Headache Crises Research Articles

Long COVID and especially headache syndromes.

This is an expert overview on recent literature about the complex relationship between coronavirus disease 2019 (COVID-19) and headache. Long COVID is a clinical syndrome characterized by the presence of persistent symptoms following the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Headache is one of the most common symptoms and is described most often as throbbing pain, associated with photo and phonofobia and worsening with physical exercise. In acute COVID-19, headache is usually described as moderate or severe, diffuse and oppressive although sometimes it has been described with a migraine-like phenotype, especially in patients with a previous history of migraine. Headache intensity during acute phase seems to be the most important predictor of duration of headache over time. Some COVID-19 cases can be associated with cerebrovascular complications, and red flags of secondary headaches (e.g. new worsening or unresponsive headache, or new onset of neurological focal signs) should be urgently investigated with imaging. Treatment goals are the reduction of number and intensity of headache crises, and the prevention of chronic forms. This review can help clinicians to approach patients with headache and infection from SARS-CoV-2, with particular attention to persistent headache in long COVID.

Pulsed Radiofrequency of the Occipital Nerves: Results of a Standardized Protocol on Chronic Headache Management.

BackgroundPulsed radiofrequency (PRF) of the occipital nerves has neuromodulative properties and is used for chronic pain management. However, its role in various types of chronic headaches has not been adequately investigated so far.ObjectivesΤhis was an observational, open-label, prospective study aiming to assess the efficacy of PRF of occipital nerves on various types of chronic headache management.MethodsPatients with chronic headaches followed up at the pain management unit were scheduled for PRF of both occipital nerves after a positive diagnostic nerve block. PRF was applied following a standardized protocol at 42°C, and the number of headaches per month was assessed as a primary outcome at baseline (before treatment), as well as after 1, 3, and 6 months. Pain intensity during headache crises was recorded using the Numeric Rating Scale (NRS, 0 - 10),ResultsFifty-seven patients suffering from chronic migraines, cluster headaches, tension-type headaches, and occipital neuralgia were studied. PRF significantly improved the number of headache episodes per month, as well as the pain intensity of the crises. The median number of headache episodes per month was significantly reduced in patients with migraine, from 14.5 to 4 after 1 month, and to 6.5 after 6 months. The same was seen for patients with clusters, who were also improved. A statistically significant reduction in NRS values over time was seen for all types of headaches.ConclusionsPRF of the occipital nerves can lead to a reduction of the number of headache episodes per month, improving the intensity of pain during each episode.

Chronic Migraine with Medication Overuse: Clinical Pattern and Evolution from a Retrospective Cohort in Seville, Spain

Chronic migraine (CM) with medication overuse (MO) develops in patients with a pre-existing primary headache after a regular overuse of symptomatic medication. In these patients, headache crisis may occur together with other painful pathologies which can increase the frequency and intensity of the pain episodes. Such comorbidities need to be assessed as they influence the clinical evolution of the patients. A cohort of 102 patients (89 women and 13 men) with a diagnosis of chronic migraine (CM) with medication overuse (MO) was retrospectively analysed. Patients enrolled in the study were actively followed up 23 months in the Neurology Service of the University Hospital Virgen del Rocio in Seville, Spain. We observed that most of the patients overused multiple symptomatic drugs (34.3%) and NSAIDs (26.5%). In this cohort, the most effective treatments were topiramate and the combination of multiple prophylactic drugs with an effectiveness of 41.6% and 53.8%, respectively, at the end of the study. We observed the ratio of patients reducing their headache crisis was significantly higher among patients abandoning their medication overuse. Detoxification, or withdrawal of medication overuse, is linked to the reduction of the frequency and intensity of 50% or more of the headache crisis in these patients.

Effects of Different Exercise Intensities on Headache: A Systematic Review.

The aim of the study was to investigate the effects of different exercise intensities on headache parameters. A systematic review of clinical trials that analyzed the effect of physical exercise on headache, without time or language restriction. The TESTEX scale was used to evaluate the methodological quality of the articles. Sixteen (16) articles were included with interventions with aerobic training and resistance training. Primary results are positive effects of exercise on migraine symptoms, tension-type headache among others, and a decrease in the use of headache-related medications. On the other hand, the studies did not provide information on exercise intensity, especially studies with aerobic exercises. The intensities used for aerobic training was mostly controlled subjectively and the resistance training ranged from 10% to 80% of maximum repetition. Exercise had a positive influence on the frequency and severity of headache crises, although the studies presented inconclusive data regarding the exercise parameters.

Case report: Three years of refractory atypical depression successfully treated with“old school” moclobemide (maoi-r)

BackgroundAtypical depression is linked to bipolarity and specific response to mono amino oxidase inhibitors (MAOI), treatments not commonly used due to their complex handling. We describe a successfully treated case.MethodologyClinical description. Depression severity is assessed with Montgomery Asberg depression rating scale (MADRS).Clinical caseFemale, 54-year-old. Major depression, since 2011, refractory to venlafaxine/aripiprazol and escitalopram 20 mg/day. Manic episode with psychotic symptoms after potentiation with duloxetine. Diagnose of schizoaffective disorder was made, treated with aripiprazol 10 mg/day, with established chronical depressive symptoms, despite addition of valproate and venlafaxine, and partial response to pramipexole up to 1 mg/day.– Decision of cleaning up aripiprazol during 8 days and switch to moclobemide monotherapy was made due to atypical features. Baseline MADRS: 31. At week 2, there is change in mood, expression, psychomotor features and speech formal and content alterations. At week 4, activity increases, and biorythms normalize. At week 8 (with 600 mg/day increased dose), full response is obtained, including drive, and anxiety, with MADRS 12.– After one year of treatment, she has kept stability with no manic or psychotic symptoms emergence. Reduction in dose are linked to depression relapses. She still struggles with psychosocial recovery.– Tolerance has been good in all moment, except for headache crisis, not linked to high blood pressure or diet.ConclusionsMAOI still has a role in affective disorders treatment, given its effectiveness, unique mechanism of action and good tolerability. Targeted psychopharmacological and phenomenology knowledge can be the key to a recovery.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Women Living Together Have a Higher Frequency of Menstrual Migraine.

Menstrual migraine is a highly prevalent disorder among adult women, resulting in disability and loss of quality of life. Some studies have reported menstrual cycle synchrony among women living together. No study has reported whether there may also be a higher prevalence of menstrual migraine among these women. Thus, they reported here the prevalence of menstrual migraine in a group of women living together compared with a control group of women living alone, and discussed the possible factors involved. The study was conducted on female university students aged 18-30 years with a diagnosis of migraine according to the criteria of the International Classification of Headache Disorders III, beta appendix criteria. The subjects were divided into a group of women who lived together with two or more other students and a control group of age-matched students who lived alone, interviewed with a specific questionnaire and assessed for 3 months by means of a paper pain diary. The data evaluated included frequency of headache, presence of menstrual migraine, intensity of headache, medications used including contraceptives, and triggering factors such as diet, sleep deprivation, and stress. The menstrual data and data related to migraine were also investigated in the roommates. A higher occurrence of menstrual migraine among women living together (9, 50%) compared with women living alone (3, 16.7%) (P = .03) was detected. After binary logistic regression analysis, this finding was not related to the main influencing factors detected, that is, use of a contraceptive, test stress, or sleep deprivation (P = .03, adjusted odds ratio: 7.87; 1.23-50.36). These women also showed menstrual cycle synchrony with their roommates (8, 44.4%) and the presence of headache crises during the menstruation of their colleagues (11, 61.1%). The present study detected a higher occurrence of menstrual migraine among women who lived together. Since there was no previous description of this topic in the literature, it was believed that the present study could represent a step toward more elaborate investigations of this complex topic.

Fixed combination of cinnarizine and dimenhydrinate in the prophylactic therapy of vestibular migraine: an observational study.

Vestibular migraine (VM) is one of the most frequent causes of episodic vertigo, with a lifetime prevalence of 0.98%. Prophylactic therapy includes calcium channel blockers, beta-blockers, antiepileptic drugs and antidepressants. We studied the association of cinnarizine 20 mg and dimenhydrinate 40 mg (Arlevertan) in a group of 22 patients affected by definite VM. Proposed therapy included one tablet twice a day for 1 month, which was repeated three times with 1 month of interval between drug intake; results were compared with those of a control group of 11 VM patients who asked to observe only lifestyle measures for migraine. The main outcome was the number of vertigo and headache crises in the 6 months before therapy and in the 6 months of follow-up. Subjects performing Arlevertan presented during the 6 months of therapy a decrease of vertigo attacks from 5.3 to 2.1 and of headaches from 4.3 to 1.7 (p < 0.0001); 68% of these subjects reported a decrease of at least 50% of vertigo attacks, while 63% of headaches. Conversely, vertigo attacks decreased from 3.5 to 2.2 and headaches from 2.6 to 2 in patients observing only lifestyle; 18% of these subjects reported a decrease of at least 50% of vertigo crises and 27% of headaches. Our data do not differ from those of previous works assessing efficacy of different prophylactic therapies for VM and reporting consistent reduction of vertigo spells in a rate of patients ranging from 60 and 80%.

Migraine and menstrual cycle synchrony in females: is there a relationship? Case report

BACKGROUND AND OBJECTIVES: Migraine is a highly prevalent disorder among adult females, being that very often these patients have crises during the menstrual cycle. On the other hand, some studies have described menstrual cycle synchrony in females living together. No study has described whether there would also be migraine crisis synchrony among these females. This study aimed at reporting the case of a patient with migraine episodes synchronized with the menstrual cycle of her companion, discussing possible involved triggering factors. CASE REPORT: Female patient, 50 years old, menopausal for at least one year, with history of migraine without aura according to International Headache Society’s criteria, with typically migraine headache crises during her companion’s menstrual cycle. Patient was evaluated for 3 months by the pain diary, including frequency of headache crises, intensity of crises, drug doses and triggering factors for crises, in addition to follicle exfoliating hormone and estradiol dosing in different periods of the month. Patient had headache crises during her companion’s menstrual cycle with no evidence of other associated factors (diet, sleep deprivation, stress). Patient’s level of stimulating follicle hormone varied throughout the month, according to companion’s menstrual cycle. CONCLUSION: There is no consensus with regard to menstrual cycle synchrony among females. However, we believe that this report could be a step further for the development of further studies on such a complex subject.

Relation between primary headache and restriction of cervical range of motion: a pilot study

Introduction: Headache is the most common neurological symptom across the world. The presence of this alteration promotes different effects on the biomechanics of cervical muscles, which may limit cervical mobility and also bring damage to patients suffering with headache. Objective: Evaluate the relation between the presence of primary headache and cervical range of motion restriction. Methods: Pilot study conducted by using a sample of 33 subjects aged between 20 and 38 years (26 ± 5 years). To evaluate active cervical mobility, universal goniometer was used. The degree of cervical dysfunction was assessed by Neck Disability Index questionnaire. To sort the primary headache were used criteria established by the International Classification of Headache Disorders (ICHD-III beta version, 2013). Results: There was no statistical difference between the groups in relation to gender and last headache crisis. The cervical mobility differs between groups with headache and healthy, but this was not statistically significant. There were also differences between the headache and the healthy group regarding to the Neck Disability Index (NDI). Conclusion: The study does not demonstrate a difference between the cervical mobility in patients with primary headache compared to healthy subjects.

Non-traumatic spontaneous acute epidural hematoma in a patient with sickle cell disease

A 19-year-old female with sickle cell anemia (SCD) was referred to our hospital after two days of hospitalization at another hospital for a headache crisis. This headache crisis was due to a raised intracranial pressure; these symptoms were noted and included in her comprehensive list of symptoms. There was an acute drop in the hemoglobin and hematocrit levels. The cranial CT scan demonstrated a left fronto-parietal acute epidural hematoma (AEH) and a calvarial bone expansion, which was suggestive of medullary hematopoiesis. The patient underwent emergent craniotomy and evacuation of the hematoma. There were no abnormal findings intra-operatively apart from the AEH, except skull thickening and active petechial bleeding from the dural arteries. Repeated CT scan showed a complete evacuation of the hematoma. The possible underlying pathophysiological mechanisms were discussed. In addition to the factors mentioned in the relevant literature, any active petechial bleeding from the dural arteries on the separated surface of the dura from the skull could have contributed to the expanding of the AEH in our patient. Neurosurgeons and other health care providers should be aware of spontaneous AEH in patients with SCD.

Lifestyle, quality of life, nutritional status and headache in school-age children.

Headache has been described as a factor with significant negative impact on the quality of life of school-aged children with a high risk of developing in chronic and persistent form in adulthood. Among other headache associated triggers or aggravating factors, lifestyle and obesity has been investigated, but results are still conflicting. To evaluate the prevalence of headache in school-aged children and its relationship to anthropometric characteristics, lifestyle, and quality of life. A cross-sectional study was conducted in six schools located in two cities in southern Brazil, involving 750 students aged 7 to 14 years. Information was collected on sociodemographic characteristics, clinical variables (presence of headache and menarche), anthropometric data, lifestyle, and quality of life. A total of 185 (24.7%) students reported having headache crises in the last 3 months. Among students aged 10 to 14 years, presence of headache was associated with female sex, affecting 32.2% of girls vs. 23.3% of boys (p = 0.042, chi-square test). Anthropometric parameters (data on overweight/obesity) were consistent with national prevalence rates, and there was no association between Body Mass Index (BMI) and headache. Regarding lifestyle, 2.0% of students reported smoking and 1.6% consuming alcohol occasionally, and neither was associated with headache. Quality of life, especially aspects of social life, appeared to be affected by the presence of headache. This study found a high prevalence of headache in school-aged children, which was associated with female students aged 10-14 years and quality of life.

The ‘headache tree’ via umbellulone and TRPA1 activates the trigeminovascular system

The California bay laurel or Umbellularia californica (Hook. & Arn.) Nutt., is known as the 'headache tree' because the inhalation of its vapours can cause severe headache crises. However, the underlying mechanism of the headache precipitating properties of Umbellularia californica is unknown. The monoterpene ketone umbellulone, the major volatile constituent of the leaves of Umbellularia californica, has irritating properties, and is a reactive molecule that rapidly binds thiols. Thus, we hypothesized that umbellulone stimulates the transient receptor potential ankyrin 1 channel in a subset of peptidergic, nocioceptive neurons, activating the trigeminovascular system via this mechanism. Umbellulone, from µM to sub-mM concentrations, selectively stimulated transient receptor potential ankyrin 1-expressing HEK293 cells and rat trigeminal ganglion neurons, but not untransfected cells or neurons in the presence of the selective transient receptor potential ankyrin 1 antagonist, HC-030031. Umbellulone evoked a calcium-dependent release of calcitonin gene-related peptide from rodent trigeminal nerve terminals in the dura mater. In wild-type mice, umbellulone elicited excitation of trigeminal neurons and released calcitonin gene-related peptide from sensory nerve terminals. These two responses were absent in transient receptor potential ankyrin 1 deficient mice. Umbellulone caused nocioceptive behaviour after stimulation of trigeminal nerve terminals in wild-type, but not transient receptor potential ankyrin 1 deficient mice. Intranasal application or intravenous injection of umbellulone increased rat meningeal blood flow in a dose-dependent manner; a response selectively inhibited by systemic administration of transient receptor potential ankyrin 1 or calcitonin gene-related peptide receptor antagonists. These data indicate that umbellulone activates, through a transient receptor potential ankyrin 1-dependent mechanism, the trigeminovascular system, thereby causing nocioceptive responses and calcitonin gene-related peptide release. Pharmacokinetics of umbellulone, given by either intravenous or intranasal administration, suggest that transient receptor potential ankyrin 1 stimulation, which eventually results in meningeal vasodilatation, may be produced via two different pathways, depending on the dose. Transient receptor potential ankyrin 1 activation may either be caused directly by umbellulone, which diffuses from the nasal mucosa to perivascular nerve terminals in meningeal vessels, or by stimulation of trigeminal endings within the nasal mucosa and activation of reflex pathways. Transient receptor potential ankyrin 1 activation represents a plausible mechanism for Umbellularia californica-induced headache. Present data also strengthen the hypothesis that a series of agents, including chlorine, cigarette smoke, formaldehyde and others that are known to be headache triggers and recently identified as transient receptor potential ankyrin 1 agonists, utilize the activation of this channel on trigeminal nerves to produce head pain.

Headache precipitated by Valsalva maneuvers in patients with congenital Chiari I malformation

The objective of this study was to characterize the headache precipitated by Valsalva maneuvers associated with Chiari type I malformation (CM-1). Nineteen patients were evaluated, with ages ranging from 30 to 75 years. Ten of them presented headache. Pain was more prevalent in the occipital (80%) and frontal region (60%). The headaches were of significantly shorter duration in the women compared with the men. The frequency of headache crises was relatively high. All patients with Valsalva-related headache suffered from at least one episode per month. The most prevalent precipitating factors were coughing, which is well described in the literature, and sexual activity, which only now is recognized as an event associated with CM-1.

Prevalence and management of headache in a selected area of Southern Santa Catarina

Headache is a worldwide health problem which affects quality of life. To identify the prevalence and management of headache and examine its impact. A cross-sectional study with 240 participants was performed to collect data related to (a) headache occurrence, (b) its impact through the "Migraine Disability Assessment Test" (Midas), and (c) headache management. Last year prevalence (2008) was 64.6%. There was a low Midas score in 80.6% of cases. With regard to headache management, 86.4% of respondents said that they use medicines, mainly analgesics (73.9%). Prescribed medicines were used in 31.0% of cases, although 72.4% of those were old prescriptions. Headache was associated with gender (p=0.0002), occupation (p=0.0109) and mean age (p=0.0083), while the Midas score was associated with pain intensity (p=0.0069) and the use of drugs only during headache crisis (p=0.0464). There was a high prevalence of headaches and a low level of disability among the population studied, being the management based on self-medication.

ESTUDO COMPARATIVO ENTRE INCIDÊNCIA, LOCALIZAÇÃO, INTENSIDADE, FATORES DESENCADEANTES DA CEFALÉIA E MEDICAÇÕES UTILIZADAS PELOS FUNCIONÁRIOS DO HOSPITAL MISSEN E HOSPITAL CRISTO REDENTOR NA CIDADE DE SÃO MIGUEL D’OESTE - SC.

Rara a existência de um indivíduo que nunca apresentou ao longo de sua vida uma crise de cefaléia. Estima-se que a prevalência ao longo da vida na população seja superior a 90%. Vários estudos epidemiológicos de cefaléias são realizados com o objetivo de reconhecer e aprimorar suas características, auxiliando para o melhor entendimento fisiopatológico desta enfermidade. Estudos de prevalência sugerem fatores de risco sendo genéticos e sociodemográficos.O estudo realizado é do tipo survey descritivo, com a aplicação de um questionário a todos os funcionários do Hospital Missen e do Hospital psiquiátrico Cristo Redentor, ambos localizados na cidade de São Miguel d’Oeste, Santa Catarina. É sabido que as mais diversas populações são estudadas, mas colaboradores do ambiente hospitalar têm recebido pouca atenção; fazendo disso o objetivo para a realização deste trabalho. Com este estudo concluiu-se que a cefaléia na comunidade hospitalar foi marcante, com grande incidência em ambos os sexos e o estresse foi o fator desencadeante mais pronunciado, prejudicando o bem estar e a produtividade dos colaboradores. A implantação de medidas simples e baratas poderia melhorar a qualidade de vida bem como aumentar a produtividade destes funcionários.

Topiramate and Triptans Revert Chronic Migraine With Medication Overuse to Episodic Migraine

This is a randomized, double-blind versus placebo study aimed at evaluating the efficacy of topiramate (TPM) in reducing the number of days with headache and the amount of acute medication taken monthly in patients with chronic migraine with medication overuse. We also studied the efficacy of single triptans available in Italy in interrupting headache crises during preventive treatment. The studied sample was made up of 50 subjects: 30 patients were randomized for treatment with TPM, 100 mg/d, and 20 for placebo. Subjects treated with TPM were further randomized to evaluate, in double-blind versus placebo, the efficacy of single triptans available in Italy. The double-blind phase consisted of a titration phase (4 weeks) and of a maintenance phase (8 weeks). The reduction in the number of days with headache per 28 days and the reduction in the amount of acute medication taken per 28 days throughout the clinical trial in the TPM group were compared with those of the placebo group; the number of patients who were pain-free at 2 hours after the triptan intake and the headache recurrence rate in the 22 hours after the pain-free condition in the triptan group were compared with those of the placebo group. We also looked at tolerability profile. The group treated with TPM had a significant reduction in the number of days with headache (P < 0.0001 vs placebo) and in the mean amount of acute medication taken (P < 0.0001 vs placebo); all triptans were superior to placebo; there were no significant differences between different triptans; the analgesic effect of triptans increased throughout the trial. Topiramate proved to be well tolerated and effective in reverting chronic migraine with medication overuse to episodic migraine.

Clinical evaluation of the efficacy of the paracetamol and caffeine combination in the treatment of tension headache

Tension type headache in both its forms, episodic and chronic, is the most common type of headache experienced by the population. The headache attack or the prevention of new crises may be treated with pharmacological as well as non-pharmacological measures. This study included 5,490 patients from out-patient clinics and medical offices covering various regions of Brazil. Approximately 95% of the subjects had episodic tension type headache, while 5% had chronic tension type headache. The majority of the patients presented with crisis of moderate intensity (62.19%). In 5,419 patients a tension type headache crisis was treated with acetaminophen 1000 mg and caffeine 130 mg. In 93.98%, onset of relief occurred within 2 hours of taking the medication. In 77.61%, complete reversion of the crisis occurred within 2 hours. Good/excellent efficacy ratings were achieved in 61.93%/37.80% of the cases according to the physician's assessment and in 48.51%/40.29% according to the patients' assessment. Adverse events, commonly gastrointestinal manifestations, were reported by 5.57% of the patients. This is a Brazilian study of the efficacy and safety of the combined use of acetaminophen-caffeine for the treatment of tension type headache.

The Placebo Effect in Acute Headache Management: Ketorolac, Meperidine, and Saline in the Emergency Department

In a prospective, double-blind, randomized study, ketorolac 60 mg, meperidine 50 mg plus promethazine 25 mg, and normal saline given by intramuscular injection were compared as treatment for acute headache crises. Thirty patients (6 men and 24 women) presenting to an urban emergency department with any type of benign headache were randomized into three groups and filled out the McGill Short-Form Pain Questionnaire with a Pain Rating Index and a Visual Analogue Pain scale. They received one of the study medications and repeated the testing after 1 hour. The objective was to test the efficacy of ketorolac in this population. Separate analyses of the McGill Short-Form (Total, Sensory, Affective, and Pain Rating Index scales) and the Visual Analogue Pain scale responses showed that the three treatments produced a significant reduction in pain (P < .0001), but that pain reduction did not differ among the treatments. This profound reduction observed after administration of a placebo prevented accurate evaluation of the effects of ketorolac. The placebo response must be considered in the design of future trials using intramuscular medications in the acute intervention of headache crises. In addition, the use of a standard analgesic is necessary to demonstrate both assay sensitivity and magnitude of response to placebo.

Effectiveness of subcutaneous dihydroergotamine by home injection for migraine.

The effectiveness of dihydroergotamine administered by home subcutaneous injection by the patient or family for severe headache attacks was assessed retrospectively in 51 patients. Average follow-up was 21 weeks. Twenty-one patients had intermittent migraine attacks, 27 had transformed migraine with chronic daily headache, and 3 had chronic tension-type headache. Of the 51 patients taught home injection, 35% had an excellent overall response, 18% had a good response, 12% had a poor response but continued to use dihydroergotamine, and 35% had discontinued dihydroergotamine use. Side effects were the main reason for stopping dihydroergotamine. These included nausea or vomiting or both, limb pain or numbness or both, chest or throat tightness or both, and soreness at the injection site. Thirty-three patients (65%) continued to use dihydroergotamine at the end of the follow-up period. In patients who previously required injections from medical personnel for headache crises and in whom home injection of dihydroergotamine was effective, a dramatic reduction occurred in hospital emergency room and physician office utilization. Dihydroergotamine use by home injection can be an effective treatment for a significant proportion of patients with severe migraine including patients with transformed migraine and medication overuse.

Headache Associated With Aseptic Meningeal Reaction as Clinical Onset of Fabry's Disease

This report concerns an 18-year-old boy who is hemizygote for Fabry's disease. Varying degrees of nonpulsating headache crises, lasting from a few hours to several days, began when he was 16 years of age. Painful crises in the extremities, characteristic of Fabry's disease, were not present. Although only occasional, he had several episodes of throbbing headache with vomiting without aura. The meningeal signs were equivocal, although the patient had noninfectious pleocytosis, intracranial hypertension, delayed radioisotope clearance on cisternography, and multiple old cerebral infarcts. Nonsteroidal anti-inflammatory drugs, antidepressants, carbamazepine, and glycerol were of no benefit for his headache. Although its mode of action remains obscure, prednisolone was effective for treating the headache and the aseptic meningeal reaction.