[Effect of treatment with benzodiazepines on the hospital prognosis of Coronavirus disease 2019]

INTRODUCTION

The consequences of the use of of benzodiazepines in coronavirus disease 2019 have not yet been studied. We compared the hospital prognosis of patients hospitalized for coronavirus disease 2019 in benzodiazepine users and non-users.

PATIENTS AND METHODS

Observational study with a retrospective cohort design. All consecutive patients admitted with a confirmed diagnosis of coronavirus disease 2019 were included. The patients under chronic treatment with benzodiazepines at the time of admission were studied and compared with non-users. The primary objective was to analyze the mortality of patients who used chronic benzodiazepines at the time of admission and compare them with those who did not use them. The secondary objective was to analyze the risk of severe disease due to coronavirus 2019, acute respiratory distress syndrome and admission to the Intensive Care Unit in both groups of patients.

RESULTS

We included 576 patients, 138 (24.0%) used benzodiazepines. After adjusting for sex, age, baseline situation and all the different variables between both groups, benzodiazepine users did not show a higher odds of mortality (OR: 1,1, IC 95%: 0,7-1,9, p = 0,682) or higher risk of severe disease due to coronavirus 2019 (OR: 1.2, 95% CI: 0.7-1.8, p = 0.523). They also did not have a higher risk of acute respiratory distress syndrome (OR: 1.2, IC 95%: 0.8-1.9, p = 0.315) or more admission to the Intensive Care Unit (OR: 0.8, 95% CI: 0.4-1.4, p = 0.433).

CONCLUSION

In our sample, treatment with benzodiazepines at the time of admission was not associated with a worse hospital prognosis in patients with coronavirus disease 2019.

Patients and general practitioners assessment of the main outcomes employed in the acute and preventive treatment of migraine: a cross sectional study

Background

We aim to describe and compare patients and general practitioners’ opinions about the different variables related to acute and preventive treatment for migraine.

Patients and methods

An observational descriptive study was performed. Patients with episodic migraine and general practitioners, from our healthcare area, were invited to answer a survey about the different variables related to migraine treatment. They were asked for their opinions on the different variables, and to consider the desired efficacy in percentage terms and the desired action times of treatment.

Results

Fifty-five patients and fifty-five general practitioners were selected. Effectiveness was considered the most important variable for symptomatic and preventive treatment. Cost was considered the least important variable. Patients desired percentage of efficacy was 84.0% (±16.7%) for symptomatic treatment and 79.9% (±17.1%) for preventive treatment. General practitioners desired percentage of efficacy was 75.0% (±14.0) for symptomatic treatment and 70.4% (±14.3) for preventive treatment. For symptomatic treatment the desired action time for pain cessation was selected as 27.5 min (±13.8) for patients and 24.0 min (±18.3) for GPs. For preventive treatment the desired action time for effect was 7.1 days (±4.5) for patients and 13.9 days (±8.9) for general practitioners.

Conclusion

The most important endpoints were, for acute: effectiveness, a short action time and a persistent effect. For prophylactic: effectiveness, sustained effect and tolerability. Both patients and general practitioners agreed on the most and least preferred endpoints. Desired percentage of efficacy was above 75% for both symptomatic and preventive treatment; and the desired action time was below 30 min for acute treatment and 2 weeks for preventive treatment.

Daily Headache in Chronic Migraine Is a Predictive Factor of Response in Patients Who Had Completed Three Sessions of OnabotulinumtoxinA

OnabotulinumtoxinA is one of the main preventive treatments for chronic migraine. Despite that up to one third of patients with chronic migraine suffer from daily headache, these individuals have hardly been studied. We conducted a prospective cohort study, including patients with chronic migraine and treated with OnabotulinumtoxinA according to the PREEMPT paradigm. The primary endpoint was to assess whether patients with chronic migraine and daily headache had a different response after three sessions of OnabotulinutoxinA than patients without daily headache. The secondary endpoint was to analyse the presence of predictive factors that could be associated with a higher response to OnabotulinumtoxinA. Patients with daily headache had a reduction of 14.9 (SD: 9.7) headache days per month, patients with 22–29 headache days a reduction of 10.6 (SD: 9.9) days, and patients with 15–21 headache days a reduction of 8.6 (SD: 7.1) days (p < 0.001). In the univariate regression analysis, a higher number of headache days per month at baseline was associated with higher odds of reduction in the number of headache days per month after OnabotulinumtoxinaA treatment (OR: 0.474, 95% CI: 0.278–0.670, p < 0.001). This association was maintained in the multivariate regression analysis (OR: 0.540, 95% CI: 0.333–0.746, p < 0.001). In our sample, daily headache was not associated with a worse response to OnabotulinumtoxinA treatment. A higher frequency of headache at baseline was a predictor of better response to OnabotulinumtoxinA treatment.

SECONDARY NUMMULAR HEADACHE: A NEW CASE SERIES AND REVIEW OF THE LITERATURE

BACKGROUND

Nummular Headache (NH) is defined in the International Classification of Headache Disorders (ICHD) by the presence of localized pain circumscribed to a small round area of the scalp, not better accounted by any other diagnosis. As in many other primary headache disorders, secondary cases might occur. To date, 13 secondary cases have been published. We aim to present a long series of secondary NH and review the literature of symptomatic NH.

PATIENTS AND METHODS

Retrospective analysis of an observational prospective cohort in a headache unit located in a tertiary hospital. We included patients that fulfilled ICHD criteria and were attributed to a secondary cause. We describe the clinical characteristics, the underlying causes, and the response to treatment.

RESULTS

We included 274 NH patients, 8 of them (2.9%) were considered secondary. In 1 patient the underlying cause was subcutaneous, as for 6 cases the lesion was located in the bone (two hemangiomas, 1 osteoma, 3 different types of cysts), and in one was intracranial but closely related with internal diploe (cavernoma). Among our patients with secondary NH, a preventive therapy was not always needed and, when required, gabapentin or onabotulinumtoxinA were used with positive response.

CONCLUSION

Secondary NH phenotype overlaps primary NH. Therefore, we recommend routine imaging study in every NH patient. Concerning treatment, it was not necessary to remove the underlying lesion to control the pain and many cases responded to the same prophylactics as primary NH cases.

Linear Headache: A Novel Entity or a Variant of Nummular Headache? Clinical Characteristics and Treatment Response in a Series of 16 Patients

OBJECTIVE

Linear headache has been recently described as an episodic or chronic unilateral pain distributed along a fixed linear trajectory, which combines some characteristics of epicrania fugax and nummular headache. The aim of this study was to describe the clinical characteristics and therapeutic response of a series of 16 new patients.

DESIGN

This is an observational study with a series of cases.

SETTING

The study period encompassed June 2014 to June 2019. Demographic, clinical, and therapeutic response data were recorded.

METHODS

We included all consecutive patients who presented pain with the following characteristics: sharply contoured, fixed in size and shape, with linear shape, without movement along a trajectory, and not circumscribed to the territory of any nerve.

RESULTS

Twelve patients were women, and four were men. The mean age at onset was 40.1 years. Pain was described as pressing in seven patients, burning in five, and electric or stabbing in two each. Symptomatic treatment had been used by 13 patients (81.2%), with analgesics being the most frequent treatment used. Thirteen patients received preventive treatment. The response to oral medications and anesthetic blockade was insufficient. OnabotulinumtoxinA was used in six cases, with an optimal (>75%) response observed in half.

CONCLUSION

Linear headache appears to be a distinct headache syndrome from epicrania fugax or nummular headache. Preventive treatment is often required. The drug with the best response was onabotulinumtoxinA.

Clinical Characteristics and Therapeutic Results in a Series of 68 Patients with Occipital Neuralgia

OBJECTIVE

Cranial pain is a condition that has a negative impact on human lives, and occipital neuralgia is among its causes. This study aims to evaluate the clinical characteristics and therapeutic results of a series of patients with occipital neuralgia.

DESIGN

Prospective registry (observational study).

SETTINGS

Headache outpatient clinic in a tertiary hospital.

SUBJECTS

Sixty-eight cases.

METHODS

Demographic and nosological characteristics have been analyzed, as well as treatment response of occipital neuralgia. All patients were recruited between January 2008 and January 2018, and the diagnosis of occipital neuralgia was made according to the International Headache Society (International Classification of Headache Disorders) criteria being utilized at the time of diagnosis.

RESULTS

Sixty-eight patients were diagnosed with occipital neuralgia, which corresponded to 1.2% of the total number of patients (5,515) who visited our Headache Unit during the aforementioned period. Fifty-four (79.4%) of them were female. Baseline pain was present in 62 (91.1%) patients, and exacerbations in 42 (61.8%). Latency from onset (range) was 27.7 ± 56.1 (1-360) months.

CONCLUSIONS

Occipital neuralgia is an uncommon disorder in the sample explored. The prolonged latency between the onset of symptoms and diagnosis suggests that there should be an increased awareness of this disorder.

Neurological symptoms in Covid-19 patients in the emergency department

BACKGROUND

Coronavirus disease 2019 (Covid-19) might present neurological symptoms. We aimed to evaluate the frequency of them at the moment of emergency department (ED) visit and their impact in the prognosis.

METHODS

Retrospective cohort study including all consecutive hospitalized cases between March 8th and April 11th, 2020. Covid-19 diagnosis was confirmed by polymerase chain reaction test and/or serology. We compared, in patients with and without neurological symptoms on admission, demographic, clinical presentation, and frequency and type of abnormal laboratory values. We analyzed the variables that were associated with in-hospital all-cause mortality by Cox-regression log-rank test.

RESULTS

We included 576 hospitalized patients, 250 (43.3%) female, aged 67.2 years. At the moment of ED visit, 320 (55.6%) described neurological symptoms, including anosmia (146, 25.3%), myalgia (139, 24.1%), headache (137, 23.8%), and altered mental status (98, 17.0%). Neurological symptoms started the first symptomatic day in 198 (54.2%) cases. Patients with neurological symptoms presented later to the ED (7.9 versus. 6.6 days, p = .019). Only four (0.6%) cases had no typical Covid-19 general symptoms, and only six (1.9%) had a normal laboratory results, for a sensitivity of 98.7% (95% confidence interval (CI): 96.6%-99.6%) and 98.1% (95% CI: 95.7%-99.2%), respectively. In the multivariate Cox-regression of mortality predictors, anosmia (HR: 0.358, 95%CI: 0.140-0.916) and altered mental status (HR: 1.867, 95%CI: 1.162-3.001) were significant.

CONCLUSION

Neurological symptoms were the most frequent extrapulmonary symptoms. They were present in half of the Covid-19 patients at the time of the ED visit. Anosmia on admission was an independent predictor of lower in-hospital mortality and altered mental status on admission predicted in-hospital mortality.

Severe Epistaxis after Tissue Plasminogen Activator administration for Acute Ischemic Stroke in SARS-COV-2 Infection

Patients with COVID-19 may suffer from hemorrhagic complications. Our article highlights two cases of COVID-19-infected patients, who suffered severe epistaxis after initiation of intravenous recombinant tissue plasminogen activator (IV-rtPA) for acute ischemic stroke, followed by a sudden decline in their clinical status and ultimately leading to death within days. Given the global impact and mortality of COVID-19, it is essential to be aware of its unusual presentation and improve therapeutic strategies. We present two cases of individuals who suffered from a large vessel occlusion of and were candidates for both IV-rtPA and mechanical thrombectomy. They received IV-rtPA but had epistaxis so severe that they were not able to receive MT and died within the next few days. There are many potential mechanisms by which epistaxis can happen in an individual with COVID-19 who received IV-rtPA including invasion of the nasal mucosa and endothelium through angiotensin-converting enzyme 2 receptors by the virus. We also hypothesize that the coagulation abnormality seen in COVID-19 patients can be potentiated by the use of treatments such as IV-rtPA. We review these issues with a diagram illustrating the possible mechanisms.

[Temporal pole encephalocele, a surgical treatable cause of drug-resistant epilepsy]

INTRODUCTION

Encephaloceles are herniation of brain parenchyma through a bony skull defect that can cause drug-resistant epilepsy. In these cases, a surgical approach should be considered.

CASE REPORT

38-year-old man with drug-resistant epilepsy and 1.5 T magnetic resonance imaging performed with no relevant findings. After video-electroencephalogram, 3 T magnetic resonance imaging and F-18-fluoro-deoxy-glucose positron emission tomography, a right temporal encephalocele was confirmed. A right temporal polar resection was performed four years ago and the patient remains seizure-free.

DISCUSSION

Anterior temporal encephaloceles are an underdiagnosed cause of epilepsy, and a 3 T magnetic resonance imaging reviewed by an epilepsy expert radiologists is key to diagnosis.

CONCLUSION

In drug-resistant cases with presurgical evaluation compatible with the location, surgical treatment must be considered.

[Chronic migraine with daily headache. Literature review]

INTRODUCTION

Despite representing a significant number of cases, patients with chronic migraine and daily headache are frequently excluded from large therapeutic clinical trials. These individuals have hardly been studied and could have specific properties. Development. A third of patients with chronic migraine may suffer from headaches every day, representing up to 1.7 - 3.3% of patients in a general neurology consultation. These patients are excluded from most studies, so little information is available. They may have a longer lasting migraine and different response to treatment. Patients with chronic migraine and daily headache may have complex pathophysiological mechanisms that favor the daily manifestation of migraine. The management of these patients is a therapeutic challenge, and OnabotulinumtoxinA may be useful.

CONCLUSION

Patients with chronic migraine and daily headache may have specific clinical and therapeutic characteristics. New studies could lead to differentiate it from chronic migraine.

Anosmia is associated with lower in-hospital mortality in COVID-19

BACKGROUND

Anosmia is common in Coronavirus disease 2019, but its impact on prognosis is unknown. We analysed whether anosmia predicts in-hospital mortality; and if patients with anosmia have a different clinical presentation, inflammatory response, or disease severity.

METHODS

Retrospective cohort study including all consecutive hospitalized patients with confirmed Covid-19 from March 8th to April 11th, 2020. We determined all-cause mortality and need of intensive care unit (ICU) admission. We registered the first and worst laboratory parameters. Statistical analysis was done by multivariate logistic and linear regression.

RESULTS

We included 576 patients, 43.3% female, and aged 67.2 years in mean. Anosmia was present in 146 (25.3%) patients. Patients with anosmia were more frequently females, younger and less disabled and had less frequently hypertension, diabetes, smoking habit, cardiac and neurological comorbidities. Anosmia was independently associated with lower mortality (OR: 0.180, 95% CI: 0.069-0.472) and ICU admission (OR: 0.438, 95% CI: 0.229-0.838, p = 0.013). In the multivariate analysis, patients with anosmia had a higher frequency of cough (OR: 1.96, 95%CI: 1.18-3.28), headache (OR: 2.58, 95% CI: 1.66-4.03), and myalgia (OR: 1.74, 95% CI: 1.12-2.71). They had higher adjusted values of hemoglobin (+0.87, 95% CI: 0.40-1.34), lymphocytes (+849.24, 95% CI: 157.45-1541.04), glomerular filtration rate (+6.42, 95% CI: 2.14-10.71), and lower D-dimer (-4886.52, 95% CI: -8655.29-(-1117.75)), and C-reactive protein (-24.92, 95% CI: -47.35-(-2.48)).

CONCLUSIONS

Hospitalized Covid-19 patients with anosmia had a lower adjusted mortality rate and less severe course of the disease. This could be related to a distinct clinical presentation and a different inflammatory response.

Triptanophobia in migraine: A case-control study on the causes and consequences of the nonuse of triptans in chronic migraine patients

Background: Triptanophobia is the excessive and inadequately justified concern about potential risks of triptans. We evaluated causes and consequences of nonuse of triptans in chronic migraine (CM) Methods: Case-control study. We included CM patients firstly referred to aheadache unit. Patients were cases or controls depending on whether they were triptan naïve, or not. We analyzed if nonuse of triptans was justified by formal contraindications or adverse events. We assessed if triptan naïve patients had higher frequency of vascular risk factors (VRF), contraceptive drugs or older age. Results: We included 941 patients, 247 (26.2%) triptan users. Triptans had been discontinued due to tolerability in 116 patients (12.3%), being 578 patients (61.4%) triptan naïve. Formal contraindications were found in 23 patients (2.4%). Frequency of VRF, contraceptive drugs or age did not differ between the groups (p > 0.1). Triptan users consumed symptomatic medications fewer days/month (13.9 vs 17.1, p < 0.001), were under prophylactic treatment more frequently (79.4% vs 34.8%, p < 0.001) and had medication overuse headache less frequently (55.1% vs. 63.0%, p = 0.03). Conclusion: Triptans were not used by three-quartersof CM patients. Nonuse of triptans was not justified by tolerability, frequency of contraindications, or frequency of VRF. Expert opinion: In the present study, we evaluated causes and consequences of the nonuse of triptans in CM sufferers. We analyzed frequency of triptan use in CM patients. We compared, between triptan users and triptan naïve patients, the presence of contraindications, frequency of vascular risk factors, and differences in management prior to the referral to a headache unit.

Frequency and Type of Red Flags in Patients With Covid-19 and Headache: A Series of 104 Hospitalized Patients

Objective

In this study, we aimed to evaluate the frequency of the main red flags in patients with headache who do have Covid‐19.

Background

Headache is one of the most frequent neurologic symptoms of Coronavirus disease 2019 (Covid‐19). Diagnosis of secondary headache disorders is still based on the presence of red flags.

Design and Methods

Cross‐sectional study of hospitalized patients with confirmed Covid‐19 disease. We interrogated every patient about the presence of headache and if so, a headache expert conducted a structured interview assessing the presence and type of the main red flags. We evaluated the presence of laboratory abnormalities on admission.

Results

We screened 576 consecutive patients, 130/576 (22.6%) described headache, and 104 were included in the study. Mean age of patients was 56.7 (standard deviation: 11.2) and 66/104 (63.4%) were female. Red flags concerning prior medical history were present in 79/104 (76.0%) cases, and those related to the headache itself were observed in 99/104 (95.2%) patients. All patients 104/104 (100%) described systemic symptoms and 86/104 (82.7%) some neurologic symptoms. Laboratory results were abnormal in 98/104 (94.2%) cases. The most frequent red flags were fever, in 93/104 (89.4%) patients, cough, in 89/104 (85.6% cases), and increased C‐reactive protein in 84/100 (84.0%) cases.

Conclusion

In patients with Covid‐19 that described the headache red flags were present in most cases. There was not any universal red flag, being necessary the comprehensive evaluation of all of them.

Factors associated with the presence of headache in hospitalized COVID-19 patients and impact on prognosis: a retrospective cohort study

INTRODUCTION

Headache is one of the most frequent neurologic manifestations in COVID-19. We aimed to analyze which symptoms and laboratory abnormalities were associated with the presence of headache and to evaluate if patients with headache had a higher adjusted in-hospital risk of mortality.

METHODS

Retrospective cohort study. We included all consecutive patients admitted to the Hospital with confirmed SARS-CoV-2 infection between March 8th and April 11th, 2020. We collected demographic data, clinical variables and laboratory abnormalities. We used multivariate regression analysis.

RESULTS

During the study period, 576 patients were included, aged 67.2 (SD: 14.7), and 250/576 (43.3%) being female. Presence of headache was described by 137 (23.7%) patients. The all-cause in-hospital mortality rate was 127/576 (20.0%). In the multivariate analysis, patients with headache had a lower risk of mortality (OR: 0.39, 95% CI: 0.17-0.88, p = 0.007). After adjusting for multiple comparisons in a multivariate analysis, variables that were independently associated with a higher odds of having headache in COVID-19 patients were anosmia, myalgia, female sex and fever; variables that were associated with a lower odds of having headache were younger age, lower score on modified Rankin scale, and, regarding laboratory variables on admission, increased C-reactive protein, abnormal platelet values, lymphopenia and increased D-dimer.

CONCLUSION

Headache is a frequent symptom in COVID-19 patients and its presence is an independent predictor of lower risk of mortality in COVID-19 hospitalized patients.

Neurological Comorbidity Is a Predictor of Death in Covid-19 Disease: A Cohort Study on 576 Patients

Introduction: Prognosis of Coronavirus disease 2019 (Covid-19) patients with vascular risk factors, and certain comorbidities is worse. The impact of chronic neurological disorders (CND) on prognosis is unclear. We evaluated if the presence of CND in Covid-19 patients is a predictor of a higher in-hospital mortality. As secondary endpoints, we analyzed the association between CND, Covid-19 severity, and laboratory abnormalities during admission.

Methods: Retrospective cohort study that included all the consecutive hospitalized patients with confirmed Covid-19 disease from March 8th to April 11th, 2020. The study setting was Hospital Clínico, tertiary academic hospital from Valladolid. CND was defined as those neurological conditions causing permanent disability. We assessed demography, clinical variables, Covid-19 severity, laboratory parameters and outcome. The primary endpoint was in-hospital all-cause mortality, evaluated by multivariate cox-regression log rank test. We analyzed the association between CND, covid-19 severity and laboratory abnormalities.

Results: We included 576 patients, 43.3% female, aged 67.2 years in mean. CND were present in 105 (18.3%) patients. Patients with CND were older, more disabled, had more vascular risk factors and comorbidities and fewer clinical symptoms of Covid-19. They presented 1.43 days earlier to the emergency department. Need of ventilation support was similar. Presence of CND was an independent predictor of death (HR 2.129, 95% CI: 1.382–3.280) but not a severer Covid-19 disease (OR: 1.75, 95% CI: 0.970–3.158). Frequency of laboratory abnormalities was similar, except for procalcitonin and INR.

Conclusions: The presence of CND is an independent predictor of mortality in hospitalized Covid-19 patients. That was not explained neither by a worse immune response to Covid-19 nor by differences in the level of care received by patients with CND.

Brain Atrophy and the Risk of Futile Endovascular Reperfusion in Acute Ischemic Stroke

Background and Purpose- We aimed to evaluate the impact of brain atrophy on long-term clinical outcome in patients with acute ischemic stroke treated with endovascular therapy, and more specifically, to test whether there are interactions between the degree of atrophy and infarct volume, and between atrophy and age, in determining the risk of futile reperfusion. Methods- We studied consecutive patients with acute ischemic stroke with proximal anterior circulation intracranial arterial occlusions treated with endovascular therapy achieving successful arterial recanalization. Brain atrophy was evaluated on baseline computed tomography with the global cortical atrophy scale, and Evans index was calculated to assess subcortical atrophy. Infarct volume was assessed on control computed tomography at 24 hours using the formula for irregular volumes (A×B×C/2). Main outcome variable was futile recanalization, defined by functional dependence (modified Rankin Scale score >2) at 3 months. The predefined interactions of atrophy with age and infarct volume were studied in regression models. Results- From 361 consecutive patients with anterior circulation acute ischemic stroke treated with endovascular therapy, 295 met all inclusion criteria. Futile reperfusion was observed in 144 out of 295 (48.8%) patients. Cortical atrophy affecting parieto-occipital and temporal regions was associated with futile recanalization. Total global cortical atrophy score and Evans index were independently associated with futile recanalization in an adjusted logistic regression. Multivariable adjusted regression models disclosed significant interactions between global cortical atrophy score and infarct volume (odds ratio, 1.003 [95%CI, 1.002-1.004], P<0.001) and between global cortical atrophy score and age (odds ratio, 1.001 [95% CI, 1.001-1.002], P<0.001) in determining the risk of futile reperfusion. Conclusions- A higher degree of cortical and subcortical brain atrophy is associated with futile endovascular reperfusion in anterior circulation acute ischemic stroke. The impact of brain atrophy on insufficient clinical recovery after endovascular reperfusion appears to be independently amplified by age and by infarct volume.

Observational, open-label, non-randomized study on the efficacy of onabotulinumtoxinA in the treatment of nummular headache: The pre-numabot study

Background

Nummular headache is a primary headache characterised by superficial, coin-shaped pain. Superficial sensory fibre dysfunction might be involved in its pathophysiology. Considering the mechanism of action of onabotulinumtoxinA, it could be a reasonable option in treatment of nummular headache. The aim of the study was to evaluate the efficacy and tolerability of onabotulinumtoxinA in a series of nummular headache patients.

Patients and methods

This was an observational, prospective, non-randomized and open-label study. Nummular headache patients with at least 10 headache days in three preceding months were included. They were administered 25 units of onabotulinumtoxinA. The primary endpoint was the decrease of headache days per month, evaluated between weeks 20 to 24, compared with baseline. The secondary endpoints included reduction of intense headache days and acute treatment days evaluated between weeks 20–24 and weeks 8–12, compared with baseline. The 30%, 50% and 75% responder rates were determined, and tolerability described.

Results

We included 53 patients, 67.9% females, with a median age of 54 years. Preventive treatment had been used previously in 60.4% of patients. The median diameter of the nummular headache was 5 cm. At baseline, the number of headache days per month was 24.5 (7.3); the number of intense headache days was 12.5 (10.1), and the number of acute treatment days was 12.8 (7.8). After onabotulinumtoxinA, the mean number of headache days per month decreased to 6.9 (9.3) between weeks 20 and 24 ( p < 0.001). Secondary endpoints concerning intense headache days per month and acute treatment days per month were also statistically significant ( p < 0.001). The 50% responder rate, evaluated between weeks 20 and 24, was 77.4% and the 75% responder rate was 52.8%. Concerning tolerability, 26 patients (49.1%) experienced an adverse event (AE), the commonest being injection-site pain in 12 cases (22.6%). There were no moderate or severe AEs.

Conclusion

It was found that after injecting onabotulinumtoxinA, the number of headache days per month was reduced in nummular headache patients. The number of intense headache days per month and acute treatment days were also lowered. No serious adverse events occurred during treatment.

Epicrania Fugax as the presenting symptom of a cerebellar abscess

Background

Epicrania fugax is included in the appendix of the International Classification of Headache Disorders and is characterized as recurrent brief attacks of linear or zigzag pain moving across the cranial surface, commencing and terminating in the distribution of different nerves. We present a new case of epicrania fugax in which the headache was the presenting symptom of a cerebellar abscess.

Case report

We present a 58-year-old woman with prior history of Chiari I malformation who underwent suboccipital craniectomy. Two weeks after surgery, she experienced paroxysmal pain episodes of 1–3 seconds, with constant linear trajectory from the right occipital surface to the right orbital region, remaining pain free between episodes. Cranial tomography showed a hypodense intraaxial lesion in the right cerebellar hemisphere. Magnetic Resonance Imaging exhibited intralesional bleeding and peripheral enhancement after gadolinium administration. Post-surgical cerebellar abscess was diagnosed and antibiotic therapy was started; the patient underwent urgent surgical drainage. Pain disappeared after the surgery and the patient remains pain free with 12 months of follow-up.

Conclusion

Posterior fossa abnormalities have been described as a possible cause of secondary epicrania fugax. The presence of red flags should encourage conducting of paraclinical tests to rule out a symptomatic form.