Etiology Of Headache Research Articles

Delayed acute onset post traumatic sigmoid sinus/cerebral venous thrombosis

Post traumatic Sinus/cerebral venous thrombosis is a rare entity. A high index of suspicion is required as the prognosis is poor in this clinical setting, in view of the effects of the head injury. We report 2 cases of the patient worsening acutely after initial recovery from trauma. The etiology and pathogenesis in such cases are varied and hypothetical with no definite underlying cause identified. Cerebral venous thrombosis (CVT) as an etiology of headache is not always easy to diagnose unless suspected, and in any patient with head injury and delayed deterioration after initial recovery, post traumatic Cerebral venous thrombosis should be kept as a differential diagnosis.

Postpartum Headache: A Prospective Study.

To prospectively assess the incidence and etiology (ie, primary vs symptomatic) of headache in women during the first month postdelivery, with particular emphasis on the type of presentation as a clue for identifying potentially harmful etiologies. A secondary aim was to evaluate the relative frequency of migraine- vs tension-type headache in cases of primary headache. A total of 900 consecutive women were enrolled in the study and examined within 3 days of delivery, both clinically and with transcranial color-coded sonography (TCCS). During the course of follow-up, all subjects presenting with headache suspected of being secondary to intracranial pathology underwent a complete clinical and instrumental assessment with TCCS and magnetic resonance imaging (MRI) and angiography. A telephone interview was administered to all subjects 1 month after delivery. Two-tailed t test, Mann-Whitney test, Pearson chi-square test, and multiple logistic regression were used to analyze the data. At the end of the follow-up period, 241 women (26.8% of the sample) reported at least one headache attack. In 88 of these 241 cases (9.8%), the headache attack occurred soon after delivery and was already recorded at the first visit. Thunderclap headache occurred in 34 (3.8%) of the subjects. In all but one of these subjects, the course was spontaneously benign. None of the recorded variables allowed discrimination of the subjects with thunderclap headache from those without headache. Three subjects had thunderclap headache following dural anesthesia, and one subject was found to have reversible cerebral vasoconstriction syndrome. Headache with gradual onset was recorded in 207 subjects (23%). Three of these subjects fulfilled the criteria for pre-eclampsia, and 13 had postural headache after dural anesthesia. Migraine history and urinary protein were independent predictors of gradual onset headache, and migraine history and parity were significant independent predictors of pulsating pain with gradual onset headache. Headache appeared early in the first days postdelivery, and its incidence increased in the first month thereafter. Predictors were different according to whether the headache had a gradual onset or a thunderclap presentation. Primary headache accounted for the overwhelming majority of the recorded cases.

Occipital Headaches in Children: Are They a Red Flag?

Occipital headache is considered a risk factor for serious secondary headache pathology. The purpose of our study was to assess the etiology of occipital headaches among children visiting the emergency department. Subjects were children aged 5 to 18 years who were referred to the emergency department due to headaches during the years 2013 to 2014. A total of 314 patients with headaches were seen at our emergency department. Thirty-nine patients had occipital headaches. Viral infections were the most prevalent final diagnosis (97; 31%), followed by migraine (37; 11.8%). None of our patients had a brain tumor. There was no difference in final diagnosis between the occipital and nonoccipital groups. The most common causes of occipital headaches are viral infections and primary headaches. Serious intracranial disorders presenting solely as occipital headaches and not accompanied by other neurologic signs are uncommon. Thus, occipital headaches should be evaluated in the same manner as other headache locations.

Serum concentration of magnesium as an independent risk factor in migraine attacks: a matched case-control study and review of the literature.

There is controversy over the role of magnesium in the etiology of migraine headaches. We aimed to evaluate and compare serum levels of magnesium between healthy individuals and those with migraine headaches during migraine attacks and between attacks to evaluate the role of magnesium in the etiology of migraine headaches. Forty patients with migraine headaches and 40 healthy individuals were enrolled in this matched case-control study. Malnutrition, digestive system disorders, history of smoking, drug abuse, and history of medications use were recorded at baseline. The pain scores of patients were measured and recorded based on a 10 cm visual analog scale. Subsequently, blood samples were collected at 8-10 in the morning to determine serum levels of magnesium. Analysis of variance, χ-test, and conditional logistic regression were used for data analysis. There were no significant differences in demographic data between the two groups. There were significant differences in magnesium serum levels between the three groups (1.09±0.2 mg/dl during migraine headaches; 1.95±0.3 mg/dl between the attacks; and 1.3±0.4 mh/dl in the control group; P<0.0001). Odds of acute migraine headaches increased 35.3 times (odds ratio=35.3; 95% confidence interval: 12.4-95.2; P=0.001) when serum levels of magnesium reached below the normal level. The odds in patients who are not in the acute attack phase were 6.9 folds higher (odds ratio=6.9; 95% confidence interval: 1.3-2.1; P=0.02). The serum level of magnesium is an independent factor for migraine headaches and patients with migraine have lower serum levels of magnesium during the migraine attacks and between the attacks compared with healthy individuals.

Spontaneous Subarachnoid Hemorrhage: A Systematic Review and Meta-analysis Describing the Diagnostic Accuracy of History, Physical Examination, Imaging, and Lumbar Puncture With an Exploration of Test Thresholds.

Spontaneous subarachnoid hemorrhage (SAH) is a rare, but serious etiology of headache. The diagnosis of SAH is especially challenging in alert, neurologically intact patients, as missed or delayed diagnosis can be catastrophic. The objective was to perform a diagnostic accuracy systematic review and meta-analysis of history, physical examination, cerebrospinal fluid (CSF) tests, computed tomography (CT), and clinical decision rules for spontaneous SAH. A secondary objective was to delineate probability of disease thresholds for imaging and lumbar puncture (LP). PubMed, Embase, Scopus, and research meeting abstracts were searched up to June 2015 for studies of emergency department patients with acute headache clinically concerning for spontaneous SAH. QUADAS-2 was used to assess study quality and, when appropriate, meta-analysis was conducted using random effects models. Outcomes were sensitivity, specificity, and positive (LR+) and negative (LR-) likelihood ratios. To identify test and treatment thresholds, we employed the Pauker-Kassirer method with Bernstein test indication curves using the summary estimates of diagnostic accuracy. A total of 5,022 publications were identified, of which 122 underwent full-text review; 22 studies were included (average SAH prevalence = 7.5%). Diagnostic studies differed in assessment of history and physical examination findings, CT technology, analytical techniques used to identify xanthochromia, and criterion standards for SAH. Study quality by QUADAS-2 was variable; however, most had a relatively low risk of biases. A history of neck pain (LR+ = 4.1; 95% confidence interval [CI] = 2.2 to 7.6) and neck stiffness on physical examination (LR+ = 6.6; 95% CI = 4.0 to 11.0) were the individual findings most strongly associated with SAH. Combinations of findings may rule out SAH, yet promising clinical decision rules await external validation. Noncontrast cranial CT within 6 hours of headache onset accurately ruled in (LR+ = 230; 95% CI = 6 to 8,700) and ruled out SAH (LR- = 0.01; 95% CI = 0 to 0.04); CT beyond 6 hours had a LR- of 0.07 (95% CI = 0.01 to 0.61). CSF analyses had lower diagnostic accuracy, whether using red blood cell (RBC) count or xanthochromia. At a threshold RBC count of 1,000 × 10(6) /L, the LR+ was 5.7 (95% CI = 1.4 to 23) and LR- was 0.21 (95% CI = 0.03 to 1.7). Using the pooled estimates of diagnostic accuracy and testing risks and benefits, we estimate that LP only benefits CT-negative patients when the pre-LP probability of SAH is on the order of 5%, which corresponds to a pre-CT probability greater than 20%. Less than one in 10 headache patients concerning for SAH are ultimately diagnosed with SAH in recent studies. While certain symptoms and signs increase or decrease the likelihood of SAH, no single characteristic is sufficient to rule in or rule out SAH. Within 6 hours of symptom onset, noncontrast cranial CT is highly accurate, while a negative CT beyond 6 hours substantially reduces the likelihood of SAH. LP appears to benefit relatively few patients within a narrow pretest probability range. With improvements in CT technology and an expanding body of evidence, test thresholds for LP may become more precise, obviating the need for a post-CT LP in more acute headache patients. Existing SAH clinical decision rules await external validation, but offer the potential to identify subsets most likely to benefit from post-CT LP, angiography, or no further testing.

Endoscopic Solution to Rhinogenic Contact Headaches

Introduction&#x0D; Headache is a common complaint that brings patients to multidisciplinary clinics. It is utmost important to have meticulous clinical diagnosis of patients with rhinogenic and non sinusogenic headaches. The diagnosis has become easier with the advent of modern endoscopy and endoscopic sinus surgical techniques. This study aims to investigate the role of some anatomical nasal abnormalities in rhinogenic contact headache and to evaluate response to endoscopic surgery.&#x0D; &#x0D; Materials and Method&#x0D; A prospective study was conducted at a secondary level regional referral Hospital in the Sultanate of Oman. Patients with long-lasting, frequent, severe headaches not amenable to medical treatment, above 20 years of age were taken into consideration. Routine nasal endoscopy, Computerized tomography scan of the paranasal sinuses, Nasal decongestion and various surgical techniques to correct the anatomical abnormalities were included in our study and results were correlated statistically.&#x0D; &#x0D; Result&#x0D; There was a male predominance in our study with duration of headache ranging from 2 weeks to 5 years. There was a preponderance of headache in frontal region in our study group. Diagnostic nasal endoscopy and CT scan of PNS revealed Deviated nasal septum / septal spur, concha bullosa, Haller cell, pneumatised uncinate process and agar nasi cells. The overall success rate of the surgery in relieving headaches, measured by the MIDAS- VAS score, was approximately 75 %. The non-parametric Wilcoxon signed rank test, Chi square and paired T tests shows that the following study has rejected the null hypothesis as statistically significant where the P value &lt;0.05.&#x0D; &#x0D; Discussion&#x0D; Researchers have examined the contact points as a source of rhinogenic / contact headache. Intranasal mucosal contact released substance P, causing pain and headache, Substance P has a potent vasodilator effect. Vasodilatation and perivascular inflammation are the final common pathways in pain. Surgical treatment for contact point-induced headaches has had good success.&#x0D; &#x0D; Conclusion&#x0D; The etiology of rhinogenic headache is multifactorial. Complete history taking, scrupulous preoperative evaluations, multidisciplinary consultations, Initial medical controls, long observation, and diligent postoperative follow-ups are mandatory for not only accurate diagnosis but also for promising surgical outcomes of non-sinusitis related rhinogenic headache. Our experience reveals that patients with rhinogenic contact headaches can benefit significantly from meticulous endoscopic decompression

Overlap between Headache, Depression, and Anxiety in General Neurological Clinics: A Cross-sectional Study.

Background:Many studies have reported that depression and anxiety have bidirectional relationship with headache. However, few researches investigated the roles of depression or anxiety in patients with headache. We surveyed the prevalence of depression and anxiety as a complication or cause of headache among outpatients with a chief complaint of headache at neurology clinics in general hospitals. Additional risk factors for depression and anxiety were also analyzed.Methods:A cross-sectional study was conducted at 11 general neurological clinics. All consecutive patients with a chief complaint of headache were enrolled. Diagnoses of depression and anxiety were made using the Chinese version of the Mini International Neuropsychiatric Interview, and those for headache were made according to the International Classification of Headache Disorders, 2nd Edition. The headache impact test and an 11-point verbal rating scale were applied to assess headache severity and intensity. Logistic regression was used to analyze risk factors of patients with headache for depression or anxiety.Results:A total of 749 outpatients with headache were included. Among them, 148 (19.7%) were diagnosed with depression and 103 (13.7%) with anxiety. Further analysis showed that 114 (15.2%) patients complaining headache due to somatic symptoms of psychiatric disorders and 82 (10.9%) had a depression or anxiety comorbidity with headache. Most patients with depression or anxiety manifested mild to moderate headaches. Poor sleep and severe headache-related disabilities were predictors for either depression or anxiety.Conclusion:Clinicians must identify the etiology of headache and recognize the effects of depression or anxiety on headache to develop specific treatments.

Headache and health in the Brazilian Imperial Period

Treatment of headaches always has been a challenge for people and health care professionals. The purpose of this article is to review the treatments found in bibliographic sources of the Brazilian Imperial period, and make a narrative description. The sources consulted, such as the "Chernoviz Manual" and the writings of Sigaud revealed that the treatment of headaches was frequently based on homemade treatments or Amerindians herbs recipes. Only recently headache was included as a relevant issue to medicine, as well as its scientific approach. This article provides information about the view at that time concerning to the etiology of headaches and ways of treatment, to trace a narrative scenario of these aspects in the nineteenth century in the Empire of Brazil.

Incidence and predictors of dural venous sinus pressure gradient in idiopathic intracranial hypertension and non-idiopathic intracranial hypertension headache patients: results from 164 cerebral venograms.

OBJECTIVE Cerebral venous pressure gradient (CVPG) from dural venous sinus stenosis is implicated in headache syndromes such as idiopathic intracranial hypertension (IIH). The incidence of CVPG in headache patients has not been reported. METHODS The authors reviewed all cerebral venograms with manometry performed for headache between January 2008 and May 2015. Patient demographics, headache etiology, intracranial pressure (ICP) measurements, and radiographic and manometric results were recorded. CVPG was defined as a difference ≥ 8 mm Hg by venographic manometry. RESULTS One hundred sixty-four venograms were performed in 155 patients. There were no procedural complications. Ninety-six procedures (58.5%) were for patients with IIH. The overall incidence of CVPG was 25.6% (42 of 164 procedures): 35.4% (34 of 96 procedures) in IIH patients and 11.8% (8 of 68 procedures) in non-IIH patients. Sixty procedures (36.6%) were performed in patients with preexisting shunts. Seventy-seven patients (49.7%) had procedures preceded by an ICP measurement within 4 weeks of venography, and in 66 (85.7%) of these patients, the ICP had been found to be elevated. CVPG was seen in 8.3% (n = 5) of the procedures in the 60 patients with a preexisting shunt and in 0% (n = 0) of the 11 procedures in the 77 patients with normal ICP (p < 0.001 for both). Noninvasive imaging (MR venography, CT venography) was assessed prior to venography in 112 (68.3%) of 164 cases, and dural venous sinus abnormalities were demonstrated in 73 (65.2%) of these cases; there was a trend toward CVPG (p = 0.07). Multivariate analysis demonstrated an increased likelihood of CVPG in patients with IIH (OR 4.97, 95% CI 1.71-14.47) and a decreased likelihood in patients with a preexisting shunt (OR 0.09, 95% CI 0.02-0.44). CONCLUSIONS CVPG is uncommon in IIH patients, rare in those with preexisting shunts, and absent in those with normal ICP.

Diagnosis and Management of Childhood Headache

Headache is one of the most common chief complaints seen in the pediatrician's office. Oftentimes, identifying the etiology of headache and differentiating primary and secondary causes can present a diagnostic conundrum. Understanding the most common causes of primary and secondary headache is vital to making a correct diagnosis. Here we review the typical presentations of the most common primary headache disorders and the approach to evaluation of the pediatric patient presenting with headache. Diagnostic workup, including the key features to elicit on physical examination, when to order head imaging, and the use of other ancillary tests, is discussed. Current treatment modalities and their indications are reviewed. We will also describe some of the new, emerging therapies that may alter the way we manage headache in the pediatric population. Headache can, at times, be a frustrating symptom seen in the pediatrician's office, but here we hope to better elucidate the approach to evaluation, management, and treatment as well as provide some hope in regards to more effective upcoming therapies.

Aplasia of the Internal Carotid Artery with Dandy-Walker Variant.

Dear Editor, A 28-year-old woman presented with a 2-year history of headache, and magnetic resonance imaging (MRI) led to a diagnosis of suspected intracranial malformation. She had been in good health and had developed normally prior to developing the symptom. A neurological examination on admission revealed no anomaly. Brain MRI revealed agenesis of the inferior part of cerebellar vermis and a large posterior fossa cyst communicating with the fourth ventricle without hydrocephalus, suggestive of Dandy-Walker variant (DWv) (Fig. 1A and B). Paraclinoidal vascular dilation (Fig. 1B) and thinning of the occipital bone (Fig. 1C) were also observed. Catheter angiography revealed that the right internal carotid artery (ICA) was absent at the sixth segment, and the remnant of the intracranial clinoidal ICA and the left anterior cerebral artery territory were supplied by the right posterior communicating artery. The remnant segment of the ICA had an aneurysmal appearance, and was approximately 6.5 mm in diameter (Fig. 1E and F). The absence of the right ICA in the carotid canal confirmed the diagnosis (Fig. 1D). The patient's symptom was relieved by the administration of vasodilator agents. Fig. 1 Aplasia of the internal carotid artery (ICA) with Dandy-Walker variant. A: T1-weighted sagittal magnetic resonance imaging (MRI) showing a hypoplastic cerebellar vermis (long white arrow). B: T2-weighted axial MRI revealing a paraclinoidal aneurysmal ... Congenital aplasia of the ICA is an extremely rare vascular anomaly that occurs in less than 0.01% of the population, and is usually symptomless. Common symptoms and signs include recurrent headache, convulsions, blurred vision, hearing loss, hemiparesis with or without cranial nerve palsy, or transient ischemic attack and subarachnoid hemorrhage, depending on the collateral circulation and hemodynamics-related aneurysms, with an incidence of 25-34%.1 DWv consists of malformations with less severe cerebellar vermis hypoplasia, less notable or absent upward rotation of the vermis, and communication between the fourth ventricle and subarachnoid space, with no hydrocephalus.2 The etiology of the patient's headache remains to be established. The sporadic nature of the unilateral headaches along with the associated nausea is consistent with the diagnosis of either neurovascular insufficiency or intermittent high intracranial pressure. This report describes a new association with DWv in a patient with no ICA, which has not been previously reported in the literature. Such patients must be followed clinically and radiographically in order to monitor for the possibility of cerebrovascular disorders, especially the development of aneurysms and hydrocephalus.

The Natural History and Management of Petrous Apex Cholesterol Granulomas.

To evaluate the clinical and radiographic characteristics of cholesterol granulomas of the petrous apex, as well as the outcomes of operative and conservative management. Retrospective chart review. Two independent tertiary academic referral centers. Adult and pediatric patients with cholesterol granulomas of the petrous apex were identified from the experience of two separate centers. Patients were included after radiographic diagnosis and clinical evaluation. All patients with less than 6 months of follow-up and those with iatrogenic postoperative cholesterol granulomas were excluded. Demographic information, presenting symptoms, imaging characteristics, treatment strategies, and outcomes were recorded. Patients were evaluated on the basis of symptom and radiographic evolution during time, with or without operative intervention. Ninety petrous apex cholesterol granulomas were analyzed (57.8% females, 55.6% right-sided). The average age at presentation was 43.1 years (median 42.0, range 8.0-77.0 years). The most common presenting symptom was headache (56.7%), and the average lesion size in the greatest dimension was 2.1 cm (median 1.7, range 0.7-5.0 cm). During a mean follow-up of 46.0 months, no cases of spontaneous rupture or carotid injury occurred. Twenty-three patients (25.6%) ultimately underwent surgical management, most commonly for intractable headache, and only 47.8% of these patients experienced durable symptom improvement by their last postoperative follow-up. Many cholesterol granulomas of the petrous apex remain stable during time and can be safely managed with primary observation. Surgery should be reserved for lesions that are causing, or threatening, neurologic dysfunction because of mass effect or erosion of critical structures such as the otic capsule. Cranial neuropathy associated with cholesterol granuloma may improve after operative management; however, symptoms such as headache and dizziness are less likely to benefit from surgery. As a general guideline, in the presence of a radiologically stable cholesterol granuloma in the petrous apex, alternative etiologies for headache and dizziness should be considered and treated before offering surgical intervention.

Physiopathologie de l’algie vasculaire de la face (AVF)

The aetiology of cluster headache is partially unknown. Three areas are involved in the pathogenesis of cluster headache: the trigeminal nociceptive pathways, the autonomic system and the hypothalamus. The cluster headache attack involves activation of the trigeminal autonomic reflex. A dysfunction located in posterior hypothalamic gray matter is probably pivotal in the process. There is a probable association between smoke exposure, a possible genetic predisposition and the development of cluster headache.

O019. Headache as an emergency in children and adolescents.

Pediatric and adolescence headache is one of the most common causes of access in Emergency Departments (ED). We reviewed the literature and we found that headache in ED is generally a benign condition that tends to be self-limited or resolves after an appropriate drug treatment. Causes of non-traumatic headache in ED include more frequently primary headaches (21.8-66.3%) and secondary benign headaches (35.4-63.2%), while secondary life-threatening headaches are less frequent (2-15.3%) (Table ​(Table1).1). The most frequent worrying conditions include ventricoloperitoneal shunt malfunction, central nervous system infections, brain tumors, hydrocephalus, pseudotumor cerebri and hemorrhage. In a pediatric ED, the primary objective is to recognize the serious life-threatening conditions requiring immediate medical care among the wide spectrum of headache diagnoses. The diagnostic approach starts with a thorough history followed by a complete physical and neurologic examination. The temporal features may be useful to classify headaches into four temporal patterns (acute, recurrent acute, chronic progressive, chronic non-progressive) that aid in reaching the etiological diagnosis. A normal neurological examination has been demonstrated to highly correlate with the absence of relevant intracranial processes in several pediatric studies. Neuroimaging should be considered in patients with recent-onset severe headache or change in the type of headache or with associated signs or symptoms suggestive for intracranial diseases. The therapeutic management of headache in ED depends on general clinical conditions of the patients and the presumable etiology of headache [1]. Table 1 Comparison of the studies about etiology of headache in ED * only patients with focal neurological signs at admission to ED.

Are Right to Left Shunts Underdiagnosed in the Etiology of Migraine Headache?

Are Right to Left Shunts Underdiagnosed in the Etiology of Migraine Headache?

Are Right to Left Shunts Underdiagnosed in the Etiology of Migraine Headache? --A Response.

Are Right to Left Shunts Underdiagnosed in the Etiology of Migraine Headache? --A Response.

Pneumocephalus associated with epidural and spinal anesthesia for labor.

Headache resulting from dural puncture in epidural and spinal anesthesia is usually secondary to a CSF leak. Pneumocephalus may also occur in this setting but has not been well-characterized. Although the risk factors for a CSF leak and pneumocephalus may overlap, their rates, clinical features, and treatments may be different. Our retrospective review of 182 patients with acute headache in the antepartum, peripartum, and postpartum settings yielded a 5:1 ratio of postdural puncture headache to pneumocephalus. The 3 patients with pneumocephalus had the defining characteristic of thunderclap headache during anesthesia. Early diagnosis is helpful as treatment with supplemental oxygen may hasten recovery. Pneumocephalus should be considered as a possible etiology of thunderclap headache in the setting of epidural and spinal anesthesia.

Cervical spine pain related to the facet joints

Neck pain is a common diagnostic entity, with a lifetime prevalence of between 65% and 80%. Appreciation of the role of the cervical facet joints in the etiology of cervical spine pain is paramount to providing sustained pain relief for individuals suffering from degenerative and posttraumatic neck pain. Studies have demonstrated that approximately 60% of patients who sustain whiplash-type rear-end motor vehicle collisions would have pain that results from the facet joints alone, or in conjunction with the cervical intervertebral disks. An appreciation of the anatomical foundation for the development of these painful conditions includes knowledge of the dual, overlapping innervation of each cervical facet joint with contributions from levels at, and above the joint. Medial branch nerves invest the joints; are held closely adherent to the articular pillars by tendons of the semispinalis capitis muscles; and can be treated using local anesthetic nerve blocks followed by radiofrequency (RF) procedures for prolonged benefit. Nerves in facet joints contain modified nociceptors, including silent nociceptors, low-threshold mechanoreceptors, and mechanically sensitive nociceptors. Nerves within facet joints are both free and encapsulated and contain Substance P and calcitonin gene–related peptide. Treatment approaches must address these diverse anatomical and physiological phenomena to provide the highest level of interventional therapy. Large, well-conducted studies have demonstrated the efficacy and safety of providing short-term symptomatic pain relief using cervical facet medial branch nerve blocks. Continuous-energy thermal lesioning RF ablation techniques of the cervical medial branches may produce pain relief that persists for up to 12 months in two-thirds of patients so treated. A systematic review of well-conducted studies recently published confirmed that the evidence in favor of using RF ablation is level II for the long-term effectiveness of RF neurotomy and facet joint nerve blocks in managing cervical facet joint pain. Imaging for performing these procedures is mandatory to assure success and to minimize adverse events from occurring. Fluoroscopy is a standard imaging technique, but ultrasound and even computed tomography scan guidance have been documented to be satisfactory in properly trained interventionalists. The cervical facet joints with their medial branches represent a reliable target for directing interventional therapies aimed at addressing nociceptive type pain, albeit with a neurogenic component. Future studies would reflect our evolving appreciation of these intricate anatomical networks of innervation and their role in the etiology of chronic headache and neck pain.

Problem with defining headache etiology using patient symptomatology.

Problem with defining headache etiology using patient symptomatology.

Imaging Miscues in Pediatric Headache

Much has been written regarding the indications for imaging in pediatric headache to facilitate the detection of potentially catastrophic structural lesions (i.e., tumors and hydrocephalus). Detection of such lesions is typically straightforward with CT or MRI. Imaging correlates for certain well-described causes of pediatric headache, however, may be more subtle and, therefore, potentially overlooked. Furthermore, the overlap of imaging patterns may result in the potential for misinterpretation. The purpose of this article is to highlight some of the entities in which imaging findings are subtle and/or overlooked in this population of children with headache. In particular, we discuss: (1) inferior cerebellar tonsillar ectopia as a manifestation of Chiari I malformation, and its mimics; (2) subtle imaging findings of vascular etiologies for headache, including circle of Willis vasculopathy and dural sinus thrombosis; and (3) typical imaging features of migraine variants presenting in the pediatric population, including hemiplegic and ophthalmoplegic migraine.