Unilateral Headache Research Articles

Anaesthetic challenges of coronavirus disease (COVID-19) associated mucormycosis: A case series

During the second wave of COVID -19 Indian subcontinent suffered another pandemic of covid associated mucormycosis (CAM) which further burderned the already overexhausted health care infrastructure. To share our experience of anaesthetic management of eighteen patients with covid associated mucormycosis who underwent surgical resection of necrotized tissues at a tertiary care hospital of North India. : Eighteen patients with COVID-19 infection or previous history of COVID-19 infection based on RT-PCR and histopathologically proven rhino orbital mucormycosis, presented for endoscopic and open surgeries during May and June 2021. According to institutional protocol, institutional ethical committee clearance was not required for a case series. Data regarding the demographic details, clinical manifestations, COVID-19 course, laboratory parameters, imaging reports, pre-operative evaluation, airway management, intraoperative and postoperative management, and complications were collected. Out of eighteen patients 12(66.7%) were male and six (33.33%) were female, with a median age of 51 years. Six patients (33.33%) had a past history of COVID-19, twelve patients had concurrent COVID-19 (66.66%). Most of the patients presented with unilateral facial swelling, retro-orbital pain, ptosis and headache. Fifteen (83.33%) patients had high blood sugars, seven (46.66%) were known type 2 diabetics and eight (53.33%) developed new-onset diabetes after taking prolong systemic corticosteroids. All eighteen patients received antifungal treatment,eight (44.44%)patients had derranged renal function tests with raised serum creatininine (2.4-2.8) and normal blood urea nitrogen. Eight (44.44%) of them had difficult airway because of swelling on face and limited mouth opening, two patients were reoperated (n=2/18). Three (27.27%) patients deveoped arrythmias and ST changes intraoperatively, two(n=2/18) patients were extubated next day after surgery, one patient was tracheostomised in view of preoperative difficult airway and extensive surgery. One fiftyfive year old covid positive female patient died on fifth postoperative day. : In our case series, all 18 patients had covid associated rhino-orbital mucormycosis, most of them had diabetes and hypertension, cerebrovascular accident, coronary artery disease, asthma and post KTP status. Twelve patients were covid positive and 6 had recent history of covid. One patient developed hemiparesis and one patient died because of intracranial extension of mucormycosis. Disseminated or cerebral mucormycosis, severe covid, elderly age group, associated comorbidities like uncontrolled diabetes and renal failure have been found to increases mortality in CAM patients. : Physicians caring for covid associated mucormycosis patients must be aware of the severity of the covid-19 as well as mucormycosis, associated comorbidities and various side effects of the medications used for treatment. Early diagnosis and timely medical and surgical management are necessary to improve outcome in covid associated mucormycosis.

Long-term outcome of cervical artery dissection

ObjectiveThe aim of the study is to evaluate the natural history of extracranial cervical artery dissection (CAD) including comorbidities, symptoms at presentation, recurrence of symptoms, and long-term outcome following different treatment approaches. MethodsA retrospective review of patients treated for acute CAD was performed over a 5-year period from January 2017 to April 2022. ResultsThirty-nine patients were included in the study, 25 (64.1%) with acute internal carotid artery dissection and 14 (35.9%) with acute vertebral artery dissection. Thirty-four patients (87.1%) had spontaneous CAD, and five patients (12.8%) had traumatic CAD. The mean age of the cohort was 54.2 years. The mean time from symptom onset to presentation was 4.34 days. The most common symptoms in internal carotid artery dissection were unilateral weakness (44%), headache (44%), slurred speech (36%), facial droop (28%), unilateral paraesthesia (24%), neck pain (12%), visual disturbance (8%), and Horner’s syndrome (8%). The most common symptoms in vertebral artery dissection were headache (35.7%), neck pain (35.7%), vertigo (28.57%), ataxia (14.28%), and slurred speech (14.28%). The imaging modalities used for diagnosis included computed tomography angiography (48.7%), magnetic resonance angiography (41%), and duplex ultrasound (10.2%). In patients with carotid artery dissection, 57% had severe stenosis, 24% had moderate stenosis, and 20% had mild stenosis. All patients treated were managed conservatively with either anticoagulation or antiplatelets. Long-term clinical follow-up was available for 33 patients (84.6%). Thirty patients (90.9%) reported complete resolution of symptoms, and three patients (9%) reported persistent symptoms. Anatomic follow-up with imaging was available for 17 patients (43.58%). Thirteen patients (76.47%) had complete resolution of dissection, two patients (11.76%) had partial resolution of dissection, and two patients (11.76%) had persistent dissection. There was one death unrelated to CAD in a multi-trauma patient. There were four early recurrent symptoms in the first 3 to 8 weeks post discharge. The mean follow-up time was 308.27 days. ConclusionsThe majority of CADs can be managed conservatively with good clinical and anatomical outcome and low rates of recurrence.

Transient headache and neurological deficits with cerebrospinal fluid lymphocytosis syndrome: A comprehensive systematic review of 93 patients from 57 studies.

Headache with neurologic deficits and cerebrospinal fluid lymphocytosis, previously also termed pseudomigraine with temporary neurologic symptoms and lymphocytic pleocytosis, is a self-limiting syndrome characterized by moderate to severe headache associated with focal neurological deficits occurring in the context of lymphocytosis in the cerebrospinal fluid. As a consequence of its rarity, data regarding headache with neurologic deficits and cerebrospinal fluid lymphocytosis is sparse. Therefore, we conducted this review to analyze data related to 93 patients of headache with neurologic deficits and cerebrospinal fluid lymphocytosis, to characterize their demographics, clinical manifestations, investigations and treatment options. We performed a systematic review of cases reported through PubMed and Google scholar database, using Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol. Keywords used were 'Headache with Neurologic Deficits and cerebrospinal fluid lymphocytosis', 'Headache with neurologic deficits and cerebrospinal fluid lymphocytosis syndrome'. The quality of the included studies was assessed using the Joanna Briggs Institute Critical Appraisal Tool. We analyzed a total of 93 cases of headache with neurologic deficits and cerebrospinal fluid lymphocytosis with a mean age of 28.8 years at onset. Seventy patients (75.2%) were adults, while 23 (24.7%) belonged to the pediatric age group. Comparing these groups, mean age at onset was 32.5 years and 14.3 years, respectively. The average duration of follow-up was 11.08 months. Thirty percent of patients experienced relapsing episodes of headache with neurologic deficits and cerebrospinal fluid lymphocytosis symptoms. The most common type of headache reported was unilateral severe throbbing episodic headache. Other associated symptoms included sensory deficit (60%) and motor deficits (54.8%). The least common symptoms were nystagmus and agraphia, which were reported in one patient each. Antiviral agents were a common treatment option in the acute phase (n = 23 patients [23.6%]), while Flunarizine was the most commonly used agent in the chronic setting (n = 3 patients [3.2%]). While most of the patients had normal brain magnetic resonance imaging, 20 patients had magnetic resonance imaging abnormalities, including (but not limited to) non-specific white matter lesions (eight patients) and meningeal enhancement (six patients). The most common electroencephalographic findings included diffuse and focal slowing. The mean cerebrospinal fluid opening-pressure was 240.5 mmH2O. Cerebrospinal fluid protein was elevated in 59 (63.4%) patients, with a mean value of 114 mg/dL. Two patients in our cohort were found to have cerebrospinal fluid oligoclonal bands. Headache with neurologic deficits and cerebrospinal fluid lymphocytosis tends to affect young individuals with a slight male predominance. Unilateral severe throbbing episodic headache with associated hemi-paresthesia and hemiparesis were the most common symptoms based on our review. Elevated cerebrospinal fluid opening-pressure can be seen in headache with neurologic deficits and cerebrospinal fluid lymphocytosis syndrome. Early recognition of the syndrome is paramount. Antivirals were found to be among the most widely used treatments in the acute setting. Magnetic resonance imaging of the brain is mostly normal. Diffuse and focal slowing were among the most common electroencephalographic findings. Cerebral flow abnormalities on perfusion scans are not uncommon in headache with neurologic deficits and cerebrospinal fluid lymphocytosis. Prospective studies with a larger sample size are needed to validate our findings and guide the clinical care of these patients.

Long-term results of migraine surgery and the relationship between anatomical variations and pain

BackgroundMigraine headache surgery has been recently reported and supported by studies as management to provide long-term relief in migraine sufferers. This study aimed to monitor the long-term results of patients who underwent migraine surgery in our clinic and determine the relationship between pain and anatomical anomalies. MethodsA prospective review was conducted of 93 patients who underwent surgery for migraine headaches performed between 2017 and 2021 by the senior author (M.U.) and had at least 12 months of follow-up. Anatomical data were obtained by recording the findings during surgery. Migraine surgery was performed bilaterally in all patients. Anatomical symmetry differences between the right and left sides were recorded. ResultsA total of 79 (84.9%) patients experienced at least 50% reduction in migraine headache. Furthermore, 13 (14%) patients reported complete elimination of migraine headache. A significant difference was found before and after surgery in Migraine Disability Assessment score, migraine headache index, frequency, duration, and pain (p < 0.001). Also, 30 (32.3%) of the patients had bilateral headaches and 63 (67.7%) had primarily unilateral headaches. Then, 51 (81%) patients with mostly unilateral headache were anatomically asymmetrical and 12 (12%) were anatomically symmetrical. Patients with mostly unilateral headache were found to be anatomically highly asymmetrical (p < 0.005). ConclusionsThis study shows that surgical treatment is effective and long-term protection and has mild complications that are easily tolerated by the patient. The fact that headache side and anatomical asymmetry were significant in this study supports the peripheral mechanism.

A clinical observation of recurrent painful ophthalmoplegic neuropathy in a 49-year old female patient

Recurrent painful ophthalmoplegic neuropathy is a rare clinical syndrome, included into the International Classification of Headache Disorders, 3rd edition, and characterized by recurrent headache episodes associated with dysfunction of one or more ocular motor nerves. The diagnosis implies mandatory exclusion of other potential causes of the symptoms. The paper presents a clinical case of a 49-year old female patient with a unilateral headache paroxysms and subsequent paresis of the oculomotor nerve. A thorough clinical assessment, with neuroimaging (brain magnetic resonance imaging and magnetic resonance angiography of arteries and veins of the head) showed no morphological abnormalities that could cause clinical symptoms of oculomotor neuropathy. Her past history was remarkable for a similar episode of prolonged unilateral headache and oculomotor paresis about 10 years before, which were at that time considered as an acute cerebrovascular accident. Thus, two episodes of similar clinical signs of painful neuropathy, the absence of other possible causes of the disease, and the complete regression of symptoms after treatment (ibuprofen and gabapentin) confirmed the diagnosis of recurrent painful ophthalmoplegic neuropathy.

Headache characteristics to screen for cervicocerebral artery dissection in patients with acute onset unusual headache.

The aim of this preplanned primary analysis was to investigate the clinical manifestations of headache to screen for CAD patients with acute onset headache only. Spontaneous cervicocerebral artery dissection (CAD) with acute onset headache is not rare in clinical practice; however, it is underdiagnosed. On the other hand, subsequent infarction or subarachnoid hemorrhage mainly occurs within 1 week of headache onset. Between April 2017 and January 2022, we conducted a single-center, cross-sectional retrospective study on 197 consecutive referred patients from neurosurgical outpatient clinics with acute onset unusual headache (stronger or longer headache than usual). All patients underwent magnetic resonance imaging to screen for secondary headache and were diagnosed based on the diagnostic protocol. We examined patient background data and the following headache characteristics: distribution, condition at the onset of headache, accompanying vomiting or nausea, worsening headache, and analgesic effects against headache. These factors were analyzed to identify independent diagnostic predictors of CAD. In this study, the rate of missing data was 41% for improvement of headache by analgesia and multiple imputation by chained equations was performed. A total of 93 patients (46 men and 47 women; mean age: 48 years, range: 25-73 years) were diagnosed with CAD. Univariate logistic regression analysis showed CAD was associated with current smoking, systolic blood pressure >140 mmHg, unilateral headache, worsening headache, and no headache improvement by analgesia. Unilateral, worsening headache and no headache improvement by analgesia remained independent diagnostic predictors in multivariable logistic regression after multiple imputation. No headache improvement by analgesia had the highest sensitivity (86%), while worsening headache had the highest specificity (84%). CAD needs to be considered in patients with unilateral, worsening headache and no headache improvement by analgesia.

Ultrasound-Guided Zygomaticotemporal Nerve Block for Refractory Temporal Headaches: A Case Series.

Landmark-guided zygomaticotemporal nerve blocks are a well-described modality to manage headaches in the temporal region. We report 3 cases in which ultrasound-guided zygomaticotemporal nerve blocks were performed for severe unilateral temporal headaches that failed to respond to standard treatment in the outpatient pain clinic. All the patients reported substantial and durable pain relief with no complications.

A Case of Recovered Severe Rhino-Orbito-Cerebral Mucormycosis

Background: Mucormycosis is a rare disease with high morbidity and mortality, and its diagnosis is difficult and often delayed. Also, the disease tends to progress rapidly. Therefore, urgent surgical and medical intervention is lifesaving. Case Presentation: A 24-year-old woman with diabetes since 3 months ago presented with excessive tearing in her left eye, unilateral headache with epistaxis, and loss of consciousness at Razi Hospital, Rasht City, Iran, in June 2021. A clinical and pathologic diagnosis of mucormycosis was established. Imaging the head and paranasal sinuses revealed extensive involvement of the brain, paranasal sinuses, and left orbit. Treatment with liposomal amphotericin B (5 mg/kg) was administered for about 50 days until discharge. During the treatment period, the patient underwent several surgical procedures, such as enucleation of the left eye, surgery on soft and hard palates, sinuses, and neurosurgery for debridement of necrotizing tissues. After 50 days of intensive medical and surgical treatments, the patient was recovered and discharged. Conclusion: In the era of the COVID-19 pandemic, many diabetic patients acquire that infection. Physicians caring for these patients should be alert to mucormycosis as a complication of severe or mild COVID-19 infection. Early diagnostic and therapeutic interventions could be lifesaving for these patients.

Clinical characteristics of persistent headaches after the first-ever ischemic stroke (follow-up of 529 patients)

Background. Although persistent headaches are a common post-stroke pain syndrome, the epidemiology and clinical features of persistent headache after first-ever ischemic stroke have not been considered previously. There is no exact data on how often headache attributed to stroke persists for more than 3 months, i.e. meets the criteria for persistent headache after stroke and what are their distinctive clinical features. The tasks of our study were: to analyze the occurrence/incidence of persistent headaches after the first-ever ischemic stroke; to determine clinical characteristics and types of persistent headaches in comparison with headaches at the onset of stroke.&#x0D; Materials and methods. The study included 550 patients (mean age 63.1 years, 54% men) with first-ever ischemic stroke, of which 529 patients were followed up for at least three months after the stroke. Standardized semi-structured interview forms were used to assess these headaches during professional face-to-face interviews at the onset of stroke and 3 months after the stroke using telephone interview by neurologist.&#x0D; Results. Among 529 follow up patients 55 (10.4%) had persistent headaches after first-ever ischemic stroke. Among these 55 patients 34 patients had persistent new-type headaches which arose for the first time during the onset of stroke, they included predominated migraine-like headaches (n=20), tension-type-like headaches (n=9) and thunderclap-like headaches (n=5). 21 patients had persistent headaches with altered characteristics: predominated tension-type-like headaches (n=16), and less common migraine-like headaches (n=5). Persistent headaches after stroke had the following characteristics compared to headaches at onset of stroke: severe headache intensity, a gradual decrease of occurrence of accompanying symptoms (photo- and phonophobia; p=0.03), the transition of unilateral headaches in bilateral (p=0.004), the presence of headaches 15 days per month in 30.9% of the patients.&#x0D; Conclusion. Persistent post-stroke headaches represent a persistent pain syndrome with severe intensity and frequency of attacks, which requires their further study and creation of guidelines for their management.

SUNCT/SUNA: frequently misdiagnosed as trigeminal neuralgia?

Identify the number of cases with a possible diagnosis of short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) or short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms (SUNA) in patients with a previous diagnosis of Trigeminal Neuralgia (TN) at the Neurology Service of the National Medical Center 20 de Noviembre. This will confirm that these trigeminal-autonomic cephalalgias should be ruled out and considered as differential diagnoses of trigeminal neuralgia. Cross-sectional and retrospective study. The complete electronic medical records of 100 patients with a diagnosis of TN were evaluated during the period from April 2010 to May 2020. Autonomic symptoms were intentionally searched for in these patients and compared with the diagnostic criteria of SUNCT and SUNA of the 3rd edition of the International Classification of Headache Disorders. Chi-square tests and subsequent bivariate regression were performed to determine the association between variables. One hundred patients with a diagnosis of TN were included. After reviewing the clinical manifestations, 12 patients with autonomic symptoms were found and compared with the diagnostic criteria of SUNCT and SUNA. However, they did not meet the absolute criteria to be diagnosed with the previously mentioned diseases, nor to be ruled out. TN is a painful and frequent entity that can present with autonomic symptoms, therefore making it important to identify SUNCT and SUNA as differential diagnoses, to recognize them and treat them appropriately.

A Retrospective Comparative Study in Patients with SUNA and SUNCT.

Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) and short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms (SUNA) are rare primary headache disorders. The aim of the study is to describe and compare the clinical characteristics of patients with SUNA and SUNCT. Patients with SUNCT or SUNA observed in a neurology clinic of a tertiary hospital in India between January 2017 and December 2022 were evaluated. Thirteen patients with SUNA (seven female, 54%) and 16 patients with SUNCT (nine female, 56%) were identified for the evaluation. The mean ages at the onset of SUNA and SUNCT were 36.8.5 ± 8.1 years and 37.2 ± 8.4 years, respectively. The age of onset in our patients was somewhat younger than that of other large series. The demographic and clinical features of SUNA patients were comparable to those of SUNCT patients. Orbital/retro-orbital area was the most common site of pain in both types of headaches. The pattern of pain was noted as single stab (in all patients), repetitive stabs (SUNA vs. SUNCT: 77% vs. 75%), and sawtooth patterns (SUNA vs. SUNCT: 23% vs. 25%). The majority of attacks in both groups lasted less than two minutes. Conjunctival injection and tearing were present in all SUNCT patients (as a part of the diagnostic criteria). The prevalence of conjunctival injection and tearing in SUNA was 46% and 31%, respectively. All patients reported spontaneous attacks. Triggers were reported in seven (54%) patients with SUNA and nine (56%) with SUNCT. Only one patient in each group had a refractory period following a trigger-induced episode. Two patients in the SUNCT group had compression of the trigeminal nerve by a vascular loop. This is the largest case series from India. There were no significant differences between patients with SUNA and SUNCT.

Percutaneous balloon compression of the trigeminal ganglion for refractory short-lasting unilateral neuralgiform headache with conjunctival redness and tearing syndrome

Percutaneous balloon compression of the trigeminal ganglion for refractory short-lasting unilateral neuralgiform headache with conjunctival redness and tearing syndrome

Gray Zones in the Trigeminal Autonomic Cephalalgias

Background: Limited data are available about the importance of migrainous features of the trigeminal autonomic cephalalgias (TACs). Methods: We enrolled 99 patients with TACs including 71 cluster headaches, 11 with short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing, 10 with paroxysmal hemicrania, and seven with hemicrania continua. The presence of diagnostic migraine criteria such as throbbing headache, nausea and/or vomiting, photophobia, phonophobia, and aggravation by physical activity was questioned in these patients as well as autonomic features. Furthermore, supportive features of migraine including motion sickness, atopy and allergy, exacerbation during menstrual periods, irregular sleep, dizziness, and family history of any primary headache were noted. Results: The most common cranial autonomic symptom was lacrimation (87.9%) and the most common migrainous features were throbbing headache (51.5%), phonophobia (41.4%), nausea (39.4%), and photophobia (34.3%). Family history of any primary headache (25.3%) and atopy and allergy (13.1%) was the most common supportive features. Conclusion: We found higher percentages of migrainous features in patients with TACs; phonophobia, throbbing headache, and nausea frequently accompanied TACs. Aggravation by physical activity, which is one of the diagnostic migraine criteria, and motion sickness, which is one of the supportive features of migraine, were much lower in patients with TAC compared with migraineurs.

AN INSTITUTIONAL STUDY ON COVID-19 ASSOCIATED RHINO-ORBITAL-CEREBRAL MUCORMYCOSIS

Background: Prior to the COVID-19 pandemic, the prevalence of mucormycosis in India was approximately 0.14 cases per 1000 population. With the second wave of the COVID-19 pandemic, there has been a tremendous increase in the number of Rhino-Orbital mucormycosis cases with a high mortality of 30.7%.This paper discusses the institutional experience of 67 cases of rhino–orbital–cerebral mucormycosis related to COVID-19 infection. Methods: In this case series, 67 proven cases of COVID-19 associated rhino-orbital-cerebral mucormycosis were analyzed retrospectively from April 2021 to March 2022. Clinical profile of all the patients were studied for signs and symptoms at presentation, possible risk factors and comorbidities. Microbiological and imaging studies was done in all patients and taken up for surgical management which included open or endoscopic debridement, maxillectomy, orbital decompression, orbital exenteration etc. Postoperatively patients were started on parenteral antifungal and discharged on oral antifungal after repeat imaging and endoscopy to rule out residual or recurrent disease. Results: The mean age of presentation was 49.1 years. Diabetes and use of steroids during covid treatment was seen in 91% and 83.5% of cases respectively. Unilateral headache and nasal obstruction were the most common symptoms. Open debridement using Weber Ferguson incision and medial maxillectomy was the most common surgical approach followed in our institution with good recovery and less chances of need for revision surgery. Conclusion: Timely diagnosis and intervention in the form of thorough surgical debridement and antifungal therapy are critical aspects in improving clinical outcomes in such patients.

Astrocytic Glutamate Transporters and Migraine.

Glutamate levels and lifetime in the brain extracellular space are dinamically regulated by a family of Na+- and K+-dependent glutamate transporters, which thereby control numerous brain functions and play a role in numerous neurological and psychiatric diseases. Migraine is a neurological disorder characterized by recurrent attacks of typically throbbing and unilateral headache and by a global dysfunction in multisensory processing. Familial hemiplegic migraine type 2 (FHM2) is a rare monogenic form of migraine with aura caused by loss-of-function mutations in the α2 Na/K ATPase (α2NKA). In the adult brain, this pump is expressed almost exclusively in astrocytes where it is colocalized with glutamate transporters. Knockin mouse models of FHM2 (FHM2 mice) show a reduced density of glutamate transporters in perisynaptic astrocytic processes (mirroring the reduced expression of α2NKA) and a reduced rate of glutamate clearance at cortical synapses during neuronal activity and sensory stimulation. Here we review the migraine-relevant alterations produced by the astrocytic glutamate transport dysfunction in FHM2 mice and their underlying mechanisms, in particular regarding the enhanced brain susceptibility to cortical spreading depression (the phenomenon that underlies migraine aura and can also initiate the headache mechanisms) and the enhanced algesic response to a migraine trigger.

Recurrent Painful Ophthalmoplegic Neuropathy Mistaken for Oculomotor Schwannoma: A Case Report

AbstractRecurrent painful ophthalmoplegic neuropathy (RPON) is a headache disorder classified as a cranial neuropathy. It is characterized by episodes of unilateral headache followed by ipsilateral ophthalmoplegia due to ocular cranial nerve palsy. Symptoms usually subside spontaneously within weeks to months. RPON commonly occurs in childhood, though it is overlooked at times as a possible differential diagnosis. The pathophysiology of RPON is not entirely clear. Typical magnetic resonance imaging (MRI) findings in children include nerve thickening and gadolinium enhancement. However, these findings are not specific to this condition. Nerve thickening in RPON can resemble schwannomas, thereby causing a diagnostic dilemma. Here, we present a 13-year-old boy with a history of unilateral headaches associated with ipsilateral ptosis and diplopia. The first MRI indicated thickening and gadolinium enhancement of the right oculomotor nerve, which was interpreted as a schwannoma. However, his symptoms resolved after a few weeks and the follow-up MRI showed resolution of nerve changes. This clinical presentation was consistent with RPON. This case demonstrates the need for a careful follow-up of RPON patients.

The Development of Psychiatric Illness and Chemoprophylaxis of Botulinum Toxin in Migraine: A Narrative Review.

A migraine is not just a headache. It is an extremely prevalent neurological condition marked by periodic episodes of unilateral headache, with more than 10 million cases yearly. Migraine often begins at the age of puberty. It substantially impacts the brain and, consequently, psychiatric behavior linked with frequent migraine attacks that may be moderate to severe in intensity. A crucial aspect of migraine variability is comorbidity with other neurological diseases, vascular diseases, and mental illnesses. Psychiatric disorders related to migraine include anxiety disorders, panic disorder, bipolar disorder, depression, etc. It is also estimated that people suffering from migraine are about five times more likely to develop depression than others without migraine. The stimulus for migraine is stress, lack of sleep, skipped meal or fasting, visual stimulation due to high intensity of light, auditory stimulus due to noise, and olfactory stimulus due to a pungent smell. A majority of patients suffer from migraine attacks triggered by noise, some due to visual stimulation, and a few due to perfumes or other odors that trigger their migraine. Diagnosis of this is primarily dependent on history taking and clinical evaluation. Migraine can be classified depending on whether an aura is present or absent. It can further be divided based on the frequency of headaches into episodic migraine or chronic migraine, which may be determined by the duration of the headache. The development of migraine is influenced by both genetics and the environment. It has a detrimental effect on children's quality of life. A comprehensive analysis of psychiatric illnesses in migraine contributes to early diagnosis and proper treatment of the disease. Also, having a healthy lifestyle (including exercise, a balanced diet, and enough sleep) seems to prevent and improve the condition. Headache in migraine is resistant to medical treatment but responds well to botulinum toxin. This review primarily focuses on the psychiatric issues like depression and anxiety that often accompany migraine. The article also highlights the effects of botulinum toxin on migraine.

AN OVERLOOKED HEADACHE

Giant cell arteritis, otherwise known as temporal arteritis or cranial arteritis is a common cause of vasculitis among older adults. We report a case of Giant Cell Arteritis in an elderly female patient who presented with a recent onset unilateral headache and symptoms of polymyalgia rheumatica. Prompt diagnosis and comprehensive workup can help an alert physician to clinch the diagnosis and be instrumental in early treatment and thereby prevent permanent blindness.

Post-traumatic Headaches after Traumatic Brain Injury in a Military and Veteran Cohort

<h3>Research Objectives</h3> To examine post-traumatic headaches (PTH) characteristics in subjects with post-TBI. <h3>Design</h3> Cohort analysis of TBI patients participating in a prospective longitudinal study to examine TBI outcomes. Descriptive statistics used to describe the headache characteristics of the participants. <h3>Setting</h3> VA Palo Alto Polytrauma Rehabilitation Center. <h3>Participants</h3> 224 U.S Military Service Members and Veterans diagnosed with mild-severe TBI, seen for rehabilitation/treatment and followed at Years: 1, 2, and 5 post-injury. <h3>Interventions</h3> Not applicable. <h3>Main Outcome Measures</h3> Patterns and trajectory of PTHs. <h3>Results</h3> 39% of the injuries were Blast-related, following 22% motor vehicular accidents. Most participants reported having headaches at the time of rehabilitation and treatment (61%). Among those with mild TBI 75% reported experiencing headaches post-TBI. The percentage of participants that reported experiencing 15 or more headache episodes per month, was 48% of those with mild-TBI. The majority of the severe TBI 49%, and mild-TBI 35% participants reported an episodic pattern of headaches, lasting between 4 hrs to 24 hrs, untreated headaches during the first year. Unilateral headache episodes among the mild TBI were reported with some headaches, 35%, and among severe TBI with every headache, 34%. In describing the level of headache pain, 37% of mild TBI participants reported feeling throbbing or pulsating sensation when it is at its worst, and 33% of the severe TBI participants reported feeling pressure or "vise-like' headache sensation. <h3>Conclusions</h3> Post-traumatic headaches are a common sequelae post-injury, and are often a difficult post-concussive symptom for patients to manage. This analysis serves as a foundation for understanding PTHs and for informing advances in treatment. <h3>Author(s) Disclosures</h3> I have no financial interests or relationships to disclose.

Cellular and Biochemical Characterization of Mesenchymal Stem Cells from Killian Nasal Polyp.

Killian's (antrochoanal) polyp is a unilateral nasal polypoid lesion of the maxillary sinus especially affecting children and young adults with unilateral nasal obstruction, pus discharge, and headache. Although its etiology is unclear, chronic inflammation, autoreactivity, allergies, and viral infections are implicated in its formation and development, causing nasal tissue remodeling. In this context, we isolated and cultured mesenchymal stem cells from surgical biopsies of three patients with Killian nasal polyp (KNP-MSCs) while healthy nasal tissue (HNT-MSCs) was used as control. Our results demonstrated that KNP-MSCs exhibited reduced cell proliferation compared to HNT-MSCs, and migrated less than the control, showing a partial epithelial phenotype with low mRNA levels of I-CAM and a significant increase of E-cad. Subsequently, both MSCs were induced to osteoblastic or adipocyte differentiation for up to 20 days. KNP-MSCs underwent to differentiate into osteoblasts but exhibited reduced ALP activity and calcium deposits and low mRNA levels of osteogenesis-associated genes compared to osteogenic induced-HNT-MSCs. Conversely, KNP-MSCs and HNT-MSCs have shown the same adipogenic differentiation potential, with a similar lipid droplet amount, adipocyte gene expression, and triacylglycerols content. Taken together, these results first demonstrated the cellular and molecular characterization of MSCs derived from the Killian nasal polyp.