Concordant occipital and supraorbital neurostimulation therapy for hemiplegic migraine; initial experience; a case series.

INTRODUCTION: Hemiplegic migraine is a particularly severe form of the disease that often evolves to a debilitating chronic illness that is resistant to commonly available therapies. Peripheral neurostimulation has been found to be a beneficial therapy for some patients among several diagnostic classes of migraine, but its potential has not been specifically evaluated for hemiplegic migraine. MATERIALS AND METHODS: Four patients with hemiplegic migraine were treated with concordant, combined occipital and supraorbital neurostimulation over periods ranging 6-92 months. The clinical indicators followed included assessments of headache frequency and severity, frequency of hemiplegic episodes, functional impairment, medication usage, and patient satisfaction. RESULTS: All reported a positive therapeutic response, as their average headache frequency decreased by 92% (30 to 2.5 headache days/month); Visual Analog Score by 44% (9.5 to 5.3); frequency of hemiplegic episodes by 96% (7.5 to 0.25 hemiplegic episodes/month); headache medication usage by 96% (6 to 0.25 daily medications); and Migraine Disability Assessment score by 98% (249 to 6). All were satisfied and would recommend the therapy, and all preferred combined occipital-supraorbital neurostimulation to occipital neurostimulation alone. CONCLUSIONS: Concordant combined occipital and supraorbital neurostimulation may provide effective therapy for both the pain and motor aura in some patients with hemiplegic migraine.

Stop football save brains: a point counterpoint discussion.

In a recent Opinion Editorial posted on the Listserv of the Southern Headache Society (http://www.SouthernHeadache.org), Dr. Lawrence Robbins of the Robbins Headache Clinic, Northbrook, Illinois, explored how headaches resulting from trauma are sometimes difficult to treat and often remain refractory. Most neurologists likely encounter young athletes who have a moderate-to-severe post-concussion syndrome. The following discussion, therefore, is relevant to the practice of headache medicine. In this Point Counterpoint, Dr. Robbins has repurposed his OpEd once more for Headache, followed by a response from Dr. Frank Conidi of the Florida Center for Headache and Sports Neurology, and Team Neurologist for the Florida Panthers of the National Hockey League. The discussion concludes with a retort from Dr. Robbins.

Brain injury in sports.

OBJECTIVE: Helmets are used for sports, military, and transportation to protect against impact forces and associated injuries. The common belief among end users is that the helmet protects the whole head, including the brain. However, current consensus among biomechanists and sports neurologists indicates that helmets do not provide significant protection against concussion and brain injuries. In this paper the authors present existing scientific evidence on the mechanisms underlying traumatic head and brain injuries, along with a biomechanical evaluation of 21 current and retired football helmets. METHODS: The National Operating Committee on Standards for Athletic Equipment (NOCSAE) standard test apparatus was modified and validated for impact testing of protective headwear to include the measurement of both linear and angular kinematics. From a drop height of 2.0 m onto a flat steel anvil, each football helmet was impacted 5 times in the occipital area. RESULTS: Skull fracture risk was determined for each of the current varsity football helmets by calculating the percentage reduction in linear acceleration relative to a 140-g skull fracture threshold. Risk of subdural hematoma was determined by calculating the percentage reduction in angular acceleration relative to the bridging vein failure threshold, computed as a function of impact duration. Ranking the helmets according to their performance under these criteria, the authors determined that the Schutt Vengeance performed the best overall. CONCLUSIONS: The study findings demonstrated that not all football helmets provide equal or adequate protection against either focal head injuries or traumatic brain injuries. In fact, some of the most popular helmets on the field ranked among the worst. While protection is improving, none of the current or retired varsity football helmets can provide absolute protection against brain injuries, including concussions and subdural hematomas. To maximize protection against head and brain injuries for football players of all ages, the authors propose thresholds for all sports helmets based on a peak linear acceleration no greater than 90 g and a peak angular acceleration not exceeding 1700 rad/sec(2).

Some unusual sports-related neurologic conditions.

PURPOSE OF REVIEW: This article reviews some of the unusual sports-related neurologic disorders within the new and rapidly growing field of sports neurology that neurologists may encounter. RECENT FINDINGS: Surfer's myelopathy is a potentially tragic disorder predominantly affecting novice surfers, leaving many who are affected by this condition with permanent paralysis. Neck-tongue syndrome is a rare primary headache disorder that can occur in athletes and nonathletes, and consists of paroxysmal neck and occipital pain and transient ipsilateral tongue numbness, triggered by sudden rotation of the neck. Athletes are also at risk for cervical arterial dissections, with golfers especially prone to vertebral rather than carotid dissections. Finally, "the yips" likely represents a form of occupational dystonia described in golfers. SUMMARY: The syndromes described in this article range from relatively minor syndromes that cause discomfort or abnormal movement to potentially devastating cerebrovascular or myelopathic syndromes. Although the disorders described in this article are not common, they can affect individuals involved in sports at all levels, from the novice to the elite athlete, and may present to any neurologist. Neurologists should be aware of the potential for these syndromes to occur as a consequence of athletic activities in order to provide the most appropriate diagnosis, management, and counseling.