Severe episodic headache as the sole presenting ictal event in patients with a solitary cysticercus granuloma

OBJECTIVES: Most patients with a solitary cysticercus granuloma present with seizures and severe episodic headache as the sole presenting symptom is rare in these patients. We report the clinical features, evolution and outcome of the disease in patients with a solitary cysticercus granuloma who had severe headache alone without seizures as the sole presenting event. MATERIAL AND METHODS: This was a prospective study which included all patients who presented with severe episodic headache alone and had a diagnosis of a solitary cysticercus granuloma based on CT imaging and follow-up and were managed in our department between June 1, 1991 and May 31, 1998. RESULTS: Out of nearly 550 patients diagnosed to have a solitary cysticercus granuloma during the period of the study, 15 patients (2.5%) presented with severe episodic headache alone. While 9 patients had 1 episode of headache, 6 patients had 2 to 5 episodes. Patients were managed with conservative symptomatic therapy (13 patients) and albendazole therapy (2 patients). Follow-up scans showed complete or partial resolution of the granuloma in 8 patients and a lesion of the same size in 4 patients. None of the patients with complete resolution of the granuloma reported further episodes of headache. CONCLUSIONS: It is important to recognize this presentation of a solitary cysticercus granuloma as it could be confused clinically with other acute central nervous system illnesses such as subarachnoid haemorrhage and meningitis. In regions endemic for cysticercosis a contrast enhanced CT scan of the brain should be performed in patients presenting with sudden onset of severe headache when a plain scan does not reveal intracranial haemorrhage as only a contrast enhanced scan will reveal the granuloma.