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Miedl M, Baumgartner P, Disse LR, Weber KP, Pohl H, Wegener S. Harlequin syndrome in a patient with probable hemicrania continua and exertional headache - is there a link? a case report. BMC Neurol 2024; 24:247. [PMID: 39020271 PMCID: PMC11253322 DOI: 10.1186/s12883-024-03731-y] [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: 11/29/2023] [Accepted: 06/14/2024] [Indexed: 07/19/2024] Open
Abstract
BACKGROUND The harlequin syndrome is a rare disorder of the autonomic nervous system characterized by unilateral diminished flushing and sweating of the face following exposure to heat or physical activity. It results from sympathetic dysfunction and most commonly occurs idiopathically. A secondary development due to an underlying pathology (e.g., carotid artery dissection, tumors) must be excluded at first appearance. There is evidence that the cranial autonomic system is involved in the pathophysiology of trigeminal autonomic headaches like hemicrania continua. Therefore, an overlap in the pathophysiology of harlequin syndrome and trigeminal autonomic headache disorders seems plausible. However, the association of a harlequin syndrome with hemicrania continua was never reported. CASE PRESENTATION This work describes the case of a 42-year-old female patient presenting to our headache unit. The patient reported persisting unilateral headache of the right side of dragging or squeezing character accompanied by trigeminal autonomic symptoms, including lacrimation, nasal congestion, conjunctival injection and Horner's syndrome, and was responsive to treatment with 75mg/d indomethacin. Five months after the initial consultation, the patient noted that the upper right quadrant of her face was pale after jogging. A harlequin syndrome was diagnosed. Further, she developed a short-lasting, bilateral headache of pulsatile character during strenuous exercise consistent with exertional headache. Comprehensive diagnostic evaluations, encompassing cranial and cervical MRI scans, laboratory tests, and biopsies, culminated in the diagnosis of Sjögren's syndrome. This finding suggests that the trigemino-autonomic dysfunction may either be idiopathic or a direct manifestation of Sjögren's syndrome. CONCLUSIONS This report documents the case of a rare combination of a headache resembling probable hemicrania continua and the harlequin syndrome (and even exertional headache). It illustrates the underlying anatomy of the autonomic nervous system in a clinical context and emphasizes the hypothesis of a pathophysiological link between abnormal sympathetic activity and trigeminal autonomic headaches.
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Affiliation(s)
- Markus Miedl
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
| | | | - Leah Raffaela Disse
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
- Department of Ophthalmology, University Hospital Zurich, Zurich, Switzerland
| | - Konrad Peter Weber
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
- Department of Ophthalmology, University Hospital Zurich, Zurich, Switzerland
| | - Heiko Pohl
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
| | - Susanne Wegener
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland.
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Alalami K, Goff J, Grimson H, Martin O, McDonald E, Mirza T, Mistry D, Ofodile A, Raja S, Shaker T, Sleibi D, Forget P. Does Topical Capsaicin Affect the Central Nervous System in Neuropathic Pain? A Narrative Review. Pharmaceuticals (Basel) 2024; 17:842. [PMID: 39065693 PMCID: PMC11279538 DOI: 10.3390/ph17070842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2024] [Revised: 06/21/2024] [Accepted: 06/25/2024] [Indexed: 07/28/2024] Open
Abstract
Research has been conducted investigating the neuronal pathways responsible for the generation of chronic neuropathic pain, including the components of it in conditions such as chronic post-surgical pain, phantom limb pain, and cluster headaches. Forming part of the management of such conditions, capsaicin as a molecule has proven effective. This review has investigated the central nervous system modifications exhibited in such conditions and the pharmacological mechanisms of capsaicin relevant to this. The current paradigm for explaining topical capsaicin-induced analgesia is that TRPV1-mediated calcium ion influx induces calpain, in turn causing axonal ablation and functional defunctionalisation in the PNS (Peripheral Nervous System). Demonstrated through the analysis of existing data, this review demonstrates the changes seen in the CNS (Central Nervous System) in chronic neuropathic pain, as well as some of the evidence for capsaicin modulation on the CNS. Further supporting this, the specific molecular mechanisms of capsaicin-induced analgesia will also be explored, including the action of TRPV1, as well as discussing the further need for clinical research into this area of uncertainty due to the limited specific data with suitable parameters. Further research this review identified as potentially useful in this field included fMRI (functional Magnetic Resonance Imaging) studies, though more specific observational studies of patients who have already been administered capsaicin as a current treatment may prove helpful in studying the modification of the CNS in the long term.
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Affiliation(s)
- Kareem Alalami
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Polwarth Building, Foresterhill Health Campus, Aberdeen AB24 3FX, UK; (K.A.); (D.S.)
| | - Jenna Goff
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Polwarth Building, Foresterhill Health Campus, Aberdeen AB24 3FX, UK; (K.A.); (D.S.)
| | - Hannah Grimson
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Polwarth Building, Foresterhill Health Campus, Aberdeen AB24 3FX, UK; (K.A.); (D.S.)
| | - Oliver Martin
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Polwarth Building, Foresterhill Health Campus, Aberdeen AB24 3FX, UK; (K.A.); (D.S.)
| | - Eloise McDonald
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Polwarth Building, Foresterhill Health Campus, Aberdeen AB24 3FX, UK; (K.A.); (D.S.)
| | - Thonima Mirza
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Polwarth Building, Foresterhill Health Campus, Aberdeen AB24 3FX, UK; (K.A.); (D.S.)
| | - Dhruvi Mistry
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Polwarth Building, Foresterhill Health Campus, Aberdeen AB24 3FX, UK; (K.A.); (D.S.)
| | - Adanma Ofodile
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Polwarth Building, Foresterhill Health Campus, Aberdeen AB24 3FX, UK; (K.A.); (D.S.)
| | - Sara Raja
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Polwarth Building, Foresterhill Health Campus, Aberdeen AB24 3FX, UK; (K.A.); (D.S.)
| | - Tooba Shaker
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Polwarth Building, Foresterhill Health Campus, Aberdeen AB24 3FX, UK; (K.A.); (D.S.)
| | - Danah Sleibi
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Polwarth Building, Foresterhill Health Campus, Aberdeen AB24 3FX, UK; (K.A.); (D.S.)
| | - Patrice Forget
- Epidemiology Group, Institute of Applied Health Sciences, School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Polwarth Building, Foresterhill Health Campus, Aberdeen AB25 2ZN, UK
- Department of Anaesthesia, NHS Grampian, Aberdeen AB25 2ZN, UK
- Pain and Opioids after Surgery (PANDOS) Research Groups, European Society of Anaesthesiology and Intensive Care, 1000 Brussels, Belgium
- Anesthesia Critical Care, Emergency and Pain Medicine Division, 30900 Nîmes University Hospital, IMAGINE UR UM 103, Montpellier University, 30900 Nîmes, France
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Pohl H. History of cluster headache. CEPHALALGIA REPORTS 2022. [DOI: 10.1177/25158163221128183] [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
Objective: To summarise the history of cluster headache evolving concepts and growing insights. Background: Excruciating pain, activation of the parasympathetic nervous system, and circadian rhythmicity characterise cluster headache attacks. Results: We find the oldest descriptions of patients suffering from the disorder in case reports of the 17th and 18th centuries. Only in the 19th and early 20th centuries did physicians start hypothesizing its cause. Initially, many researchers suspected the origin of the pain in peripheral nerves or blood vessels. However, eventually, they understood that the cause of the disease lies in the brain. In 1998, Positron emission tomography studies revealed increased activity of the posterior hypothalamus, whose role remains incompletely understood. Only recently have researchers realised that being diseased implies more than dysfunction. Recent studies analysed the consequences of cluster headache for each patient. Many struggle to deal with the disorder even in the absence of pain. Conclusion: Physicians have been aware of this type of pain for at least 300 years. Only when researchers studied pathological anatomy and physiology did knowledge accrue. A more comprehensive picture of the disease severity emerged when they also considered its consequences.
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Affiliation(s)
- Heiko Pohl
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
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