Ongoing Headaches Research Articles

P025 Routine Giant-cell arteritis turned Heidenhain variant of sporadic Creutzfeldt-Jakob disease: a mysterious case report!

Abstract Background/Aims Giant-cell arteritis (GCA) is a large vessel vasculitis predominantly affecting those above 50 years of age. Creutzfeldt-Jacob disease (CJD) is not a well-recognised differential diagnosis of GCA presentation. Prion diseases are progressive, currently untreatable and ultimately fatal. Methods We report the case of a 76-year-old female who had an eventful hospital stay of 37 days. She has a history of asthma, hypertension, ulcerative colitis and right-sided GCA 5 years back (normal inflammatory markers & biopsy). Results The patient presents to Harlow ED with a right temporal headache with tenderness, jaw claudication symptoms, blurred vision, diplopia, dizziness and painful right eye movements. Her CRP was <1 and ESR was 5. The plan was to treat it as a recurrence of her GCA and to continue with the high dose Prednisolone started by the ED. CT Head was normal. Owing to poor response, IV Methyl Pred was given. On day six, patient was re-admitted with worsening headache and generalised decline. Ophthalmology review noted multiple visual field defects and treated as GCA. A neurology review noted the patient to be encephalopathic. Advice was for MRI head and CSF analysis - both NAD. On day 12 she had ongoing headache, diplopia, poor vision/memory, and reduced hearing in right ear, but alert and following instructions. On day 17, ENT suggestion was to treat as Meniere’s and start on Betahistine. On day 22, the patient had a TIA episode and discussed with Stroke team. Repeat CT Head was nil acute. By day 26, the patient was unresponsive intermittently and was treated as hypoactive delirium. On day 31 a seizure activity was noticed. Neurology review on day 33 noted rapid decline- the patient being mute, seizure/atypical encephalitis. MRI-Head with contrast showed the possibility of CJD. The very next day patient was reviewed by the team from National CJD Research and Surveillance team, Edinburgh. The formal diagnosis given was: probable Sporadic CJD (visual/Heidanhain variant), rapidly progressive cognitive decline with visual signs, myoclonus, and akinetic mutism, positive MRIs, bland CSF, no clear iatrogenic or variant risk factors, and no credible alternative diagnosis. The distressed family members were updated and the patient was put on EoL pathway. She died peacefully four days later (Day 37). Conclusion The importance of this case is the conflicting inputs from at least five specialities in a rapidly deteriorating patient. A background of previous right-sided GCA did prompt initial treatment in those lines. MRI Head DWI sequence did show the classic ‘cortical ribboning’ with right caudate and lentiform hyperintensity; which clinched the mysterious diagnosis of this rare disease which requires public health surveillance. CJD is to be suspected in any undiagnosed rapidly progressive mental deterioration or dementia, often with behavioural abnormalities and myoclonus. Disclosure S. Narikkoottungal: None. K. Gunasekera: None. K. Ahmed: None.

Predictors and concomitants of the remission of frequent headache in pediatrics: A longitudinal community study.

We aimed to examine factors associated with frequent headache remission in schoolchildren aged 10-18 years. Frequent headache is a common health problem in adolescence, and some individuals in this population experience remission. Factors preceding headache remission as opposed to ongoing headache, and their development over time, have not been examined extensively. Data were derived from a large school sample (N = 2280). Over the course of 1 year, n = 156 adolescents experienced remission from frequent headaches, while n = 125 adolescents continued to have frequent headaches throughout the year. In this longitudinal case-control study, we predicted headache remission using demographic, pain, psychosocial, sleep, and physiological characteristics. Additionally, we sought to explore the development of psychosocial, sleep, and physiological characteristics in relation to remitted versus ongoing headache over the 1-year period. A model containing the variables sex (odds ratio [OR] = 0.43, 95% confidence interval [CI] = 0.248-0.76, p = 0.003), headache intensity (OR = 0.85, 95% CI = 0.73-0.99, p = 0.035), anxiety score (OR = 0.92, 95% CI = 0.85-1.01, p = 0.071), and depression score (OR = 0.94, 95% CI = 0.89-1.00, p = 0.041) predicted the outcome variable (remitted vs. non-remitted headache), explaining 17% of the variance in group membership. Schoolchildren reporting remitted headache at the end of the year exhibited lower depression (F[1, 557.01] = 45.77, p < 0.001) and anxiety scores (F[1, 557.01] = 21.72, p < 0.001), higher school satisfaction (F[1, 209.46] = 7.15, p = 0.008), and fewer difficulties falling asleep (F[1, 856.52] = 41.21, p < 0.001) or sleeping through the night (F[1, 731.12] = 26.42, p < 0.001) throughout the year compared to those with non-remitted headache. Depression scores declined significantly over the year in the group with remitted headache, whereas these scores remained constant in the group with non-remitted headache. Our results suggest a correlation between headache remission and male sex, improved mental health, and reduced pain-related burden. Moreover, there was an observed decline in symptoms of depression during headache remission. Psychotherapy may be a promising treatment strategy for addressing frequent headaches reported by children and adolescents.

A study of acromegaly-associated headache with somatostatin analgesia.

To characterise somatostatin analogue responsive headache in acromegaly, hitherto not systematically documented in a significant cohort. Using the UK pituitary network, we have clinically characterised a cohort of 18 patients suffering from acromegaly-related headache with a clear response to somatostatin analogues. The majority of patients had chronic migraine (78%) as defined by the International Headache Society diagnostic criteria. Headache was present at the time of acromegaly presentation and clearly associated temporally with disease activity in all cases. Short-acting somatostatin analogues uniquely resolved pain within minutes and the mean duration of analgesia was 1-6 hours. Patients on long-acting analogues required less short-acting injections (mean 3.7 vs. 10.4 injections per day, p=0.005). 94% used somatostatin analogues to control ongoing headache pain. All patients presented with macroadenoma, most had incomplete resection (94%) and headache was ipsilateral to remnant tissue (94%). Although biochemical control was achieved in 78% of patients, headache remained in 71% of them. Patients selected for this study had ongoing headache post-treatment (mean duration 16 years after diagnosis); only 4 patients reached headache remission 26 years (mean, range 14-33) after the diagnosis. Headache in acromegaly patients can be persistent, severe, unrelieved by surgery, long-lasting and uncoupled from biochemical control. We show here that long-acting analogues allow a decrease in the number of short-acting analogue injections for headache relief. Further studies are needed to understand the mechanisms, markers and tumour tissue characteristics of acromegaly-related headache. Until then, this publication serves to provide the clinical characteristics as a reference point for further study.

Persistent post-COVID headache is associated with suppression of scale-free functional brain dynamics in non-hospitalized individuals.

Post-acute coronavirus disease 2019 (COVID-19) syndrome (PACS) is a growing concern, with headache being a particularly debilitating symptom with high prevalence. The long-term effects of COVID-19 and post-COVID headache on brain function remain poorly understood, particularly among non-hospitalized individuals. This study focused on the power-law scaling behavior of functional brain dynamics, indexed by the Hurst exponent (H). This measure is suppressed during physiological and psychological distress and was thus hypothesized to be reduced in individuals with post-COVID syndrome, with greatest reductions among those with persistent headache. Resting-state blood oxygenation level-dependent (BOLD) functional magnetic resonance imaging data were collected for 57 individuals who had COVID-19 (32 with no headache, 14 with ongoing headache, 11 recovered) and 17 controls who had cold and flu-like symptoms but tested negative for COVID-19. Individuals were assessed an average of 4-5 months after COVID testing, in a cross-sectional, observational study design. No significant differences in H values were found between non-headache COVID-19 and control groups., while those with ongoing headache had significantly reduced H values, and those who had recovered from headache had elevated H values, relative to non-headache groups. Effects were greatest in temporal, sensorimotor, and insular brain regions. Reduced H in these regions was also associated with decreased BOLD activity and local functional connectivity. These findings provide new insights into the neurophysiological mechanisms that underlie persistent post-COVID headache, with reduced BOLD scaling as a potential biomarker that is specific to this debilitating condition.

THU454 Paget’s Disease Of Bone As An Atypical Cause Of Headaches

Abstract Disclosure: A.N. Delgado Nieves: None. C. Gomez Hernandez: None. R. Nassar: None. P.A. Goulden: None. Background: Worsening Paget’s disease of bone (PDB) typically manifests as pelvic or spine bone pain. Headache as a primary presenting symptom of PDB is uncommon. Case Presentation: A 54-year-old female with Paget’s disease on alendronate presented at our institution with progressively worsening headaches, frontal bossing, alkaline phosphatase (ALP) of 1,668 U/L, and serum C-telopeptide of 986 pg/mL, indicating active disease. Subsequently, a bone scan confirmed active PDB, and zoledronic acid injection was administered in clinic. When re-evaluated, repeat laboratory values showed an ALP of 191 U/L, serum C-telopeptide of 511 pg/mL, PTH of 103 pg/mL, and vitamin D of 25.6 ng/mL, consistent with improved yet persistently active disease. Likewise, the patient complained of ongoing headaches, dizziness, hearing loss, and jaw pain. An X-ray of the skull showed diffuse expansile mixed Paget's disease, predominantly sclerotic, involving the calvarium with some basilar invagination noted. Subsequent whole-body bone scan showed intensely increased uptake in the skull. Audiology evaluation revealed slight to mild sensorineural hearing loss in bilateral ears. A second dose of zoledronic acid infusion was administered, and the patient’s ALP and C-telopeptide decreased to normal levels. Conclusion: We describe a case of advanced Paget’s disease presenting with persistent headaches. Clinicians should identify Paget’s disease as an atypical cause of headaches to provide appropriate treatment and prevent complications of skull involvement such as hearing loss. Presentation: Thursday, June 15, 2023

P04 A case of zoledronate-induced ANCA associated vasculitis

Abstract Introduction Bisphosphonates are a well-established treatment for osteoporosis and other metabolic bone disorders. In up to 40% of recipients, infusion is associated with a transient cytokine-mediated acute-phase response. It has been hypothesised that this can rarely cause autoimmune reactions, with case reports linking bisphosphonate infusion to the development of giant cell arteritis (GCA), urticarial vasculitis and dermatomyositis. In this report, we describe a case of ANCA associated vasculitis (AAV) with 3rd nerve palsy, finger joint synovitis, fevers and cough, preceded by zoledronate infusion. To our knowledge, this is the first description of a zoledronate-induced AAV. Case description A 75-year-old lady with a background of ulcerative colitis and gout was referred to rheumatology for the management of osteoporosis after sustaining a left neck of femur fracture. A decision was made to commence zoledronate treatment. Within a few hours of receiving zoledronate, the patient began to feel unwell with fevers, vomiting, headache, and general malaise. Within 24 hours of the infusion she developed pain, stiffness and swelling to the small joints of her hands with fatigue, mild intermittent cough without breathlessness, and ongoing headaches. The initial impression was that she had developed a side effect to zoledronate which would be self limiting and she was treated with over the counter analgesics. Two weeks later she remained symptomatic and bloods showed a newly raised CRP of 29 and ESR of 18. Rheumatoid factor, ANA and CCP were negative. Her joint symptoms settled with a short course of oral prednisolone, which was prescribed for a possible diagnosis of zoledronate-induced inflammatory osteoarthritis. By this point, her chest symptoms had completely resolved. Four weeks after the zoledronate infusion, the patient developed a sudden onset 3rd nerve palsy, headache, eye pain and tingling to her face whilst in Prague. CRP was 1 and PR3 was strongly positive (131.5). MRI brain did not show any inflammation. She was treated with intravenous methylprednisolone for 6 days and her symptoms improved. On return to the UK, she was seen by rheumatology, ophthalmology, and neurology teams. Examination showed a resolving 3rd nerve palsy, without features of retinal vasculitis or any systemic symptoms, likely due to an AAV. She has continued on oral prednisolone and her symptoms have resolved. Her bloods show a down trending PR3 (131.5 to 23.7). Discussion Although zoledronate is generally well-tolerated, up to 40% of patients develop transient flu-like symptoms after infusion. Commonly reported symptoms include fever, chills, muscle and joint pains and headache. These symptoms are thought to be due to a transient acute-phase response mediated by pro-inflammatory cytokines. Symptoms generally reach their peak during the first two days post-infusion, with a rapid decrease in frequency after 3 days. In our case, the patient described many features in keeping with the well-described acute-phase response. Atypically, her symptoms were more persistent than usual with joint pain and swelling lasting for 2 weeks and an associated rise in inflammatory markers. Following an initial improvement in symptoms with oral prednisolone, our patient developed sudden-onset 3rd nerve palsy. Investigations were in keeping with AAV and the patient responded well to corticosteroid therapy. Although the literature is sparse, case reports and series have suggested a rare link between zoledronate and the development of autoimmune disease in patients with pre-existing risk factors . In these patients, it has been hypothesised that the acute phase response can trigger autoimmunity, however further work is needed to understand the underlying pathophysiology. Existing literature suggests that zoledronate can trigger a range of autoimmune pathology. Narkovits et al described six patients who developed a new-onset or an exacerbation of known autoimmune disease within 3 months of zoledronate infusion. These included new-onset rheumatoid arthritis, polymyalgia rheumatica and autoimmune haemophilia with other patients reporting flares of pre-existing Crohn’s disease. Some case reports have described the development of vasculitis secondary to zoledronate. Swarnkar et al, 2021, reported a case of zoledronate induced biopsy-confirmed urticarial vasculitis and there have been two case reports of GCA possibly triggered by zoledronate (Naderi, 2019 and Metyas et at, 2014). To our knowledge, there have been no other reports of zoledronate induced AAV. Key learning points Zoledronate infusion is associated with a proinflammatory acute phase response in up to 40% of recipients. The most common symptoms include fevers, joint pain and swelling, gastrointestinal symptoms including abdominal pain, diarrhoea, nausea and vomiting and general features including fatigue, dizziness, headache and malaise. Very rarely, zoledronate is associated with eye symptoms including pain and scleritis. There have been case reports linking zoledronate infusion to the development of autoimmune and autoinflammatory disease, including vasculitis. Although further work is needed to fully understand this association, clinicians should be aware of these rare reactions in order for rapid diagnosis and prompt management. In this case, zoledronate-associated AAV responded effectively to conventional therapies with corticosteroids.

Ost-COVID-19 Syndrome - case report

Background: Coronaviruses are enveloped RNA viruses that are widely distributed among humans and other mammals and birds causing respiratory, enteric, liver, and neurological diseases. At the end of December 2019, a group of patients with pneumonia of unknown etiology were registered, where a new virus called SARS-CoV-2 was later presented, and the disease it causes, COVID-19. The main clinical manifestations of this virus are fever, dry cough, dyspnea and acute respiratory stress. Many subjects have mild symptoms, such as headache, non-productive cough, fatigue, myalgia, and anosmia. The recovery time from this disease and the reasons why the sequelae it leaves vary so much between patients is still unknown. Symptoms and clinical manifestations after SARS-CoV-2 / COVID-19 infection have appeared in many survivors and are similar to those of fatigue after Severe Acute Respiratory Syndrome. The most commonly reported symptoms are fatigue, anxiety, joint pain, ongoing headache, chest pain, dementia, depression, and dyspnea. The NICE guideline defines post-COVID-19 syndrome as the set of signs and symptoms that develop during or after an infection compatible with COVID-19 that continues for more than 12 weeks and is not explained by an alternative diagnosis. Post-COVID-19 syndrome has the characteristic that its symptoms cause a disability, which is why it generates a great impact on the individual, the care, and rehabilitation units. Purpose: The objective of this report is to present a clinical case of a patient with the post-COVID-19 syndrome and its management. Materials and methods: This is a 57-year-old female patient, with a previous history that in June 2021 began with a clinical picture consisting of asthenia, adynamia, anosmia, ageusia, headache, myoarthralgia, nausea, cough chest and lumbar pain, for which the PCR test for SARS-CoV-2 was performed, which was positive, his clinical picture worsened at home, for which he consulted an emergency service in the city of Palmira, Valle del Cauca (Colombia). Subsequently, they conclude through paraclinical SARS-CoV-2 infection plus bacterial pneumonia due to Klebsiella pneumoniae, for which she is transferred to the hospitalization room and treatment with antibiotics is started, however, At the beginning of July, the patient maintained hemodynamic and ventilatory stability, without cardiovascular support, but still with minimal ventilatory support, with oximetry goals, so it was decided to start the gradual withdrawal of sedatives in favor of spontaneous modes of mechanical ventilation. On July 6, the patient tolerates extubation with the transition to non-invasive mechanical ventilation and a decision was made to transfer to hospitalization. Then, on July 15, a patient was seen in acceptable general conditions, with support even by nasal cannula, on physical examination with attenuated vesicular murmur with declining rales, for which it was decided to discharge. Results: Currently, the patient manifests 15 symptoms 4 months after her discharge from the clinic. Conclusions: The post-COVID-19 patient must have an individual and comprehensive rehabilitation, which takes into account their needs, since this syndrome varies from person to person, it must be an early rehabilitation so as not to decrease the functionality of the patient, and does not deteriorate their physical or mental health. The great challenge identified in the midst of the pandemic is that work must be done to build an improved and strengthened health system, where true integration and coordination between levels of care, primary care, and hospital care is achieved.

Glymphatic System Dysfunction: A Novel Mediator of Sleep Disorders and Headaches.

Sleep contributes to the maintenance of overall health and well-being. There are a growing number of patients who have headache disorders that are significantly affected by poor sleep. This is a paradoxical relationship, whereby sleep deprivation or excess sleep leads to a worsening of headaches, yet sleep onset also alleviates ongoing headache pain. Currently, the mechanism of action remains controversial and poorly understood. The glymphatic system is a newly discovered perivascular network that encompasses the whole brain and is responsible for removing toxic proteins and waste metabolites from the brain as well as replenishing nutrition and energy. Recent studies have suggested that glymphatic dysfunction is a common underlying etiology of sleep disorders and headache pain. This study reviews the current literature on the relationship between the glymphatic system, sleep, and headaches, discusses their roles, and proposes acupuncture as a non-invasive way to focus on the glymphatic function to improve sleep quality and alleviate headache pain.

Study to assess existing knowledge of headache disorders among registered osteopaths practising in the UK: A cross-sectional survey

BackgroundHeadache disorders are highly prevalent worldwide. Many headache sufferers search for answers outside medical and pharmaceutical models. Complementary and alternative medicine (CAM) including osteopathy are widely used by headache patients. Indeed 9% of patients consulting osteopaths do so for headaches. There is no existing assessment of headache knowledge among practising Osteopaths in the UK. MethodsThis study was a cross-sectional survey employing an anonymous online questionnaire. An original questionnaire was developed. The scope was based on established guidelines in the primary care setting. Multiple choice and closed-ended questions assessed knowledge of the diagnostic criteria, potential red flags and appropriate investigations. The answers were informed by the International Classification Headache Disorder (ICHD-3) and the British Association for the Study of Headaches (BASH) guidelines. Three case vignettes relevant to osteopathic practice were included. Participants were invited to give optional free text feedback. The questionnaire was open to be self-completed by participants for 30 days. ResultsThere were 398 responders of which 383 were included and all of whom completed the questionnaire. The study found areas where knowledge was good, areas where it was limited and areas of uncertainty. The mean knowledge score was 6.93 out of 10 (range 2.18–9.42). There was a significantly lower mean knowledge score in those who had no prior headache education of −0.716 with a difference in means (−1.075 to −0.353, 95% C.I.) compared to those with prior education. Gender and years qualified had no significant effect on mean knowledge score. Optional free text feedback was given by 81 (21.2%) of the respondents and analyzed. The main themes were acknowledgment of knowledge gaps and a desire for more headache education. ConclusionThe findings suggest there are gaps in the existing knowledge on headache among UK osteopaths and the extent of this is dependent on prior headache education. We propose that ongoing headache education among osteopaths is needed in the field.

Öncesinde Asemptomatik Olan Subdural Higroma İle Seyreden Spontan Araknoid Kist Rüptürü: Olgu Sunumu

Aim: Spontaneous rupture of an arachnoid cyst resulting in a subdural hygroma is an infrequent event. We report an adult patient who had no previous neuroimaging and had acute onset headache, dizziness, and nausea unrelated to trauma.&#x0D; &#x0D; Case: A 67-year-old male patient was brought to the emergency service complaints of sudden onset of dizziness, headache, and vomiting while working in the garden. He described ongoing nausea and headache localized to the frontal region. Brain CT imaging was planned for the patient whose nausea and dizziness worsened while his symptomatic treatment continued. In the brain CT, a large hypodense extracerebral collection was detected in the area starting from the middle fossa in the right cerebral hemisphere and extending to the convexity level in the frontoparietal region. The patient was consulted in the neurosurgery unit. Surgical intervention was not considered, and the patient was admitted to the neurosurgery service for treatment. Due to the asymptomatic course in the service follow-ups, he was discharged with outpatient clinic control recommendations.&#x0D; &#x0D; Conclusion: This case illustrates the importance of recognizing the possibility of spontaneous rupture of an arachnoid cyst. This phenomenon should be considered as a differential diagnosis in patients without head trauma. Although it is rare, being aware of such a case is helpful in preventing possible bad outcomes.

Hypersensitivity to calcitonin gene-related peptide in chronic migraine.

To investigate if calcitonin gene-related peptide infusion induces migraine-like attacks in chronic migraine patients. Fifty-eight patients with chronic migraine, either with or without headache on the experimental day, were assessed for the incidence of migraine-like attacks after an intravenous infusion with calcitonin gene-related peptide 1.5 µg/min over 20 min. The primary endpoint was the incidence of migraine-like attacks after calcitonin gene-related peptide. Exploratory endpoints were the association between the incidence of migraine-like attacks and presence of headache on the experimental day, and headache frequency in the past month. Migraine-like attack data was compared to a historic cohort of 91 episodic migraine patients without headache on the experimental day. Total tenderness score, pressure-pain threshold and supra-threshold pressure pain at baseline were investigated in relation to incidence of migraine-like attacks and presence of headache on the experimental day. In total, 83% of the 58 chronic migraine patients developed migraine-like attacks after calcitonin gene-related peptide infusion. Migraine-like attacks were found in 92% of chronic migraine patients with headache on the experimental day compared to 65% of chronic migraine patients without headache on the experimental day (p = 0.035). No differences were observed in total tenderness score and pressure-pain threshold between chronic migraine patients with and without headache on the experimental day. The incidence of migraine-like attacks following calcitonin gene-related peptide in chronic migraine patients without headache (65%) was equal to the historic cohort of 91 episodic migraine patients without headache (67%) on the experimental day. Chronic migraine patients are hypersensitive to calcitonin gene-related peptide. The potency of calcitonin gene-related peptide as a migraine inductor is increased in chronic migraine patients with ongoing headache. We suggest that calcitonin gene-related peptide, besides being a migraine trigger also acts as a modulator of nociceptive transmission in the trigeminal system.

Headache: A striking prodromal and persistent symptom, predictive of COVID-19 clinical evolution.

ObjectiveTo define headache characteristics and evolution in relation to COVID-19 and its inflammatory response.MethodsThis is a prospective study, comparing clinical data and inflammatory biomarkers of COVID-19 patients with and without headache, recruited at the Emergency Room. We compared baseline with 6-week follow-up to evaluate disease evolution.ResultsOf 130 patients, 74.6% (97/130) had headache. In all, 24.7% (24/97) of patients had severe pain with migraine-like features. Patients with headache had more anosmia/ageusia (54.6% vs. 18.2%; p < 0.0001). Clinical duration of COVID-19 was shorter in the headache group (23.9 ± 11.6 vs. 31.2 ± 12.0 days; p = 0.028). In the headache group, IL-6 levels were lower at the ER (22.9 (57.5) vs. 57.0 (78.6) pg/mL; p = 0.036) and more stable during hospitalisation. After 6 weeks, of 74 followed-up patients with headache, 37.8% (28/74) had ongoing headache. Of these, 50% (14/28) had no previous headache history. Headache was the prodromal symptom of COVID-19 in 21.4% (6/28) of patients with persistent headache (p = 0.010).ConclusionsHeadache associated with COVID-19 is a frequent symptom, predictive of a shorter COVID-19 clinical course. Disabling headache can persist after COVID-19 resolution. Pathophysiologically, its migraine-like features may reflect an activation of the trigeminovascular system by inflammation or direct involvement of SARS-CoV-2, a hypothesis supported by concomitant anosmia.

Association of Intranasal and Neurogenic Dural Inflammation in Experimental Acute Rhinosinusitis.

BackgroundNasal cavity and sinus disorders, such as allergic rhinitis, rhinosinusitis, or certain anatomical defects, are often associated with transient or ongoing headaches. On the other hand, migraine headache patients often exhibit pain referral over the area of nasal sinuses and typical nasal autonomic symptoms involving congestion and rhinorrhea. Mechanism for convergence of nasal or sinus disorders and headaches is unknown. Herein, we examined the association of sino-nasal inflammatory pain with common preclinical indicators of trigeminovascular system activation such as dural neurogenic inflammation (DNI) and neuronal activation in brainstem nociceptive nuclei.MethodsNasal and paranasal cavity inflammation and pain was induced by formalin (2.5%/10 μl) or capsaicin (0.1%/10 μl) instillation at the border of maxillary sinus and nasal cavity in rats. Quantification of inflammation of nasal mucosa and DNI was performed by spectrophotometric measurement of Evans blue - plasma protein complex extravasation. Pain behavior was quantified by rat grimace scale (RGS). Nociceptive neuronal activation in caudal part of spinal trigeminal nucleus (TNC) was assessed by c-Fos protein immunohistochemistry.ResultsCapsaicin and formalin administered into rat nasal cavity increased plasma protein extravasation in the nasal mucosa and dura mater. Intensity of plasma protein extravasation in nasal mucosa correlated with extravasation in dura. Similarly, facial pain intensity correlated with nociceptive neuronal c-Fos activation in the TNC.ConclusionPresent data show that inflammatory stimuli in deep nasal and paranasal structures provoke distant intracranial changes related to trigeminovascular system activation. We hypothesize that this phenomenon could explain overlapping symptoms and comorbidity of nasal/paranasal inflammatory disorders with migraine.

Trampoline Training Trauma: A Diver's Injury

HISTORY: A 15 year old male presented to the emergency department with back pain after sustaining an injury while practicing a diving routine on the trampoline. He was in forward rotation when he landed awkwardly on his chin and upper chest, sending his back into hyperextension with his legs landing above his head. He felt immediate low back pain and complete loss of sensory and motor function of his legs for about 30 seconds. All sensory and motor function subsequently returned and he was able to ambulate from the trampoline into the home. He denied ongoing sensory or motor deficits in his legs, loss of consciousness, neck pain, urinary or bowel incontinence, or upper extremity weakness. PHYSICAL EXAMINATION: Examination revealed a well appearing male who was able to ambulate slowly but independently with normal gait. He had midline tenderness in the upper lumbar vertebrae. There was normal alignment of the spine without step offs. His strength was 5/5 and reflexes were 2+ in lower extremities. He did not have deficits to touch sensation and did not have saddle anesthesia. DIFFERENTIAL DIAGNOSES: 1. Spinal cord contusion 2. Lumbar vertebral fracture 3. Lumbar sprain 4. Acute spondylolysis or spondylolisthesis 5. Lumbosacral neurapraxia TESTS AND RESULTS: Xray of cervical spine, chest, and pelvis: unremarkable CT cervical spine: unremarkable MRI cervical-thoracic-lumbar: - traumatic injury of the lumbar spine with disruption of the interspinous ligament at the L1-L2 level - small ventral extradural hematoma contained by the posterior longitudinal ligament at L2-L4 MRI lumbar spine, hospital day #2: - decrease in size and cradiocaudal extent of the ventral extradural collection - edema within psoas and paraspinal muscles at L2-L4 FINAL DIAGNOSIS: Extradural hematoma of lumbar spine at L2-L4 Tear of interspinous ligament at L1-L2 TREATMENT AND OUTCOMES: 1. Admission to PICU for close neurologic monitoring with neurosurgery and trauma on consult. He did not report further numbness or tingling in lower extremities 2. Physical therapy 3. Stepped down to general pediatric floor on hospital day #2 4. Discharged on hospital day #3 with lumbar sacral orthosis brace 5. Experienced ongoing headaches for several weeks 6. Back to activity as tolerated, continue to monitor recovery.

27-Year-Old Woman With Fever, Headache, and Anemia

27-Year-Old Woman With Fever, Headache, and Anemia

Development and validation of a model predicting post-traumatic headache six months after a motor vehicle collision in adults

ImportanceThe prognosis of post-traumatic headache is poorly understood. ObjectiveTo develop and validate a prognostic model to predict the presence of post-traumatic headache six months after a traffic collision in adults with incident post-traumatic headache. DesignSecondary analyses of adults with incident post-traumatic headache injured in traffic collisions between November 1997 and December 1999 in Saskatchewan, Canada (development cohort); and between January 2004 and January 2005 in Sweden (validation cohort). SettingThe Saskatchewan cohort (development) was population-based (N = 4162). The Swedish cohort (validation) (N = 379) were claimants from two insurance companies covering 20 % of cars driven in Sweden in 2004. ParticipantsAll adults injured in traffic collisions who completed a baseline questionnaire within 30 days of collision. Excluded were those hospitalized >2 days, lost consciousness >30 min, or reported headache <3/10 on the numerical rating scale. Follow-up rates for both cohorts were approximately 80 %. PredictorsBaseline sociodemographic, pre-injury, and injury factors. OutcomeSelf-reported headache pain intensity ≥3 (numerical rating scale) six months after injury. ResultsBoth cohorts were predominantly female (69.7 % in Saskatchewan, 65.2 % in Sweden), with median ages 35.9 years (Saskatchewan), and 38.0 years (Sweden). Predictors were age, work status, headache pain intensity, symptoms in arms or hands, dizziness or unsteadiness, stiffness in neck, pre-existing headache, and lower recovery expectations. With a positive score (i.e., ≥0.75 probability), the model can rule in the presence of post-traumatic headache at six months (development: specificity = 99.8 %, 95 % CI 99.5 %–99.9 %; sensitivity = 1.6 %, 95 % CI 1.0 %–2.6 %; positive likelihood ratio (LR+) = 8.0, 95 % CI 2.7−24.1; negative likelihood ratio (LR-) = 1.0, 95 % CI 1.0−1.0; validation: specificity = 95.5 %, 95 % CI 91.1 %–97.8 %; sensitivity = 27.2 %, 95 % CI 20.4 %–35.2 %); LR+ = 6.0, 95 % CI 2.8−13.2; LR- = 0.8, 95 % CI 0.7−0.8). Conclusions and relevanceClinicians can collect patient information on the eight predictors of our model to identify patients that will report ongoing post-traumatic headache six months after a traffic collision. Future research should focus on selecting patients at high risk of poor outcomes (using our model) for inclusion in intervention studies, and determining effective interventions for these patients.

P36 Never say never: two cases of PET-CT negative but biopsy proven giant cell arteritis

Abstract Background Giant cell arteritis (GCA) usually affects the temporal arteries but can result in systemic vasculitis that can be seen on Positron Emission Tomography-Computed Tomography (PET-CT). Currently PET-CT is not used first line to diagnose cranial-GCA and temporal artery biopsy (TAB) remains the most common investigation to assess for this. There have been few studies performed to assess the use of PET-CT as an initial diagnostic tool in cranial-GCA. One study performed PET-CT for suspected GCA in their cohort of 64 patients. They found, when compared with TAB, global GCA assessment by PET-CT had a sensitivity of 92%, specificity of 85%, positive predictive value of 61% and negative predictive value of 98%. They concluded PET-CT had good diagnostic accuracy when compared with TAB and can be used as a first-line test to assess for GCA and rule out lower-risk GCA. Another study used PET-CT in steroid-naïve patients and also showed a high accuracy (sensitivity 64% and specificity of 100%) in diagnosing cranial artery inflammation. Methods We present two cases where the patient had symptoms of headache, constitutional symptoms and raised inflammatory markers, however PET-CT did not suggest GCA. The patients were subsequently re-referred later with ongoing symptoms and TAB confirmed GCA. Results Case 1: A 71-year-old woman presented with a one-month history of intermittent right sided headache and rigors. Her inflammatory markers were elevated (CRP of 115mg/L and ESR of 57mm/hr). Suspecting GCA, prednisolone 30mg od was commenced. Upon rheumatology review, it was felt her symptoms were atypical for GCA. Prednisolone was discontinued, and a PET-CT scan was arranged. This was performed ten days later and did not show any features of vasculitis. Six weeks later, the patient presented to ophthalmology reporting visual aura, ongoing headache with elevated inflammatory markers. Prednisolone 60mg od was commenced and a TAB was arranged. This was reported as partially treated GCA. Case 2: A 73-year-old gentleman had a prolonged admission for pyrexia of unknown origin. Headache was present throughout admission and rheumatology opinion was sought. A PET-CT did not show vasculitis. The patient was discharged when pyrexia improved however his inflammatory markers remained consistently high (CRP of 82mg/L and ESR 106mm/hr). One-month post-discharge, the patients GP contacted rheumatology concerned about ongoing headache and scalp tenderness. Prednisolone 40mg od was commenced and a TAB was arranged which reported features consistent with GCA. Both patients responded well to steroids. Conclusion As demonstrated, patients with biopsy proven GCA do not always exhibit vasculitis on imaging. A negative PET-CT did not reliably exclude GCA in our patients suggesting its use as a diagnostic investigation for GCA needs to be approached with caution. A TAB should also be performed when there is ongoing suspicion of GCA. Disclosures S. Khalid None. J. Maxwell Honoraria; BMS, Pfizer, Lilly, Abbvie. Other; Talks, BMS, Pfizer, Lilly, Abbvie.

Cryptococcal meningitis and immune reconstitution inflammatory syndrome in a pediatric patient with HIV after switching to second line antiretroviral therapy: a case report

BackgroundCryptococcal meningitis (CCM) is a common and deadly disease among HIV-infected patients. Notable about CCM is its association with the immune reconstitution inflammatory syndrome (IRIS). Though it has been posited a switch from first to second-line antiretroviral therapy (ART) can induce CCM IRIS, a case presentation of CCM IRIS has not been published.Case presentationA 10-year-old, HIV-infected girl who initially presented with severe headache and new-onset seizures, with cerebrospinal fluid that returned antigen, India Ink, and culture positive for Cryptococcus neoformans. Notably, 8 weeks prior to seizures, she had switched from first line to second-line ART (abacavir-lamivudine-efavirenz to zidovudine-lamivudine-lopinavir/ritonavir) due to virologic failure, with a viral load of 224,000 copies/milliliter. At time of seizures and 8 weeks on second-line ART, her viral load had reduced to 262 copies/milliliter.Her hospital course was prolonged, as she had ongoing headaches and developed bilateral cranial nerve VI palsies despite clearance of Cryptococcus from cerebrospinal fluid on antifungal therapy and therapeutic lumbar punctures. However, symptoms stabilized, and she was discharged with oral fluconazole. Cranial nerve palsies resolved 10 weeks post discharge and she has remained disease free.ConclusionsWe describe a case of CCM IRIS in a 10-year-old HIV infected child after changing to second-line ART. This case provides evidence that screening for cryptococcal antigenaemia prior to switch from first-line to second-line ART could be an important measure to prevent cryptococcal disease.

Headache in Petrous Apicitis: A Case Report of Chronic Migraine‐like Headache Due to Peripheral Pathology

To report a case of petrous apicitis that manifested as chronic migraine without aura and to discuss the pathophysiological mechanisms behind this presentation. Petrous apicitis is a rare complication of acute otitis media with varied clinical presentations that stem from the close proximity of the petrous apex to numerous neurovascular structures. Headache is among the common symptoms of petrous apicitis. A case of new onset headache in the setting of petrous apicitis with symptomatic response to antibiotic therapy was reported. We provided a brief review of peripheral pathophysiological mechanisms of migraine and correlated to mechanism of headache in petrous apicitis. A 65-year-old man with chronic otitis externa/media presented with ongoing headache fulfilling International Classification of Headache Disorders 3rd edition (ICHD-3) criteria for chronic migraine without aura that persisted despite undergoing right mastoidectomy and tympanoplasty with multiple courses of oral antibiotic therapy for his chronic otitis. MRI brain revealed petrous apicitis, otomastoiditis, and clival osteomyelitis. His imaging findings improved and his migraine-like headache completely resolved after treatment with a prolonged course of antibiotics. Petrous apicitis can present as a headache with features of migraine, and in this case in particular, as chronic migraine without aura. The pathophysiological mechanisms that may underlie the generation of migraine-like headache in petrous apicitis may include the activation of nociceptive fibers within the periosteum of the petrous apex and clivus whose cell bodies originate in the trigeminal ganglion and upper cervical dorsal root ganglia. By treating the peripheral pathology, resolution of the headache may be achieved.

Headaches in Idiopathic Intracranial Hypertension.

Headache is the most common symptom of idiopathic intracranial hypertension (IIH) and may not resolve with intracranial pressure-lowering treatments. Many patients with IIH have a pre-existing history of migraine. Approximately two-thirds of patients with IIH continue to experience headaches after the other manifestations of the disorder resolve. There are no evidence-based guidelines for treating IIH-related headaches. This review proposes mechanisms by which IIH produces both acute and ongoing headache. The article analyzes the literature regarding medical and procedural therapies for IIH, apropos to their effectiveness for treating headaches. It then proposes strategies to use in clinical practice, incorporating treatments used for the primary headache disorders of migraine and tension-type headache, the most common phenotypes of IIH-associated headache. Treatments used to manage primary headache disorders may be effective in the management of IIH-associated headache, although none have been specifically studied in this condition. Recommendations provided consider a holistic approach to the problem based on existing guidelines and clinical experience.