Fasting headache: a review of the literature and new hypotheses.

Headache is a common disorder in the general population. It is often highly debilitating for the people affected and highly costly to society. Although we know much about primary headaches, little is known about secondary headaches which, however,are a frequent occurrence in the general population. A study conducted on Denmark's general population found a lifetime prevalence rate of 22% for headache forms attributed to disorder of homeostasis, including fasting headache.The purpose of this review was to analyze literature data on fasting headache, in order to evaluate its possible pathophysiological mechanisms and to suggest therapeutic strategies.We considered only English-language articles published in scientific journals and searched for these articles on PubMed using "headache," "fasting," "Yom Kippur," "Ramadan," "hypoglycemia,"and "caffeine withdrawal" as key words, with no limitations to the year of publication. In most cases, fasting headache has the same clinical features as tension-type headache and the probability of onset increases directly with the duration of fasting.Hypoglycemia and caffeine withdrawal have been especially implicated as causative factors, but much remains to be understood about this topic.

Cardiac cephalgia.

The purpose of this review was to provide a critical evaluation of medical literature on so-called "cardiac cephalgia" or "cardiac cephalalgia". The 2004 International Classification of Headache Disorders codes cardiac cephalgia to 10.6 in the group of secondary headaches attributed to disorder of homoeostasis. This headache is hardly recognizable and is associated to an ischaemic cardiovascular event, of which it may be the only manifestation in 27% of cases. It usually occurs after exertion. Sometimes routine examinations, cardiac enzymes, ECG and even exercise stress test prove negative. In such cases, only a coronary angiogram can provide sufficient evidence for diagnosis. Cardiac cephalgia manifests itself without a specific pattern of clinical features: indeed, in this headache subtype there is a high variability of clinical manifestations between different patients and also within the same patient. It "mimics" sometimes a form of migraine either accompanied or not by autonomic symptoms, sometimes a form of tension-type headache; on other occasions, it exhibits characteristics that can hardly be interpreted as typical of primary headache. Pain location is highly variable. When the headache occurs as the only manifestation of an acute coronary event, the clues for suspicion are a) older age at onset, b) no past medical history of headache, c) presence of risk factors for vascular disorders and d) onset of headache under stress. Knowledge of cardiac cephalgia is scarce, due to its rare clinical occurrence and to the scant importance given to headache as a symptom concomitantly with an ischaemic cardiac event.

Evaluation of the patterns of diagnostic and therapeutic care for first referrals at the Parma Headache Centre.

BACKGROUND AND AIM OF THE WORK: To evaluate the patterns of care for patients referred for the first time to a Headache Centre. METHODS: A semistructured questionnaire was administered to all patients consecutively referred for the first visit to the Parma Headache Centre between 15 March and 28 September 2006. RESULTS: The study included 202 patients, 55 men (27.2%) and 147 women (72.8%), mean age 40.6 years (41.8 for men and 40.2 for women). In 146 patients (72.3%), no diagnosis was made before. In the 56 patients (27.7%) with a prior diagnosis, there was concordance only in 16 cases (28.6%). The most common reason to get treatment at the Centre was having a specialistic opinion(n = 81, 40.1%). Sixty-two patients (30.7%) came for worsening of headache and 50 pts. (24.8%) for recent headache onset. Nine patients (4.4%) came for other reasons. Only in 98 cases (48.5%) the physician's prescription was correct with an explicit "visit at Headache Centre" request. The average waiting time was 191.1 days (range, 0-270). The most prescribed tests were EEGs (33.5%, i.e. 47.2% for men and 44.2% for women) and brain CT-scans (28.7%, i.e. 49% for men and 34.6% for women). Out of the 27 patients already taking tryptans, 25 were found to have migraine and two cluster headache. The prescription of tryptan was correct. Most patients were already taking NSAIDs (n =174, 86.1%). Only one female patient was taking ergot derivatives and antiemetics. CONCLUSIONS: Management of care should be improved to reduce waiting lists and unnecessary tests.

Hemicrania continua evolving from cluster headache responsive to valproic acid.

Hemicrania continua (HC) is a rare type of primary headache characterized by a prompt and enduring response to indomethacin. We describe a patient who suffered from cluster headache evolving into ipsilateral HC, who does not tolerate a long-term indomethacin therapy. The case was complex in terms of diagnosis, associated comorbidity, and choice of treatment; after several trials with different therapeutic regimens, we started the patient on a therapy with valproic acid and obtained an improvement of her HC.