Trigeminal Autonomic Cephalalgias

Cluster headache due to structural lesions: A systematic review of published cases

BACKGROUND

Cluster headache (CH) is a severe incapacitating headache disorder. By definition, its diagnosis must exclude possible underlying structural conditions.

AIM

To review available information on CLH caused by structural lesions and to provide better guides in the distinguishing process and to ensure that there is not a potentially treatable structural lesion.

METHODS

We conducted a systematic review of 77 published cases of symptomatic CH and cluster-like headache (CLH) in PubMed and Google Scholar databases.

RESULTS

Structural pathologies associated with CH were vascular (37.7%), tumoral (32.5%) and inflammatory (27.2%). Brain mass-like lesions (tumoural and inflammatory) were the most common diseases (28.6%), among which 77.3% lesions were at the suprasellar (pituitary) region. Cases of secondary CH related to sinusitis rose dramatically, occupying 19.5%. The third most common disease was internal carotid artery dissection, accounting for 14.3%. Atypical clinical features raise an early suspicion of a secondary cause: Late age at onset and eye and retroorbital pains were common conditions requiring careful evaluation and were present in at least one-third of cases. Abnormal neurological examination was the most significant red flag for impaired cranial nerves. CLH patients may be responsive to typical CH treatments; therefore, the treatment response is not specific. CLH can be triggered by contralateral structural pathologies. CLH associated with sinusitis and cerebral venous thrombosis required more attention.

CONCLUSION

Since secondary headache could perfectly mimick primary CH, neuroimaging should be conducted in patients in whom primary and secondary headaches are suspected. Cerebral magnetic resonance imaging scans is the diagnostic management of choice, and further examinations include vessel imaging with contrast agents and dedicated scans focusing on specific cerebral areas (sinuses, ocular and sellar regions). Neuroimaging is as necessary at follow-up visits as at the first observation.

Trigeminal autonomic cephalalgias presenting in a multidisciplinary tertiary orofacial pain clinic

Abstract

Orofacial pain may have a variety of causes and offers a significant clinical challenge for its diagnosis and management.

Objective

To assess the headache disorders presenting in a tertiary multidisciplinary orofacial pain clinic, after dental causes have been excluded.

Methods

Clinic letters from the initial consultation and subsequent follow up reviews of the 142 patients, who were seen in the tertiary Multidisciplinary Orofacial Pain clinic between January 2015 until January 2018 were reviewed as a clinical audit.

Results

The most common diagnoses were possible trigeminal autonomic cephalalgia (n = 62, 44%), migraine (n = 38, 27%) and painful post-traumatic trigeminal neuropathy (n = 17, 12%). The most common trigeminal autonomic cephalalgia diagnosis was hemicrania continua (n = 13, 9%), which is higher than the reported prevalence in neurology and headache clinics.

Conclusion

This study demonstrates the importance of a multidisciplinary approach to diagnosing complex orofacial pain patients and the importance of awareness of primary headache disorders, in particular trigeminal autonomic cephalalgias, thereby reducing unnecessary diagnostic delays or procedures.

Cluster Headache in Kuwait: A Hospital-Based Study

Background: Cluster headache (CH) is a relatively uncommon primary headache disorder. Few studies in our region described CH. We aimed to study demographics, clinical characteristics and treatment modalities of CH patients referred to Headache Clinic in Kuwait. Materials and Methods: This cross-sectional study included all CH patients who are referred to headache clinic. The diagnosis of CH based on the CH diagnostic criteria of the Headache Classification Committee of the IHS, 3rd edition (beta version) (ICHD-3-beta). The demographics, clinical characteristics and treatment modalities of CH patients were recorded. Results: Forty six patients were diagnosed with CH which constituted 1.7% of all headache patients and 0.1% of all visits to Neurology clinic. Male:Female ratio was 15.3:1. Mean age was 40.1 ± 10.7 years and mean age at onset was 29 years (20-49). Family history was positive in 6.5%. Smoking was seen in 63.0% of patients while 6.5 % reported alcohol intake. CH was episodic in 84.4% and chronic in 15.2%. Seasonal predilection was seen in all patients; the most frequent season was Autumn 47.8%. The mean duration of the cluster bouts was 6 weeks (2-12 weeks). The mean duration of the attack was 60 min (15-180 min). Number of attacks per day ranged from 2 to 10 attacks with a mean of 5 attacks/day. The median of attack severity by Visual Analog Scale (VAS) was 8.5 (7-10). The time taken to diagnose the patients ranged from <1 year to 12 years with a mean of 4 years. Chronic CH have a statically significant relation with smoking (P = 0.036), older age (P = 0.027), and longer time taken to diagnosis (P = 0.026) compared to episodic CH. Conclusion: Our results reported that there is higher proportion of males compared to females and less positive family history. Smoking was a significant risk factor for chronicity in addition to advanced age, higher age at disease onset and a longer time taken till diagnosis.

Uncommon Pediatric Primary Headache Disorders

Migraine and tension-type headaches are common primary headache disorders encountered among children and adolescents presenting to a pediatric clinic. At times, children present with a headache with unusual or peculiar features that can be alarming and perplexing. These can be in the form of a brief stabbing headache with lacrimation in one eye or a continuous headache locked to one side of the head or face. These headache syndromes tend to be more common among adults but, on occasion, are known to occur or have their onset during childhood. This review outlines some of the uncommon primary headache disorders in children and adolescents that may be encountered in a pediatric clinic. Knowledge of these interesting conditions may avert the need for immediate neurological consultation and prevent delays in initiating specific therapy. [Pediatr Ann. 2018;47(2):e69-e73.].

Side-locked headaches: an algorithm-based approach

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.