Absence Of Headache Research Articles

Acute hypopituitarism associated with periorbital swelling and cardiac dysfunction in a patient with pituitary tumor apoplexy: a case report

BackgroundPituitary tumor apoplexy is a rare clinical syndrome caused by acute hemorrhage or infarction in a preexisting pituitary adenoma. It typically manifests as an acute episode of headache, visual disturbance, mental status changes, cranial nerve palsy, and endocrine pituitary dysfunction. However, not all patients present with classical symptoms, so it is pertinent to appreciate the clinical spectrum of pituitary tumor apoplexy presentation. We report an unusual case of a patient with pituitary tumor apoplexy who presented with periorbital edema associated with hypopituitarism.Case presentationAn 83-year-old Japanese man developed acute anterior hypopituitarism; he showed anorexia, fatigue, lethargy, severe bilateral periorbital edema, and mild cardiac dysfunction in the absence of headache, visual disturbance, altered mental status, and cranial nerve palsy. Magnetic resonance imaging showed a 2.5-cm pituitary tumor containing a mixed pattern of solid and liquid components indicating pituitary tumor apoplexy due to hemorrhage in a preexisting pituitary adenoma. Replacement therapy with oral hydrocortisone and levothyroxine relieved his symptoms of central adrenal insufficiency, central hypothyroidism, periorbital edema, and cardiac dysfunction.ConclusionsCommon causes of periorbital edema include infections, inflammation, trauma, allergy, kidney or cardiac dysfunction, and endocrine disorders such as primary hypothyroidism. In the present case, the patient’s acute central hypothyroidism was probably involved in the development of both periorbital edema and cardiac dysfunction. The present case highlights the need for physicians to consider periorbital edema as an unusual predominant manifestation of pituitary tumor apoplexy.

Identification of clinical and paraclinical findings predictive for headache occurrence during spontaneous subarachnoid hemorrhage

ObjectivesHeadache is recognized as the main but unwarranted symptom of subarachnoid hemorrhage (SAH). There are no enough findings identified as predictive for headache occurrence in SAH. We evaluated the clinical and paraclinical factors predictive for headache occurrence in SAH. Patients and methodsWe retrospectively analyzed medical records of 431 consecutive non traumatic SAH patients (264 females and 167 males), ages from 19 to 91 years, presenting with headache (70.3%) and without headache (29.7%) during period of 11years. ResultsAmong all tested parameters, as negative predictors for headache occurrence were recognized: patients‘ ages (OR 0.97 [95%CI: 0.96–0.99], p=0.025), persistence of coagulation abnormality (OR 0.23 [95%CI: 0.08–0.67], p=0.006), atrial fibrilation (OR 0.23 [95%CI: 0.09–0.59], p=0.002), chronic renal failure (OR 0.26 [95%CI: 0.09–0.76], p=0.014) and more diseases (OR 0.11 [95%CI: 0.04–0.32], p<0.0001), as higher clinical score (OR 0.94 [95%CI: 0.90–0.99], p=0.018) including positive neurological findings (OR 0.34 [95%CI: 0.21–0.55], p<0.001) and loss of consciousness (OR 0.22 [95%CI: 0.12–0.39], p<0.001) at the SAH onset, while the complaint of neck stiffness was identified as its positive predictor (OR 1.93 [95%CI: 1.19–3.10], p=0.007). ConclusionsAlthough diagnosis based solely on clinical presentation is not reliable and speculative, our findings could provide physicians with evidence to consider SAH not only in conditions of its headache occurrence but also in those with headache absence.

Presence of headache and headache types in patients with tumors of the sellar region-can surgery solve the problem? Results of a prospective single center study.

Headache is a common presenting feature of patients with pituitary adenomas and other tumors of the sellar region. However, at present, it still is unclear whether the headache is actually caused by the tumor. To explore whether there is a relation, we examined in detail the headache types, their relationship to the underlying pathology, and if the headache responded to neurosurgery in a prospective study design. One hundred twelve patients with tumors of the sellar region scheduled for neurosurgery in a single center were analyzed for presence and quality of headache before surgery and at least 3 months after surgery. Patients received headache and depression self-rating inventories, presented on a handheld computer (PainDetect®). Clinical variables thought to impact on headache were analyzed in conjunction with the inventories. Fifty-nine (53%) patients reported headache in the 3 months prior to neurosurgery, 49 (44%) had headache at the time of filling in the questionnaires. The four patients with pituitary apoplexy described thunderclap headache. In the other patients diverse headache types were encountered, most frequently migraine. Untreated gonadotroph deficiency was significantly associated with absence of headache, while none of the other clinical and morphological variables related to headache. Presence of headache and disability due to headache were not significantly reduced after surgery. Apart from pituitary apoplexy we detected no specific headache type in our patient group and no significant improvement of headache after neurosurgery. Headache alone constitutes neither a valid diagnostic marker for the presence of tumors of the sellar region nor a sufficient indication for tumor removal.

The effect of intravenous propofol on the incidence of post-dural puncture headache following spinal anesthesia in cesarean section

Introduction: Post Dural puncture headache is still a common complication among young women undergone cesarean section, although use of small size spinal needles reduced its prevalence. Several methods have been suggested for prevention and treatment of this side effect; such as complete bed rest, hydration, non-opioid analgesics, caffeine, codeine, which none of them proved to be totally effective. The last option would be epidural blood patch, if headache persist. The aim of this study was evaluation the efficacy of intravenous propofol on post dural puncture headache incidence after cesarean section. Methods: In a randomized clinical trial 120 patients aged 18-45 years old in American Society of Anesthesiologist (ASA) class I or II, who had no history of headache, analgesic consumption, substance abuse and drug addiction, candidate for elective cesarean section, were randomly assigned into intervention (propofol) and control groups. The anesthesia method for both groups was precisely the same. After spinal anesthesia in the first group 30µg/kg/min of intravenous propofol have been infused slowly. Then at 1, 6, 18, 24 hours and 2nd to 7th days after surgery, anesthesiologist asked groups for presence or absence of headache. The data analyzed with SPSS 16.0 software. Results: Headache incidence rate in the group who receiving propofol was significantly reduced (P.V=0.001). Conclusion: This study showed that 30µg/kg/min of intravenous propofol caused reduced the incidence of post spinal headache in young women undergone elective cesarean section. � Supportive interventions must be considered as an indispensable part of care for children with cancer.

Idiopathic Intracranial Hypertension (IIH) Manifesting with Nausea and Vomiting in the Absence of Headache in an Adult (P4.393)

Idiopathic Intracranial Hypertension (IIH) Manifesting with Nausea and Vomiting in the Absence of Headache in an Adult (P4.393)

Seizures in supratentorial meningioma: a systematic review and meta-analysis.

OBJECT Meningioma is the most common benign intracranial tumor, and patients with supratentorial meningioma frequently suffer from seizures. The rates and predictors of seizures in patients with meningioma have been significantly under-studied, even in comparison with other brain tumor types. Improved strategies for the prediction, treatment, and prevention of seizures in patients with meningioma is an important goal, because tumor-related epilepsy significantly impacts patient quality of life. METHODS The authors performed a systematic review of PubMed for manuscripts published between January 1980 and September 2014, examining rates of pre- and postoperative seizures in supratentorial meningioma, and evaluating potential predictors of seizures with separate meta-analyses. RESULTS The authors identified 39 observational case series for inclusion in the study, but no controlled trials. Preoperative seizures were observed in 29.2% of 4709 patients with supratentorial meningioma, and were significantly predicted by male sex (OR 1.74, 95% CI 1.30-2.34); an absence of headache (OR 1.77, 95% CI 1.04-3.25); peritumoral edema (OR 7.48, 95% CI 6.13-9.47); and non-skull base location (OR 1.77, 95% CI 1.04-3.25). After surgery, seizure freedom was achieved in 69.3% of 703 patients with preoperative epilepsy, and was more than twice as likely in those without peritumoral edema, although an insufficient number of studies were available for formal meta-analysis of this association. Of 1085 individuals without preoperative epilepsy who underwent resection, new postoperative seizures were seen in 12.3% of patients. No difference in the rate of new postoperative seizures was observed with or without perioperative prophylactic anticonvulsants. CONCLUSIONS Seizures are common in supratentorial meningioma, particularly in tumors associated with brain edema, and seizure freedom is a critical treatment goal. Favorable seizure control can be achieved with resection, but evidence does not support routine use of prophylactic anticonvulsants in patients without seizures. Limitations associated with systematic review and meta-analysis should be considered when interpreting these results.

CO-44: The paradoxical significance of headache in hypertension

Background The cardiovascular prognostic value of various types of headache, particularly migraine, in the general population is still controversial. The aim of the present study was to assess this prognostic value for all-cause, cardiovascular and stroke mortalities, in hypertensive patients. Methods 1914 hypertensive individuals were categorized first, according to the absence or the presence of headache and then according to 3 subtypes of headache: migraine, “daily headache” and “other headache”. The predictors of headaches at baseline were assessed by multiple logistic regressions. The prognostic value of headache in terms of all-cause, cardiovascular and stroke deaths was first estimated by Kaplan-Meier survival curves (log-rank statistic) according the presence versus absence of headache. The prognostic value of subtypes of headache was represented with Cox Regression curves adjusted for age, while these subgroups have major difference for age. The prognostic value (presence versus absence and subtypes of headache) were also tested by a multivariable cox regression after adjustment for age, sex, systolic BP, diastolic BP, diabetes, total cholesterol, smoking status, MDRD, antihypertensive treatment, previous cardiovascular disease, essential hypertension and body mass index. Download : Download high-res image (130KB) Download : Download full-size image Abstract CO-44 – Figure Results Multiple regression analysis demonstrated that all kinds of headache were predicted by gender (women), diastolic blood pressure, absence of diabetes, secondary hypertension and a trend for severe retinopathy. After 30 years of follow-up, we observed 1076 deaths of whom 580 from cardiovascular cause and 97 acute strokes. Kaplan-Meier curves demonstrated a decrease risk of all-cause and cardiovascular mortality for patients with headache (see Figure next page). In a multivariable Cox model adjusted for major confounders, patients having headache had a decreased risk for all-cause mortality (HR 0.82; 95% CI [0.73-0.93]), for cardiovascular mortality (HR 0.80; 95% CI [0.68-0.95]), but not for stroke mortality (HR 1.00; 95% CI [0.70-1.43]). Considering only patients with headache, we observed a better prognostic value for patients with “daily headache” for all-cause and cardiovascular mortality in comparison to those with migraine (HR 0.85; 95% CI [0.65-1.11]; HR 0.78; 95% CI [0.55-1.10] respectively) and “other headache” (HR 0.73; 95% CI [0.61-0.87]; HR 0.73; 95% CI [0.57-0.93] respectively). Conclusions Non-specific headache in hypertensive patients does not seem to convey a negative impact on their prognosis over the long-term. However, they may present a high-risk profile requiring a thorough treatment of their risk factors.

Clinical Assessment and Differential Diagnosis of Pediatric Pseudotumor Cerebri Syndrome: Pearls and Pitfalls

Pseudotumor cerebri syndrome (PTCS) is defined by the presence of elevated intracranial pressure in the setting of normal brain parenchyma and normal cytologic and chemical analyses of the cerebrospinal fluid. Pathophysiology of this syndrome remains unclear, while its incidence may be potentially rising in children. The presenting signs and symptoms of PTCS are heterogeneous to usually include headache, papilledema, and visual disturbances (i.e., vision loss or double vision). The clinical features of PTCS in children have changed over the years, making the diagnosis challenging in some cases. Young children may present with atypical symptoms, such as those mimicking a posterior fossa tumor. There are reports of PTCS in children in the absence of headache. Papilledema, considered the acute hallmark of PTCS at onset, can also be absent. It is thus important for pediatricians to recognize atypical presentations especially as previous studies have suggested children presenting with headache in the absence of papilledema or those with papilledema in the absence of any other clinical signs may have increased risk of developing visual constriction deficits and permanent loss of vision, respectively. Moreover, many conditions in the pediatric age group may mimic PTCS, such as migraine and tension headaches. Cerebral venous sinus thrombosis and some neoplastic processes such as gliomatosis cerebri and leptomeningeal spread of hematologic malignancies are known to augment intracranial pressure and have to be carefully excluded. To avoid misdiagnosis and potential long-term sequel, a thorough clinical assessment is crucial to promptly and correctly recognize PTCS.

Impact of initial symptom for accurate diagnosis of vertebral artery dissection.

It has been recognized that spontaneous vertebral artery dissection without neurological symptoms is not rare and easily misdiagnosed. Clinical clue for diagnosis of vertebral artery dissection includes initial symptoms such as headache, neck pain, or dizziness. To assess the role of initial symptoms for diagnosis of spontaneous vertebral artery dissection. Between September 2007 and January 2014, we retrospectively reviewed clinical records of 83 patients with unilateral vertebral artery dissection without consciousness disturbance at admission. Based on the diagnostic criteria of the Spontaneous Cervicocephalic Arterial Dissections Study, the patients were divided into three groups: possible, probable, and definite cases of vertebral artery dissection. Initial symptoms were collected at the time of diagnosis from medical record for the presence or absence of headache, neck pain, tinnitus and vertigo, as well as the area of pain and its characteristics. The numbers of definite, probable, and possible vertebral artery dissection were 39, 26, and 18, respectively. Out of 83 cases, unilateral or bilateral headache was the most commonly seen (in 60 cases), followed by neck pain (in 41 cases) and vertigo (in 20 cases). Statistically, unilateral headache and/or neck pain was more common in cases with definite vertebral artery dissection group compared with other classification of the Spontaneous Cervicocephalic Arterial Dissections Study (P = 0·040). Vertigo was also associated with the stratification of Spontaneous Cervicocephalic Arterial Dissections Study criteria (P = 0·012). In our study, headache and/or neck pain, especially unilateral presentation, and vertigo were symptoms associated with the stratification of Spontaneous Cervicocephalic Arterial Dissections Study criteria. Physicians should carefully obtain clinical history for the presence of a unilateral headache and/or neck pain and vertigo when vertebral artery dissection is suspected in patients with or without objective neurological signs.

QTc Prolongation in Acute Pediatric Migraine.

Migraine headache is common in pediatrics and is frequently assessed in emergency departments. Altered cardiac conduction, including prolongation of the QTc interval on electrocardiogram, has been observed in adults during migraine headache and resolves interictally. Prolonged QTc is associated with life-threatening arrhythmia, and many acute and prophylactic therapies for migraine can further prolong the QTc interval. It is the objective of this prospective cohort study to examine whether the QTc interval prolongs significantly during periods of acute migraine headache in children. Patients ages 6 to 17 years presenting to the emergency department with acute migraine headache were recruited prospectively. Exclusion criteria included the use of QTc-prolonging medications and medical illnesses, including cardiovascular abnormalities, infection, or head injury. Paired, one-tailed Student t tests compared QTc intervals with and without headache and evaluated for QTc prolongation of 30 ms or longer during headache. Thirteen patients with migraine (mean age, 11.6 ± 2.6 years) were evaluated. Mean QTc interval during headache was significantly longer than the QTc interval in the absence of headache (437.9 ± 27.7 ms compared with 419.3 ± 29.9 ms; p = 0.04). Three patients (23%) had unequivocal prolongation of the QTc (>460 ms) during the migraine, two of which normalized with headache resolution. The mean increase in QTc during headache did not reach or exceed 30 ms (p = 0.86) CONCLUSIONS: This study is the first to illustrate a connection between QTc prolongation and acute migraine headache in children. If confirmed in future studies, children should be monitored for QTc prolongation during the acute treatment of migraine in the emergency department when using medications that can lengthen the QTc interval.

A Poorly Known Cerebrospinal Fluid Shunt Complication: Miyazaki Syndrome

We studied a poorly known form of cerebrospinal fluid hypotension characterized by cervical myelopathy, a considerable growth in volume of the venous plexus of the cervical spine, and absence of headache. This form was first described by Miyazaki. We reported a case brought to our attention, reviewed the literature, and formulated etiopathogenic theories that might explain all the various clinical aspects of this pathology.

Sore throat in primary care project: a clinical score to diagnose viral sore throat.

Objective.Viral agents cause the majority of sore throats. However, there is not currently a score to diagnose viral sore throat. The aims of this study were (i) to find the rate of bacterial and viral causes, (ii) to show the seasonal variations and (iii) to form a new scoring system to diagnose viral sore throat.Methods.A throat culture for group A beta haemolytic streptococci (GABHS) and a nasopharyngeal swab to detect 16 respiratory viruses were obtained from each patient. Over a period of 52 weeks, a total of 624 throat cultures and polymerase chain reaction analyses were performed. Logistic regression analysis was performed to find the clinical score.Results.Viral infection was found in 277 patients (44.3%), and GABHS infection was found in 116 patients (18.5%). An infectious cause was found in 356 patients (57.1%). Rhinovirus was the most commonly detected infectious agent overall (highest in November, 34.5%), and the highest GABHS rate was in November (32.7%). Analysis of data provided a scoring system, called the Mistik Score, to diagnose viral sore throat. The predictive model for positive viral analysis included the following variables: absence of headache, stuffy nose, sneezing, temperature of ≥37.5°C on physical examination, and the absence of tonsillar exudate and/or swelling. The probability of a positive viral analysis for a score of 5 was 82.1%.Conclusion.The Mistik Score may be useful to diagnose viral sore throat. We suggest its use either alone or in combination with the Modified Centor Score.

Cerebral venous thrombosis in the absence of headache.

Although headache is the most common symptom in cerebral venous thrombosis, 5% to 30% of patients do not report headache at baseline. Characteristics of these patients have not been investigated. In post hoc analysis of the International Study on Cerebral Vein and Dural Sinus Thrombosis study, patients who might not have been able to report headache (aphasia, stupor, coma, or mental status disorder) were excluded. Three hundred eighty-two of the original 624 patients (61%) were included, of whom 38 (10%) did not report headache at baseline. Patients without headache were older (mean age, 45 versus 37; P=0.001) and less often female (63% versus 77%; P=0.06). Paresis (42% versus 27%; P=0.05) and seizures (58% versus 32%; P=0.001) were more common in patients without headache, whereas papilledema was less common (8% versus 35%; P=0.001). Isolated cortical vein thrombosis (16% versus 2%; P=0.001), brain parenchymal lesions (66% versus 46%; P=0.02), and malignancies (18% versus 6%; P=0.009) were more common among patients without headache. Outcome at last follow-up was worse in patients without headache (modified Rankin Scale, 0-1; 76% versus 89%; P=0.04; mortality, 13% versus 5%; P=0.05), but after adjustment for prognostic variables, headache was not an independent predictor of outcome. Patients with cerebral venous thrombosis but without headache are a heterogeneous subgroup, in which older patients, men, and some associated conditions are over-represented. Patients without headache had a worse clinical outcome, but after adjustment for imbalances, headache was not an independent predictor of outcome.

Photic hypersensitivity in the premonitory phase of migraine--a positron emission tomography study.

Sensitivity to light (photophobia) is a common ill-understood symptom of migraine, whose neurobiology is important in understanding the disorder. Patients reporting premonitory symptoms before migraine headache were infused with nitroglycerin (GTN) at a first visit. Patients who responded with premonitory symptoms followed by a delayed headache resembling their migraine had positron emission tomography (PET) scans at least 1 week later, during which GTN infusion was repeated. H2 (15) O PET scans were performed during baseline (pain free), premonitory phase (pain free) and migraine headache. Patients were divided into two groups, with and without photophobia in the premonitory phase. The differences between the premonitory and baseline scans were analysed within groups and between groups using statistical parametric mapping. Thirteen patients participated in the PET study, 10 of whom had at least one PET scan during the premonitory phase in the absence of pain. Data from these 10 patients were included in the final analysis. Five patients had photophobia and five patients did not have photophobia in the premonitory phase. Comparing the premonitory scans to baseline scans, there was activation of extrastriate visual cortex (BA18) in patients with photophobia. This activation was significantly greater than in the patients without photophobia. Our findings indicate that photic hypersensitivity is linked to activation of the visual cortex during the premonitory phase of migraine in the absence of headache.

Recovery and Quality of Life in Patients with Ruptured Cerebral Aneurysms

Subarachnoid hemorrhage (SAH) secondary to ruptured cerebral aneurysm is a common and frequently devastating condition with a high mortality and morbidity among survivors. The purpose of this study was to conduct a long-term follow-up of SAH patients, assess the changes in functional outcomes, describe quality of life (QOL), and determine its predictors 3.6years after the hemorrhage. The study design is an exploratory, descriptive correlational design. Results were collected from a sample of 113 SAH survivors treated in our institution over a 2-year period (January 2006 until December 2007). We collected data on early and long-term functional outcomes and compared the differences. The health-related QOL was measured using the Polish version of The Short Form - 36 Health Survey Questionnaire (SF-36v2). Multivariable logistic regression was derived to define independent predictors of the QOL. The mean follow-up time was 3.6years. Sixty-six percent of patients had improvement in functional outcomes and among previously employed people 56% returned to work. QOL deteriorated in 24% of patients with the most affected dimension of Physical Role. Factors that predict good QOL are male gender, younger age, good economic/professional status, lack of physical handicaps, rehabilitation in a professional center, subjective improvement in health status, and absence of headaches or physical decline. Recovery process in SAH patients is dynamic and progresses over time. Since physical handicaps and low economic status significantly reduce the quality of life, an effort should be made to provide intensive rehabilitation and to encourage SAH survivors to return to work.

Concomitant Headache Influences Long-term Prognosis After Acute Cerebral Ischemia of Noncardioembolic Origin

Acute cerebral ischemia is frequently associated with headache. It is unknown whether concomitant headache reflects a partly different pathogenesis, and thus, may influence long-term prognosis after stroke. Here, we compared the long-term risk of recurrent vascular events in patients in whom a transient ischemic attack or minor ischemic stroke of noncardioembolic origin was associated with headache with those without headache. We used data from the Life Long After Cerebral ischemia (LiLAC) cohort. Participants were grouped on the basis of presence or absence of headache at presentation. We calculated the hazard ratios (HRs) and corresponding 95% confidence intervals (CI) for any first vascular event (primary outcome) or any cardiac or cerebral event (secondary outcomes). Adjustments were made for baseline clinical characteristics. Of 2473 participants, 420 (17%) experienced headache during the acute event. Median follow-up was 14.1 years. For the primary outcome, the crude HR of headache versus no headache was 0.75 (95% CI, 0.66-0.89) and the adjusted HR 0.83 (95% CI, 0.71-0.97). For cardiac events the adjusted HR was 0.88 (95% CI, 0.67-1.14) and for cerebral events, 0.97 (95% CI, 0.76-1.24). The ratio of cardiac versus cerebral events, however, did not differ between the 2 groups. Participants with headache were at lower risk of vascular death (adjusted HR, 0.73; 95% CI, 0.61-0.87). Patients who experienced headache in association with a transient ischemic attack or minor ischemic stroke have a better vascular prognosis than those without concomitant headache. This may, at least partly, reflect a different pathogenesis.

Prognostic indicators in bacterial meningitis: a case–control study

This was a case–control study to identify prognostic indicators of bacterial meningitis in a reference hospital in Pernambuco/Brazil. The data were collected from charts of 294 patients with bacterial meningitis between January 2000 and December 2004. Variables were grouped in biological, clinical, laboratory and etiologic agent/treatment. Variables selected in each step were grouped and adjusted for age. Two models were created: one containing clinical variables (clinical model) and other containing laboratory variables (laboratory model). In the clinical model the variables associated with death due to bacterial meningitis were dyspnea (p=0.006), evidence of shock (p=0.051), evidence of altered mental state (p=0.000), absence of headache (p=0.008), absence of vomiting (p=0.052), and age ≥40 years old (p=0.013). In the laboratory model, the variables associated with death due to bacterial meningitis were positive blood cultures (p=0.073) and thrombocytopenia (p=0.019). Identification of prognostic indicators soon after admission may allow early specific measures, like admission of patients with higher risk of death to Intensive Care Units.

Prostaglandins and prostaglandin receptor antagonism in migraine.

Human models of headache may contribute to understanding of prostaglandins' role in migraine pathogenesis. The current thesis investigated the migraine triggering effect of prostaglandin E2 (PGE2) in migraine patients without aura, the efficacy of a novel EP4 receptor antagonist, BGC20-1531, in prevention of PGE2-induced headache and the ability of prostaglandin F2α (PGF2α) to trigger headache without any vasodilatation in healthy volunteers. All studies were designed as double-blind, placebo-controlled, cross-over experiments, where PGE2/PGF2α or saline were infused over 20-25 min. In the study with EP4 receptor antagonist healthy volunteers were pre-treated with two different doses of BGC20-1531 or placebo followed by PGE2 infusion over 25 min. The headache data were collected during the whole study day, whereas the possible vascular changes were measured during the in-hospital phase of 1.5 h. The infusion of PGE2 caused the immediate migraine-like attacks and vasodilatation of the middle cerebral artery in migraine patients without aura. The highly specific and potent EP4 receptor antagonist, BGC20-1531, was not able to attenuate PGE2-induced headache and vasodilatation of both intra- and extra-cerebral arteries. The intravenous infusion of PGF2α did not induce headache or statistically significant vasoconstriction of cerebral arteries in healthy volunteers. Novel data on PGE2-provoked immediate migraine-like attacks suggest that PGE2 may be one of the important final products in the pathogenesis of migraine. The lack of efficacy of EP4 receptor antagonist suggests that a single receptor blockade is not sufficient to block PGE2 responses, hence EP2 receptor should be investigated as a potential drug target for the treatment of migraine. The absence of headache during the PGF2α infusion demonstrates that vasodilating properties are necessary for the induction of headache and migraine.

Headache at the onset of stroke: Frequencies, background characteristics and correlation with mortality

Background: Headache is a common symptom and sometimes makes patients worry about stroke. Some stroke patients actually have headache. However, the frequency of headache at the onset of stroke and the relationship between headache and outcomes are not fully clarified. Objective: The aim of the study is to clarify frequency of headache, and to compare patients with headache with patients without headache in their characteristics, risk factors and early mortalities. Methods: We confirmed the presence or absence of onset headache in 1671 patients in the Kyoto Stroke Registry. We studied frequencies of headache, age, sex, blood pressure, arrhythmia, diabetes mellitus, hyperlipemia, tobacco and alcohol use and mortality of stroke patients. Results: Headache was observed in 21.4% of stroke patients; 12.0% in cerebral infarction (CI), 29.8% in cerebral hemorrhage (CH), and 93.9% in subarachnoid hemorrhage (SAH). Blood pressure at the first medical examination after stroke was higher in patients with headache. Factors associated with headache were age, diastolic blood pressure, hypertension and hyperlipemia histories, alcohol use, and paresis in CI, age, alcohol and tobacco use and paresis in CH and systolic blood pressure in SAH. The mortality rate 30 days after the stroke event was higher by 6.8% in CI and by 11.4% in CH in patients with headache than that in patients without headache. The hazard ratios for death between patients with headache and patients without headache were 4.94 (1.73 - 14.08, p = 0.003) in CI, and 3.20 (1.10 - 9.36, p = 0.033) in CH. Conclusions: Headache is common in stroke and predicts outcome. Headache is associated with younger age and alcohol use in CI and CH. Patients who could express presence of headache at the onset of CI or CH have higher mortality than patients who could express absence of headache. Headache is important both as an identifier of stroke and as a poor prognostic indicator in stroke.

Are Occlusal Characteristics, Headache, Parafunctional Habits and Clicking Sounds Associated with the Signs and Symptoms of Temporomandibular Disorder in Adolescents?

[Purpose] To assess the association between the oclusal characteristics, headache, parafunctional habits and clicking sounds and signs/symptoms of TMD in adolescents. [Subjects] Adolescents between 14 and 18 years of age. [Methods] The participants were evaluated using the Helkimo Index and a clinical examination to track clicking sounds, parafunctional habits and other signs/symptoms of temporomandibular disorder (TMD). Subjects were classified according to the presence or absence of headache, type of occlusion, facial pattern and type of bite. In statistical analyse we used the chi-square test and Fisher's exact test, with a level of significance of 5%. [Results] The sample was made up of 81 adolescents with a mean age of 15.64 years; 51.9% were male. The prevalence of signals/symptoms of TMD was 74.1%, predominantly affecting females. Signals/symptoms of TMD were significantly associated with clicking sounds, headache and nail biting. No associations were found between signals/symptoms of TMD and angle classification, type of bite and facial pattern. [Conclusion] Headache is one of the most closely associated symptoms of TMD. Clicking sounds were found in the majority of cases. Therefore, the sum of two or more factors may be necessary for the onset and perpetuation of TMD.