Secondary Headache Disorders Research Articles

Current understanding of pineal gland structure and function in headache.

The pineal gland plays an important role in biological rhythms, circadian and circannual variations, which are key aspects in several headache disorders. Melatonin, the main pineal secreting hormone, has been extensively studied in primary and secondary headache disorders. Altered melatonin secretion occurs in many headache syndromes. Experimental data show pineal gland and melatonin both interfere in headache animal models, decreasing trigeminal activation. Melatonin has been shown to regulate CGRP and control its release. Melatonin has been used successfully as a treatment for migraine, cluster headaches and other headaches. There is a rationale for including the pineal gland as a relevant brain structure in the mechanisms of headache pathophysiology, and melatonin as a treatment option in primary headache.

Secondary Headaches During Pregnancy: When to Worry.

Headaches in pregnancy are a frequent cause of worry for both patients and healthcare providers. Physiological changes during this period increase the risk of a number of secondary headache disorders, and often also have an impact on primary headache disorders. This article reviews recent research into distinguishing worrisome vs non-worrisome headache presentations during pregnancy. Recent research suggests that secondary causes of headache are highly prevalent during pregnancy, in between 25 and 42.4% of women seeking medical attention. Secondary causes of headache in pregnancy are most commonly homeostatic disturbances and hypertensive disorders of pregnancy, vascular problems, space-occupying lesions, and infections. Migraine itself also increases the risk of hypertensive disorders of pregnancy. Specific red flags for a secondary cause of headache in pregnancy include absence of any headache history, more severe pain, systemic features such as elevated blood pressure, and abnormal laboratory tests including thrombocytopenia or thrombocytosis, elevated liver function tests, elevated C-reactive protein, or proteinuria, in addition to traditional red flags, such as a change in headache pattern. Secondary causes of headache are common in women seeking medical attention during pregnancy. Red flags for secondary causes of headache during pregnancy may be remembered with the mnemonic PREGNANT HA (proteinuria, rapid onset, elevated blood pressure or temperature, gestational age in third trimester, neurological signs or symptoms, altered level of consciousness, no headache history or known history of a secondary headache disorder, thrombocytopenia or thrombocytosis, high liver function tests or CRP, or agonizingly severe pain). Increased education of patients and their providers may help improve selection of patients for workup of a secondary cause.

Occipital Neuralgia and Cervicogenic Headache: Diagnosis and Management

Occipital neuralgia (ON) and cervicogenic headache (CGH) are secondary headache disorders with occipital pain as a key feature. Due to significant phenotypic overlap, differentiating ON and CGH from primary headache disorders such as migraine or tension-type headache, or other secondary headache disorders, can be clinically challenging. This article reviews the anatomy, clinical features, unique diagnostic considerations, and management approaches relating to ON and CGH. Conservative therapeutic approaches are considered first-line. Anesthetic nerve blocks may have a dual role in both supporting diagnosis and providing pain relief. Newer minimally invasive procedures, such as pulsed radiofrequency (PRF) and occipital nerve stimulation (ONS), represent an exciting therapeutic avenue for severe/refractory cases. Surgical interventions should be reserved for select patient populations who have failed all other conservative and minimally invasive options, to be weighed against potential risk. ON and CGH represent an ongoing diagnostic challenge. Further studies are required to consolidate efficacy regarding the comprehensive management of ON and CGH.

An Approach to Identifying Headache Patients That Require Neuroimaging.

Headache is one of the most common clinical scenarios faced by a neurologist or neurologist in training. However, the decision process on when to complete neuroimaging can be difficult in clinical practice. This article focuses on a well-organized and evidence-based approach to identify patients with headache that require neuroimaging and will lend confidence to the clinician faced with these scenarios in clinical practice. The approach includes neuroimaging in episodic migraine, chronic migraine, identifying secondary headache disorders in clinic and the emergency department, and discusses pitfalls to over imaging. The article concludes with a flowchart to summarize an overall clinical approach.

The Hypertensive Headache: a Review.

The purpose of this review is to provide an overview and update on the common causes of headache attributed to arterial hypertension with a focus on secondary headache disorders. We will also highlight uncommon and recent findings in this area of research. There is some controversy in the relationship between chronic hypertension and headache, particularly migraine; recent research suggests that there may be a link, but it is likely complex and multifactorial. Many recent studies and case reports demonstrate that the pathophysiology underlying the onset of headache as it relates to abrupt rises in blood pressure seems to lie at the cellular level and mechanically becomes an issue with disruption of the blood-brain barrier. Although not a formally defined headache entity, carotid revascularization syndrome demonstrates this phenomenon and also has a recent set of proposed criteria that include headache and elevated blood pressure. This paper reviews the various etiologies of hypertensive headaches, mostly in regard to headache as a secondary symptom of elevated blood pressure. We will also discuss trends of hypertensive headache in pregnancy. Finally, we will touch on controversy that exists in relation to chronic hypertension and its causal relationship to headache as well as the relationship between hypertension and migraine.

MIGRAINE;

Objectives: To determine the various patterns of headache presenting to Neurology OPD Liaquat University Hospital Jamshoro/Hyderabad. Study Design: Descriptive, cross-sectional study. Setting: Department of Neurology, Liaquat University of Medical & Health Sciences (LUMHS). Period: July to December 2016. Methods: Data was collected on developed profoma, the same was analyzed on SPSS 22nd version. Results: Out of 238 patients, 61 (25.6%) were male 177 (74.4%) were female patients. Age group distribution of study population ranged from 04 - 65 years with mean age was 31.66 with standard deviation of12.72. Out of 238 patients 170 (71.4%) were diagnosed as primary headache disorders, 56 (17%) were secondary headache while 12 (%) were labeled as cranial neuropathies and facial pains. Migraine without aura 113(65.3%) followed by tension type headache 35(20.2%) were most common primary headache disorder. Among secondary headaches Cervicogenic headache 16(30.2%) was most common cause followed by headache secondary to sinusitis, hypertension and trauma 8(15.1%), 7 (13.2%) and 6(11.3%) respectively. Trigeminal Neuralgia 9 (75.0%) was most common painful cranial neuropathies. Conclusion: Primary as well as secondary headache disorders are most prevalent in female at an age range of 21-40 years with majority of them suffering from migraine followed by tension and Cervical origin respectively.

The IASP classification of chronic pain for ICD-11: chronic secondary headache or orofacial pain.

This article describes chronic secondary headache and chronic orofacial pain (OFP) disorders with respect to the new International Classification of Diseases (ICD-11). The section refers extensively to the International Classification of Headache Disorders (ICHD-3) of the International Headache Society that is implemented in the chapter on Neurology in ICD-11. The ICHD-3 differentiates between primary (idiopathic) headache disorders, secondary (symptomatic) headache disorders, and OFP disorders including cranial neuralgias. Chronic headache or OFP is defined as headache or OFP that occurs on at least 50% of the days during at least 3 months and lasting at least 2 hours per day. Only chronic secondary headache and chronic secondary OFP disorders are included here; chronic primary headache or OFP disorders are listed under chronic primary pain syndromes that have been described in a companion publication. The subdivisions of chronic secondary OFP of ICHD-3 are complemented by the Diagnostic Criteria for Temporomandibular Disorders and contributions from the International Association for the Study of Pain Special Interest Group on Orofacial and Head Pain and include chronic dental pain. The ICD-11 codes described here are intended to be used in combination with codes for the underlying diseases, to identify patients who require specialized pain management. In addition, these codes shall enhance visibility of these disorders in morbidity statistics and motivate research into their mechanisms.

Trigeminal autonomic cephalalgias: The impersonators

Orofacial pain disorders are highly prevalent and debilitating conditions involving the head, face, and neck. Headache is the most common complaint reported to dental and medical practitioners, which manifests as a myriad of neuro-ophthalmologic symptoms, including orbital pain, disturbances of vision, aura, photophobia, lacrimation, conjunctival injection, ptosis, and other manifestations. The differential diagnosis is extensive and includes both primary and secondary headache disorders. The similarity in clinical presentation and diagnostic features is a challenge to the clinicians because of two facts: (a) the orofacial region is complex and (b) pain can arise from many sources. The term “trigeminal autonomic cephalalgias (TACs)” includes a group of headache disorders characterized by moderate-to-severe, short-lived head pain in the trigeminal distribution, with accompanying unilateral cranial parasympathetic autonomic features, such as lacrimation, rhinorrhea, conjunctival injection, eyelid edema, and ptosis. TACs include cluster headache (CH), paroxysmal hemicrania (PH), short-lasting unilateral neuralgiform headache attacks, and hemicrania continua. They are grouped on the basis of their shared clinical features of unilateral headache of varying durations and ipsilateral cranial autonomic symptoms. TACs are rare with the prevalence rate of <1%. The peculiarity of these conditions is their similar clinical presentation and overlapping features. A sound knowledge of TACs is essential for proper diagnosis. Moreover, multidisciplinary approaches for the management of these conditions are strongly recommended. Hence, the aim of this article is to provide an overview of trigeminal autonomic cephalalgias.

Headache after Delivery, a Misleading Presentation of Sheehan's Syndrome: A Case Report

Post dural puncture is one of the most common causes of postpartum headache. Other causes are benign primary headache disorders (migraine, tension-type headache) and secondary headache disorders such as stroke, ischaemia or pituitary apoplexy and venous sinus thrombosis. Headache in the new mother after delivery, mandates a differential diagnosis because it is not appropriate to focus only on the most common diseases, such as post dural puncture headache. In this report we discuss a case of postpartum headache with delayed cause diagnosis in complicated labour and delivery.

Chapter 28 - Headache in the elderly

Headache is the most common neurologic symptom and affects nearly half the world's population at any given time. Although the prevalence declines with age, headache remains a common neurologic complaint among elderly populations. Headaches can be divided into primary and secondary causes. Primary headaches comprise about two-thirds of headaches among the elderly. They are defined by clinical criteria and are diagnosed based on symptom pattern and exclusion of secondary causes. Primary headaches include migraine, tension-type, trigeminal autonomic cephalalgias, and hypnic headache. Secondary headaches are defined by their suspected etiology. A higher index of suspicion for a secondary headache disorder is warranted in older patients with new-onset headache. They are roughly 12 times more likely to have serious underlying causes and, frequently, have different symptomatic presentations compared to younger adults. Various imaging and laboratory evaluations are indicated in the presence of any "red flag" signs or symptoms. Head CT is the procedure of choice for acute headache presentations, and brain MRI for those with chronic headache complaints. Management of headache in elderly populations can be challenging due to the presence of multiple medical comorbidities, polypharmacy, and differences in drug metabolism and clearance.

Migraine Headache: Diagnosis and Current and Emerging Preventive Treatments.

Migraine is associated with considerable pain and disability. Accurate diagnosis that differentiates migraine from other primary and secondary headache disorders is needed, and clinicians should assess the patient's risk of progressing to chronic migraine. Many patients will benefit from preventive treatment. Clinicians must know how to identify these patients and be familiar with the numerous preventive treatments. Finally, clinicians must select the safest, most effective treatment while keeping in mind individual characteristics such as coexisting conditions and patient preferences.

Red and orange flags for secondary headaches in clinical practice: SNNOOP10 list.

A minority of headache patients have a secondary headache disorder. The medical literature presents and promotes red flags to increase the likelihood of identifying a secondary etiology. In this review, we aim to discuss the incidence and prevalence of secondary headaches as well as the data on sensitivity, specificity, and predictive value of red flags for secondary headaches. We review the following red flags: (1) systemic symptoms including fever; (2) neoplasm history; (3) neurologic deficit (including decreased consciousness); (4) sudden or abrupt onset; (5) older age (onset after 65 years); (6) pattern change or recent onset of new headache; (7) positional headache; (8) precipitated by sneezing, coughing, or exercise; (9) papilledema; (10) progressive headache and atypical presentations; (11) pregnancy or puerperium; (12) painful eye with autonomic features; (13) posttraumatic onset of headache; (14) pathology of the immune system such as HIV; (15) painkiller overuse or new drug at onset of headache. Using the systematic SNNOOP10 list to screen new headache patients will presumably increase the likelihood of detecting a secondary cause. The lack of prospective epidemiologic studies on red flags and the low incidence of many secondary headaches leave many questions unanswered and call for large prospective studies. A validated screening tool could reduce unneeded neuroimaging and costs.

Narrative Review of the Pathophysiology of Headaches and Photosensitivity in Mild Traumatic Brain Injury and Concussion.

The most common symptom of post-concussive syndrome (PCS) is post-traumatic headache (PTH) accompanied by photophobia. Post-traumatic headache is currently categorized as a secondary headache disorder with a clinical phenotype described by its main features and resembling one of the primary headache disorders: tension, migraine, migraine-like cluster. Although PTH is often treated with medication used for primary headache disorders, the underlying mechanism for PTH has yet to be elucidated. The goal of this narrative literature review is to determine the current level of knowledge of these PTHs and photophobia in mild traumatic brain injury (mTBI) in order to guide further research and attempt to discover the underlying mechanism to both symptoms. The ultimate purpose is to better understand the pathophysiology of these symptoms in order to provide better and more targeted care to afflicted patients. A review of the literature was conducted using the databases CINAHL, EMBASE, PubMed. All papers were screened for sections on pathophysiology of PTH or photophobia in mTBI patients. Our paper summarizes current hypotheses. Although the exact pathophysiology of PTH and photophobia in mTBI remains to be determined, we highlight several interesting findings and avenues for future research, including central and peripheral explanations for PTH, neuroinflammation, cortical spreading depolarization and the role of glutamate excitotoxicity. We discuss the possible neuroanatomical pathways for photophobia and hypothesize a possible common pathophysiological basis between PTH and photophobia.

Nerve blocks in paediatric and adolescent headache disorders.

Headaches in children and adolescents are common, causing debilitating symptoms in many. Treatment of headache disorders can be complex and standard lifestyle changes as well as oral medications may offer inadequate relief. The purpose of this article is to review the mechanism of action, efficacy and technique of peripheral nerve blocks (PNBs) and the role they play in treating paediatric headache disorders. Evidence for the use of PNBs in youth is limited. However, available studies show evidence of benefit in both primary and secondary headache disorders. Variability exists in the type of block, medication choice, volume infused and frequency of this treatment. There are no serious side effects associated with PNBs. PNBs are well tolerated and effective as adjunctive therapy for many disabling paediatric headache disorders. The technique can be easily learned by frontline and specialty practitioners. Prospective placebo-controlled studies are needed to determine how to best maximize PNBs for headache management (i.e. medication choice, timing and so on).

Headaches Through a Woman's Life.

Headaches affect women across their life span, with menses, pregnancy, and menopause being times that pose unique challenges in diagnosis and treatment. The correct diagnosis and treatment of headache can prevent unnecessary interventions, the worsening of chronic headache disorders, and complications of secondary headaches. The objective of this article is to educate women's health care providers about the diagnosis, differential diagnosis, and treatment of headache during menses, pregnancy, the puerperium, and menopause to improve the quality of care for women with chronic and acute headache. Current articles were reviewed addressing headache during menses, pregnancy, the postpartum period, and menopause. Articles with the highest level of evidence were compiled in this article to provide a summary of recommendations. Multiple diagnostic and therapeutic options for chronic and acute headache are available for women regardless of their stage in life or comorbidities. The effects of headaches span a woman's life span, with puberty and menopause being times of increased frequency. Pregnancy is an at-risk time for women to develop secondary headache disorders. All women's health care providers should know how to screen for, diagnose, and treat headache at all stages of a woman's life. Effective treatment options are available for acute and chronic headache both during and outside pregnancy.

A Hospital Based Retrospective Study of Acute Postpartum Headache.

To describe acute headache diagnoses in women presenting emergently in the postpartum period and to determine which factors may be associated with secondary vs primary headache. Hormonal, vascular, and procedural factors elevate the risk for both secondary and primary headache disorders in the postpartum period. Differentiating between these can be a diagnostic challenge, particularly among the most severe patients referred for urgent neurological consultation. A single-center retrospective study of consecutive postpartum women age ≥18 years presenting with acute headache to a large urban tertiary-care hospital and receiving neurological consultation. Of 63 women who presented with acute postpartum headache, 17 (27.0%) were diagnosed with a primary headache disorder and 46 (73.0%) were diagnosed with a secondary headache disorder. Migraine comprised the majority of primary headache diagnoses (76.5%). Secondary headache most commonly featured postdural puncture headache (PDPH) (45.7%), postpartum preeclampsia (PEC) (26.1%), and a diverse group of cerebrovascular headache disorders (21.7%). Presentation within 24 hours and lack of side predominance helped to differentiate PDPH from migraine. However, abnormal diagnostic testing was more prevalent in the patients with headache secondary to cerebrovascular disorders/PEC. Nearly three-quarters of postpartum women who present with acute onset headache and receiving neurological consultation are found to have a secondary headache - with nearly half of the secondary headaches attributed to PEC or cerebrovascular headache disorders. The absence of a headache history and a clear PDPH description should prompt strong consideration for neuroimaging to rule out cerebrovascular etiologies of headache as well as close monitoring for signs and symptoms of preeclampsia in women presenting with acute severe postpartum headache.

Hemicrania Continua.

Hemicrania continua (HC) is an indomethacin responsive primary chronic headache disorder which is currently classified as a subtype of trigeminal autonomic cephalalgias (TACs). It is not very uncommon. There are >1000 cases of HC in the literature, and it constitutes 1.7% of total headache in the clinic settings. Misdiagnosis for HC is very common at all clinical settings. A diagnosis of HC is missed even by neurologists and headache specialists. It is characterized by a continuous strictly unilateral headache with superimposed exacerbations. Just like other TACs, exacerbations are associated with cranial autonomic symptoms and restlessness. A large number of patients may have migrainous features (nausea, vomiting, photophobia, and phonophobia) during exacerbations phase. The “key” feature of HC is persistent featureless background headaches. However, patients and physicians may focus only on the exacerbation part. As durations, frequency and associated symptoms of exacerbations are highly variables; it may mimic a large number of primary and secondary headache disorders. Migraine and cluster headache are two most common misdiagnosed conditions. Another specific feature of HC is remarkable repose to indomethacin. A “complete” response to indomethacin is as “sine qua non” for HC. However, a few other medications may also be effective in a subset of HC patients. Various surgical procedures have been tried with mixed results in patients who were intolerant to indomethacin or other drugs.

Experts\u2019 opinion about the pediatric secondary headaches diagnostic criteria of the ICHD-3 beta

BackgroundThe 2013 International Classification of Headache Disorders-3 was published in a beta version to allow clinicians to confirm the validity of the criteria or suggest improvements based on field studies. The aim of this work was to review the Secondary Headache Disorders and Cranial Neuralgias and Other Headache Disorders sections of ICHD-3 beta data on children and adolescents (age 0–18 years) and to suggest changes, additions, and amendments.MethodsSeveral experts in childhood headache across the world applied different aspects of ICHD-3 beta in their normal clinical practice. Based on their personal experience and the available literature on pediatric headache, they made observations and proposed suggestions for the mentioned headache disorders on children and adolescents.ResultsSome headache disorders in children have specific features, which are different from adults that should be acknowledged and considered. Some features in children were found to be age-dependent: clinical characteristics, risks factors and etiologies have a strong bio psychosocial basis in children and adolescents making primary headache disorders in children distinct from those in adults.ConclusionsSeveral recommendations are presented in order to make ICHD-3 more appropriate for use in children.

Headache in Resource-Limited Settings.

This review summarizes the unmet need of headache burden and management in resource-limited settings. It provides a general overview of the nuances and peculiarities of headache disorders in resource-limited settings. The review delivers perspectives and explanations for the emerging burden of both primary and secondary headache disorders. Important discussion on demographic and epidemiologic transition pertinent to low-resource settings is included. A critical analysis of headache disorders is made within the context of growing burden non-communicable disorders in low-resource countries. Challenges are examined and prospective feasible solutions tailored to existing resources are provided to address headache disorders in resource-limited settings. Many low-resource countries are entering into the third epidemiological transition featuring increasing burden of non-communicable disorders of which headache disorders contribute a significant proportion. Exponential population growth involving youthful demographic and massive rural-urban migration is taking place in low-resource countries. Youthful demographic is the natural cohort for primary headache such as migraine. Socioeconomic mobility and lifestyle changes are leading to higher levels of physical inactivity and obesity, both of which are related to headache. Life expectancy is rising in some resource-restricted countries; this increases prevalence of secondary headache attributed to neurovascular causes. Many low-resource countries are still burdened with tropical infectious causes of secondary headache. Health care facilities are primarily designed to respond to infectious epidemic and not to chronic burden such as headache. Many low-resource-restricted settings are plagued by poor and corrupt governance, ill-equipped regimes with malfunctioning health policies, war, and poverty. Many low-resource settings do not have access to generic headache medications such as triptans. Headache training and expertise is low. Healthy lifestyle changes emphasizing on improving regular exercise can be inexpensive method to reducing primary headache burden and its comorbidities (e.g. obesity). Addressing the increasing burden of headache disorders in resource-limited settings is important to avert accrued disability which in turn lowers productivity and socioeconomic performance in a young booming population.

Primary Headache Disorders- Part 2: Tension-type headache and medication overuse headache

In Part 2 of Primary Headache disorders, we discuss the fourth Primary Headache Disorder, Tension-Type Headache (TTHA). We are again using the ICHD-III (Beta) definitions of such headaches, taking into consideration episodic and chronic TTHA, as well as the presence or absence of pericranial muscle tenderness. We discuss the pathophysiology and pharmacotherapeutic treatment of TTHA, and the aspects of the Myofascial Pain Syndrome that enhance and help the development of TTHA. We then discuss Medication Overuse Headache (MOH), itself a Secondary headache disorder, but one that is extremely important as it assists with the chronification of both migraine and TTHA. Finally we discuss how to manage and treat those patients with MOH. Chronic migraine, which is TTHA, Migraine as well as, in many patients, MOH, is discussed along with the treatment of this multifaceted disorder.