No relationship between vasoactive intestinal polypeptide expression and headache in pituitary tumours

Clinical Presentation and Management of Headache in Pituitary Tumors

PURPOSE OF REVIEW

This article provides an overview of headache in the setting of pituitary adenoma. The purpose of this article is to educate providers on the association, possible pathophysiology, and the clinical presentation of headache in pituitary tumor.

RECENT FINDINGS

Recent prospective evaluations indicate that risk factors for development of headache in the setting of pituitary adenoma include highly proliferative tumors, cavernous sinus invasion, and personal or family history of headache. Migraine-like headaches are the predominant presentation. Unilateral headaches are often ipsilateral to the side of cavernous sinus invasion. In summary, this paper describes how the size and type of pituitary tumors play an important role in causation of headaches. Pituitary adenoma-associated headache can also mimic primary headache disorders making recognition of a secondary process difficult. Therefore, this paper highlights the association of between trigeminal autonomic cephalgias and pituitary adenomas and urges practitioners to maintain a high index of suspicion when evaluating patients with these uncommon headache presentations. However, on balance, given the prevalence of both primary headache disorders and pituitary adenomas, determining causality can be challenging. A thoughtful and multidisciplinary approach is often the best management strategy, and treatment may require the expertise of multiple specialties including neurology, neurosurgery, and endocrinology.

Clinical characteristics and risk factors for headache associated with non-functioning pituitary adenomas

Background Headaches associated with pituitary adenoma have been reported to be related to the structural characteristics and endocrine factors of the tumour itself. Objectives The objective of this study was to investigate the prevalence and clinical characteristics of, and the risk factors for, non-functioning pituitary adenoma (NFPA)-associated headaches in Chinese patients with normal endocrine activity. Methods Ninety-seven patients with a NFPA with normal endocrine laboratory results were prospectively enrolled in this study. The relevant clinical demographic data were collected and examined with the appropriate statistical methods. Results The pre-operative prevalence of tumour-associated headaches was 48.5%; 87.2% of these patients had migraine-like headaches. A family history of primary headache (odds ratio (OR) 3.67; p = 0.032) and a higher tumour Knosp grade (OR 1.83; p = 0.001) were identified as risk factors for the occurrence of NFPA-associated headaches. The patient's age, sex, visual disturbances, optic chiasm compression, tumour size and tumour volume were not significantly associated with NFPA-associated headaches ( p > 0.05). In addition, headache severity was significantly correlated with the Knosp grade ( r = 0.339; p = 0.001). The sides of the headaches and of cavernous sinus invasion were significantly concordant (48.9% agreement; κ = 0.257; p = 0.007). Conclusions Migraine-like headaches are a common clinical manifestation in patients with NFPAs. A family history of primary headaches and cavernous sinus invasion are risk factors for NFPA-associated headaches.

Quantitative evaluation of headache severity before and after endoscopic transsphenoidal surgery for pituitary adenoma

OBJECT The relationship between headaches, pituitary adenomas, and surgical treatment of pituitary adenomas remains unclear. The authors assessed the severity and predictors of self-reported headaches in patients referred for surgery of pituitary adenomas and evaluated the impact of endoscopic transsphenoidal surgery on headache severity and quality of life (QOL). METHODS In this prospective study, 79 patients with pituitary adenomas underwent endoscopic transsphenoidal resection and completed the Headache Impact Test (HIT-6) and the 36-Item Short Form Health Survey (SF-36) QOL questionnaire preoperatively and at 6 weeks and 6 months postoperatively. RESULTS Preoperatively, 49.4% of patients had mild headache severity, 13.9% had moderate severity, 13.9% had substantial severity, and 22.8% had intense severity. Younger age and hormone-producing tumors predisposed greater headache severity, while tumor volume, suprasellar extension, chiasmal compression, and cavernous sinus invasion of the pituitary tumors did not. Preoperative headache severity was found to be significantly associated with reduced scores across all SF-36 QOL dimensions and most significantly associated with mental health. By 6 months postoperatively, headache severity was reduced in a significant proportion of patients. Of the 40 patients with headaches causing an impact on daily living (moderate, substantial, or intense headache), 70% had improvement of at least 1 category on HIT-6 by 6 months postoperatively, while headache worsened in 7.6% of patients. The best predictors of headache response to surgery included younger age, poor preoperative SF-36 mental health score, and hormone-producing microadenoma. CONCLUSIONS The results of this study confirm that surgery can significantly improve headaches in patients with pituitary adenomas by 6 months postoperatively, particularly in younger patients whose preoperative QOL is impacted. A larger multicenter study is underway to evaluate the long-term effect of surgery on headaches in this patient group.

Prolactinoma-associated headache and dopamine agonist treatment

AIM

The aim of this article is to investigate the phenotype and etiology of prolactinoma-associated headache as well as present and discuss the plausible pain-relieving effect of dopamine agonist treatment.

METHODS

In this case-based audit we included 11 patients with prolactinomas and one patient with idiopathic hyperprolactinemia presenting with headache that subsequently improved or resolved after dopamine agonist treatment.

RESULTS

A significant ipsilateral location of tumor mass and reported headache symptoms was observed (p = 0.018). After dopamine agonist treatment seven out of 12 patients became pain free within 2.5 months; after one year of treatment 11 out of 12 reported headache improvement or resolution. Average tumor volume reduction after treatment was 47 ± 22% during 9.5 ± 8.4 months of follow-up. There was no significant association between headache relief and tumor shrinkage (p = 0.43) or normalization of serum prolactin (p = 1.00), respectively.

CONCLUSIONS

1) The significant association between lateralization of tumor and headache suggests a mechanical origin of the headache, 2) headache responded to dopamine agonist treatment in most patients, and 3) our observations encourage future prospective controlled trials to investigate the role of hyperprolactinemia in the pathogenesis of headache as well as the therapeutic effects of dopamine agonists.

Headache and pituitary disease: a systematic review

Headache is very common in pituitary disease and is reported to be present in more than a third of all patients with pituitary adenomas. Tumour size, cavernous sinus invasion, traction or displacement of intracranial pain-sensitive structures such as blood vessels, cranial nerves and dura mater, and hormonal hypersecretion are implicated causes. The present review attempts to systematically review the literature for any combination of headache and pituitary or hormone overproduction or deficiency. Most data available are retrospective and/or not based on the International Headache Society (IHS) classification. Whereas in pituitary apoplexy a mechanical component explains the almost universal association of the condition with headaches, this correlation is less clear in other forms of pituitary disease and a positive impact of surgery on headaches is not guaranteed. Similarly, invasion into the cavernous sinus or local inflammatory changes have been linked to headaches without convincing evidence. Some studies suggest that oversecretion of GH and prolactin may be important for the development of headaches, and treatment, particularly with somatostatin analogues, has been shown to improve symptoms in these patients. Otherwise, treatment rests on general treatment options for headaches based on an accurate clinical history and a precise classification which includes assessment of the patient's psychosocial risk factors.

Treatment of severe trigeminal headache in patients with pituitary adenomas

BACKGROUND

The incidence of headache in patients with pituitary adenomas is high, and the underlying pathological mechanisms are not completely understood.

OBJECTIVE

We tested the efficacy of percutaneous ganglion block and trigeminal rhizotomy in the treatment of severe trigeminal/autonomic headache associated with pituitary tumors.

METHODS

Eleven patients treated surgically for pituitary adenomas in whom intractable trigeminal headaches developed were enrolled in the study and underwent ictal cerebral single-photon emission computed tomography before starting treatment. Initially, all patients underwent a 6-month medical treatment trial. Patients who did not experience improvement in headache severity, addressed by the Headache Impact Test-6 scale, underwent trigeminal percutaneous ganglion blockade. Two patients subsequently underwent trigeminal balloon rhizotomy.

RESULTS

Among the 11 patients, 6 did not have improved Headache Impact Test-6 scale scores after 6 months of treatment with medications and underwent trigeminal ganglion blockade. Significant improvement in headache severity was noted in 3 of them. Long-term response was obtained in 1 patient, and the other 2, in whom the response was transient, were then successfully treated with trigeminal rhizotomy. Cerebral single-photon emission computed tomography showed increased uptake in the thalamus/hypothalamus region in patients who responded well to manipulation of the trigeminal-hypothalamic system.

CONCLUSION

Percutaneous ganglion blockade and trigeminal rhizotomy may be promising alternative options for the treatment of severe headache in selected patients with pituitary adenomas.

Secondary headaches: secondary or still primary?

The second edition of the International Classification of Headache Disorders makes a distinction between primary and secondary headaches. The diagnosis of a secondary headache is made if the underlying disease is thought to cause headache or if a close temporal relationship is present together with the occurrence of the headache. At first glance, this may allow clearly secondary headaches to be distinguished from primary headaches. However, by reviewing the available literature concerning several selected secondary headaches, we will discuss the hypothesis that some secondary headaches can also be understood as a variation of primary headaches in the sense that the underlying cause (e.g. infusion of glyceryl trinitrate [ICHD-II 8.1.1], epilepsy [7.6.2], brain tumours [7.4], craniotomy [5.7], etc.) triggers the same neurophysiologic mechanisms that are responsible for the pain in primary headache attacks.

Headache attributed to non-vascular intracranial disorder

This chapter deals with non-vascular intracranial disorders resulting in headache. Headache attributed to high or low cerebrospinal fluid pressure is separated into headache attributed to idiopathic intracranial hypertension (IIH), headache attributed to intracranial hypertension secondary to metabolic, toxic, or hormonal causes, headache attributed to intracranial hypertension secondary to hydrocephalus, post-dural puncture headache, cerebrospinal fluid (CSF) fistula headache, headache attributed to spontaneous (or idiopathic) low CSF pressure. Headache attributed to non-infectious inflammatory disease can be caused by neurosarcoidosis, aseptic (non-infectious) meningitis or lymphocytic hypophysitis. Headache attributed to intracranial neoplasm can be caused by increased intracranial pressure or hydrocephalus caused by neoplasm or attributed directly to neoplasm or carcinomatous meningitis. Other causes of headache include hypothalamic or pituitary hyper- or hyposecretion and intrathecal injection. Headache attributed to epileptic seizure is separated into hemicrania epileptica and post-seizure headache. Finally headache attributed to Chiari malformation type I (CM1) and the syndrome of transient headache and neurological deficits with cerebrospinal fluid lymphocytosis (HaNDL) are described.

Significant headache improvement after transsphenoidal surgery in patients with small sellar lesions

OBJECT

Pituitary adenomas represent a large proportion of brain tumors that are increasing in incidence because of improved imaging techniques. Headache is the primary symptom in patients with large tumors (macroadenomas), but is also a symptom in patients with small tumors (microadenomas, tumors < 1.0 cm). The prevalence and optimal treatment of headaches associated with pituitary tumors is still unclear, particularly in cases of microadenoma. If conventional medical management fails, transsphenoidal surgery (TSS) may be considered as an alternative treatment for intractable headaches.

METHODS

The authors conducted a retrospective review of 512 patients who underwent TSS at Oregon Health & Science University between 2001 and 2007; patients with Cushing disease were excluded. The authors identified 41 patients with small pituitary tumors who underwent TSS, and retrospectively evaluated the resolution and/or treatment of headache.

RESULTS

Ninety percent of patients who presented with nonfunctioning microadenomas and Rathke cleft cysts experienced resolution or improvement in their headaches after TSS, and 56% of patients who presented with hyperfunctioning pituitary microadenomas had improvement in their headaches. There were no postoperative complications.

CONCLUSIONS

In this retrospective study, the authors demonstrate the efficacy of TSS in the treatment of intractable headaches in patients who present with pituitary microadenomas (nonsecreting and hypersecretory) and Rathke cleft cysts.

Chronic headache and pituitary tumors

Pituitary tumors come to clinical attention due to endocrine dysfunction, distortion of local structures surrounding the pituitary fossa, or as an incidental finding during neuroimaging for headache. Explanations for pituitary tumor-associated headache include stretching of the dura mater and invasion of pain-producing structures within the cavernous sinus. However, small functional pituitary lesions may present with severe headache without cavernous sinus invasion or suprasellar extension. Prolactinomas and growth hormone-secreting tumors have a high prevalence of rare headache phenotypes with or without autonomic features, suggesting that biochemical abnormalities within the hypothalamo-pituitary axis may play a role in headache. Somatostatin analogues may be highly effective at aborting headache associated with functionally active pituitary lesions, particularly in the case of acromegaly. A proposed mechanism for this is inhibition of nociceptive peptides. This article summarizes the clinical features, pathophysiology, and potential treatment approaches to pituitary tumor-associated headache.