Spontaneous Intracranial Hypotension: Headache With a Reversible Arnold-Chiari Malformation

Spontaneous intracranial hypotension is characterized by severe postural headache in the setting of low CSF pressure, usually attributed to a cryptic CSF leak. We report a patient whose prolonged refractory headache was characterized by the clinical symptoms of occipital neuralgia, but was also associated with the radiographic appearance of an Arnold-Chiari malformation, type I and low CSF pressure. After extensive diagnostic evaluation, CT cisternomyelography ultimately demonstrated a CSF leak at the C2 vertebral level. Symptomatic relief was sustained only with long-term theophylline administration. The apparent Arnold-Chiari malformation resolved with treatment of the low CSF pressure.     

Arnold-Chiari畸形MRI诊断

目的：探讨Ａｒｎｏｌｄ－Ｃｈｉａｒｉ畸形（ＡＣＭ）ＭＲＩ表现，并评价ＭＲＩ对其早期诊断及预测病情进展的临床价值；材料和方法：２７例ＡＣＭ均经ＭＲＩ诊断、手术及临床证实，其中男性１１例，女性１６例，年龄８～５６岁，平均３１岁；结果：小脑扁桃体疝至枕大孔平面下５～２６ｍｍ２０例，２～４ｍｍ７例；２５例扁桃体下极变尖，边缘锐直，２例生理曲度存在；２５例扁桃体前池变形，其中扁桃体前池消失和／或颈延髓扭曲成角１１例；伴脊髓空洞１３例，在Ｔ２加权像上脑脊液流空信号减弱３例，经手术证明均为多房空洞；颅颈部各种骨畸形１５例；结论：小脑扁桃体位于枕大孔下５ｍｍ即可诊断ＡＣＭ，对＜５ｍｍ者，在诊断ＡＣＭ前须注意正常扁桃体暂时低位；小脑扁桃体前池消失和／或颈延髓扭曲成角，表示延髓受压，患者病情将迅速恶化；根据Ｔ２加权像脊髓空洞内脑脊液流空信号变化可判断空洞是多房或单房，并能评价ＡＣＭ术后疗效。     

Arnold-Chiari畸形合并脊髓空洞症的显微外科手术治疗

目的：总结54例Chiari畸形合并脊髓空洞症的显微外科手术治疗经验。方法：本组对1998年9月至2005年9月共收治的54例Chiari畸形合并脊髓空洞症患者采用后路手术入路,对颅底凹陷症采用后路减压,显微镜下行小脑扁桃体软膜下部分切除,正中孔开放手术治疗。结果：54例患者术中观察发现延髓和上颈髓明显受压和不同程度同小脑扁桃体粘连,正中孔引流不畅;随访1月～7年,术后42例症状显著改善,12例明显改善;影像学复查提示脊髓空洞明显缩小。结论：显微外科手术治疗Chiari畸形合并脊髓空洞症疗效确切可靠。     

Chiari-associated exertional,cough, and sneeze headache responsive to medical therapy

Benign exertional headache is coded as a separate entity within the International Headache Society's classification system, but the pathophysiological mechanisms underlying this clinical headache subtype are unknown and possibly are similar to those generating migraine. Coexistence of migraine and benign exertional headache in the same patient is not unusual, and antimigraine pharmacologic treatments are often effective in both headache types. Regardless, optimal management mandates that the clinician exclude any intracranial or systemic disease that could mimic "primary" exertional headache. The same holds for primary headaches induced by coughing or sneezing; congenital malformations or neoplasms, particularly within the posterior fossa, are not rare in these patients. The neurologic examination may not be sufficiently sensitive to detect the offending lesion. We describe a patient with migraine without aura and exertional secondary headache due to Chiari malformation type I whose headaches responded to treatment with propranolol and indomethacin.     

Headache and Arachnoid Cysts

Arachnoid cysts are commonly encountered when neuroimaging is obtained for headaches. Their clinical relevance is not always immediately clear and they may confound medical management.     

Diagnoses and Symptom Patterns in Children Presenting to a Pediatric Headache Clinic

SYNOPSIS
The diagnosis of migraine headache in children and adolescents is complex and not well understood. This study was conducted to compare diagnostic rates, using various criteria for pediatric migraine, and specific symptom characteristics in a sample of children referred for care to a specialized pediatric headache clinic. A structured interview was used at the patient's initial assessment visit to elicit symptom patterns and therapies attempted for headache. Clinical diagnoses were based on consensus agreement reached by a multidisciplinary team. Statistically derived diagnostic rates based on International Headache Society (IHS), Prensky, Vahlquist and our own criteria were significantly lower than clinical diagnostic rates. IHS diagnostic rates were differentially distributed as a function of race, but no other effects were found for demographic variables on diagnostic rates. Specific symptom patterns, however, varied as a function of race, gender and age of the child. The results underscore the need for comprehensive, developmentally based models of the evolution of migraine headache as a foundation for future research and the further development of clinically sensitive diagnostic criteria for pediatric migraine.     

颅颈交界畸形外科治疗中辅助外固定支具的应用

目的探讨在颅颈交界畸形外科治疗中辅助外固定支具的选择和应用。方法回顾48例先天性颅颈交界畸形外科治疗中辅助外固定支具的应用,其中包括颈围、头环胸衣(Halo-vest)、胸骨-枕骨-下颔固定器(SOMI)3种颈部支具。结果后路内固定术后辅助外固定支具初选分别为费城式颈围(20例)、SOMI(16例)、头环胸衣(12例),应用效果优良率分别为80.0%、87.5%和91.7%。初选支具效果不满意者经更改支具后,最终在康复期应用的支具分别为费城式颈围16例、SOMI15例、头环胸衣17例35例(72.9%)获得了随访4个月以上,支具固定时间均超过3个月,满足所需术后支具外固定时间。结论颈围、头环胸衣、SOMI3种颈部支具在颅颈交界畸形外科治疗的围手术期和康复期的应用具有重要临床价值,需结合患者的病情特点和外科治疗不同阶段加以选择应用。     

Migraine‐Like Headache With Autonomic Symptoms in Midbrain Malformation

We report a case of midbrain malformation characterized by right deviation of the medulla oblongata associated with elongation and ectasia of the basilar and left vertebral arteries in a patient with a long history of migraine‐like headache with autonomic symptoms.     

Headache and Symptoms of Temporomandibular Disorder: An Epidemiological Study

(Headache 2010;50:231‐241) Objectives.— A population‐based cross‐sectional study was conducted to estimate the prevalence of migraine, episodic tension‐type headaches (ETTH), and chronic daily headaches (CDH), as well as the presence of symptoms of temporomandibular disorders (TMD) in the adult population. Background.— The potential comorbidity of headache syndromes and TMD has been established mostly based on clinic‐based studies. Methods.— A representative sample of 1230 inhabitants (51.5% women) was interviewed by a validated phone survey. TMD symptoms were assessed through 5 questions, as recommended by the American Academy of Orofacial Pain, in an attempt to classify possible TMD. Primary headaches were diagnosed based on the International Classification of Headache Disorders. Results.— When at least 1 TMD symptom was reported, any headache happened in 56.5% vs 31.9% (P < .0001) in those with no symptoms. For 2 symptoms, figures were 65.1% vs 36.3% (P < .0001); for 3 or more symptoms, the difference was even more pronounced: 72.8% vs 37.9%. (P < .0001). Taking individuals without headache as the reference, the prevalence of at least 1 TMD symptom was increased in ETTH (prevalence ratio = 1.48, 95% confidence interval = 1.20‐1.79), migraine (2.10, 1.80‐2.47) and CDH (2.41, 1.84‐3.17). At least 2 TMD symptoms also happened more frequently in migraine (4.4, 3.0‐6.3), CDH (3.4; 1.5‐7.6), and ETTH (2.1; 1.3‐3.2), relative to individuals with no headaches. Finally, 3 or more TMD symptoms were also more common in migraine (6.2; 3.8‐10.2) than in no headaches. Differences were significant for ETTH (2.7 1.5‐4.8), and were numerically but not significant for CDH (2.3; 0.66‐8.04). Conclusion.— Temporomandibular disorder symptoms are more common in migraine, ETTH, and CDH relative to individuals without headache. Magnitude of association is higher for migraine. Future studies should clarify the nature of the relationship.     

Headache Associated With the Chiari Type I Malformation.

SYNOPSIS
The main purpose of the present study was to define and understand more clearly the headache, and in particular the long-lasting attacks or continuous pain associated with the Chiari type I malformation. Of 34 patients with the malformation, the 20 patients who had or had had headache problems were interviewed according to a standardized questionnaire. Many patients had several headache types. Ten patients had shortlasting "cough headache" attacks lasting less than 5 minutes, 14 patients had relatively long-lasting attacks lasting from 3 hours to several days, and 8 patients had continuous headache. Unlike the short-lasting cough headache attacks, long-lasting attacks were usually not precipitated by Valsalva-like maneuvers. With discriminant analysis, this headache could rather well be differentiated from that of migraine and cervicogenic headache patients. In many respects, however, this headache resembled cervicogenic headache with occipital and neck pain, pain In the arm, restriction of neck movement, and dizziness often accompanying the headache. Dizziness was the meat distinguishing feature in the Chiari patients. These features, together with a beneficial effect of surgical treatment in some patients, suggest a causal relationship between the malformation and headache. From the histories of a few Illustrative cases, It is suggested that the malformation may cause long-lasting headache attacks or continuous head pain by compression of the brainstem, central cord degeneration or intracranial hypertension.     

Subcutaneous Sumatriptan in the Clinical Setting: The First 50 Consecutive Patients With Acute Migraine in a Pediatric Neurology Office Practice

An open prospective study was undertaken to assess the efficacy and safety of subcutaneous sumatriptan in 50 consecutive children ages 6 to 18 years with severe migraine. There were 28 females and 22 males. The dose of sumatriptan was 0.06 mg/kg. Parameters included overall efficacy, time to relief, recurrence rate, adverse events, and objective global rating. Overall efficacy, defined by headache reduction from severe or moderate to mild or none, was 78%. Twenty-six percent responded within 30 minutes, 46% responded in 60 minutes, and 6% responded between I to 2 hours. Twenty-two percent had no response or a suboptimal response. Recurrence rate was only 6%. There was a difference in efficacy between male and female, as 91% of the males responded, while only 68% of the females responded. The males had more migraine alone while the females had migraine often with a coexistent tension-type headache. Eighty percent of all the patients had some adverse event which was usually mild and transient; however, one patient developed a transitory confusional state which resolved in 2 hours. Eighty-four percent reported a global rating of good to excellent, while 16% rated the treatment only fair to poor. These findings suggest that subcutaneous sumatriptan can be both effective and safe in childhood migraine, especially in dealing with migraine alone,     

Anger and Hostility in Tension-Type Headache

A battery of standardized psychometric tests was administered to a group of 47 episodic tension-type headache sufferers and 47 headache-free controls. Compared to controls, headache subjects showed higher levels of anxiety, depression, and anger/hostility. The groups did not differ significantly on a measure of anger expressed toward persons or objects, but headache subjects showed significantly greater levels of suppressed anger. The results provide objective data that are in general agreement with predictions derived from psychosomatic theories about the interrelationships among anxiety,     

Acute and interictal allodynia in patients with different headache forms: an Italian pilot study

OBJECTIVE: To investigate allodynia in patients with different primary headaches. BACKGROUND: Many migraineurs have allodynia during headache attacks; some may have allodynia outside attacks; allodynia may also be associated with other primary headaches. METHODS: A total of 260 consecutive primary headache patients presenting for the first time at a headache center, and 23 nonheadache controls answered written questions (subsequently repeated verbally) to determine the presence of acute and interictal allodynia. RESULTS: We divided the patients into: episodic migraine (N = 177), subdivided into only migraine without aura (N = 114) and those sometimes or always reporting migraine with aura (N = 63); episodic tension-type headache (N = 28); chronic headaches (headache > or = 15 days/month, N = 52), including chronic migraine, chronic tension-type headache, and medication-overuse headache; and other headache forms (N = 3). Acute allodynia was present in 132 (50.7%), significantly more often in patients sometimes or always suffering migraine with aura, and those with chronic headache forms, compared to patients with migraine without aura and episodic tension-type headache. Interictal allodynia was present in 63 (24.2%) patients, with significantly higher frequency in those having migraine with aura attacks than controls and common migraine patients. CONCLUSIONS: Allodynia is not specific to migraine but is frequent in all headache patients: acute allodynia was reported in half those interviewed and in over a third of patients in each headache category; interictal allodynia was reported by nearly 25%.     

Headache and Sferics

Many patients with migraine believe weather is a trigger for their headaches. The objective of this study was to determine if very low frequency sferics, pulse-shaped electromagnetic fields originating from atmospheric discharges (lightning), are precipitating factors. The occurrence of sferics impulses is characterized by a daily, as well as an annual, periodicity and is thought to be associated with various pathological processes. The diaries of 37 women suffering from migraine and tension-type headaches were analyzed over a period of 6 months and correlated with daily sferics activity and other weather phenomena in the area of Giessen, Germany. From October through December (autumn), sferics activity was correlated with the occurrence of migraine (r = 0.33, P<.01); however, there was no correlation in July and August (summer), when the thunderstorm activity had been very intense. In summer, tension-type headaches were associated with other weather parameters such as temperature (r = 0.36, P<.01) and vapor pressure (r = 0.27, P<.05).     

Frequency of Headaches in Children is Influenced by Headache Status in the Mother

(Headache 2010;50:973‐980) Background.— Migraine aggregates within families. Nonetheless the familial aggregation of chronic daily headaches (CDH) and of episodic headaches of different frequencies has been very poorly studied. Accordingly herein we test the hypothesis that frequency of primary headaches aggregates in the family. Methods.— Sample consisted of 1994 children (5‐12 years) identified in the population. Validated questionnaires were used to interview the parents. Crude and adjusted prevalences of low‐frequency (1‐4 headache days/month), intermediate‐frequency (5‐9 days/month), high‐frequency (10‐14 headache days/month), and CDH (15 or more headache days/month) in children were calculated as a function of headaches in the mother. Results.— Frequency of headaches in the mother predicted frequency of headaches in the children; when the mother had low frequency headaches, the children had an increased chance to have low or intermediate headache frequency (relative risk = 1.4, 1.2‐1.6) but not CDH. When the mother had CDH, risk of CDH in the children was increased by almost 13‐fold, but the risk of infrequent headaches was not increased. In multivariate models, headaches in the children were independently predicted by headaches in the mother (P < .001); headache frequency in the children was also predicted by frequency in the mother (P < .001). Conclusions.— Frequency of headaches in children is influenced by frequency of headaches in the mother and seems to aggregate in families. Future studies should focus on the determinants of headache aggregation, including genetic and non‐genetic factors.     

Possible Identification of Cervicogenic Headache Among Patients With Migraine: An Analysis of 374 Headaches

According to Sjaastad, the pain in cervicogenic headache, a form not recognized by the IHS, is long lasting and always side-locked unilateral. The frequency of side-locked unilateral pain (defined here as no change in side from onset) and other characteristics of cervicogenic headache were investigated in 300 outpatients using information collected on standard forms in structured interviews. Three hundred seventy-four headaches diagnosed according to IHS criteria were identified. Three hundred forty-eight of these headaches were long-lasting (duration of more than 4 hours); migraine (65%) followed by tension-type headache (25%) were the commonest forms. Side-locked unilaterality was present in 29% (101 of 348), and occurred most frequently in migrainous disorders not fulfilling the criteria (25 of 56, 44.6%). This group differed significantly from the other migraine conditions for longer pain duration ( P <0.02) and less frequent nausea, vomiting, photophobia, phonophobia ( P <0.0001), and aggravation by physical activity ( P <0.02). With these characteristics, this group resembled cervicogenic headache. However, in none of these patients was pain triggered by head or neck movements, and the frequency of head or neck trauma did not differ from other headaches. A more precise definition of clinical criteria for cervicogenic headache vs migraine is, therefore, required.     

Suggestibility and Headache Reports in Schoolchildren: A Problem in Epidemiology

SYNOPSIS
In a sample from the general population of school children of 15 years of age, we studied whether receiving information about the prevalence of headaches had any effect on their subsequent headache report. Sixty children in the fourth year at four secondary schools were allocated at random to two conditions: a biased condition emphasizing the high prevalence of headaches and a neutral condition. Subjects in the biased condition reported more headaches but they did not report more other physical symptoms than the subjects in the neutral condition. The results are discussed in terms of Pennebaker's theory on reporting symptoms. It is concluded that epidemiological research using the general population should deal more explicitly with the way in which subjects are motivated to participate.     

Paroxetine in the Treatment of Chronic Daily Headache

SYNOPSIS
Forty-eight patients with chronic daily headache, unresponsive to several combinations of pharmacological treatments, were selected for an open-label study using paroxetine. Patients were given 10 mg to 50 mg of paroxetine for a period of 3 to 9 months. Ninety-two percent of the patients improved significantly, based on the patients' percent of the reduction in number of headache days per month. The common side effects were fatigue, insomnia, and urogenital disturbances. The possible mechanism of action of paroxetine in the treatment of chronic daily headache is discussed. Paroxetine appears to be effective in the treatment of chronic daily headache; however, double blind studies are needed to confirm these preliminary findings.     

Arnold—Chiari畸形患者术后早期与晚期功能锻炼的对照研究

目的探讨Arnold-Chiafi畸形患者术后早期或晚期功能锻炼对术后症状缓解和并发症发生的影响。方法按术后是否早期下床活动，将74例Arnold-Chiari畸形患者分为早期活动组41例和晚期活动组33例。观察两组术后自觉症状、客观体征和护理指标。结果2组间疼痛缓解、肌力改善、温度觉改善、肢体麻木缓解、压疮、头晕、泌尿系感染等差异有统计学意义，早期活动组优于晚期活动组。结论Arnold-Chiari畸形患者术后早期进行功能锻炼，对缓解术后症状、减少患者并发症的发生有积极的影响。