Positional headache associated with a dilated cyst of the septum pellucidum.

OBJECTIVE: A cavum septum pellucidum is an anatomical variant that is usually considered an incidental finding of little clinical significance. This is a fluid-containing structure between the lateral ventricles whose walls exhibit lateral bowing and are 10-mm apart or greater. It has been hypothesized that enlarged cysts of this type may cause hydrocephalus and resultant headache (HA), but there have been very few reports in the literature and even fewer reports of successful treatments. METHODS: We describe a patient with subacute onset of positional HA who was found to have a large dilated cavum cyst on magnetic resonance imaging. RESULTS: The patient underwent endoscopic fenestration of the cyst, which eradicated his HAs. CONCLUSIONS: We hypothesize that this patient's large cavum septum pellucidum cyst was causing intermittent, positional hydrocephalus and thus HAs. This is a very unusual but highly treatable cause of positional HA that could be overlooked easily.

Clinical review and epidemiology of headache disorders in US service members: with emphasis on post-traumatic headache.

Migraine or headache is a common problem in the active duty population, in the recently deployed service members, and is a cardinal symptom of traumatic brain injury. While there is increasing appreciation of the clinical burden of post-traumatic headache (PTHA) in the military traumatic brain injury population, there remain significant research gaps related to the epidemiology of PTHA, including lack of understanding of natural history, whether there are predisposing factors that predict the development or prognosis of headache post trauma and, most basically, the features that distinguish PTHA from other forms of chronic headache. Although diagnostic criteria for PTHA are included in the International Classification of Headache Disorders, 2nd edition, revised, these criteria are somewhat arbitrary and were not empirically defined. This lack of precision about the PTHA phenotype limits the rigor of observational studies of PTH but does not appear to significantly hamper treatment, provided the treatment involves a multi-modality approach.

Randomized, double-blind, comparative-effectiveness study comparing pulsed radiofrequency to steroid injections for occipital neuralgia or migraine with occipital nerve tenderness.

Occipital neuralgia (ON) is characterized by lancinating pain and tenderness overlying the occipital nerves. Both steroid injections and pulsed radiofrequency (PRF) are used to treat ON, but few clinical trials have evaluated efficacy, and no study has compared treatments. We performed a multicenter, randomized, double-blind, comparative-effectiveness study in 81 participants with ON or migraine with occipital nerve tenderness whose aim was to determine which treatment is superior. Forty-two participants were randomized to receive local anesthetic and saline, and three 120 second cycles of PRF per targeted nerve, and 39 were randomized to receive local anesthetic mixed with deposteroid and 3 rounds of sham PRF. Patients, treating physicians, and evaluators were blinded to interventions. The PRF group experienced a greater reduction in the primary outcome measure, average occipital pain at 6 weeks (mean change from baseline -2.743 ± 2.487 vs -1.377 ± 1.970; P < 0.001), than the steroid group, which persisted through the 6-month follow-up. Comparable benefits favoring PRF were obtained for worst occipital pain through 3 months (mean change from baseline -1.925 ± 3.204 vs -0.541 ± 2.644; P = 0.043), and average overall headache pain through 6 weeks (mean change from baseline -2.738 ± 2.753 vs -1.120 ± 2.1; P = 0.037). Adverse events were similar between groups, and few significant differences were noted for nonpain outcomes. We conclude that although PRF can provide greater pain relief for ON and migraine with occipital nerve tenderness than steroid injections, the superior analgesia may not be accompanied by comparable improvement on other outcome measures.

Outcomes from a US military neurology and traumatic brain injury telemedicine program.

OBJECTIVE: This study evaluated usage of the Army Knowledge Online (AKO) Telemedicine Consultation Program for neurology and traumatic brain injury (TBI) cases in remote overseas areas with limited access to subspecialists. We performed a descriptive analysis of quantity of consults, response times, sites where consults originated, military branches that benefitted, anatomic locations of problems, and diagnoses. METHODS: This was a retrospective analysis that searched electronic databases for neurology consults from October 2006 to December 2010 and TBI consults from March 2008 to December 2010. RESULTS: A total of 508 consults were received for neurology, and 131 consults involved TBI. For the most part, quantity of consults increased over the years. Meanwhile, response times decreased, with a mean response time of 8 hours, 14 minutes for neurology consults and 2 hours, 44 minutes for TBI consults. Most neurology consults originated in Iraq (67.59%) followed by Afghanistan (16.84%), whereas TBI consults mainly originated from Afghanistan (40.87%) followed by Iraq (33.91%). The most common consultant diagnoses were headaches, including migraines (52.1%), for neurology cases and mild TBI/concussion (52.3%) for TBI cases. In the majority of cases, consultants recommended in-theater management. After receipt of consultant's recommendation, 84 known neurology evacuations were facilitated, and 3 known neurology evacuations were prevented. CONCLUSIONS: E-mail-based neurology and TBI subspecialty teleconsultation is a viable method for overseas providers in remote locations to receive expert recommendations for a range of neurologic conditions. These recommendations can facilitate medically necessary patient evacuations or prevent evacuations for which on-site care is preferable.

Posttraumatic headache.

Headache is a common symptom after traumatic head injury and is a frequent feature of the postconcussive syndrome. A variety of headache subtypes can be precipitated by head trauma, although posttraumatic headaches most often resemble migraine or tension-type headache. A lack of clinical trials limits evidence-based treatment recommendations for both acute and chronic posttraumatic headaches. However, numerous pharmacologic and nonpharmacologic interventions can be used to successfully manage posttraumatic headaches. This article reviews the classification, epidemiology, prognosis, and pathophysiology of headaches after head trauma and provides a practical clinical approach for evaluating and treating patients with posttraumatic headaches.