Severe Headache Research Articles

Reversible cerebral vasoconstriction syndrome post-cardiac transplantation: a therapeutic dilemma: case report

BackgroundReversible cerebral vasoconstriction syndrome (RCVS) is characterized by diffuse, multifocal segmental narrowing of cerebral arteries and can result in ischaemic stroke. Causal factors, identified in 60% of cases, include immunosuppressant pharmacotherapy. The few reports following heart transplantation are almost all in Asian recipients. We report on a Caucasian Australian patient with immunotherapy induced RCVS post heart transplantation to highlight the state of knowledge of the condition and the treatment dilemma it poses.Case presentationA 51-year-old female underwent orthotopic heart transplantation at our institution. Induction immunotherapy comprised basiliximab, mycophenolate mofetil and methylprednisolone. On day 6 post-transplantation the patient was transitioned to oral prednisolone and tacrolimus. On day 7 the patient began to experience bilateral, severe, transient occipital and temporal headaches. On day 9 tacrolimus dose was up-titrated. A non-contrast computed tomography brain (CTB) was normal. Endomyocardial biopsy on day 12 demonstrated moderate Acute Cellular Rejection (ACR), which was treated with intravenous methylprednisolone. That evening the patient experienced a 15-minute episode of expressive dysphasia. The following morning she became confused, aphasic, and demonstrated right sided neglect and right hemianopia. A CT cerebral perfusion scan demonstrated hypoperfusion in the left middle cerebral artery (MCA) territory and cerebral angiography revealed widespread, focal multi-segmental narrowing of the anterior and posterior circulations. A diagnosis of RCVS was made, and nimodipine was commenced. As both steroids and tacrolimus are potential triggers of RCVS, cyclosporin replaced tacrolimus and methylprednisolone dose was reduced. A further CTB demonstrated a large left MCA territory infarct with left M2 MCA occlusion. The patient made steady neurological improvement. She was discharged 34 days post-transplantation with mild residual right lower limb weakness and persistent visual field defect on verapamil, cyclosporine, everolimus, mycophenolate mofetil and prednisolone.ConclusionReversible cerebral vasoconstriction syndrome is rare after orthotopic heart transplantation. Until now, RCVS has been almost exclusively described in Asian recipients, and is typically caused by immunotherapy. The condition may lead to permanent neurological deficits, and in the absence of definitive treatments, early recognition and imaging based diagnosis is essential to provide the opportunity to remove the causal agent(s). Co-existent ACR, can pose unique treatment difficulties.

Pituitary Apoplexy: a re-appraisal of risk factors and best management strategies in the COVID-19 era.

Pituitary apoplexy (PA) is a clinical syndrome caused by acute hemorrhage and/or infarction of the pituitary gland, most commonly in the setting of a pituitary macroadenoma. PA generally presents with severe headache, nausea, vomiting, visual disturbance, and, in more severe cases, altered mental status. Many factors have been attributed to the risk of developing PA, including most recently, numerous reports showcasing an association with COVID-19 infection or vaccination. Initial management of PA includes evaluation and correction of deficient hormones and electrolytes and an assessment if surgical decompression to relieve pressure on optic nerves and other brain structures is needed. While prompt recognition and treatment are crucial to avoid morbidity and mortality, in the modern era, PA is less commonly considered a true neurosurgical emergency requiring immediate (< 24h) surgical decompression. Traditionally, surgical decompression has been the standard of care for significant mass effects. However, several studies have shown similar outcomes in visual and hormonal recovery with either surgical decompression or conservative medical management. Unfortunately, most evidence on optimal management strategies is limited to retrospective case series, small prospective studies, and one multi-center observational study. This review aims to provide the most up-to-date evidence on the role of COVID-19 in PA and best management strategies.

ENPP1 enzyme replacement therapy improves ectopic calcification but does not rescue skeletal phenotype in a mouse model for craniometaphyseal dysplasia.

Craniometaphyseal dysplasia (CMD) is a rare genetic bone disorder, characterized by progressive thickening of craniofacial bones and flared metaphyses of long bones. Craniofacial hyperostosis leads to the obstruction of neural foramina and neurological symptoms such as facial palsy, blindness, deafness, or severe headache. Mutations in ANKH (mouse ortholog ANK), a transporter of small molecules such as citrate and ATP, are responsible for autosomal dominant CMD. Knock-in (KI) mice carrying an ANKF377del mutation (AnkKI/KI ) replicate many features of human CMD. Pyrophosphate (PPi) levels in plasma are significantly reduced in AnkKI/KI mice. PPi is a potent inhibitor of mineralization. To examine the extent to which restoration of circulating PPi levels may prevent the development of a CMD-like phenotype, we treated AnkKI/KI mice with the recombinant human ENPP1-Fc protein IMA2a. ENPP1 hydrolyzes ATP into AMP and PPi. Male and female Ank+/+ and AnkKI/KI mice (n ≥ 6/group) were subcutaneously injected with IMA2a or vehicle weekly for 12wk, starting at the age of 1wk. Plasma ENPP1 activity significantly increased in AnkKI/KI mice injected with IMA2a (Vehicle/IMA2a: 28.15 ± 1.65/482.7 ± 331.2 mOD/min; p <.01), which resulted in the successful restoration of plasma PPi levels (Ank+/+ /AnkKI/KI vehicle treatment/AnkKI/KI IMA2a: 0.94 ± 0.5/0.43 ± 0.2/1.29 ± 0.8μM; p <.01). We examined the skeletal phenotype by X-Ray imaging and μCT. IMA2a treatment of AnkKI/KI mice did not significantly correct CMD features such as the abnormal shape of femurs, increased bone mass of mandibles, hyperostotic craniofacial bones, or the narrowed foramen magnum. However, μCT imaging showed ectopic calcification near basioccipital bones at the level of the foramen magnum and on joints of AnkKI/KI mice. Interestingly, IMA2a treatment significantly reduced the volume of calcified nodules at both sites. Our data demonstrate that IMA2a is sufficient to restore plasma PPi levels and reduce ectopic calcification but fails to rescue skeletal abnormalities in AnkKI/KI mice under our treatment conditions.

Hypersensitivity to man-made electromagnetic fields (EHS) correlates with immune responsivity to oxidative stress: a case report

ABSTRACT There is increasing evidence that exposure to weak electromagnetic fields (EMFs) generated by modern telecommunications or household appliances has physiological consequences, including reports of electromagnetic field hypersensitivity (EHS) leading to adverse health effects. Although symptoms can be serious, no underlying mechanism for EHS is known and there is no general cure or effective therapy. Here, we present the case study of a self-reported EHS patient whose symptoms include severe headaches, generalized fatigue, cardiac arrhythmia, attention and memory deficit, and generalized systemic pain within minutes of exposure to telecommunications (Wifi, cellular phones), high tension lines and electronic devices. Tests for cerebral, cardiovascular, and other physiological anomalies proved negative, as did serological tests for inflammation, allergies, infections, auto-immune conditions, and hormonal imbalance. However, further investigation revealed deficits in cellular anti-oxidants and increased radical scavenging enzymes, indicative of systemic oxidative stress. Significantly, there was a large increase in circulating antibodies for oxidized Low-Density Lipoprotein (LDLox), byproducts of oxidative stress accumulating in membranes of vascular cells. Because a known primary effect of EMF exposure is to increase the concentration of cellular oxidants, we propose that pathology in this patient may be causally related to a resulting increase in LDLox synthesis. This in turn could trigger an exaggerated auto-immune response consistent with EHS symptoms. This case report thereby provides a testable mechanistic framework for EHS pathology with therapeutic implications for this debilitating and poorly understood condition.

Microsurgical clipping of large MCA aneurysm in a 2-month-old child.

Cerebral aneurysms in children have a low incidence and accounts for less than 4% of all cerebral aneurysms. These aneurysms have been linked to various factors. Severe headache, seizures, and motor-sensory deficits are common presentations. We describe the case of a 2-month-old male patient who presented with generalized tonic-clonic seizures for 4days. At the hospital, he was stabilized with ventilatory support, sedation, and antiepileptic drugs. A NCCT (Head) showed intraparenchymal hemorrhage in the left fronto-parieto-temporal lobe and subarachnoid hemorrhage. Subsequently a CT angiogram revealed an aneurysm of the left M3 segment of MCA. Successfully, the patient underwent microsurgical clipping of aneurysm and evacuation of hematoma. Pediatric cerebral aneurysms differ from their adult counterparts, mainly in their etiology and evolution. As per literature, aneurysmal clipping and neurological endovascular therapy have shown similar results.

Insights Into the Patient Experience of Hormone Therapy for Early Breast Cancer Treatment Using Patient Forum Discussions and Natural Language Processing.

Understanding the real-world experience of patients with early breast cancer (eBC) is imperative for optimizing outcomes and evolving patient care. However, there is a lack of patient-level data, hindering clinical development. This social listening study was performed to understand patient insights into symptoms and impacts of hormone therapy (HT) for eBC using posts from patient forums on breastcancer.org to inform future clinical research. Natural language processing (NLP) and machine learning techniques were used to identify themes related to eBC from a sample of 500,000 posts. After relevant data selection, 362,074 eBC posts were retained for further analysis of symptoms and impacts related to HT, as well as insights into symptom severity, pain locations, and symptom management using exercise and yoga. Overall, 32 symptoms and nine impacts had significant associations with ≥one HT. Hot flush (relative risk [RR], 6.70 [95% CI, 3.36 to 13.36]), arthralgia (RR, 6.67 [95% CI, 3.53 to 12.59]), weight increased (RR, 4.83 [95% CI, 3.20 to 7.28]), mood swings (RR, 7.36 [95% CI, 5.75 to 9.42]), insomnia (RR, 4.76 [95% CI, 3.14 to 7.22]), and depression (RR, 3.05 [95% CI, 1.71 to 5.44]) demonstrated the strongest associations. Severe headache, dizziness, back pain, and muscle spasms showed significant associations with ≥one HT despite their low overall prevalence in eBC posts. The social listening approach allowed the identification of real-world insights from posts specific to eBC HT from a large-scale online breast cancer forum that captured experiences from a uniquely diverse group of patients. Using NLP has a potential to scale analysis of patient feedback and reveal actionable insights into patient experiences of treatment that can inform the development of future therapies and improve the care of patients with eBC.

Progress and recognition of idiopathic intracranial hypertension: A narrative review.

Idiopathic intracranial hypertension (IIH) mainly affects obese young women, causing elevated intracranial pressure, headaches, and papilledema, risking vision loss and severe headaches. Despite weight loss as the primary treatment, the underlying mechanisms remain unclear. Recent research explores novel therapeutic targets. This review aimed to provide a comprehensive understanding of IIH's pathophysiology and clinical features to inform pathogenesis and improve treatment strategies. Recent publications on IIH were searched and summarized using PubMed, Web of Science, and MEDLINE. The review highlights potential pathomechanisms and therapeutic advances in IIH. IIH incidence is rising, with growing evidence linking it to metabolic and hormonal disturbances. Early diagnosis and treatment remain challenging.

Reversible Cerebral Vasoconstriction and Vertebral Artery Dissection Presenting as Positional Headache

Positional headache refers to a headache that worsens or improves with changes in posture. It is often secondary in nature, associated with various pathologies that may have serious consequences if left undiagnosed or untreated. The authors report a patient who complained of severe positional headache and was diagnosed with concurrent reversible cerebral vasoconstriction syndrome and vertebral artery dissection, thus highlighting the importance of considering such conditions in a patient with postural headaches.

Prophylactic Cyproheptadine to Control Paroxysmal Hemicrania Attacks: A Preliminary Investigation.

Paroxysmal hemicrania (PH) is a severe short-lasting headache usually localized around the eye. It might occur in conjunction with ipsilateral autonomic manifestations of trigeminal nerve stimulation. PH responds well to indomethacin treatment; however, considering the adverse effects of indomethacin, its long-term use is a matter of question and investigations about other prophylactic medications are going on, but they are inconclusive. The current study aims to investigate the efficacy of prophylactic use of cyproheptadine to control PH symptoms. The current clinical trial was conducted on 20 children diagnosed with PH undergoing prophylactic treatment with cyproheptadine syrup at a dosage of 0.2-0.4 mg/kg twice daily for a period of 3 months. The duration, frequency, and severity of headaches were assessed at baseline and then monthly for 3 months. Significantly shorter duration, less frequency, and less severity of headaches were observed in the postintervention assessments of the patients (P < 0.001). The effect size analysis showed that the greatest effect of the treatment was on the intensity of the headache (effect size: 0.866) and the least effect was on duration of the headache (effect size: 0.775). Drowsiness (5%) and increased appetite (30%) were the only adverse effects of treatment with cyproheptadine. Findings of this study showed that short-term prophylactic cyproheptadine in divided doses of 0.2-0.4 mg/kg could appropriately improve PH in terms of frequency, duration, and the intensity of the attacks. Nevertheless, further investigations are strongly recommended.

Visual inspection versus spectrophotometry for xanthochromia detection in patients with sudden onset severe headache-A diagnostic accuracy study.

There is still disagreement about whether to routinely use spectrophotometry to detect xanthochromia in cerebrospinal fluid (CSF) or whether visual inspection is adequate. We aimed to evaluate the diagnostic accuracy of these methods in detecting an aneurysmal subarachnoid hemorrhage in patients with sudden onset severe headache. When a patient presents to the emergency department with a headache for which there is suspicion of a subarachnoid hemorrhage, the gold standard to rule this out is to perform a CSF analysis for xanthochromia with or without spectrophotometry if the cranial non-contrast computed tomography (CT) upon admission is negative. Having applied the gold standard, we retrospectively included patients with acute headache who underwent both CT scan and CSF spectrophotometry at our hospital in the period 2002-2020. Patients were excluded if the cranial CT was interpreted as positive, there was a bloody CSF, or if visual assessment data of the CSF was unavailable. We scrutinized the patients' medical records and evaluated the benefit of spectrophotometry compared to visual inspection. The net bilirubin absorbance cut-off for support of subarachnoid hemorrhage was set at >0.007 absorbance units. The spectrophotometry was also considered positive if the net bilirubin absorbance was ≤0.007 and net oxyhemoglobin absorbance was ≥0.1 absorbance units. We calculated and compared the sensitivity and specificity of CSF spectrophotometry and visual inspection of the CSF. In total, 769 patients, with a mean age of 42.3 ± (standard deviation [SD] = 17.3) years, were included. The headache onset was classified as a thunderclap headache in 41.5%, and 4.7% had a sudden loss of consciousness. Fifteen patients (2%) were finally diagnosed with a subarachnoid hemorrhage, six (0.8%) had an aneurysmal subarachnoid hemorrhage, seven (0.9%) had a perimesencephalic hemorrhage, one (0.1%) had a cortical cerebral sinus venous thrombosis, and one (0.1%) had a spinal epidural hematoma. Four patients (0.5%) had a subarachnoid hemorrhage that was not detected by visual inspection, and two were caused by an aneurysmal rupture. One of these two patients died just before intervention, and the other underwent coiling for an anterior communicating aneurysm. The number needed for lumbar puncture to detect a subarachnoid hemorrhage was 51, but 128 to detect an aneurysmal hemorrhage. The corresponding numbers needed for CSF spectrophotometric analysis were 192 and 385, respectively. Spectrophotometry was positive in 31 patients (4.0%), of whom 18 (2.3%) also had visually detected xanthochromia (11 true positive). The mean net bilirubin absorbance in the 13 samples with visually clear CSF was 0.0111 ± (SD = 0.0103) absorbance units, compared to 0.0017 ± (SD = 0.0013) in the CSF with negative spectrophotometry. The corresponding figures for net oxyhemoglobin absorbance were 0.0391 ± (SD = 0.0522) versus 0.0057 ± (SD = 0.0081). The sensitivity of spectrophotometric xanthochromia detection was 100% (95% confidence interval [CI], 78-100), compared to 73% (95% CI, 45-92) for visual xanthochromia detection. The specificity of spectrophotometric xanthochromia detection was 98% (95% CI, 97-99) compared to 99% (95% CI, 98-100) for visual xanthochromia detection. Both methods had high negative predictive values: 100% (95% CI, 99.5-100) versus 99.5% (95% CI, 98.6-99.9), respectively. Both visual inspection and spectrophotometry have high diagnostic accuracy for detecting CSF xanthochromia, but the lower sensitivity of visual assessment makes it unreliable, and we recommend the use of spectrophotometry in clinical practice.

Curing of chronic hepatitis C combined with coronavirus disease 2019 in a couple over 85 years old: a case series study.

Data on the management of patients aged more than 85 years with chronic hepatitis C virus (HCV) and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) sequential infections are lacking. The current study described the management of an older couple aged more than 85 years with these above-mentioned two diseases treated with 12 weeks of sofosbuvir/velpatasvir (Epclusa®) and 5 days of nirmatrelvir/ritonavir (Paxlovid®) sequentially. The effectiveness and safety profiles were closely monitored during therapy and till 9 months posttreatment. In late March 2023, the husband with the main complaint of repeated gingival bleeding and asymptomatic wife were 86 and 85 years old, and had HCV RNA levels of 91,800 and 6,630,000 IU/mL, respectively. On the fourth day of sofosbuvir/velpatasvir treatment, the husband had a moderate headache, and the wife had severe headache and moderate fever and dizziness. We then found that their SARS-CoV-2 test results were positive. After careful consideration, the expert panel decided to treat the couple with oral nirmatrelvir/ritonavir (300 mg/100 mg, twice daily) beginning on the fifth day of sofosbuvir/velpatasvir treatment for 5 days. During the 5 days of nirmatrelvir/ritonavir treatment, the patient's symptoms and signs gradually improved, and the patient was negative for SARS-CoV-2 RNA on the fifth day of nirmatrelvir/ritonavir therapy. Meanwhile, the husband's HCV RNA was not detectable after one week of sofosbuvir/velpatasvir treatment till posttreatment month 9, and his ALT level was normal beginning at week 1 of sofosbuvir/velpatasvir treatment. Moreover, the wife's HCV RNA was not detectable after week 4 of sofosbuvir/velpatasvir treatment till posttreatment month 9. Notably, no other symptoms or signs occurred during the treatment or follow-up period, and other serum biochemical parameters remained stable until 9 months after the discontinuation of sofosbuvir/velpatasvir treatment. The older couple aged more than 85 years with chronic HCV and SARS-CoV-2 sequential infection were safely cured by the sofosbuvir/velpatasvir and nirmatrelvir/ritonavir sequential treatment. This study suggested that old age should not be a barrier to HCV/SARS-CoV-2 treatment. Given that the proportion of older HCV-infected patients is increasing, clinical trials of direct-acting antiviral agents should include older HCV-infected individuals.

Neuropsychiatric Manifestations, As a Rare Presentation of Venous Sinus Thrombosis Two Weeks After Cesarean Section: First Report in the Gambia

Cerebral venous sinus thrombosis (CVST) is a rare and potentially fatal condition, accounting for about 0.5% of all cerebrovascular disease cases globally. It is challenging to diagnose due to its rarity and diverse clinical presentations that can mimic other acute neurological conditions [1]. The reported worldwide incidence of CVST during pregnancy and postpartum is approximately 3 to 4 cases per million, with superior sagittal sinus thrombosis (SSST) being the most prevalent type. Risk factors include the prothrombotic state of pregnancy in the third trimester, obesity, accidental dural puncture, deficiencies in protein C and S, antiphospholipid syndrome, and the use of oral contraceptives among others. Symptoms typically manifest within the first three weeks postpartum, with severe headache being the most common complaint. The low number of reported cases in sub-Saharan Africa suggests underdiagnosing or underreporting, with infection being the primary cause in this region. We report a case at our facility who, two weeks after a cesarean section, presented with severe headache, confusion, irritability, restlessness, and later developed a focal motor deficit. Imaging studies were crucial in diagnosing SSST and ruling out other conditions causing acute brain injury. This is the first reported case in The Gambia, and one of the few described in West Africa related to an obstetric procedure. The onset, characterized by neuropsychiatric symptoms, is unusual and interesting, as these manifestations are less common than the typical headache, seizure, and focal motor deficit described in the literature.

The effect of P2X7 antagonism on subcortical spread of optogenetically-triggered cortical spreading depression and neuroinflammation

Migraine is a neurological disorder characterized by episodes of severe headache. Cortical spreading depression (CSD), the electrophysiological equivalent of migraine aura, results in opening of pannexin 1 megachannels that release ATP and triggers parenchymal neuroinflammatory signaling cascade in the cortex. Migraine symptoms suggesting subcortical dysfunction bring subcortical spread of CSD under the light. Here, we investigated the role of purinergic P2X7 receptors on the subcortical spread of CSD and its consequent neuroinflammation using a potent and selective P2X7R antagonist, JNJ-47965567. P2X7R antagonism had no effect on the CSD threshold and characteristics but increased the latency to hypothalamic voltage deflection following CSD suggesting that ATP acts as a mediator in the subcortical spread. P2X7R antagonism also prevented cortical and subcortical neuronal activation following CSD, revealed by bilateral decrease in c-fos positive neuron count, and halted CSD-induced neuroinflammation revealed by decreased neuronal HMGB1 release and decreased nuclear translocation of NF-kappa B-p65 in astrocytes. In conclusion, our data suggest that P2X7R plays a role in CSD-induced neuroinflammation, subcortical spread of CSD and CSD-induced neuronal activation hence can be a potential target.

Sociodemographic and Health Characteristics of Hispanic Veteran Patients With Traumatic Brain Injury and Its Association to Mortality: A Pilot Study.

Traumatic brain injury (TBI) is among the most common conditions in the military. VA Caribbean Healthcare System (VACHS) patients with Traumatic Brain Injury (TBI) have a higher mortality rate than Veterans in other VA health care systems in the United States. The main goal of this study was to develop sociodemographic profiles and outline health characteristics of Hispanic patients with TBI treated at the VA Caribbean Healthcare System in a search for potential explanations to account for the higher mortality rate. This study advocates for equity in health services provided for minorities inside the militia. Data collected from electronic medical records and VA databases were used to create sociodemographic and health characteristics profiles, in addition to survival models. The population of the study were post 911 Veteran soldiers who had been diagnosed with TBI. Adjusted models were created to provide hazard ratios (HR) for mortality risk. Out of the 16,549 files available from all 10 selected VA sites, 526 individuals were identified as treated at the VACHS. Of 526 subjects screened, 39 complied with the inclusion/exclusion criteria. Results include: 94.4% male, 48.7% between the ages of 21 and 41 years, 89.7% have depression, 66.7% have post-traumatic stress disorder (PTSD), 82.1% receive occupational therapy, 94.9% have severe headaches, 100% suffer from pain, 94.9% have memory problems, and 10.3% have had suicidal thoughts. Over 60% had a first-hand explosion experience, be it just the explosion or with another type of injury. Data showed that 33% of our patients had a Magnetic Resonance Imaging (MRI), 31% had a CT, 15.4% had a SPECT, and 2.6% had PET scan. Significant associations were found between MRIs and speech therapies, and MRIs and total comorbidities. The Cox proportional-hazards model for survival adjusted for age, gender, race/ethnicity, and comorbidities shows that VACHS Veterans diagnosed with a TBI had a higher mortality risk rate (HR 1.23 [95% CI 1.10, 1.37]) when compared to the other 9 health centers with the highest percentage of Hispanic Veterans. Since explosions were the most common mechanism of injury, further research is needed into the experiences of Veterans in connection with this specific variable. A high percentage of the patients suffered from depression and PTSD. Additionally, over half of the patients had an unmeasured TBI severity. The effects these aspects have on symptomatology and how they hinder the recovery process in Hispanic patients should be examined in further detail. It is also important to highlight that family and friends' support could be key for injury treatment. This study highlights the use of the 4 types of scans (MRI, CT, PET/CT, and SPECT/CT) as ideal diagnosis tools. The alarming number of patients with suicidal thoughts should be a focus in upcoming studies. Future studies should aim to determine whether increased death rates in TBI Veterans can be linked to other United States islander territories. Concepts, such as language barriers, equal resource allocation, and the experiences of Veterans with TBIs should be further explored in this Veteran population.

Intraventricular hemorrhage secondary to ruptured arteriovenous malformation: A case report

Introduction: An arteriovenous malformation (AVM) is a lesion in which the feeding artery and the draining vein are connected by a coiled, tortuous vascular link. This nidus is where arteriovenous shunting occurs. While pediatric AVM is uncommon, there has been evidence of possible impairments and an increased risk of hemorrhage. This study aimed to elaborate on a rare case of pediatric arteriovenous malformation with intraventricular hemorrhage. Case report: A male patient, fifteen years of age, was referred from P hospital due to a severe headache that was accompanied by nausea and vomiting two days prior to hospital admission. Chief Computed Tomography Digitizing and Angiographic Images In the left lateral ventricle, the posterior horn of the right lateral ventricle, the third ventricle, and the left pericallosal area AVM (Spletzer Martin grading: 2), intraventricular hemorrhage (IVH), and moderate cerebral edema were all seen during an angiography. AVM was managed conservatively with head positioning 30o, analgesics, and ranitidine. Phenytoin was given as a precaution for seizure in intracerebral hemorrhage. The headache improved gradually during the hospital stay. Upon follow-up at the outpatient clinic, headache and other neurological symptoms were absent, and the patient had typical vital signs. Conclusion: AVM rupture can cause IVH that occurs more often in young patients. Management of pediatric AVM requires discussion among pediatric neurologists, neurosurgeons, and interventional radiologists to decide the best care for the patient. AVM patients who received conservative treatment had a higher risk of bleeding and, therefore, required routine monitoring.

Migraine: pathophysiology, evaluation, and management

Migraine is a common long term primary headache disorder characterized by recurrent bouts of moderate to severe headaches. Migraine attacks can be debilitating with significant functional disability. Research has identified key mechanisms and triggers in migraine pathophysiology which has enabled development of promising new targets in migraine management. There are many therapeutic options in the treatment of migraine and the choice of treatment should be geared to the patient needs and co-morbidities.

Acute morphological changes of impending rupture of vertebral artery dissection: clinical management of symptomatic but unruptured vertebral artery dissection. Illustrative case.

The reported actual risk of rupture for vertebral artery dissection (VAD) in patients presenting with headache is very low, ranging from 0.4% to 1.0%. The authors report a case in which the dissection site dilated rapidly within several hours after the dissection occurred resulting in subarachnoid hemorrhage (SAH). A 49-year-old healthy man who had participated in a marathon noticed a headache while running. Magnetic resonance imaging (MRI) performed 2 days later revealed no findings suspicious for right VAD, but a string sign was observed in the left side, suggesting left VAD. Three hours following MRI, he developed severe headaches and became unconscious at home, prompting emergency services to rush him to the hospital. A computed tomography scan showed diffuse SAH and a rapidly enlarged aneurysmal dilatation in the right vertebral artery. He underwent endovascular internal trapping to prevent rebleeding. He was discharged without any neurological symptoms. No recurrence or new dissection occurred after 2 years of follow-up. Even in the absence of typical imaging findings, strict management, such as blood pressure control, is required when clinical findings strongly suggest VAD, and differentiation of VAD from primary headache is important. https://thejns.org/doi/10.3171/CASE24202.

Three-month treatment outcome of medication-overuse headache according to classes of overused medications, use of acute medications, and preventive treatments

Medication overuse headache (MOH) is a chronic headache disorder that results from excessive use of acutely symptomatic headache medications, leading to more frequent and severe headaches. This study aims to assess the 3-month treatment outcomes in MOH patients, focusing on the types and usage of overused medications, as well as preventive treatments. This prospective cross-sectional study analyzed the treatment outcomes of 309 MOH patients from April 2020 to March 2022. Patients were advised to discontinue overused medications immediately and offered preventive treatments based on clinical judgment. Data on headache characteristics, medication use, and impact on daily life were collected at baseline and 3 months. Results showed overall significant improvements in headache-related variables in patients completing the 3-month treatment follow-up. The median number of headache days per month decreased from 15 days at baseline to 8 days after 3 months (p < 0.001). Patients who overused multiple drug classes demonstrated increased disability levels (mean Headache Impact Test-6 score: 62 at baseline vs. 56 at 3 months, p < 0.01). Those who continued overusing medications reported more days of severe headache (mean 18 days at baseline vs. 14 days at 3 months, p < 0.05) and greater impact (mean Migraine Disability Assessment score: 35 at baseline vs. 28 after 3 months, p < 0.05) compared to the baseline. Differences in headache outcomes were evident across different preventive treatment groups, with generalized estimating equation analyses highlighting significant associations between clinical characteristics, overused medication classes, and preventive treatments. Most MOH clinical features significantly improved after 3 months of treatment. However, notable interactions were observed with certain clinical presentations, suggesting possible influences of overused medication classes, usage patterns, and preventive treatment types on MOH treatment outcomes. This study underscores the importance of individualized treatment strategies and the potential benefits of discontinuing overused medications.

Role of calcitonin gene-related peptide (CGRP) receptor antagonist in acute and preventive treatment of migraine.

Migraine is the most common neurological disease in the world. It is characterized by recurrent attacks of severe headaches of a one-sided, throbbing nature, often accompanied by sensory and motor disturbances and generally associated with nausea and increased sensitivity to light and sound. Migraine treatment can be divided into emergency treatment and preventive treatment, which aims to reduce the overall frequency and severity of attacks. In the first case, nonsteroidal anti-inflammatory drugs (NSAIDs) can be used, but in some patients they do not have the desired effect. The gold standard in the fight against migraine pain are triptans (selective serotonin 5-HT1 receptor agonists), although they too are not effective in all patients. Current understanding suggests that CGRP plays a significant role in the pathophysiology of migraines. Evidence supporting this includes increased CGRP levels during migraine attacks, causing inflammation and activation of other pathophysiological processes responsible for pain. The hope for patients are CGRP receptor antagonists, which greatly expand therapeutic options.

Acute headache with a twist

This case report follows the events of a 36-year-old woman who presented to a hospital five days post-partum with an acute severe headache and vomiting. Despite a normal initial computed tomography (CT) head scan, a CT venogram was done due to neurological deterioration and revealed hydrocephalus secondary to subarachnoid haemorrhage (SAH). We discuss the role of CT imaging in the diagnosis of SAH, the risks of current guidelines for lumbar puncture (LP) and describe other important differential diagnoses for headache in the postpartum patient.