Postlumbar Puncture Headache and its Relation to Chronic Tension-Type Headache

One hundred consecutive patients, the majority suffering from bilateral chronic tension-type headache, investigated with lumbar puncture, were studied as to age, sex, body mass index, diagnosis, lumbar cerebrospinal fluid pressure, and signs of inflammation in the serum in relation to postlumbar puncture headache. Patients younger than 40 years of age were significantly more prone to develop postlumbar puncture headache than patients older than 40 years of age ( P =0.01). Sex, body mass index, cerebrospinal fluid pressure, and signs of inflammation in the serum were not related to the frequency of postlumbar puncture headache in the present study. Postlumbar puncture headache occurred significantly more often in patients with bilateral chronic tension-type headache than in patients with unilateral headache ( P =0.02) and in patients without headache ( P <0.01). In a regression analysis with age, sex, and chronic tension-type headaches, only bilateral headache contributed significantly to the prediction of postlumbar puncture headache ( P <0.01). Age did not contribute apart from the common variance with chronic tension-type headache/no chronic tension-type headache. The results may indicate that postlumbar puncture headache and chronic tension-type headache have etiologic mechanisms in common, mechanisms presumably localized intracranially rather than extracranially.     

Posttraumatic Headache: Determining Chronicity

SYNOPSIS
In the headache literature, there exists a great deal of discrepancy regarding when posttraumatic headache (PTH) may be classified as chronic. Although chronic pain is usually described as pain persisting for longer than six months, many view chronic posttraumatic headache as persisting for more than two months, including the International Headache Society criteria. Observations made by Brenner and Friedman in 1944 have been repeatedly cited for this determination. Surprisingly, a review of this original source revealed that the term "chronic" was never used when discussing posttraumatic headache over two months duration. The authors, in fact, suggested two months as an "arbitrary" dividing line. Recent studies suggest that many patients with PTH continue to improve or change over the first six months but start to plateau after that time. We feel six months serves as a better time indicator for defining chronicity in cases of posttraumatic headache. This would be more consistent with the current literature concerning chronic pain and the International Headache Society criteria for chronic tension headache.     

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.     

Postoperative Headache in Acoustic Neuroma

Recently, it has become obvious that disabling postoperative headache is a major problem with acoustic neuroma surgery. A questionnaire was used to retrospectively evaluate the incidence, clinical features, prognosis and possible therapeutic measures of this particular form of headache. Forty-two percent (42%) of patients had some headache prior to surgery but this was not a major complaint. After surgery, 75% of patients experienced headache. Only 24% had complete relief of headache. A very gradual improvement of the pain occurred in 32%. Pathogenesis remains unclear, but clinical characteristics of the headache suggest a combination of tension-type, neuralgic and vascular components. Postoperative pain occurs mostly around the surgical site suggesting that this type of headache is the result of surgical trauma. A prospective long-term study is needed to delineate this condition further. Some therapeutic suggestions are offered.     

Middle Turbinate Headache Syndrome

The middle turbinate and nasal septum are innervated by the anterior ethmoidal nerve, a branch of the ophthalmic division of the trigeminal nerve. As reported in the classical work of Wolff (1948), stimulation of these regions causes pain in the medial canthus of the supraorbital region. Periorbital pain due to middle turbinate compression against the septum or the lateral wall of the nose may be due to congestion of the nasal mucosa or to pneumatization of the middle turbinate (concha bullosa). The diagnosis is made by exclusion and requires a high index of suspicion, anterior rhinoscopy, computerized tomography (CT), and confirmation by the lidocaine test. We present five cases of middle turbinate headache syndrome, all with contha bullosa. Four were treated surgically by partial middle turbinectomy and septoplasty more than 1 year ago, with excellent results. One patient refused surgical treatment which was suggested after failure of medical treatment with antihistamines, decongestants, and a topical corticosteroid, and continues to be symptomatic. Despite the small number of cases studied, the authors conclude that the procedure used was effective for the resolution of headache.     

Medication Overuse Headache

Questions from patients about pain conditions and analgesic pharmacotherapy and responses from authors are presented to help educate patients and make them more effective self-advocates. In reply to a question about medication overuse headache, its presentation, causes, treatment, and prevention will be discussed.     

The International Headache Society (IHS) Headache Classification as applied to a headache clinic population

Four hundred patients attending a headache clinic were classified using the IHS criteria. The majority required more than two, often three or four, diagnoses. Even though migraine was the most common diagnosis, only 1/4 of those with a migraine diagnosis had it as the only diagnosis. Seventy-five percent of migraine patients had coexistent chronic tension-type headache (CTTH), drug-induced headache or both. Ninety-six percent of patients diagnosed as having migraine with aura also suffered from migraine without aura. More than 1/3 of patients (37.7%) attending the clinic suffered from chronic daily headache (CDH) (chronic cluster headache excluded), which is not included as a separate entity in the IHS classification. Pure CTTH formed only a small minority of CDH, whereas 86.6% of CDH had migraine as one of the diagnoses. Drug-induced headache was a prominent second or third diagnosis. The advantages and disadvantages of multiple verses single diagnosis in CDH and the need to recognize the natural history of headache disorders in the classification are discussed.     

Postangiography Headache

In order to study the frequency and characteristics of post-angiography headache, we interviewed 45 consecutive patients (mean age ± SD= 57 ± 15 years; M/F=15/30) who underwent transfemoral cerebral angiography for: ischemic cerebrovascular disease (n=33); suspected arteriovenous malformations (n=4; one confirmed); suspected cerebral aneurysm (n=5; two confirmed); and arterial dissection (n=3; one confirmed and one was a follow-up study of a previously demonstrated dissection). Postangiography headache developed in 15 (33%) patients, 125 ± 99 min after the completion of the study. It was unilateral in nine (60%) patients, homolateral to the usual side of migraine headache in two of three migraineurs, and pulsating in six (40%). Nausea, vomiting, photophobia, and phonophobia accompanied postangiography headache in 20%, 7%, 33%, and 20% respectively. Postangiography headache fulfilled the International Headache Society criteria for migraine without aura (except for the number of attacks) in 27% of patients. Patients with and those without postangiography headache were comparable in mean age, sex, and indication for angiography. Fifty-three percent (8/15) of patients with postangiography headache and 23% (7/30) of the non postangiography headache group reported prior recurrent headaches (P =0.047, likelihood ratio chi-square). Postangiography headache has the characteristics of delayed arterial pain which may be related to a catheter-induced or contrast dye-induced release of vasoactive substances, notably nitric oxide and serotonin.     

Hijab (Headscarf) Headache

Hijab (headscarf) headache is well known among wearers and is a common topic of discussion. It has never previously been reported in the medical literature. Five women described bilateral headache either prompted by or worsened by donning the hijab, or headscarf. The headache always resolved soon after removal of the headscarf. Hijab headache may also be alleviated by minimal modifications in style while allowing women to maintain their moral conviction. It likely represents an extracranial etiology of headache, and recognition may prevent unnecessary evaluation and suffering in hijab wearers.     

Headache in sleep apnea syndrome

OBJECTIVE: To find out whether there is a relationship between the headache characteristics and polysomnographic findings in patients with prediagnosis of the sleep apnea syndrome (SAS) and, if there is, to search for its possible cause. BACKGROUND: Chronic morning headache is considered by many to be an important part of the SAS. Some reports support this relationship, and some do not. METHODS: We questioned 75 patients with SAS about headache. Headaches were classified according to the International Headache Society (IHS-88) system. We evaluated the relationship between headache and polysomnographic findings. RESULTS: There was no statistically significant relationship between headache and apnea hypopnea index (AHI) or minimal oxygen saturation (P >.05). CONCLUSIONS: We could not demonstrate a statistically significant relationship between headache, AHI, and minimal oxygen saturation in our patients with SAS.