Occasional Headaches Research Articles

Intraosseous cavernous malformations of the skull: clinical characteristics and long-term surgical outcomes.

Intraosseous cavernous malformations (ICMs) of the skull are relatively rare, benign, and slow-growing tumors. Knowledge of these lesions is poor. The goals of this study were to describe the clinical manifestations, radiological features, and long-term surgical outcomes of this disease. We performed a retrospective analysis of a series of 16 cranial ICM patients who underwent surgical treatment in our hospital between 2003 and 2016. The incidence of cranial ICM was 1.15% among the entire series of intracranial and intraspinal CMs. Our cohort included 6 male and 10 female patients; their mean age at operation was 38.7years (range, 1.9 to 63years). Slowly growing swelling was the commonest clinical manifestation of this disease. Complete lesion resection was achieved in all but one patient, and cranioplasty was performed using titanium mesh in 11 cases. Postoperative complication was found in one patient who developed diplopia, and this symptom resolved spontaneously before discharge. The mean follow-up period after operation was 76.2months (range, 19 to 119months). Only the patient with petroclival ICM had some occasional headaches (mRS = 1); others were all in stable neurological status (mRS = 0). No lesion recurrence was found during the follow-up period. Although cranial ICM is rare, it should always be considered as a differential diagnosis in the case of firm, gradually enlarging skull lesions. Surgical resection should be the treatment of choice for the symptomatic patients and their long-term outcomes were excellent after gross total removal.

New therapies to relieve pain: The search for more efficient and safer alternatives to opioid pain killers.

EMBO Reports (2018) e46925 Opioids are a largely efficient medication for relieving severe pain and are prescribed for a wide variety of indications including metastatic cancer, arthritis, neuropathy or post‐surgical pain. These drugs target opioid receptors to produce effects similar to morphine and include moderately strong painkillers such as oxycodone and hydrocodone (Vicodin), and strong drugs like fentanyl, which resembles opium‐derived morphine and heroin. The great efficiency of opioids in treating severe pain has also been the major drawback for longer‐term use given their addictive power. This does not matter for short‐term use, for instance to ease post‐operative pain, or terminal cancer when the primary requirement is to relieve suffering. Yet, the addictive side effect has become a huge societal problem; in addition, opioids do not work against all types of chronic pain, including some of the most severe cases such as cancer‐induced bone pain or some cases of neuropathy resulting from nerve damage. These problems have spurred efforts to develop new drugs for treating pain with some success in developing derivatives with reduced side effects. The other major avenue of research is the identification of relevant pain pathways or protein binding sites including those involved in the placebo effect. Their efficiency has spurred physicians to prescribe opioids too readily, while drug companies have heavily advertised their effects and understated the side effects to boost usage. This three‐way collusion between patients, doctors and pharmaceutical companies has stoked the ongoing epidemic of opioid addiction that has afflicted the USA and Canada in particular, but also other developed countries in Europe and Asia. Apart from exacting a heavy social toll through loss of motivation or loss of jobs, impact on relationships, crime and so on, opioid addiction has dangerous physiological effects, notably on the respiratory system, which causes most of the overdose …

Post-traumatic right carotid-cavernous fistula resulting in symptoms in the contralateral eye: a case report and literature review

BackgroundTo report a case of a carotid-cavernous fistula (CCF) that occurred after a motor vehicle accident and review the uniqueness of this case and the main confusing points for the diagnosis of such cases.Case presentationA 22-year-old man complained of left eyelid swelling, eye redness, visual decrease and occasional headache after motor vehicle accident 4 months prior during which he experienced a head injury. He was initially thought to have glaucoma, but he was finally diagnosed with a right CCF based on magnetic resonance imaging (MRI) and digital subtraction angiography (DSA). Timely embolization surgery resulted in obvious relief of the ocular symptoms and an improved prognosis.ConclusionThis is the first reported case of a post-traumatic unilateral CCF with contralateral symptoms in direct CCF, it is very infrequent and deserves our attention. We should maintain high suspicion of CCF and confirm the diagnosis by DSA when managing such patients to prevent serious consequences. Early diagnosis and treatment can improve the prognosis of patients.

Relationship between Cough-Associated Changes in CSF Flow and Disease Severity in Chiari I Malformation: An Exploratory Study Using Real-Time MRI.

Currently no quantitative objective test exists to determine disease severity in a patient with Chiari I malformation. Our aim was to correlate disease severity in symptomatic patients with Chiari I malformation with cough-associated changes in CSF flow as measured with real-time MR imaging. Thirteen symptomatic patients with Chiari I malformation (tonsillar herniation of ≥5 mm) were prospectively studied. A real-time, flow-sensitized pencil-beam MR imaging scan was used to measure CSF stroke volume during rest and immediately following coughing and relaxation periods (total scan time, 90 seconds). Multiple posterior fossa and craniocervical anatomic measurements were also obtained. Patients were classified into 2 groups by neurosurgeons blinded to MR imaging measurements: 1) nonspecific Chiari I malformation (5/13)-Chiari I malformation with nonspecific symptoms like non-cough-related or mild occasional cough-related headache, neck pain, dizziness, paresthesias, and/or trouble swallowing; 2) specific Chiari I malformation (8/13)-patients with Chiari I malformation with specific symptoms and/or objective findings like severe cough-related headache, myelopathy, syringomyelia, and muscle atrophy. The Spearman correlation was used to determine correlations between MR imaging measurements and disease severity, and both groups were also compared using a Mann-Whitney U test. There was a significant negative correlation between the percentage change in CSF stroke volume (resting to postcoughing) and Chiari I malformation disease severity (R = 0.59; P = .03). Mann-Whitney comparisons showed the percentage change in CSF stroke volume (resting to postcoughing) to be significantly different between patient groups (P = .04). No other CSF flow measurement or anatomic measure was significantly different between the groups. Our exploratory study suggests that assessment of CSF flow response to a coughing challenge has the potential to become a valuable objective noninvasive test for clinical assessment of disease severity in patients with Chiari I malformation.

Usage of continuous glucose monitoring (CGM) for detecting an unrecognized hypoglycemia and management of glucocorticoid replacement therapy in adult patients with central hypoadrenalism

Patients with adrenal insufficiency require appropriate glucocorticoid replacement therapy; however, reliable biological parameters for optimizing glucocorticoid supplementation are limited. The physician has to rely primarily on clinical judgment, carefully taking into account signs and symptoms potentially suggestive of over- or under-replacement. We have found that some patients who are viewed as receiving sufficient doses of glucocorticoids occasionally exhibit morning headache or morning discomfort, which may be caused by unrecognized nocturnal hypoglycemia. Our aim in this study was to evaluate the usefulness of continuous glucose monitoring (CGM) for detecting unrecognized hypoglycemia and optimizing glucocorticoid replacement therapy in adult patients with central hypoadrenalism. Six patients with central hypoadrenalism of various etiologies were included in this study. All patients exhibited occasional morning headache or discomfort. We performed CGM to measure plasma glucose levels in all patients, and CGM identified unrecognized hypoglycemia episodes at midnight and early in the morning in five patients (83%). The CGM findings were used to fine-tune the dosing and regimens of glucocorticoid replacement and to re-evaluate glucose levels to avoid further unrecognized hypoglycemic events. This optimization of hydrocortisone supplementation prevented additional nocturnal hypoglycemia incidences in all cases. The addition of L-thyroxine with hydrocortisone continued to provide favorable glycemic control. Occasional symptoms also improved after maintenance in all patients. These findings demonstrated that CGM may represent a powerful tool for identifying unrecognized hypoglycemia and for optimizing supplementary hormones in patients with central hypoadrenalism, thereby improving their quality of life.

Dego's disease in a female child with Anti-Scl-70 antibody positivity

Degos' disease (DD) also known as malignant atrophic papulosis is considered to be a disorder of abnormal coagulation with obliterative arteritis. Its association has been described with connective tissue disorders, human immunodeficiency virus infection (HIV) and wegener's granulomatosis. Gastrointestinal, neurological, ocular, cardiovascular, and pulmonary involvement can also occur in DD. Benign version of DD with only cutaneous manifestations has been described. We are presenting a case of 7-year-old female with multiple irregular-shaped crusted tender lesions with porcelain white scars of healed lesions mainly over the trunk and upper limb and few lesions involving face and legs for the last 6 months. There was a history of occasional headache. Other systemic examination by experts was within normal limit. On further investigation, antinuclear antibody, and anti-Scl-70 antibody were positive with histopathology suggestive of DD. The patient had reduced peak expiratory flaw rate (PEFR). The patient was given oral prednisolone without much improvement. With oral aspirin for a month, the patient had mild improvement. The patient is presently under follow-up for future systemic involvement and response to therapy. Anticipated mortality in DD is 50%–60%. Earlier diagnosis and proper management at such a younger age might benefit the patient; however, they need to be followed up for complications. DD is very rare and very few cases have been reported in children. Ours is unique with anti-Scl-70 antibody positivity.

Case of Metastasis of Alveolar Soft Part Sarcoma Lower Limb To Brain Diagnosed on Squash Cytology

A 19‑year‑old male patient was admitted, after experiencing occasional headaches during the previous 6 months. The patient's headaches had become progressively more severe 1 month prior to admis­sion to hospital, and were associated with right upper limb weakness. As revealed by cranial computed tomog­raphy, a high‑density lesion was observed in the left parietal region [CT values, 52 Houns field units, (HU)] and a peripheral low‑density edematous zone was visible.(figure a) . The medical history of the patient included an indolent 4x4 cm subcutaneous iliac mass in the left lower limb from last one year, which the patient had neglected. Therefore, the patient was diagnosed as space occupying lesion brain. During surgery, a purplish‑red tumor was observed in the brain. Intraoperative crush cytology was asked for. JMS 2017;20(2):108

Hypertension in Children and Adolescents.

1. Donald J. Weaver Jr, MD, PhD* 1. *Division of Nephrology and Hypertension, Department of Pediatrics, Levine Children’s Hospital at Carolinas Medical Center, Charlotte, NC * Abbreviations: ABPM: : ambulatory blood pressure monitoring ACE: : angiotensin-converting enzyme ADE: : adverse drug event ARB: : angiotensin receptor blocker CCB: : calcium channel blocker CT: : computed tomographic LV: : left ventricular MR: : magnetic resonance Hypertension in children and adolescents is often underdiagnosed. Blood pressure should be assessed at every medical encounter in children aged 3 years and older, as well as high-risk children younger than 3 years. Pharmacologic therapy is safe and effective for controlling blood pressure and preventing end-organ changes in this population. After completing this article, readers should be able to: 1. Recognize and properly classify hypertension in children and adolescents. 2. Develop a differential diagnosis and diagnostic approach for evaluation of hypertension, based on signs and symptoms. 3. Initiate a discussion with patients and their families on the nonpharmacologic management of hypertension. 4. Discuss the classes of antihypertensive medications used in children and adolescents. Danielle is a 16-year-old who presents to your office for a routine health maintenance visit. She has generally been feeling well, except for occasional headaches. They do not localize to a specific location, and they occur weekly and resolve spontaneously. They are not associated with any other neurological symptoms. Her past medical history is unremarkable. She is not taking any medications. Her family history is remarkable for hypertension in both the maternal and paternal grandparents. The review of systems has yielded otherwise negative findings. The physical examination showed a height at the 25th percentile and a weight in the 75th percentile. Initial blood pressure obtained by using an automated oscillometric device was 154/82 mm Hg. At examination, she was well appearing and in no distress. Her physical examination findings were normal, except for a dark, velvety discoloration on her neck. A manual auscultatory blood pressure obtained at the end of the physical examination with the appropriately sized cuff and with the patient sitting was 134/78 mm Hg. Most data …

A Case Report on Frontal Osteoma

A 13 years old boy admitted with the complaint of progressive exophthalmos and gradually decreasing vision on right eye, also occasional headache and deformity on the right fronto-orbital region. Radiological & clinical findings revealed a case of frontal osteoma in the right frontal sinus extending up to right frontal lobe, eroding right roof of the orbit. Complete excision of the tumor mass was possible surgically. Biopsy confirmed a case of osteoma. Below is a discussion on diagnosis & management of frontal osteomaPulse Vol.9 January-December 2016 p.45-48

Tension-Type Headache: Epidemiology, Diagnosis, and Pathophysiology

Tension-type headache (TTH) is a significant but underappreciated condition that is much more frequent than migraine, 42% versus 11%, and produces significant socioeconomic burden. Why then do research advances in this condition seem to lag? One reason is that precise epidemiologic data are lacking, with lifetime prevalence estimates varying from about 13 to 78%. Also, classification is confounded by whether or not to include the occasional but universal headache as TTH. Furthermore, TTH pathophysiology is debated, with some feeling that the pathophysiology of TTH is similar to and on a spectrum with migraine, and some feeling that it is entirely separate and related to peripheral and muscular mechanisms. More recently, central pain mechanisms have also been implicated in the pathophysiology. In addition, a large body of information connects stress and TTH. Although TTH varies widely in frequency and severity among and within patients, TTH pain, compared with pain in other headache types, could be characterized generally as more mild in severity and more generalized in location. This review discusses the current epidemiologic data and diagnostic challenges in TTH and the current pathophysiologic mechanisms.

Endovascular Therapy Using Flow Diversion for Giant Internal Carotid Artery Pseudoaneurysm Arising in the Setting of an Invasive Pituitary Macroadenoma

This report illustrates the unusual occurrence of a pseudoaneurysm arising in the setting of a skull base mass and describes the first reported use of endovascular flow diversion therapy in such a setting. A 63-year-old man with occasional headaches during the preceding month presented with the acute onset of severe left retroorbital headache and oculomotor nerve palsy. Computed tomography (CT) and CT angiogram revealed a destructive skull base mass with an associated giant probable pseudoaneurysm of the cavernous segment of the left internal carotid artery. The patient underwent endoscopic transsphenoidal biopsy with a subsequent diagnosis of prolactinoma. Endovascular therapy utilizing two Pipeline™ flow diversion embolization devices was performed with subsequent resolution of the patient's headache and improvement in his cranial nerve deficits/cavernous sinus syndrome.

A Case Of Cystic Pheochromocytoma With Hypertension And Headaches Mimicking A Large Pancreatic Cystic Tumor

ABSTRACT Objective: Cystic pheochromocytomas can become enlarged without abdominal symptoms and can potentially be confused with other abdominal cystic tumors. Methods: We report here a case of a 45-mm cystic pheochromocytoma that was initially considered a pancreatic cystic tumor. The patient had a 4-year history of treatment for hypertension and occasional headaches. Left cystic pheochromocytoma was diagnosed based on excessive catecholamine levels, 18F-fluoro-2-deoxy-d-glucose positron emission tomography/computed tomography (18F-FDG PET/CT), and 123I-metaiodobenzylguanidine (123I-MIBG) scintigraphy. Results: Left adrenalectomy ameliorated the patient's hypertension and headache. Pathologic findings showed an enlarged cyst with an irregular, thick wall adherent to the normal adrenal tissues. Conclusion: A large cystic pheochromocytoma can be misdiagnosed as a large pancreatic cystic tumor. CT and magnetic resonance imaging (MRI) are less important in excluding the possibility of pheochromocytoma than b...

Tension-Type Headache: Epidemiology, Diagnosis, and Pathophysiology

Tension-type headache (TTH) is a significant but underappreciated condition that is much more frequent than migraine, 42% versus 11%, and produces significant socioeconomic burden. Why then do research advances in this condition seem to lag? One reason is that precise epidemiologic data are lacking, with lifetime prevalence estimates varying from about 13 to 78%. Also, classification is confounded by whether or not to include the occasional but universal headache as TTH. Furthermore, TTH pathophysiology is debated, with some feeling that the pathophysiology of TTH is similar to and on a spectrum with migraine, and some feeling that it is entirely separate and related to peripheral and muscular mechanisms. More recently, central pain mechanisms have also been implicated in the pathophysiology. In addition, a large body of information connects stress and TTH. Although TTH varies widely in frequency and severity among and within patients, TTH pain, compared with pain in other headache types, could be characterized generally as more mild in severity and more generalized in location. This review discusses the current epidemiologic data and diagnostic challenges in TTH and the current pathophysiologic mechanisms.

Tension-Type Headache: Epidemiology, Diagnosis, and Pathophysiology

Tension-type headache (TTH) is a significant but underappreciated condition that is much more frequent than migraine, 42% versus 11%, and produces significant socioeconomic burden. Why then do research advances in this condition seem to lag? One reason is that precise epidemiologic data are lacking, with lifetime prevalence estimates varying from about 13 to 78%. Also, classification is confounded by whether or not to include the occasional but universal headache as TTH. Furthermore, TTH pathophysiology is debated, with some feeling that the pathophysiology of TTH is similar to and on a spectrum with migraine, and some feeling that it is entirely separate and related to peripheral and muscular mechanisms. More recently, central pain mechanisms have also been implicated in the pathophysiology. In addition, a large body of information connects stress and TTH. Although TTH varies widely in frequency and severity among and within patients, TTH pain, compared with pain in other headache types, could be characterized generally as more mild in severity and more generalized in location. This review discusses the current epidemiologic data and diagnostic challenges in TTH and the current pathophysiologic mechanisms.

Antiseizure medications: Brand name vs generic.

For many years, there has been a debate between “brand name” and “generic” medications.1,2 When a person has an occasional headache and takes acetaminophen to relieve the pain, he or she may have the same relief as if he or she had taken the brand name, Tylenol. However, what if the illness is chronic? Now suppose the illness is something more serious, such as seizures. Is there a difference between generic and brand name? If so, which one is better? Which one will control the seizures better? Which one will have fewer side effects?

Recurrent intracranial neurenteric cyst with malignant transformation: A case report and literature review.

Neurenteric cysts (NCs) are uncommon congenital cystic lesions. Malignantly transformed NCs are extremely rare. The present study reports the case of a recurrent foramen magnum NC with a malignant transformation and reviews 8 previously reported cases. A 58-year-old woman with a 5-month history of occasional headaches, dizziness and vomiting presented to the Beijing Tiantan Hospital (Beijing, China) with palsy of the left cranial IX and X nerves, decreased sensation in the limbs on the right side and an ataxic gait. Magnetic resonance imaging (MRI) scans revealed a cystic mass in the left side of the foramen magnum, positioned anteriolaterally to the medulla oblongata. Surgery using a left suboccipital retrosigmoid approach was performed. The lesion was partially resected and was histopathologically diagnosed as an NC with focal hyperplasia of the epithelial cells. Additional MRI scans that were performed 25 months later revealed a solid lesion posterior to the medullar oblongata. Therefore, surgery using a suboccipital midline approach was performed. The solid lesion was sub-totally removed and was histopathologically diagnosed as a well-differentiated papillary adenocarcinoma. At 1 month post-surgery, the patient's condition worsened, eventually resulting in mortality due to respiratory failure. Based on the findings of the present case and previous literature, strict criteria for malignant-transformed NCs were created. The location distribution of malignant-transformed NCs does not coincide with the location distribution of all NCs, and malignantly transformed NCs usually occur in adult patients and present as atypical radiological features. Surgery is the optimal treatment for malignantly transformed NCs, and the effectiveness of adjuvant therapy requires additional studies.

Effects of Smoking on Pilots of Bangladesh Air Force in Dhaka Area

Introduction: Smokers have a high morbidity and mortality rate and the causes of excess morbidity and mortality include lung cancer, COPD (Chronic Obstructive Pulmonary Disease) and cor pulmonale. An estimated 100 million people died in the 20th century from tobacco-associated diseases. Smoking also affects the performance and cause physical deterioration of pilots.
 Objectives: To evaluate the effects of smoking on pilots of Bangladesh Air Force (BAF), Dhaka area.
 Materials and Methods: This cross sectional study was conducted during the period of January to June 2014 among the available pilots of different age and ranks of 6 flying squadrons of BAF Dhaka area. Data were collected by using a pre-tested semistructured questionnaire distributed among the pilots. Information were also collected from Central Medical Board (CMB), BAF about total number of pilots placed in low medical category and nature of their sickness. Finally chest X-ray and ECG of the pilots were done to find out any respiratory and cardiovascular abnormalities. Data obtained were entered into SPSS version 21.0 for analysis.
 Results: Total 190 pilots were interviewed and among them, 80(42%) were smokers and 110(58%) were non-smokers. Most of the pilots were within the age group of 26-30 years (30%). Out of 80 smoker, 37(46%) smoked for more than 10 years, rest smoked for 10 years and less. Stress was the most common cause of starting smoking (96.3%). Fifty eight (72.5%) pilots agreed that their stamina and physical efficiency decreased due to smoking, 21 (26.3%) experienced breathlessness at high altitude, 26(32.5%) experienced visual disturbance during night flying. Fifty three (66.3%) pilots complained of occasional episode of palpitation along with increase in pulse rate. Thirty one (39%) experienced occasional headache during high altitude flight, 58(72.5%) had heart burn related to smoking. Thirty eight (47.5%) had occasional bouts of cough with sputum and 40(50%) complained of occasional gum bleeding. These pilots also informed that they reported sick several times for headache, heart burn, cough and URTI (Upper Respiratory Tract Infection) and were unfit for flying duties. During January-June 2014, a total of 10 pilots of BAF Dhaka area were placed in low medical category out of them 6 (60%) pilots had smoking habits and suffered from IHD-4 (Ischemic Heart Disease) and HTN-2 (Hypertension). There was statistically significant association between number of the cigarette smoked, period of smoking and physical deterioration of smoker pilots (P<0.05). Those who smoked more than 10 sticks/day and more than 10 years had moderate to severe physical deterioration.
 Conclusion: Smoking adversely affects all systems of human body. It impairs altitude tolerance, early induction of hypoxia, impairment of night vision. It affects autonomic systems and thus impairs all compensatory mechanism needed at higher altitudes. Morbidity and mortality related to smoking have linear relation. Pilots must be indoctrinated not to smoke for the sake of their safety flight, own life, their families and the nation.
 Journal of Armed Forces Medical College Bangladesh Vol.12(1) 2016: 22-27

Reversible central sleep events in type I Chiari malformation

A 13-year-old girl with a 2-year history of snoring and witnessed sleep apnea, with occasional headache and poor academic performance, was referred for a sleep study. Physical examination was normal, with tonsil size of II/IV and no neurologic findings. She underwent a polysomnography (PSG) for suspected obstructive sleep apnea (OSA), but no obstructive events were found. The test revealed a slightly higher conventional central apnea index, where events are associated with arousal or oxygen desaturation (2.2/h) and other central breathing events without oxygen desaturations or arousals (Figs 1 and 2). Oxygen desaturation index was 1.2/h with a minimum oxygen saturation of 95%. Capillary blood gas analysis showed a pCO2 of 32 mmHg. Cerebral magnetic resonance imaging (MRI) revealed Chiari malformation type I (CM-I) associated with cervical and dorsal syringomyelia (Figs 3–5). A watchful waiting approach was taken. One year later, the PSG is completely normal (Fig. 6). Central apnea index is 0.2/h without any other events, and end-tidal pCO2 and capillary blood gas analyses are also normal.

Sleep apnea headaches

Article type Review article Obstructive sleep apnea syndrome (OSAS) is a common disorder characterized by recurrent apnea during sleep. Nocturnal laboratory-based polysomnography (PSG) is the gold standard test for diagnosis of OSA. The sufferers may complain from daytime sleepiness, snoring or occasional headaches. Serious consequences such as cardiovascular complications, stroke or symptoms of depression may complicate the syndrome. Headache prevalence due to sleep apnea is estimated 1%-2% in general population and affects 2%-8% of middle age population. Morning headache is more common in the OSAS patients. OSAS patients present with various characteristics of morning headache. Treatment with continuous positive airway pressure usually reduces headache. The pathophysiologic background for a relation between obstructive sleep apnea and morning headache is multifactorial. Some theories have been proposed for OSAS-related headaches such as changing oxygen saturation during sleep, cerebral vasodilation and increased intracranial pressure due to cerebral vasodilation, sleep disruption and depression but the definite cause of headaches in OSAS patients is not yet clear.

Hormonally Active Adrenocortical Oncocytic Carcinoma Presenting with Hirsutism and Amenorrhea: A Rare Case Report and Literature Review

Hormonally Active Adrenocortical Oncocytic Carcinoma Presenting with Hirsutism and Amenorrhea: A Rare Case Report and Literature Review Thirty-seven year old female, referred to our Urology Service from Internal Medicine and General Surgery for an assessment of an injury to the left adrenal gland. The injury was discovered incidentally by abdominal imaging, as the patient had been suffering from amenorrhoea and hypertrichosis for over a year. The patient also referred to a tingling sensation in the face and neck and to occasional headaches and blurred vision, as well as weight loss during this time period. The exploration showed widespread oedema, more pronounced on the lower limbs, a marked distribution of hair over the abdomen, chest, arms, and legs, and erythematous rashes on the chest, forearms and abdomen..