Headaches in Hospitalized Cocaine Users

We reviewed the medical records of 283 cocaine users consecutively admitted to a municipal hospital and identified 37 patients (13.1%) complaining of headaches. These patients were divided into three groups. Three patients had migraine-like headaches and transient hemiparesis associated with cocaine use. Five patients had headaches associated with cocaine withdrawal. In 29 patients headaches were not clearly associated with cocaine. Twenty-two of the 29 had chronic daily headaches; nine of these patients were depressed. Three had focal brain lesions with chronic daily headache or acute onset global headache. The four remaining patients had other headaches. Based on these findings, we conclude that: (1) Headache is a common complaint in hospitalized cocaine users; (2) Cocaine may occasionally trigger a syndrome which resembles hemiplegic migraine. The potential mechanisms of this syndrome will be discussed; (3) Hospitalized cocaine users who present with headaches most frequently have depression with suicidal ideation, often associated with cocaine withdrawal; and (4) Structural brain disease in these patients may result from a variety of causes.     

Headache profiles in patients with a dilatated cyst of the cavum septi pellucidi

The dilatated cyst of the cavum septi pellucidi (CSP) is rare and may be associated with headaches. We reviewed the computerized database of 54,000 patients' computed tomography or magnetic resonance images and found 22 cases (0.04%) involving a dilatated cyst of the CSP. Sixteen patients had a chief complaint of headache, which was classified as acute episodic headache (type I, n = 7, 43.7%), chronic daily headache (CDH) with acute onset (type II, n = 5, 31.3%), or CDH with insidious onset (type III, n = 4, 25%). Acute Valsalva-induced headaches were common with type I (85%) or II (100%); 70% of these responded to indomethacin. At follow-up, patients with type I headache had the highest remission rate (71%), and type III patients the lowest (0%). Dilatated cysts of the CSP should be considered a cause of acute Valsalva-induced headache or new daily persistent headache, and may respond to indomethacin. A protracted course (> or = 3 months) indicates a worse outcome.     

Diagnostic criteria for acute headache attributed to ischemic stroke and for sentinel headache before ischemic stroke

BackgroundDefining the relationship between a headache and stroke is essential. The current diagnostic criteria of the ICHD-3 for acute headache attributed to ischemic stroke are based primarily on the opinion of experts rather than on published clinical evidence based on extensive case-control studies in patients with first-ever stroke. Diagnostic criteria for sentinel headache before ischemic stroke do not exist. The present study aimed to develop explicit diagnostic criteria for headache attributed to ischemic stroke and for sentinel headache.MethodsThis prospective case-control study included 550 patients (mean age 63.1, 54% males) with first-ever ischemic stroke and 192 control patients (mean age 58.7, 36% males) admitted to the emergency room without any acute neurological deficits or severe disorders. Standardized semi-structured interview forms were used to evaluate past and present headaches during face-to-face interviews by a neurologist on admission to the emergency room in both groups of patients. All headaches were diagnosed according to the ICHD-3. We tabulated the onset of different headaches before a first-ever ischemic stroke and at the time of onset of stroke. We divided them into three groups: a new type of headache, the previous headache with altered characteristics and previous unaltered headaches. The same was done for headaches in control patients within one week before admission to the hospital and at the time of entry. These data were used to create and test diagnostic criteria for acute headache attributed to stroke and sentinel headache.ResultsOur previous studies showed that headache at onset of ischemic stroke was present in 82 (14.9%) of 550 patients, and 81 (14.7%) patients had sentinel headache within the last week before a stroke. Only 60% of the headaches at stroke onset fulfilled the diagnostic criteria of ICHD-3. Therefore, we proposed alternative criteria with a sensitivity of 100% and specificity of 97%. Besides, we developed diagnostic criteria for sentinel headache for the first time with a specificity of 98% and a sensitivity of 100%.ConclusionsWe suggest alternative diagnostic criteria for acute headache attributed to ischemic stroke and new diagnostic criteria for sentinel headache with high sensitivity and specificity.     

Stabbing Headache as the Presenting Manifestation of Intracranial Meningioma: A Report of Two Patients

Stabbing headache may occur as a primary headache disorder, may accompany other primary headaches, or, in rare instances, may be associated with secondary headache syndromes. We report two patients with intracranial meningioma in whom stabbing headache was the heralding symptom. Headache remitted promptly following surgical resection. These cases stress the importance of excluding underlying pathology in patients presenting with new-onset stabbing headache.     

Evidence-based diagnosis of nontraumatic headache in the emergency department: a consensus statement on four clinical scenarios

Objective.—To provide to emergency department (ED) physicians with guidelines for diagnosis of patients with nontraumatic headaches.
Background.—Many patients present to an ED with the chief complaint of headache. Causes of nontraumatic headache include life-threatening illnesses, and distinguishing patients with such ominous headaches from those with a primary headache disorder can be challenging for the ED physician.
Conclusion.—We present a consensus statement aimed to be a useful tool for ED doctors in making evidence-based diagnostic decisions in the management of adult patients with nontraumatic headache.
Methods.—A multidisciplinary work performed an extensive review of the medical literature and applied the information obtained to commonly encountered scenarios in the ED.     

New daily persistent headache

New daily persistent headache (NDPH), which is the acute onset of headache within 3 days and is persistent for 15 days or more each month for at least 3 months, is a predominantly female heterogeneous subtype of chronic daily headache, typically with migraine features of unknown etiology. NDPH may be a presentation of other primary headaches such as new onset migraine, tension, or benign thunderclap headache. The headaches can be difficult to treat. The diagnosis is one of excluding the many secondary types or NDPH mimics, which is especially critical early in the course of the disease when a secondary etiology is more likely. NDPH mimics include postmeningitis headache, NDPH with medication rebound, neoplasms, temporal arteritis, chronic meningitis, chronic subdural hematoma, post-traumatic headaches, sphenoid sinusitis, hypertension, subarachnoid hemorrhage, low cerebrospinal fluid pressure syndrome, cervical artery dissections, pseudotumor cerebri without papilledema, and cerebral venous thrombosis.     

Brief Sharp Stabs of Head Pain and Giant Cell Arteritis

Giant cell arteritis (GCA) should be considered in the differential diagnosis of any new onset headache occurring in individuals over the age of 50 years. Headache is the most common complaint in GCA patients but the clinical characteristics of the headache itself does not help in making a diagnosis as the headache can occur anywhere on the head, not just the temples, be mild to severe in intensity and be dull to throbbing in quality. As other things can cause new onset headache in older individuals, additional clinical symptoms or signs that may suggest GCA as a diagnosis would be useful to clinicians. Two cases are presented that suggests that new onset stabbing headache associated with a new daily persistent headache is a possible diagnostic sign for a diagnosis of GCA. Nothing in the literature to date has mentioned new onset stabbing headache as part of the presenting symptom complex for GCA.     

Post-Traumatic Headache Therapy in the Athlete

Post-traumatic headache can occur after any traumatic brain injury, regardless of severity. Headache is consistently the most common symptom following concussion and occurs in over 90 % of athletes with sports-related concussion. Despite this prevalence, the complaint of headache after a possible concussive injury is often dismissed. Even when sports-related concussion is accurately diagnosed, many athletes fall victim to mismanagement of this associated symptom by clinicians who are not well-versed in headache treatment. Furthermore, benign headaches may also occur incidentally in the context of head trauma. This complex, and often non-specific, nature of headaches provides a significant challenge in return to play decision-making. Post-traumatic headaches are generally categorized according to primary headache disorders in an attempt to guide treatment; however, there is minimal medical literature on headache management in the concussed athlete. There is clearly a continued need for prospective studies of existing treatments and new approaches.     

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.     

A 22-Year-Old Woman With Chronic Daily Headaches

Tension-type headache is a common clinical complaint occurring in 78% of the general population. Chronic tension-type headache in adult patients is defined as attacks of headaches occurring on at least 15 days per month over a period of at least 3 consecutive months. The association between headaches and psychological factors represents a significant clinical problem that leads to a broader discussion about whether primary headaches could lead to anxiety or whether anxiety symptoms may precipitate primary headaches. This case highlights the positive outcomes associated with the appropriate identification and treatment of a comorbid psychiatric condition.     

Indicators of a major depressive episode in primary care patients with a chief complaint of headache

OBJECTIVE: To identify the indicators of major depressive episode (MDE) in primary care patients with a chief complaint of headache. BACKGROUND: MDE is very frequent among headache patients in primary care. However, primary care physicians often fail to recognize the coexistence of MDE. METHODS: A total of 177 consecutive new adult patients who visited 19 primary care clinics from January 2002 to December 2002 with a chief complaint of headache were enrolled in the study. All subjects completed a self-report questionnaire that included questions regarding the duration and severity of their headaches, changes in headache severity, and other symptoms. The questionnaire also identified distressed high utilizers (patients who consulted different doctors for the same episode of an illness, without being referred). MDE was diagnosed using a module of the mini international neuropsychiatric interview (MINI). To identify potential indicators of depression, both univariate analysis and multiple logistic regression analysis were performed. RESULTS: Forty-five of 177 patients (25.4%) fulfilled the diagnostic criteria for MDE. Univariate analysis revealed that severe headache, longer duration of headaches, multiple somatic symptoms, and being a distressed high utilizer were associated with MDE. Multiple logistic regression analysis revealed that patients with headaches lasting 6 months or longer and those with multiple somatic symptoms were more likely to be suffering from MDE (adjusted odds ratios: 3.1, 95% CI: 1.7-10.6; and 3.9, 95% CI: 1.2-8.1, respectively). CONCLUSIONS: MDE is highly prevalent in headache patients visiting a primary care setting. Multiple somatic symptoms and longer duration (> or =6 months) of headaches are particularly useful indicators of MDE.     

Factors associated with the onset and remission of chronic daily headache in a population-based study

The etiology and prognosis of chronic daily headache (CDH) are not well understood. The aim of this study is to describe factors that predict CDH onset or remission in an adult population. Potential cases (180+ headaches per year, n=1134) and controls (two to 104 headaches per year, n=798) were interviewed two times over an average 11 months of follow-up. Factors associated with CDH prevalence at baseline were evaluated. The incidence of CDH and risk factors for onset were assessed in controls whose headache frequency increased to 180+ per year at follow-up. Prognostic factors were assessed in CDH cases whose headache frequency fell at follow-up. CDH was more common in women, in whites, and those of less education. CDH cases were more likely to be previously married (divorced, widowed, separated), obese, and report a physician diagnosis of diabetes or arthritis. At follow-up, 3% of the controls reported 180 or more headaches per year. Obesity and baseline headache frequency were significantly associated with new onset CDH. In CDH cases, the projected 1-year remission rate to less than one headache per week was 14% and to less than 180 headaches per year was 57%. A better prognosis was associated with higher education, non-white race, being married, and with diagnosed diabetes. Individuals with less than a high-school education, whites, and those who were previously married had a higher risk of CDH at baseline and reduced likelihood of remission at follow-up. New onset CDH was associated with baseline headache frequency and obesity.     

Chronic daily headache in U.S. soldiers after concussion

(Headache 2012;52:732‐738) Objective.— To determine the prevalence and characteristics of, and factors associated with, chronic daily headache (CDH) in U.S. soldiers after a deployment‐related concussion. Methods.— A cross‐sectional, questionnaire‐based study was conducted with a cohort of 978 U.S. soldiers who screened positive for a deployment‐related concussion upon returning from Iraq or Afghanistan. All soldiers underwent a clinical evaluation at the Madigan Traumatic Brain Injury Program that included a history, physical examination, 13‐item self‐administered headache questionnaire, and a battery of cognitive and psychological assessments. Soldiers with CDH, defined as headaches occurring on 15 or more days per month for the previous 3 months, were compared to soldiers with episodic headaches occurring less than 15 days per month. Results.— One hundred ninety‐six of 978 soldiers (20%) with a history of deployment‐related concussion met criteria for CDH and 761 (78%) had episodic headache. Soldiers with CDH had a median of 27 headache days per month, and 46/196 (23%) reported headaches occurring every day. One hundred seven out of 196 (55%) soldiers with CDH had onset of headaches within 1 week of head trauma and thereby met the time criterion for posttraumatic headache (PTHA) compared to 253/761 (33%) soldiers with episodic headache. Ninety‐seven out of 196 (49%) soldiers with CDH used abortive medications to treat headache on 15 or more days per month for the previous 3 months. One hundred thirty out of 196 (66%) soldiers with CDH had headaches meeting criteria for migraine compared to 49% of soldiers with episodic headache. The number of concussions, blast exposures, and concussions with loss of consciousness was not significantly different between soldiers with and without CDH. Cognitive performance was also similar for soldiers with and without CDH. Soldiers with CDH had significantly higher average scores on the posttraumatic stress disorder (PTSD) checklist compared to soldiers with episodic headaches. Forty‐one percent of soldiers with CDH screened positive for PTSD compared to only 18% of soldiers with episodic headache. Conclusions.— The prevalence of CDH in returning U.S. soldiers after a deployment‐related concussion is 20%, or 4‐ to 5‐fold higher than that seen in the general U.S. population. CDH following a concussion usually resembles chronic migraine and is associated with onset of headaches within the first week after concussion. The mechanism and number of concussions are not specifically associated with CDH as compared to episodic headache. In contrast, PTSD symptoms are strongly associated with CDH, suggesting that traumatic stress may be an important mediator of headache chronification. These findings justify future studies examining strategies to prevent and treat CDH in military service members following a concussive injury.     

Cluster Headache as the Index Event in MS: A Case Report

We report a 42‐year‐old woman who presented with cluster headache (CH) in association with other neurological symptoms as the index event of new onset multiple sclerosis (MS). Her initial symptoms were left‐sided headache with ipsilateral lacrimation and nasal congestion associated with ipsilateral facial numbness. A subsequent similar headache attack was also associated with ipsilateral arm ataxia and gait ataxia. She had many additional short headache attacks without focal neurological symptoms. Her cluster‐like headache attacks have not recurred since intiation of dimethyl fumarate. Our patient illustrates that cluster‐like headache attacks can occur as a first symptom of MS, in our patient in association with other neurological symptoms. A striking finding in our patient was a large demyelinating lesion in the brachium pontis ipsilateral to the headaches, although additional supratentorial demyelinating lesions were also present. Although CH associated with MS is rare, our patient and the two other reported patients with MS and CH with similar ipsilateral brachium pontis lesions suggest that the lesions in this location may have played a role in the generation of the cluster‐like attacks.     

Red Ear: Syndrome or Symptom?

Red ear syndrome (RES) is a rare disorder characterized by attacks of unilateral ear pain during which the ear becomes red. Episodes can occur spontaneously, or be triggered, in most cases, by rubbing or touching the ear. Both duration and frequency are variable. RES has been explained by a dysfunction of cervical spinal nerves (C3 root) and a dysregulation with disinhibition of brainstem trigemino‐autonomic circuits, leading to sympathetic inhibition and parasympathetic hyperactivity producing vasodilation. We describe 6 new cases of RES with different characteristics. Although all presented the cardinal symptom of red ear, the headache patterns were suggestive of other primary headaches (migraine or cluster headache). Therapeutic response was obtained when directed to the associated primary headache phenotype, suggesting that RES may be a phenomena associated with different headaches, rather than a syndrome in itself.     

Etiology and distribution of headaches in two Brazilian primary care units

OBJECTIVES: To determine (a) which patients seek primary care services with a complaint of headache, (b) the percentages of the various types of headache in this population, and (c) the impact of the care provided to these patients on the basic health care network. BACKGROUND: Headache is one of the most frequent symptoms reported in medical practice, resulting in significant medical services costs and loss of patient productivity, as well as reduced quality of life. METHODS: A prospective study was conducted in two towns (Ribeir?o Preto and S?o Carlos) in the State of S?o Paulo, Brazil. The participants in the study consisted of 6006 patients (52.4% women) with highly varied acute symptoms. The patients ranged in age from 14 to 98 years. RESULTS: Headache as the main complaint was reported by 561 (9.3%) of the patients considered, with 312 (55.6%) of those patients presenting with primary headache, 221 (39.4%) with headaches secondary to systemic disorders, and 28 (5.0%) with headaches secondary to neurological disorders. Migraine, the most prevalent primary headache, accounted for 45.1% of patients reporting headache as the single symptom. The most frequent etiologies of headaches secondary to systemic disorders were fever, acute hypertension, and sinusitis. The most frequent headaches secondary to neurological disorders were posttraumatic headaches, headaches secondary to cervical disease, and expansive intracranial processes. Of the 26 cases of drug abuse, 20 were secondary to alcohol (hangover). Headaches secondary to systemic disorders were more frequent in the extreme age ranges. CONCLUSIONS: Headache is a very frequent symptom among patients seen at primary health care units and should be considered a public health problem. The dissemination of the diagnostic criteria of the International Headache Society among primary health care physicians is urgently needed in order to avoid the repeated return of patients or their referral to more differentiated emergency units, which overburden an already insufficient health care network.     

Primary headache and sleep disturbances in adolescents

OBJECTIVE: The aim of the present study was to assess sleep patterns and the prevalence of sleep problems in adolescents with primary headaches using a validated sleep screening instrument, as well as to test the association between headache and pain features and adolescent sleep behaviors. BACKGROUND: Sleep disturbance is a common complaint that has long been associated with primary headaches, but there exists limited evidence of the headache-sleep relationship among teens. METHODS: Sixty-nine adolescents aged 13 to 17 years (M= 14.7; SD= 1.4) were evaluated for headaches at 2 pediatric neurology departments (90% migraine; 10% tension-type headache diagnoses). Participants completed the School Sleep Habits Questionnaire and a standardized questionnaire regarding headache characteristics. RESULTS: Sleep complaints were prevalent among adolescents with headaches including insufficient total sleep (65.7%), daytime sleepiness (23.3%), difficulty falling asleep (40.6%), and night wakings (38%). Statistically significant relationships between headache characteristics (eg, frequency, pain intensity) and teen sleep behaviors also emerged. CONCLUSIONS: Our findings provide further support for an association between headache and sleep disturbances among adolescents with primary headaches. This information may provide further understanding of the nature and course of the patient's headache experience, as well as facilitate treatment planning to include recommendations for promoting good sleep hygiene.     

Space headache: a new secondary headache

Headache is a common, but rarely voiced, complaint during space flights, usually attributed to space motion sickness (SMS). We used a specifically designed questionnaire based on the criteria of the International Classification of Headache Disorders, 2nd edn (ICHD-II). Of the 16 male and one female astronauts who participated in the survey, 12 (71%) reported having experienced at least one headache episode while in space, whereas they had not suffered from headache when on earth. There were in total 21 space headache episodes, of moderate to severe intensity in 71%. In two astronauts (12%) the headache and associated symptoms would match the ICHD-II criteria for migraine and in three (18%) astronauts for tension-type headache; in 12 (70%) astronauts the headache was non-specific. The vast majority of headache episodes (76%) were not associated with symptoms of SMS. We conclude that space flights may trigger headaches without other SMS symptoms in otherwise 'super-healthy' male subjects. We propose to classify space headache as a separate entity among the secondary headaches attributed to disorders of homeostasis.     

New Daily Persistent Headache Caused by a Multinodular Goiter and Headaches Associated With Thyroid Disease

A 33‐year‐old female is presented with the first case to our knowledge of new daily persistent headache (NDPH) with a large right benign non‐toxic multinodular goiter causing carotid and vertebral compression with complete resolution of the headache immediately after thyroidectomy. Although this may be quite rare, hypothyroidism or hyperthyroidism causing NDPH, migraine, or an exacerbation of pre‐existing migraine is not. Clinicians should consider routinely obtaining serum thyroid‐stimulating hormone (TSH) and free T4 in patients with new onset frequent headaches or an exacerbation of prior primary headaches.     

Overview of diagnosis and management of paediatric headache. Part I: diagnosis

Headache is the most common somatic complaint in children and adolescents. The evaluation should include detailed history of children and adolescents completed by detailed general and neurological examinations. Moreover, the possible role of psychological factors, life events and excessively stressful lifestyle in influencing recurrent headache need to be checked. The choice of laboratory tests rests on the differential diagnosis suggested by the history, the character and temporal pattern of the headache, and the physical and neurological examinations. Subjects who have any signs or symptoms of focal/progressive neurological disturbances should be investigated by neuroimaging techniques. The electroencephalogram and other neurophysiological examinations are of limited value in the routine evaluation of headaches. In a primary headache disorder, headache itself is the illness and headache is not attributed to any other disorder (e.g. migraine, tension-type headache, cluster headache and other trigeminal autonomic cephalgias). In secondary headache disorders, headache is the symptom of identifiable structural, metabolic or other abnormality. Red flags include the first or worst headache ever in the life, recent headache onset, increasing severity or frequency, occipital location, awakening from sleep because of headache, headache occurring exclusively in the morning associated with severe vomiting and headache associated with straining. Thus, the differential diagnosis between primary and secondary headaches rests mainly on clinical criteria. A thorough evaluation of headache in children and adolescents is necessary to make the correct diagnosis and initiate treatment, bearing in mind that children with headache are more likely to experience psychosocial adversity and to grow up with an excess of both headache and other physical and psychiatric symptoms and this creates an important healthcare problem for their future life.