Influence of next-generation artificial intelligence on headache research, diagnosis and treatment: the junior editorial board members' vision - part 1.

Artificial intelligence (AI) is revolutionizing the field of biomedical research and treatment, leveraging machine learning (ML) and advanced algorithms to analyze extensive health and medical data more efficiently. In headache disorders, particularly migraine, AI has shown promising potential in various applications, such as understanding disease mechanisms and predicting patient responses to therapies. Implementing next-generation AI in headache research and treatment could transform the field by providing precision treatments and augmenting clinical practice, thereby improving patient and public health outcomes and reducing clinician workload. AI-powered tools, such as large language models, could facilitate automated clinical notes and faster identification of effective drug combinations in headache patients, reducing cognitive burdens and physician burnout. AI diagnostic models also could enhance diagnostic accuracy for non-headache specialists, making headache management more accessible in general medical practice. Furthermore, virtual health assistants, digital applications, and wearable devices are pivotal in migraine management, enabling symptom tracking, trigger identification, and preventive measures. AI tools also could offer stress management and pain relief solutions to headache patients through digital applications. However, considerations such as technology literacy, compatibility, privacy, and regulatory standards must be adequately addressed. Overall, AI-driven advancements in headache management hold significant potential for enhancing patient care, clinical practice and research, which should encourage the headache community to adopt AI innovations.

Computed Tomography Findings of Patients Presenting With Headache: 4-Year Retrospective Two-Center Study in Central and Western Regions of Ghana.

Objectives: The radiographic assessment of the head is a crucial part of headache care. A computed tomography (CT) scan enables a more detailed analysis of the condition and more focused care. This study examined head CT scans to determine what kinds of anomalies were present in patients with headaches as their primary complaint. Methods: We evaluated 4 years' worth of CT scan data from head exams conducted at two diagnostic facilities in Ghana's western and central regions. We examined data on 477 patients with a headache as their primary complaint between January 2017 and December 2020. We employed chi-square and Fisher's exact tests (where applicable) to compare head CT diagnoses between age groups, gender, headache subtypes, and brain lesion subgroups. Results: There were 53.5% (n = 255) females and 46.5% (n = 222) males in the study. The average age of patients was 38.67 ± 17.23 years, with an annual rate of abnormal CT diagnoses ranging from 35.9% in 2017 to 45.4% in 2022. Abnormal head CT diagnoses are strongly correlated with age groups and patient gender (p = 0.011 and p = 0.009, respectively). Of the 202 patients, 15.3% and 24.3% were classified as intracranial lesions and extracranial lesions, respectively. Maxillary sinusitis affected nearly 60% of the patients, while tumors and hemorrhages affected 25.2% and 11.9%, respectively. Conclusions: A CT scan of the head is essential to detect abnormalities in nearly 50% of patients suffering from various degrees of headache. Sinusitis, brain tumors, and hemorrhage were common lesions detected. It is crucial to create local standard operating procedures to promote better utilization of this type of imaging service, particularly among patients who have been diagnosed with headaches.

A Study of Neurological Involvement in Dengue and Chikungunya Infection.

INTRODUCTION: Chikungunya virus (CHIKV) and dengue fever have been reported for recent epidemics worldwide, with varied clinical involvement. Chikungunya was first reported to affect the nervous system in the 1960s. The clinical profile of dengue with multi-organ involvement is varied with reported involvement of the central nervous system in some. AIM: The aim of this study was to study the frequency and pattern of neurological involvement in patients admitted with dengue and chikungunya in a tertiary care hospital. MATERIALS AND METHODS: Patients admitted with confirmed chikungunya and dengue were evaluated clinically and investigations were enrolled in the study. Patients with preexisting neurological issues, obvious metabolic, vascular, or septic causes for neurological involvement were excluded from the study. RESULTS: A total of 309 patients with chikungunya were included in the study. Out of these, 11 (3.56%) patients were found to have neurological involvement. The most common presentations were altered sensorium (100%) followed by headache (81.81%). The relative risk of mortality in patients with neurological involvement due to chikungunya was 7.96. A total of 443 patients with dengue fever were enrolled in the study. Out of these, 5 (1.10%) patients were found to have neurological involvement. The most common presentations were altered sensorium and headache (100%), followed by vomiting (80%). The relative risk of mortality in patients with neurological involvement due to dengue was 5.15. CONCLUSION: The recent epidemic of chikungunya and dengue virus infections was associated with various neurological complications. Neurological involvement of chikungunya and dengue was identified to be a bad prognostic factor with significantly higher mortality. LIMITATIONS: This is a single center study, involving only the patients admitted to the hospital. Furthermore, being an observational study, follow-up could not be done to look for neurological sequelae.

Résumé Introduction:le virus du chikungunya (CHIKV) et la dengue ont été signalés pour des épidémies récentes dans le monde, avec une implication clinique variée. Chikungunya a d'abord affecté le système nerveux dans les années 1960. Le profil clinique de la dengue avec une implication multi-organes est varié avec l'implication rapportée du système nerveux central dans certains.Objectif:Le but de cette étude était d'étudier la fréquence et le schéma d'implication neurologique chez les patients admis avec de la dengue et le chikungunya dans un hôpital de soins tertiaires.Matériaux et méthodes:patients Admis avec le chikungunya et la dengue confirmés ont été évalués cliniquement et les enquêtes ont été inscrites à l'étude. Les patients présentant des problèmes neurologiques préexistants, des causes métaboliques, vasculaires ou septiques évidentes de participation neurologique ont été exclues de l'étude.Résultats:Un total de 309 patients atteints de chikungunya ont été inclus dans l'étude. Parmi ceux-ci, 11 (3,56%) patients se sont révélés avoir une atteinte neurologique. Les présentations les plus courantes ont été modifiées du sensorium (100%) suivie de maux de tête (81,81%). Le risque relatif de mortalité chez les patients présentant une atteinte neurologique due au chikungunya était de 7,96. Au total, 443 patients atteints de dengue ont été inscrits à l'étude. Parmi ceux-ci, 5 (1,10%) patients se sont révélés avoir une atteinte neurologique. Les présentations les plus courantes ont été modifiées du sensorium et des maux de tête (100%), suivis par des vomissements (80%). Le risque relatif de mortalité chez les patients présentant une atteinte neurologique due à la dengue était de 5,15.Conclusion:L'épidémie récente des infections du chikungunya et du virus de la dengue a été associée à diverses complications neurologiques. L'atteinte neurologique du chikungunya et de la dengue a été identifiée comme étant un mauvais facteur pronostique avec une mortalité significativement plus élevée.Limites:Il s'agit d'une étude centrale unique, impliquant uniquement les patients admis à l'hôpital. De plus, étant une étude observationnelle, le suivi n'a pas pu être fait pour rechercher des séquelles neurologiques.

Aseptic meningitis with recurrent headache episodes, vomiting, and central fever as first manifestation of isolated neurosarcoidosis: a case report.

BACKGROUND: Neurosarcoidosis is a rare entity, usually within the context of systematic sarcoidosis. Isolated neurosarcoidosis and especially a manifestation with pachymeningitis is a notable rarity. CASE REPORT: A 26-year-old patient presented to the emergency department with acute onset, recurrent episodes of occipital headaches spreading over the whole cranium and vomiting without food consumption, for three days. The clinical examination did not reveal any neurological deficits. The laboratory exams showed no pathological findings. A CT examination with angiography did not detect any acute intracranial or vessel pathology. A lumbar puncture was performed to rule out subarachnoid hemorrhage. The results showed a lymphocytic pleocytosis of 400/µL, elevated protein levels of 1077 mg/dL and reduced glucose levels (CSF: 55 mg/dL, Serum: 118 mg/dL). Extensive infectiological examinations did not reveal any signs of infection, including Borrelia spp. and M. tuberculosis. No positive auto-antibodies or vasculitis-related auto-antibodies were detected. The CSF analysis showed negative oligoclonal bands but an isolated increase in ß2-microglobulin, neopterin, and IL-2R levels. The MRI examination revealed a dural gadolinium-enhancement, pronounced in the basal cerebral structures and the upper segment of the cervical spine, consistent with neurosarcoidosis. Corticosteroid treatment rapidly led to a significant improvement of the symptoms. No systemic manifestations of sarcoidosis were found. CONCLUSIONS: This case report aims to highlight aseptic meningitis with atypical, acute onset headache attacks as a possible manifestation of isolated neurosarcoidosis. Neurosarcoidosis is a clinical entity that requires prompt treatment to avoid permanent neurological deficits.

Artificial intelligence and headache.

BACKGROUND AND METHODS: In this narrative review, we introduce key artificial intelligence (AI) and machine learning (ML) concepts, aimed at headache clinicians and researchers. Thereafter, we thoroughly review the use of AI in headache, based on a comprehensive literature search across PubMed, Embase and IEEExplore. Finally, we discuss limitations, as well as ethical and political perspectives. RESULTS: We identified six main research topics. First, natural language processing can be used to effectively extract and systematize unstructured headache research data, such as from electronic health records. Second, the most common application of ML is for classification of headache disorders, typically based on clinical record data, or neuroimaging data, with accuracies ranging from around 60% to well over 90%. Third, ML is used for prediction of headache disease trajectories. Fourth, ML shows promise in forecasting of headaches using self-reported data such as triggers and premonitory symptoms, data from wearable sensors and external data. Fifth and sixth, ML can be used for prediction of treatment responses and inference of treatment effects, respectively, aiming to optimize and individualize headache management. CONCLUSIONS: The potential uses of AI and ML in headache are broad, but, at present, many studies suffer from poor reporting and lack out-of-sample evaluation, and most models are not validated in a clinical setting.

Emergency Department Treatment of Elevated Blood Pressure in the Headache Patient.

Headache accounts for 1 - 3% of emergency department (ED) visits globally and is associated with elevated blood pressure (BP). It is unclear if anti-hypertensive therapy provides benefits. This retrospective study assessed effects of anti-hypertensive therapy in ED headache patients on rescue analgesic need, hospital admissions, and length of stay (LOS). 1385 patients were included. 366 received anti-hypertensive therapy. The anti-hypertensive therapy cohort was older (p < 0.001) with increased odds of admission (p < 0.001) and 2.385 hrs longer ED LOS (p < 0.001). No difference in rescue analgesia was found (p < 0.429). Anti-hypertensive therapy in hypertensive ED headache patients is associated with increased hospital admission and ED LOS, but no difference in rescue analgesia utilization.

[Advances in Headache and Future Prospects].

Headache is the most common condition encountered in neurological practice. However, despite the burden to patients, migraine, a typical primary headache, is not life-threatening, and evaluation shows no abnormalities; therefore, it is often treated using analgesics. Moreover, patients often do not visit hospitals and clinics because over-the-counter analgesics, such as nonsteroidal anti-inflammatory drugs are easily available. However, many patients continue to experience headaches. Migraine therapy has progressed remarkably following the advent of calcitonin gene-related peptide antibody drugs in recent years. Many patients with migraine do not visit hospitals and clinics and do not receive appropriate treatment. Therefore, in the future, neurologists will need to play a key role in patient education and in training physicians to enable accurate diagnosis of headaches.

Clinical Reasoning: Hyperventilation-Induced Alternating Hemiplegia With Concomitant Hemispheric EEG Slowing in a 7-Year-Old Girl With Headache.

A 7-year-old right-handed girl presented to the pediatric neurology outpatient clinic after 5 episodes of headache over the previous 3 months. Her family history was positive for migraine in the mother and maternal grandmother and for febrile seizures in the older sister. The neurologic examination and cognitive profile were normal. Five seconds after the end of hyperventilation, video-EEG showed high-amplitude delta waves predominantly over the left hemisphere with concomitant acute aphasia and right-sided weakness. After the event, which self-resolved over 8 minutes, the girl showed intact recall. A second instance of hyperventilation evoked the appearance of pseudo-rhythmic slow activity localized to the right hemisphere, associated with left-sided weakness, 20 seconds after the end of the test. This event spontaneously resolved in 3 minutes and was followed by headache.An exaggerated physiologic response to hyperventilation, the possible epileptic nature of the events, and a migraine variant were all considered in the differential. Nonetheless, the EEG slowing is shorter in duration and generalized in physiologic and paraphysiological conditions. A clear ictal morphology and evolution of the EEG activity were lacking in this case, and migraine attacks induced by hyperpnea have not been reported to date. Instead, EEG alterations similar to that observed in our patient are described in association with vascular abnormalities. We report the clinical presentation and diagnostic workup of a rare cerebrovascular disorder, highlighting the key features in the differential. Our case emphasizes the clinical value of the EEG rebuild-up phenomenon, which can help the clinician in achieving a prompt diagnosis.

Characterization of Mild Traumatic Brain Injury Cohort With Photophobia From the Defense and Veterans Eye Injury and Vision Registry.

INTRODUCTION: Photophobia is a common visual symptom following mild traumatic brain injury (mTBI), which can adversely affect the military readiness and performance of service members (SMs). We employed the Defense and Veterans Eye Injury and Vision Registry (DVEIVR) to identify and describe a cohort of SMs diagnosed with photophobia post-mTBI. The objective of this study was to characterize comorbid conditions and symptoms in an mTBI cohort with photophobia, to assess their co-occurrence, to describe the persistence of photophobia, and to assess the effectiveness of utilization of currently available International Statistical Classification of Diseases and Related Health Problems (ICD) codes in reporting photophobia in this cohort. MATERIALS AND METHODS: The DVEIVR database was searched to identify a cohort of SMs experiencing photophobia after mTBI. Photophobia and other potentially related conditions and symptoms, both coded and descriptive, which were abstracted directly from the medical records of SMs, were found within DVEIVR. The presence of the conditions and symptoms comorbid with photophobia was characterized on both patient and encounter levels. Analysis of co-occurrence of photophobia with these conditions or symptoms was performed on the encounter level using co-occur package in the statistical program R. Persistence of photophobia up to 1 year since the injury was assessed. The utilization of currently available ICD codes for photophobia was analyzed. RESULTS: A total of 639 SMs exhibiting photophobia after mTBI were identified in DVEIVR. Headaches, including migraines, were the most frequently experienced comorbidity affecting 92% of the SMs in the cohort. The second most frequent complaint was dizziness and/or vertigo (53%) followed by nausea (42%), blurry vision (31%), and irritation and discomfort in the eye (17%). In all, 20% of encounters with photophobia had a complaint of headaches, followed by 8.3% of photophobia encounters co-occurring with dizziness and vertigo, 5.7%-with nausea, 4.5%-with blurred vision, and 2.1%-with subjective sensations in the eye. All comorbidities co-occurred with photophobia at probabilities higher than by chance alone. The percentage of mTBI SMs experiencing photophobia declined to 20% at 30 days after the injury, 17% at 3 months, 12% at 6 months, and 7% at 12 months post-injury, respectively. The use of currently available ICD codes for photophobia was very low-only 27.1% of the cohort had at least 1 ICD code recorded in their medical records. CONCLUSIONS: The results of this study support the idea that there is a strong relationship between photophobia and headache after an mTBI. Additional research is warranted to better understand this relationship and its causes so that clinical management improves. The results of this study show a precipitous decline in the numbers of cases of photophobia after mTBI over the first 30 days and a longer-term persistence up to a year in a minority of cases, which is consistent with other research in this field. Various ICD codes, which are currently used to code for photophobia, along with other vision conditions, were not widely used to document photophobia symptoms. It is important to adopt a dedicated ICD code for photophobia to improve the surveillance, data collection, and analysis of this condition.

[RCVS: case-study and role of substance abuse, Covid and psychotropic drugs]. / Reversibel cerebraal vasoconstrictie­syndroom: casus en rol middelengebruik, COVID-19 en psychofarmaca.

Reversible cerebral vasoconstriction syndrome (RCVS) is a condition defined by severe sudden-onset headaches, typically ‘thunderclap’ headaches, caused by multifocal cerebral vasoconstriction. Various triggers have been described, including illegal substances, medication and infections. We observed a 27 year old man that suddenly developed severe headaches during admission to a psychiatric ward, where RCVS was diagnosed as most likely clinical cause. He was given nimodipine with rapid and full symptom remission. We aim to highlight this rare, but important, neurological syndrome and its various psychiatric risk factors.

Spontaneous Intracranial Hypotension: Role of Computed Tomography-guided Cervical Epidural Blood Patch.

BACKGROUND: Lumbar epidural blood patch (EBP) is not successful in all cases of cerebrospinal fluid (CSF) leak, particularly in the cervicothoracic region. The present study is a retrospective analysis of a cohort of patients who had undergone computed tomography (CT)-guided cervical EBP for spontaneous intracranial hypotension (SIH) due to CSF leak in the cervical region. METHODS: We retrospectively collected data from March 2009 to 2020. Our inclusion criteria were (1) clinical syndrome associated with CSF leak, (2) headache coming on shortly after assuming the erect position and relief achieved by lying down, (3) CT myelography evidence of CSF leak in the cervical region, and (4) patient not responding to conservative management for 7 days. Exclusion criteria were patients with bleeding diathesis and infection. There were six females and four males. Ages ranged from 32 to 57, with an average of 42 years. On presentation, all patients underwent contrast-enhanced magnetic resonance imaging (MRI) and CT myelography. Cervical EBP was done under CT scan guidance. Assessment of headache was done on a 10-point numerical rating scale (NRS) before and after the procedure. Results are categorized into complete relief, partial relief, and no relief categories. RESULTS: Nine out of 10 patients were completely recovered. One patient was partially recovered. The average NRS scale was 9.6 before treatment, which became 0.4 after EBP. No neurological or vascular complications were seen. CONCLUSION: Computed tomography-guided cervical EBP is an optimum and effective way of treating SIH due to a leak in the cervical region. It has a higher success rate than lumbar EBP. However, prospective randomized controlled trials of cervical vs lumbar EBP will further validate our observation.

Clinical, Etiological, and Imaging Study of Patients with Cerebral Sinus Venous Thrombosis in a Tertiary Care Hospital.

AIM OF THE STUDY: To study the clinical profile, etiology, and imaging features of subjects presenting with cerebral sinus venous thrombosis (CVST) and to correlate the clinical findings with radiological findings. MATERIALS AND METHODS: The study included 120 patients admitted with the diagnosis of CVST to Stanley Medical College and Hospital, Chennai. The study included patients of all age-groups presenting with cerebral venous thrombosis. The diagnosis was confirmed by imaging studies. RESULTS: The mean age of presentation is 24.4, predominantly males. Headache (90.8%) was the most common presentation, followed by seizures (25%), and paresis (12%). The superior sagittal sinus (SSS) is the most common sinus involved, with multiple sinuses involved in 47% of patients. Magnetic resonance imaging (MRI) brain with magnetic resonance venography (MRV) is the investigation of choice. The most common risk factor for CSVT was alcohol intake, especially in males, and females, anemia, pregnancy, usage of oral contraceptive (OC) pills, and puerperium were the common risk factors. The causes of CSVT in this study were hyperhomocystenemia in 8%, anemia in 13%, and prothrombotic state in 6%. CONCLUSION: Cerebral sinus venous thrombosis is a cause of stroke in young individuals. Even though uncommon, it is underdiagnosed because of its extremely varied clinical presentation. The correct diagnosis of CSVT relies on a high index of suspicion and the availability of advanced imaging like MRI with MR venography.

Diagnostic workup of acute headache and subarachnoid hemorrhage in a Norwegian population: An observational study.

BACKGROUND: Acute headache may be the primary symptom of subarachnoid hemorrhage (SAH). Recent guidelines suggest that non-contrast computed tomography (CT) is adequate to exclude aneurysmal SAH if performed within 6 h after symptom onset. However, most studies of acute headache including CT, lumbar puncture and SAH are multicenter studies from referral hospitals with highly selected patient populations. The main purpose of this study was to describe the diagnostic properties of head CT and cerebrospinal fluid (CSF) spectrophotometry for detecting SAH in an unselected primary hospital population with acute headache. METHODS: A retrospective cross-sectional study conducted at a large primary hospital serving roughly 10% of the Norwegian population. Diagnostic workup from consecutive patients evaluated for acute headache in 2009-2020 were collected. All CSF-spectrophotometry reports were standardized and the same CT scanner was used during the study. RESULTS: A total of 3227 patients were included. Median age was 45 years and 63% were women. In total, 170 (5.3% of all acute headache patients) had SAH. Of 3071 CT-negative patients, 2852 (93%) underwent lumbar puncture. Of the CSF reports, 2796 (98%) were negative for xanthochromia. Overall, the rate for detection of aneurysmal SAH by positive xanthochromia was 9 in 2852 cases (3‰). The miss rate for the detection of an aneurysmal SAH with a CT scan within 6 h was 0 and within 12 h 1 in 2852 cases (0.3‰). CONCLUSION: In acute headache, a CT scan taken within 6 h is practically 100% sensitive for detecting any SAH.

Headaches due to Nasal and Paranasal Sinus Disease.

Headache and rhinosinusitis are 2 of the most common conditions seen in clinical practice. Consider sinusitis in those with new-onset headache, along with nasal congestion, maxillary tooth discomfort, anosmia, cough, or fever. Most chronic and recurring headaches, especially if migraine features are present, are not due to sinus disease, with the possible exception of rhinogenic headache due to nasal contact points. Nasal endoscopy and neuroimaging with computed tomography or MRI can confirm diagnosis and guide treatment with antibiotics, adjuvant therapies and surgery.

[28-year-old male patient with headaches on the left side and facial pain]. / 28-jähriger Patient mit in den Kiefer ausstrahlenden ­Kopfschmerzen temporal links.

INTRODUCTION: A 28-year-old male suffers for two weeks from new-onset very severe headache located on his left temple radiating to his jaw. He also complains about left sided retroorbital pain and chewing aggravated symptoms. In addition, nausea and emesis in the mornings during the past six months were reported. Clinical examination revealed tender swelling over the left temple, but laboratory results showed no signs of inflammation, normal electrolytes, kidney and liver values. A CT-scan revealed a circumscriptive osteolytic lesion in the left os temporale.