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Yildiz Goksel H, Bilgin S, Digre K, Cortez MM, Ozudogru SN. The critical role of neuroimaging in hemicrania continua: A systematic review and case series. Headache 2024; 64:674-684. [PMID: 38780233 DOI: 10.1111/head.14728] [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: 02/18/2022] [Revised: 02/23/2024] [Accepted: 03/02/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND Hemicrania continua is a primary unilateral headache characterized by ipsilateral parasympathetic and sympathetic autonomic features. A key diagnostic criterion is its dramatic response to indomethacin treatment; however, various vascular or structural abnormalities have been reported to cause secondary hemicrania continua, presenting with clinical features similar to those of the primary headache presentation. OBJECTIVE We reviewed the literature to compile secondary hemicrania continua cases, highlighting the importance of imaging during the evaluation. Additionally, we also contributed our three cases to the existing studies. METHODS We conducted a review of articles from the PubMed and EMBASE databases that described reported cases of secondary hemicrania continua, covering the period from 1993 to 2021. Our review included detailed patient information, signs, and symptoms of hemicrania continua, as well as information on indomethacin usage and headache resolution (if pertinent). RESULTS Secondary hemicrania continua can result from a remarkably diverse range of structural and vascular lesions, yet clinical reports on long-term follow-up are lacking. Notably, cases may exhibit a classical response to indomethacin, emphasizing the importance of neuroimaging in excluding secondary cases. Our search yielded 41 cases meeting our criteria. We excluded six cases that were not treated with indomethacin or were unresponsive to it. Additionally, we present three cases that highlight the necessity of neuroimaging in evaluating hemicrania continua, along with short- and long-term clinical outcomes following indomethacin and lesion-directed treatments. Case 1 presented with daily right-sided headaches and cranial autonomic symptoms. Her pain completely resolved with indomethacin use. Neuroimaging of the brain revealed a laterally directed saccular aneurysm of the right internal carotid artery. Case 2 presented with continuous left-sided unilateral headaches with superimposed exacerbations. She complained of left-sided photophobia with a dull sensation in the left ear. Her symptoms decreased after 2 weeks of indomethacin use. Neuroimaging of the head indicated a benign tumor with mass effect into the left lateral medulla and inferior cerebellar peduncle. Case 3 presented with a right side-locked headache with daily, severe superimposed exacerbations. She had photophobia in the right eye and a right-sided Horner's syndrome, along with tearing during her exacerbations. Neuroimaging of the brain revealed a pituitary tumor and her pain completely resolved with indomethacin. CONCLUSION Hemicrania continua is a rare headache disorder that can be either primary or secondary. Importantly, response to indomethacin can still occur in secondary hemicrania continua. Thus, neuroimaging should be considered to rule out underlying structural etiology in all cases, regardless of their clinical responsiveness to indomethacin therapy.
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Affiliation(s)
| | - Seyma Bilgin
- Department of Internal Medicine, Saint Mary's Hospital, Waterbury, Connecticut, USA
| | - Kathleen Digre
- Department of Neurology, The University of Utah, Salt Lake City, Utah, USA
| | - Melissa M Cortez
- Department of Neurology, The University of Utah, Salt Lake City, Utah, USA
| | - Seniha N Ozudogru
- Department of Neurology, The University of Utah, Salt Lake City, Utah, USA
- Department of Neurology, The University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Delen V, İlter S. Headache Characteristics in Chronic Neck Pain Patients with Loss of Cervical Lordosis: A Cross-Sectional Study Considering Cervicogenic Headache. Med Sci Monit 2023; 29:e939427. [PMID: 36915178 PMCID: PMC10024460 DOI: 10.12659/msm.939427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2023] Open
Abstract
BACKGROUND Loss of cervical lordosis and cervicogenic headache have similar tissue abnormalities, including weakness and atrophy in the neck muscles. Cervicogenic headache is mainly unilateral and is perceived in the occipito-temporo-frontal regions. However, it is not clear whether loss of cervical lordosis is a sign of headache with cervical origin. Herein, we aimed to assess and compare headache characteristics in patients with and without loss of cervical lordosis. MATERIAL AND METHODS This was a cross-sectional study conducted on chronic neck pain patients with (n=38; F/M: 28/10; mean age 33.34±7.73 yrs; range 18 to 45 yrs) and without loss of cervical lordosis (n=38; F/M: 29/9; mean age 33.13±6.41 years; range 20 to 45 years), between May 2019 and November 2019. The 2 groups were assessed and compared for headache characteristics such as frequency, severity, localization, lateralization, duration, and spread scores. Cervical lordosis was assessed on the lateral cervical radiographs by using posterior tangent technique measuring the C2-C7 total cervical spine angle. RESULTS The 2 groups were similar for individual features, including age, sex, employment status, and duration of neck pain (P>0.05). The duration of headache attack was longer in patients with loss of cervical lordosis (5.72±8.12) than in those with normal cervical lordosis (3.29±3.92) (P=0.009). However, there were no significant differences between the 2 groups for headache characteristics, including frequency, severity, localization, lateralization, and spread scores (P>0.05). CONCLUSIONS Patients with loss of cervical lordosis have longer duration of headache attack than those without. Loss of cervical lordosis may be a specific finding associated with longer cervicogenic headache attacks.
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Affiliation(s)
- Veysel Delen
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Harran University, Sanliurfa, Turkey
| | - Server İlter
- Department of Physical Medicine and Rehabilitation, Van Yüzüncü Yıl University Dursun Odabaş Medical Center, Van, Turkey
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3
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Paemeleire K, Vandenbussche N, Stark R. Migraine without aura. HANDBOOK OF CLINICAL NEUROLOGY 2023; 198:151-167. [PMID: 38043959 DOI: 10.1016/b978-0-12-823356-6.00007-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/05/2023]
Abstract
Migraine without aura is the commonest form of migraine in both children and adults. The diagnosis is made by applying the International Classification of Headache Disorders Third Edition subsection for migraine without aura (ICHD-3 subsection 1.1). Attacks in patients with migraine without aura are characterized by their polyphasic presentation (prodrome, headache phase, postdromal phase). The symptomatology of attacks is diverse and heterogeneous, with most common symptoms being photophobia, phonophobia, nausea, vomiting, and aggravation of pain by movement. The clinician and researcher who wants to learn about migraine without aura needs to be able to apply the ICHD-3 criteria with its specific symptomatology to make a correct diagnosis, but also needs to be aware about the plethora of symptoms patients may experience. In this chapter, the reader will explore the clinical phenotypical features of migraine without aura.
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Affiliation(s)
- Koen Paemeleire
- Department of Neurology, Ghent University Hospital, Ghent, Belgium.
| | | | - Richard Stark
- Department of Neurology, Alfred Hospital, Monash University, Melbourne, VIC, Australia; Department of Neurosciences, Monash University, Melbourne, VIC, Australia
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Liu L, Zhong Y, Wu B, Tang X, Yi Z, Pan C. Hemicranial postural headache as a first symptom of a spontaneous carotid cavernous fistula: A case report. Medicine (Baltimore) 2022; 101:e31088. [PMID: 36254069 PMCID: PMC9575803 DOI: 10.1097/md.0000000000031088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
RATIONALE Spontaneous carotid cavernous fistula (CCF) is rare, and the expression of headache caused by it can be variable. PATIENT CONCERNS A case of a man hospitalized for high-intensity hemicranial headache which was aggravated by lying down and relieved when standing or sitting. The pain was of a pulsating character, localized on the right, behind the eye, followed by nausea and vomiting. He gradually appeared with ophthalmoplegia, decreased visual acuity and epistaxis. DIAGNOSIS Digital subtraction angiogram (DSA) showed a pseudoaneurysm arising from the internal carotid artery (ICA) that projected anteriorly and medially into the sphenoid sinus with occluded fistula. INTERVENTIONS The pseudoaneurysm was successfully treated with covered stent. OUTCOMES The patient was then followed up clinically at the outpatient and seen in the outpatient clinic with no further episodes of nasal bleeding or new neurologic deficit. The vision loss and ophthalmoparesis were unchanged. LESSONS Hemicranial postural headache may be the first and characteristic sign of spontaneous CCF.
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Affiliation(s)
- Li Liu
- Department of Neurology, The First People’s Hospital of Huaihua of University of South China, Huaihua, PR China
- The Advanced Stroke Center of China, Huaihua, PR China
| | - Yushi Zhong
- Department of Neurology, The First People’s Hospital of Huaihua of University of South China, Huaihua, PR China
- The Advanced Stroke Center of China, Huaihua, PR China
| | - Bin Wu
- Department of Neurology, The First People’s Hospital of Huaihua of University of South China, Huaihua, PR China
- The Advanced Stroke Center of China, Huaihua, PR China
| | - Xianbi Tang
- Department of Neurology, The First People’s Hospital of Huaihua of University of South China, Huaihua, PR China
- The Advanced Stroke Center of China, Huaihua, PR China
| | - Ziwei Yi
- The Forth People’s Hospital of Huaihua, Huaihua, PR China
| | - Chuzheng Pan
- Department of Neurology, The First People’s Hospital of Huaihua of University of South China, Huaihua, PR China
- The Advanced Stroke Center of China, Huaihua, PR China
- * Correspondence: Chuzheng Pan, Department of Neurology, The First People’s Hospital of Huaihua of University of South China, Huaihua, PR China (e-mail: )
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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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Korwisi B, Hay G, Attal N, Aziz Q, Bennett MI, Benoliel R, Cohen M, Evers S, Giamberardino MA, Kaasa S, Kosek E, Lavand'homme P, Nicholas M, Perrot S, Schug S, Smith BH, Svensson P, Vlaeyen JWS, Wang SJ, Treede RD, Rief W, Barke A. Classification algorithm for the International Classification of Diseases-11 chronic pain classification: development and results from a preliminary pilot evaluation. Pain 2021; 162:2087-2096. [PMID: 33492033 DOI: 10.1097/j.pain.0000000000002208] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 12/11/2020] [Indexed: 01/04/2023]
Abstract
ABSTRACT The International Classification of Diseases-11 (ICD-11) chronic pain classification includes about 100 chronic pain diagnoses on different diagnostic levels. Each of these diagnoses requires specific operationalized diagnostic criteria to be present. The classification comprises more than 200 diagnostic criteria. The aim of the Classification Algorithm for Chronic Pain in ICD-11 (CAL-CP) is to facilitate the use of the classification by guiding users through these diagnostic criteria. The diagnostic criteria were ordered hierarchically and visualized in accordance with the standards defined by the Society for Medical Decision Making Committee on Standardization of Clinical Algorithms. The resulting linear decision tree underwent several rounds of iterative checks and feedback by its developers, as well as other pain experts. A preliminary pilot evaluation was conducted in the context of an ecological implementation field study of the classification itself. The resulting algorithm consists of a linear decision tree, an introduction form, and an appendix. The initial decision trunk can be used as a standalone algorithm in primary care. Each diagnostic criterion is represented in a decision box. The user needs to decide for each criterion whether it is present or not, and then follow the respective yes or no arrows to arrive at the corresponding ICD-11 diagnosis. The results of the pilot evaluation showed good clinical utility of the algorithm. The CAL-CP can contribute to reliable diagnoses by structuring a way through the classification and by increasing adherence to the criteria. Future studies need to evaluate its utility further and analyze its impact on the accuracy of the assigned diagnoses.
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Affiliation(s)
- Beatrice Korwisi
- Division of Clinical Psychology and Psychotherapy, Department of Psychology, Philipps-University Marburg, Marburg, Germany
| | - Ginea Hay
- Division of Clinical Psychology and Psychotherapy, Department of Psychology, Philipps-University Marburg, Marburg, Germany
| | - Nadine Attal
- INSERM U-987, Centre d'Evaluation et de Traitement de la Douleur, CHU Ambroise Paré, Boulogne-Billancourt, France
| | - Qasim Aziz
- Centre for Neuroscience, Surgery and Trauma, Blizard Institute, Wingate Institute of Neurogastroenterology, Barts and The London School of Medicine and Dentistry, Queen Mary, University of London, London, United Kingdom
| | - Michael I Bennett
- Academic Unit of Palliative Care, University of Leeds, Leeds, United Kingdom
| | - Rafael Benoliel
- Department of Diagnostic Sciences, Rutgers School of Dental Medicine, Rutgers, Newark, NJ, United States
| | - Milton Cohen
- St Vincent's Clinical School, UNSW, Sydney, New South Wales, Australia
| | - Stefan Evers
- Department of Neurology, Krankenhaus Lindenbrunn, Coppenbrügge, Germany
- Department of Medicine, University of Münster, Münster, Germany
| | - Maria Adele Giamberardino
- Department of Medicine and Science of Aging, CAST, G D'Annunzio University of Chieti, Chieti, Italy
- European Palliative Care Research Centre (PRC),Department of Cancer Treatment, University Hospital Oslo, Oslo, Norway
| | - Stein Kaasa
- Department of Oncology, Oslo University Hospital, Oslo, Norway
- Institute of Cancer Research and Molecular Medicine, Department of Medicine, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Clinical Neuroscience, Karolinska Institute, and Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - Eva Kosek
- Department of Surgical Sciences Uppsala University, Uppsala, Sweden
- Department of Anesthesiology, Acute Postoperative Pain Service, Saint Luc Hospital, Catholic University of Louvain, Brussels, Belgium
| | - Patricia Lavand'homme
- Pain Management Research Institute, Faculty of Medicine and Health, University of Sydney and Royal North Shore Hospital, Sydney, Australia
| | - Michael Nicholas
- Pain Clinic, Cochin Hospital, Paris University, INSERM U987, Paris, France
| | - Serge Perrot
- Department of Anaesthesiology and Pain Medicine, Medical School, University of Western Australia, Perth, Australia
| | - Stephan Schug
- Division of Population Health and Genomics, University of Dundee, Dundee, United Kingdom
| | - Blair H Smith
- Department of Dentistry and Oral Health, Section of Orofacial Pain and Jaw Function, Aarhus University, Aarhus, Denmark
| | - Peter Svensson
- Research Group Health Psychology, Department of Psychology and Educational Sciences, University of Leuven, Leuven, Belgium
| | - Johan W S Vlaeyen
- TRACE, Center for Translational Health Research, KU Leuven, Ziekenhuis Oost-Limburg, Genk, Belgium
- Department of Clinical Psychological Science, Maastricht University, Maastricht, the Netherlands
- The Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Shuu-Jiun Wang
- Brain Research Center and School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Department of Neurophysiology, Mannheim Center for Translational Neuroscience (MCTN), Medical Faculty Mannheim of Heidelberg University, Mannheim, Germany
| | - Rolf-Detlef Treede
- Division of Clinical and Biological Psychology, Department of Psychology, Catholic University of Eichstätt-Ingolstadt, Eichstätt, Germany
| | - Winfried Rief
- Division of Clinical Psychology and Psychotherapy, Department of Psychology, Philipps-University Marburg, Marburg, Germany
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Prakash S, Rawat KS. Hemicrania Continua: An Update. Neurol India 2021; 69:S160-S167. [PMID: 34003161 DOI: 10.4103/0028-3886.315976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Background Hemicrania continua (HC) is not uncommon in clinical practice, and several large case series have been published in the recent past. Objectives This review provides an overview of the recent advancement in different aspects of HC. Methods We reviewed the articles published on HC in the last 2 decades. Results HC constitutes 1.7% of patients with headache in the clinics. It presents with unilateral continuous background pain with periodic exacerbations, usually accompanied by cranial autonomic features and restlessness. The continuous background headache is the most consistent and central feature of HC. Although the duration of exacerbations varies from a few seconds to a few weeks, the frequency ranges from >20 attacks/day to one attack in several months. The background pain is mild to moderate in intensity and does not hamper routine activity. Patients and physicians frequently ignore the basal pain, and a case of HC is misdiagnosed as other headaches, depending on the pattern of exacerbations. The exacerbation mimics several primary headaches and neuralgias. There are about 75 cases of secondary HC, due to 29 different pathologies. Although an absolute response to indomethacin is part of the diagnostic criteria, a subset of patients may respond to several other drugs. Headache reappears immediately on skipping a single dose of effective drug. Several surgical procedures have been tried in patients who are intolerant to indomethacin. Conclusion Misdiagnosis of HC is common. Continuous background pain and response to indomethacin are two essential features for the diagnosis of HC.
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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, Gujarat, India
| | - Kalu Singh Rawat
- Department of Neurology, Smt. B. K. Shah Medical Institute and Research Centre, Sumandeep Vidyapeeth, Piparia, Waghodia, Vadodara, Gujarat, India
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Pradhan S, Das A, Anand S, Deshmukh AR. Clinical characteristics of migraine in patients with calcified neurocysticercosis. Trans R Soc Trop Med Hyg 2020; 113:418-423. [PMID: 30953442 DOI: 10.1093/trstmh/trz018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2018] [Revised: 02/05/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Patients with neurocysticercosis (NCC) may have an increased frequency of migraine. We studied the characteristics of migraine attacks in patients with calcified NCC on brain imaging. METHODS Of 350 migraine patients who visited our outpatient department from January 2016 through June 2018, 166 had undergone brain imaging. Seventy-two patients with migraines had calcified NCC. The migraine attacks of the patients with calcification (MiC) were compared with those of 94 patients without calcification (MiNC). RESULTS Side-locked headaches were seen in 48.6% of the MiC patients. Aura preceding the migraine attack was more common in the MiC group than in the MiNC group (22.22% vs 7.4%; p=0.001). The MiC group had fewer headache episodes per month (5 vs 6; p<0.0001) with fewer common associated features (62.5% vs 84.1%; p=0.006). They also required fewer drugs for secondary prophylaxis (2 vs 3; p=0.002). CONCLUSIONS Some of the clinical characteristics of migraine attacks are sufficiently different in patients with and without NCC. This may suggest some influence of NCC in the pathophysiology of migraine to account for alterations in the clinical manifestations of the disease. Whether this difference could be inferred as NCC having a causative role in migraine needs further research.
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Affiliation(s)
- Sunil Pradhan
- Department of Neurology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, UP, India
| | - Animesh Das
- Department of Neurology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, UP, India
| | - Sucharita Anand
- Department of Neurology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, UP, India
| | - Anirudh Rao Deshmukh
- Department of Neurology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow, UP, India
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Hemicranial Cough-Induced Headache as a First Symptom of a Carotid-Cavernous Fistula-Case Report. ACTA ACUST UNITED AC 2020; 56:medicina56040194. [PMID: 32340153 PMCID: PMC7230325 DOI: 10.3390/medicina56040194] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Revised: 03/27/2020] [Accepted: 04/14/2020] [Indexed: 11/17/2022]
Abstract
Background and objectives: Spontaneous carotid-cavernous fistulas (CCFs) are rare, and they may be caused by an aneurysm rupture. Materials and Methods: A case of a man hospitalized for high-intensity hemicranial headache with sudden cough onset as part of an upper respiratory tract infection is presented. The pain was of a pulsating character, localized on the right, behind the eye, followed by nausea and vomiting. Neurological finding registered a wider rima oculi to the right and slight neck rigidity. Laboratory findings detected a mild leukocytosis with neutrophil predominance, while cytobiochemical findings of CSF and a computerized tomography (CT) scan of the endocranium were normal. Results: Magnetic resonance imaging (MRI) angiography indicated the presence of a carotid cavernous fistula with a pseudoaneurysm to the right. Digital subtraction angiography (DSA) was performed to confirm the existence of the fistula. The planned artificial embolization was not performed because a complete occlusion of the fistula occurred during angiographic examination. Patient was discharged without subjective complaints and with normal neurological findings. Conclusions: Hemicranial cough-induced headache may be the first sign of carotid cavernous fistula, which was resolved by a spontaneous thrombosis in preparation for artificial embolization.
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Wagner M, Sandor PS, Gantenbein AR. Why is it important to diagnose hemicrania continua? CLINICAL AND TRANSLATIONAL NEUROSCIENCE 2020. [DOI: 10.1177/2514183x20906775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Hemicrania continua (HC) is an indomethacin-responsive primary headache which belongs to the trigeminal autonomic cephalalgias. Although the first description of HC was 35 years ago, there are still different views regarding the clinical course, the diagnostic criteria, and the treatment. The high clinical heterogeneity of HC, missed diagnosis, and the delay to the correct diagnosis are important in patient care. Central features of HC are continuous side-locked headaches (with superimposed exacerbations) and the response to indomethacin. We are describing the case of a 29-year-old women who developed right-sided headache 3 weeks after the excision of a right-sided vestibular schwannoma. She tried different painkillers and also was started on a prophylactic treatment with oxcarbazepine, acupuncture, and physiotherapy. But nothing really helped. She was then admitted for an inpatient withdrawal program for medication overuse headache. Again the pain did not change. She has then been treated with indomethacin 50-mg tds, where after the headache improved rapidly within 3 days. This educational case presentation and review of the literature aims to consider HC as a possible differential diagnosis in chronic headache, especially when side-locked and shows that indomethacin maybe a quick therapeutic option before putting the patients on a long treatment odyssey with analgesics and other drugs.
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Affiliation(s)
| | - Peter S Sandor
- Neurorehabilitation & Pain Center, RehaClinic Bad Zurzach, Zurzach, Switzerland
- Department of Neurology, University of Zürich, Zürich, Switzerland
| | - Andreas R Gantenbein
- Neurorehabilitation & Pain Center, RehaClinic Bad Zurzach, Zurzach, Switzerland
- Department of Neurology, University of Zürich, Zürich, Switzerland
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Prakash S, Rathore C, Rana K, Joshi H, Patel J, Rawat KS. A long-term prospective observational study in 31 patients with hemicrania continua. CEPHALALGIA REPORTS 2019. [DOI: 10.1177/2515816318824694] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Introduction: Till date, there is no prospective study in patients with hemicrania continua (HC). Methods: Patients fulfilling the international classification of headache disorders criteria for HC were evaluated prospectively. All patients were subjected to a detailed clinical interview, based on a structured questionnaire. Before starting indomethacin, all patients were instructed to fill a headache diary for at least 5 days. Gradual tapering of indomethacin was done at regular intervals. Results: We enrolled 41 patients over 4.5 years, 31 of whom met the criteria after confirming the indomethacin response. The mean age was 41 years, and 55% were female. The mean duration of headache was 43.6 months. All patients had continuous strictly unilateral pain with episodic exacerbations. At least one cranial autonomic feature was noted in 81% of patients. Twenty-five patients (81%) felt a sense of restlessness during exacerbations. The mean follow-up was 2.5 years. Three-fourths of patients noted a reduction in indomethacin dose after an average 2.5 of years follow-up. The mean reduction of the dose in the follow-up was statistically significant (172 mg vs. 110 mg, p < 0.001). All patients missed the drug for various reasons over the observation period. The headache reappeared within 48 h in 97% of patients. Conclusion: Misdiagnosis of HC is still very common. Patients may not volunteer about the background pain and will focus only on the exacerbations. HC rarely remits, but indomethacin requirements may decrease over time. Skipping of the effective drug leads to the immediate reappearance of pain.
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Affiliation(s)
- Sanjay Prakash
- Department of Neurology, Smt. B.K. Shah Medical Institute and Research Centre, Sumandeep Vidyapeeth, Vadodara, Gujarat, India
| | - Chaturbhuj Rathore
- Department of Neurology, Smt. B.K. Shah Medical Institute and Research Centre, Sumandeep Vidyapeeth, Vadodara, Gujarat, India
| | - Kaushik Rana
- Department of Neurology, Smt. B.K. Shah Medical Institute and Research Centre, Sumandeep Vidyapeeth, Vadodara, Gujarat, India
| | - Hemant Joshi
- Department of Neurology, Smt. B.K. Shah Medical Institute and Research Centre, Sumandeep Vidyapeeth, Vadodara, Gujarat, India
| | - Jay Patel
- Department of Neurology, Smt. B.K. Shah Medical Institute and Research Centre, Sumandeep Vidyapeeth, Vadodara, Gujarat, India
| | - Kalu Singh Rawat
- Department of Neurology, Smt. B.K. Shah Medical Institute and Research Centre, Sumandeep Vidyapeeth, Vadodara, Gujarat, India
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12
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Szikszay TM, Luedtke K, Harry von P. Increased mechanosensivity of the greater occipital nerve in subjects with side-dominant head and neck pain - a diagnostic case-control study. J Man Manip Ther 2018; 26:237-248. [PMID: 30083047 DOI: 10.1080/10669817.2018.1480912] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Objectives: To investigate differences in pressure pain thresholds (PPTs) and longitudinal mechanosensitivity of the greater occipital nerve (GON) between patients with side-dominant head and neck pain (SDHNP) and healthy controls. Evaluation of neural sensitivity is not a standard procedure in the physical examination of headache patients but may influence treatment decisions. Methods: Two blinded investigators evaluated PPTs on two different locations bilaterally over the GON as well as the occipitalis longsitting-slump (OLSS) in subjects with SDHNP (n = 38)) and healthy controls (n = 38). Results: Pressure pain sensitivity of the GON was lower at the occiput in patients compared to controls (p = 0.001). Differences in pressure sensitivity of the GON at the nucheal line, or between the dominant headache side and the non-dominant side were not found (p > 0.05). The OLSS showed significant higher pain intensity in SDHNP (p < 0.001). In comparison to the non-dominant side, the dominant side was significantly more sensitive (p = 0.004). Discussion: Palpation of the GON at the occiput and the OLSS may be potentially relevant tests in SDHNP. One explanation for an increased bilateral sensitivity may be sensitization mechanisms. Future research should investigate the efficacy of neurodynamic techniques directed at the GON. Level of Evidence: 3b.
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Affiliation(s)
| | - Kerstin Luedtke
- University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
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Abstract
Hemicrania continua (HC) is an indomethacin responsive primary chronic headache disorder which is currently classified as a subtype of trigeminal autonomic cephalalgias (TACs). It is not very uncommon. There are >1000 cases of HC in the literature, and it constitutes 1.7% of total headache in the clinic settings. Misdiagnosis for HC is very common at all clinical settings. A diagnosis of HC is missed even by neurologists and headache specialists. It is characterized by a continuous strictly unilateral headache with superimposed exacerbations. Just like other TACs, exacerbations are associated with cranial autonomic symptoms and restlessness. A large number of patients may have migrainous features (nausea, vomiting, photophobia, and phonophobia) during exacerbations phase. The “key” feature of HC is persistent featureless background headaches. However, patients and physicians may focus only on the exacerbation part. As durations, frequency and associated symptoms of exacerbations are highly variables; it may mimic a large number of primary and secondary headache disorders. Migraine and cluster headache are two most common misdiagnosed conditions. Another specific feature of HC is remarkable repose to indomethacin. A “complete” response to indomethacin is as “sine qua non” for HC. However, a few other medications may also be effective in a subset of HC patients. Various surgical procedures have been tried with mixed results in patients who were intolerant to indomethacin or other drugs.
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Affiliation(s)
- Sanjay Prakash
- Department of Neurology, Smt. B. K. Shah Medical Institute and Research Centre, Sumandeep Vidyapeeth University, Vadodara, Gujarat, India
| | - Bansi Adroja
- Department of Medicine, Smt. B. K. Shah Medical Institute and Research Centre, Sumandeep Vidyapeeth University, Vadodara, Gujarat, India
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Abstract
Hemicrania continua (HC) is an indomethacin-responsive primary headache disorder which is currently classified under the heading of trigeminal autonomic cephalalgias (TACs). It is a highly misdiagnosed and underreported primary headache. The pooled mean delay of diagnosis of HC is 8.0 ± 7.2 years. It is not rare. We noted more than 1000 cases in the literature. It represents 1.7% of total headache patients attending headache or neurology clinic. Just like other TACs, it is characterized by strictly unilateral pain in the trigeminal distribution, cranial autonomic features in the same area and agitation during exacerbations/attacks. It is different from other TACs in one aspect. While all other TACs are episodic, HC patients have continuous headaches with superimposed severe exacerbations. The central feature of HC is continuous background headache. However, the patients may be worried only for superimposed exacerbations. Focusing only on exacerbations and ignoring continuous background headache are the most important factors for the misdiagnosis of HC. A large number of patients may have migrainous features during exacerbation phase. Up to 70% patients may fulfill the diagnostic criteria for migraine during exacerbations. Besides migraine, its exacerbations can mimic a large number of other primary and secondary headaches. The other specific feature of HC is a remarkable response to indomethacin. However, a large number of patients develop side effects because of the long-term use of indomethacin. A few other medications may also be effective in a subset of patients with HC. Various surgical interventions have been suggested for patients who are intolerant to indomethacin. Several aspects of HC are still not defined. There is a great heterogeneity in types of patients or articles on the HC in the literature. Diagnostic criteria have been modified several times over the years. The current diagnostic criteria are too restrictive in some aspects. We suggest a more accommodating type of criteria for the appendix of International Classification of Headache Disorder (ICHD).
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Affiliation(s)
- Sanjay Prakash
- Department of Neurology, Smt. B. K. Shah Medical Institute and Research Centre, Sumandeep Vidyapeeth University, Vadodara, Gujarat, India
| | - Payal Patel
- Department of Neurology, Cleveland Clinic Foundation, Cleveland, OH, USA
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