is the preferred method for evaluating these patients. Indomethacin is the treatment of choice. The headache associated with sexual activity is dull in the early phases of sexual excitement and becomes intense at orgasm. This headache is unpredictable in occurrence. Like BEH, the headache associated with sexual activity can be a manifestation of structural disease. Subarachnoid hemorrhage must be excluded, by CT scanning and CSF examination, in patients with the sexual headache. Benign headache associated with sexual activity has been successfully treated with indomethacin and beta-blockers. The second miscellaneous group of headache disorders includes those provoked by eating something cold or food additives, and by environmental stimuli. Idiopathic stabbing headache does not have a known trigger and appears frequently in migraineurs. Its occurrence may also herald the termination of an attack of cluster headache. Indomethacin treatment provides significant relief. Three headaches triggered by substances that are eaten were reviewed: ingestion of a cold stimulus, nitrate/nitrite-induced headache, and MSG-induced headache. For the most part, avoidance of these stimuli can prevent the associated headache. Lastly, we reviewed headache provoked by high altitude and hypoxia. The headache is part of the syndrome of AMS during its early or benign stage and the later malignant stage of HACE. The pain can be exacerbated by exercise. The best treatment is prevention via slow ascent and avoidance of respiratory depressants. Acetazolamide and dexamethasone have proved useful in preventing this syndrome.     

Obsessive compulsive disorder and migraine: case report,diagnosis and therapeutic approach

Psychiatric disorders, notably mood and anxiety disorders, are frequently associated with migraine and chronic daily headaches. The obsessive–compulsive disorder (OCD) is included in the spectrum of anxiety disorders and may be a comorbid condition in headache patients. However, little information has been reported in the literature about this association. This is an important issue as OCD may contribute to the development or maintenance of treatment-resistant chronic headaches. In this paper, we describe a young female patient with refractory chronic migraine and OCD. Considerations on diagnosis, management and treatment of these comorbid conditions are presented.     

Intra-arterial milrinone for reversible cerebral vasoconstriction syndrome

Reversible cerebral vasoconstriction syndrome (RCVS) usually presents with recurrent thunderclap headaches and is characterized by multifocal and reversible vasoconstriction of cerebral arteries that can sometimes evolve to severe cerebral ischemia and stroke. We describe the case of a patient who presented with a clinically typical RCVS and developed focal neurological symptoms and signs despite oral treatment with calcium channel blockers. Within hours of neurological deterioration, she was treated with intra-arterial milrinone, a phosphodiesterase inhibitor, which resulted in a rapid and sustained neurological improvement.     

Acute Spontaneous Subdural Hematoma in a Middle-Aged Adult: Case Report and Review of the Literature

Background

Acute spontaneous subdural hematomas (ASSDH) occur by a variety of pathological processes and are less common than trauma-related acute subdural hematomas (SDH). Both types are usually seen in the elderly, and only 22 cases of ASSDH in patients aged < 40 years have been reported in the medical literature. Objectives: We report a rare case of ASSDH in a middle-aged male with no previous history of head trauma. A literature review comparing the clinical presentations, etiologies, incidence, mortality rates, and prognostic factors of ASSDH in various age groups is discussed.

Case Report

A 37-year-old man presented to the Emergency Department with headaches, myalgias, and vomiting. Noncontrast computed tomography revealed a unilateral ASSDH with 9 mm of midline shift, despite a normal neurological examination. Upon admission, the patient developed an abducens palsy suggesting increased intracranial pressure and underwent an urgent hemicraniectomy. Pathological sampling revealed large atypical cells indicative of a hematopoietic neoplasm, but various advanced imaging modalities failed to identify signs of cerebral tumor, vascular malformation, or arterial extravasation.

Conclusion

Given the rarity of SDH in nonelderly patients, this case suggests a broader differential diagnosis for nontraumatic headaches to include arterial and even neoplastic origins. Our literature review confirms the paucity of reported incidences of ASSDH, yet reminds medical providers to closely monitor for developing neurological symptoms and initiate prompt medical intervention when necessary.     

Multiple Headaches in a Case of Multiple Personality Disorder

SYNOPSIS
A female with multiple personality disorder (MPD) was referred for treatment of several different anddistinct headache problems. This case is presented in detail and the literature is reviewed in regard toheadaches occurring in cases of MPD.In an extensive review of 52 previously reported cases of MPD, headaches was the most frequent somaticcomplaint, occurring in over 60%. Headaches previously reported, however, have never been well definedas to etiology, type or treatment. This paper addresses these areas and the problems involved in makingsuch determinations in this unusual personality disorder.The curious clinical observations about the headaches observed in this case of MPD suggest that thisgroup of headache patients might prove to be a unique population for further study, especially in regard tosolving some of the biochemical and emotional mechanisms of headache, and their possible interactions.     

Flunarizine Is Effective in Prophylaxis of Headache Associated With Scleroderma

Migraine-like headaches may occasionally be seen in patients with scleroderma. The mechanism of these headaches is not well established but may be secondary to central "Raynaud's phenomenon". We report a patient with such headaches that responded dramatically to the centrally acting calcium channel blocker, flunarizine. We suggest that flunarizine should be considered in the management of patients with scleroderma and migraine-like headaches.     

A colloid cyst of the third ventricle – the cause of episodic headache and sudden unexpected death in an adolescent girl

An 18-year-old girl was found dead in her bed. The autopsy revealed a colloid cyst of the third ventricle. The cyst obstructed the flow of cerebrospinal fluid, leading to prominent internal hydrocephalus with consecutive brain edema and compression of the caudal medulla at the foramen magnum. The girl's only previous complaints were episodic headaches for the previous 2-3 years. Computed tomography and magnetic resonance imaging were not performed prior to her death. This case report highlights the importance of early diagnosis of colloid cyst of the third ventricle and the need to perform computed tomography and magnetic resonance imaging in patients with episodic headaches even when they show no neurologic deficit. Although it is a very rare disorder, it should be included in the differential diagnosis of headaches in children and young adults, and also in the differential diagnosis of conditions causing increased intracranial pressure, in view of the life-saving management required to prevent a fatal outcome.     

Migraine and Cluster Headache Treatment With Calcium Antagonists Supports a Vascular Pathogenesis

SYNOPSIS
Clinical research during the past four years in this and other laboratories has demonstrated therapeutic effectiveness of three different calcium channel blockers in the prophylaxis of migraine and cluster headaches. The drugs are nimodipine, nifedipine and verapamil. Clinical observations and cephalic hemodynamic responses correlated before and during treatment with nimodipine show extremely low incidences for development of tolerance and/or side effects plus normal glucose tolerance and calcium dependent insulin secretion before and during nimodipine therapy. The results confirm potent and highly selective calcium entry blockade of cephalic smooth muscle receptors by nimodipine. Nifedipine and verapamil showed less therapeutic effectiveness in controlling headaches, higher incidence for development of tolerance and side-effects with less consistent cephalic hemodynamic changes. Taken together these observations during treatment of migraine and cluster with calcium antagonist support Wolff's theory of vascular head pain.     

Aortico-left ventricular tunnel with natal cardiac failure.

Presented is a case of aortico-left ventricular tunnel in a 1-day-old girl who was in shock and severe cardiac failure. The clinical, auscultatory, hemodynamic and angiocardiographic, surgical, and pathologic findings in this case and from the 21 others reported in the literature are described. The diagnosis should be considered in an infant or child with signs of aortic insufficiency. Aortography is diagnostic when a localized supravascular aortic channel communicating with the left ventricle is opacified. Definitive treatment is surgical, though residual aortic insufficiency is common.     

Ictal Epileptic Headache: A Review of Current Literature and Differentiation From Migralepsy and Other Epilepsies

Ictal headaches are increasingly becoming the focus of research as more data demonstrate headaches existing as a sole manifestation of an epileptic event. Due to the difficulty in diagnosing the event as an epileptic phenomenon as opposed to a migraine, the condition is often misdiagnosed. This paper seeks to review the current published literature on ictal epileptic headaches as well as provide differentiation between ictal headaches and similarly presenting conditions. In doing so, we hope to improve the diagnosis of ictal headaches and thus improve patient care. We review two case studies that exemplify the potential of multiple conditions with comparable symptoms to ictal headaches, and discuss how to differentiate the variable diagnoses. As of the writing of this paper, there is no universally agreed upon set of features of ictal headaches; however, reviewing the current literature, there do seem to be several features that should be noted when treating patients. More research on the pathophysiology of ictal epileptic headaches needs to be done before the condition can be fully understood.     

Meningismus Associated with Malpositioned Intraspinal Catheter for Drug Delivery

Background: Implanted delivery systems for intrathecal drug administration have become more common in the management of nonmalignant pain. Many postprocedural complications have been described in the literature including infection and headache provoked by position changes. Determining the etiology of a postimplant headache is important particularly when considering the possibility of a life‐threatening infection. Case Report: We present a patient who underwent placement of an implantable drug delivery system (IDDS) for intractable abdominal pain that developed positional headaches, and significant neck and back pain. Attempted cerebrospinal fluid aspiration reproduced her symptoms and imaging revealed a malpositioned intraspinal catheter tip approximated to the meninges. Revision of the system completely relieved her symptoms. Conclusion: Meningismus from malpositioned catheters is a rare complication that can mimic meningitis but should be considered in the differential for postimplant headaches. Given the increased use of IDDS, it is important to recognize and evaluate postimplant complication and treat it appropriately. We discuss this case report and appropriate work‐up and differential diagnosis for meningismus following implant.     

组织胞浆菌病3例报告并文献复习

目的:探讨组织胞浆菌病(Histoplasmosis)临床特征、诊断、鉴别诊断、误诊及治疗。方法:报告1例死亡、2例临床治愈组织胞浆菌病,并结合文献探讨该病的临床特征及诊治方法。结果:对组织胞浆菌病认识不足,病原学检查不及时是延误本病诊治的主要原因。结论:本病早期发现和治疗是可以痊愈的,单用两性霉素B(Amphotericin B,AMB)或联用伊曲康唑可能是降低本病死亡率的有效方法。     

Traumatic stressors and post-traumatic stress disorder symptoms in headache patients

OBJECTIVE: The aim of this study was to assess the prevalence of significant traumatic stressors and post-traumatic stress disorder (PTSD) symptoms in a headache population. BACKGROUND: Several recent publications have emphasized the relationship between life stressors and/or daily hassles and recurrent headaches. However, little is known about the prevalence and impact of major traumatic stressors in patients with recurrent headaches. METHODS: Eighty patients with either migraine or tension-type headache completed a PTSD checklist. Data were compared with those from patients with chronic masticatory muscle pain of similar intensity and duration. RESULTS: Almost 64% of the headache patients reported one or more major traumatic stressors. This percentage was not significantly different from that of the comparison group, and fell within the broad range reported for exposure to traumatic stressors in epidemiologic studies with nonpatient populations. One out of 6 patients in the total headache sample, and 1 out of 4 of those reporting a traumatic stressor, reported symptoms suggestive of current PTSD. The prevalence of current PTSD-like symptomatology reported by the headache patients was comparable to that of the comparison group of the present study, but higher than that reported for the general population in the available literature printed in English. Traumatic stressors most often reported were not related to direct physical trauma, but rather associated with loss or serious illness of a loved one. CONCLUSION: Exposure to traumatic events in patients with a primary diagnosis of recurrent headaches is similar to that reported for chronic masticatory muscle pain patients or nonpatient populations. However, symptoms consistent with a diagnosis of current PTSD appear to be more frequent in patients with recurrent headaches than reported in the scientific literature printed in English for nonpatient populations. Screening for PTSD symptomatology is recommended as part of the routine clinical evaluation of headache.     

Severe headaches. When to worry, what to do

All patients who present with severe headaches merit careful medical and neurologic evaluation, and many require neuroimaging studies or lumbar puncture. To avoid missing the occasional seriously ill patient among the large number of patients with relatively benign headaches, physicians must maintain a high index of suspicion and a familiarity with the differential diagnosis. Patients with severe acute headaches must be evaluated for subarachnoid hemorrhage and bacterial meningitis. Temporal arteritis must be excluded in all older patients with recurrent headaches of recent onset. Trigeminal neuralgia and cluster headache usually do not signify serious underlying disease, but the severity of the pain mandates rapid diagnosis and institution of therapy. Migraines are extremely common and often mislabeled as tension or sinus headaches. All primary care physicians should be able to recognize the many faces of migraine and be familiar with symptomatic and prophylactic therapy. Difficult cases should be referred to a neurologist for ongoing care.