Melatonin in hemicrania continua and paroxysmal hemicrania.

BACKGROUND: Hemicrania continua (HC) and paroxysmal hemicrania (PH) belong to a group of primary headache disorders called trigeminal autonomic cephalalgias. One of the diagnostic criteria for both HC and PH is the absolute response to the therapeutic dose of indomethacin. However, indomethacin is discontinued in many patients as a result of intolerance to its side effects. Melatonin, a pineal hormone, which shares similar chemical structure to indomethacin, has been reported to have some efficacy for HC in previous case reports and series. To our knowledge, there is no literature regarding the use of melatonin in PH. We aimed to describe the clinical use of melatonin in the preventive management of HC and PH. METHODS: Patient level data were extracted as an audit from routinely collected clinical records in consecutive patients seen in outpatient neurology clinic at King's College Hospital, London, UK, from September 2014 to April 2023. Our cohort of patients were identified through a search using the keywords: hemicrania continua, paroxysmal hemicrania, melatonin and indomethacin. Descriptive statistics including absolute and relative frequencies, mean ± SD, median and interquartile range (IQR) were used. RESULTS: Fifty-six HC patients were included with a mean ± SD age of 52 ± 16 years; 43 of 56 (77%) patients were female. Melatonin was taken by 23 (41%) patients. Of these 23 patients, 19 (83%) stopped indomethacin because of different side effects. The doses of melatonin used ranged from 0.5 mg to 21 mg, with a median dose of 10 mg (IQR = 6-13 mg). Fourteen (61%) patients reported positive relief for headache, whereas the remaining nine (39%) patients reported no headache preventive effect. None of the patients reported that they were completely pain free. Two patients continued indomethacin and melatonin concurrently for better symptom relief. Eight patients continued melatonin as the single preventive treatment. Side effects from melatonin were rare. Twenty-two PH patients were included with mean ± SD age of 50 ± 17 years; 17 of 22 (77%) patients were female. Melatonin was given to six (27%) patients. The median dose of melatonin used was 8 mg (IQR = 6-10 mg). Three (50%) patients responded to melatonin treatment. One of them used melatonin as adjunctive treatment with indomethacin. CONCLUSIONS: Melatonin showed some efficacy in the treatment of HC and PH with a well-tolerated side effect profile. It does not have the same absolute responsiveness as indomethacin, at the doses used, although it does offer a well-tolerated option that can have significant ameliorating effects in a substantial cohort of patients.

Cefalea atribuida a ictus isquémico. Actualización semiológica y diagnóstica / Headache attributed to ischaemic stroke. An update on its semiology and diagnosis

Introducción: La cefalea es un síntoma frecuente tras el ictus isquémico agudo. Su identificación y diagnóstico constituyen un reto por el perfil de paciente y los criterios diagnósticos actuales de esta entidad. Los objetivos del estudio fueron determinar la prevalencia de cefalea atribuida a ictus isquémico y su forma persistente, y analizar las variables clinicodemográficas y el grado de cumplimiento de los criterios de la Clasificación Internacional de Cefaleas (ICHD-III). Pacientes y métodos: Es un estudio observacional analítico de cohortes prospectivo de pacientes ingresados con ictus isquémico agudo en la unidad de ictus de un hospital de tercer nivel en un período de 12 meses. Resultados: Se incluyó a 244 pacientes con ictus isquémico agudo (el 59,8%, varones; edad media: 71 ± 12,8 años). El 23,2% presentó cefalea en el momento del ingreso o bien en las primeras 72 horas y el 12,5% de ellos presentó cefalea persistente atribuida a ictus isquémico. El 62,5% cumplió los criterios diagnósticos de acuerdo con la ICHD-III. Conclusión: La cefalea tras el ictus isquémico es un síntoma frecuente. Su aparición se asoció al sexo femenino, al ictus de territorio vertebrobasilar y a puntuaciones bajas en la National Institutes of Health Stroke Scale. Sería recomendable revisar los criterios diagnósticos actuales.(AU)

Introduction: Headache is a common symptom in acute ischemic stroke which is often overlooked and undertreated because of focus in neurologic function, communication difficulties in stroke patients and the current diagnostic criteria of this type of headache. The present study aimed to determine the prevalence of Acute and Persistent Headache Attributed to Ischemic Stroke and to analyze the fulfillment of the criteria of the International Classification of Headaches (ICHD-IID). Patients and methods: Prospective observational analytical cohort study. The study population consisted of patients with acute ischemic stroke admitted to the Stroke Unit of a tertiary care hospital over a period of 12 months. Results: Two hundred and forty-four patients with acute ischemic stroke (59.8% males, mean age 71+12.8 years) were included. Headache at onset or at the first 72 hours was present in 23.2% and 12.5% of them presented persistent headache attributed to ischemic stroke. Only 62.5% of the headaches at stroke onset fulfilled the diagnostic criteria of ICHD-III. Conclusion: Headache after ischemic stroke is a common symptom. It was associated with female sex, posterior circulation stroke and low scores on the National Institutes of Health Stroke Scale (NIHSS). The current diagnostic criteria should be reviewed.

Paroxysmal hemicrania and hemicrania continua: Review on pathophysiology, clinical features and treatment.

BACKGROUND: Paroxysmal hemicrania and hemicrania continua are indometacin-sensitive trigeminal autonomic cephalalgias, a terminology which reflects the predominant distribution of the pain, observable cranial autonomic features and shared pathophysiology. Understanding the latter is limited, both by low prevalence and the intricacies of studying brain function, requiring multimodal techniques to glean insights into such disorders. Similarly obscure is the curious response to indometacin. This review will address what is currently known about pathophysiology, the rationale for the current classification and, features which may confound the diagnosis, such as lack of cranial autonomic symptoms and those which are typically associated with migraine such as nausea, photophobia, phonophobia and aura. Despite these characteristics, a dramatic response to indometacin, which is not seen in migraine nor the other trigeminal autonomic cephalalgias , provides the hallmark of the diagnosis. The main clinical differential for paroxysmal hemicrania is based on temporal pattern and lies between cluster headache and short-lasting-neuralgiform headache attacks with tearing or additional cranial autonomic symptoms. For hemicrania continua it is more challenging as the main differential for which the disorder is often treated is migraine. A prior episodic pattern, often days at a time, and the tendency to exacerbation with analgesics will further deflect from the diagnosis. The relevance of this is that there is little overlap in therapeutics between paroxysmal hemicrania and hemicrania continua and other headache disorders and there are limited effective alternatives to indometacin. The most effective are other non-steroidal anti-inflammatory drugs including the newer COX-II inhibitors. Even though early reports suggest that a higher indometacin dose-requirement may herald a secondary precipitating pathology, this does not seem to be the case, with syndrome and response to treatment being similar with the primary disorder. In this context imaging of new onset paroxysmal hemicrania or hemicrania continua and implication of the results will be discussed as will alternative treatment options.

Prevalence and clinical features of hemicrania continua in clinic-based studies: A systematic review and meta-analysis.

OBJECTIVE: To estimate the relative frequencies of hemicrania continua and its clinical features in adult patients who were evaluated for headache in a clinic-based setting. METHODS: PubMed and Embase were searched for observational, clinic-based studies published between 1 January 2004 and 1 February 2022, that reported on the relative frequencies of hemicrania continua and its clinical features. Two independent investigators (HMA and SA-K) screened titles, abstracts, and full text-articles. A random-effects meta-analysis was conducted to estimate pooled relative frequencies of hemicrania continua and its clinical features across clinic-based studies. RESULTS: Eleven clinic-based studies were deemed eligible for inclusion. Of these, eight studies reported on the relative frequency of hemicrania continua among adult patients (n = 9854) who were evaluated for headache in a tertiary care unit. The pooled relative frequency of hemicrania continua was found to be 1.8% (95% CI; 1.0-3.3). Considerable heterogeneity was noted across studies (I2 = 89.8%). The three most common symptoms associated with hemicrania continua were lacrimation (72.3%), conjunctival injection (69.8%), and restlessness/agitation (60.2%). CONCLUSION: The findings of this meta-analysis suggest that there is limited epidemiologic data on the relative frequencies of hemicrania continua and its clinical features. Standardized data acquisition and reporting are needed to estimate prevalence rates more accurately and to better understand epidemiologic patterns. This, in turn, should increase awareness of the impact that hemicrania continua has in clinical practice.

Precisión de la prueba diagnóstica de acentuación de la cefalea mediante sacudidas cefálicas para el diagnóstico de meningitis aguda en urgencias / Diagnostic test accuracy of jolt accentuation for headache in acute meningitis in the emergency setting

No disponible

Developments in distinguishing secondary vascular headache from primary headache disorders in clinical practice.

INTRODUCTION: Vascular headaches are secondary headache disorders with potentially devastating consequences if missed. Clinicians often struggle to distinguish these from primary headache disorders whereby there is no underlying structural pathology. Here, the authors describe the advancement in our understanding of vascular headache disorders, their clinical presentation and the developments in neuroimaging that facilitate diagnosis. AREAS COVERED: Here the authors discuss the definition of primary and secondary headache disorders. They review the literature on the presentation, choice of neuroimaging and diagnostic tools that can be used to diagnose specific vascular headaches including Carotid or Vertebral artery dissection, Stroke, Temporal Arteritis, subarachnoid hemorrhage, cerebral venous thrombosis, Reversible Cerebral Vasoconstriction syndrome, Primary angiitis, AV malformation and Genetic vasculopathy. The authors discuss the influence of Covid-19 on the management of patients with headache. EXPERT OPINION: Whilst developments in neuroimaging have been of paramount importance in the diagnosis of vascular headache disorders, there is no substitute for meticulous history taking and examination. Research has aided our understanding of clinical presentation, however further studies are needed as well as increased education of neurologists and acute physicians.

Terapia de oxigenación hiperbárica en el tratamiento del dolor / Hyperbaric oxygenation therapy in pain treatment

El dolor crónico constituye un reto terapéutico especial. Se presenta una revisión narrativa sobre el papel del tratamiento de oxigenación hiperbárica (TOHB) en el tratamiento del dolor neuropático, y sus aplicaciones en dolor crónico, síndromes neurosensitivos disfuncionales y oncodolor. El conocimiento de las indicaciones de TOHB en algiología y su aplicación en la práctica médica puede contribuir a mejorar la calidad de vida del paciente. (AU)

Chronic pain represents a special therapeutic challenge. We present a narrative review on the role of Hyperbaric Oxygen Therapy (HBOT) in the treatment of neuropathic pain, and its applications in chronic pain, dysfunctional neurosensitive syndromes and oncological pain. The knowledge of the indications of HBOT in algiology and its application in medical practice can contribute to improve the quality of life of the patient. (AU)

Cefalea en jóvenes: características clínicas en una serie de 651 casos / Headache in young patients: Clinical characteristics of a series of 651 cases

Introducción: La cefalea produce un impacto negativo sobre la calidad de vida de los jóvenes. Nuestro objetivo es analizar las características de esta población en una consulta monográfica de cefaleas (CMC) y evaluar la carga de las diferentes cefaleas codificadas según la Clasificación Internacional de Cefaleas (CIC). Métodos: Durante un período de 6 años y medio, se han registrado los pacientes de edades entre los 14 y los 25 años atendidos en la CMC recogiendo de cada uno de ellos el sexo, pruebas complementarias y tratamiento utilizado previamente. Se llevó a cabo la comparación de las características de esta población con la de mayores de 25 años. Resultados: Seiscientos cincuenta y un pacientes de entre 14 y 25 años fueron atendidos durante el período de inclusión; el 95,6% había recibido tratamiento sintomático y el 30,1% tratamiento preventivo. Setecientas cincuenta y cinco cefaleas fueron registradas, 80 fueron cefaleas secundarias, la mayoría codificadas en el grupo 8. El 77,2% de ellas fueron incluidas en el grupo 1, el 3,1% en el grupo 2, el 1,2% en el grupo 3 y el 5% en el grupo 4. El 0,6% de ellas fueron clasificadas en el grupo 13 y el 0,9% en el grupo 14. En 449 pacientes la puntuación del Headache Impact Test (HIT-6) mostró al menos un impacto moderado sobre la calidad de vida. Conclusión: La mayoría de las cefaleas en jóvenes podrían ser codificadas de acuerdo con los criterios de la CIC. La migraña fue el diagnóstico más frecuente. Aunque la cefalea fue comúnmente asociada con impacto negativo en la calidad de vida, los tratamientos preventivos no fueron utilizados extensamente antes de ser derivados a la CMC

Introduction: Headache has a negative impact on health-related quality of life in young patients. We aim to analyse the characteristics of a series of young patients visiting a headache clinic and estimate the burden of different types of headaches listed by the International Classification of Headache Disorders (ICHD). Methods: We prospectively recruited patients aged 14 to 25 years who were treated at our clinic during a period of 6.5 years. We recorded each patient's sex, complementary test results, and previous treatment. We subsequently compared the characteristics of our sample to those of patients older than 25. Results: During the study period, we treated 651 patients aged 14 to 25 years; 95.6% had received symptomatic treatment, and 30.1% had received preventive treatment. A total of 755 headaches were recorded. Only 80 were secondary headaches, most of which were included in Group 8; 77.2% were included in Group 1, 3.1% in Group 2, 1.2% in Group 3, 5% in Group 4, 0.6% in Group 13, and 0.9% in Group 14. According to Headache Impact Test (HIT-6) scores, headache had at least a moderate impact on the quality of life of 449 patients. Conclusion: Most headaches in young patients can be classified according to ICHD criteria. Migraine was the most frequent diagnosis in our sample. Although headache was commonly associated with a negative impact on quality of life, most patients had received little preventive treatment before being referred to our clinic

Role of developmental venous anomalies in etiopathogenesis of demyelinating diseases.

OBJECTIVE: Multiple sclerosis (MS) is a demyelinating autoimmune disease of the central nervous system. T2W-hyperintense demyelinating lesions are detected in cranial magnetic resonance imaging (MRI). Developmental venous anomalies (DVAs) have frequently been detected in enhanced cranial MRI images, and are generally accepted as normal variants of venous development. The aim of the present study was to investigate whether there was an association between demyelinating diseases and venous anomalies. METHODS: One hundred five patients who were diagnosed as having MS in accordance with the McDonald diagnostic criteria, and 105 patients who were diagnosed as having vascular headache who had no lesions similar to MS were included in the present retrospective study. RESULTS: DVAs were detected in 31 of the study group and in 14 patients in the control group. A statistically significant higher rate of DVAs and abnormal signal increase in the neighboring tissue was detected in the study group (p = 0.004) (p = 0.006). The DVA was superficially localized in the RRMS, It was deeply located in RIS. CONCLUSION: Recent studies have emphasized the association of the central vein and the lesion severity of MS with the detection of the central collecting vein in MS lesions. In our study, DVAs, which are generally regarded as innocent developmental anomalies, and neighboring signal increase were found significantly higher in the MS group compared with the control group. The role of DVAs in the etiology of demyelinating lesions must be clarified through comprehensive future studies that use more advanced techniques.

Parche hemático como tratamiento de cefalea por hipotensión de líquido cefalorraquídeo espontánea / Blood patch as treatment of headache due to spontaneous hypotension of cerebrospinal fluid

No disponible

Serial magnetic resonance imaging findings in subarachnoid hemorrhage due to an initially angiographically occult type II spinal aneurysm: Case report.

BACKGROUND: Spinal aneurysms are rare causes of spontaneous subarachnoid hemorrhage. METHODS: We present an unusual, initially occult, case of an upper thoracic intradural extramedullary isolated aneurysm arising from the T2 intercostal-radicular circulation that was initially angiographically occult but was discovered due to unique, albeit nonspecific, magnetic resonance imaging findings of spinal cord T2 hyperintensity and contrast enhancement that were noted to progress with a clinical picture of ictal rehemorrhage. RESULTS: Repeat spinal angiography revealed a spinal aneurysm that was treated surgically. CONCLUSION: In cases of sufficient clinical suspicion and nonspecific imaging findings, continued vigilance is advised in seeking an underlying pathoanatomic etiology.

Radiosurgery for Arteriovenous Malformations and the Impact on Headaches.

BACKGROUND: Arteriovenous malformations (AVMs) can underlie many diverse neurological signs and symptoms. Headaches are a common presentation that can have a significant impact on quality of life. OBJECTIVE: The authors investigated Gamma Knife® stereotactic radiosurgery (SRS) outcomes in patients with AVMs and associated headaches. METHODS: This retrospective study analyzed 102 patients with AVMs who underwent SRS between 1995 and 2013. The patient's headache symptoms led to their AVM diagnosis or developed post hemorrhage of their AVM. Information regarding headache characteristics was obtained from the patient's medical records and at follow-up using a scripted clinical interview. The median imaging follow-up was 61.7 months and clinical follow-up was 89.7 months. The median treatment volume at SRS was 4.1 cm3 and the median marginal dose was 20 Gy. RESULTS: The actuarial AVM obliteration rate was 60% at 5 years and 78% at 10 years. Patients reported that their overall headache severity decreased by -43.6% and their headache frequency was reduced by -53.4%. Headache reduction was reported in 49.1% of patients at 1 year and 69.5% at 5 years. The median time until improvement was 6.5 months. After SRS, headache medication usage decreased in 29% of patients. Permanent adverse radiation effects after SRS occurred in 3% of patients. Until obliteration was complete, the annual risk of a hemorrhage after SRS was 0.4% per year. CONCLUSION: Although recall bias related to a retrospective analysis can impact outcomes, headache symptoms associated with AVMs may potentially be decreased or eliminated in a subset of patients treated with Gamma Knife radiosurgery.

Diet-induced obesity alters dural CGRP release and potentiates TRPA1-mediated trigeminovascular responses.

Background Clinical studies suggest a link between obesity and the primary headache disorder migraine. In our study we aimed to reveal the effect of obesity on meningeal nociceptor function in rats receiving a high-fat, high-sucrose diet. Methods Transient receptor potential ankyrin 1 (TRPA1) receptor activation-induced changes in meningeal blood flow, release of calcitonin gene-related peptide (CGRP) from trigeminal afferents and TRPA1 protein expression in the trigeminal ganglia were measured in control and obese rats. Metabolic parameters of the animals were assessed by measuring glucose and insulin homeostasis as well as plasma cytokine concentrations. Results The present experiments revealed an enhanced basal and TRPA1 receptor agonist-induced CGRP release from meningeal afferents of obese insulin-resistant rats and an attenuated CGRP release to potassium chloride. Obesity was also associated with an augmented vasodilatation in meningeal arteries after dural application of the TRPA1 agonist acrolein, a reduction in TRPA1 protein expression in the trigeminal ganglia and elevations in circulating proinflammatory cytokines IL-1ß and IL-6 in addition to increased fasting blood glucose and insulin concentrations. Conclusions Our results suggest trigeminal sensitisation as a mechanism for enhanced headache susceptibility in obese individuals after chemical exposure of trigeminal nociceptors.

Headache and analgesic in postoperative craniotomy

Objective: To identify the most prevalent type of pain in postoperative craniotomy patients and evaluate the use of analgesic in this group of patients. Method: The case studies consisted of 55 patients undergoing craniotomy. Patients were evaluated from the first to the seventh postoperative day. Data were stored and analyzed using the Statistical Package for Social Sciences (SPSS) version 17.0. The variables analyzed were gender, demographic data, assessing the presence of pain, location of pain, severity of pain, use of analgesic, professionals who recorded the pain on the patients’ charts, and presence of insomnia. Results: The results show that headache, the main pain reported by the patients, is present from the first to the seventh postoperative day. It was observed that in some cases there was no prescription of analgesics and even in the group of patients who took analgesics, these drugs were not effective for the relief of headache. The final logistic regression model revealed that insomnia ( OR = 10.6, p = < 0.001 ), the pain recorded in the patients’ charts (OR = 2.38 , p = 0.016) and use of analgesic (OR = 2.03 , p = 0.014) adequately explained the outcome. Conclusion: Headache was the chief complaint of pain after postoperative craniotomy, and its intensity varied from mild to severe. The analgesic used was not effective for the control of postoperative headache. Proper handling of post-craniotomy headache by the multidisciplinary team can contribute to early neurological recovery of patients undergoing craniotomy, and should make the post-surgical care, with a view to early recovery and the humanization of care.

Síndromes neurológicas durante a gestação / Neurological syndromes during pregnancy

A ocorrência de sintomas neurológicos agudos em gestantes ou puérperas não é incomum. Podem ser causados tanto pela exacerbação de uma doença neurológica pré-existentes quanto por doenças relacionadas com a própria gravidez. O diagnóstico preciso é essencial para o tratamento adequado. Sendo assim, é recomentado acompanhamento multidisciplinar antes, durante e após a gravidez. O objetivo do presente estudo é realizar uma revisão da literatura sobre as principais síndromes neurológicas durante a gravidez, descrevê-las e elucidar como é feito o diagnóstico adequado. Para isso, foi realizada uma busca de artigos na base de dados do Medline, via Pubmed, sendo selecionados artigos publicados nos últimos 10 anos, nas línguas inglesa ou portuguesa. Desse modo, o presente estudo demonstra a importância de saber reconhecer e tratar adequadamente cada uma dessas síndromes, bem como de um acompanhamento em centro de referência, uma vez que as síndromes neurológicas estão relacionadas com morbidade e mortalidade materna.(AU)

The occurrence of acute neurological symptoms in pregnant women and during puerperium is not uncommon. This symptoms can be caused both by the exacerbation of a preexisting neurological disease and illnesses related to the pregnancy itself. The accurate diagnosis is essential for proper treatment. Therefore, it is recommended that a multidisciplinary monitoring before, during and after pregnancy. The aim of this study is to conduct a review of the literature on the main neurological syndromes during pregnancy, describe them and elucidate how is made the proper diagnosis. For this, a search for articles on Medline database, via Pubmed was performed, being selected articles published in the last 10 years, in English or Portuguese languages. Thus, the present study demonstrates the importance of knowing recognize and properly handle each of these syndromes, as well as a follow-up in tertiary centers, once the neurologicalsyndromes are related to maternal morbidity and mortality.(AU)

Tratando Cefaleia na Unidade Básica de Saúde

Segundo a Sociedade Brasileira de Cefaleia, 95% da população apresentará uma dor de cabeça ao longo de sua vida. Cerca de 13 milhões de brasileiros apresentam dor de cabeça pelo menos 15 dias por mês, o que chamamos de cefaleia crônica diária. A cefaleia do tipo tensional é a dor de cabeça mais frequente na população. Apresenta-se como uma dor leve à moderada, geralmente em pressão ou aperto, em toda a cabeça, com duração de uma hora até vários dias. É desencadeada principalmente por cansaço e estresse emocional. Já a enxaqueca ou migrânea é uma cefaleia de moderada a forte intensidade, latejante, frequentemente acompanhada de aversão à luz, barulho e cheiros, além de náuseas e vômitos. O reconhecimento do tipo de dor de cabeça e sua abordagem precoce previnem a cronificação do quadro clínico, bem como uma melhora da qualidade de vida dos pacientes acometidos.

Síndrome de Bonnet-Wybur-Mason: dos polos de un espectro / The Bonnet-Wyburn-Mason syndrome: two poles of one spectrum

Se comunican los casos de dos pacientes con síndrome de Bonnet, Wyburn-Mason en quienes existía un aneurisma cirsoide de la retina de diferente grado de desarrollo. En uno, el cuadro oftalmoscópico era obvio; en tanto que en el otro la manisfestación fundamental era una tortuosidad vascular acentuada y en quien solo la angiografía fluoresceínica del fondo ocular mostró sutiles cambios compatibles con una malformación arteriovenosa localizada. Otro elemento inusual en el comportamiento de este tipo de malformaciones fue la asociación a una coartación de la aorta torácica y multiples anomalías esqueléticas sencillas, así como la obstrucción de un segmento muy desarrollado de la malformación arteriovenosa con infarto hemorrágico retiniano e involución posterior de parte de ella

We communicate the cases of two patients with syndrome of Bonnet, Wyburn-Mason who had cirsoide aneurysms of the retina of differnt degrees of development. In one, the ophthalmoscopic picture was obvious, while on the other, The primary manifestation was a marked vascular tortuosity and in which only the ocular fundus fluorescein angiography showed subtle changes consistent with a located arteriovenous malformation. Another unusual element in the behavior of this type of malformations was a coarctation of the thoracic aorta and multiple skeletal anomalies simple associated, as well as the obstruction of a highly developed portion of the retinal arteriovenous malformation with hemorrhagic infarction and consecutive involution of part of it