Complete Resolution Of Headache Research Articles

Headache Attributed to Refractive Error: Improvement after Topography-Guided Photorefractive Keratectomy with Corneal Cross-Linking in Patients with Keratoconus

Purpose: To investigate if topography-guided photorefractive keratectomy (TGPRK) alleviates headache, particularly headache attributed to refractive errors (HARE) in keratoconus. Methods: Patients diagnosed with keratoconus undergoing TGPRK for refractive correction were included. Best spectacle corrected visual acuity (BSCVA) using the logMAR scale and refractive error were measured. Patients answered a questionnaire exploring headaches, characteristics, treatment, and the Headache Impact Test (HIT-6) before and 6 months after the surgery. Results: 40 patients were included. Preoperatively, 24 patients (60%) met criteria for headaches: five for migraine, 14 for HARE, and five for tension-type headache (TTH). Patients with headaches preoperatively were more likely to require bilateral TGPRK, and the mean sphere and cylindrical power were higher. Postoperatively, 15 out of the 24 patients of the headache group experienced complete resolution of headaches, and only nine patients met diagnostic criteria for headaches: two for migraine, six for HARE, and one for TTH. The number of headaches reduced from 4.4 ± 2.4 to 0.5 ± 0.7 days/week (p < 0.001). Headache duration decreased from 108.5 ± 100.7 min to 34.4 ± 63.5 min (p = 0.002). Postoperatively, the consumption of analgesia decreased. The HIT-6 revealed an improvement in the quality-of-life post-procedure (p < 0.001). Conclusions: Surgical correction of irregular astigmatism in patients with keratoconus can alleviate or resolve headaches in a large proportion of patients, resulting in an improvement in their quality of life. Physicians should consider keratoconus in patients fitting criteria for HARE not alleviated by spectacle correction and suboptimal vision in glasses.

Natural History of Abortive Medication Withdrawal in the Management of Pediatric Medication Overuse Headache.

The objective of this study is to document pain scores during withdrawal of abortive medication in patients diagnosed with medication overuse headache. Cross-sectional study. Children's National Hospital's Headache Program. Patients 6-18 years of age who presented to the Headache Clinic at Children's National Hospital with presumed medication overuse headache between March 2017 and March 2019 were invited to participate. Patients were instructed to abruptly discontinue overused medications and record their headache characteristics daily in a diary for 8 weeks. Fourteen diaries were returned and analyzed at a 4-week follow-up visit. Ninety-three percent of the patients were females, with a median age of 14.9 years (standard deviation [SD] = 2.0). The average headache intensity upon study entry was 4.7 out of 10 (SD = 2.5), and the average headache intensity upon study completion was 3.1 (SD = 2.5). Of the patients, 57% had daily headaches upon study entry, 71% had improved pain intensity from the first diary entry to the last diary entry, and 57% had complete headache resolution at an average of 7.6 days from medication discontinuation (SD = 5.1). Ibuprofen was the most overused medication (71%). Our findings suggest that medication overuse headache will improve in the majority of pediatric patients who abruptly stop the offending medication(s) in an average of 8 days from withdrawal. Average pain intensity was reduced by more than one point among all patients who stopped taking abortive medications. Further larger-scale studies on medication withdrawal in pediatric patients with medication overuse headache could help us better understand whether this management strategy is effective.

Endoscopic Endonasal Orbital Apex Decompression for Carotid Cavernous Fistula.

This case report demonstrates a novel approach to treating a rare indirect carotid cavernous fistula (CCF) and associated abducens palsy. Although endovascular treatment is the standard of care in the management of CCFs, it was contraindicated in this patient. Instead, she underwent an endoscopic endonasal approach (EEA) with decompression of the medial orbital apex, including the cavernous sinus and optic nerve, with complete resolution of headache, lateral gaze palsy, and diplopia within 2 months.

A Novel Endovascular Therapy for CSF Hypotension Secondary to CSF-Venous Fistulas.

We report a consecutive case series of patients who underwent transvenous embolization of the paraspinal vein, which was draining the CSF-venous fistula, for treatment of spontaneous intracranial hypotension. These are the first-ever reported cases of this treatment for CSF-venous fistulas. All patients underwent spinal venography following catheterization of the azygous vein and then selective catheterization of the paraspinal vein followed by embolization of the vein with Onyx. All patients had improvement of clinical and radiologic findings with 4 patients having complete resolution of headaches and 1 patient having 50% reduction in headache symptoms. Pachymeningeal enhancement resolved in 4 patients and improved but did not resolve in 1 patient. Brain sag resolved in 4 patients and improved but did not resolve in 1 patient. There were no cases of permanent neurologic complications. All patients were discharged home on the day of the procedure.

Surgery versus conservative care for Rathke's cleft cyst

BackgroundRathke's cleft cysts are benign cystic lesions of the sellar region, which may cause headache, pituitary deficiencies and visual disturbances from mass effect. Their management is not standardized yet. This study is about establishing a consensus for medical care of RCC. Material and methodsWe performed a retrospective observational study of all patients that were diagnosed or followed for RCC between 2008 and 2018 (11 years), in the neurosurgical and the adult endocrine departments of our institution. The study's average time length of follow-up is 72.9 months (from 2 to 385 months). ResultsThe 57 included patients were divided into 2 groups: group A, which included 39 patients that were conservatively managed and group B, which included 18 surgically treated patients. Group A showed either an improvement or a spontaneous resolution of headaches in 56.1% of the cases (P<0.01); a resolution of hyperprolactinemia in 70% of the cases (P=0.21); and of hypogonadism, ACTH deficiency, growth hormone deficiency in 100% of the cases. There was no spontaneous improvement of visual disturbances (P<0.01) or diabetes insipidus (P=0.29) during follow-up. Regarding group B, surgery allowed improvement or complete resolution of headaches in 60% of the cases; visual troubles in 100% of the cases (P<0.01); and hyperprolactinemia in 100% of the cases. Pituitary deficiencies were not improved by surgery. ConclusionsThis study offers guidance in decision-making regarding the management of RCC patients. Surgery is particularly suitable for treating visual disturbances caused by RCC. Regular follow-up is more appropriate than surgery concerning headaches, hyperprolactinemia, endocrine disruptions and diabetes insipidus.

Headaches associated with acute SARS-CoV-2 infection: A prospective cross-sectional study.

Objectives:The prevalence and characteristics of COVID-19-related headaches are not known in Indian patients. We aim to determine the prevalence and characteristics of headache in COVID-19-infected individuals and make a comparison with those without headaches.Methods:This prospective cross-sectional observational study was conducted from 1 October to 31 October 2020. Data were collected using a detailed questionnaire. We compared the data of those with and without headaches to identify the differences between the groups.Results:During the study period of 1 month, among 225 COVID-19-infected patients, 33.8% patients had headaches. The mean age of patients with headache was 48.89 ± 15.19 years. In all, 53.9% were females. In 65.8%, headache occurred at the onset of viral illness; 44.7% described the headache as dull aching; 39.5% had bifrontal headache; and 32.9% had holocranial headache. In total, 78.9% had complete resolution of headache within 5 days. A comparison between those with and without headaches showed that those with headaches were more younger (48.89 ± 15.19 vs 54.61 ± 14.57 years, p = 0.007) and of female gender (41/76(53.9%) vs 41/149 (27.5%), p = 0.001). Primary headache disorders were more common in the headache group. Levels of inflammatory markers such as leukocyte count (7234.17 ± 3054.96 vs 8773.35 ± 5103.65, p = 0.017), erythrocyte sedimentation rate (39.28 ± 23.29 vs 50.41 ± 27.61, p = 0.02) and ferritin (381.06 ± 485.2 vs 657.10 ± 863.80, p = 0.014) were lower in those with headaches.Conclusions:Headaches are a common and early symptom of acute SARS-CoV-2 infection more frequently seen in young females and in those with a history of primary headache disorders. The lower level of inflammatory markers in those with headaches suggests that these headaches are probably due to the local spread of virus through the trigeminal nerve endings, resulting in activation of the trigeminovascular system.

Resolution of headache after reduction of prolactin levels in hyperprolactinemic patients.

Prolactin (PRL) secreting adenomas are associated with high incidence of headache. The role of hyperprolactinemia in the headache context is not clear, nor is the effect of its treatment on headache. The present longitudinal study evaluated hyperprolactinemic patients (69), in terms of presence and characteristics of headache before and after hyperprolactinemia treatment. Headache was reported by 45 (65.2%) patients, independent of the etiology of hyperprolactinemia. The migraine phenotype was the most prevalent (66.6%). Medications used in the treatment of headache not changed during the study. The first line of treatment of hyperprolactinemia was dopaminergic agonists. In the last reevaluation, PRL level under treatment was within the reference range in 54.7% of the cases, and it was observed complete or partial resolution of the headache in 75% of the cases. The median PRL at this time in patients with complete headache resolution was 17 ng/mL, in those who reported partial recovery was 21 ng/mL, and in those in whom the headache did not change was 66 ng/mL, with a significant difference between the group with complete headache resolution vs. the group with unchanged headache (p=0.022). In the cases with complete headache resolution, the median fall on PRL levels was 89% and in those cases with partial headache resolution 86%, both significantly different (p<0.001) from the fall in the cases with an unchanged headache. Data allow us to conclude that, in this series, in the majority of cases the reduction in the level of PRL was followe3d by cessation or relief of the pain.

Oral Ergotamine versus Theophylline as a Trial in Treatment of Low Tension Post Spinal Headache

AbstractBackground: Spinal anesthesia with local anesthetic agents is extensively used. It provides excellent pain relief as com-pared to intravenous or epidural route. But spinal anesthesia has some complications; one of them is post spinal headache. Which may range from mild to severe, So there were many trials for treatment of this headache.Aim: Our aim was to study the efficiency of oral ergot-amine versus theophylline in treatment of low tension post spinal headache.Material and Methods: This study was carried out on 90patient, 18-40 years, ASA I, scheduled for lower extremity and lower abdominal surgery under spinal anesthesia. Patients were randomized into three equal groups (30 patients in each group): Group 1: Patients received treatment in the form of (ergotamine 1mg/8 hours orally+ paracetamol 500mg/8 hours orally). Group 2 Patients received treatment in the form of (theophylline 250mg orally/8 hours+ paracetmaol 500mg/8 hours orally). Group 3 Patients received treatment in the form of (paracetamol 500mg/8 hours orally). The following param-eters were compared between the 3 groups: Patients will be asked for headache evaluation in sitting position in the fol-lowing times: Before medication, after 1 hour of medication then every 6 hours till complete resolution of headache, Onset of relieve of headache, Duration of treatment, Any side effects of each studied drugs and Patient satisfaction.Results: As regard headache evaluation using Numerical rating scale (NRS), theophylline group showed significant decrease in NRS when compared to ergotamine group and paracetamol group. Also mean duration to complete pain relieve showed significant decrease in theophylline group when compared to ergotamine group and paracetamol group with more patient satisfaction while, as regard onset of pain relieve, ergotamine group showed significant decrease when compared to theophylline group and paracetamol group respectively. There were no side effects recorded in the three groups.Conclusions: Adding either ergotamine or theophylline to paracetamol were more effective in decreasing intensity of PDPH pain than using paracetamol alone without side effects.In comparsion with ergotamine and paracetamol, theophylline was more effective due to lower Numerical rating scale, shorter duration till complete pain relieve with better patient satisfaction.

Effect of exclusion of frequently consumed dietary triggers in a cohort of children with chronic primary headache.

Although dietary factors are known to trigger headaches, the relationship between food and headache in children remains unclear. This prospective, observational case series aimed to evaluate the effect of exclusion of frequently-consumed foods in a cohort of children with headache. One hundred and fifteen children aged 3-15 (mean 10.5) years with primary headache were followed in a paediatric outpatient clinic. Patients who frequently consumed foods or food additives known to trigger headaches were advised to exclude them for six weeks and to return for follow-up with headache and food diary. One hundred patients attended follow-up. Of these 13 (13%) did not respond to dietary exclusion; 87 (87%) achieved complete resolution of headaches by exclusion of 1-3 of the identified food(s). Caffeine was the most common implicated trigger (28), followed by monosodium glutamate (25), cocoa (22), aspartame (13), cheese (13), citrus (10) and nitrites (six). One patient was sensitive to tomatoes. This study demonstrates the potential scale and significance of seven frequently consumed foods or food additives as triggers for primary headache in children. Also this is the first study to show that headaches can be triggered by the cumulative effect of a food that is frequently consumed, rather than by single time ingestion.

Efficacy of epidural blood patches for spontaneous low-pressure headaches: a case series.

Patients with a spontaneous cerebrospinal fluid leak, normally at a spinal level, typically present with low-pressure headache. In refractory cases, an epidural blood patch may be attempted. We aimed to assess the efficacy of lumbar epidural blood patching in spontaneous, low-pressure headaches. Methods We retrospectively analysed notes of patients who had an epidural blood patch performed for spontaneous low-pressure headaches in a single centre. Information regarding demographics, radiology and clinic follow-up was extracted from an electronic patient record system. Questionnaires regarding outcome were sent to patients a minimum of 6 months post-procedure. All patients received an epidural blood patch in the lumbar region irrespective of the site of cerebrospinal fluid leak. Results Sixteen patients who underwent lumbar epidural blood patching were analysed (11 female; mean age 43 years). The site of cerebrospinal fluid leak was evident in only 3/16 patients. Thirteen patients attended clinic follow-up; three reported complete headache resolution, four reported improvement in intensity or frequency and six described no change. Five of eight questionnaire respondents reported reduction in pain, and in these responders, mean headache severity improved from 9/10 to 3/10. Five of eight patients returning follow-up questionnaires reported sustained improvement in headache symptoms. Conclusion Epidural blood patch procedures can provide sustained improvement in headache symptoms in selected patients with spontaneous intracranial hypotension, but an untargeted approach has a lower success rate than reported in other case series.

Intravenous migraine therapy in children with posttraumatic headache in the ED

BackgroundMore than 3.8 million children sustain traumatic brain injuries annually. Treatment of posttraumatic headache (PTH) in the emergency department (ED) is variable, and benefits are unclear. ObjectiveThe objective of the study is to determine if intravenous migraine therapy reduces pain scores in children with PTH and factors associated with improved response. MethodsThis was a retrospective study of children, 8 to 21 years old, presenting to a tertiary pediatric ED with mild traumatic brain injury (mTBI) and PTH from November 2009 to June 2013. Inclusion criteria were mTBI (defined by diagnosis codes) within 14 days of ED visit, headache, and administration of one or more intravenous medications: ketorolac, prochlorperazine, metoclopramide, chlorpromazine, and ondansetron. Primary outcome was treatment success defined by greater than or equal to 50% pain score reduction during ED visit. Bivariate analysis and logistic regression were used to determine predictors of treatment success: age, sex, migraine or mTBI history, time since injury, ED head computed tomographic (CT) imaging, and pretreatment with oral analgesics. ResultsA total of 254 patients were included. Mean age was 13.8 years, 51% were female, 80% were white, mean time since injury was 2 days, and 114 patients had negative head CTs. Eighty-six percent of patients had treatment success with 52% experiencing complete resolution of headache. Bivariate analysis showed that patients who had a head CT were less likely to respond (80% vs 91%; P = .008). ConclusionsIntravenous migraine therapy reduces PTH pain scores for children presenting within 14 days after mTBI. Further prospective work is needed to determine long-term benefits of acute PTH treatment in the ED.

Uncorrected amteropia among children hospitalized for headache evaluation: a clinical descriptive study.

BackgroundHeadache is a common complaint in children occasionally requiring hospital admission. The purposes of the present study were to analyze the prevalence of uncorrected ametropia in children with headache admitted to the hospital, and evaluate the importance of refraction assessment as part of their evaluation.MethodsA retrospective review of children admitted to the Tel Aviv Medical Center for headache evaluation from December 2008 to March 2013, in whom the only abnormality found was an uncorrected refractive error.ResultsDuring the study period 917 children with headache were hospitalized for evaluation and 16 (1.7%) of them (9 boys, mean age 12 years, range 8–18 years) were found to have an uncorrected ametropia. Average headache duration was 4 months (range, 1 week to 1 year) and mean follow-up was 15 months (range, 1 month to 3 years). Twelve (75%) children had brain imaging and 4 children (25%) had a lumbar puncture before their refractive abnormality was identified. Anisometropia and myopia were the most common refractive errors encountered (n = 10 each), followed by hyperopia (n = 6) and astigmatism (n = 3). Despite having uncorrected refractive errors most children (n = 10) did not complain of any visual difficulty. All children were given proper refractive correction and 14 of them reported complete headache resolution on re-examination one month later.ConclusionsUncorrected ametropia is a possible cause of headache among hospitalized children. Therefore, complete ophthalmic evaluation, which includes proper refraction assessment, is important as it can identify a treatable headache etiology. Children without visual difficulty should be equally evaluated, as many children with headache and uncorrected amteropia do not have vision complaints.

The Prognosis of Pediatric Headaches—A 30-Year Follow-up Study

BackgroundAlthough headaches in childhood are common, there are few data available on their long-term prognosis. We have monitored a group of patients since diagnosis in 1983. MethodsPatients who were part of the 20-year follow-up study in 2003 were contacted, and data were collected using a standardized telephone interview. Details of headache characteristics and identified precipitants and alleviating factors were gathered. The most effective means of controlling the headaches were also recorded. ResultsFollow-up was achieved for 28 of 60 patients (47%). Over the 30 years since diagnosis, eight patients (29%) reported a complete resolution of headaches, including three whose headaches resolved between the 20- and 30-year follow-up studies. The type of headache varied over the 30-year time interval with only three patients maintaining the same headache type at all four time periods of 1983, 1993, 2003, and 2013. Only one patient used prescription medication as the primary method for controlling headaches. The most commonly used intervention was nonprescription analgesia, self-relaxation and/or hypnosis, and precipitant avoidance. ConclusionsHeadaches persist in approximately 70% of children 30 years after diagnosis. Encouraging children to manage their headaches with simple analgesia and precipitant avoidance appears to have long-term benefits.

Sleep-Related Headache and its Management

Sleep and headache have both generated curiosity within the human mind for centuries. The relationship between headache and sleep disorders is very complex. While Lieving in 1873 first observed that headaches were linked to sleep, Dexter and Weitzman in 1970 described the relationship between headache and sleep stages. Though our understanding of sleep and headache relationship has improved over the years with expanding knowledge in both fields and assessment tools such as polysomnography, it is still poorly understood. Headache and sleep have an interdependent relationship. Headache may be intrinsically related to sleep (migraine with and without aura, cluster headache, hypnic headache, and paroxysmal hemicrania), may cause sleep disturbance (chronic migraine, chronic tension-type headache, and medication overuse headache) or a manifestation of a sleep disorder like obstructive sleep apnea. Headache and sleep disorder may be a common manifestation of systemic dysfunction-like anemia and hypoxemia. Headaches may occur during sleep, after sleep, and in relation to different sleep stages. Lack of sleep and excessive sleep are both considered triggers for migraine. Insomnia is more common among chronic headache patients. Experimental data suggest that there is a common anatomic and physiologic substrate. There is overwhelming evidence that cluster headache and hypnic headaches are chronobiological disorders with strong association with sleep and involvement of hypothalamus. Cluster headache shows a circadian and circannual rhythmicity while hypnic headache shows an alarm clock pattern. There is also a preferential occurrence of cluster headache, hypnic headache, and paroxysmal hemicrania during REM sleep. Silencing of anti-nociceptive network of periaqueductal grey (PAG), locus ceruleus and dorsal raphe nucleus doing REM sleep may explain the preferential pattern. Sleep related headaches can be classified into (1) headaches with high association with obstructive sleep apnea, which includes cluster headache, hypnic headache, and headache related to obstructive sleep apnea; and (2) headaches with high prevalence of insomnia, medication overuse, and psychiatric comorbidity including chronic migraine and chronic tension-type headache. The initial step in the management of sleep related headache is proper diagnosis with exclusion of secondary headaches. Screening for sleep disorders with the use of proper tests including polysomnography and referral to sleep clinic, when appropriate is very helpful. Control of individual episode in less than 2hours should be the initial goal using measures to abort and prevent a relapse. Cluster headache responds very well to injectable Imitrex and oxygen. Verapamil, steroids and lithium are used for preventive treatment of cluster headache. Intractable cluster headache patients have responded to hypothalamic deep brain stimulation. Hypnic headache patients respond to nightly caffeine, indomethacin, and lithium. Paroxysmal hemicrania responds very well to indomethacin. Early morning headaches associated with obstructive sleep apnea respond to CPAP or BiPAP with complete resolution of headache within a month. Patient education and lifestyle modification play a significant role in overall success of the treatment. Chronic tension-type headache and chronic migraine have high prevalence of insomnia and comorbid psychiatric disorders, which require behavioral insomnia treatment and medication if needed along with psychiatric evaluation. Apart from the abortive treatment tailored to the headache types, - such as triptans and DHE 45 for migraine and nonsteroidal anti-inflammatory medication for chronic tension-type headache, preventive treatment with different class of medications including antiepileptics (Topamax and Depakote), calcium channel blockers (verapamil), beta blockers (propranolol), antidepressants (amitriptyline), and Botox may be used depending upon the comorbid conditions.

Endoscopic Assisted Resection of Prepontine Epidermoid Cysts

To describe an innovative endoscopic technique to treat prepontine epidermoid cysts. These cysts are typically resected in a microsurgical fashion and can be associated with significant risks and complications. This report is the first description of an endoscopic-assisted removal of an epidermoid cyst without the use of the operative microscope and evaluates the operative findings, technique, and postoperative course. Retrospective review at tertiary referral center. Two patients, one with rapidly progressive headache and ataxia, and another with trigeminal neuralgia were found to have mixed-intensity cystic lesions of the prepontine region consistent with an epidermoid cyst. A detailed description of the preoperative preparation, surgical approach, intraoperative technique, pre- and post-operative imaging findings and monitoring outcomes are emphasized. Both patients underwent resection of the epidermoid cyst using an endoscope-assisted technique. The procedures were 3 and 4 hours in duration with an estimated blood loss of 50 cc in both operations. No intraoperative complications occurred. The patients were discharged from the hospital on postoperative days 2 and 3, respectively. Postoperative imaging revealed no edema of the cerebellum and complete resolution of the cyst. Neurological examination revealed improvement of preoperative symptoms with complete resolution of headache and ataxia of case 1, with resolution of trigeminal neuralgia in case 2. Case 2 did develop an ipsilateral cranial nerve (CN) VI paresis postoperatively that resolved over a 3-week period. The patient from case 1 remains symptom free after 24-months with magnetic resonance imaging (MRI) consistent with gross-total resection of the epidermoid cyst. Case 2 has continued resolution of trigeminal neuralgia and CN VI palsy with 12-month follow-up MRI consistent with gross total resection. The use of the endoscope as the sole means to access the posterior fossa to treat prepontine cystic lesions affords the surgeon excellent visualization with minimal cerebellar retraction and can be done in a safe and effective manner with little to no morbidity.

Hypertrophic pachymeningitis in systemic sclerosis sine scleroderma

Dear Editor, Hypertrophic pachymeningitis is a clinical disorder characterized by chronic refractory headache with or without neurologic manifestations, resulting from localized or diffuse thickening of the dura mater.1, 2 These meningeal changes can be found in various autoimmune, neoplastic and infective conditions.1, 3 Idiopathic hypertrophic pachymeningitis is the diagnosis of exclusion. Systemic sclerosis sine scleroderma is a condition characterized by vasculopathy, visceral manifestations and serologic findings similar to systemic sclerosis in absence of skin sclerosis. Here we describe a patient with systemic sclerosis sine scleroderma and hypertrophic pachymeningitis. To the best of our knowledge there has been no previous report of pachymeningitis in a patient with systemic sclerosis. A 45-years-old woman, a diagnosed case of systemic sclerosis sine scleroderma, presented to us with a 4-month history of severe, throbbing, holocranial headache associated with nausea. There was no other significant medical history. General physical and systemic examination was unremarkable except for basal crackles in both lungs. Hemogram and biochemical parameters were within normal limits. Antinuclear antibody titre was 1 : 320 homogenous pattern and anti-Scl-70 was positive. Tests for syphilis, hepatitis B surface antigen, anti-hepatitis C virus and human immunodeficiency virus were negative. The levels of serum angiotensin-convertase enzyme were normal. Urinalysis and 24-h urinary calcium was within normal limits. Cerebrospinal fluid (CSF) examination showed normal opening pressure, no cells, protein 18 mg/dL, blood sugar 70 mg/dL (random blood sugar 96 mg/dL). Tuberculosis polymerase chain reaction, India ink stain and malignant cytology on CSF were negative. Chest radiograph was normal. High-resolution computed tomography (HRCT) chest scan revealed features of early interstitial lung disease. Pulmonary function tests were suggestive of restrictive lung disease and echocardiography was normal with no evidence of pulmonary arterial hypertension. Gadolinium-enhanced magnetic resonance imaging (MRI) revealed diffuse pachymeningeal thickening with enhancement throughout cerebral and cerebellar hemispheres, suggestive of hypertrophic pachymeningitis (Fig. 1). Subsequently, bronchoscopy with transbronchial lung biopsy was performed. Bronchoscopic alveolar lavage revealed alveolar macrophages (82%), lymphocytes (10%) and polymorphs (8%) and lung biopsy had normal histology. The patient did not give consent for meningeal biopsy. She was started on 50 mg oral corticosteroids daily. She showed marked clinical improvement with complete resolution of headache. Follow-up gadolinium-enhanced MRI of the brain performed in September 2010 revealed marked regression in dural enhancement (Fig. 2). Hypertrophic pachymeningitis is a rare clinical disorder which commonly presents with chronic headache with or without neurological manifestations. Neuroimaging is essential in making correct diagnosis. Gadolinium-enhanced MRI is superior to contrast-enhanced computed tomography (CT) scan for diagnoses. Corticosteroid therapy has been effective in alleviating symptoms and in arrest of clinical progression. In refractory cases, immunomodulators such as azathioprine, methotrexate and cyclophosphamide can be used.3, 4 Connective tissue diseases such as Wegener's granulomatosis, rheumatoid arthritis, mixed connective tissue disease, undifferentiated connective tissue disease, sarcoidosis, Behçet's disease and Sjögren syndrome have been reported to be associated with hypertrophic cranial pachymeningitis.1, 5-8 To conclude, hypertrophic pachymeningitis is a rare association with connective tissue diseases and it should always be suspected when a patient presents with chronic refractory headache in which other etiologies have been ruled out. To the best of our knowledge this is the first case of pachymeningitis with scleroderma.

Approach to Headache in Emergency Department

Headache remains a frequently encountered neurological symptom in Emergency department. Secondary causes of headache outnumber the primary entities such as migraine. Most of the secondary headaches have benign etiologies. The goal of emergent evaluation is to detect those with serious or life threatening causes. Identifying the pattern of headache helps in narrowing down the possible etiological diagnosis. A single episode of acute headache usually results from an acute infection ranging from viral URI to acute meningitis. Acute recurrent headaches are typically a feature of migraine. Chronic progressive headaches often indicate a serious underlying pathology such as a brain tumor and warrant a detailed neurological examination for signs of raised intracranial pressure (ICP) and focal deficits. Children with abnormal neurological findings require a neuroimaging. CT scan usually detects most of the abnormalities. Initial stabilization and management of raised ICP takes precedence in sick children. While simple analgesics like paracetamol and ibuprofen are used for symptomatic therapy, identification and appropriate treatment of underlying conditions is necessary for complete resolution of headache.

Lymph node compression of the lesser occipital nerve: A cause of migraine

Recent investigation has focussed on the concept of peripherally triggered migraine headaches caused by compression, irritation or entrapment of the sensory nerves in the head and neck. We report a case of a 52-year-old male suffering from an occipitoparietal migraine that presented with a mass in the right occipital area. The mass was found in the deep layer of subcutaneous tissue just over the semispinalis muscle, sitting on top of the lesser occipital nerve, which was preserved through delicate dissection using loupe magnification. Histopathological findings of the mass reported benign, reactive hyperplasia of the lymph node. After removal of the mass, the patient reported complete resolution of headaches. Sensation of the scalp was not altered. This is the first report of a case of hyperplastic lymph node causing migraine through physical compression of a peripheral nerve.

POH06 Headache management: greater occipital nerve injection as part of clinical practice

IntroductionOur unit, in common with many, is increasingly using greater occipital nerve injections (GONI) in the management of headache. We therefore audited outcome in this group of patients.MethodsPatients were offered...

Symptom Outcomes following Cranial Vault Expansion for Craniosynostosis in Children Older than 2 Years

Most craniosynostosis cases are treated by cranial expansion before 1 year of age. Occasionally, patients present at a later age with nonspecific symptoms of increased intracranial pressure. The purpose of this study was to review the symptoms of patients undergoing late cranial vault expansion. In all cases, the indication for surgery was treatment of the cranial dysmorphology. The authors performed a retrospective review of all patients (n = 17) undergoing cranial vault expansion from 2000 to 2007 aged older than 2 years (median, 7.4 years) for abnormal head shape who also reported preoperative symptoms consistent with increased intracranial pressure, including headaches, nausea or vomiting, or vision changes. Median follow-up was 30 months; 11 patients had nonsyndromic and six had syndromic craniosynostosis. Fourteen patients had headaches, nine had nausea and vomiting, and 11 had vision changes. Ten patients had signs of intracranial pressure elevation, such as a computed tomographic scan findings, papilledema, or both. Twelve of 14 patients had complete resolution of headaches following surgery and four had late mild recurrence. All patients with nausea and vomiting and nine of 11 patients with vision changes had resolution of symptoms. The diagnosis of increased intracranial pressure in older children with craniosynostosis is difficult in the absence of papilledema or computed tomographic findings. Clinical symptoms frequently associated with increased intracranial pressure are improved with late cranial vault expansion and demonstrate a possible benefit beyond improvement in head shape.