Cluster Headache: A Review and Update in Treatment.

PURPOSE OF REVIEW: The treatment of cluster headache has evolved to include a handheld neuromodulation device and a monoclonal antibody in addition to more traditional agents. RECENT FINDINGS: Galcanezumab is an approved treatment for episodic cluster headache. The non-invasive vagal nerve stimulator has been shown to be effective as a treatment for episodic cluster headache. Dedicated pituitary imaging may not be necessary with a normal MRI of the brain. Cluster headache is the most common trigeminal-autonomic cephalalgia, characterized by unilateral, frequent, debilitating attacks associated with ipsilateral autonomic symptoms. Attacks have a circadian and, often, seasonal pattern with periods of remission that can last months to years in episodic patients. Though a rare disease, an increasing number of studies have revealed novel targets for treatment. Treatment in cluster headache should focus on early intervention to reduce frequency of attacks and the length of the cycle, which improves outcomes and disability. Acute therapy is used to treat attacks, while bridging and preventive therapies are combined to reduce cycle length. Case 1: A 43-year-old man presents with the chief complaint of severe headaches. Upon general examination, he seems uncomfortable, agitated, and exhausted. He states that he hasn't "slept in over a week because of debilitating headaches." His headaches start around the same time every night: when he lays down to go to sleep. The pain is described as sharp, like a "hot poker" to his left eye. His partner has noticed that his eye droops and turns red when the pain starts. The attacks come on abruptly and prevent him from sleeping. The severe pain lasts 30 to 45 min, but he has mild-to-moderate pain that lingers for the rest of the night. He has seen his primary care physician, an allergist, and an ear, nose, and throat (ENT) specialist before coming to see a neurologist. Similar headaches occurred last year during the month of October as well. On further questioning, he reports that these headache attacks have been occurring almost yearly for the past 7 years. Each year, these headaches come on as the weather is changing and occur on a nightly basis for about 3 to 4 weeks.

Presentation and Management of Headache in Pituitary Apoplexy.

PURPOSE OF REVIEW: Pituitary apoplexy (PA) occurs in the setting of an infarction and/or hemorrhage of a pre-existing adenoma. The most common presenting symptom is a severe, sudden onset headache. However, the characteristics of headache in the setting of PA are varied and can sometimes mimic primary headache disorders. The purpose of this article is to review the various presentations of headache in PA. We also outline treatment options for persistent headaches following PA. RECENT FINDINGS: A recent retrospective review of patients undergoing transsphenoidal resection of sellar lesions, including PA, found that gross total resection and short duration of preoperative headache were predictors of improvement in headaches postoperatively. This strengthens the importance of timely recognition of PA as potential etiology of headache. The most common presentation of PA is thunderclap headache; however, several other primary HA disorders have been described including status migraine, SUNCT, and paroxysmal hemicrania.

Clinical Presentation and Management of Headache in Pituitary Tumors.

PURPOSE OF REVIEW: This article provides an overview of headache in the setting of pituitary adenoma. The purpose of this article is to educate providers on the association, possible pathophysiology, and the clinical presentation of headache in pituitary tumor. RECENT FINDINGS: Recent prospective evaluations indicate that risk factors for development of headache in the setting of pituitary adenoma include highly proliferative tumors, cavernous sinus invasion, and personal or family history of headache. Migraine-like headaches are the predominant presentation. Unilateral headaches are often ipsilateral to the side of cavernous sinus invasion. In summary, this paper describes how the size and type of pituitary tumors play an important role in causation of headaches. Pituitary adenoma-associated headache can also mimic primary headache disorders making recognition of a secondary process difficult. Therefore, this paper highlights the association of between trigeminal autonomic cephalgias and pituitary adenomas and urges practitioners to maintain a high index of suspicion when evaluating patients with these uncommon headache presentations. However, on balance, given the prevalence of both primary headache disorders and pituitary adenomas, determining causality can be challenging. A thoughtful and multidisciplinary approach is often the best management strategy, and treatment may require the expertise of multiple specialties including neurology, neurosurgery, and endocrinology.

A retrospective evaluation of the combination of erenumab and onabotulinum toxin A for the prevention of chronic migraine.

OBJECTIVE: Prior to the approval of erenumab, onabotulinum toxin A (onabot A) was the only Food and Drug Administration-approved chronic migraine preventive treatment. In this study, we assess the safety and efficacy of the combination of erenumab and onabot A for chronic migraine prevention. METHODS: This is a retrospective cohort study of patients with a diagnosis of chronic migraine receiving onabot A, who were additionally started on erenumab. Primary endpoint was a decrease in number of migraine days while on the combination treatment as compared to onabot A alone. Secondary endpoints included a decrease in headache days and reported side effects. RESULTS: When erenumab was added to onabot A, participants (n = 50) experienced significantly lower number of monthly migraine days (11.3 ± 9.3 vs. 14.9 ± 9.4, p < 0.001). The treatment of onabot A and erenumab also significantly lowered the number of monthly headache days (18.2 ± 10.3 vs. 20.7 ± 9.1, p = 0.042). There were no "severe" adverse effects reported in the combined treatment group. CONCLUSION: This retrospective case series showed a reduction in monthly migraine and headache days with the treatment combination of erenumab and onabot A compared to onabot A alone in patients with chronic migraine.

Reduced Hospital Costs for Ultrasound-guided Vacuum-assisted Excision Compared with Open Surgery in Patients with Benign Breast Masses and High-risk Lesions.

OBJECTIVE: Benign breast masses represent a substantial proportion of breast cancer screening results and may require multiple follow-up visits and biopsy. Even with a preceding benign core biopsy, benign masses have been excised via open surgery for a variety of reasons. This study compared the procedural costs of US-guided vacuum-assisted excision (US-VAE) versus open surgical excisions for benign breast masses and high-risk lesions (HRL). METHODS: In this retrospective cohort study, female outpatients receiving US-VAE or open excision of benign breast masses between 2015 and 2018 were identified within the Premier Healthcare Database. A secondary analysis was conducted for patients with HRLs. Propensity score matching and multivariate regression adjusted for patient demographics, encounter level covariates, and hospital characteristics. The total procedural costs were reported from a hospital perspective. RESULTS: A total of 33 724 patients underwent excisions for benign breast masses (8481 US-VAE and 25 242 open surgery). Procedural costs were significantly lower in unmatched patients who received US-VAE ($1350) versus open surgery ($3045) (P < 0.0001). After matching, a total of 5499 discharges were included in each group, with similar findings for US-VAE ($1348) versus open surgery ($3101) (P < 0.0001). A secondary analysis of matched HRL patients (41 discharges in each group) also showed significantly lower procedural costs with US-VAE ($1620) versus open surgery ($3870) (P < 0.0001). CONCLUSION: Among patients with benign breast masses or HRLs, US-VAE was associated with significantly lower procedural costs versus open surgery. If excision is performed and expected clinical outcomes are equal, US-VAE is preferable to reduce costs without compromising the quality of care.

Angiographic imaging evaluation of patient-specific bifurcation-aneurysm phantom treatment with pre-shaped, self-expanding, flow-diverting stents: feasibility study.

Aneurysm treatment using flow diversion could become the treatment of choice in the near future. While such side-wall aneurysm treatments have been studied in many publications and even implemented in selected clinical cases, bifurcation aneurysm treatment using flow diversion has not been addressed in detail. Using angiographic imaging, we evaluated treatment of such cases with several stent designs using patient-specific aneurysm phantoms. The aim is to find a way under fluoroscopic image guidance to place a low-porosity material across the aneurysm orifice while keeping the vessel blockage minimal. Three pre-shaped self-expanding stent designs were developed: the first design uses a middle-flap wing stent, the second uses a two-tapered-wing-ended stent, and the third is a slight modification of the first design in which the middle-flap is anchored tightly against the aneurysm using a standard stent. Treatment effects on flow were evaluated using high-speed angiography (30 fps) and compared with the untreated aneurysm. Contrast inflow was reduced in all the cases: 25% for Type 1, 63% for type 2 and 88% for Type 3. The first and the second stent design allowed some but substantially-reduced flow inside the aneurysm neck as indicated by the time-density curves. The third stent design eliminated almost all flow directed at the aneurysm dome, and only partial filling was observed. In the same time Type 1 and 3 delayed the inflow in the branches up to 100% compared to the untreated phantom. The results are quite promising and warrant future study.