Hypersensitivity to Substance P in the Etiology of Postlumbar Puncture Headache

Objective.-Postlumbar puncture headache may represent a model which could be used to test the hypothesis that headache pain is caused by the release of substance P in patients who are predisposed to headache due to hypersensitivity to substance P.
Methods.-We measured substance P in CSF and plasma in 37 patients undergoing diagnostic lumbar puncture. In 9 patients, plasma samples were obtained before lumbar puncture, in 28 patients plasma was obtained after lumbar puncture. Patients were followed up by telephone to determine if they developed postlumbar puncture headache. Patients were also asked about a history of chronic or recurrent headaches. Substance P was determined by radioimmunoassay.
Results.-The mean plasma substance P levels obtained before lumbar puncture was 1.0 ± 0.1 pg/mL and 1.3 ± 1.2 after lumbar puncture (P<0.0005). The mean plasma substance P levels in subjects who developed postlumbar puncture headache was 0.6 ± 0.6 pg/mL compared with 1.4 ± 1.5 in subjects who remained headache-free ( P <0.05). The mean CSF substance P levels in subjects who developed postlumbar puncture headache was 0.7 ± 0.5 pg/mL compared with 1.2 ± 0.8 in subjects who remained headache-free ( P <0.05). There were no significant differences in substance P levels between chronic headache sufferers and nonheadache subjects.
Conclusions.-Postlumbar puncture headache may be mediated by the release of substance P triggered by lumbar puncture, in patients predisposed to headache by a hypersensitivity to substance P. Hypersensitivity to substance P may also represent a mechanism for headache pain in other headache disorders.     

Changing pattern of headache pointing to cerebral venous thrombosis after lumbar puncture and intravenous high-dose corticosteroids

OBJECTIVE: To emphasize the diagnostic importance of change in the headache pattern which pointed to cerebral venous thrombosis in two patients after lumbar puncture and high-dose intravenous methylprednisolone for suspected multiple sclerosis. RESULTS: Both patients had a diagnostic lumbar puncture for suspected multiple sclerosis and were treated with high-dose intravenous methylprednisolone. Both developed a postlumbar puncture headache that was initially postural, typical of low cerebrospinal fluid pressure. Three days later, the headache became constant, lost its postural component, and was associated with bilateral papilledema. Magnetic resonance imaging of the brain disclosed superior sagittal and lateral sinuses thrombosis. The diagnostic difficulties of such cases and the potential role of lumbar puncture and corticosteroids as risk factors for cerebral venous thrombosis are discussed. CONCLUSIONS: When a typical postdural puncture headache loses its postural component, investigations should be performed to rule out cerebral venous thrombosis, particularly in the presence of other risk factors.     

Is chronic tension-type headache a vascular headache? The relation between chronic tension-type headache and cranial hemodynamics

Twenty-seven patients with chronic tension-type headache were studied as to end-tidal PCO2, heart rate, mean blood pressure, diameter and blood flow of the common carotid arteries, cranial vascular resistance, and headache intensity at supine rest, after administration of nitroglycerin, and at head down tilt. The results were compared to the results of nitroglycerin and head down tilt provocations in age- and sex-matched controls. During supine rest, no change in chronic tension-type headache occurred. Nitroglycerin and tilting induced significant increase of the headache intensity compared to baseline in patients with chronic tension-type headache (P=0.01 and P<0.05, respectively) in contradistinction to controls who did not develop significant headache. Common carotid artery blood flow changes were similar during nitroglycerin provocations in the two groups, but greater (P<0.05) during head down tilt in patients than in controls. Lumbar cerebrospinal fluid pressure was found to be greater than 20 but less than 26 cm H2O in 45% of the 22 patients studied with chronic tension-type headache. The results indicate that the pain in chronic tension-type headache is related to cranial hemodynamics, presumably to distention of intracranial veins.     

Blood pool scintigraphy of the skull in relation to head-down tilt provocation in patients with chronic tension-type headache and controls

OBJECTIVE: To investigate the mechanisms behind the increase of chronic tension-type headache during head-down tilt. BACKGROUND: The pathophysiology of chronic tension-type headache is unknown. DESIGN AND METHODS: Ten patients suffering from chronic tension-type headache and 10 age- and sex-matched controls were studied with respect to pain intensity and alterations in cranial blood volume using planar scintigraphy and radiolabeled autologous erythrocytes before, during, and after head-down tilt, a procedure known to increase chronic tension-type headache. RESULTS: Four of 8 patients with chronic tension-type headache studied had increased cerebrospinal fluid pressure. During head-down tilt, the pain increased significantly in the group with chronic tension-type headache (P <.001) while the procedure did not cause headache in the controls. Blood volume significantly increased extracranially and decreased intracranially in both groups during head-down tilt. The extracranial nasal blood volume was significantly related to the pain experienced by the patients with chronic tension-type headache before and during head-down tilt. CONCLUSIONS: Although the changes in blood volume and, presumably, the increase of intracranial pressure were similar in the patients with chronic tension-type headache and the controls, only the patients experienced pain and pain increase during head-down tilt. This indicates that the pre-head-down tilt conditions must be different in the 2 groups and should be related to increased cerebrospinal fluid pressure/intracranial venous pressure in patients with chronic tension-type headache compared with controls. A difference in central mechanisms may, however, also be of importance for the difference in headache provocation in the 2 groups during head-down tilt.     

An MRI Study of Lumbar Puncture Headaches

We studied 11 patients undergoing a routine lumbar puncture to determine if there were cerebrospinal fluid leaks at the puncture site and whether the maximum volume of leakage correlates with a lumbar puncture headache. Patients completed a headache questionnaire before and after the lumbar puncture. Limited magnetic resonance imaging of the lumbar spine was obtained 8 to 36 hours after the lumbar puncture and two patients also had later imaging. In a blinded fashion, the largest diameter of cerebrospinal fluid leakage into the paraspinous area was determined from T2 weighted magnetic resonance images and the maximum possible fluid volume was calculated. Six patients had a small cerebrospinal fluid leakage (< 10 mL), two had a medium leakage (10 to 110 mL), and three had a large leakage (> 110 mL). The volume of cerebrospinal fluid leakage did not corre late with occurrence of a lumbar puncture headache. The study demonstrates that cerebrospinal fluid usually leaks into the paraspinous area after a lumbar puncture, but the volume of escaped fluid does not correlate with a lumbar puncture headache.     

Headache Associated With Aseptic Meningitis

A retrospective analysis of all patients admitted with the diagnostic codes of aseptic or viral meningitis was performed at two institutions over 3 years. Forty-one patients with cerebrospinal fluid confirmation of aseptic meningitis (increased protein; increased white count; negative gram stain; and negative fungal, tuberculosis, and bacterial cultures) were analyzed.
All the patients had headache, which was typically severe and bilateral in 39 of the 41 patients. The headache was of abrupt onset or the worst of the patient's life in 24 of the patients. The quality of the headache, when described, was usually throbbing (11 of 14). Nineteen patients had prodromal symptoms, including malaise, myalgia, gastrointestinal symptoms, and urinary tract infections. All had associated symptoms, including nausea (25), vomiting (23), photophobia (18), stiff neck (25), and back pain (11). Thirty patients were febrile. Lumbar puncture was performed for headache and fever unexplained by systemic illness in 30 patients, meningeal signs in 15, headache of abrupt onset or the worst headache ever in 24, neurologic signs or symptoms in 12, and for other reasons in 2. Computerized tomography, when performed, was negative in all cases. Focal neurologic findings were present in 5 patients, a decreased level of consciousness in 6, and papilledema in 1.
A severe headache that worsens, is abrupt in onset, or is the worst of the patient's life could be due to aseptic meningitis, bacterial meningitis, or a subarachnoid hemorrhage. Although not universally present, meningeal signs, fever, and neurologic signs or symptoms should alert one to a possible central nervous system infection.     

Muscular Factors are of Importance in Tension-Type Headache

Recent studies have indicated that muscular disorders may be of importance for the development of increased pain sensitivity in patients with chronic tension-type headache. The objective of the present study was to investigate this hypothesis by examining the pain perception in tension-type headache with and without muscular disorders defined as increased tenderness. We examined 28 patients with episodic tension-type headache, 28 patients with chronic tension-type headache, and 30 healthy controls. Pericranial myofascial tenderness was recorded with manual palpation, and pressure pain detection and tolerances in cephalic and extracephalic locations with an electronic pressure algometer. In addition, thermal pain sensitivity and electromyographic activity were recorded. The main result was significantly lower pressure pain detection thresholds and tolerances in all the examined locations in patients with chronic tension-type headache with a muscular disorder compared to those without a muscular disorder. There were no such differences in any of the examined locations when the two subgroups of patients with episodic tension-type headache were compared. Thermal pain sensitivity did not differ between patients with and without a muscular disorder, while electromyographic activity levels were significantly higher in patients with chronic tension-type headache with than in those without a muscular disorder. Our results strongly indicate that prolonged nociceptive stimuli from the pericranial myofascial tissue sensitize the central nervous system and, thereby, lead to an increased general pain sensitivity. Muscular factors may, therefore, be of major importance for the conversion of episodic into chronic tension-type headache. The present study complements the understanding of the important interactions between peripheral and central factors in tension-type headache and may lead to a better prevention and treatment of the most prevalent type of headache.     

Headache resembling tension-type headache as the single manifestation of Lyme neuroborreliosis

We present two patients with monosymptomatic headache resembling chronic tension-type headache as the first manifestation of Lyme neuroborreliosis. The headache developed over a few days in both cases and lasted for three months in the first case and for two and a half years in the second case before the diagnosis of Lyme neuroborreliosis was made. Neuroimaging and many laboratory investigations did not lead to the diagnosis, which was only established after lumbar puncture. The CSF in both cases showed high protein, lymphocytic pleocytosis and Borrelia burgdorferi-specific intrathecal antibody synthesis. The headache disappeared completely after treatment with penicillin G. In patients suffering from daily headaches which have developed subacutely, Lyme neuroborreliosis should be considered even in the absence of signs of meningeal irritation. A lumbar puncture should be performed more often than is presently customary and the CSF should be examined for pleocytosis as well as Borrelia burgdorferi -specific intrathecal antibody synthesis.     

Amitriptyline Is Effective in Chronic But Not in Episodic Tension-Type Headache: Pathogenetic Implications

The tricyclic antidepressant amitriptyline, is an effective drug for the treatment of chronic tension-type headache and for other chronic pain syndromes, but it is also effective in the prophylaxis of an episodic type of headache such as migraine. However, its efficacy in episodic tension-type headache has not yet been clarified. We compared the efficacy of amitriptyline (25 mg/day) in 82 nondepressed patients with either chronic or episodic tension-type headache in an open-label study. Amitriptyline significantly reduced ( P <0.05) frequency and duration of headache as well as analgesic consumption in chronic, but not in episodic, tension-type headache. Further placebo-controlled trials, possibly with higher doses of amitriptyline, might confirm if the different pattern of response to amitriptyline can be explained in terms of different involvement of central nociception and of peripheral myofascial factors in the chronic and in the episodic forms of tension-type headache.     

Relationship between chronic tension-type headache, cranial hemodynamics, and cerebrospinal pressure: study involving provocation with sumatriptan

OBJECTIVE: To study the relationship between chronic tension-type headache, cranial hemodynamics, and cerebrospinal pressure. BACKGROUND: Cerebrospinal pressure has been found to be above 200 mm in about 50% of patients with chronic tension-type headache. METHODS: Heart rate, blood pressure, common carotid artery diameter and blood flow, and craniovascular resistance and pain at regular intervals before, during, and after head-down tilt-a procedure which increases cerebrospinal pressure, were recorded. After head-down tilt, subcutaneous injections of either placebo or 6 mg of sumatriptan were administered. Chronic tension-type headache intensity before and after withdrawal of 20 mL of cerebrospinal fluid was documented. Cerebrospinal pressure and chronic tension-type headache intensity were measured after subcutaneous injection of 6 mg of sumatriptan. RESULTS: Head-down tilt provoked an increase of headache compared with baseline. Common carotid artery blood flow decreased and craniovascular resistance increased after sumatriptan injection, but not after placebo injection. The pain decreased after head-down tilt and placebo injection, but not after sumatriptan injection. Chronic tension-type headache intensity decreased in all 4 patients studied after withdrawal of 20 mL of cerebrospinal fluid. Cerebrospinal pressure increased in 5 patients with chronic tension-type headache after subcutaneous injection of 6 mg of sumatriptan with slight or no increase of pain. CONCLUSION: The results indicated that cerebrospinal pressure or intracranial venous pressure (or both) are related to chronic tension-type headache.     

Neck Mobility in Different Headache Disorders

The main purpose of this study was to assess neck mobility (by Cybex equipment) in different headache disordered and, in particular, cervicogenic headache, and to compare; these findings with those in controls. A total of 51 control subjects and 90 headache patients were investigated, whereof 28 patients suffered from common migraine (migraine without aura), 34 from tension-type headache (H episodic and 25 chronic), and 28 patients from cervicogenic headache. One-way ANOVA and post hoc Bonferroni analysis showed significant differences between those with cervicogenic headache and the other groups for rotation ( P <0.001) and flexion/extension ( P <0.001), but not for lateral neck movement ( P =NS). There were no significant differences between migraine patients, tension-type headache patients, and controls. In all four groups, there was a significant positive correlation between active and passive neck movement for rotation ( P <0.001), flexion/extension ( P <0.001), and lateral neck movement ( P <0.001). Repeated measures analysis of variance (ANOVA) showed no significant day-to-day differences in 10 control subjects. In the control group (n=51), there was a significant negative correlation between age and neck movement. For rotation. Pearson's correlation coefficient was: r =-0.71 ( P <0.001), for flexion/extension r =-0.71 ( P <0.001), and for lateral neck movement r =-0.67 ( P <0.001). No significant sex difference was found as for any of the neck movements. Pain at the time of investigation did not seem to influence neck mobility. Cervicogenic headache has been recognized as a pair syndrome by the International Association for the Study of Pain (IASP). Since reduced neck mobility is one of the major criteria for this diagnosis, it emphasizes the need for systematic, objective neck mobility measurements in the individual patient to substantiate the diagnosis. The technique is simple and proved reliable.     

Decreased Serum Interleukin-2 Level in Patients With Chronic Headache

Some cellular immune functions are impaired in cluster headache patients. Interleukin-2 (IL-2) is a polypeptide secreted by antigen or mitogen-actuated T lymphocytes that functions as a growth factor for T cells. To investigate cellular immune functions in patients with chronic headache, we measured the IL-2 concentration of sera in patients with migraine and in patients with tension-type headache. Thirteen subjects suffering from migraine without aura (5 males and 8 females, mean age: 32.8 years) and 46 subjects (20 males and 26 females, mean age: 39.7 years) with tension-type headache (TH) were selected for this study. Forty-three normal healthy volunteers composed the control group (15 males and 28 females, average age 41.6 years). The IL-2 levels of sera were determined using enzyme-linked immunosorbent assay (ELISA) techniques. The IL-2 levels of sera were 3.18 +/- 1.8 U/ml (mean +/- SD) in the healthy controls, 2.29 +/- 2.6 U/ml in the patients with migraine and 1.59 +/- 1.0 U/ml in the patients with TH. The serum level of IL-2 in the patients with migraine was significantly lower than in the controls. The serum level of IL-2 in the patients with TH was significantly lower than in the controls. The central nervous system (CNS) has been considered to be involved in the development of the immune phenomena. In the patients with TH or migraine, reduction in platelet 5-hydroxytryptamine (5-HT) levels and sympathetic hypofunction have been observed. These phenomena might reflect decrease in 5-HT levels in CNS in the patients with TH or migraine. The decreased serum IL-2 level, observed in this study, might reflect a reduction in 5-HT or catecholamine levels in CNS in the patients with migraine or TH.     

Plasma Monoamines in Tension-Type Headache

SYNOPSIS
Clinical and pharmacological data suggest a derangement of central monoaminergic systems in tension-type headache. Biochemical evidence has been rarely recognized. These findings may relate with pathophysiological mechanisms of headache or with underlying depression. We measured platelet-rich plasma serotonin and plasma catecholamines (norepinephrine, epinephrine, and dopamine) in 30 patients with tension-type headache and in 20 healthy controls, using High-Pressure Liquid Chromatography. We studied differences between groups and the relation between biochemical parameters and clinical indices evaluating duration and severity of headache and depression. Platelet serotonin levels in tension headache patients were higher than in controls ( P <0.001). Plasma catecholamine levels were lower in patients than in controls ( P 相似文献   

Lumbar iohexol myelography and diagnostic lumbar puncture. Headache and associated side effects in relation to neurological signs and diagnosis, previous mental symptoms and pain history

Various possible risk factors for postlumbar puncture (and postiohexol-myelographic) headache and associated side effects were analysed. Headache and nausea occurred significantly more often in patients without clinical findings than in those with findings. We found significantly different incidences of severe headache and nausea between diagnostic subgroups after a lumbar puncture. The greatest headache incidence was found in patients without a definite neurological diagnosis, while nausea occurred most frequently in patients with various painful disorders. Following iohexol myelography, nausea occurred most often in patients who had a history of previous mental symptoms and in patients with a history of previous headache disorders. Mental symptoms were more frequently reported in patients who also had experienced mental symptoms previously. The relationship between side effects and negative clinical findings was stronger than the relationship between side effects and previous mental symptoms.     

Epidemiologic and Clinical Characteristics of Migraine and Tension-Type Headache in Korea

This is the first population-based epidemiologic study of chronic headache in South Korea. The diagnosis and classification of headache was according to the criteria of the International Headache Society. Sixty-eight percent of the studied population experienced headache during the preceding year. The estimated prevalences were 22.3% for migraine (male 20.2%, female 24.3%) and 16.2% for tension-type headache (male 17.8%, female 14.7%). In migraine, the 15-to 19-year age group showed maximal prevalence in both sexes (male 28.5%, female 34.7%). The prevalence of tension-type headache was highest in the 50- to 59-year age group in men(24.2%) and in the 20- to 29-year age group in women(20.2%). In migraine, headache intensity was more severe in women than in men, but in tension-type headache there was no difference in the severity of headache between the sexes. Phonophobia was the most common associated symptom of migraine (65.1%). In the migraine with aura group, the most common aura was visual disturbance, including scintillation and image distortion (82.3%). Only 24.4% of migraineurs and 12.3% of patients with tension-type headache had ever consulted a doctor for headache. The prevalence of migraine was not lower than in western countries and much higher than in previous studies conducted in other Asian countries.     

Quantification of Headache Disability: A Diagnostic-Based Approach

The quantification of the social and economic handicaps caused by headache is a complex problem, especially given the great variability of headache patients' clinical pictures. In the present study, 400 patients, consecutively admitted to Headache Centers in Pavia and Milan, were interviewed on the relationship between headache and their work and social activities, in order to evaluate their socioeconomic handicap due to headache. The analysis of the data primarily focused on attack-type headaches (migraine, cluster headache, and episodic tension-type headache) and chronic or daily headaches (chronic tension-type headache and migraine combined with tension-type headache). These latter types were often characterized by the daily use or abuse of analgesics.
The overall profile which emerged from the study reveals relatively low levels of handicap or disability in work and social activities. These low levels can be mainly attributed to timely, and at times excessive, use of analgesics.     

Chronic bilateral headache responding to indomethacin

Three patients with bilateral chronic tension-type headache (meeting IHS diagnostic criteria) responded with complete control of the headache during the more than 2 years they were treated with indomethacin. The headache recurred within 12 to 26 hours after indomethacin was stopped. Fifty milligrams of intravenous indomethacin resulted in complete relief of headache for 6.5 to 25 hours, similar to results found earlier in patients with hemicrania continua. It is concluded that there may be a subgroup of patients with bilateral chronic headache who respond to indomethacin in the group of patients otherwise diagnosed as having chronic tension-type headache.     

Magnetic Resonance Imaging in Migraine and Tension-Type Headache

Cerebral magnetic resonance imaging was performed on 63 patients with chronic primary headache (28 with migraine with and without aura, 35 with tension-type headache). Fifty-four headache-free individuals of the same age range were used as controls. The headache sufferers showed an incidence of focal white matter abnormalities on T2-weighted magnetic resonance imaging significantly higher than the age-matched control group (33.3% vs 7.4%). The incidence of white matter abnormalities did not correlate with age (except for patients older than 60 years), sex, headache history, headache status, or ergotamine consumption. Migraine (with and without aura) and tension-type headache patients had similar prevalence of white matter abnormalities (32.1% vs 34.3%). The lesions were predominantly distributed in the frontal region, independent of the side of usual aura or headache. Our findings indicate that both migraine and tension-type headache may be associated with early pathologic changes in the brain and may share, at least in part, common pathogenic pathways.     

Behavioral Response to Headache: A Comparison Between Migraine and Tension-type Headache

OBJECTIVE: To compare patients with migraine and tension-type headache in their behavior during the attacks and the maneuvers used to relieve the pain. BACKGROUND: Patients with headache often perform nonpharmacological measures to relieve the pain, but it is not known if these behaviors vary with the diagnosis, clinical features, and pathogenesis. METHODS: One hundred consecutive patients with either migraine (n = 72 ) or tension-type headache (n = 28) were questioned (including the use of a checklist) concerning their usual behavior during the attacks and nonpharmacological maneuvers performed to relieve the pain. The results of the two types of headache were compared. RESULTS: Patients with migraine tended to perform more maneuvers than individuals with tension-type headache (mean, 6.2 versus 3). These maneuvers included pressing and applying cold stimuli to the painful site, trying to sleep, changing posture, sitting or reclining in bed (using more pillows than usual to lay down), isolating themselves, using symptomatic medication, inducing vomiting, changing diet, and becoming immobile during the attacks. The only measure predominantly reported by patients with tension-type headache was scalp massage. However, the benefit derived from these measures was not significantly different between the two groups (except for a significantly better response to isolation, local pressure, local cold stimulation, and symptomatic medication in migraineurs). CONCLUSIONS: The behavior of patients during headache attacks varies with the diagnosis. Measures that do not always result in pain relief are performed to prevent its worsening or to improve associated symptoms. These behavioral differences may be due to the different pathogenesis of the attacks or to different styles of dealing with the pain. They can also aid the differential diagnosis between headaches in doubtful cases.     

The Relationship of Locus of Control and PsychosociaI-Behavioral Response in Chronic Headache

It has been suggested that patients' perceptions of the impact chronic headache has on their lives as well as perceived control of their headaches may be associated with the intensity, duration, and exacerbation of pain they experience. The present study examined associations among International Headache Society (IHS) diagnostic category, pain characteristics such as severity and duration, perceived impact and control of headaches, and adaptive response. Two hundred twenty-five patients with migraine, tension-type, or combined migraine and tension-type headache served as subjects. General activity level was related to IHS diagnosis, with migraine headache patients reporting that they are more active than tension-type headache patients (F(2, 196) = 5.69, P < .01). Headache locus of control was not significantly related to IHS diagnosis, however external headache locus of control was significantly related to headache intensity (r = .32, P < .001, r = .25, P < .001), as well as to patients' perceptions of the extent to which pain interfered with various domains of their lives (r = .33, P < .001, r = .28, P < .001), and adaptive response (F(6, 402) = 4.68, P < .001). It appeared that perceived control over headaches and perceived impact of headaches were not related to IHS diagnostic category and were not strongly related to each other, but were related to headache severity.