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Background and purpose: Previous studies have shown that human herpes simplex virus (HSV) infection may be associated with the onset of headache or migraine. We aimed to investigate the association between HSV infection and severe headache or migraine. Materials and methods: The cross-sectional data on 5,730 participants aged 20-49 years were obtained from the 1999-2004 National Health and Nutrition Examination Survey (NHANES). We used weighted logistic regression analysis to assess the association between HSV infection (HSV-1 gG-1 and HSV-2 gG-2) and severe headache or migraine, and performed subgroup analyses. Results: Our study found that women, higher education, higher body mass index, better family conditions, smoking and alcohol consumption were all associated with severe headaches or migraines. After adjusting for confounding factors such as sex, age, race, and education, HSV-2 (+) was still significantly associated with severe headache or migraine (OR = 1.22, 95%CI:1.03-1.46, p = 0.0443). In subgroup analyses, we found that participants with HSV-1 (-) and HSV-2 (+) were also significantly associated with severe headache or migraine (OR = 1.41, 95%CI:1.04-1.91, p = 0.0281). Conclusion: HSV-2 gG-2(+) was significantly associated with severe headache or migraine. [ABSTRACT FROM AUTHOR]

Background: Severe headache or migraine is a neurological disease that seriously affects the quality of human life. Oxidative stress is considered a main factor in the pathogenesis of severe headache or migraine. The Composite Dietary Antioxidant Index (CDAI) is a score calculated using six dietary antioxidant components (including vitamins A, C, E, selenium, zinc, and carotenoid), which represents a person's level of dietary antioxidant ingredients. Based on the theory of oxidative stress, we speculated that CDAIs may be relevant to the risk of severe headache or migraine, as the relationship between the CDAI and severe headache or migraine is unclear. Hence, the purpose of this study was to explore the relationship between the CDAI and severe headache or migraine in participants. Methods: We performed a cross-sectional study using data from the National Health and Nutrition Examination Survey (NHANES) that were collected from 2001 to 2004. A total of 4,943 participants were included, of whom 1,232 experienced severe headaches or migraines. Participants' CDAIs were calculated based on their intake of six dietary antioxidants. We used logistic regression models, limited cubic spline analysis, and subgroup analysis to assess the association of CDAI with severe headache or migraine. Results: The multivariate logistic regression model (correcting for all potential covariates) revealed that the odds ratio (95% Confidence Interval [CI]) for the association between CDAI and severe headache or migraine was 0.97 (95% CI=0.95-1.00, p=0.048). Compared with individuals with low CDAIs in Quartile (Q)1, the adjusted Odds Ratio between the CDAI and severe headache or migraine in Q2, Q3, and Q4 were 0.84 (95% CI=0.69-1.01, p=0.07), 0.77 (95% CI=0.63-0.96, p=0.017), and 0.73 (95% CI=0.56-0.95, p=0.02), respectively. Restricted cubic spline regression analysis showed an L-shaped relationship between the CDAI and severe headache or migraine. Conclusion: Our findings indicate that higher CDAI was associated with a lower risk of severe headache or migraine. [ABSTRACT FROM AUTHOR]

Previous studies have revealed that an antioxidant diet is a protective factor against migraine. However, the association between zinc, an important antioxidant obtained from the diet, and migraine has received little attention. The purpose of this study was to explore the association between zinc intake with migraine. The present study used cross-sectional data from individuals who participated in the National Health and Nutrition Examination Survey (NHANES) between 1999 and 2004. Logistic regression models and restricted cubic spline models were performed to explore the association between zinc intake and migraine. A total of 9849 adults aged 20 years or older were included in this study. Zinc intake was negatively associated with migraine. Compared to participants in the lowest group of dietary zinc intake Q1 (≤5.93 mg/day), the adjusted ORs for migraine in Q2 (5.94–8.38 mg/day), Q3 (8.39–11.26 mg/day), Q4 (11.27–15.75 mg/day), and Q5 (≥15.76 mg/day) were 0.73 (95% CI: 0.60–0.89, p = 0.004), 0.72 (95% CI: 0.55–0.95, p = 0.02), 0.76 (95% CI: 0.58–0.99, p = 0.04) and 0.73 (95% CI: 0.50–1.05, p = 0.08), respectively. Our findings also suggested an interaction between zinc intake and age (P for interaction = 0.007). Additionally, the relationship between zinc intake and migraine in adults with 20–50 years was non-linear. A higher zinc intake is significantly associated with a decreased prevalence of migraine, and age can modify the association between them. [ABSTRACT FROM AUTHOR]

Introduction: The ObserVational survey of the Epidemiology, tReatment and Care Of MigrainE (OVERCOME) European Union (EU) is part of an overarching population-based study program that also includes the United States and Japan. Here, we report data on the migraine/severe headache burden and the use of acute medication and healthcare resources in Spain and Germany. Methods: OVERCOME (EU) was an online, non-interventional, cross-sectional survey conducted in adults in Spain and Germany between October 2020 and February 2021. A total migraine cohort was established based on health survey participants who reported headache/migraine in the last 12 months AND identified as having migraine based on modified International Classification of Headache Disorders, third edition criteria OR self-reported physician diagnosis. Data were analyzed for the total migraine cohort and the subcohort with moderate to severe headache attacks, with average pain severity ≥ 5 points, pain duration ≥ 4 h, and at least moderate disability due to migraine [Migraine Disability Assessment (MIDAS) score ≥ 11] over the past 3 months. Results: Pain of moderate or severe intensity was the most frequent symptom in the total migraine cohort (n = 19,103/20,756; 92.0%). Proportions of participants reporting severe disability (MIDAS Grade IV), poorer quality of life (QoL; Migraine-Specific QoL Questionnaire), and higher interictal burden (Migraine Interictal Burden Scale-4), generally increased with number of headache days (HDs)/month. Most participants (92.5%) reported current acute migraine/severe headache medication use, although only 39.0% were using triptans. In the moderate to severe attacks subcohort (n = 5547), 48.4% were using triptans, with nonsteroidal anti-inflammatory drugs the most common acute medication. The moderate to severe attacks subcohort also reported poorer QoL and greater pain and disability with increasing HDs/month, although severe interictal burden was reported for ~ 60% of participants regardless of HDs/month. Treatment satisfaction (six-item migraine Treatment Optimization Questionnaire) in those using triptans was generally poor in both total and subcohorts. Conclusion: High migraine-related burden levels were reported, despite use of acute medication. Although triptans are recommended for moderate to severe migraine attacks in Spanish and German guidelines, less than half of participants were using triptans; treatment satisfaction in those using triptans was generally poor. New tailored treatment options may help address unmet needs in current acute treatment. [ABSTRACT FROM AUTHOR]

Abstract Introduction The ObserVational survey of the Epidemiology, tReatment and Care Of MigrainE (OVERCOME) European Union (EU) is part of an overarching population-based study program that also includes the United States and Japan. Here, we report data on the migraine/severe headache burden and the use of acute medication and healthcare resources in Spain and Germany. Methods OVERCOME (EU) was an online, non-interventional, cross-sectional survey conducted in adults in Spain and Germany between October 2020 and February 2021. A total migraine cohort was established based on health survey participants who reported headache/migraine in the last 12 months AND identified as having migraine based on modified International Classification of Headache Disorders, third edition criteria OR self-reported physician diagnosis. Data were analyzed for the total migraine cohort and the subcohort with moderate to severe headache attacks, with average pain severity ≥ 5 points, pain duration ≥ 4 h, and at least moderate disability due to migraine [Migraine Disability Assessment (MIDAS) score ≥ 11] over the past 3 months. Results Pain of moderate or severe intensity was the most frequent symptom in the total migraine cohort (n = 19,103/20,756; 92.0%). Proportions of participants reporting severe disability (MIDAS Grade IV), poorer quality of life (QoL; Migraine-Specific QoL Questionnaire), and higher interictal burden (Migraine Interictal Burden Scale-4), generally increased with number of headache days (HDs)/month. Most participants (92.5%) reported current acute migraine/severe headache medication use, although only 39.0% were using triptans. In the moderate to severe attacks subcohort (n = 5547), 48.4% were using triptans, with nonsteroidal anti-inflammatory drugs the most common acute medication. The moderate to severe attacks subcohort also reported poorer QoL and greater pain and disability with increasing HDs/month, although severe interictal burden was reported for ~ 60% of participants regardless of HDs/month. Treatment satisfaction (six-item migraine Treatment Optimization Questionnaire) in those using triptans was generally poor in both total and subcohorts. Conclusion High migraine-related burden levels were reported, despite use of acute medication. Although triptans are recommended for moderate to severe migraine attacks in Spanish and German guidelines, less than half of participants were using triptans; treatment satisfaction in those using triptans was generally poor. New tailored treatment options may help address unmet needs in current acute treatment.

Abstract Background Patients with severe thalassemia may experience adverse effects from transfusion such as fever, rash, and iron overload after long-term transfusion therapy. Severe headaches as a side effect of blood transfusion in patients with thalassemia are not commonly observed, especially when combined with superficial siderosis of the central nervous system, which is easily misdiagnosed and requires excessive examination and treatment. Case Presentation A 31-year-old woman was admitted with severe headache and vomiting over 3 days following blood transfusion. She was diagnosed with intermediate α-thalassemia at 2 years of age and had a history of irregular blood transfusions. Physical examination revealed horizontal nystagmus with no other abnormal neurological signs. Magnetic resonance (MR) imaging, MR venography, MR arteriography, and cerebrospinal fluid analysis were normal. However, susceptibility-weighted imaging showed abnormal signals in the bilateral and fourth ventricles. Initial antibiotics, antivirals, decompression of intracranial pressure, iron chelation, and symptomatic treatments were administered; subsequently, small intermittent blood transfusions were cautiously administered for severe anemia. The patient’s headache was gradually relieved, and she was discharged on day 9. At the 5-month follow-up, the patient’s headache recurred following another transfusion. Conclusions Severe post-transfusion headache in patients with thalassemia has not been fully recognized and is easily misdiagnosed, leading to excessive examination and treatment. Understanding the clinical features of transfusion-related headaches can help identify this complication, but the exact pathophysiological mechanism requires further research.

Folate, also known as vitamin B9, is a water-soluble vitamin. Previous studies on dietary folate intake in severe headache patients were equivocal. Therefore, we conducted a cross-sectional study to elucidate the relationship between folate intake and severe headache. This cross-sectional study used data from participants over 20 years old who participated in the National Health and Nutrition Examination Survey (NHANES) from 1999 to 2004. The diagnosis of severe headache was made through participants' self-report in the NHANES questionnaire section. We performed multivariate logistic regression and restricted cubic spline (RCS) regression to explore the relationship between folate intake and severe headache. A total of 9859 participants took part in the study, 1965 of whom were severe headache patients and the rest were non-severe headache. We found that dietary folate intake was significantly and inversely associated with severe headache. Compared with participants with lower folate intake Q1 (≤ 229·97 ug/d), the adjusted OR values for dietary folate intake and severe headache in Q2 (229·98–337 ug/d), Q3 (337·01–485 ug/d) and Q4 (≥ 485·01 ug/d) were 0·81 (95 % CI: 0·67, 0·98, P = 0·03), 0·93 (95 % CI: 0·77, 1·12, P = 0·41) and 0·63 (95 % CI: 0·49, 0·80, P < 0·001), respectively. For women aged 20–50 years, there was a non-linear association between folate intake and severe headache in the RCS. Women aged 20–50 years should have higher awareness of dietary folate and increase their dietary intake of folate, which may aid in preventing severe headache. [ABSTRACT FROM AUTHOR]

Background: Patients with severe thalassemia may experience adverse effects from transfusion such as fever, rash, and iron overload after long-term transfusion therapy. Severe headaches as a side effect of blood transfusion in patients with thalassemia are not commonly observed, especially when combined with superficial siderosis of the central nervous system, which is easily misdiagnosed and requires excessive examination and treatment. Case Presentation: A 31-year-old woman was admitted with severe headache and vomiting over 3 days following blood transfusion. She was diagnosed with intermediate α-thalassemia at 2 years of age and had a history of irregular blood transfusions. Physical examination revealed horizontal nystagmus with no other abnormal neurological signs. Magnetic resonance (MR) imaging, MR venography, MR arteriography, and cerebrospinal fluid analysis were normal. However, susceptibility-weighted imaging showed abnormal signals in the bilateral and fourth ventricles. Initial antibiotics, antivirals, decompression of intracranial pressure, iron chelation, and symptomatic treatments were administered; subsequently, small intermittent blood transfusions were cautiously administered for severe anemia. The patient's headache was gradually relieved, and she was discharged on day 9. At the 5-month follow-up, the patient's headache recurred following another transfusion. Conclusions: Severe post-transfusion headache in patients with thalassemia has not been fully recognized and is easily misdiagnosed, leading to excessive examination and treatment. Understanding the clinical features of transfusion-related headaches can help identify this complication, but the exact pathophysiological mechanism requires further research. [ABSTRACT FROM AUTHOR]

Abstract Background Insights into the burden, needs and treatment of migraine from internet-based surveys in diverse real-world migraine populations are needed, especially at a time when novel preventive migraine medications are becoming part of the therapeutic armamentarium. The objectives of this analysis are to describe traditional preventive (orals and onabotulinum toxin A) treatment patterns in the OVERCOME (EU) study migraine cohort, as well as treatment patterns and patient satisfaction with current treatment in a subgroup of respondents eligible for migraine preventive medication. Methods The cross-sectional non-interventional OVERCOME (EU) study was conducted (October 2020–February 2021) via an online survey among adults (aged ≥ 18 years) resident in Germany or Spain. Participants, registered in existing online panels, who were willing to provide consent were considered. The migraine cohort included participants reporting headache/migraine in the past year, identified based on a validated migraine diagnostic questionnaire and/or self-reported physician diagnosis. A subgroup of survey respondents defined as eligible for migraine preventive medication at the point in time the cross-sectional survey was taken was also analysed. Variables assessed included sociodemographic and migraine-related clinical characteristics, preventive (traditional and calcitonin gene-related peptide monoclonal antibodies) treatment patterns and patient satisfaction with current treatment. Results are descriptive only. Results Of the 20,756 participants in the migraine cohort, 78.5% sought professional medical care, 50.8% received a migraine diagnosis and only 17.7% had ever used preventive medication. Half (53.3%) of participants currently using preventives took their most recent medication for six months or less. Most patients (73.9%) classified as eligible for preventive medication (based on headache frequency and/or at least moderate disability due to migraine) reported not using traditional preventives and many of those who did (66.8%) were not satisfied with their current standard of care. Conclusions Our findings highlight the low proportion of people diagnosed with migraine despite a higher rate of consultation and suggest the need for better access to treatment for people with migraine and new preventive therapies with improved efficacy and safety profiles to improve adherence and patient satisfaction.

Background: Insights into the burden, needs and treatment of migraine from internet-based surveys in diverse real-world migraine populations are needed, especially at a time when novel preventive migraine medications are becoming part of the therapeutic armamentarium. The objectives of this analysis are to describe traditional preventive (orals and onabotulinum toxin A) treatment patterns in the OVERCOME (EU) study migraine cohort, as well as treatment patterns and patient satisfaction with current treatment in a subgroup of respondents eligible for migraine preventive medication. Methods: The cross-sectional non-interventional OVERCOME (EU) study was conducted (October 2020–February 2021) via an online survey among adults (aged ≥ 18 years) resident in Germany or Spain. Participants, registered in existing online panels, who were willing to provide consent were considered. The migraine cohort included participants reporting headache/migraine in the past year, identified based on a validated migraine diagnostic questionnaire and/or self-reported physician diagnosis. A subgroup of survey respondents defined as eligible for migraine preventive medication at the point in time the cross-sectional survey was taken was also analysed. Variables assessed included sociodemographic and migraine-related clinical characteristics, preventive (traditional and calcitonin gene-related peptide monoclonal antibodies) treatment patterns and patient satisfaction with current treatment. Results are descriptive only. Results: Of the 20,756 participants in the migraine cohort, 78.5% sought professional medical care, 50.8% received a migraine diagnosis and only 17.7% had ever used preventive medication. Half (53.3%) of participants currently using preventives took their most recent medication for six months or less. Most patients (73.9%) classified as eligible for preventive medication (based on headache frequency and/or at least moderate disability due to migraine) reported not using traditional preventives and many of those who did (66.8%) were not satisfied with their current standard of care. Conclusions: Our findings highlight the low proportion of people diagnosed with migraine despite a higher rate of consultation and suggest the need for better access to treatment for people with migraine and new preventive therapies with improved efficacy and safety profiles to improve adherence and patient satisfaction. [ABSTRACT FROM AUTHOR]

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Mohamed Abdulahi Hassan, Abdullahi Abdirahman Omar, Ibrahim Abdullahi Mohamed Department of Internal Medicine and Intensive Care Unit, Dr. Sumait Hospitals of Simad University, Mogadishu, SomaliaCorrespondence: Mohamed Abdulahi Hassan, Tel +252615987780, Email modhassan@simad.edu.soIntroduction: Cerebral venous thrombosis (CVT) remains one of the most frequent cause of stroke in young adults although it is a rare disorder. It has a serious emergency manifestation during pregnancy and postpartum. It is frequently under diagnosed and limited publications in developing countries especially sub-Saharan Africa.Case Presentation: Here, we report the case of a 35-year-old female, para 8 and gravida 8, brought to emergency department on her ninth day postpartum, having severe headaches and confusion; during her admission to emergency, she suffered two episodes of generalized seizure. On admission, the patient’s blood pressure was 200/120 mmHg. The patient was firstly diagnosed with postpartum eclampsia and managed with magnesium sulfate for seizures and hydralazine for blood pressure control. On ward admission, she continued having seizures and her level of consciousness decreased with left side weakness. An urgent MRI of head and MR venography performed immediately revealed acute thrombosis involving the anterior aspect of superior sagittal sinus and the left transverse sinus. The patient was moved to the ICU. Anti-coagulant LMW enoxaparin and anticonvulsant were started. After improving on clinical and biochemical tests, the patient was transferred to the inpatient ward on fifth day. Another two days later in the ward, she improved significantly, and then a head CT (contrast) angiography/venography was performed before she was discharge and showed no evidence of filling defect in cortical/dural venous sinuses.Conclusion: Cerebral venous sinus thrombosis (CVST) and postpartum eclampsia may have similar manifestations in young women of reproductive age. Early prompt diagnosing and therapeutic intervention of CVST can prevent further neurological deterioration and immediately improve the patient.Keywords: cerebral venous thrombosis, postpartum eclampsia, severe headache, CVT

Pneumocephalus is defined as air in the intracranial space. It is commonly caused by traumatic skull fractures and is diagnosed by head plain computer tomography. Treatment involves initial stabilization of vital signs and surgical intervention if symptoms do not resolve. We report a unique case of pneumocephalus following sneeze suppression.

Cerebrospinal fluid (CSF) leakage is considered the cause of spontaneous intracranial hypotension (SIH), an important etiology for new daily persistent headaches and a potentially life-threatening condition. Minor traumatic events rarely lead to CSF leakage, contrasting with iatrogenic interventions such as a lumbar puncture or spinal surgery, which are commonly complicated by dural tears. Most meningeal lesions are found in the cervicothoracic region, followed by the thoracic region, and rarely in the lumbar region, and extremely rarely in the sacral region. We describe two patients admitted to our hospital for severe headaches aggravated in the orthostatic position, with a recent history of minor trauma and sustained physical effort, respectively. In the first case, a bone fragment pierced an incidental congenital meningocele creating a dural fistula. An extensive extradural CSF collection, spanning the cervicothoracic region (C4–T10), was described in the second case. In both patients, the clinical evolution was favorable under conservative treatment.

Background and Purpose: Previous studies have shown that human herpes simplex virus (HSV) infection may be associated with the onset of headache or migraine. We aimed to investigate the association between HSV infection and severe headache or migraine., Materials and Methods: The cross-sectional data on 5,730 participants aged 20-49 years were obtained from the 1999-2004 National Health and Nutrition Examination Survey (NHANES). We used weighted logistic regression analysis to assess the association between HSV infection (HSV-1 gG-1 and HSV-2 gG-2) and severe headache or migraine, and performed subgroup analyses., Results: Our study found that women, higher education, higher body mass index, better family conditions, smoking and alcohol consumption were all associated with severe headaches or migraines. After adjusting for confounding factors such as sex, age, race, and education, HSV-2 (+) was still significantly associated with severe headache or migraine (OR = 1.22, 95%CI:1.03-1.46, p  = 0.0443). In subgroup analyses, we found that participants with HSV-1 (-) and HSV-2 (+) were also significantly associated with severe headache or migraine (OR = 1.41, 95%CI:1.04-1.91, p  = 0.0281)., Conclusion: HSV-2 gG-2(+) was significantly associated with severe headache or migraine., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Zheng, Jiang, Li, Zeng, Yu, Duan, Wang and Liu.)

Rhinoscleroma is a rare endemic disease in low socioeconomic settings characterized by nasal growth, nasal blockage, and epistaxis. The causative organism is not an usual nasal commensal, and diagnosis is often delayed. Characteristic Mikulicz cells should be visualized microscopically for definitive diagnosis. We present our experience of rhinoscleroma with unusual presentation of severe headache and orbital mass in three patients over an 11-year period in the pathology laboratory of a tertiary hospital. [ABSTRACT FROM AUTHOR]

Background: Severe headache or migraine is a neurological disease that seriously affects the quality of human life. Oxidative stress is considered a main factor in the pathogenesis of severe headache or migraine. The Composite Dietary Antioxidant Index (CDAI) is a score calculated using six dietary antioxidant components (including vitamins A, C, E, selenium, zinc, and carotenoid), which represents a person's level of dietary antioxidant ingredients. Based on the theory of oxidative stress, we speculated that CDAIs may be relevant to the risk of severe headache or migraine, as the relationship between the CDAI and severe headache or migraine is unclear. Hence, the purpose of this study was to explore the relationship between the CDAI and severe headache or migraine in participants., Methods: We performed a cross-sectional study using data from the National Health and Nutrition Examination Survey (NHANES) that were collected from 2001 to 2004. A total of 4,943 participants were included, of whom 1,232 experienced severe headaches or migraines. Participants' CDAIs were calculated based on their intake of six dietary antioxidants. We used logistic regression models, limited cubic spline analysis, and subgroup analysis to assess the association of CDAI with severe headache or migraine., Results: The multivariate logistic regression model (correcting for all potential covariates) revealed that the odds ratio (95% Confidence Interval [CI]) for the association between CDAI and severe headache or migraine was 0.97 (95% CI = 0.95-1.00, p  = 0.048). Compared with individuals with low CDAIs in Quartile (Q)1, the adjusted Odds Ratio between the CDAI and severe headache or migraine in Q2, Q3, and Q4 were 0.84 (95% CI = 0.69-1.01, p  = 0.07), 0.77 (95% CI = 0.63-0.96, p  = 0.017), and 0.73 (95% CI = 0.56-0.95, p  = 0.02), respectively. Restricted cubic spline regression analysis showed an L-shaped relationship between the CDAI and severe headache or migraine., Conclusion: Our findings indicate that higher CDAI was associated with a lower risk of severe headache or migraine., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Zhang, Chen, Fang, Ye, Tang and Huang.)

Dyke–Davidoff–Masson syndrome (DDMS) (also referred to as cerebral hemiatrophy) is a rare condition characterized by seizures, facial asymmetry, contralateral spastic hemiplegia, or hemiparesis, with or without learning difficulties. It usually presents in the early childhood or late adolescence. The diagnosis is mainly associated with the presence of radiologic findings which include contralateral cerebral hemiatrophy with ipsilateral dilatation of the lateral ventricle and hypertrophy of the sinuses. Here, we report a case of a 49-year-old female patient who presented with chronic headache episodes for 10 years, and radiological findings revealed the DDMS.

Abstract Background Vertebral artery dissection (VAD) sometimes has no specific symptoms and is difficult to differentiate from other forms of headache. Case presentation A woman in her thirties had a severe, throbbing left-sided headache. A migraine without aura was suspected and zolmitriptan was administered, which alleviated the symptoms. The woman was consequently deemed to have a migraine without aura. Despite the lack of abnormal neurological findings and showed no abnormalities on cranial computed tomography, her symptoms were not typical for migraines and showed little improvement with therapy. She therefore underwent a cranial magnetic resonance imaging (MRI) examination, which revealed VAD, for which she was transferred to the department of neurosurgery for conservative treatment. Conclusion The possibility of vertebral artery dissection should be considered in the differential diagnosis of severe secondary headaches, and prompt diagnosis and treatment based on detailed MRI and magnetic resonance angiography examinations should be performed.

AIM: To point to the importance of EMS physicians in recognizing symptoms of a headache as a sign of a serious illness. The case report shows that besides professionalism and skills of doctors, cooperation between a patient and a doctor have essential relevance. MATERIALS AND METHODS: Retrospective case report using the data from the protocols of the services that participated in the patient diagnosis and treatment. CASE REPORT: In the early evening, the Emergency Department Service receives a call from a female person, 54 years old. She complains of a severe headache that has lasted for two hours. She claims that this is the most serious headache in her life. She has taken the regular antihypertensive therapy, analgesic but the headache does not stop. Upon arrival of EMS team, the patient complains of a severe, occipital headache, neck pain and nausea. Anamnesis reveals that the patient is a doctor, and the fact that there is a positive family history of cerebrovascular diseases. Despite normal neurological status of the patient, transport by EMS was proposed in order to give the observation which she rejected as a colleague, a doctor, insisting on intramuscular therapy. After three hours, there was the second call from the husband of the same person. He stated vomiting and difficulties in communication. On going again and examination, somnolence, focal neurological deficit and rigidity of cervical spine were ascertained. The patient was transported to the neurological emergency department. The condition worsened rapidly, progressing to coma and that evening the patient was referred to the neurosurgery diagnosed intracranial hemorrhage. CT scan showed that it was a subarachnoid hemorrhage. CONCLUSION: An intense headache, never experienced before, like a 'thunder strike' is one of the key symptoms in the context of clinical features of SAH. It is equally important for EMS physicians to recognize a headache as a potential medical emergency and for a patient cooperation. In patients, who survive, severe disability usually remains and therefore the significance of cooperation at all levels is of crucial importance because it is often a difference between life and death, but also a difference in the quality of life of survivors.

Cavernous malformations are congenital or acquired vascular abnormalities. They are uncommon entities with an incidence of 0.5 % of the general population and usually are unnoticed until a hemorrhagic event occurs. Cerebellar cavernomas (CCMs) account for 1.2 to 11.8 % of all intracranial cases and 9.3 to 52.9 % of all infratentorial cases. Cavernomas can be concurrently seen with developmental venous anomalies (DVAs) in 20 % (range 20 %–40 %) of cases, in which case they are known as mixed vascular malformations. We report a case of a healthy young adult who presented with acute onset of headache, with characteristics of chronic headache that gets progressively worse. The patient complains of frequent dizziness when sitting and standing for a long time. Complaints have been felt for two years and have worsened for the past two weeks. Additional complaints are dizziness and nausea with intermittent episodes of vomiting for four days. Magnetic resonance imaging (MRI) revealed an underlying cavernoma that had bled and a coexisting DVA. The patient was discharged home with no deficits. Outpatient follow-up two months later showed no symptoms or neurologic deficits. Cavernous malformations are congenital or acquired vascular anomalies that occur in approximately 0.5 % of the general population. Our patient likely had dizziness due to localization of the bleeding of the cavernoma on the left side of the cerebellum. In our patient, brain imaging revealed numerous abnormal blood vessels radiating from the cerebellar lesion, a highly suggestive of DVAs associated with cavernoma. A cavernous malformation is an uncommon entity that might coexist with deep venous anomalies, making management more challenging. • Cavernous malformation is a benign vascular lesion in the CNS and other organs such as the liver or skin. The CNS cavernoma accounts for 5-13% of all intracranial vascular anomalies, and they vary in size from a few millimetres to a few centimetres in diameter. • A cavernous malformation is an uncommon entity that might coexist with deep venous anomalies, making management more challenging. [ABSTRACT FROM AUTHOR]

An otherwise serious and potentially fatal organic condition may present with a co-existing strong functional component. We encountered a female patient who presented with bouts of severe headache over the occipital region, associated with blurring of vision. Initially, non-contrast computed tomography (CT) scan (Brain) showed normal study, and she was deemed as having functional symptoms. Later, magnetic resonance imaging (MRI) (Brain) showed filling defect in right sigmoid sinus and magnetic resonance (MR) venography confirmed right sigmoid sinus thrombosis. On adequate anticoagulation, she did not improve and still had bouts of severe headache, although no longer associated with impaired vision. The treating neurophysician concluded that symptoms could no longer be accounted for by the organic condition. Overt and covert psychosocial stressors were found to be present in a detailed psychological exploration. Psychological intervention effectively controlled the headache. Thus, functional overlay can complicate the clinical picture in a severe organic condition and may require active psychiatric intervention over and above medical treatment.

Objective We examined whether the prevalence of complementary and alternative medicine (CAM) use varies by gender, and assessed the interaction of gender and CAM use on moderate mental distress (MMD) in U.S. adults with migraines/severe headaches. Methods We used data from the 2012 National Health Interview Survey, which represents non-institutionalized U.S. adults with migraines/severe headaches (n = 4645 unweighted). Using a cross-sectional design with survey sampling techniques, we conducted descriptive analyses for prevalence of CAM use by gender. Multivariate logistic regression analyses were run to investigate potential roles of migraines/severe headaches and CAM use on MMD by gender. Results The overall prevalence of past year CAM use was 44.4%. Women consistently used CAM more frequently than men ( P = .004). The most commonly used CAM types included herbal supplements (22.2%), massage (14.2%), and chiropractic/osteopathic (13.9%). After controlling for covariates, the odds of MDD were increased by the presence of migraines/severe headaches ( P < .001) and the use of any CAM ( P < .001). The interaction effect of migraines/severe headaches and CAM use decreased the odds of MMD by 27% in women ( P < .05), but not in men. Conclusion Women used CAM more frequently than men among adults with migraines/severe headaches in the United States. In addition, the interaction of gender and CAM use exists; the CAM use was associated with decreased odds of MMD among women only, suggesting that women with migraines/severe headaches may have benefited from CAM for their mental distress. Future research is needed to explore why such patterns vary by gender. [ABSTRACT FROM AUTHOR]

31 years old male patient admitted to the emergency department because of recurrent severe head aches which continued for two years. The patient has been consulted our clinic of internal medicine because of thyroid function abnormalities. Laboratory investigations revealed elevated serum TSH of 8,6 mU/L (normal range (N); 0.34-5,6), free T4 (fT4) of 1,73 (N;0,61-1,12ng/dl), and free T3(fT3) of 5,48 (N; 2,5-3,9pg/mL). Other laboratory parameters were normal. Physical examination revealed stage 3 goiter. The other system examinations were normal. We have learned that two years ago brain computed tomography scan was performed due to head a cheand result was reported as normal. Considering secondary hyper thyroidism pituitary MR was performed. Pituitary MR revealed a 13x18 mm macro adenoma (Figure). The patient under went transphenoidal surgery. Final diagnosis wasTSH secreting adenoma after pathological examination. After surgery head a cheand hyperthyroidism were recovered.