[Headache in the emergency department]. / Kopfschmerz in der Notaufnahme.

Headache is one of the most frequent symptoms leading to visits at the emergency department. Here, we aim at presenting a pragmatic algorithm for headache patients at the emergency department. The basic principle is taking a detailed history of the current headache with a focus on dynamics, phenotype and trigger factors as well as a possible preexisting headache. "Red flags" should be interrogated specifically. Hypotheses of the etiology of the headache should be generated in combination with the clinical examination (vital signs, neurological exam, otorhinolaryngological and ophthalmological exams) and should be tested appropriately with imaging, laboratory, cerebral spinal fluid studies and ultrasound. Secondary headache have to be treated with a causal approach, if necessary also symptomatically. When a secondary headache can be excluded, we recommend aiming for a primary headache diagnosis with subsequent specific therapy. When a headache patient can be discharged, we recommend scheduling a follow-up appointment to understand the development of a secondary headache and its cause. In case of a primary headache, optimizing prophylaxis and acute therapy is important to prevent future emergency department visits.

Evolution of MRI Findings in Patients with Idiopathic Intracranial Hypertension after Venous Sinus Stenting.

BACKGROUND AND PURPOSE: The correlation between imaging findings and clinical status in patients with idiopathic intracranial hypertension is unclear. We aimed to examine the evolution of idiopathic intracranial hypertension-related MR imaging findings in patients treated with venous sinus stent placement. MATERIALS AND METHODS: Thirteen patients with idiopathic intracranial hypertension (median age, 26.9 years) were assessed for changes in the CSF opening pressure, transstenotic pressure gradient, and symptoms after venous sinus stent placement. Optic nerve sheath diameter, posterior globe flattening and/or optic nerve protrusion, empty sella, the Meckel cave, tonsillar ectopia, the ventricles, the occipital emissary vein, and subcutaneous fat were evaluated on MR imaging before and 6 months after venous sinus stent placement. Data are expressed as percentages, medians, or correlation coefficients (r) with P values. RESULTS: Although all patients showed significant reductions of the CSF opening pressure (31 versus 21 cm H2O; P = .005) and transstenotic pressure gradient (22.5 versus 1.5 mm Hg; P = .002) and substantial improvement of clinical symptoms 6 months after venous sinus stent placement, a concomitant reduction was observed only for posterior globe involvement (61.5% versus 15.4%; P = .001), optic nerve sheath diameter (6.8 versus 6.1 mm; P < .001), and subcutaneous neck fat (8.9 versus 7.4 mm; P = .001). Strong correlations were observed between decreasing optic nerve sheath diameters and improving nausea/emesis (right optic nerve sheath diameter, r = 0.592, P = .033; left optic nerve sheath diameter, r = 0.718, P = .006), improvement of posterior globe involvement and decreasing papilledema (r = 0.775, P = .003), and decreasing occipital emissary vein diameter and decreasing headache frequency (r = 0.74, P = .035). Decreasing transstenotic pressure gradient at 6 months strongly correlated with decreasing empty sella (r = 0.625, P = .022) and regressing cerebellar ectopia (r = 0.662, P = .019). CONCLUSIONS: Most imaging findings persist long after normalization of intracranial pressure and clinical improvement. However, MR imaging findings related to the optic nerve may reflect treatment success.

Headache in patients with a meningioma correlates with a bone-invasive growth pattern but not with cytokine expression.

We included 58 patients with meningioma in a prospective study to analyse the prevalence of and risk factors for different types of meningioma-associated headache. Twenty-three patients (40%) had meningioma-associated headache. Of these, the pain was migraine-like in five (22%) and tension-type headache (TTH)-like in 13 (57%). Sixteen of 21 (76%) experienced relief of pain intensity of at least 50% after 18-24 months. Univariate analysis revealed bone-invasive growth pattern (P = 0.007) as a risk factor for headache and intake of antiepileptic drugs (P = 0.04) or large surrounding oedema (P = 0.04) as possible protective parameters. For migraine-like headache, risk factors were a positive history of migraine (P = 0.009) and bone-invasive growth pattern (P = 0.046) and, for TTH-like headache, only bone-invasive growth pattern (P = 0.009). Binary logistic regression analysis added to assess predictability and interaction effects could not identify a single factor predicting the occurrence of headache in the presence of a meningioma (correct prediction in 74% by a model consisting of bone-invasive growth pattern, history of head surgery, intake of antiepileptic drugs, temporal tumour location and moderate and large surrounding oedema). Analysis of 38 tumour specimens could not confirm the hypothesis that the occurrence of headache correlates with the expression magnitude of signal substances known to be present in meningiomas [stroma cell-derived factor 1, interleukin (IL)-1ß, IL-6, vascular endothelial growth factor A] or thought to be relevant to headache/pain pathophysiology [prostaglandin-endoperoxide synthase 2, calcitonin-related polypeptide alpha, nitric oxide synthase (NOS) 1, NOS2A, NOS3, transforming growth factor-alpha, tumour necrosis factor, tachykinin, vasoactive intestinal peptide]. The affection of bone integrity and the expression of molecules thought to be relevant to headache pathophysiology might be important for meningioma-associated headache in predisposed individuals.

Headache syndromes after acoustic neuroma surgery and their implications for quality of life.

The patients of this prospective study were analysed for headache as a sequela of surgery for acoustic neuroma (AN). Thirty-two per cent (30/95) of patients complained about a persisting headache syndrome with a severity of at least 6/10 on the nominal analogue scale 6 months after surgery. The occurrence of headache was significantly correlated with the prospectively evaluated parameters preoperative headache and the number of perioperative complications. Postoperative failure to return to the preoperative level of activity was also associated with the occurrence of headache, but also with the risk of retirement after successful surgery of the AN. Headache is therefore, like postoperative ataxia, dysgeusia and probably facial paresis, an important factor for the overall outcome of patients after AN surgery. Hypacusis is not as important. The symptoms and course of each individual patient were analysed. The attempt to categorize the headaches according to the second edition of the International Classification of Headache Disorders revealed five headache syndromes, the most prevalent being tension-type-like headache (46.7%), followed by neuralgia of the occipital nerve (16.6%), trigeminal neuropathy (16.6%), neuropathy of the intermedian nerve (10.0%) and cervicogenic headache (10.0%). The respective pathophysiological mechanisms are discussed and treatment options based on the clinical picture are presented.

[Migraine recurrence due to intracranial metastasis of a thyroid carcinoma]. / Migränerezidiv durch intrakranielle Metastasierung eines Schilddrüsenkarzinoms.

We report a 57-year-old female with a history of migraine without aura in her early adulthood who complained about new migraine attacks after being free of them for 30 years. As a possible trigger, an intracranial metastasis of a thyroid cancer was found which also caused elevated serum prolactin. The mechanism of a para- or endocrinal effect of the tumour is discussed, showing the relevance of intracranial tumours as a human headache model. The recurrence of a primary headache syndrome after long latency should result in the exclusion of a pathological cause.

[Headache in the elderly]. / Kopfschmerzen im Alter.

Chronic headache is still a frequent problem in old age, affecting about 10% of all women and 5% of all men older than 70 years. The incidence of primary headache decreases with advancing age, while that of secondary headache increases. The clinical characteristics of migraine can also change with age; for example, vegetative symptoms are less prominent, and less intense migrainous pain localized predominantly in the neck is frequently reported. Migraine aura can also be experienced more frequently in isolation, without a headache. Hypnic headache is a rare primary headache syndrome that occurs almost exclusively in the elderly. Most of the secondary headache syndromes that occur more frequently in old age present clinically as tension-type headache. Examples of rather common reasons for secondary headache syndromes in the elderly are intracranial space-occupying lesions, ophthalmological problems and autoimmune diseases such as giant cell arteritis. Elderly patients are especially likely to have a number of illnesses at any one time for which they take various medications each day, so that headaches can also quite often be caused by their medication or by withdrawal of these. As a result of such multimorbidity the homeostasis is disturbed in such patients, leading to various conditions that can entail concomitant headaches (sleep apnoea syndrome, dialysis headache, headache attributed to arterial hypertension or hypothyroidism). Familiar facial neuralgias, such as trigeminal neuralgia or postherpetic neuralgia following manifest herpes zoster affecting the face, become markedly more frequent with age. In general, in the treatment of headaches in the elderly it is essential to pay careful attention to potential interactions with the multiple drugs needed because of other diseases; in addition, the comorbidities themselves have to be taken into account, especially depression, anxiety and cognitive impairment, necessitating multimodal, interdisciplinary therapy plans.

Characteristics of brain tumour-associated headache.

Eighty-five brain tumour patients were examined for further characteristics of brain tumour-associated headache. The overall prevalence of headache in this population was 60%, but headache was the sole symptom in only 2%. Pain was generally dull, of moderate intensity, and not specifically localized. Nearly 40% met the criteria of tension-type headache. An alteration of the pain with the occurrence of the tumour was experienced by 82.5%, implying that the pre-existing and the brain tumour headaches were different. The classic characteristics mentioned in the International Classification of Headache Disorders (worsening in the morning or during coughing) were not found; this might be explained by the patients not having elevated intracranial pressure. Univariate analysis revealed that a positive family history of headache and the presence of meningiomas are risk factors for tumour-associated headache, and the use of beta-blockers is prophylactic. Pre-existing headache was the only risk factor according to logistic regression, suggesting that patients with pre-existing (primary) headache have a greater predisposition to develop secondary headache. Dull headache occurs significantly more often in patients with glioblastoma multiforme, and pulsating headache in patients with meningioma. In our study, only infratentorial tumours were associated with headache location, and predominantly with occipital but rarely frontal pain.