Headache attributed to airplane travel ('airplane headache'): clinical profile based on a large case series.

BACKGROUND: The 'headache attributed to airplane travel', also named 'airplane headache' (AH), is a recently described headache disorder that appears exclusively in relation to airplane flights, in particular during the landing phase. Based on the stereotypical nature of the attacks in all reported cases, we proposed provisional diagnostic criteria for AH in a previously published paper. Up to now 37 cases have been described in the literature. METHODS: After our paper was disseminated via the Internet, we received several email messages from subjects around the world who had experienced such a peculiar headache. Their cooperation, by completing a structured questionnaire and allowing the direct observation of three subjects, enabled us to carry out a study on a total of 75 patients suffering from AH. RESULTS: Our survey confirmed the stereotypical nature of the attacks, in particular with regard to the short duration of the pain (lasting less than 30 minutes in up to 95% of the cases), the clear relationship with the landing phase, the unilateral pain, the male preponderance, and the absence of accompanying signs and/or symptoms. It is conceivable to consider barotrauma as one of the main mechanisms involved in the pathophysiology of AH. The observation that the pain appears inconstantly in the majority of cases, without any evident disorder affecting the paranasal sinuses, could be consistent with a multimodal pathogenesis underlying this condition, possibly resulting in the interaction between anatomic, environmental and temporary concurrent factors. CONCLUSIONS: This is by far the largest AH case series ever reported in the literature. The diagnostic criteria that we previously proposed proved to be valid when applied to a large number of patients suffering from this condition. We support its recognition as a new form of headache, to be included in the forthcoming update of the International Headache Society Classification, within '10. Headache attributed to disorder of homoeostasis'. Its formal validation would favour further studies aimed at improving the understanding of its pathophysiology and implementing preventative measures.

Migraine responsive to warfarin: an update on anticoagulant possible role in migraine prophylaxis.

We report the case of a patient suffering from migraine with and without aura who had a complete remission of both during warfarin treatment for pulmonary embolism; the attacks reappeared promptly during two treatment withdrawals. We highlight warfarin as prophylactic drug in migraine prophylaxis and discuss about new, safer and more specific anticoagulants that could be used in migraine treatment. Their use could also clarify literature's conflicting data about anticoagulants' efficacy in migraine prophylaxis and clear if their efficacy in migraine treatment could be related aspecifically to anticoagulation's effect or to a particular mechanism in the coagulation cascade.

The borderland of migraine with aura: episodic unilateral mydriasis.

We present the case of a patient who had a 3-year history of episodes of transitory unilateral mydriasis with omolateral blurred vision followed by headache. Thereafter, during the last 4 years, the patient developed a migraine with visual aura, without further episodes of transitory mydriasis. We suggest that the transitory mydriasis previously present could be considered as an unusual form of migrainous aura. A possible pathogenetic mechanism is proposed.

Cluster-like headache. A comprehensive reappraisal.

Among the primary headaches, cluster headache (CH) presents very particular features allowing a relatively easy diagnosis based on criteria listed in Chapter 3 of the International Classification of Headache Disorders (ICHD-II). However, as in all primary headaches, possible underlying causal conditions must be excluded to rule out a secondary cluster-like headache (CLH). The observation of some cases with clinical features mimicking primary CH, but of secondary origin, led us to perform an extended review of CLH reports in the literature. We identified 156 CLH cases published from 1975 to 2008. The more frequent pathologies in association with CLH were the vascular ones (38.5%, n = 57), followed by tumours (25.7%, n = 38) and inflammatory infectious diseases (13.5%, n = 20). Eighty were excluded from further analysis, because of inadequate information. The remaining 76 were divided into two groups: those that satisfied the ICHD-II diagnostic criteria for CH, 'fulfilling' group (F), n = 38; and those with a symptomatology in disagreement with one or more ICHD-II criteria, 'not fulfilling' group (NF), n = 38. Among the aims of this study was the possible identification of clinical features leading to the suspicion of a symptomatic origin. In the differential diagnosis with CH, red flags resulted both for F and NF, older age at onset; for NF, abnormal neurological/general examination (73.6%), duration (34.2%), frequency (15.8%) and localization (10.5%) of the attacks. We stress the fact that, on first observation, 50% of CLH presented as F cases, perfectly mimicking CH. Therefore, the importance of accurate, clinical evaluation and of neuroimaging cannot be overestimated.

Sympathy for Pontius Pilate. Hemicrania in M. A. Bulgakov's The Master and Margarita.

The aim of this study was to explore the description of the migraine attack of Pontius Pilate (a character in the novel The Master and Margarita by M. A. Bulgakov). Some of its features are analysed in light of current migraine literature. It is hypothesized that, at least in part, this description is based on the personal experience of the novel's author. We studied and analysed the text of the novel, other works by Bulgakov, his biography, including his medical training and practice, and the recently published diaries of Bulgakov and his wife E. S. Bulgakova. The novel contains a comprehensive description of a migraine attack. It includes a prodrome/aura of osmophobia. Olfactory perception during or shortly before the migraine attack is altered to the point where neutral or even pleasant odours become unbearable. Bulgakov's extensive history of migraines is seen in his diary, the diary of his wife, letters and other literary works. This is one of the most detailed and extensive depictions of a migraine attack in literature, with osmophobia described with great emphasis. It is likely that Pilate's migraine is described based on the personal history of the novel's author.

Osmophobia in migraine and tension-type headache and its clinical features in patients with migraine.

Intolerance to smell is often reported by migraine patients. This study evaluates osmophobia in connection with the diagnosis of migraine and episodic tension-type headache (ETTH). The characteristics of this symptom are also investigated. We recruited from our Headache Centre 1005 patients (772 female, 233 male; age 37 +/- 11 years), of whom 677 were migraine without aura (MoA), 130 migraine with aura (MA) and 198 TTH. Patients with two or more forms of primary headache were excluded. Among migraine patients, 43.9% with MoA and 38.5% with MA reported osmophobia during the attacks; none of the 198 TTH patients suffered this symptom. Most frequently offending odours were scents (63.9%), food (55.2%) and cigarette smoke (54.8%). Osmophobia appears structurally integrated into the migraine history of the patient. It seems to be a peculiar symptom favouring the diagnosis of migraine (MoA and MA) in the differential diagnosis with ETTH.

Cryptogenic temporal lobe epilepsy. semi-quantitative interictal 99mTc HMPAO SPECT: statistical correlation with clinical data and EEG.

The aim of our work was to identify clinical and electroencephalographic factors that are statistically correlated to 99mTc HMPAO hypofixation in cryptogenic temporal lobe epilepsy. We selected a homogeneous group of patients (28 males and 17 females) affected by temporal lobe epilepsy and having normal results on computed tomography and magnetic resonance imaging. Patients were classified according to semeiological characteristics of the seizures, presence or absence of spikes on electroencephalography (EEG), age at onset, illness duration, and drug resistance. The presence of focal interictal spikes on EEG was statistically correlated to 99mTc HMPAO temporal hypofixation (p = 0.04). The other electroclinical factors considered in this series did not play an important role in modifying radiopharmaceutical fixation in focal epilepsy in interictal phase. We speculate that a possible explanation for focal radiopharmaceutical hypofixation, in addition to hypoperfusion, is an increased permeability of the blood-brain barrier (due to perivascular inflammation or other causes) which can be responsible for 99mTc HMPAO escape with a resultant hypofixation.

Chronic paroxysmal hemicrania, hemicrania continua and SUNCT syndrome in association with other pathologies: a review.

We present a review of 22 cases of headache mimicking chronic paroxysmal hemicrania (CPH) (17 female and five male; F : M ratio 3.4), nine cases mimicking hemicrania continua (HC) (seven female and two male) and seven cases mimicking SUNCT syndrome (five male and two female) found in association with other pathologies published from 1980 up to the present. All case reports were discussed with respect to diagnostic criteria proposed by International Headache Society (IHS) for CPH, by Goadsby and Lipton for HC and SUNCT, and evaluated to identify a possible causal relationship between the pathology and the onset of headache. The aim of the present review was to evaluate if the presence of associated lesions and their location could help elucidate the pathogenesis of trigeminal autonomic cephalalgias (TACs).

Spontaneous carotid artery dissection with cluster-like headache.

A case of carotid artery dissection in a 41-year-old-woman is described whose main symptom was cluster-like pain. The case is interesting for its atypical presentation with only two other like cases in the literature, and the site of dissection, localized in the intrapetrous curvature of the carotid artery. The case highlights the need for active co-operation between clinician and neuroradiologist during neuroimaging assessment which must be focused on the clinical evaluation of the individual patient so as to avoid error, particularly in atypical cases.