Factors associated with initiation of pharmacological therapy and treatment changes in postural orthostatic tachycardia syndrome.

Purpose: Postural Orthostatic Tachycardia Syndrome (POTS) is a heterogenous disorder of the autonomic nervous system that is often disabling. There are no FDA-approved therapies for the treatment of this condition. While some patients recover with baseline non-pharmacological intervention, others require repeated trials of off-label pharmacological therapies. The reasoning for this variable treatment response is unknown. The purpose of this work is to identify potential factors that are associated with higher odds of starting pharmacotherapy and/or a higher rate of POTS treatment changes. Methods: Chart review of demographic, disease and treatment descriptions, medical history, and tilt table examinations of 322 POTS patients who were diagnosed between 2018 and 2020 at our tertiary care center was completed. We first identified the most significant factors associated with an increased odds of starting pharmacotherapy using variable selection techniques and logistic regression. We then identified the most significant factors associated with changes in POTS treatment strategies using variable selection techniques and negative binomial regression modeling. A significance level of 0.05 was utilized. Results: A total of 752 POTS-specific treatment courses were cataloged, and 429 treatment changes were observed. The most cited reason for a change in management was uncontrolled symptoms. History of migraine headaches, reported fatigue, reported palpitations and a previous POTS diagnosis at an outside institution were found to be associated with a higher odds of starting pharmacotherapy for POTS symptoms (Odds Ratio of 2.40, 1.94, 2.62, 2.08, respectively). History of migraine headaches, reported fatigue, and higher heart rate differences on tilt table examination were found to be associated with an increase in the rate of POTS treatment changes (44, 66, 13% increase in incidence rate, respectively), while reported neck pain was associated with a decrease (27% decrease in incidence rate). Conclusion: Our work identifies important areas of focus in the development of high-quality trials involving both the non-pharmacological and pharmacological treatment of POTS and highlights several characteristics of patients that may be more refractory to both baseline non-pharmacological treatments and current pharmacological treatment strategies.

Presumed Pituitary Apoplexy Resulting in the Spontaneous Resolution of a Pituitary Neuroendocrine Tumor: A Case Report.

Pituitary apoplexy is a result of rapid enlargement of the pituitary, due to episodes of hyperplasia, which outpaces vascular development resulting in ischemia and potential infarction of pituitary tissue. This can present in several different ways from asymptomatic to hormonal deficiencies. Here we present a case of spontaneous reduction of a non-functioning pituitary mass, likely due to apoplexy, in which the mass went from compromising the optic chiasm to complete reduction and relief of the optic chiasm. The infarction happened spontaneously without treatment and complications. This may encourage future conservative management of pituitary tumors, rather than immediate surgical intervention.

Updates on Patent Foramen Ovale (PFO) Closure.

PURPOSE OF REVIEW: Patent foramen ovale (PFO) has been previously linked to left circulation thromboembolism and stroke. This review article aims to discuss the latest evidence, updated societal guidelines, diagnostic algorithms and novel therapeutic devices for PFO closure. RECENT FINDINGS: PFO closure for cryptogenic stroke and systemic embolization is supported by a large body of evidence and has a strong societal recommendation. Limited data are available for platypnea-orthodeoxia syndrome, although closure appears to be beneficial. Current data do not support routine closure for migraines and decompression Illness. Development of heart-brain teams can improve identification of patients most likely to benefit from closure, utilizing a combination of imaging test and risk score algorithms. Multiple novel devices aiming at reducing complications and improving the long-term impact of current available devices are being evaluated. PFO closure has significantly progressed over the last years, with new data supporting its superiority in reducing risk of recurrent embolic stroke in patients with PFO-related stroke. Additional clinical data are required to provide further refinements on patient selection and guidance on treatment of specific subgroups.

A rare variation of the infraorbital nerve, entrapping the infraorbital artery.

Anatomical variations are a common feature of the human anatomy. Variation can explain some pathological conditions and is important to keep them in mind during surgical procedures. The relations between nerves and their adjacent arteries have been proposed to play a role in the generation of peripheral trigger migraines. Close opposition between nerves and arteries can lead to vascular compression of the nerve that triggers episodes of pain. We did a routine dissection of the infratemporal fossa and orbital floor by opening the maxillary sinus. Here we report a case where the infraorbital nerves form a nervous loop entrapping the infraorbital artery in the infraorbital channel. Similar cases of close nervous and arterial apposition are described for the auriculotemporal and occipital nerves. We think that accumulating knowledge of these rare variations could expand our understanding of rare conditions such as primary infraorbital neuralgia.

Recovery After Sport-Related Concussion in Collegiate Athletes With Self-Reported Pre-Injury Migraines.

Pre-injury migraines might be a risk factor for prolonged recovery after sport-related concussion (SRC). We sought to examine whether a pre-injury history of migraines is associated with worse recovery following SRC in collegiate athletes. Data were collected through a prospective concussion surveillance system in 11 National Collegiate Athletic Association (NCAA) Division III college athletic programs between September 2014 and March 2020. Our primary independent variable, pre-injury migraines, were self-reported by the athletes. Between those with and without migraines, the outcomes of days to return-to-learn (RTL) without academic accommodations and return-to-play (RTP) were compared using Mann-Whitney U tests. Each athlete's RTL and RTP status was dichotomized (i.e., returned vs. not returned) at various time points for RTL (i.e., 7/14/21/28 days) and RTP (i.e., 14/21/28/56 days). Chi-squared tests were performed to compare the proportions of RTL and RTP status between groups. Multivariable regressions analyzed potential predictors of RTL and RTP adjusting for age, gender, prior concussions, other health conditions, and symptom severity. Of 1409 athletes with an SRC, 111 (7.9%) had a pre-injury history of migraines. Compared with those without migraines, those with migraines had longer median (interquartile range [IQR]) days to RTL (migraines = 7.0 [3.0-12.3] vs. no migraines = 5.0 [2.0-10.0], U = 53,590.5, p = 0.022). No differences were found in RTP between the two groups (migraines = 16.0 [10.0-33.0] vs. nχo migraines 15.0 [11.0-23.0], U = 38,545.0, p = 0.408). Regarding RTL, significantly lower proportions of athletes in the migraine group had fully RTL, without accommodations, at ≤14 days (77.5% vs. 85.2%, χ2 = 4.33, p = 0.037), ≤21 days (85.3% vs. 93.0%, χ2 = 7.99, p = 0.005), and ≤28 days (88.2% vs. 95.6%, χ2 = 10.60, p = 0.001). Regarding RTP, a significantly lower proportion of athletes in the migraine group RTP at ≤28 days (72.0% vs. 82.7%, χ2 = 5.40, p = 0.020) and ≤56 days (84.0% vs. 93.0%, χ2 = 8.19, p = 0.004). In a multivariable model predicting RTL that was adjusted for age, gender, acute concussion symptoms, and other health variables (e.g., attention-deficit/hyperactivity disorder [ADHD], history of mental health difficulties), pre-injury history of migraine was associated with longer RTL (ß = 0.06, p = 0.030). In a multivariable model predicting RTP, pre-injury history of migraine was not associated with RTP (ß = 0.04, p = 0.192). In collegiate athletes, pre-injury migraine history was independently associated with longer RTL but not RTP. When comparing the proportions of those with successful RTP by days, significantly lower proportions of those with migraines showed successful RTP at ≤28 days and ≤56 days. Futures studies should study the generalizability of our findings in other school levels.

Chronic Migraine May Be Associated With Postprandial Hypoglycemia in Adult Men: A Case Series.

Migraine is a common neurological disorder that significantly impacts patients around the world. In the United States, one in six individuals suffers from a migraine disorder. Despite its high prevalence, the etiology of migraine is not well understood. Multiple factors likely contribute to the development of both acute and chronic migraine, making the consensus as to the cause and treatment difficult. Presented here are three case studies involving adult males suffering from chronic migraine. Each subject provided a medical history and underwent physical, psychological, and neurological examinations. In addition, relevant bloodwork and cervical spine X-rays were obtained. Physical examination, laboratory studies, imaging, and psychological metrics were unremarkable with the notable exception of the three-hour oral glucose tolerance tests. All three patients displayed hypoglycemia at three hours. Furthermore, their symptoms markedly improved with the initiation of a ketogenic diet. These data are suggestive of a potential link between postprandial hypoglycemia and chronic migraine. Despite the small sample size, we feel that this report presents possible evidence for a connection between postprandial hypoglycemia and chronic migraine. Furthermore, properly controlled studies of larger sample sizes are required, but we suggest that clinicians consider screening patients for this easily overlooked metabolic disturbance, especially in the absence of other options.

Management of post blood patch severe rebound intracranial hypertension by the usage of an external ventricular drain.

Spontaneous intracranial hypotension (SIH) is a condition characterised by postural headaches due to low cerebrospinal fluid (CSF) pressure, often stemming from CSF leakage. Diagnosis poses a significant challenge, and the therapeutic approach encompasses both conservative measures and operative interventions, such as the epidural blood patch (EBP). However, EBP carries the potential risk of inducing rebound intracranial hypertension (RIH), subsequently leading to high-pressure headaches. We present a case wherein RIH following EBP was effectively managed through the implementation of an external ventricular drain (EVD) aimed at reducing CSF pressure. The patient improved significantly, underscoring the potential utility, if not necessity, of EVD in carefully selected cases, highlighting the imperative for further research to enhance the management of SIH and optimise EBP-related complications.

Triad of cluster-like headaches, hypertension and hypercoagulability a pointer to pheochromocytoma.

We report the case of a middle-aged hypertensive woman presenting to the neurology department with short-lasting episodic headaches for 4 years. She was initially diagnosed and treated with cluster headaches for one year. Following this, she presented with right lower limb arterial claudication. Arterial Doppler of lower limbs showed thrombosis of the bilateral common femoral arteries. Further computed tomography (CT) angiogram of the lower limbs confirmed extensive arterial thrombosis in bilateral lower limbs. The CT angiogram incidentally detected a left adrenal lesion. She had elevated urinary vanillylmandelic Acid and 24-hour metanephrines suggesting the presence of a pheochromocytoma. She was initially medically managed and later underwent left open adrenalectomy. Histopathology examination of the sections proved pheochromocytoma. Postsurgery, the patient's symptoms improved remarkably. This case highlights the importance of diagnosing pheochromocytoma when you encounter a patient with refractory short-lasting headaches, hypertension and hypercoagulability.

sEMG Biofeedback for Episodic Migraines: A Pilot Randomized Clinical Trial.

The aim of this study was to assess the feasibility and potential effectiveness of a 6-week virtual sEMG biofeedback intervention for patients with episodic migraines. Patients with episodic migraines were randomized to treatment with a novel surface EMG (sEMG) at-home biofeedback device or a treatment as usual control group; they completed validated baseline and post-intervention assessments of migraine related disability (migraine-specific quality of life, anxiety and depression). Participants also underwent a series of Quantitative Sensory Testing (QST) procedures referring to several different tests that quantitatively assess responses to mechanical stimuli during two separate visits (baseline and post intervention). No adverse events were reported during the study. Compared to the treatment as usual comparison group, patients in the sEMG biofeedback group reported lower migraine disability (p < 0.05). Compared to baseline, participants in the sEMG biofeedback group demonstrated statistically significant reductions in anxiety (p < 0.01), and significant increases in quality of life (p < 0.001), and significant decreases in temporal summation (p < 0.05) assessed by QST. No significant changes were observed in any of the outcomes in the control comparison group (p > 0.05). No significant changes were observed in migraine frequency in either of the two groups (p > 0.05). In addition, mediation analyses revealed that changes in migraine related quality of life mediated group effects on changes in migraine disability. Virtual sEMG biofeedback shows promise as a potential therapy for reducing disability, anxiety and depression and improving quality of life in individuals with episodic migraines. These results demonstrate the feasibility of a digital intervention for migraines and set the basis for conducting a future, larger scale randomized controlled trial to confirm these preliminary findings.

Medication-overuse headache overlapping with serotonin syndrome.

Serotonin syndrome (SS) is an iatrogenic, drug-induced clinical syndrome caused by an increase in the intrasynaptic concentration of serotonin. Serotonin plays a significant role in the pathophysiology of migraines. Upregulation of 5-HT2A receptors is found in medication-overuse headache (MOH). Several migraine medications, both preventative and abortive drugs, act on serotonin receptors. We report two patients with chronic migraine who developed MOH. Besides headache, patients had frequent attacks of dizziness, restlessness, irritability, insomnia, excessive sweating, abdominal discomforts and tremors. These symptoms were suggestive of withdrawal headache. However, on physical examinations, we elicited hyperreflexia, hypertonia, clonus, tachycardia, hypertension, mydriasis and hyperactive bowel sound. Both patients also met the criteria for SS. Cyproheptadine was started. All features, including headaches, got better after cyproheptadine administration within 24 hours. In 7 days, there was practically total improvement. Both patients continued to take cyproheptadine as a preventative medicine, and migraine frequency was under control.

Minimally invasive nerve and artery sparing surgical approach for temporal migraines.

Background: Temporal migraines (TM) present with throbbing, pulsating headaches in the temporal area. Different surgical techniques ranging from resecting the auriculotemporal nerve (ATN) and or ligating the superficial temporal artery (STA) have shown similar good results to decrease TM symptoms. No conclusive data supports a specific disease of the STA in TM patients. A minimally invasive technique is proposed to preserve both vascular and nerve structures. Methods: Patients with drug resistant TM were selected and treated with two techniques: nerve sparing and nerve and artery sparing. The study included 57 patients with TM, with an average age of 47.5 years. TM improvement was quantified after at least one year of follow up time. STA biopsies were sent for histological analysis. Results: Forty-two patients underwent nerve-sparing decompression, with a therapeutic success rate of 78.6%, corresponding to 22.1 days with migraine per month decreasing to 6.2. Histological analysis of the STA showed varying degrees of endofibrosis in 75% of the samples. Histological results do not correlate with the intensity of symptoms before or after surgery. Fifteen patients underwent nerve and artery sparing arteriolysis, with an overall therapeutic success rate of 86.6% of which 80% had >90% improvement. The average migraine days dropped from 24 to 2.5 days per month in this group. Conclusion: Minimally invasive nerve sparing approaches are an effective and safe treatment to improve drug resistant TM symptoms. Endofibrosis of the STA was present in 75% of the cases, but it was found to be unrelated to pre-operative symptoms and outcome. Results are promising, but the limited numbers of patients treated with artery and nerve sparing technique needs further investigations.

Varicella-zoster virus vasculopathy in a patient with multiple sclerosis receiving natalizumab.

We present a case of a woman in her 30s with relapsing-remitting multiple sclerosis, treated with natalizumab, who developed ophthalmic varicella zoster virus (VZV) infection, with subsequent vasculopathy causing cerebral ischaemic lesions. She was treated with acyclovir, prednisolone and acetylsalicylic acid and fully recovered. VZV vasculopathy is associated with stroke and immunomodulating treatments may increase the risks of these adverse events. To date, nine VZV-related vasculopathy cases in patients treated with natalizumab have been reported in English literature and are summarised in this paper. Although rare, VZV intracerebral vasculopathy is an important differential diagnosis in patients with unexplained new-onset neurological symptoms after a herpes zoster infection. Treatment guidelines for VZV vasculopathy and for continuing treatment of multiple sclerosis after such an event are currently not established.

Case of infiltrative optic neuropathy with hypertrophic pachymeningitis as a manifestation of en plaque meningioma.

We describe a case of infiltrative optic neuropathy with hypertrophic pachymeningitis noted on MRI of the brain, presenting a diagnostic dilemma with a wide variety of differential diagnoses to consider. Our patient is a middle-aged woman with a 20-year history of migranous-sounding headaches who was incidentally found to have worsening vision in her left eye during a routine driving test visual acuity check. Neurological examination revealed a left grade III relative afferent pupillary defect and a central scotoma with red desaturation. Subsequent MRI of her brain and anterior visual pathway revealed features suggestive of an infiltrative left optic neuropathy with hypertrophic pachymeningitis. An extended workup including diagnostic lumbar puncture and blood tests for possible autoimmune, infective and neoplastic causes proved unyielding. Eventually, an endoscopic transsphenoidal biopsy helped to clinch the diagnosis of a (meningothelial subtype) WHO grade 1 meningioma as the cause of her clinical and radiological presentation.

The physical impact of migraines on female chiropractic patients: A qualitative study.

Background: Migraines are highly prevalent among the female population and have a significant burden on one's quality of life and physical functioning. Aim: The study explored the physical impact and contributory factors of migraines on women and their experience of chiropractic treatment for migraine pain management. Setting: The study was conducted in the eThekwini region of KwaZulu-Natal, South Africa. Methods: The study used a qualitative descriptive design and adopted purposive sampling. The data were collected through 12 semi-structured interviews, between March and September 2021, and analysed using thematic analysis. Results: The first theme that emerged focused on the physical effects of migraines. The second theme related to the factors that contributed to migraines. The third theme that emerged focused on chiropractic treatment for migraines. Conclusion: The majority of the participants experienced chronic migraines and migraines without aura. The participants felt incapacitated and experienced debilitating physical effects with their migraines. The study highlighted that chiropractic treatment was favourable among the female population in improving the quality of life and reducing the severity, disability, duration of suffering and frequency of migraines. It was revealed that chiropractic was the preferred non-pharmacological approach for migraine treatment, as it proved to be a beneficial and effective treatment for migraine pain management. Contribution: The findings contribute to a greater awareness of chiropractic as an effective evidence-based treatment approach for migraine pain management, which may be beneficial to migraineurs and healthcare practitioners.

Facial pain associated with vein of Trolard thrombosis Case report Neurology.

Cerebral venous thrombosis is a rare condition, with identified and described risk factors mainly associated with prothrombotic states, with a wide variety of symptomatology based on the site affected, the most common being intracranial hypertensive syndrome, focal or encephalopathy. Cortical veins of the superficial system are among the least frequently affected veins. The following describes a case of painful facial symptoms progressing to a focal syndrome associated with a history of chronic oral contraceptive use, with thrombosis of vein of Trolard detected and successfully treated with oral anticoagulants.

Paracentral acute middle maculopathy in systemic sclerosis and subsequent branch retinal artery occlusion.

Purpose: We report a case of systemic sclerosis-associated paracentral acute middle maculopathy (PAMM) in a young woman who subsequently developed branch retinal artery occlusion. Observations: A 22-year-old woman presented with a paracentral scotoma. Optical coherence tomography (OCT) revealed bilateral paracentral acute middle maculopathy. Upon systemic examination, she was diagnosed with systemic sclerosis (SSc). She subsequently developed branch retinal artery occlusion despite vasodilator medications. After the prescription of aspirin, she did not experience a new event for one year. Conclusion and importance: This case illustrates that SSc may affect the retinal vascular system and vision and cause PAMM. The optimal prophylaxis for patients with recurrent retinal events should be investigated in future studies.

Heart Break or Headache: A Case Report of Sumatriptan-Induced Takotsubo Syndrome.

Takotsubo syndrome (TS) describes a transient type of dilated cardiomyopathy that mimics acute coronary syndrome (ACS) on initial presentation. Classic TS presents with marked dilation and ballooning of the left ventricular apex with hyperdynamic basal segments. The most frequent etiology is from emotional and stressful triggers; recently, evidence suggests neurologic and psychiatric involvement. There are increasing reports of TS occurring secondary to migraine abortives. We describe a unique case of TS in a woman after taking sumatriptan to abort her headache.

The psychosocial impact of migraines on women and alternative therapies for migraine management.

Background: Migraines are one of the leading causes of disability globally and in South Africa. There is a paucity of local empirical literature regarding the psychosocial impact of migraines on women. Although there are a variety of treatment approaches, many women prefer alternative and holistic treatment for their migraines. Aim: The aim of this study was to explore the psychosocial impact of migraines on women and their use of complementary and alternative therapies for migraine pain management. Setting: The study was conducted in the eThekwini region of KwaZulu-Natal, South Africa. Methods: The study adopted a qualitative descriptive design. Purposive sampling was used to recruit participants for the study. Data were collected through 12 semi-structured interviews and subsequently analysed using thematic analysis. Results: Theme 1 related to the psychological and cognitive effects experienced by the participants. Theme 2 focused on the effects migraines had on personal, family and social relationships. Theme 3 discussed the self-management of migraines. Conclusion: The pertinent psychological effects of migraines were depression, anxiety, feelings of hopelessness and withdrawal, fear-avoidance behaviour, lifestyle changes, and acceptance of migraines. The participants experienced a lack of understanding about their migraine severity from co-workers, family and social networks. The alternative therapies that were sought to alleviate migraine symptoms included chiropractic, massage, meditation, reflexology, yoga, cupping and acupuncture. Contribution: The awareness of the effectiveness of complementary and alternative therapies for women may be beneficial for healthcare providers seeking a multidisciplinary approach to migraine management.

Mathematical Psychiatry: On Cortical Spreading Depression-A Review.

The concept of migraine with aura (MwA) is a widespread condition that can affect up to 30% of migraine patients and manifests itself as a temporary visual illusion followed by a prolonged headache. It was initially pitched as a neurological disease, and observed that the spread of accompanying electrophysiological waves as part of the condition, which came to be known as cortical spreading depression (CSD). A strong theoretical basis for a link between MwA and CSD has eventually led to knowledge of the dynamics between the pair. In addition to experiment-based observations, mathematical models make an important contribution towards a numerical means of expressing codependent neural-scale manifestations. This provides alternate means of understanding and observing the phenomena while helping to visualize the links between the variables and their magnitude in contributing towards the emanation and dynamic pulsing of the condition. A number of biophysical mechanisms are believed to contribute to the MwA-CSD, spanning ion diffusion, ionic currents of membranes, osmosis, spatial buffering, neurotransmission, gap junctions, metabolic pumping, and synapse connections. As part of this review study, the various mathematical models for the description of the condition are expressed, reviewed, and contrasted, all of which vary in their depth, perspective, and level of information presented. Subsequent to this, the review looked into links between electrophysiological data-driven manifestations from measurements such as EEG and fMRI. While concluding remarks forged a structured pathway in the area on sub-themes that need to be investigated in order to strengthen and robustify the existing models, they include an accounting for inter-personal variability in models, sex and hormonal factors, and age groups, i.e., pediatrics vs. adults.