Treatment of miscellaneous idiopathic headache disorders (Group 4 of the IHS classification)--report of an EFNS task force

Ecchordosis physaliphora presenting as hypnic headache

Ecchordosis physaliphora (EP) is a rare benign congenital hamartomatous lesion originating from remnants of the notochord. EP has never been associated with hypnic headache before. We report for the first time two cases of EP associated with an hypnic headache. The latter is a form of sleep-related nocturnal headache whose pathogenesis has not been fully elucidated. A 61-year-old woman and a 41-year-old man had been complaining of a dull headache that woke them up every night for many months. In both cases, an enlarged cystic lesion in the prepontine cistern, compatible with ecchordosis physaliphora, was found on brain MRI. A diagnosis of hypnic headache secondary to EP was made. Ecchordosis physaliphora presenting as hypnic headache had never been described before. The low prevalence of both conditions (EP and HH) and their presence in two cases might suggest a possible causal association between the two conditions.

Hints on Diagnosing and Treating Headache

BACKGROUND

Headache, like dizziness, is one of the more common presenting complaints in outpatient care and in the emergency room. More than 200 varieties of headache have been described, and the false impression may arise that the diagnosis and treatment of these syndromes is a highly challenging task.

METHODS

This review is based on pertinent articles retrieved by a selective search in PubMed.

RESULTS

In primary headache, the headache is not a symptom but a disease in its own right. There are four types of primary headache: migraine, tension headache, trigeminal autonomic cephalalgia, and other primary headache disorders. By definition, the physical examination is normal, including the neurological examination. Secondary headache, in contrast, is a symptom of another disease (e.g., a tumor or cerebral hemorrhage). Triptans and nonsteroidal anti-inflammatory drugs (NSAID) are the drugs usually given for the acute treatment and prophylaxis of migraine. In tension headache, NSAID are given acutely, and tricyclic drugs for prophylaxis. There are various options for the treatment of trigeminal autonomic cephalalgia syndromes such as cluster headache and paroxysmal hemicrania. For group 4 headaches (other primary headache disorders), the treatment must be chosen on an individual basis; indomethacin is often effective.

CONCLUSION

If the patient is clearly suffering from none of the four types of primary headache, the problem must be a headache of a secondary nature, potentially reflecting a dangerous underlying disease. The treatment of headache is usually successful and thus highly rewarding for physicians of all medical specialties.

[Sleep disorders in chronic pain syndromes]

Sleep disorders and pain syndromes are widespread in the general population. This review presents data on comorbidity of these phenomena and possibility of their mutual influence on each other including data based on long-term prospective studies. Studies of pain syndromes and sleep disorders dynamics are analyzed in detail. Anatomical basis of sleep-pain interactions is described, and results of the emotional influence on sleep and pain associations are presented. Non-pharmacological and drug-based approaches to treatment with detailed description of the biochemical basis of their action are considered. The authors conclude that pain syndromes and sleep disorders have reciprocal relations; the improvement of sleep quality helps in various pain syndromes; sleep normalization could play a preventive role with regard to pain.

Pathophysiology of hypnic headache

Background

Hypnic headache (HH) is a rare primary headache disorder that is characterized by strictly sleep related headache attacks.

Purpose

The underlying pathophysiology of HH is mainly enigmatic but some clinical characteristics such as circadian rhythmicity and caffeine responsiveness may point toward possible underlying mechanisms.

Method

Current studies that deal with the pathophysiology of HH are summarized. Data on cerebral imaging, sleep, electrophysiology studies, effectiveness of drugs, and symptomatic headache types are discussed to illuminate underlying pathophysiologic mechanisms.

Conclusion

HH can be clearly differentiated by its clinical presentation as well as imaging and electrophysiological study results from other primary headaches such as migraine or cluster headache. The underlying pathophysiology is still enigmatic but a hypothalamic involvement seems to be likely.

Mechanism of action of indomethacin in indomethacin-responsive headaches

Indomethacin, as a member of the non-steroidal anti-inflammatory drug class, plays a special role in the treatment of headaches. By definition, it is completely efficacious in the treatment of the primary headache disorders paroxysmal hemicrania and hemicrania continua. Therefore, indomethacin is also used as a tool for differential diagnosis in headache clinics. Indomethacin has a clear action as a cyclooxygenase inhibitor. Additional mechanisms and interactions with cell signaling pathways and inflammatory pathways are considered in this article. However, it is not known what mechanism or interaction with pathophysiological mechanisms is the key to indomethacin's specific pharmacology in headache therapy. Focusing on headache therapy, we summarize the current knowledge of pharmacology, treatment options, and recommendations for the use of indomethacin in primary headaches. New findings from the field of headache research, as well as from Alzheimer's disease and cancer research on the pharmacological actions of indomethacin and their potential implications on the pathophysiology of indomethacin sensitive headaches, are discussed.