The Surgical Treatment of Headache

Medically refractory headache is an uncommon but difficult‐to‐treat clinical problem. Patients who fail maximal medical management may be candidates for invasive treatment. In this review, we critically examine the literature on the range of surgical treatments currently available for migraine, trigeminal autonomic cephalalgias, idiopathic intracranial hypertension and Chiari malformation type 1, with particular attention to patient selection, treatment efficacy, and complications.     

Understanding the link between obesity and headache- with focus on migraine and idiopathic intracranial hypertension

BackgroundObesity confers adverse effects to every system in the body including the central nervous system. Obesity is associated with both migraine and idiopathic intracranial hypertension (IIH). The mechanisms underlying the association between obesity and these headache diseases remain unclear.MethodsWe conducted a narrative review of the evidence in both humans and rodents, for the putative mechanisms underlying the link between obesity, migraine and IIH.ResultsTruncal adiposity, a key feature of obesity, is associated with increased migraine morbidity and disability through increased headache severity, frequency and more severe cutaneous allodynia. Obesity may also increase intracranial pressure and could contribute to headache morbidity in migraine and be causative in IIH headache. Weight loss can improve both migraine and IIH headache. Preclinical research highlights that obesity increases the sensitivity of the trigeminovascular system to noxious stimuli including inflammatory stimuli, but the underlying molecular mechanisms remain unelucidated.ConclusionsThis review highlights that at the epidemiological and clinical level, obesity increases morbidity in migraine and IIH headache, where weight loss can improve headache morbidity. However, further research is required to understand the molecular underpinnings of obesity related headache in order to generate novel treatments.     

Headache in the elderly

Although the prevalence is lower in the elderly than in young adults, headache is a common complaint in the aged population. A broad differential diagnosis and unique diagnostic considerations must be considered for the elderly patient with a complaint of headache. In addition, the evaluation and management of headache in older individuals must be considered in the context of comorbid conditions and polypharmacy, which are common in the elderly. As with children and young adults, headache classification in the elderly can be divided into primary and secondary headache disorders. The primary headache disorders consist of free-standing conditions such as migraine, cluster headache, and tension-type headache. Secondary headache disorders reflect underlying organic diseases such as giant cell arteritis, intracranial mass lesion, or metabolic abnormality. This article provides a review of the various etiologies, both primary and secondary, as well as guidelines for the treatment of headache in the elderly.     

Obesity and chronic daily headache

Population studies suggest that obesity is associated with migraine progression from episodic to chronic daily headaches. Although not a risk factor for episodic migraine, obesity is associated with frequent and severe headaches among migraineurs. We suggest that obesity is an exacerbating factor for migraine. This association seems to be specific to migraine and does not apply to tension-type headache. We review the clinical evidence that links obesity and migraine progression. We then review the potential pathophysiologic mechanisms to support this relationship. We close by briefly discussing clinical interventions related to obesity and migraine.     

Drug-Related Headache

A survey was made of 10,506 reports to the WHO Collaboration Centre for International Drug Monitoring from five countries concerning headache, migraine, aggravated migraine and intracranial hypertension associated with drugs. The ten drugs most frequently reported to be associated with headache were indomethacin, nifedipine, cimetidine, atenolol, trimethoprim-sulphamethoxazole, zimeldine, glyceryl trinitrate, isosorbide dinitrate, zomepirac and ranitidine. Regarding migraine, oral contraceptives were also among the most implicated drugs. Most reports of intracranial hypertension concerned tetracyclines, isotretinoin and trimethoprim-sulphamethoxazole. Vasodilatation and salt and water retention with subsequent redistribution of intracranial fluid seem to be common mechanisms underlying drug-related headache. For certain frequently reported drugs, however, the mechanisms of the headache are unknown.     

Obesity and Migraine in Childhood

Purpose of Review

The purpose of this work was to review the current literature on the epidemiology and pathophysiology of pediatric obesity and migraine, underlying pathogenic mechanisms that may explain the association between the two disorders, and the effects of treatment.

Recent Findings

In children and adolescents, the bulk of the available data support an association between obesity and headache disorders in general, though a small number of studies contradict these findings. Relative to the adult population, however, few studies have focused specifically on migraine, and no wide-ranging meta-analyses have been conducted to date. It seems that the pathophysiology of obesity and migraine in adults holds true for the pediatric population as well. The association between obesity and migraine in the pediatric population is likely to be multifactorial and to involve both central and peripheral mechanisms. More attention is currently being addressed to the role of the hypothalamus and the bioactive neurotransmitters and neuropeptides that modulate energy homeostasis, namely serotonin, orexin, and the adiponectins, in migraine. A few innovative studies have demonstrated some benefit for migraine from weight reduction treatments such as exercise and lifestyle management.

Summary

Many open questions remain regarding the modifiable nature of the obesity–migraine relationship and its implications in clinical practice. Further studies of these issues are needed.

     

Headache Currents Commentary

Neuro‐ophthalmology is a field that interfaces intimately with headache medicine. Examples include common and uncommon visual disturbances related to migraine, painful loss of vision, eye pain, photophobia, pupillary disorders, and painful ophthalmoplegia. There are often articles relevant to headache specialists that are published in the ophthalmic literature. This commentary highlights 2 interesting clinical articles. All neurologists and headache medicine specialists should read the review on photophobia by Digre and Brennan as it is relevant, clinical, and comprehensive. The literature review on topiramate‐related acute angle‐closure glaucoma provides us with useful information about the epidemiology and pathophysiology of this rare but potentially vision‐threatening condition that may occur with the most widely used of migraine preventives.     

Obesity and Chronic Daily Headache

Obesity may be the greatest epidemic of modern times. It leads to diabetes and heart disease and shortens lifespan. Although not a risk factor for migraine, it is associated with an increased frequency and intensity of migraine. Obesity is also comorbid with chronic daily headache and is a major risk factor for chronification of episodic migraine in adults and children. Although obesity is not a factor in the effectiveness of migraine treatment, it does increase the peripheral and central events in migraine, ultimately increasing the neurologic potential for migraine. Although evidence suggests that obesity is a modifiable risk factor for migraine progression, it is unknown if weight loss is related to decrease in headache frequency. Recent surgical results suggest that this is true. We suggest all possible effective techniques aimed at weight loss be undertaken for migraineurs, especially obese migraineurs, and that carefully monitoring weight changes should be routinely done as part of their migraine care.     

Migraine and Obesity: Epidemiology,Mechanisms, and Implications

(Headache 2010;50:631‐648) Adipose tissue is a dynamic neuroendocrine organ that is involved in multiple physiological and pathological processes, and when excessive, results in obesity. Clinical and population‐based data suggest that migraine and chronic daily headache are associated with obesity, as estimated by anthropometric indices. In addition, translational and basic science research shows multiple areas of overlap between migraine pathophysiology and the central and peripheral pathways regulating feeding. Specifically, neurotransmittors such as serotonin, peptides such as orexin, and adipocytokines such as adiponectin and leptin have been suggested to have roles in both feeding and migraine. In this article, we first review the definition and ascertainment of obesity. This is followed by a review of the clinical and population‐based studies evaluating the associations between obesity and chronic daily headache and migraine. We then discuss the central and peripheral pathways involved in the regulation of feeding, where it overlaps with migraine pathophysiology, and where future research may be headed in light of these data.     

The Child With Headache in a Pediatric Emergency Department

Objectives.— To investigate clinical features of a pediatric population presenting with headache to a pediatric emergency department (ED) and to identify headache characteristics which are more likely associated with serious, life‐threatening conditions in distinction from headaches due to more benign processes. Background.— Although headache is a common problem in children visiting a pediatric ED, a few studies thus far have attempted to identify the clinical characteristics most likely associated with suspected life‐threatening disease. Methods.— A retrospective chart review of all consecutive patients who presented with a chief complaint of headache at ED over a 1‐year period was conducted. Etiologies were classified according to the International Headache Society diagnostic criteria 2nd edition. Results.— Four hundred and thirty‐two children (0.8% of the total number of visits) aged from 2 to 18 years (mean age 8.9 years) were enrolled in our study. There were 228 boys (53%) and 204 girls (47%). School‐age group was the most represented (66%). The most common cause of headache was upper respiratory tract infections (19.2%). The remaining majority of non‐life‐threatening headache included migraine (18.5%), posttraumatic headache (5.5%), tension‐type headache (4.6%). Serious life‐threatening intracranial disorders (4.1%) included meningitis (1.6%), acute hydrocephalus (0.9%), tumors (0.7%). We found several clinical clues which demonstrated a statistically significant correlation with dangerous conditions: pre‐school age, recent onset of pain, occipital location, and child's inability to describe the quality of pain and objective neurological signs. Conclusions.— Differential diagnosis between primary and secondary headaches can be very difficult, especially in an ED setting. The majority of headaches are secondary to respiratory infectious diseases and minor head trauma. Our data allowed us to identify clinical features useful to recognize intracranial life‐threatening conditions.     

Tension-type Headache and Migraine in Multiple Sclerosis

We review the evidence for a link between multiple sclerosis (MS) and two of the most common primary headache disorders: tension-type headache and migraine. We argue that the association between migraine and MS is biologically plausible and is confirmed by most studies. We discuss possible explanations for the association. First, we consider the possibility that the association is spurious. Next, we consider unidirectional causal models in which one of the conditions increases the risk of the other. A bidirectional model would suggest that each disease predisposes to the other. Alternatively, genetic or environmental risk factors shared by each condition may account for the association between them. We also address the question of whether coexisting migraine or tension-type headache in a patient with MS affects the symptom profile, clinical course, and radiographic characteristics of MS.     

Headache and facial pain in the elderly

Whilst headache disorders belong to the most common health problems of the younger population, the occurrence diminishes with advancing age. However, in individual cases headaches may be especially severe in old age significantly reducing the quality of life. Typical causes of headache in the elderly are giant cell arteritis (arteritis temporalis), cranial neuralgia and hypnic headache. The incidence of intracranial mass lesions also increases with age. In addition to these secondary forms of headache, the typical primary headache disorders migraine, tension headache and cluster headache may also persist in the elderly. In drug treatment of headaches in the elderly, an impairment of renal and/or hepatic function has to be taken in account, as should be the potential multimorbidity of elderly patients.     

The evaluation of children and adolescents with headache

Headache can be caused by primary entities (as in migraine or tension-type headache) or the pain may result from secondary causes, such as brain tumors, idiopathic intracranial hypertension, chronic meningitis, hydrocephalus, drug intoxications, paranasal sinus disease, or acute febrile illnesses (eg, influenza). To determine the nature of a child’s headache, the evaluation begins with a thorough medical history, followed by methodic physical examination with measurement of vital signs and complete neurologic examination. The diagnosis of primary headache disorders such as migraine and tension-type rests principally on clinical criteria as set forth by the International Headache Society (). Clues to the presence and identification of secondary causes of headache are uncovered through this systematic process of history and physical examination. The performance of ancillary diagnostic testing rests upon information or concerns revealed during the history and physical examination.     

Headache in Resource-Limited Settings

Purpose of Review

This review summarizes the unmet need of headache burden and management in resource-limited settings. It provides a general overview of the nuances and peculiarities of headache disorders in resource-limited settings. The review delivers perspectives and explanations for the emerging burden of both primary and secondary headache disorders. Important discussion on demographic and epidemiologic transition pertinent to low-resource settings is included. A critical analysis of headache disorders is made within the context of growing burden non-communicable disorders in low-resource countries. Challenges are examined and prospective feasible solutions tailored to existing resources are provided to address headache disorders in resource-limited settings.

Recent Findings

Many low-resource countries are entering into the third epidemiological transition featuring increasing burden of non-communicable disorders of which headache disorders contribute a significant proportion. Exponential population growth involving youthful demographic and massive rural-urban migration is taking place in low-resource countries. Youthful demographic is the natural cohort for primary headache such as migraine. Socioeconomic mobility and lifestyle changes are leading to higher levels of physical inactivity and obesity, both of which are related to headache. Life expectancy is rising in some resource-restricted countries; this increases prevalence of secondary headache attributed to neurovascular causes. Many low-resource countries are still burdened with tropical infectious causes of secondary headache. Health care facilities are primarily designed to respond to infectious epidemic and not to chronic burden such as headache. Many low-resource-restricted settings are plagued by poor and corrupt governance, ill-equipped regimes with malfunctioning health policies, war, and poverty. Many low-resource settings do not have access to generic headache medications such as triptans. Headache training and expertise is low. Healthy lifestyle changes emphasizing on improving regular exercise can be inexpensive method to reducing primary headache burden and its comorbidities (e.g. obesity).

Summary

Addressing the increasing burden of headache disorders in resource-limited settings is important to avert accrued disability which in turn lowers productivity and socioeconomic performance in a young booming population.

     

Neurostimulation for Neck Pain and Headache

Patients with medically refractory headache disorders are a rare and challenging‐to‐treat group. The introduction of peripheral neurostimulation (PNS) has offered a new avenue of treatment for patients who are appropriate surgical candidates. The utility of PNS for headache management is actively debated. Preliminary reports suggested that 60‐80% of patients with chronic headache who have failed maximum medical therapy respond to PNS. However, complications rates for PNS are high. Recent publication of 2 large randomized clinical trials with conflicting results has underscored the need for further research and careful patient counseling. In this review, we summarize the current evidence for PNS in treatment of chronic migraine, trigeminal autonomic cephalagias and occipital neuralgia, and other secondary headache disorders.     

Coexistence of Migraine and Cluster Headache: Report of 10 Cases and Possible Pathogenetic Implications

We report on 10 patients suffering from two types of primary headache, migraine and cluster, diagnosed according to IHS criteria, and selected from headache patients attending two Italian headache centers. We briefly review the literature on coexisting migraine and cluster headache, considering the time relationships between these two headaches. The present series seems not to confirm the hypothesis that migraine transforms into cluster headache since both headaches persist together in the patients. The series is of clinical interest particularly with regard to diagnosis and to treatment strategies. Furthermore, while migraine and cluster headache comorbidity must be confirmed by population-based epidemiological studies, the possibility arises that the two conditions may be linked pathophysiologically: common genetic factors or functional alterations in the same central neurological circuits may play a role in the pathogenesis of both disorders.     

Headache in Patients With Neurofibromatosis Type 1

A study of headache in a homogeneously ascertained population of 181 subjects suffering from neurofibromatosis type I is described. All subjects underwent a diagnostic protocol including imaging studies (for subjects over 5 years old up until 1992). Headache data were collected by means of a questionnaire. Headache was present in 55 of 181 subjects (25 males). Overall headache frequency was 30%, which is not significantly different from the frequency of headache reported in the general population. Headache was primary in 52 cases (5 migraine and 47 tension-type) and secondary to obstructive hydrocephalus with brain tumor-induced intracranial hypertension in 3 with a tension-type pattern.
It was concluded that headache is not a specific feature of neurofibromatosis ype 1, it is not significantly related to central nervous system abnormalities, and in itself, it is not an indication for neuroradiological examination.     

Diagnosis and Management of Headache in Older Adults

Headache is a common, disabling neurologic problem in all age groups, including older adults. In older adults, headache is most likely a primary disorder, such as tension-type headache or migraine; however, there is a higher risk of secondary causes, such as giant cell arteritis or intracranial lesions, than in younger adults. Thus, based on the headache history, clinical examination, and presence of headache red flags, a focused diagnostic evaluation is recommended, ranging from blood tests to neuroimaging, depending on the headache characteristics. Regardless of the primary or secondary headache disorder diagnosis, treatment options may be limited in older patients and may need to be tailored to the presence of comorbid medical conditions. The purpose of this review is to provide an update on the management of headache in older adults, from diagnosis to treatment.