Benign Headache Research Articles

The diagnosis of and emergent care for the patient with subarachnoid haemorrhage in resource-limited settings

Non-traumatic subarachnoid haemorrhage (SAH) is a neurosurgical emergency that may present similarly to a benign headache, yet poses high morbidity and mortality in what often times are young and otherwise healthy patients. While the diagnosis may be made via several different modalities, not all of these are available to every emergency physician. A high suspicion for SAH along with a good history and physical examination may best serve patients in these resource-limited settings. Adequate resuscitative and supportive care, combined with prompt transfer to a facility with neurosurgical capabilities is integral to optimizing patient outcomes.

Missed diagnosis of stroke in the emergency department: a cross-sectional analysis of a large population-based sample.

BackgroundSome cerebrovascular events are not diagnosed promptly, potentially resulting in death or disability from missed treatments. We sought to estimate the frequency of missed stroke and examine associations with patient, emergency department (ED), and hospital characteristics.MethodsCross-sectional analysis using linked inpatient discharge and ED visit records from the 2009 Healthcare Cost and Utilization Project State Inpatient Databases and 2008–2009 State ED Databases across nine US states. We identified adult patients admitted for stroke with a treat-and-release ED visit in the prior 30 days, considering those given a non-cerebrovascular diagnosis as probable (benign headache or dizziness diagnosis) or potential (any other diagnosis) missed strokes.ResultsThere were 23,809 potential and 2243 probable missed strokes representing 12.7% and 1.2% of stroke admissions, respectively. Missed hemorrhages (n = 406) were linked to headache while missed ischemic strokes (n = 1435) and transient ischemic attacks (n = 402) were linked to headache or dizziness. Odds of a probable misdiagnosis were lower among men (OR 0.75), older individuals (18–44 years [base]; 45–64:OR 0.43; 65–74:OR 0.28; ≥ 75:OR 0.19), and Medicare (OR 0.66) or Medicaid (OR 0.70) recipients compared to privately insured patients. Odds were higher among Blacks (OR 1.18), Asian/Pacific Islanders (OR 1.29), and Hispanics (OR 1.30). Odds were higher in non-teaching hospitals (OR 1.45) and low-volume hospitals (OR 1.57).ConclusionsWe estimate 15,000–165,000 misdiagnosed cerebrovascular events annually in US EDs, disproportionately presenting with headache or dizziness. Physicians evaluating these symptoms should be particularly attuned to the possibility of stroke in younger, female, and non-White patients.

Internal jugular vein valve insufficiency is not increased in migraine: an ultrasound study in migraine patients and control participants

BackgroundMigraine is a common neurological disorder of unclear pathogenesis. Recently incompetence of internal jugular vein valve (IJVVI) was found to be associated with some neurological conditions of unknown etiology such as benign cough headache, primary exertional headache or transient global amnesia. Common vascular mechanism linking transiently increased cerebral venous pressure with the above mentioned conditions was then postulated. Therefore we decided to investigate whether IJVVI may be associated with migraine.Aim and methodsThe aim of our study was to evaluate the occurrence of IJVVI and retrograde flow duration in 70 (56 females) migraine patients by color Doppler ultrasound during Valsalva maneuver.We assessed internal jugular vein valve in 44 patients with migraine without aura (39 female); mean age 37 ± 9 yrs. and in 26 patients with migraine with typical aura (17 female); mean age 34 ± 9 yrs. Age- and sex-matched control group consisted of 42 healthy persons (33 female); mean age 32 ± 1 yrs.ResultsFrequency of the internal jugular vein valve insufficiency was similar in patients with migraine and in the healthy subjects (51% v. 40%, p = 0.26). Also mean values of retrograde flow duration were similar in both groups (2.4 ± 0.8 sec in migraine group and 2.2 ± 1.2 sec in controls, p = 0.14).ConclusionThe results of our study show no evidence for an increased prevalence of IJVVI in migraine patients.

Headaches After Renal Transplantation—A Case Report

Headaches are one of the most common medical complaints. The differentiation of benign primary headaches from the small number of patients with secondary headaches may be challenging, but failure to recognize a serious headache can be fatal. We report the case of a 49-year-old renal transplant patient, who was admitted to hospital because of intractable right-sided headaches. Cerebral imaging was unremarkable. Not until 2 days later did the patient develop a rash of grouped vesicles located in the right dermatome C3. Consecutively cerebrospinal fluid tested positive for Varizella zoster virus (VZV), indicating VZV meningitis. Therapy was started with intravenous acyclovir with rapid improvement.Here in we have described an atypical case of VZV reactivation in a renal transplant patient, who initially presented with headaches without any skin manifestation. Because of their compromised immune system, transplant patients have a high risk for visceral involvement of VZV infections, which are a life-threatening emergency. Therefore, vaccination of seronegative patients should be part of the pretransplant workup. Accurate and fast diagnosis of infection is essential to immediately start antiviral therapy.

Risk associated behavior in premorbid multiple sclerosis: A case-control study

BackgroundIt is generally accepted that individuals who subsequently develop MS are more likely to be smokers, have suffered glandular fever and to have a low blood vitamin D level. Previous research suggested that a unifying premise is risk-associated behavior before MS onset. This survey explores several health-adverse premorbid behaviors using a case-control design. MethodsA questionnaire was completed by 94 patients with clinically definite MS. Their responses were compared to a control group of 59 who were patients with benign headache. Questions explored pre-symptomatic experience of: (a) alcohol, smoking, substance abuse, glandular fever; (b) blood transfusion; (c) hazardous sport, gambling (d) sexual history, gynecologic infection, number of pregnancies, terminations of pregnancy. Data were adjusted for age of first symptoms, gender and smoking. ResultsCompared to the headache group, MS subjects showed significant differences prior to symptom onset, adjusted for age of first symptoms, gender and smoking, with odds ratios for reporting or means and 95% confidence intervals as follows: (a) consuming alcoholic drinks, OR 6.91 (1.74 to 27.45; p=0.006) and at an earlier age, mean 16.9y (16.4 to 17.5; p=0.046) (b) cigarette smoking, OR 2.24 (1.09 to 4.59; p=0.028) and to have smoked more per day, mean 9.45 (5.55 to 13.35; p=0.001) (c) history of glandular fever/infectious mononucleosis, OR 3.07 (1.11 to 8.49; p=0.031); (d) consumed recreational drugs, OR 3.90 (1.32 to 11.50; p=0.014), notably cannabis, OR 4.10 (1.40 to 12.09; p=0.011); (e) used a car seat belt, OR 4.45 (1.43 to 13.83; p=0.010); (f) attended all-night parties, OR 2.45 (1.12 to 5.36; p=0.025); (g) sunbathed, OR 2.770 (1.02 to 7.52; p=0.046); (h) had more sexual partners, mean 3.97 (2.00 to 5.95; p<0.001), more pregnancies, mean 1.43 (0.99 to 1.86; p=0.015) and one or more terminations of pregnancy, OR 5.05 (1.003 to 25.386; p=0.049). ConclusionAll but one of the statistically significant variables (use of car seat belt) supports our hypothesis that MS subjects lead a riskier premorbid lifestyle. Strong associations were found for smoking, alcohol and glandular fever as suggested by others. Novel associations were found for recreational drug use; attending all-night parties; gambling on the lottery; more sexual partners, more pregnancies and one or more terminations of pregnancy. Such behavior during the MS prodrome may expose an individual to a variety of hostile environmental agents.

A thunderclap headache

The non-contrast CT scan (Fig. 1 of Images in Neuroscience: Question) shows subarachnoid haemorrhage (SAH) within a right frontal lobe sulcus. While the arterial phase image (Fig. 2 of Images in Neuroscience: Question) of the digital subtraction angiography is normal, the early and late venous phase images (Fig. 3a and b of Images in Neuroscience: Question) demonstrate a persistent linear filling defect within the Vein of Trolard confirming thrombus. MRI to assess cerebral parenchyma shows a tubular structure showing high signal on T1-weighted imaging (Fig. 4a of Images in Neuroscience: Question) confined within the pre-central sulcus, indicating thrombus within a vessel or SAH. There is high signal on fluid attenuated inversion recovery MRI and blooming artefact on gradient echo imaging around the previously described tubular structure extending further along the sulcus (Fig. 4b and c of Images in Neuroscience: Question). Together with the CT scan findings and the venogram images, the MRI findings confirm Vein of Trolard thrombosis with adjacent SAH. Thunderclap headache is classically described as severe headache, which takes less than a minute or a few minutes from its onset to peak. The differential diagnosis for thunderclap headache includes SAH, cerebral venous sinus thrombosis, idiopathic benign recurrent headache disorder, arterial dissection, pituitary apoplexy, spontaneous intracranial hypotension, and hypertensive encephalopathy. Cerebral venous thrombosis confined to a cortical vein without involvement of the venous sinuses is rare. In our patient, this was associated with SAH. This phenomenon of SAH secondary to isolated cortical venous thrombosis has been described in a few

Subarachnoid haemorrhage as the presenting feature of lumbar spinal arteriovenous malformation

A 41-year-old man presented with a sudden onset severe occipital headache, vomiting, neck stiffness and photophobia. He had been previously well, aside from chronic mid and lower back pain. There...

Migraine After Sneezing: Pathophysiological Considerations, Focused on the Difference With Coughing

In patients reporting acute headache after sneezing or coughing, rupture of an intracranial aneurysm is the first diagnosis to be considered. Sneezing, however, might also be a trigger for migraine attacks, as exemplified in our case. We describe a patient who suffered 3 headache attacks after sneezing, each fulfilling criteria of migraine without aura. Sneezing as a specific trigger for migraine has not been described before. The differential diagnosis of acute headache after sneezing (eg, subarachnoid hemorrhage and reversible cerebral vasoconstriction), and the differences between migraine after sneezing and "benign cough headache" are discussed. We conclude that a pathophysiological association between migraine and sneezing might exist and hypothesize on underlying mechanisms.

Pediatric Headache: A Review

1. Heidi K. Blume, MD, MPH 1. Division of Pediatric Neurology, Seattle Children’s Hospital and Research Institute, Seattle, WA. * Abbreviations: CSF: : cerebrospinal fluid ICH: : intracranial hemorrhage ICP: : intracranial pressure IIH: : idiopathic intracranial hypertension NDPH: : new daily persistent headache NSAID: : nonsteroidal anti-inflammatory drug SVT: : sinus venous thrombosis TAC: : trigeminal autonomic cephalalgia Headaches are common in children; while most are caused by a benign problem or primary headache disorder, headaches can be a sign of a serious underlying condition. Pediatricians must be aware of the most recent recommendations for evaluating and managing headaches. After reading this article, readers should be able to: 1. Understand the evaluation of a child who has headache. 2. Recognize the diagnostic criteria for pediatric migraine. 3. Recognize “red flags” for elevated intracranial pressure or other underlying conditions in the child who has headache. 4. Discuss treatment strategies for migraine, tension, and chronic headache disorders. Headaches are common in children and adolescents and are a frequent chief complaint in office and emergency department visits. The vast majority of childhood headaches are due to a primary headache disorder, such as migraine, or an acute, relatively benign process, such as viral infection. However, clinicians also need to consider other causes of headaches in children. Even when headaches are benign, they may cause significant dysfunction for the child and family and must be managed appropriately to minimize disability and optimize function. In this review, we discuss the epidemiology of childhood headache, evaluation of the child who has headaches, when to consider secondary headache syndromes, and the diagnosis and management of primary headache disorders such as migraine and tension-type headaches. Acute and chronic headaches are relatively common in children and adolescents, although estimates of the precise prevalence of headache and migraine vary widely. Depending on the study definition of headache, population involved, and time periods studied, 17% to 90% of children report headaches, with an overall prevalence of 58% reporting some form of headache in the past year. (1 …

Headaches Induced by Pornography Use

A24-year-oldunmarriedmalesoftwareprofessional,notaknown caseofdiabetesorhypertension,presentedwithepisodesofsevere, explodingholocranialheadacheonwatchingpornographicvideos for the last 2 years. The headache would develop gradually over 5 min of viewing videos and would peak within 8–10 min. The intensitywassoseverethathehadtoabortwatching.Therewasno accompanying nausea, vomiting, or phonophobia. Progressively, he started to refrain from viewing videos as a means of avoiding headaches.Therewasnohistoryofheadacheassociatedeitherwith masturbation or with coitus. He had no history of head injury or meningoencephalitis in early childhood. There was no history suggestive of migraine in the family. He did not have a history suggestive of migraine, tension type or exertional headache. A physical and systemic examination was unremarkable. The neurological examination was normal. Magnetic Resonance (MR) Imaging, MR angiography of brain, and electroencephalogram were normal. He was advised non-steroidal anti-inflammatory agent combination (ibuprofen 400 mg and paracetamol 500 mg) halfanhourbeforewatching, towhichhereportedsignificantpain relief. Headaches associated with sexual activity are uncommon (Anand & Dhikav, 2009). Pre-orgasmic headache may be related tospace-occupyinglesions.Orgasmicheadacheisoftensevereand excruciating, whether due to aneurysm rupture or to the explosive component of benign coital headache. Post-orgasmic headache mayoccurasamanifestationofmigraine(Banerjee,1996).Astudy by Frese et al. (2003) stratified headaches associated with sexual activityandfound that there wasamale preponderance. It has two onset peaks (between 20–24 and 35–44 years). It can be dull type, increasing gradually with sexual excitement or explosive type. Paincanbebilateral and diffuseoroccipital.Headacheassociated with sexual activity has not been shown to be dependent upon specificsexualhabits andoccursoftenafterhavingsexualactivity with partner or during masturbation. There was a high co-morbidity with migraine and other types of headaches (e.g., benign exertionalandtension-type).Themechanismofheadacheinduced bysexualactivityismainlyatrigeminal-vasculareffect,butthereis a definite muscular component (Anand & Dhikav, 2009). Muscularcontractionplaysamajorrole,especiallyinmilderheadaches that become more intense as the sexual excitement increases. The probable mechanisms behind occurrence of headache in the present case could be alteration of nocioceptive mechanisms in the trigemino-vascular system with increased pain sensitivity associatedwitha heightenedemotional state associatedwithviewing pornorgraphy.

Other primary headaches

The ‘Other Primary Headaches’ include eight recognised benign headache disorders. Primary stabbing headache is a generally benign disorder which often co-exists with other primary headache disorders such as migraine and cluster headache. Primary cough headache is headache precipitated by valsalva; secondary cough has been reported particularly in association with posterior fossa pathology. Primary exertional headache can occur with sudden or gradual onset during, or immediately after, exercise. Similarly headache associated with sexual activity can occur with gradual evolution or sudden onset. Secondary headache is more likely with both exertional and sexual headache of sudden onset. Sudden onset headache, with maximum intensity reached within a minute, is termed thunderclap headache. A benign form of thunderclap headache exists. However, isolated primary and secondary thunderclap headache cannot be clinically differentiated. Therefore all headache of thunderclap onset should be investigated. The primary forms of the aforementioned paroxysmal headaches appear to be Indomethacin sensitive disorders. Hypnic headache is a rare disorder which is termed ‘alarm clock headache’, exclusively waking patients from sleep. The disorder can be Indomethacin responsive, but can also respond to Lithium and caffeine. New daily persistent headache is a rare and often intractable headache which starts one day and persists daily thereafter for at least 3 months. The clinical syndrome more often has migrainous features or is otherwise has a chronic tension-type headache phenotype. Management is that of the clinical syndrome. Hemicrania continua straddles the disorders of migraine and the trigeminal autonomic cephalalgias and is not dealt with in this review.

Huge supratentorial arachnoid cyst presenting as an orgasmic headache

Headache related with sexual activity (HAS) is a rare benign headache disorder. HAS is classified into pre-orgasmic and orgasmic headache. Increased intracranial pressure secondary to a Valsalva maneuver during orgasm has been proposed as a possible mechanism for orgasmic headache. We report a patient presenting with orgasmic headache associated with large supratentorial arachnoid cyst.

An unusual case of hypnic headache ameliorated utilizing a mandibular advancement oral appliance

AbbreviationsHH Hypnic headacheTMJ Temporomandibular jointBMI Body mass indexMAD Mandibular advancement applianceCH Cluster headacheOSA Obstructive sleep apneaCPAP Continuous positive airway pressureSCN Suprachiasmatic nucleusPAG Periaqueductal graySRBDs Sleep-related breathing disordersIntroductionHypnic headache (HH), first reported by Raskin [1], is arare and recurrent benign headache disorder that occursexclusively during sleep and usually presents after the ageof 60. Generally described as a primary headache of theelderly [2], the attacks are usually of short duration(30 min) and awaken the patient at a constant time eachnight. According to the International Classification ofHeadache Disorders, second edition (ICHD-2) [3], HHmust fulfill the following criteria:1. A dull headache fulfilling criteria 2–4:2. Develops only during sleep and awakens the patient3. At least two of the following characteristics:(a) Occurs >15 times per month(b) Lasts ≥15 min after waking(c) First occurs after the age of 50 years4. No autonomic symptoms and no more than one ofnausea, photophobia or phonophobia5. Not attributed to another disorderIn a case series, HH has been reported to account for0.07% of all headache patients [4]. The pathophysiology ofhypnic headache is yet to be fully elucidated, but due to itscircadian nature as well as its reported responsiveness tolithium [1], a disturbance of chronobiologic rhythmsappears to be putative. Previous reports of utilizing positiveairway pressure in hypnic headache patients have proven tobe inconclusive [5–8].The relationship between headache and sleep haspreviously been reported in the literature [9]. As hypnicheadaches will only occur during sleep, it potentiallyprovides us with the most robust insight into the commonetiologic mechanisms of these two entities. Additionalprimary headaches that occur during nocturnal sleep aremigraine, cluster headache, and chronic paroxysmal hemi-crania [10]. Other disorders that should be considered withheadaches that awaken us are obstructive sleep apnea(OSA) or sleep hypoxia/hypercapnia, restless leg syndromeor periodic limb movements during sleep, psychophysio-logic insomnia, chronic pain syndrome or fibromyalgia, ordepression/anxiety [10]. All should be considered in thedifferential until proven otherwise. A comprehensivehistory is necessary to accurately diagnose these headachedisorders. Headaches associated with OSA or sleep hypox-ia/hypercapnia are classified as secondary headaches orheadaches attributed to a disorder of homeostasis [11].Morning headaches will occur at a rate of 18–74% ofpatients with OSA [12]. About 40% of patients withinsomnia have headaches in the morning [13]. It has beenreported that 65% of sleep bruxism (SB) patients reportedfrequent headaches [14, 15]. However, laboratory studieshave demonstrated that most morning headaches are notdirectly correlated with SB [16, 17].

Are butyrophenones effective for the treatment of primary headache in the emergency department?

Butyrophenones have been reported to provide effective migraine relief in the emergency department (ED). We conducted a systematic review of the evidence for their use in the ED. We searched the Cochrane, Medline, Embase, and CINAHL databases. Included studies were randomized trials of a parenteral butyrophenone (droperidol, haloperidol) versus placebo or a comparator in migraine or benign headache with results available in English. Study quality was determined using the Jadad score. Six articles were included. Primary outcomes were subjective or objective headache relief (>50% improvement in visual analogue scale scores). Secondary outcomes included side effects. We reported pooled odds ratios (ORs) with their 95% confidence intervals (CIs) for subjective or objective headache relief for butyrophenones versus placebo or comparator agents. Three studies reported subjective headache relief with a butyrophenone versus placebo or meperidine in migraine. Two studies reported objective headache relief with droperidol versus prochlorperazine, whereas one study compared droperidol versus olanzapine in benign headache. The pooled OR for subjective headache relief was 8.08 (95% CI 1.54-42.30) for a butyrophenone versus placebo, whereas it was 1.50 (95% CI 0.33-6.77) for droperidol versus meperidine in migraine. The pooled OR for objective headache relief was 2.96 (95% CI 1.36-6.43) for droperidol versus prochlorperazine in benign headache. Rates of side effects were 10 to 45%; akathesia and sedation were the most common. Butyrophenones are effective for the relief of migraine or benign headache. However, adverse effects make it difficult to recommend butyrophenones above agents with similar effectiveness and fewer problems.

Manual therapy versus usual GP care for chronic tension-type headache: We now have better evidence, but important questions remain

Manual therapy and other physical and manipulative treatments are often recommended for patients with recurrent, benign headache disorders. The evidence base supporting their use, though, is not as firm as that for many pharmacological headache treatments (1). In fact, the authors of a recent systematic review concluded that more and better quality research is needed to establish the place of these therapies in headache care (2). The randomized controlled trial reported by Castien and colleagues is therefore a timely contribution to headache science. The authors randomized participants with chronic tension-type headache (CTTH) to receive either manual therapy or ‘‘usual’’ general practitioner (GP) care for the duration of the study. The premise of the intervention was that improvement in craniocervical muscle function should lessen headache, so the manual therapy intervention was designed to improve cervical mobility, stability and posture. The components of usual GP care were not as clearly specified but consisted of elements outlined in Dutch headache treatment guidelines. At both 8 and 26 weeks, the manual therapy group experienced a statistically significantly greater decline in headache days compared with the usual care group, and was more likely to achieve a 50% or greater reduction in headache frequency. The manual therapy group also did better than the usual care group on a variety of secondary outcome measures such as pain intensity and disability. Based on these findings, the authors conclude that ‘‘manual therapy is more effective than usual GP care in reducing symptoms of CTTH’’. Two things about this study are noteworthy. Firstly, this was a comparative effectiveness trial, which means that the study treatment was compared to another active treatment rather than to placebo or sham treatment (3). Secondly, this was a pragmatic trial, in which the investigators aimed to evaluate the intervention, as far as possible, in conditions that approximate those of real-life medical care. Both of these attributes are virtues when viewed from the perspective of clinical decision making. In the real world of headache care, doctors and patients do not usually choose between ‘‘treatment’’ and ‘‘no treatment’’ but instead choose among available treatments. A study that compares two active treatments, then, provides more useful information for clinical decision making than does a placebo or sham-controlled study. The pragmatic aspect of this study, with both treatments tested in headache sufferers drawn from clinical practice and delivered under conditions typical of routine practice, further increases its clinical relevance. Viewed from a scientific perspective, though, these virtues are not unalloyed. The tricky thing about comparative effectiveness research is the choice of comparator. Ideally, the treatment match-up should compare therapies that have been first been shown effective in comparison to placebo or sham treatment. This is not clearly the case for either manual therapy or for usual GP headache care following the Dutch treatment guidelines (4). Comparative effectiveness studies should also stage a ‘‘fair fight’’, in which both treatments are delivered at a reasonable intensity and dose. In this case, although study GPs followed Dutch treatment guidelines, their care does not appear to have been standardized to the same degree as the

Headaches Attributable to Infectious Diseases

Headache is the most common symptom that humans experience. While the vast majority of headaches are due to benign primary headache disorders, a small but important minority of headaches are due to secondary causes. Whereas significant emphasis is placed on educating physicians regarding prompt recognition of subarachnoid hemorrhage and headaches secondary to brain tumors, attention toward headaches secondary to infectious causes is often neglected. Unfortunately, a missed or delayed diagnosis of a headache secondary to meningitis, encephalitis, brain abscess, subdural empyema, or other infectious etiologies can lead to dire consequences for both the patient and physician. Accordingly, this article provides an overview of headaches attributed to systemic and intracranial infectious causes.

Myth: Ibuprofen is superior to acetaminophen for the treatment of benign headaches in children and adults

Myth: Ibuprofen is superior to acetaminophen for the treatment of benign headaches in children and adults

Neurological Manifestation of Behcet’s Disease: A Case Report

Behcet's disease causes inflammation of blood vessels but it is of unknown aetiology. When it involves the nervous system, it may present with benign headaches, aseptic meningitis, meningoencephalitis, cranial nerve palsies, seizures, personality changes, and cerebral venous thrombosis. We present the case of A.G is a 26-year old male, was a student in a Nigerian tertiary institution and resided in Lagos and Ibadan. He presented with a 2-year history of progressive and recurrent headaches, genital and mouth ulcers and weakness of the left limbs. Physical examination revealed a right handed, conscious, but apathetic and abulic young adult. All meningeal signs were positive. He had bilateral 6th nerve palsies, upper motor neuron (UMN) left 7th nerve palsy and a left partial ptosis. He had a bulbar speech with a cerebellar dysarthric twist and a grade 3 spastic left hemiparesis. However, his sensory system was intact and his presenting vital signs were within normal range. His brain computed tomogram confirmed areas of multiple infarcts, and a number of negative tests ruled out other possible differential diagnosis. He was treated for Behcet’s disease and had a dramatic positive response to antiplatelets and steroids. He was adequately stabilized on an out-patient basis, when under aunt’s care in Lagos. He, however, died following his relocation to Ibadan. An autopsy could not be done. Key Words : Behcet’s Disease, Neurological manifestations

Service development or research: make sure you know which game you are playing.

Background Benign headache is a common neurological symptom in both primary care (5% of consultations) and secondary care (20-30% of neurology referrals). Question Does a simple patient information sheet improve headache severity, frequency and impact as measured by the HIT-6 score? Methods A randomised controlled trial (RCT) in an NHS setting. Results The trial terminated early due to incomplete recruitment over a two year period. The information sheet had strong face validity with patients and patient groups but no meaningful conclusions can be drawn because of recruitment problems. One hundred and sixty eight patients were randomised from a projected sample size of 220 and only 62 fully completed the trial. Conclusions We analysed the reasons for trial failure, and they fall into a number of distinct groups: (1) major service configuration/re-orientation occurred concurrently as the trial was run with 'Choose and Book' and the '18 week targets' being introduced; (2) our aim was a classical evidence-based superiority trial, whereas the PCT aim was demand management; (3) there was a funding and resource shortfall. Our experience generates discussion about appropriate level of evaluation required for service development.

Lumbar punctures: use and diagnostic efficiency in emergency medical departments

BackgroundLumbar punctures (LP) are regularly and effortlessly used in the emergency medical departments (EMD). LP use and efficiency have not been fully explored in the published literature.AimsThe goal of this study was to assess in a French EMD, the frequency of use and the diagnostic efficiency of LP, the final diagnoses, and related medical practices.MethodsWe retrospectively studied all patients who underwent an LP after admission to our adult EMD in 2004 and 2005. Patients’ medical files were reviewed to collect clinical and paraclinical features. We defined efficient LP as abnormal LP, which confirmed a suspected diagnosis in an emergency setting.ResultsA total of 247 patients, representing 0.5% of all admissions, underwent an LP. LP were efficient in fewer than 15% of cases and confirmed aseptic meningitis (8.5%), bacterial meningitis (2.4%), Guillain-Barré syndromes (1.6%), subarachnoid hemorrhages (SAH, 0.4%), and carcinomatous meningitis (0.4%). The principal differential diagnoses were infections outside the central nervous system (CNS, 30%), noninfectious neurological disorders (28.7%), and benign headaches (14.2%). The main assumed LP indications were to search for CNS infection (62%) and for SAH (25%). LP efficiency decreased dramatically according to patients’ age. Brain imaging was performed in 90% of patients prior to LP. Excessive use of polymerase chain reaction to detect herpes simplex in cerebrospinal fluid was observed. The only LP complications found were postdural puncture headaches (6.1% of cases). The rate of traumatic LP was 17%.ConclusionsOur results are in accordance with the few published surveys on this topic. LP efficiency is modest but must be considered in light of the seriousness of suspected diagnoses. However, the search for differential diagnoses should not be neglected.