Hemicranial Headache Research Articles

Successful Management of Refractory Headache and Facial Pain due to Cavernous Sinus Meningioma with Sphenopalatine Ganglion Radiofrequency.

Headaches and facial pain can be extremely difficult to manage for the patient and the clinician. In the medical literature, it has been suggested that the autonomic reflex plays an important role in the pathophysiology of facial neuralgia. The sphenopalatine ganglion is the largest parasympathetic ganglion outside the cranium. It is an easy accessible target for pain management. The application of radiofrequency nerve ablation was described in the medical literature. In this case report, we describe a 54-year-old female. She was diagnosed with a cavernous sinus meningioma. She underwent surgical resection and gamma knife radiosurgery. She was suffering from an intractable hemifacial pain for many years. Her pain started shortly after surgery and continued throughout many years. Sphenopalatine ganglion block in multiple occasions was able to provide temporary relief. The patient's intractable hemicranial headaches and hemifacial pain responded to the sphenopalatine ganglion radiofrequency nerve ablation. The pain response remained unchanged for 12 months after procedure. This case report increased our current knowledge about the sphenopalatine ganglion role in the headache and facial intractable pain management. The failure of available antalgic medications to adequately control pain in similar patients underscores the need to develop an algorithm for therapies.

Retinal thrombosis secondary to the combination therapy of pegylated interferon and ribavirin for chronic hepatitis C virus infection: A rare complication

A 52-year-old man with chronic HCV genotype 2b infection was treated with 100 μg of pegylated interferon alpha-2b per week and 800 mg of ribavirin per day. He was asymptomatic before treatment. At 24 weeks, the patient was classified as a responder and 4 weeks after treatment he presented with left hemicranial headache and deteriorating vision on the left side. Fundus examination detected a generalized thinning of the arteriole and flame hemorrhages in the superior hemiretina with macular involvement (Fig. 1). Bilateral fluorescein angiography detected a delay in the inferior venous filling of the left eye. Abundant early phase hypofluorescent lesions due to blockage that were consistent with intraretinal blood, and microaneurysms in the macula were found (Fig. 2). Protein C and protein S levels were normal and the patient did not have Factor V Leiden. Ischemic occlusion of the superior venous branch of the central vein of the retina was diagnosed. Antiangiogenic therapy was prescribed (bevacizumab, a monoclonal antibody directed against vascular endothelial growth factor [VEGF]) every 6 weeks that resulted in a 70 % recovery of visual acuity. There are fewer than 10 reports in the international literature on retinal thrombosis associated with interferon and ribavirin combination therapy (2-4). Previous studies suggest that interferon may cause immune complex deposition in the retinal vasculature that leads to retinal ischemia, congestion, and hemorrhage (4). The use of an anti-VEGF therapy is based on Retinal thrombosis secondary to the combination therapy of pegylated interferon and ribavirin for chronic hepatitis C virus infection. A rare complication

Mysterious meningioma: Surviving the odds

Dear Editor, Clinical and imaging markers are a part and parcel of decision-making in neurosurgery, often prompting the surgeon to intervene before doom strikes. But, nature and its mechanisms, best not understood, do play a vital role. We herein present a case, which survived the odds, including the odds by neurosurgeon to teach us a lesson on the mystery of nature. A 62-year-old female presented with history of seizures of 8 years duration and was worked up as a case of left temporo-parietal meningioma 7 years back and was kept on phenytoin. She also had a history of left hemicranial headache, which was partially relievable with medications. She presented to our outpatient department with history of increased seizure frequency and severity of headache with associated occasional vomitings. There was no other significant history. On examination, the patient was remarkably preserved with no focal sensory or motor deficits. She presented with previous imaging done 7 years ago, which to our astonishment was showing a well-defined 4 × 5 × 5 cm extra-axial lesion in the left temporo-parietal region with squashing of ipsilateral ventricle and significant mass effect and midline shift to the opposite side and considerable peri-lesional edema [Figure 1]. The patient was advised surgery in 2005 but was deferred for lack of consent for surgical intervention. There was no history of any steroid intake. A repeat CT scan of the brain showed the lesion had significant increase in size, which was isodense on plain CT and enhancing homogenously on contrast and significant peri-lesional edema with mass effect and midline shift towards right side [Figures ​[Figures22 and ​and33]. Figure 1 Axial CT scan brain contrast study showing a well-defined 4 × 5 × 5 cm lesion in the left temporo – parietal region, uniformly enhancing on contrast administration with significant mass effect and midline shift (imaging done in ... Figure 2 Axial CT scan brain contrast study showing significant increase in the lesion size with persistent compression and midline shift (imaging done in 2011) Figure 3 CT brain coronal section showing the lesion causing squashing of the ipsilateral frontal horn and compression (imaging done in 2011) The presented case assumes significance in many contexts. First, with the first scan done 7 years ago, none could have contemplated a conservative approach, and an emergency surgical excision of the lesion would have been the top priority on any attending surgeon's mind. Second, despite any surgical intervention for such a long duration of 7 years, the patient remained well-preserved with no focal deficits or any deterioration, except for a recent increase in seizure frequency. Third, this underscores the paramount role of neuronal plasticity of the brain and other accommodative mechanisms responsible for the preserved neurological status over such a long duration. One also needs to take into account that since it being a meningioma imageologically, the expected rate of growth is around 1-2 mm per year. But, since a significant peri-lesional edema was already present in the very first image, the possibility of a malignant meningioma could not be ruled out. A review of literature was done in this context, and it was observed in a study on outcomes of untreated meningiomas by Rubin, et al. that[2] the incidence of rate of growth was low in elderly-aged group and that the presence of associated calcifications in the lesion portended a favorable prognosis. In another study by Sughrue, et al.,[4] it was observed that incidentally discovered meningiomas less than or equal to 2.5 cm in size do not proceed to cause symptoms during subsequent 5 years of their discovery. According to the study on natural history on intracranial meningiomas by Ova, et al.,[3] patients younger than 60 years of age with imaging demonstrating hyperintensity on T2WI with edema and size greater than 25 mm and lack of associated calcifications need to be followed up more closely. In another significant study by Desmurget, et al.,[1] it was observed that the temporal pattern of insult inflicted on the brain was significant in the process of recruitment of remote brain areas in ipsilateral and contralateral hemispheres and that the functional recovery and adaptment is significantly better in slow-growing lesions. In this case, the age of the patient being above 60 years could also have a contributory role in accommodating such a large lesion along with a reasonable anti-epileptic regimen causing no acute decompensation. This case epitomizes the role of plasticity of the human brain and unquestionably redefines the role of emergent surgical intervention in cases with large malignant meningiomas with significant mass effect and midline shifts.

The thing of which she could not speak: transient biopercular syndrome as a very late complication of unsuccessful chemical abortion

A 40-year-old schoolteacher with no medical history developed a left hemicranial headache accompanied with vertigo, followed by anarthria, sialorrhea, and paresthesias in both cheeks and in the tip of the tongue. The symptoms lasted approximately half an hour. When she consulted the next morning, she only presented with a slight left central facial paresis and a hypoesthesia that resolved in the following days. Fluid attenuated inversion recovery sequences of a magnetic resonance imaging (MRI) showed a corticosubcortical hypersignal, interpreted as gliosis, of the posterior part of the left frontal lobe and the right prerolandic region, on both sides extending into the insula, but sparing the most superficial cortical layers and mild local cortical atrophy (Fig. 1a, b). There were no hemosiderin deposits on T2 gradient sequences or signs of gadolinium uptake. Technetium 99-m single photon emission computed tomography showed a disruption of cortical activity in both opercular regions (Fig. 1c). Electroencephalography (on day 1) and blood analysis including basic metabolic panel, C-reactive protein, liver and thyroid function, antinuclear antibodies and anticoagulation tests were normal. There was no serological evidence for a bacterial, viral or parasitic infection and routine cerebrospinal fluid analysis was normal. Formal neuropsychological testing was normal. Given the absence of persisting clinical signs compared to the extension and the chronic character of the lesions, the biopercular syndrome might be attributed to an epileptic decompensation of otherwise silent perinatal brain injuries. Initially, there was no history of perinatal complications, but later on, the patient’s mother confessed that she had undergone an attempt of a chemical abortion. Eight years later and without treatment, the patient is still symptom free.

De secretis mulierum, de chirurgia et de modo medendi libri septem. Neurología y mujer en la literatura médica medieval

The School of Salerno stood as a landmark in the teaching and practice of medicine in the Western mediaeval world. Women could be both teachers and students and made significant contributions to its abundant scientific production. One of the most important of such women was Trotula of Salerno, the 12th century author of the Passionibus mulierum curandorum. De secretis mulierum, de chirurgia et de modo medendi libri septem is an anonymous medical poem from the School of Salerno, which was discovered in a manuscript from the 13th century. It consists of seven books and 7280 dactylic hexameters. The first book is specifically devoted to women's diseases and the second is a treaty on cosmetics. Books III and IV deal with surgery and follow the classical a capite ad calcem formula. The seventh book, De modo medendi, deals with therapeutics. We review the references to neurological diseases, using a critical translation of this text to carry out our study.The poem proposes therapies to treat epilepsy, headache or tinnitus. The treatment to be prescribed for headache differs depending on its origin. It puts forward pathophysiological explanations for the different types of headache, it relates engorged blood vessels with hemicranial headache, and suggests an excess of phlegm as the origin of mild occipital headache.Neurological pathology is well represented in this mediaeval monograph on women's diseases. Furthermore, it also shows us the vision that the Salerno physician has of these conditions and the therapeutic arsenal (based mainly on medicinal plants) that was available for use.

Repeat Stroke Associated with ‘Migraine with Aura’ and Middle Cerebral Artery Stenosis

We present a 21 year-old female, known migraineur, who presented with visual aura followed by throbbing left hemicranial headache, associated with sudden onset of weakness of the right side of the body and moderate to severe pains on the paretic limb (mixed lacuna stroke), three days after the onset of headache. She had a similar episode about 12 months prior to the present ictus. Findings on examination revealed essentially, right spastic hemiparesis with dysaesthesia and subtle right facial paresis. Brain MRI (magnetic resonance imaging) was normal, while MRA (magnetic resonance angiography) revealed middle cerebral artery (M2) stenosis. She was managed with aspirin, propranolol, amitriptyline and physiotherapy on which she made steady progress.

Unilateral headache associated with a pontine infarction

Brain stem structures are implicated in the generation of migraine and other types of headache. The patient described herein had chronic left hemicranial headaches associated with a left pontine infarction.

Spontaneous thrombosis of internal carotid artery: a natural history of giant carotid cavernous aneurysms

To describe five cases of giant carotid cavernous aneurysms which evolved with spontaneous thrombosis of internal carotid artery (STICA), with emphasis at epidemiology, clinical presentation, natural history, related factors and neurological outcome. There were 711 consecutives patients with 802 aneurysms with and without surgical treatment during a period of 19 years. We selected 35 patients with 40 carotid cavernous aneurysms (5%) of which 20 (50%) were giant aneurysms. Among those cases, 5 patients evolved with STICA (25%). Symptoms and findings at presentation were recorded and compared with those at outcome. Clinical presentation was commonly related to atherosclerotic factors such as elevated blood pressure (80%), diabetes mellitus (40%) and dislipidemy (40%). All patients presented with hemicranial headache, ophthalmparesy and retro bulbar pain, and after STICA all presented improvement of symptoms. After STICA, 4 patients had regression of deficit, 2 partial and 2 complete. Four patients had sensorial trigeminal neuropathy in V1 and V2 territories, also showing improvement of symptoms after STICA. STICA is a common outcome in giant carotid cavernous aneurysms, and is related with significant improvement of symptoms; however, it may be catastrophic for those patients without efficient collateral circulation.

Isolated Unilateral Temporal Muscle Hypertrophy: A Rare Cause of Hemicranial Headache

A case of isolated unilateral hypertrophy of the Musculus temporalis identified by magnetic resonance imaging associated with recurrent hemicranial headache in a 22-year-old woman with Turkish ancestry is presented. Symptomatic relief was achieved by administration of acetaminophen. A review of the literature is presented and additional treatment options are discussed.

Sensory “pseudoperipheral” migraine aura

The prevalence of migraine with aura in a large sample of a Danish population was 4.75% [5]. In this study, visual aura was the most frequent type of migraine aura (99%), followed by sensory (31%), aphasic (18%) and motor (6%) aura. Sensory aura usually affected the hand and the face (cheiro-oral distribution, 97%), whereas involvement of the body and legs were rare [5]. We report two patients with typical migraine attacks that were preceded by sensory symptoms affecting one lower limb with a ‘‘pseudoperipheral’’ distribution. Patient 1 was a 52 year-old woman with a 37-year history of attacks of migraine without aura and with visual aura, with no other previous diseases. She reported family history of migraine with and without aura. She was evaluated because of four episodes (the first occurred 1 year before) starting with gradually progressive paresthesias and dysesthesias restricted to the sensory territory of the right superficial peroneal nerve, reaching maximum development in 20 min, and lasting 45 min, that were followed by bilateral frontal throbbing headache with nausea, vomiting, photophobia and phonophobia, lasting 4–12 h. General and neurological examinations were normal. Blood count, routine biochemistry, thyroid hormones levels and serological studies for syphilis and Brucella were normal or negative. Brain and lumbosacral spine MRI, needle electromyography of the right lower limb, nerve conduction studies (right and left sural, superficial peroneal and deep peroneal nerves), and somatosensory evoked potentials obtained by right tibial nerve stimulation were normal. Patient 2 was a 29 year-old woman with a 17-year history, and family history, of migraine without aura. She was evaluated because of three episodes (the first occurred 7 months before) starting with low back pain radiating to the left posterior thigh, leg and first toe, that was accompanied by paresthesia in the same locations, which was gradually progressive, reaching maximum development in 10 min, and lasting 30 min. These symptoms were followed by right hemicranial throbbing headache with nausea and photophobia, lasting 6 h. General and neurological examinations were normal. Blood count, routine biochemistry, thyroid hormones levels and serological studies for syphilis and Brucella were normal or negative. Brain and lumbosacral spine MRI, needle electromyography of the left lower limb, and somatosensory evoked potentials obtained by left tibial nerve stimulation were normal. The possibility that brain cortical [3, 4, 7] or subcortical [2] lesions could cause symptoms resembling those of peripheral nervous system lesions has been previously reported, especially in the French neurological literature [3, 4, 7]. Although most of the reported patients presented with a motor deficit contralateral to the cortical lesion [3, 4, 7], some of them presented with pain or sensory dysfunction as well [2, 7]. In many of these patients, the first symptoms resembled those of L5 and S1 radicular lesions, and the neuroimaging studies showed parasagital frontal, parietal or centrum semiovale lesions [2, 4, 7]. H. Alonso-Navarro (&) Section of Neurology, Complejo la Mancha-Centro, Alcazar de San Juan, Ciudad Real, Spain e-mail: hortalon@yahoo.es

Benign Raeder Syndrome Evolving Into Indomethacin‐Responsive Hemicranial Headache

Benign Raeder syndrome is characterized by a self-limiting unilateral continuous headache associated with ipsilateral ptosis, miosis, and frequently, facial hypohydrosis. Hemicrania continua is a chronic, strictly unilateral continuous headache associated with ipsilateral cranial autonomic symptoms. We report a 50-year-old man who presented with benign Raeder syndrome, which evolved into an indomethacin-responsive hemicranial headache that resembled hemicrania continua.

Malignant transformation of iris melanocytoma to iris ring melanoma

Melanocytoma, a benign uveal melanocytic tumour, represents only 3% of iris naevi, and seldom undergoes malignant transformation.1 2 We report an unusual case of an iris melanocytoma suggested by two...

Migraine Pain Location at Onset and During Established Headaches in Children and Adolescents: A Clinic-Based Study from Eastern India

Literature documenting the location of pain at onset of migraine attacks and during established headaches in children and adolescents is sparse. Through a prospective study (2003-2005) of 200 children with migraine (ICHD-2: 1.1 and 1.2.1), we set out to document (i) the site of onset of pain and (ii) the location of pain during established attacks (on >50% of occasions) through semistructured interviews of patients and parents. Of the 200 children, the male:female ratio was 118 : 82 (1 : 0.69), the age range was 7-15 years (mean 11.8 years) and the duration of migraine 6 months to 4 years (mean 1.6 years). Ninety-three percent of subjects were ethnic Bengalis from the eastern Indian state of West Bengal, capital city Calcutta. Migraine types were: 1.1, 197 (98.5%); 1.2.1, three (1.5%). Location of pain at onset: 20.5% of subjects had unilateral onset; of these, 26.8% had eye pain, 65.9% frontal and 12.3% temporal pain. Thirty-three percent had bilateral location of pain, mostly bifrontal or ocular. None had vertex onset pain. However, in 35% of subjects, pain was holocranial at onset. Only 11.5% experienced pain in the occipito-cervical region at onset. Location of established headaches: in 53.7% of subjects with unilateral onset, headaches subsequently became holocranial. Hemicranial headaches occurred in only 19.5%. Of bilateral onset pains, 57.8% also became holocranial subsequently. In all, 73.5% of children ultimately experienced holocranial headaches. This study documents pain location at onset and during established headaches in children with migraine largely from a specific ethnic group.

Cerebral microhemorrhages in a patient with mycotic aneurysm: Relevance of T2-GRE imaging in SBE

A 43-year-old man presented with sudden onset left hemicranial headache and right superior quadrantanopia after 5 weeks of treatment with antibiotics for subacute bacterial endocarditis (SBE). Head CT (figure, A) showed left occipital …

Migraine headache: a rare complication after cervicothoracic block

post-injury complex regional pain syndrome (CRPS) type II involving her left hand came to the Pain Clinic. The rest of her medical history was unremarkable. A left cervicothoracic sympathetic block according to the classic method, using 8 ml of 0.375% ropivacaine, was performed without incident. The patient developed a left side Horner’s syndrome and other signs of sympathetic blockade in her left arm. Thirty minutes following the block, she developed sudden blurry vision added to speech disturbances and 30 min later she reported an intensive and progressive left frontal headache accompanied by nausea and phonophobia. The patient did not have a history of migraine headache or any other chronic headache condition. She received sumatriptan succinate, with good response. Twenty-four hours later she came to the ER reporting the same intense left hemicranial headache with aura. During the following 3 months her episodic left headaches occurred once every couple of weeks. The neurologist reported a normal neurologic examination and diagnosed the headache as a limited migraine headache with aura and her episodic headache resolved completely. We only found one other report describing this phenomenon in a patient, with a previous history of meningitis [1]. But how did the cervicothoracic block trigger the headache in a patient without neurological or vascular disorders? Extracranial blood flow is increased by 50% during migraine headache, compared to normal subjects, and there is some evidence that this contributes to pain in some migraine sufferers [2]. This increase may result from alterations in sympathetic tone. Cervicothoracic block increases intracranial blood flow [3], and probably the sympathetic blockade produced by the technique may precipitate the migraine headache [4]. Other possible explanations include coincidence and factitious or psychogenic causes. Finally, we cannot conclude on the pathogenesis of migraine, but vascular and neurologic mechanisms are involved in this complex disorder.

Autonomic headache with autonomic seizures: a case report

The aim of the report is to present a case of an autonomic headache associated with autonomic seizures. A 19-year-old male who had had complex partial seizures for 15 years was admitted with autonomic complaints and left hemicranial headache, independent from seizures, that he had had for 2 years and were provoked by watching television. Brain magnetic resonance imaging showed right hippocampal sclerosis and electroencephalography revealed epileptic activity in right hemispheric areas. Treatment with valproic acid decreased the complaints. The headache did not fulfil the criteria for the diagnosis of trigeminal autonomic cephalalgias, and was different from epileptic headache, which was defined as a pressing type pain felt over the forehead for several minutes to a few hours. Although epileptic headache responds to anti-epileptics and the complaints of the present case decreased with antiepileptics, it has been suggested that the headache could be a nontrigeminal autonomic headache instead of an epileptic headache.

Internal Carotid Artery Obstruction Derived From Persistent Arterial Wall Dissection Associated With Old Trivial Trauma-Case Report-

A 59-year-old man presented with acute onset of visual loss in his right eye. He was treated under a diagnosis of retinal artery thrombosis. Ultrasonography revealed obstruction of the ipsilateral internal carotid artery (ICA). He had no risk factor for stroke and he denied any history of trauma. Follow-up ultrasonography obtained 6 months later showed spontaneous ICA recanalization. Cerebral angiography demonstrated an arterial wall flap suggesting ICA dissection at the craniocervical junction. He then remembered suffering hemicranial headache and Horner's sign of several days' duration after jumping off a stepladder 1 year earlier. The present case is quite unusual in that persistent carotid arterial wall dissection was thought to proceed to ICA obstruction and manifested as retinal ischemia after a long asymptomatic period.

Spontaneous Resolution of Residual Pituitary Adenoma-Case Report-

A 34-year-old man presented with progressive diminution of vision in the left eye for 7 years. He had suffered left hemicranial headache associated with left retro-orbital pain and diplopia for 3 months. Magnetic resonance (MR) imaging revealed a pituitary tumor located in the sella and extending into the right cavernous sinus. After transsphenoidal surgery, the vision improved drastically but the diplopia persisted. Postoperative MR imaging showed residual tumor in the right cavernous sinus. Follow-up examination after 3 years showed the diplopia had completely recovered and the residual tumor in the cavernous sinus had disappeared. Spontaneous resolution of a large intracavernous sinus residue of a pituitary adenoma may occur due to tumor necrosis.

Tamoxifen

Cerebral sinus thrombosis (CST) can cause cerebral venous infarcts, frequently hemorrhagic. CST has many etiologies including otitis media, trauma, pregnancy, hypercoagulable states, and cancer. Systemic thrombosis is well recognized in cancer patients because of associated hypercoagulability, metastatic spread, and direct tumor infiltration and as a complication of chemotherapy.1 Tamoxifen, a selective estrogen-receptor modulator, is the most common hormonal therapy in the treatment and prophylaxis of breast cancer. One of its known side effects is systemic thromboembolic events.2 Recently, two reports have related tamoxifen to CST in absence of other risk factors.3,4⇓ To confirm this association, we report two patients receiving tamoxifen treatment who developed CST. ### Case 1. A 46-year-old woman presented with a 7-day history of intense right hemicranial headache, right ear tinnitus, and nausea. Past medical history included breast cancer 5 years previously treated with quadrantectomy, axillary dissection, and local radiotherapy. A local recurrence was detected 3 years later. Radical mastectomy was performed, and treatment with tamoxifen 20 mg/day was initiated. At the time of admission, neurologic and funduscopic …

Headache caused by polycythemia vera. Classification of a headache under the heading of metabolic disturbances

As polycythemia vera is a myeloproliferative syndrome, it is based on an autonomic increase in the proliferation of all hematopoetic cells--mostly of erythropoesis. An increase in blood viscosity induces disturbed microcirculation, resulting in headaches with clinical symptoms. So far, the headache in polycythemia vera has not been classified. We would like to demonstrate a case of a female patient aged 58 years who had been complaining of persistent hemicranial right-sided headaches for the last 16 days, alternating between throbbing and stabbing pain as well as a retrobulbar feeling of pressure. Blood chemistry demonstrated pronounced changes: hemoglobin, 20,1 g/dl; hematocrit, 58%; erythrocytes, 6,8 T/l (6,800,000/microl) leucocytes, 14,400/microl; thrombocytes, 543,000/microl A punch biopsy from the pelvic rim showed cell-rich bone marrow, demonstrating a myeloproliferative syndrome suggestive of polycytemia vera. Following hemodilution, the headache disappeared within 3 days following normalization of blood chemistry: hemoglobin, 14.9 g/dl; hematocrit, 44%; erythrocytes, 5.2 T/l (5,200,000/microl; leucocytes, 13,100/microl. Further diagnosis of the headache by means of MRI of the head, extra and transcranial doppler sonography as well as MRI of the cervical spine did not produce findings with the exception of retrospondylophyth at C5-6. The patient was therefore managed on aspirin 300 mg daily and was given weekly isovolemic bleeding. The headaches did not recur. We diagnosed a headache caused by polycythemia vera and recommend classification of this headache under the heading of metabolic disturbances, because this classification meets the diagnostic criteria of the international headache classification.