Risk factors and analysis of long-term headache in sporadic vestibular schwannoma: a multicenter cross-sectional study

OBJECT

The primary goals of this study were: 1) to examine the influence of disease and treatment on headache in patients with sporadic vestibular schwannoma (VS); and 2) to identify clinical predictors of long-term headache disability.

METHODS

This was a cross-sectional observational study with international multicenter enrollment. Patients included those with primary sporadic <3-cm VS and a separate group of general population control subjects without tumors. Interventions included a postal survey incorporating the Headache Disability Inventory (HDI), the Hospital Anxiety and Depression Scale, and a VS symptom questionnaire. The main outcome measures were univariate and multivariable associations with HDI total score.

RESULTS

The overall survey response rate was 79%. Data from 538 patients with VS were analyzed. The mean age at time of survey was 64 years, 56% of patients were female, and the average duration between treatment and survey was 7.7 years. Twenty-seven percent of patients received microsurgery, 46% stereotactic radiosurgery, and 28% observation. Patients with VS who were managed with observation were more than twice as likely to have severe headache disability compared with 103 control subjects without VS. When accounting for baseline differences, there was no statistically significant difference in HDI outcome between treatment modalities at time of survey. Similarly, among the microsurgery cohort, the long-term risk of severe headache disability was not different between surgical approaches. Multivariable regression demonstrated that younger age, greater anxiety and depression, and a preexisting diagnosis of headache were the primary predictors of severe long-term headache disability, while tumor size and treatment modality had little influence.

CONCLUSIONS

At a mean of almost 8 years following treatment, approximately half of patients with VS experience headaches of varying frequency and severity. Patient-driven factors including age, sex, mental health, and preexisting headache syndrome are the strongest predictors of long-term severe headache disability. Tumor size and treatment modality have less impact. These data may assist with patient counseling regarding long-term expectations following diagnosis and treatment.

Characteristics of Post-Ictal Headaches in Patients with Epilepsy: a Longitudinal Study

OBJECTIVES

This study aimed to investigate the clinical predictors of post-ictal headache (PIH) in patients with epilepsy in a tertiary center in Brazil.

METHODS

302 individuals with adult-onset epilepsy were followed for 9.8 years in our Hospital. Structured questionnaires about headaches were applied. The presence of PIH was the primary outcome. We used multilevel linear modeling in our data analysis.

RESULTS

From the total, 46.3% had post-ictal headaches. Tension-type post-ictal headache was present in 55% (N = 77) of the subjects, migrainous in 32.1% (N = 45), and both types in 12.8% (N = 18). Family history of migraine (Odds ratio: 1.696; 95% CI: 1.372 to 2.096), diagnosis of drug-resistant epilepsy (Odds ratio: 1.169; 95% CI: 1.135 to 2.146), months since last visit (Odds ratio: 1.464; 95% CI: 1.243 to 2.888), and generalized seizure onset type of epilepsy (Odds ratio: 1.527; 95% CI: 1.114 to 1.668), were significant determinants of PIH on multilevel linear modeling.

DISCUSSION

PIH are associated with drug-resistant epilepsy, generalized seizures, and family history of migraine. The rates of pos-ictal headaches could be influenced by the use of antiepileptic drugs.

Cardiac cephalgia: a diagnostic headache

A 73-year-old man presented with a 6-month history of exertional headaches. Exercise tolerance test demonstrated progressive ischaemic changes concomitant with worsening headache. Cardiac cephalgia was diagnosed and his symptoms resolved after coronary artery bypass surgery. Cardiac cephalgia may occasionally present as exertional headache without chest symptoms.

Efficacy and Safety of Cryoneurolysis for Treatment of Chronic Head Pain Secondary to Occipital Neuralgia: A Pilot Study

Purpose

Treatment of chronic pain associated with occipital neuralgia (ON) is complex, and no consensus statement or guidelines have been published for ON management. This pilot study evaluated the efficacy and safety of cryoneurolysis for management of ON-associated chronic pain.

Patients and Methods

The study was a prospective, multicenter, nonrandomized cohort study assessing the degree and duration of clinical effect of cryoneurolysis therapy for reducing pain in patients diagnosed with unilateral or bilateral ON. The primary outcome measure was improvement in pain due to ON from baseline to day 7, measured on an 11-point numeric rating scale for pain. Secondary outcome measures included duration of treatment effects and safety events, including anticipated observations and adverse events. Treatment effect was assessed at days 7, 30, and 56 by asking the patient if they were continuing to experience a treatment effect, with potential responses of “effect,” “no effect,” or “no longer effective.” A posttreatment questionnaire evaluated patient satisfaction.

Results

Twenty-six patients (9 men, 17 women) with a mean age of 49.1 years enrolled and completed the study. A total of 64% (16/25) of participants reported a clinically important improvement of ≥2 points in numeric rating scale pain scores at day 7; similar results persisted to day 30. Treatment effects were reported by 50% (13/26) of participants at day 30, with a continued effect reported by 35% (9/26) of participants at day 56. Overall, ~70% of participants were satisfied with treatment at 7, 30, and 56 days. No serious anticipated observations, adverse events, or unanticipated adverse device effects were reported.

Conclusion

Cryoneurolysis provided significant relief from pain associated with ON ≤30 days after treatment and had an acceptable safety profile.

NON-CERVICOGENIC HEADACHE

A 40 year old overweight female presented with an intractable headache which had been present over a two week period. The patient had a history of cervicogenic headache which had responded to manipulation. Examination revealed elevated blood pressure and papilloedema. The differential diagnosis of papilloedema is discussed in respect to this case.

Efficacy of ketorolac in the treatment of acute migraine attack: A systematic review and meta-analysis

OBJECTIVES

This review was designated to evaluate the efficacy of parenteral ketorolac in treating acute migraine headache.

METHODS

We searched databases Cochrane Central Register of Controlled Trials (CENTRAL), Medline, and Google Scholar up to January 2021 and identified randomized controlled trials comparing ketorolac to any other medications in treating patients presenting with migraine headache.

RESULTS

Thirteen trials were included in our review, comprising 944 participants. We derived seven comparisons: ketorolac versus phenothiazines, metoclopramide, sumatriptan, dexamethasone, sodium valproate, caffeine, and diclofenac. There were no significant differences in the reduction of pain intensity at 1 h under the comparisons between ketorolac and phenothiazines (standard mean difference [SMD] = 0.09, p = 0.74) or metoclopramide (SMD = 0.02, p = 0.95). We also found no difference in the outcome recurrence of headache (ketorolac vs. phenothiazines (risk ratio [RR] =0.98, p = 0.97)], ability to return to work or usual activity (ketorolac vs. metoclopramide [RR = 0.64, p = 0.13]), need for rescue medication (ketorolac vs. phenothiazines [RR = 1.72, p = 0.27], ketorolac vs. metoclopramide [RR 2.20, p = 0.18]), and frequency of adverse effects (ketorolac vs. metoclopramide [RR = 1.07, p = 0.82]). Limited trials suggested that ketorolac offered better pain relief at 1 h compared to sumatriptan and dexamethasone; had lesser frequency of adverse effects than phenothiazines; and was superior to sodium valproate in terms of reduction of pain intensity at 1 h, need for rescue medication, and sustained headache freedom within 24 h.

CONCLUSIONS

Ketorolac may have similar efficacy to phenothiazines and metoclopramide in treating acute migraine headache. Ketorolac may also offer better pain control than sumatriptan, dexamethasone, and sodium valproate. However, given the lack of evidence due to inadequate number of trials available, future studies are warranted.

Pulsed Radiofrequency Neuromodulation of the Greater Occipital Nerve for the Treatment of Headache Disorders in Adults: A Systematic Review

Background

Pulsed radiofrequency neuromodulation (PRFN) of greater occipital nerve (GON) is considered in patients with headaches failing to achieve sustained analgesic benefit from nerve blocks with local anesthetic and steroids. However, the evidence supporting this practice is unclear.

Aims

This narrative systematic review aims to explore the effectiveness and safety of GON PRFN on headaches.

Methods

Databases were searched for studies, published up to February 1, 2024, investigating PRFN of GON for adults with headaches. Abstracts and posters were excluded. Primary outcome was change in headache intensity. Secondary outcomes included effect on monthly headache frequency (MHF), mental and physical health, mood, sleep, analgesic consumption, and side-effects. Two reviewers screened and extracted data.

Results

Twenty-two papers (2 randomized controlled trials (RCT), 11 cohort, and 9 case reports/series) including 608 patients were identified. Considerable heterogeneity in terms of study design, headache diagnosis, PRF target and settings, and image-guidance was noted. PRFN settings varied (38-42°C, 40-60 V, and 150-400 Ohms). Studies demonstrated PRFN to provide significant analgesia and reduction of MHF in chronic migraine (CM) from 3 to 6 months; and significant pain relief for ON from six to ten months. Mild adverse effects were reported in 3.1% of cohort. A minority of studies reported on secondary outcomes. The quality of the evidence was low.

Conclusions

Low-quality evidence indicates an analgesic benefit from PRFN of GON for ON and CM, but its role for other headache types needs more investigation. Optimal PRFN target and settings remain unclear. High-quality RCTs are required to further explore the role of this intervention. PROSPERO ID CRD42022363234.

Association of atopic dermatitis and headache disorder: a systematic review and meta-analyses

Background

Growing evidence suggests that headache disorders and atopic dermatitis share similar pathological mechanisms and risk factors. The aim of this study was to assess the risk for headache disorders in patients with atopic dermatitis.

Methods

We systematically searched the PubMed and Embase databases from inception to December 1, 2023, for observational studies that examined risk of migraine in subjects with atopic dermatitis. Risk estimates from individual studies were pooled using random-effects models.

Results

Ten studies with 12,717,747 subjects were included in the meta-analysis. Our results showed that patients with atopic dermatitis were associated with a higher risk of headache disorder (OR, 1.46, 95% CI = 1.36-1.56; P < 0.001; I2 = 98%) or migraine (OR, 1.32, 95% CI = 1.18-1.47; P < 0.001; I2 = 98.9%). Most of the results of the subgroup analyses were consistent with the overall results.

Conclusion

The findings of this meta-analysis suggest that atopic dermatitis is a potential risk indicator for headache disorder or migraine. Further studies are still needed to verify our findings due to the substantial heterogeneity in our analyses.

The Reduction of Cervical Hyperlordosis and Resolution of Craniocervical Symptoms in an Adolescent Female: A Chiropractic Biophysics Case Report With Long-Term Follow-Up

Cervical hyperlordosis is a rare condition in the pediatric population. We present a unique case of the application of Chiropractic Biophysics® (CBP®) technique protocols to reduce a hyperlordotic cervical spine corresponding with many craniocervical symptoms, including chronic migraines and neck pain. A 15-year-old female presented with chronic headaches, neck pain, and neck stiffness among other complaints following a martial arts sprain injury several months prior. There were many positive orthopedic tests and limited range of motion. Radiographs revealed a cervical hyperlordosis and a right lateral head translation. CBP® treatment was given and involved cervical distraction traction as well as corrective exercises twice a week for 12 weeks, and then monthly for one year with a complementary home program. After 12 weeks, there was a full recovery from migraines and neck pain correlating with an 8° reduction in lordosis and correction of head translation. At 15 months, the patient remained well and achieved a 13° total reduction in the neck curve. This is the first case documenting the successful application of CBP® methods to reduce cervical spine hyperlordosis in peer-reviewed literature. We propose too much curve may be as detrimental as too little curve in the cervical spine with respect to causing adverse stresses and strains in the surrounding soft tissues leading to pathological processes and nociceptive tendencies.

An Ominous Cause of Headache in a Teenager

We present the case of an adolescent male who presented to the emergency department with headache and vomiting. We discuss the differential diagnosis and the need to maintain a high index of suspicion to avoid missing ominous causes of headache. In this case, the patient had a pineoblastoma, detected on a noncontrast CT scan. The CT scan was done as part of the emergency department workup to evaluate headache accompanied by vomiting in this otherwise healthy teenager.