Exploring the Interictal Neuropsychological Burden of Pediatric Migraine.

Peripheral sensory neurons, long appreciated for their role in detecting environmental stimuli, also play an active role in local and systemic immune responses. In response to tissue damage, the coordinated activation of peripheral sensory neurons and immune cells facilitates tissue repair. When dysregulated, however, these neuroimmune interactions can become maladaptive and contribute to chronic disorders such as chronic pain or headache. Recent single-cell transcriptomic studies have uncovered multiple distinct sensory neuron subtypes, each with unique molecular profiles, anatomical niches, and immune functions. In this review, we examine how distinct sensory neuron subtypes coordinate immune responses in barrier and internal tissues, forming cell type– and context-specific neuroimmune circuits. We also discuss how disruption of these circuits contributes to neuroinflammatory diseases such as atopic dermatitis and neuropathic pain. Clarifying these subtype-specific neuroimmune mechanisms offers a path toward more precise and effective therapies that target maladaptive neuroimmune circuitry in multiple disorders.

Hallucinogen persisting perception disorder (HPPD) is characterised by episodes of altered perception linked to past psychoactive drug use, accompanied by distress and functional impairment. To date, clinical characterisation has been limited in scale. Using TriNetX, a global federated health research network of electronic health records, we conducted a retrospective cohort study comparing clinical associations in individuals with HPPD versus population and psychedelic-using controls. Cumulative incidences of psychiatric and medical disorders were compared. Cox proportional hazards models assessed risk factors for developing HPPD, and odds ratios (ORs) were used to evaluate associated conditions following diagnosis. We identified 25,778 individuals diagnosed with HPPD. Prior to diagnosis, high rates of comorbidities were observed, including depressive episodes (29.2%), anxiety disorders (26.2%), chronic pain (15.9%), headache syndromes (14.7%), post-viral fatigue (12.3%), ADHD (6.6%), and fibromyalgia (6.7%). Anxiety and functional somatic syndromes were significantly more common in the HPPD group than in psychedelic-using controls (p < 0.001). Anxiety (OR 1.5) and post-viral fatigue (OR 1.9) predicted HPPD development in psychedelic users. HPPD diagnosis was associated with increased risk of subsequent functional somatic syndromes (OR 2.0) and psychiatric disorders (OR 1.4) versus psychedelic-using controls. This largest-to-date study of HPPD highlights its psychiatric and somatic complexity, with strong associations with anxiety and functional somatic syndromes. Several methodological limitations are acknowledged. Further research should explore overlapping pathophysiological mechanisms linking HPPD, visual disorders (e.g. visual snow syndrome), anxiety, and functional somatic syndromes.

Cyclical vomiting syndrome (CVS) is a functional gastrointestinal disorder marked by recurrent vomiting. Lack of awareness and symptom overlap often leads to incorrect diagnosis. There is limited data from the developing world, especially on the natural history of the disease in children. Thus, the aim of our study was to evaluate the clinical presentation, natural history, treatment and outcomes of CVS in children. Retrospective audit of children (≤ 18years) diagnosed with CVS between January 2008 to December 2024. Clinical data was retrieved from hospital records and telephonic interviews. Seventy-one patients (age of onset 7[IQR 4-9] years, boys [39, 54.9%]) were enrolled. Median diagnostic delay was 1.2(IQR 1-3) years and 31(43.6%) were misdiagnosed elsewhere initially. Patients had five (IQR 4-8) episodes of vomiting per year. Most (n = 55, 77.5%) required hospitalization. Precipitants were identified in 48(67.6%) cases, most common being psychological stress (n = 23, 32.4%). Family history of migraine was present in 37 (52.1%) cases. Rome IV, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) and International Classification of Headache Disorders,3rd edition (ICHD-3) criteria fulfilled in 71(100%), 47(66.2%) and 44(62%) cases, respectively. Younger children (≤ 5years) had longer delay in diagnosis, more often required hospitalization and had fewer early morning episodes as compared to older children. All patients presented with severe disease phenotype and received prophylaxis. At follow-up of eight (interquartile range [IQR] 5-12) years, 36(50.7%) had complete, 25(35.3%) significant, five(7.6%) partial and five(7.5%) no response. Prophylaxis was successfully stopped in 13 (36.1%) complete responders of which three relapsed post-withdrawal. CVS is often underdiagnosed in children. Awareness of CVS is necessary for early diagnosis and reduced morbidity. Younger children had longer diagnostic delay and more often required hospitalization. Timely recognition and optimal management were associated with favorable outcomes.

Objective: to study clinical and imaging characteristics in patients with rheumatoid arthritis (RA) with atlantoaxial joint involvement. Material and methods. A total of 60 patients with RA were examined; mean age was 53.6±12.4 years. Median DAS28-CRP was 5.1 [4.8; 5.3], and median disease duration was 120 [66; 300] months. Extended clinical assessment included evaluation of neurological status, components of neuropathic pain and central sensitization, quality of life, and the degree of functional impairment. Magnetic resonance imaging (MRI) of the craniovertebral junction (CVJ) was performed with assessment of structural changes and measurement of five craniometric parameters to detect displacement of the CII odontoid process. Results and discussion. Clinical signs of cervical spine (C-spine) involvement were present in 91.7% of patients: neck and head pain, varying degrees of activity limitation due to neck pain, and neurological manifestations. MRI revealed CVJ changes in 90% (n=54) of patients: structural abnormalities in 81.7% and displacement of the CII odontoid process in 68.3%. The strongest correlations of structural changes were found with the presence of neck pain, low quality-of-life scores (EQ-5D), high RA activity, peripheral joint erosions on radiographs, arterial hypertension, high body mass index, and the absence of systemic manifestations of the disease. Craniometric abnormalities were associated (p&lt;0.05) with older age, concomitant osteoporosis, poorer quality of life, neuropathic pain, features of the RA course (duration, positivity for anti-cyclic citrullinated peptide antibodies, small joint involvement at onset, functional limitations, fewer systemic manifestations), elevated CRP, more advanced radiographic stage, and glucocorticoid use. Long-term therapy with nonsteroidal anti-inflammatory drugs and biologic agents was associated with less pronounced MRI changes (p&lt;0.05). Conclusion. Based on the study, the risk factors for C-spine involvement in RA patients are neck pain, certain features of the RA course, comorbidity, functional limitations (HAQ), and low quality of life (EQ-5D).

Tamaka Shwasa is one of the Pranavaha Sroto Vikara which is generally described as YapyaVyadhi or Krichra Sadhya. However, the patient has Pravara Bala, recent origin of disease or both said to be Sadhya. Therefore, proper line of treatment and proper lifestyle is required for this disease. It is analogous to Bronchial Asthma which is prevalent in 13.1% of population all over the world. This is a single case study of a 51-year-old male patient came with C/O Cough with yellowish sputum since 5months . He also complaints of sour belching &amp; burning sensation in chest region, dust allergy,weakness,pain and heaviness of head. According to patient, he was apparently well before 6 month and gradually he developed cough. It was treated by internal Ayurvedic medicines and got significant improvement. Present case study emphasizes the effect of Vyadhihara Chikitsa like Tab ShwasaKutura Rasa, Tab Amlant, Cap Grab,Dhanyakahima,Ksharabala, Syrp Tulsi Kantakari and external medications like Sarvanga Udvartana, SarvangaParisheka with DMQ, GudaNagara Nasya,Nebulisation with Bharangi Arka and Shodhana by means of SadhyoVirechana for its effect on expelling out the vitiated pitta dosha and Pranayama for providing symptomatic relief in TamakaShwasa. Keywords: Tamaka Shwasa, Bronchial Asthma, Vyadhihara Chikitsa, Shodhana, SadhyoVirechana.

Patients with head and neck cancer commonly experience severe neuropathic pain. This pain is often challenging to treat and may be refractory to standard analgesic approaches. We describe the use of subcutaneous Botox injections to manage pain in such a patient. A patient with poorly differentiated carcinoma of the right base of skull with perineural invasion presented to the pain clinic with intractable facial pain. Subcutaneous Botox injections were performed. The patient experienced a significant reduction in the intensity of her pain following subcutaneous Botox injections. Subcutaneous Botox injections represent a safe and effective option for patients with head and neck cancer experiencing neuropathic pain refectory to standard analgesic medications.

Cluster headache presents with severe headache attacks that typically occur during sleep. This study aims to evaluate the efficacy, tolerability, and safety of low sodium oxybate (LXB), a sleep-deepening drug, for nocturnal attacks in chronic cluster headache. In this randomized, double-blind, placebo-controlled, bi-center trial, we will include 52 participants (18-75 years) with chronic cluster headache and ≥4 nocturnal attacks per week. Participants with a contraindication for LXB will be excluded. After a 4-week baseline phase, participants will be randomized to receive either LXB or placebo as a twice nightly regimen during the treatment phase. All participants will undergo a 6-week titration phase followed by a 4-week stable dose treatment phase. The primary outcome is the change from baseline in the average weekly frequency of nocturnal cluster headache attacks during the 4-week stable dose treatment phase, comparing the LXB group to the placebo group. Secondary and exploratory outcomes include change in daytime attack frequency, the improvement of sleep quality and sleep continuity parameters. The results of this trial could have a substantial impact on the treatment for chronic cluster headache, particularly for patients suffering from frequent nocturnal attacks. The www.clinicaltrials.gov identifier is NCT06950281.

Chronic pain imposes substantial individual, occupational, and societal burdens. This study explores the prevalence, severity, and associated burden of chronic back pain and headaches-defined as pain experienced repeatedly or persisting for at least 3 months within the past 12 months-in a nationwide sample of the working population in Germany (N = 4,751). It also examines how demographic and psychosocial factors are associated with chronic pain. Among participants, 34.4% experienced mild, 25.1% moderate, and 13% (very) severe chronic back pain symptoms; 35.6% experienced mild, 20.1% moderate, and 10.8% (very) severe chronic headaches. Gender, age, sleep problems, and burnout were identified as key correlates of chronic back pain and headaches. These findings indicate that chronic pain may be more prevalent and burdensome than previously believed, underscoring the need for comprehensive prevention and management strategies that integrate both biological and psychosocial perspectives. Further research should investigate the underlying mechanisms and inform targeted interventions.

Introduction Headache is one of the most frequent neurological symptoms in SLE; however, its definition and relationship with the disease remain unclear. Distinguishing whether a headache is attributable to lupus or represents a primary headache disorder can be challenging. This preliminary study aimed to investigate the prevalence, frequency, and associated clinical factors of primary headaches in juvenile-onset SLE (jSLE) compared to healthy peers. Methods This cross-sectional case-control study included 32 children with jSLE and 38 age- and sex-matched healthy controls, who were evaluated between July and September 2025. Headache characteristics were assessed using a standardized questionnaire and classified according to the International Classification of Headache Disorders, 3rd edition (ICHD-3). All participants underwent neurological and fundoscopic examinations. Clinical, laboratory, and treatment-related parameters including disease activity (SLEDAI-2K), cumulative dose of systemic corticosteroids, and autoantibody profiles were compared between jSLE patients with and without primary headache. Results Primary headache was observed in 31.3% of jSLE patients (10/32) and 10.5% of controls (4/38) ( p = 0.03). Among jSLE patients with headache, migraine without aura (60%) and tension-type headache (40%) were the predominant subtypes. Compared with those without headache, patients with headache had higher BMI z-scores ( p = 0.03), shorter sleep duration ( p = 0.03), more frequent antiphospholipid antibody positivity ( p = 0.04), and higher cumulative corticosteroid doses ( p = 0.02). Disease activity and duration did not differ significantly. Conclusion Primary headaches, particularly migraine, are more frequent in pediatric lupus compared to healthy controls. Their associations with BMI, sleep, antiphospholipid antibodies, and corticosteroid exposure suggest multifactorial origins rather than direct links to disease activity. These findings highlight the need for larger, prospective studies to clarify underlying mechanisms.

Background Spontaneous intracranial hypotension (SIH) is a secondary headache disorder caused by spontaneous cerebrospinal fluid (CSF) leakage, typically from dural tears, meningeal diverticula, or CSF venous fistulas, in the absence of preceding trauma or procedures. Although increasingly recognized, SIH remains underdiagnosed and frequently mistaken for primary headache syndromes. MethodsThis narrative review synthesizes current evidence on the epidemiology, pathophysiology, clinical manifestations, neuroimaging features, complications, and management of SIH. Recent literature and expert consensus were analyzed to integrate advances in imaging-based diagnosis and leak type specific therapeutic strategies. ResultsSIH arises from low CSF volume rather than true hypotension, leading to brain descent, venous engorgement, and the characteristic MRI features summarized by the SEEPS mnemonic: subdural collections, pachymeningeal enhancement, venous engorgement, pituitary enlargement, and brain sagging. Orthostatic headache is the hallmark symptom, though up to 15% of patients lack clear positional features. Associated symptoms include vestibulocochlear disturbances, neck or interscapular pain, cranial nerve palsies, and cognitive or motor dysfunction. Brain and whole spine MRI are first line diagnostic tools. MR myelography distinguishes SLEC positive (types 1 and 2) from SLEC negative (type 3) leaks, guiding targeted myelography with dynamic CT or digital subtraction techniques for leak localization. Treatment should be tailored to leak type and site: epidural blood or fibrin patching for dural and diverticular leaks, and transvenous embolization for CSF venous fistulas. Surgical repair is reserved for refractory or anatomically complex cases. Reported complications include subdural hematoma, cerebral venous thrombosis, superficial siderosis, and bibrachial amyotrophy. ConclusionsSIH represents a heterogeneous spinal disorder with intracranial manifestations. Early recognition, standardized imaging algorithms, and multidisciplinary management are crucial to improving outcomes. Ongoing research into imaging biomarkers, predictors of response, and consensus based care pathways will help advance precision medicine in SIH.

Endothelial dysfunction is a universal mechanism of injury, not specifically associated with any one nosology. It is characterized by insufficient production of vasodilators, prothrombotic and proinflammatory cell activation, and pathologically increased endothelial permeability. It is clinically heterogeneous, with regional variability in the expression of various pro- and anticoagulant factors. Essentially, all processes represent a continuum of genetic, epigenetic, transcriptomic, proteomic, metabolic, morphological, and functional changes. In 2023, a new concept for the pathogenesis of endothelial dysfunction as a systemic process was developed, enabling the prediction, prevention, and management of a number of diseases. Ten stages of endothelial damage and three degrees of severity are distinguished: mild, moderate, and severe. Mild endothelial dysfunction is characterized by reduced nitric oxide (NO) production and a noncritical decrease in ATP levels, coupled with increased energy consumption to adapt to increasing hypoxia. Clinically, this degree is most often associated with asthenic manifestations. Moderate/ severe ED is associated with progressive neurotransmitter imbalance, adhesion cell activation, microthrombosis, hypoxia, and neuroinflammation. The most pronounced clinical characteristics are secondary headache, cognitive, and anxiety-depressive disorders. Severe ED leads to endothelial cell death. Endothelial loss itself does not lead to thrombosis, but disruption of the parietal membrane integrity can affect blood rheology. Delayed neurological and systemic complications arise at this stage. Understanding the staging of damage is crucial for the development of individualized therapeutic interventions, from lifestyle modification to targeted therapy, with the search for a universal endothelial protector.

Headache disorders, specifically migraine headaches, are highly debilitating neurological disorders, with the potential to incapacitate an individual for several hours. Cannabinoid receptors are present in both peripheral and central nervous tissue, which serve as a potential target for the treatment of migraine. Cannabis sativa is a medicinal plant that has been used as self-medication for the treatment of headaches, but insufficient scientific information is currently available regarding their interactions with receptors, as well as intranasal delivery. The intranasal route of administration offers the potential for systemic delivery, as well as delivery into the brain. Nose-to-brain delivery offers a pathway directly to the brain via olfactory epithelium and trigeminal nerves and bypasses both the first-pass metabolism and the blood-brain-barrier (BBB). Known phytochemicals of C. sativa were docked in silico into the active site of the 6KPC crystal structure of the cannabinoid type 2 (CB2) receptor to screen for receptor affinity. Ex vivo permeation studies were done on these four selected cannabinoid compounds across excised sheep nasal epithelial tissue. Four cannabinoid compounds were identified with affinity for the CB2 receptor that may provide activity against migraine, namely cannabicyclol, cannabidiolic acid, cannabicitran and cannabielsoin. The ex vivo membrane permeation results revealed that some of the cannabinoids can be delivered to a similar extent than moderately permeable model drugs across nasal epithelium for systemic delivery and potentially also for direct nose-to-brain delivery. Through affinity for the CB2 receptor, the identified compounds have shown potential in migraine treatment. There is also potential for nose-to-brain delivery.

Spontaneous intracranial hypotension (SIH) is a rare, often underdiagnosed cause of secondary headache resulting from spontaneous cerebrospinal fluid leakage. Indian data on its clinical profile and treatment outcomes remain limited. We aimed to describe the clinical, radiological, and treatment characteristics of patients with SIH at a tertiary neurology centre in South India and to compare outcomes between those treated with epidural blood patch (EBP) and conservative management. This retrospective observational study included 33 patients fulfilling the International Classification of Headache Disorders - 3 (ICHD-3) diagnostic criteria for SIH between 2004 and 2024. Clinical features, magnetic resonance imaging (MRI) findings, treatment modalities, and outcomes were analyzed. Statistical comparisons were performed using Chi-square or t tests, with P < 0.05 considered significant. Of the 33 patients (73% female; mean age, 42 ± 11 years), orthostatic headache was present in 91%. Pachymeningeal enhancement was the most common MRI finding (90%), followed by pituitary engorgement (59%) and spinal epidural fluid collections (52%). Twenty patients (61%) received EBP, and thirteen (39%) were managed conservatively. EBP led to significantly higher rates of headache resolution at discharge (80% vs. 31%, P = 0.005), although long-term outcomes at 3 months were comparable (75% vs. 62%, P = 0.5). Procedure-related complications were mild and transient. This study represents the largest Indian SIH series to date, highlighting the predominance of orthostatic headache and pachymeningeal enhancement. EBP offers rapid symptomatic relief and remains the preferred initial therapy. Early recognition and standardized imaging protocols are vital for improved outcomes.

Giant disfiguring occipital lipoma: successful surgical management of a late-presenting case in a resource-limited setting in Somaliland

ABSTRACTIntroductionMigraine is a primary headache disorder, which leads to diminished health‐related quality of life (HRQoL). There is limited evidence assessing efficacy of cannabis‐based medicinal products (CBMPs) for migraine. This study investigates the efficacy and safety of CBMPs to treat migraine headache using validated patient‐reported outcome measures.MethodsThis case series utilizes data from the UK Medical Cannabis Registry. Primary outcomes included changes in Headache Impact Test 6 (HIT‐6), Migraine Disability Assessment Test (MIDAS), Generalized Anxiety Disorder 7 (GAD‐7), Single Item Sleep Quality Scale (SQS), and EuroQol 5‐Dimensions 5‐Levels (EQ‐5D‐5L) from baseline up to 24 months. Adverse events (AEs) and their severity were recorded. A p‐value < 0.050 was statistically significant.ResultsTwo hundred and three adult patients met inclusion criteria. Improvements at all intervals up to 24 months, relative to baseline, were observed in the HIT‐6, GAD‐7, SQS, and EQ‐5D‐5L (p < 0.010) and up to 12 months in the MIDAS (p < 0.050). Female sex (odds ratio [OR] 0.48, 95% confidence interval [CI] 0.23–0.98, p = 0.046) and a bottom quartile THC dose (OR 0.25, CI 0.06–0.93, p = 0.047) were negative predictors of MIDAS improvement. One in seven (n = 31; 15.27%) patients reported 249 AEs (n = 110, 44.18% mild; n = 79, 31.73% moderate; n = 57, 26.91% severe; n = 3, 1.20% life‐threatening).DiscussionCBMPs were associated with improvements in HRQoL measures up to 2 years, being relatively well tolerated. Higher THC doses were associated with a greater likelihood of improvement on migraine‐specific measures, although wide confidence intervals warrant caution in interpreting results.ConclusionFindings indicate utility of CBMPs for migraine, but randomized controlled trials are required to establish causation.

This scoping review aims to synthesize current evidence regarding the association between chronic pain and suicide risk across diverse populations, identify key psychological and clinical predictors, and explore the mediating roles of mental health disorders and interpersonal factors. The review utilises 239 original studies with 4265434 total participants (topic deduplicated ΣN). This scoping review maps a consistent signal that chronic pain is associated with elevated suicidality, including a 2.29-fold higher odds of screening positive for suicide risk in medical inpatients and a 2.00-fold higher risk of death by suicide in genomic analyses. Across the evidence base, the most recurrent amplifiers were depression and other psychiatric comorbidity, mental defeat, perceived burdensomeness, sleep disturbance, pain catastrophizing, and functional impairment, while overdose-related outcomes and opioid tapering or discontinuation emerged as particularly important clinical contexts. The mapped literature also suggests that risk is not uniform: it appears especially salient in veterans, adolescents, older adults, and selected pain phenotypes such as fibromyalgia and chronic headache, and some care processes such as nonpharmacological treatment, exercise exposure, empathy, and acceptance-based approaches may be protective. Clinically, these findings support routine suicide screening in pain care and closer monitoring during periods of psychiatric worsening, sleep disruption, escalating pain burden, or opioid regimen change. Because much of the evidence remains heterogeneous and observational, the next priority is longitudinal and interventional research that tests whether targeting modifiable pathways such as depression, insomnia, catastrophizing, burdensomeness, and mental defeat can reduce suicidal ideation and suicidal behavior in chronic pain populations.

Interstitial Thermal Therapy in Mesial Temporal Lobe Epilepsy Original Article Citation: Landazuri P, Cheng JJ, Leuthardt E, Kim AH, Southwell DG, Fecci PE, Neimat J, Sun D, Lega B, Panov F, Chiang V, Abel T, Ben-Haim S, Piccioni DE, Shih JJ, Palys V, Rodriguez A, Bandt SK, Petronio J, Lacroix M, Baumgartner J. JAMA Neurology. 2025;82(9):915-924. Importance Laser interstitial thermal therapy (LITT) is a surgical tool used to ablate epileptic foci and brain tumors. Understanding clinical and procedural outcomes of LITT for mesial temporal lobe epilepsy (MTLE) is relevant to clinicians and patients. Objective To describe seizure outcomes, procedural outcomes, and safety data of MTLE LITT. Design, setting, and participants Laser Ablation of Abnormal Neurological Tissue Using Robotic NeuroBlate System (LAANTERN) is a prospective multicenter registry with up to 5 years of follow-up lasting from October 2015 to March 2023 at LAANTERN epilepsy sites, which are all level IV National Association of Epilepsy Centers in the United States. Adult and pediatric LAANTERN enrollees undergoing LITT for drug-resistant MTLE with at least 6 months of follow-up were included. Those with epilepsy related to a malignant lesion were excluded. Intervention LITT for drug-resistant MTLE. Main outcomes and measures Demographic, epilepsy, and seizure characteristics; procedural data; postsurgical seizure outcomes; safety data; and quality of life (QOL) scores were prospectively collected. Results Fifteen centers enrolled 145 patients (73 [50.3%] female) with MTLE undergoing LITT, with 77 reaching 2-year follow-up. The mean (SD) age was 39.2 (15.4) years at the time of LITT, with 14 of 145 in the pediatric range (younger than 22 years). The 2 most common etiologies were mesial temporal sclerosis (n = 74) and unknown etiology or magnetic resonance imaging normal (n = 31). Mean (SD) ablation volume was 28.2 (29.8) mL. Mean (SD) surgery duration was 4.3 (2.1) hours, and mean (SD) blood loss was 22 (17.6) mL. Median (IQR) length of stay was 1 (1-3) day, and 33 patients (23%) had no intensive care unit stay postprocedure. Median (IQR) intensive care unit time was 22 (19.2-28.8) hours. Mean (SD) discharge head pain score was 2.1 (2.6) on a 0–10 scale. Most patients (n = 140 [96.6%]) were discharged home. Two-year seizure outcomes were 45 of 77 (58.4%) and 44 of 77 (57.2%) for Engel 1 and International League Against Epilepsy 1/2, respectively. No clinical characteristics were associated with seizure outcome. Adverse events were seen in 24 patients (16.5%), most being mild and transient. Pediatric seizure outcomes were similar to adult outcomes. One-third of patients stopped or decreased their antiseizure medicines. Improvements in QOL scores were seen at almost all time points assessed. Conclusions In the largest prospective multicenter MTLE LITT cohort, LITT was found to be well tolerated with clinically meaningful seizure outcomes and QOL improvements. These findings indicate that LITT may be considered as a treatment option for drug-resistant MTLE.

This study was conducted to provide a clinically oriented, mechanism-based framework for interpreting neuroimaging across disorders of cerebrospinal fluid (CSF) pressure, with particular emphasis on patients who fall between classic diagnostic categories of spontaneous intracranial hypotension (SIH) and idiopathic intracranial hypertension (IIH). Headache specialists are increasingly asked to evaluate patients whose symptoms, imaging, and opening pressures do not fit neatly within International Classification of Headache Disorders, 3rd edition criteria. At the same time, modern work in SIH, IIH, CSF-venous fistulas (CVFs) and rebound intracranial hypertension (RIH) has highlighted that these entities are better understood as dynamic expressions of a shared craniospinal physiology rather than isolated syndromes. This narrative review synthesizes contemporary literature on SIH, IIH, CVF, and RIH together with the authors' experience in a tertiary CSF disorder program. We focus on imaging markers of buoyancy loss and venous adaptation, the Bern score and its extensions, adjunctive MRI features that refine pretest probability when the brain MRI is normal, evolving myelographic techniques including photon-counting computed tomography, modern MRI phenotyping in IIH, and recent data on opening pressures in SIH and CVF. These data are organized around a unifying physiologic model rather than by individual disease labels. In SIH, the shift from a binary to a probability-based imaging paradigm-anchored by the Bern score-has been complemented by additional markers such as meningeal diverticula, optic nerve sheath narrowing, and imaging findings suggestive of migraine that further inform decisions about advanced myelography even when the brain MRI is formally normal. Recognition of lateral dural tears with small herniated arachnoid pouches mimicking meningeal diverticula and CVFs detectable with only advanced myelographic techniques underscores that absence of a localized leak does not exclude SIH. Most patients with imaging-proven SIH have normal or even elevated opening pressures, challenging current diagnostic criteria and suggesting that some leaks may arise in the setting of chronically increased craniospinal pressure. In IIH, only a subset of MRI features meaningfully discriminates true IIH from mimics, and venous sinus behavior emerges as a dynamic marker of compliance rather than a simple anatomic lesion. RIH after leak closure and "popping the balloon" in patients with established IIH who develop spinal leaks both illustrate how modest shifts in CSF volume and venous capacitance can drive rapid transitions between high- and low-pressure states. Disorders of CSF pressure are best conceptualized as points along an interconnected physiologic continuum in which buoyancy, venous compliance, leak morphology, and CSF-venous communication interact to produce the observed clinical and imaging phenotypes. For patients with mixed or subtle findings, applying this mechanism-oriented framework can improve interpretation of MRI and myelography, prevent premature exclusion of SIH or IIH on the basis of normal opening pressure or "negative" imaging, and support more nuanced, individualized treatment decisions in clinical practice.

Migraine is a common and disabling neurological disorder with complex symptoms, which may include eating-related symptoms before, during, and after headache (HA) pain. This study aimed to use a novel case-crossover design to assess dietary intake in temporal relation to migraine attacks. Data were collected from 25 people with migraine over a 28 d period, consisting of twice weekly dietary recalls combined with daily HA diaries assessing migraine symptoms. Micro- and macronutrient intakes were assessed, along with dietary quality. Generalized estimating equations assessed relationships between migraine attack phases and day-level dietary intake. Participants included 23 females and 2 males, with a mean (M) age of 31 ± 12 y and with a mean migraine disability assessment score in the severe range at 28.6 ± 20.2. Vitamin D and choline had the lowest frequencies of participants meeting the Dietary Reference Intakes. During the prodrome phase, the Healthy Eating Index (HEI) component score for total protein foods [M: 4.6; 95% confidence interval (CI): 4.4, 4.9], calories from total protein (M: 19.6%; 95% CI: 17.1%, 22.0%), and animal protein (M: 13.4%; 95% CI: 10.8%, 16.1%) were significantly higher than on interictal days [(M: 4.1; 95% CI: 3.9, 4.4), (M: 15.7%; 95% CI: 14.5%, 16.9%), and (M: 9.6%; 95% CI: 8.4%, 10.8%), respectively]. On HA days with mild pain, total HEI scores [(M: 61.9; 95% CI: 53.8, 69.9), total vegetable HEI component (M: 4.4; 95% CI: 3.9, 5.0)], greens/beans component (M: 3.8; 95% CI: 2.7, 4.9) and fiber density (M: 15.6 g/1000 kcal; 95% CI: 12.8, 18.3 g/1000 kcal)], were higher than on HA days with severe pain [(M: 52.6; 95% CI: 47.5, 57.8), (M: 3.1; 95% CI: 2.5, 3.8), (M: 2.3; 95% CI: 1.4, 3.1), and (M: 11.1; 95% CI: 9.2, 13.0), respectively]. A study design utilizing a novel combination of dietary recalls and HA diaries enables the observation of day-level differences in protein intake and dietary quality in relation to phase of the migraine attack and HA pain severity. The methodology is successful in consistently gathering detailed data that supports future designs, which represent diverse populations with migraine.