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Boezaart AP, Smith CR, Zasimovich Y, Przkora R, Kumar S, Nin OC, Boezaart LC, Botha DA, Leonard A, Reina MA, Pareja JA. Refractory primary and secondary headache disorders that dramatically responded to combined treatment of ultrasound-guided percutaneous suprazygomatic pterygopalatine ganglion blocks and non-invasive vagus nerve stimulation: a case series. Reg Anesth Pain Med 2024; 49:144-150. [PMID: 37989499 DOI: 10.1136/rapm-2023-104967] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 11/06/2023] [Indexed: 11/23/2023]
Abstract
In 1981, Devoghel achieved an 85.6% success rate in treating patients with treatment-refractory cluster headaches with alcoholization of the pterygopalatine ganglion (PPG) via the percutaneous suprazygomatic approach. Devoghel's study led to the theory that interrupting the parasympathetic pathway by blocking its transduction at the PPG could prevent or treat symptoms related to primary headache disorders (PHDs). Furthermore, non-invasive vagus nerve stimulation (nVNS) has proven to treat PHDs and has been approved by national regulatory bodies to treat, among others, cluster headaches and migraines.In this case series, nine desperate patients who presented with 11 longstanding treatment-refractory primary headache disorders and epidural blood patch-resistant postdural puncture headache (PDPH) received ultrasound-guided percutaneous suprazygomatic pterygopalatine ganglion blocks (PPGB), and seven also received nVNS. The patients were randomly selected and were not part of a research study. They experienced dramatic, immediate, satisfactory, and apparently lasting symptom resolution (at the time of the writing of this report). The report provides the case descriptions, briefly reviews the trigeminovascular and neurogenic inflammatory theories of the pathophysiology, outlines aspects of these PPGB and nVNS interventions, and argues for adopting this treatment regime as a first-line or second-line treatment rather than desperate last-line treatment of PDPH and PHDs.
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Affiliation(s)
- Andre P Boezaart
- Anesthesiology, University of Florida College of Medicine, Gainesville, Florida, USA
- Lumina Health, Surrey, UK
| | - Cameron R Smith
- Anesthesiology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Yury Zasimovich
- Anesthesiology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Rene Przkora
- Anesthesiology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Sanjeev Kumar
- Anesthesiology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Olga C Nin
- Anesthesiology, University of Florida College of Medicine, Gainesville, Florida, USA
| | | | | | - André Leonard
- Private Neurology Practice, Mossel Bay, South Africa
| | - Miguel A Reina
- Anesthesiology, University of Florida College of Medicine, Gainesville, Florida, USA
- Anesthesiology, CEU San Pablo University Faculty of Medicine, Madrid, Spain
| | - Juan A Pareja
- Neurology, Hospital Universitario Quirón Madrid, Madrid, Spain
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2
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Alberola-Amores FJ, Moral-Rubio J. Drug-resistant epicrania fugax: Responding to onabotulinumtoxinA. Headache 2023; 63:839-842. [PMID: 37337680 DOI: 10.1111/head.14532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 04/10/2023] [Accepted: 05/03/2023] [Indexed: 06/21/2023]
Abstract
Epicrania fugax (EF) is a primary headache consisting of brief paroxysms of pain, lasting 1-10 s, that move through different nerve territories of one hemicranium with a linear or zigzag trajectory, although there are some clinical variants. Preventive therapy with anti-seizure medication such as gabapentin and lamotrigine are most commonly used in patients presenting with frequent and non-remitting attacks. In some cases, greater occipital nerve blockades are used for short- or long-term relief. Here, we report two patients with a paroxysmal EF-type pain who meet the criteria for EF of the International Classification of Headache Disorders, 3rd edition, with clear triggers and autonomic ocular signs and who failed multiple preventive treatments, but had a sustained response to onabotulinumtoxinA.
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Affiliation(s)
| | - Jorge Moral-Rubio
- Headache Unit, Department of Neurology, Hospital General Universitario de Elche, Elche, Spain
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3
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Abstract
BACKGROUND Nummular headache and epicrania fugax are two primary headaches that fall under the heading of epicranial headaches. METHODS This article reviews the epidemiological and clinical features of nummular headache and epicrania fugax, proposed pathogenic mechanisms and state-of-the-art management, according to the literature. RESULTS AND CONCLUSIONS Nummular headache and epicrania fugax are generally viewed as rare headache disorders, but no population-based epidemiological data are available. Nummular headache is characterized by continuous or intermittent head pain, which remains circumscribed in a round or oval area of the scalp, typically one to six centimeters in diameter. Epicrania fugax manifests with brief paroxysms of pain that move along the surface of the head, following a linear or zigzag trajectory through different nerve territories. Nummular headache and epicrania fugax are mostly primary headaches, but some secondary cases have been reported. The pathogenesis of these headaches is not fully understood. Nummular headache could probably originate in epicranial tissues or adjacent intracranial structures, while the origin of epicrania fugax could be extracranial or intracranial. Diagnostic assessment requires careful examination of the symptomatic areas. Underlying disorders should be excluded by additional investigations, including neuroimaging and appropriate blood tests. No controlled clinical trials have been conducted in nummular headache or epicrania fugax. Analgesics and anti-inflammatory drugs, botulinum toxin and gabapentin are currently the most recommended treatment options for nummular headache. In epicrania fugax, the most used treatments are gabapentin, lamotrigine, and other antiseizure medications.
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Affiliation(s)
- María-Luz Cuadrado
- Headache Unit, Department of Neurology, Instituto de Investigación Sanitaria San Carlos, Hospital Clínico San Carlos, Madrid, Spain.,Department of Medicine, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
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4
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Raieli V, Reina F, D’Agnano D, Nocera GM, Capizzi M, Marchese F, Sciruicchio V. The Pediatric Trochlear Migraine: Diagnostic and Therapeutic Implications. J Clin Med 2022; 11:2826. [PMID: 35628950 PMCID: PMC9142906 DOI: 10.3390/jcm11102826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Revised: 05/02/2022] [Accepted: 05/16/2022] [Indexed: 11/16/2022] Open
Abstract
Trochlear Migraine has been recently described as the concurrence of strictly unilateral migraine and ipsilateral trochleodynia with relief of migraine after successful treatment of trochleodynia. This disorder has been interpreted as "cluster-tic syndrome" or "seizure-triggered migraine". Trochlear Migraine is unrecognized and rarely described in childhood. The aim of this study is to review the few cases of Trochlear Migraine reported in the literature in addition to the cases observed in our clinical experience. In particular, our cases showed recurrent attacks of severe and pulsating headache associated with nausea, vomiting, phonophobia, photophobia, and strict trochlear localization of pain. They often presented with alternating side attacks. Therefore, we suggest that the term "Trochlear Migraine" should be reserved for clinical migraine attacks strictly localized in the trochlear region, and we assume that the excessive increase in descriptions of new primary headache syndromes, according to the International Classification of Headache Disorders, can be probably be ascribed to the common physiopathological mechanisms characterizing these forms of migraine.
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Affiliation(s)
- Vincenzo Raieli
- Child Neuropsychiatry Unit ISMEP, ARNAS Civico, 90134 Palermo, Italy;
| | - Federica Reina
- Child Neuropsychiatry School, University of Palermo, 90128 Palermo, Italy; (F.R.); (G.M.N.); (M.C.)
| | - Daniela D’Agnano
- Children Epilepsy and EEG Center, PO, San Paolo ASL, 70132 Bari, Italy; (D.D.); (V.S.)
| | - Giovanna Martina Nocera
- Child Neuropsychiatry School, University of Palermo, 90128 Palermo, Italy; (F.R.); (G.M.N.); (M.C.)
| | - Mariarita Capizzi
- Child Neuropsychiatry School, University of Palermo, 90128 Palermo, Italy; (F.R.); (G.M.N.); (M.C.)
| | | | - Vittorio Sciruicchio
- Children Epilepsy and EEG Center, PO, San Paolo ASL, 70132 Bari, Italy; (D.D.); (V.S.)
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5
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Zhou S, Badash I, Doherty JK. Nummular and Side-locked Headaches for the Otolaryngologist. Otolaryngol Clin North Am 2022; 55:697-706. [PMID: 35490038 DOI: 10.1016/j.otc.2022.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Side-locked headaches are a common symptom having a wide-ranging differential. Unchanging in laterality, these headaches can represent neuralgias, trigeminal autonomic cephalgias, ophthalmologic disorders, otolaryngologic and craniofacial disorders, vascular disorders, and malignancy. In rarer situations, they have presented secondary to neurosurgical or dermatologic considerations. Loss of cranial nerves and visual changes warrant additional evaluation.
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Affiliation(s)
- Sheng Zhou
- LAC+USC Medical Center Otolaryngology Department, 1200 North State Street, Suite A2E, Los Angeles, CA 90033, USA.
| | - Ido Badash
- LAC+USC Medical Center Otolaryngology Department, 1200 North State Street, Suite A2E, Los Angeles, CA 90033, USA
| | - Joni K Doherty
- USC Caruso Department of Otolaryngology Head and Neck Surgery, 1450 San Pablo Street #5100, Los Angeles, CA 90033, USA
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6
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Cuadrado ML, González-García N, Porta-Etessam J. Epicrania fugax originating from a surgical scar of the scalp. Pain Pract 2022; 22:600-601. [PMID: 35313072 DOI: 10.1111/papr.13109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 03/14/2022] [Indexed: 11/27/2022]
Affiliation(s)
- María-Luz Cuadrado
- Headache Unit, Department of Neurology, Hospital Clínico San Carlos, Madrid, Spain.,Department of Medicine, School of Medicine, Universidad Complutense, Madrid, Spain
| | | | - Jesús Porta-Etessam
- Headache Unit, Department of Neurology, Hospital Clínico San Carlos, Madrid, Spain.,Department of Medicine, School of Medicine, Universidad Complutense, Madrid, Spain
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7
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Chavarría-Miranda A, Guerrero ÁL, Talavera B, Martínez-Pías E, Trigo-López J, Sierra Á, García-Azorín D. Linear Headache: A Novel Entity or a Variant of Nummular Headache? Clinical Characteristics and Treatment Response in a Series of 16 Patients. PAIN MEDICINE 2021; 22:1158-1166. [PMID: 33723599 DOI: 10.1093/pm/pnaa436] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Linear headache has been recently described as an episodic or chronic unilateral pain distributed along a fixed linear trajectory, which combines some characteristics of epicrania fugax and nummular headache. The aim of this study was to describe the clinical characteristics and therapeutic response of a series of 16 new patients. DESIGN This is an observational study with a series of cases. SETTING The study period encompassed June 2014 to June 2019. Demographic, clinical, and therapeutic response data were recorded. METHODS We included all consecutive patients who presented pain with the following characteristics: sharply contoured, fixed in size and shape, with linear shape, without movement along a trajectory, and not circumscribed to the territory of any nerve. RESULTS Twelve patients were women, and four were men. The mean age at onset was 40.1 years. Pain was described as pressing in seven patients, burning in five, and electric or stabbing in two each. Symptomatic treatment had been used by 13 patients (81.2%), with analgesics being the most frequent treatment used. Thirteen patients received preventive treatment. The response to oral medications and anesthetic blockade was insufficient. OnabotulinumtoxinA was used in six cases, with an optimal (>75%) response observed in half. CONCLUSION Linear headache appears to be a distinct headache syndrome from epicrania fugax or nummular headache. Preventive treatment is often required. The drug with the best response was onabotulinumtoxinA.
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Affiliation(s)
- Alba Chavarría-Miranda
- Headache Unit, Neurology Department, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Ángel L Guerrero
- Headache Unit, Neurology Department, Hospital Clínico Universitario de Valladolid, Valladolid, Spain.,Institute for Biomedical Research of Salamanca (IBSAL), Salamanca, Spain.,Department of Medicine, University of Valladolid, Valladolid, Spain
| | - Blanca Talavera
- Headache Unit, Neurology Department, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Enrique Martínez-Pías
- Headache Unit, Neurology Department, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Javier Trigo-López
- Headache Unit, Neurology Department, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Álvaro Sierra
- Headache Unit, Neurology Department, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - David García-Azorín
- Headache Unit, Neurology Department, Hospital Clínico Universitario de Valladolid, Valladolid, Spain.,Institute for Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
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8
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Thomas DC, Heir GM, Patil AG, Soni PK. Nummular Headache - a Case Report of a Rare Entity. Curr Pain Headache Rep 2020; 24:71. [PMID: 33047184 DOI: 10.1007/s11916-020-00901-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/10/2020] [Indexed: 01/11/2023]
Abstract
PURPOSE OF REVIEW The purpose of this manuscript is to shed light on systematic work-up of a diagnostic challenge such as nummular headache (NH), and to summarize the relevant literature on NH. RECENT FINDINGS The specific nature of the shape of the pain site is usually characteristic of NH. Multiple modalities of investigation including succinct imaging are necessary to successfully rule out other similar conditions. A 26-year-old female patient of Asian-Indian origin presented to the clinic with the chief complaint of chronic persistent left parietal headache for more than 10 years, which has been worsening over the past few days with no specific identifiable trigger. The diagnosis of nummular headache is challenging and confusing due to the rare occurrence and inadequate references in the literature. Appropriate imaging was done, which revealed no pathology that could explain the headache presentation. These findings are consistent with our diagnosis of nummular headache, and helped in the successful management of the case.
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Affiliation(s)
- Davis C Thomas
- Center for TMD and Orofacial Pain, Rutgers School of Dental Medicine, Newark, NJ, USA.
| | - Gary M Heir
- Center for TMD and Orofacial Pain, Rutgers School of Dental Medicine, Newark, NJ, USA
| | - Amey G Patil
- Department of Restorative Dentistry and Department of Diagnostic Sciences, Center for TMD and Orofacial Pain, Rutgers School of Dental Medicine, Newark, NJ, USA
| | - Prutha K Soni
- Center for TMD and Orofacial Pain, Rutgers School of Dental Medicine, Newark, NJ, USA
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9
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Gutiérrez-Sánchez M, García-Azorín D, Gutiérrez-Viedma Á, González-García N, Horga A, Martín S, Guerrero ÁL, Cuadrado ML. Paroxysmal headache with extracephalic irradiation: Proposal for a new variant of epicrania fugax in a series of five patients. Cephalalgia 2020; 40:959-965. [DOI: 10.1177/0333102420920646] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Epicrania fugax consists of brief paroxysms of pain, which radiate in a line or in zigzag trajectory across the surface of the scalp or the face. Methods A prospective, descriptive study was performed in five patients presenting with an epicrania fugax-type pain with extracephalic irradiation. Results All patients were women, and the mean age at onset was 59.8 (standard deviation, 10.9). They had unilateral paroxysms of electrical pain starting at a particular point in the head (parietal, n = 3; vertex, n = 1; frontal, n = 1) and rapidly radiating downwards in a lineal trajectory to reach extracephalic regions (ipsilateral limbs, n = 2; shoulder, n = 2; low neck, n = 1) in 1–3 seconds. Pain intensity was moderate or severe. Three patients had nummular headache at the point where the paroxysms originated. One patient had spontaneous remission, and four patients achieved complete or almost complete response with therapy (onabotulinumtoxinA, n = 2; indomethacin, n = 1; amitriptyline, n = 1; lamotrigine, n = 1). Conclusion The spectrum of epicrania fugax may include paroxysms with extracephalic irradiation. The propagation of pain beyond the head and the face supports the involvement of central mechanisms in the pathophysiology of this entity.
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Affiliation(s)
- María Gutiérrez-Sánchez
- Headache Unit, Neurology Department, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - David García-Azorín
- Headache Unit, Neurology Department, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Álvaro Gutiérrez-Viedma
- Neurology Department, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria San Carlos (IdISSC), Madrid, Spain
| | - Nuria González-García
- Neurology Department, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria San Carlos (IdISSC), Madrid, Spain
| | - Alejandro Horga
- Neurology Department, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria San Carlos (IdISSC), Madrid, Spain
| | - Susana Martín
- Neurophysiology Department, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria San Carlos (IdISSC), Madrid, Spain
| | - Ángel L Guerrero
- Headache Unit, Neurology Department, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
- Institute for Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
- Department of Medicine, School of Medicine, Universidad de Valladolid, Valladolid, Spain
| | - María-Luz Cuadrado
- Neurology Department, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria San Carlos (IdISSC), Madrid, Spain
- Department of Medicine, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
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10
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Gómez‐Mayordomo V, García‐Sáez R, Gallego‐Gallego M, González‐García N, Cuadrado ML. Cranial and Facial Epicrania Fugax: Combination of Both Clinical Pictures in the Same Patients. Headache 2020; 60:621-623. [DOI: 10.1111/head.13755] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Accepted: 12/05/2019] [Indexed: 11/27/2022]
Affiliation(s)
| | - Rafael García‐Sáez
- Headache Unit Department of Neurology Hospital Clínico San Carlos Madrid Spain
| | | | | | - María Luz Cuadrado
- Headache Unit Department of Neurology Hospital Clínico San Carlos Madrid Spain
- Department of Medicine School of Medicine Universidad Complutense Madrid Spain
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11
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García-Azorín D, Dotor García-Soto J, Martínez-Pías E, Guerrero-Peral AL. Epicrania Fugax as the presenting symptom of a cerebellar abscess. Cephalalgia 2019; 39:1200-1203. [DOI: 10.1177/0333102419839793] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Background Epicrania fugax is included in the appendix of the International Classification of Headache Disorders and is characterized as recurrent brief attacks of linear or zigzag pain moving across the cranial surface, commencing and terminating in the distribution of different nerves. We present a new case of epicrania fugax in which the headache was the presenting symptom of a cerebellar abscess. Case report We present a 58-year-old woman with prior history of Chiari I malformation who underwent suboccipital craniectomy. Two weeks after surgery, she experienced paroxysmal pain episodes of 1–3 seconds, with constant linear trajectory from the right occipital surface to the right orbital region, remaining pain free between episodes. Cranial tomography showed a hypodense intraaxial lesion in the right cerebellar hemisphere. Magnetic Resonance Imaging exhibited intralesional bleeding and peripheral enhancement after gadolinium administration. Post-surgical cerebellar abscess was diagnosed and antibiotic therapy was started; the patient underwent urgent surgical drainage. Pain disappeared after the surgery and the patient remains pain free with 12 months of follow-up. Conclusion Posterior fossa abnormalities have been described as a possible cause of secondary epicrania fugax. The presence of red flags should encourage conducting of paraclinical tests to rule out a symptomatic form.
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Affiliation(s)
| | | | | | - Angel L Guerrero-Peral
- Headache Unit, University Hospital of Valladolid, Valladolid, Spain
- Institute of Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
- Department of Medicine, University of Valladolid, Valladolid, Spain
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12
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Rammohan K, Shyma MM, Das S, Shaji CV. Clinical Features and Psychiatric Comorbidity of Epicrania Fugax. J Neurosci Rural Pract 2018; 9:143-148. [PMID: 29456360 PMCID: PMC5812141 DOI: 10.4103/jnrp.jnrp_304_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Background: Epicrania fugax (EF) is a rare newly described primary headache characterized by paroxysms of unilateral pain radiating across one hemicranium. Aim: We aimed to describe 10 new cases of EF and assess the psychiatric comorbidity. Materials and Methods: Cases of EF were identified from patients attending the neurology outpatient department of a tertiary level referral and teaching hospital by the first author during a period extending from January 1, 2015 to April 31, 2017. Case ascertainment was done as per ICHD 3 beta criteria from among patients presenting with complaints of headache after detailed history and clinical examination. Clinical and demographic features were noted and patients were subjected to Mini Neuropsychiatric Interview to screen for psychiatric comorbidity followed by Becks Anxiety/Depression Inventory. Results: A total of 10 subjects were obtained during the study period, 4 males, and 6 females. Mean age of subjects was 45.3 years (standard deviation-10). Seventy percent had anteroposterior, and 30% had posteroanterior radiation of pain. The most common character of pain was stabbing (50%) followed by electrical (40%) and pressing (10%). None of the subjects had autonomic symptoms or focal symptoms in the scalp while 30% subjects had hyperesthesia in the affected area of the scalp. Six subjects (60%) patients had episodic course while 40% had chronic course. Sixty percent had comorbid anxiety while one (10%) had comorbid depression. A significant relation was obtained between duration of disease and occurrence of anxiety as well as Becks Anxiety Inventory scores while there was no correlation with attack duration. There was also a nonsignificant correlation between visual analog score and occurrence of anxiety symptoms. Conclusions: Our study conclusively proves the existence of EF as a rare, distinct primary headache syndrome in our study population. It has a significant psychiatric comorbidity consisting of 60% of generalized anxiety disorder, 10% of panic attacks, and 10% of depression.
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Affiliation(s)
- K Rammohan
- Department of Neurology, T D MCH, Alappuzha, Kerala, India
| | - M M Shyma
- Department of Neurology, PVS Memorial Hospital, Kochi, Kerala, India
| | - Soumitra Das
- Department of Psychiatry, NIMHANS, Bengaluru, Karnataka, India
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13
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Cuadrado ML, López-Ruiz P, Guerrero ÁL. Nummular headache: an update and future prospects. Expert Rev Neurother 2017; 18:9-19. [DOI: 10.1080/14737175.2018.1401925] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- María Luz Cuadrado
- Department of Neurology, Instituto de Investigación Sanitaria San Carlos (IdISSC), Hospital Clínico San Carlos, Madrid, Spain
- Department of Medicine, School of Medicine, Universidad Complutense de Madrid (UCM), Madrid, Spain
| | - Pedro López-Ruiz
- Department of Neurology, Hospital Universitario Quirón Madrid, Pozuelo de Alarcón, Madrid, Spain
| | - Ángel L Guerrero
- Department of Neurology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
- Department of Medicine, School of Medicine, Universidad de Valladolid (UVA), Valladolid, Spain
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14
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Jaimes A, García-Sáez R, Gutiérrez-Viedma Á, Cuadrado ML. Case report: Wallenberg’s syndrome, a possible cause of symptomatic epicrania fugax. Cephalalgia 2017; 38:1203-1206. [DOI: 10.1177/0333102417726334] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Epicrania fugax has been described as a primary headache. Nevertheless, a symptomatic form was recently found in a patient with a skull base meningioma abutting the trigeminal nerve. Here we report on a patient with facial pain with the features of epicrania fugax occurring after Wallenberg’s syndrome. Case report A 53-year-old man suffered a right-sided dorsolateral medullary ischaemic stroke. Nine months later, he presented with brief electric shock-like paroxysms of pain stemming from the right eye and radiating to the ipsilateral forehead, the temple or the cheek in a zigzag trajectory. Some episodes were accompanied by ipsilateral conjunctival injection and eyelid oedema. Treatment with eslicarbazepine abolished the pain. Conclusion A pain with the features of epicrania fugax may be associated with medullary lesions. This finding suggests that the central trigeminal pathways and/or the spinal trigeminal nucleus may play an important role in the pathophysiology of this type of pain.
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Affiliation(s)
- Alex Jaimes
- Department of Neurology, Hospital Clínico San Carlos, Madrid, Spain
- Department of Neurology, Fundación Jiménez Díaz, Madrid, Spain
| | | | - Álvaro Gutiérrez-Viedma
- Department of Neurology, Hospital Clínico San Carlos, Madrid, Spain
- Department of Medicine, School of Medicine, Universidad Complutense, Madrid, Spain
| | - María-Luz Cuadrado
- Department of Neurology, Hospital Clínico San Carlos, Madrid, Spain
- Department of Medicine, School of Medicine, Universidad Complutense, Madrid, Spain
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15
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Navarrete JJ, Ruiz M, Juanatey A, Barón J, Cuadrado ML, Guerrero AL. The Relationship of Auriculotemporal Neuralgia and Epicrania Fugax. PAIN MEDICINE 2017; 19:635-636. [DOI: 10.1093/pm/pnx158] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- J J Navarrete
- Headache Unit, Neurology Department, Hospital Clínico Universitario, Valladolid, Spain
| | - M Ruiz
- Headache Unit, Neurology Department, Hospital Clínico Universitario, Valladolid, Spain
| | - A Juanatey
- Headache Unit, Neurology Department, Hospital Clínico Universitario, Valladolid, Spain
| | - J Barón
- Headache Unit, Neurology Department, Hospital Clínico Universitario, Valladolid, Spain
| | - M L Cuadrado
- Headache Unit, Neurology Department, Hospital Clínico Universitario San Carlos, Madrid, Spain
| | - A L Guerrero
- Headache Unit, Neurology Department, Hospital Clínico Universitario, Valladolid, Spain
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Barón-Sánchez J, Gutiérrez-Viedma Á, Ruiz-Piñero M, Pérez-Pérez A, Guerrero ÁL, Cuadrado ML. Epicrania fugax combining forward and backward paroxysms in the same patient: the first four cases. J Pain Res 2017; 10:1453-1456. [PMID: 28721087 PMCID: PMC5499947 DOI: 10.2147/jpr.s135810] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Background The first description of epicrania fugax (EF) reported brief painful paroxysms that start in posterior regions of the scalp and move forward to reach the ipsilateral forehead, eye, or nose. A backward variation, wherein pain stems from frontal areas and radiates to the posterior scalp, has also been acknowledged. We report four patients with features reminiscent of EF and the coexistence of forward and backward pain paroxysms. Methods We considered all patients attending the headache outpatient office at two tertiary hospitals from March 2008 to March 2016. We enrolled four patients with paroxysms fulfilling criteria for EF and a combination of forward and backward radiations. Results In all cases, pain paroxysms moved both in forward and backward directions with either a zigzag (n=2) or linear (n=2) trajectory. Three patients presented two stemming points, in the occipital scalp and forehead (n=2) or in the parietal area and eye (n=1), whereas the fourth patient only had a stemming point located in the parietal region. Pain quality was mainly stabbing, and its intensity was moderate (n=1) or severe (n=3). The duration of the paroxysms was highly variable (3–30 seconds), and two patients reported autonomic symptoms. Conclusion The clinical picture presented by our patients does not fit with other types of known headache or neuralgia syndromes; we propose it corresponds to a bidirectional variant of EF.
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Affiliation(s)
- Johanna Barón-Sánchez
- Headache Unit, Department of Neurology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | | | - Marina Ruiz-Piñero
- Headache Unit, Department of Neurology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | | | - Ángel Luis Guerrero
- Headache Unit, Department of Neurology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain.,Department of Medicine, School of Medicine, Universidad de Valladolid, Valladolid, Spain
| | - María L Cuadrado
- Department of Neurology, Hospital Clínico San Carlos, Madrid, Spain.,Department of Medicine, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
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Abstract
Ocular or eye pain is a frequent complaint encountered not only by eye care providers but neurologists. Isolated eye pain is non-specific and non-localizing; therefore, it poses significant differential diagnostic problems. A wide range of neurologic and ophthalmic disorders may cause pain in, around, or behind the eye. These include ocular and orbital diseases and primary and secondary headaches. In patients presenting with an isolated and chronic eye pain, neuroimaging is usually normal. However, at the beginning of a disease process or in low-grade disease, the eye may appear "quiet," misleading a provider lacking familiarity with underlying disorders and high index of clinical suspicion. Delayed diagnosis of some neuro-ophthalmic causes of eye pain could result in significant neurologic and ophthalmic morbidity, conceivably even mortality. This article reviews some recent advances in imaging of the eye, the orbit, and the brain, as well as research in which neuroimaging has advanced the discovery of the underlying pathophysiology and the complex differential diagnosis of eye pain.
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Prakash S, Rathore C. Side-locked headaches: an algorithm-based approach. J Headache Pain 2016; 17:95. [PMID: 27770404 PMCID: PMC5074931 DOI: 10.1186/s10194-016-0687-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 10/04/2016] [Indexed: 01/03/2023] Open
Abstract
The differential diagnosis of strictly unilateral hemicranial pain includes a large number of primary and secondary headaches and cranial neuropathies. It may arise from both intracranial and extracranial structures such as cranium, neck, vessels, eyes, ears, nose, sinuses, teeth, mouth, and the other facial or cervical structure. Available data suggest that about two-third patients with side-locked headache visiting neurology or headache clinics have primary headaches. Other one-third will have either secondary headaches or neuralgias. Many of these hemicranial pain syndromes have overlapping presentations. Primary headache disorders may spread to involve the face and / or neck. Even various intracranial and extracranial pathologies may have similar overlapping presentations. Patients may present to a variety of clinicians, including headache experts, dentists, otolaryngologists, ophthalmologist, psychiatrists, and physiotherapists. Unfortunately, there is not uniform approach for such patients and diagnostic ambiguity is frequently encountered in clinical practice. Herein, we review the differential diagnoses of side-locked headaches and provide an algorithm based approach for patients presenting with side-locked headaches. Side-locked headache is itself a red flag. So, the first priority should be to rule out secondary headaches. A comprehensive history and thorough examinations will help one to formulate an algorithm to rule out or confirm secondary side-locked headaches. The diagnoses of most secondary side-locked headaches are largely investigations dependent. Therefore, each suspected secondary headache should be subjected for appropriate investigations or referral. The diagnostic approach of primary side-locked headache starts once one rule out all the possible secondary headaches. We have discussed an algorithmic approach for both secondary and primary side-locked headaches.
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Affiliation(s)
- Sanjay Prakash
- Department of Neurology, Smt. B. K. Shah Medical institute and research Centre, Sumandeep Vidyapeeth, Piparia, Waghodia, Vadodara, 391760, Gujarat, India. .,Department of Neurology, Smt B. K. Shah Medical institute and research Centre, Piperia, Waghodia, Vadodara, 391760, Gujarat, India.
| | - Chaturbhuj Rathore
- Department of Neurology, Smt. B. K. Shah Medical institute and research Centre, Sumandeep Vidyapeeth, Piparia, Waghodia, Vadodara, 391760, Gujarat, India
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Gutiérrez-Viedma Á, González-García N, Yus M, Jorquera M, Porta-Etessam J, García-Moreno H, García-Azorín D, Cuadrado ML. Facial epicrania fugax: A prospective series of eight new cases. Cephalalgia 2016; 37:1145-1151. [DOI: 10.1177/0333102416668656] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction Epicrania fugax (EF) is a primary headache whose main feature is the dynamic character of the pain. EF pain typically moves across different dermatomes in a linear or zigzag trajectory. Recently, a facial variant of EF has been described, with the pain starting in the lower face and radiating upwards. Aim We report eight patients with an EF-type of pain of facial location and either upward or downward radiation. Methods For each patient, we recorded relevant demographic and clinical data. Magnetic resonance imaging (MRI) with fast imaging employing steady state acquisition (FIESTA) was obtained in all cases for the assessment of neurovascular compression of the trigeminal nerve. Results There were seven women and one man, and the mean age was 76.1 years (standard deviation, 11.3). Six patients had a paroxysmal pain starting at the lower face and moving upwards, while two patients had downward radiation. The pain always followed a fixed linear trajectory across different dermatomes. All cases had triggers, and pain intensity was consistently severe. Half of the patients had accompanying autonomic features. Neurovascular compression with imprinting over the trigeminal root on the symptomatic side was identified in three patients. All cases responded to antiepileptic drugs, and three had spontaneous remissions. Conclusions This series reinforces the facial variant of EF and extends the phenotype with cases of downward radiation. It also contributes to enriching the differential diagnosis of facial pain. Neurovascular compression of the trigeminal nerve may be found in some cases, although a possible pathogenic link needs further research.
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Affiliation(s)
| | | | - Miguel Yus
- Neuroradiology Unit, Department of Radiology, Hospital Clínico San Carlos, Madrid, Spain
| | - Manuela Jorquera
- Neuroradiology Unit, Department of Radiology, Hospital Clínico San Carlos, Madrid, Spain
| | - Jesús Porta-Etessam
- Headache Unit, Department of Neurology, Hospital Clínico San Carlos, Madrid, Spain
- Department of Medicine, School of Medicine, Universidad Complutense, Madrid, Spain
| | - Héctor García-Moreno
- Headache Unit, Department of Neurology, Hospital Clínico San Carlos, Madrid, Spain
| | - David García-Azorín
- Headache Unit, Department of Neurology, Hospital Clínico San Carlos, Madrid, Spain
| | - María-Luz Cuadrado
- Headache Unit, Department of Neurology, Hospital Clínico San Carlos, Madrid, Spain
- Department of Medicine, School of Medicine, Universidad Complutense, Madrid, Spain
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Fernández-Matarrubia M, Gutiérrez-Viedma Á, Cuadrado ML. Case report: Epicranial pain after radiotherapy for skull base meningioma – the first symptomatic epicrania fugax? Cephalalgia 2016; 36:1389-1391. [DOI: 10.1177/0333102416642425] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Revised: 03/07/2016] [Accepted: 03/11/2016] [Indexed: 01/03/2023]
Abstract
Background To date, no symptomatic forms of epicrania fugax (EF) have been reported. Here, we describe the first EF-type pain to be probably caused by an underlying disorder. Case report A 77-year-old woman started suffering from left V1–V2 trigeminal neuralgia at 72 years of age. Neurologic examination was normal. Magnetic resonance imaging (MRI) showed a left middle sphenoid wing meningioma compressing the left trigeminal nerve medially. After trying several neuromodulators, she received stereotactic radiotherapy. One month later, the episodes of facial pain were significantly diminished, but she started feeling brief electric paroxysms across her left hemicranium that were clinically identical to those of backwards EF. Serial MRI showed persistence of the meningioma without changes. Conclusion Although the pathogenesis of EF remains uncertain, this case is consistent with a symptomatic origin in the trigeminal root/pathway. The onset of the EF-like pain could have been caused by the compressive effect of the tumour or, most likely, by the radiation.
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Affiliation(s)
| | | | - María-Luz Cuadrado
- Department of Neurology, Hospital Clínico San Carlos, Madrid, Spain
- Department of Medicine, Universidad Complutense, Madrid, Spain
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