Neurological sciences : official journal of the Italian Neurological Society and of the Italian Society of Clinical Neurophysiology
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Multicenter Study
Does headache represent a clinical marker in early diagnosis of cerebral venous thrombosis? A prospective multicentric study.
The main aim of this study is to look for early clinical markers of cerebral venous thrombosis (CVT). As headache represents the major clinical manifestation at presentation we focused our attention on this symptom. We present the preliminary results of a prospective multicentric study that includes cases diagnosed as CVT in the participating centres. ⋯ The onset of pain was mostly acute-subacute (38.5%-50.0%) and the intensity moderate-severe (37.0%-51.9%). On univariate analysis, we found a positive correlation between CVT, acute headache onset (p=0.001) and severe headache (p=0.004). These preliminary results seem in accordance with our previous findings in the retrospective study, suggesting that CVT is more often associated with acute-onset headache of severe intensity.
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Patients with subarachnoid haemorrhage (SAH) frequently describe the occurrence of an underestimated or even ignored severe headache in the days or weeks preceding the bleeding. If recognised early, this warning headache might lead to specific investigations and, if indicated, a surgical approach might avoid a dramatic haemorrhagic event. In a recent and exhaustive systematic review, the incidence of a sentinel headache (SH) was evaluated in a range of 10-43% of SAH patients. ⋯ Nevertheless, a warning headache can precede a SAH in unruptured aneurysm even without a minor bleeding. Underestimation or misdiagnosis of SH depends on incorrect evaluation of the headache characteristics (unusual, severe, abrupt, thunderclap), overestimation of cranial CT sensitivity (false negative increasing over the elapsing time), failure to perform lumbar puncture (LP) in patients with negative CT, incorrect evaluation of CSF findings (xanthochromia may be absent in the first 12 h) and failure to differentiate traumatic tap from true SAH. Considering the diagnosis of SH in all cases of a severe, sudden-onset (thunderclap) headache, and performing all the appropriate diagnostic exams, including LP if necessary, could prevent subsequent massive bleeding and its invalidating or fatal consequences.
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Patients with chronic migraine and medication overuse are particularly difficult to treat. No clear consensus exists about treatment strategies to be used and little data exists about the functional impact of headache in these patients. The purpose of the study was to determine (1) the clinical course of a sample of chronic migraine patients with medication overuse 36 months following treatment intervention and (2) whether functional impairment, assessed by the Migraine Disability Assessment (MIDAS) questionnaire, improved upon treatment. ⋯ However, notable improvement both in headache parameters and in disability measures occurred concurrently with treatment. This suggests that successful treatment has more wide-ranging positive benefits beyond mere symptom reduction. To our knowledge, this is the first investigation where the MIDAS questionnaire has been used as an outcome measure in patients with chronic headache to assess disability during such a long follow-up period.
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The International Classification of Headache Disorders 2nd Edition (ICHD-II), published in 2004, marks an unquestionable progress from the preceding 1988 edition, but the in-depth analysis it offers is not immune from drawbacks and shortcomings. First of all, it is still basically a classification of attacks and not of syndromes. For the migraine group, while the revised classification more accurately characterises migraine with aura, it fails to provide a sufficiently structured description of those forms of migraine without aura that over the years evolve to so-called daily chronic forms. ⋯ The inclusion of short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) in the cluster headache group is bound to generate some perplexity, while the recognition of new daily persistent headache (NDPH) included in the group of other primary headaches as a separate clinical entity appears somewhat premature. Doubts are also raised by the actual existence of triptan-overuse headache, which ICHD-II includes in Group 8 among medication-overuse headaches. Finally, the addition of headache attributed to psychiatric disorder, which is certainly a good option in perspective, is not yet supported by an adequate systematisation.
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The strictly unilateral headaches, more commonly known as trigeminal autonomic cephalalgias (TACs), are characterised by severe, strictly unilateral pain in the territory of the distribution of the trigeminal nerve, associated with autonomic manifestations. The recent International Headache Society classification lists the strictly unilateral headaches as cluster headache (CH), episodic and chronic paroxysmal hemicrania, and short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing. ⋯ Convincing proposals for pathophysiologic mechanisms must explain the trigeminal distribution of the pain, the homolateral autonomic manifestations; and, for CH, the usually periodic recurrence of the crises and clusters. With regard to CH, (i) the pain is always located periorbitally-frontally, implicating nociceptive mechanisms involving the trigeminal nerve; (ii) the autonomic manifestations homolateral to the pain seem to be both parasympathetic (lacrimation and rhinorrhoea) and sympathetic (ptosis and miosis); and (iii) the periodicity of the attacks and seasonal recurrence of the cluster periods suggest involvement of a biological clock within hypothalamus.