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The triggers of primary headaches have considerable significance for our understanding and management of headache and migraine. Triggers explain the variance in headaches - why they occur when they do. Trigger management is generally viewed as an important component of a comprehensive treatment approach for headaches. Historically, however, triggers have not had a prominent place in the headache literature. This situation began to change 20 to 30 years ago, and the pace of change has increased exponentially in recent times. Nevertheless, the field is beset with issues that have held it back from achieving more. This review will focus on elaborating those issues with the goal of suggesting ways forward. The first issue considered will be the definition of a trigger, and how specific triggers are labeled. Consideration will then be given to a classification system for triggers. The review will discuss next the evidence relating to whether self-reported triggers can, indeed, precipitate headaches, and how the capacity to elicit headaches may be acquired or extinguished. Attention will be given to the very important clinical issue of trigger management. Finally, the pathways forward will be proposed. Perhaps the most useful thing to accomplish at this point in time would be agreement on a definition of headache triggers, a list of triggers, and a classification system for triggers. This would greatly assist in comparing research on triggers from different research groups as well as eliminating some of the issues identified in this review. An authoritative body such as the American Headache Society or the International Headache Society, could establish a multidisciplinary committee that would complete these tasks. Consideration should also be given to incorporating triggers into the International Classification of Headache Disorders as an axis or via the use of codes, as this would raise the profile of triggers in assessment and management., (© 2020 American Headache Society.)

The coronavirus disease 2019 (COVID-19) pandemic has now affected more than 5 million people globally. Typical symptoms include fever, cough, and shortness of breath. Patients with underlying medical comorbidities such as cardiovascular disease and diabetes are more likely to become severely ill. To date there is limited information on how COVID-19 affects patients with a history migraine. Here, we present the cases of 2 women with a history of migraine whose first symptom of COVID-19 was a severe persistent headache., (© 2020 American Headache Society.)

The American College of Emergency Physicians (ACEP) published guidelines in July 2019 on the diagnosis and management of acute nontraumatic headaches in the emergency department, focusing predominantly on the diagnosis of subarachnoid hemorrhage and the role of imaging and lumbar puncture in diagnosis. The ACEP Clinical Policies document is intended to aide Emergency Physicians in their approach to patients presenting with acute headache and to improve the accuracy of diagnosis, while promoting safe patient care practices. The Clinical Policies document also highlights the need for future research into best practices to distinguish primary from secondary headaches and the efficacy and safety of current treatment options for acute headaches. The following commentary on these guidelines is intended to support and expand on these guidelines from the Headache specialists' perspective, written on behalf of the Refractory, Inpatient, Emergency Care section of the American Headache Society (AHS). The commentary have been reviewed and approved by Board of Directors of the AHS., (© 2020 American Headache Society.)

Objectives: This study aimed to explore the views and experiences of a group of Spanish patients suffering from new daily persistent headache (NDPH)., Methods: A qualitative descriptive study was conducted with patients diagnosed with NDPH. Purposeful sampling was performed among patients attending a specialized Headache Unit at 2 university hospitals between February 2017 and December 2018. In total, 18 patients (11 women, 7 men; mean age 45.3, standard deviation 10.6) with a median duration of illness of 70 months (interquartile range, 24-219) were recruited to this study. Data were collected through in-depth interviews, researchers' field notes and patients' drawings. Thematic analysis was used to identify emerging themes., Results: Three main themes were identified: (1) the origin of the illness and seeking answers; (2) characteristics of the pain; and (3) the impact of pain on patients' lives. The patients precisely recalled the time of onset and the trigger of the pain. Pain was constantly present, although it varied in form. At the onset, pain was perceived as a sign of alarm while, over time, it became an invisible illness. The headache commonly had a major impact on everyday life and could cause lifestyle changes. In addition, pain could be emotionally disruptive and could also lead to family estrangement and a search for solitude., Conclusions: Our results provide insight into how NDPH is experienced, which may be helpful in managing NDPH patients. In our cohort, patients identified precipitating events but sought answers regarding the origin of their illness and their pain. Pain was a continuous sensation that had a major impact on patients' daily lives and emotions., (© 2019 American Headache Society.)

Objective: The objective of this case series was to describe botulinum toxin therapy as a novel treatment of intractable head pain following lateral skull base surgery., Background: Intractable headaches following lateral skull base surgery are described in 23%-75% of patients and can significantly impact quality of life. Currently, the etiology of the headaches is unclear and treatment options are limited. Botulinum toxin is indicated for a multitude of functional and cosmetic reasons, including chronic migraine, and has been further described in treatment of various postsurgical pain syndromes., Methods: In this case series, 4 patients underwent subcutaneous peri-incisional injections of botulinum toxin for intractable headache and head pain syndromes. Three patients had undergone lateral skull base surgery and the fourth patient had undergone a temporoparietal fascial flap harvest. Average injection dose ranged from 20 to 60 units with an average duration of effect ranging from 2 weeks to 4 months., Results: All patients experienced significant relief of chronic head pain and returned for additional peri-incisional botulinum toxin injections, suggesting meaningful patient-perceived value., Conclusions: Botulinum toxin therapy may represent a novel treatment for intractable head pain following lateral skull base surgery and temporoparietal fascial flap harvest. This study represents a small case series and, although 100% of the patients who were treated significantly improved, future inquiry is necessary to confirm these findings., (© 2019 American Headache Society.)

Objective: This study investigated a potential association between visual factors and symptoms related to migraine. It was predicted that photophobia and visual aura would be positively associated with interictal light sensitivity and visual headache triggers (flicker, glare, and eyestrain), and that these 2 visual symptoms would also be associated., Background: Previous studies have found independent neurophysiological associations between several visual factors and symptoms related to headache disorders. Many of these connections appear to be associated with increased cortical hypersensitivity, a phenomenon that might be in part due to repeated avoidance and reduced tolerance to triggers. If true, and if associations between visual factors and symptoms can be established, this may have implications for an exposure-based treatment for migraine symptoms., Methods: Four hundred and ninety-one participants (411 female, 80 male) were recruited through Griffith University (AUS), Headache Australia, Pain Australia, and through social media. Participants were grouped based on the presence of headache disorder symptoms and the presence or absence of photophobia and/or visual aura. A cross-sectional online survey design was utilized to gather information pertaining to interictal light sensitivity, visual triggers, and visual symptoms., Results: With respect to interictal light sensitivity and photophobia, a significant difference (P < .001, eta squared [η 2 ] = 0.084) was found between the 3 groups, where headache disorder participants with photophobia (group A1; mean [M] = 2.5, standard deviation [SD] = 0.97) reported significantly greater light sensitivity than participants with headache disorder and no photophobia (A2; M = 1.68, SD = 0.62) and control group participants (A3; M = 1.82, SD = 0.85). This pattern was repeated for participants reporting flicker as a headache trigger (P < .001, η 2 = 0.061), with group A1 (M = 2.45, SD = 1.24) significantly higher than groups A2 (M = 1.68, SD = 0.83) and A3 (M = 1.68, SD = 0.89), and was also seen for glare as a headache trigger (P < .001, η 2 = 0.092), with group A1 (M = 2.92, SD = 0.96) significantly higher than A2 (M = 2.31, SD = 0.89) and A3 (M = 2.09, SD = 0.93). This pattern of results was not replicated for headache disorder participants with and without visual aura. A significant association (P < .001) was found between photophobia and visual aura in headache disorder participants based on a chi-square test of independence, with 86/136 participants reporting either both or neither visual symptom., Conclusions: This study supports a link between certain visual phenomena in headache disorder populations, and supports future research into exposure-based treatments for migraine symptoms., (© 2019 American Headache Society.)

Background: Persistent post-stroke headache is a clinical entity that has recently entered the International Classification of Headache Disorders, 3rd edition. In contrast to acute headache attributed to stroke, the epidemiology, clinical features, potential pathophysiology, and management of persistent post-stroke headache have not been reviewed., Methods: We summarize the literature describing persistent headache attributed to stroke., Results: Persistent headache after ischemic or hemorrhagic stroke affects up to 23% of patients. These persistent headaches tend to have tension-type features and are more frequent and severe than acute stroke-related headaches. Risk factors include younger age, female sex, pre-existing headache disorder, and comorbid post-stroke fatigue or depression. Other factors including obstructive sleep apnea or musculoskeletal imbalances may contribute to headache persistence. Although more evidence is needed, it may be reasonable to treat persistent post-stroke headache according to headache semiology., Conclusion: Recognition of persistent post-stroke headache as a separate clinical entity from acute stroke-attributed headache is the first step toward better defining its natural history and most effective treatment strategies., (© 2018 American Headache Society.)

Objective: In this retrospective study of active duty service members (ADSMs), possible relationships were examined between extent of headache pain depicted on head/neck diagrams and headache phenomenology., Background: The signature injury of US military operations in Iraq and Afghanistan is mild traumatic brain injury (mTBI). Blast injury, especially from improvised explosive devices, was the most common cause during the height of the wars; the most persistent symptom remains posttraumatic headache (PTH). Neurologic patients were asked to draw pain diagrams/maps, a method of pain assessment in several clinical settings., Methods: Thirty-four ADSMs attributing PTH to both blast and non-blast sources underwent clinical evaluations; diagnoses and headache characteristics were obtained. They completed 58 drawings depicting craniofacial/cervical headache pain on non-standardized templates. Drawings were of 29 continuous and 29 non-continuous headaches (CHA and NCHA, respectively). Surface area was calculated using a grid and expressed as a percentage., Results: The sample was male (100%), primarily white (83%), with an average age of 30.3 years. Evidence for statistical independence of observations is provided (intra-class correlation = 0.004). Percent surface area was larger for CHA (median [mdn] = 35.2, interquartile range [IQR] = 9.0, 78.3) than NCHA (mdn = 9.1, IQR = 5.4, 34.1, P = .029). In those with blast injury, CHA percent surface areas (mdn = 45.9, IQR = 27.0, 100) were larger than NCHA (mdn = 11.6, IQR = 5.8, 28.9; P = .0012), a relationship not observed in patients with PTH from non-blasts (CHA: mdn = 26.8, IQR = 8.5, 52.0; NCHA: mdn = 9.1, IQR = 5.0, 47.6, P = .050). This pattern is observed after pooling at the median (blast, P < .012; non-blast: P = .264)., Conclusion: Painful craniofacial/cervical surface area, as shown on patient drawings, is related to PTH phenomenology (continuous versus non-continuous headache). This relationship is stronger after blast injury., (© 2018 American Headache Society.)

Objective: The objective of this article is to report a rare case of headache as the initial symptom of granulomatosis with polyangiitis (GPA) and to review the recent literature., Background: Granulomatosis with polyangiitis is a rare, systemic, autoimmune disease of unknown etiology. GPA has a wide spectrum of clinical symptomatology, including involvement of the nervous system, even as the initial manifestation. Symptoms of the peripheral nervous system used to dominate the clinical symptomatology. However, recent reports are focusing increasingly in granulomatous lesions of the central nervous system, and especially on the increased frequency of patients with hypertrophic pachymeningitis (HP). We report the case of a patient with headache linked to intracranial hypertension and hypertrophic pachymeningitis as the initial and dominant presentation of GPA and we review the recent literature., Methods: A 54-year-old male, without any related medical history developed a severe headache. In the following 2 months, he gradually developed hoarseness and diplopia at the left and lower fields of vision. A brain MRI revealed wide-spread fattening and meningeal enhancement over the left hemisphere and the left cerebellar hemisphere. An endoscopy of the pharynx revealed the presence of a tumor-like mass in the left half of the nasopharynx. A biopsy showed inflammation with presence of polykaryocyte Langhans giant cells. The laboratory testing revealed important albuminuria and microhematuria, positive c-ANCA and negative p-ANCA. A diagnosis of GPA was established., Results: A steroid treatment was administered initially, which improved the headache drastically, followed by the administration of a combination of cyclophosphamide and corticosteroid, which led to a gradual resolve of the remaining symptomatology. A follow-up brain MRI showed a decrease in meningeal enhancement, whereas a second one, 2 years later, was completely normal., Conclusions: HP was considered an extremely rare manifestation of GPA. However, recent studies are reporting an increased frequency of HP and are distinguishing a granulomatous and a vasculitic phenotype, with different localization and relapse rates, that may eventually constitute a different clinical spectrum of GPA., (© 2018 American Headache Society.)

Objective: We present a case of a patient who had severe unilateral headaches related to a small, unruptured ophthalmic artery aneurysm, who experienced complete headache cessation following endovascular coiling., Background: Small unruptured intracranial aneurysms are generally managed and followed conservatively due to minimal risk of rupture. Headaches are frequently reported in patients with intracranial aneurysms, but these aneurysms are typically considered incidental and unrelated, given the undefined association between headaches and most aneurysms., Conclusion: There may be some unruptured intracranial aneurysms that can cause intractable headaches and warrant interventional treatment. Future prospective studies are needed that compare pre- and post-procedure headache character and diagnosis, aneurysm characteristics such as size, location, orientation, and shape, type of aneurysm repair with materials used, and other potential risk factors for worsening post-procedure headache in order to better predict headache association to aneurysms, as well as outcomes following endovascular aneurysm treatment., (© 2015 American Headache Society.)

Objective: To define what are the age and gender differences for new daily persistent headache (NDPH) triggering events and how this may relate to the pathogenesis of NDPH. To describe several new triggering events for NDPH., Methods: All patients were diagnosed with primary NDPH at a headache specialty clinic during the time period of 01/2009 through 01/2013. This was a retrospective analysis of patient medical records utilizing an electronic medical record system., Results: Ninety-seven patients were diagnosed with primary NDPH (65 women and 32 men). The mean average age of onset was younger in women than men 32.4 years vs 35.8 years. Fifty one of ninety seven NDPH patients (53%) did not recognize a triggering event while an infection or flu-like illness triggered NDPH in 22%, a stressful life event in 9%, a procedure (surgical) in 9%, and some "other" recognized trigger in 7%. All of the NDPH patients who developed new onset headache after an invasive surgical procedure were intubated. There was no significant difference in frequency for any of the triggering events between genders. The youngest age of onset was for a post stressful life event trigger while the oldest age of onset was in the post-surgical subgroup. Women developed NDPH at a younger age of onset for all recognized triggers, but there was no significant difference in ages of onset between the genders. There was no significant difference in the number of NDPH patients who had a history of migraine or no history and if they developed NDPH after any triggered event vs no triggering event. However, the majority of patients who developed NDPH after a stressful life event did have a precedent migraine history (67%). Newly noted triggers include: hormonal manipulation with progesterone, medication exposure, chemical/pesticide exposure, massage treatment, and immediately post a syncopal event., Conclusion: More than 50% of NDPH sufferers do not recognize a triggering event to their headaches. A key finding from the present study is the recognition that of those patients who developed NDPH after an invasive surgical procedure all required intubation and we speculate a cervicogenic origin to their headaches. The fact that both genders had an almost equal rate of occurrence for most NDPH triggers and almost the same age of onset suggests a common underlying pathogenesis for similar triggering events. A precedent history of migraine did not enhance the frequency of triggered vs nontriggered NDPH except possibly for a stressful life event., (© 2015 American Headache Society.)

Botulinum neurotoxin (BoNT) has been used successfully to treat primary headache syndromes, but there are no published data on its use for chronic postcraniotomy headache. Botulinum neurotoxin type A (BoNT-A) (4:1 dilution) was injected at a dose of 15-50 units into peri-incisional sites of the scalp in 3 patients who had undergone craniotomy remotely for traumatic epidural hematoma. All patients reported reductions in headache lasting at least 2.5 months. Repeat injections were performed in all cases with favorable outcomes. There were no complications. Peri-incisional BoNT-A appears to be a potentially valuable tool in the chronic management of post craniotomy headache after traumatic brain injury., (Copyright © 2015 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)

Background and Purpose: Our aim was to prospectively describe the course of headache during the first year of idiopathic intracranial hypertension (IIH)., Methods: Patients with newly diagnosed IIH were consecutively included from December 2010 to June 2013. Treatment according to standard guidelines was initiated. Headache history was obtained by headache diaries and standardized interviews performed at baseline and after 1, 2, 3 and 12 months. Parallel changes in papilledema were assessed by optical coherence tomography (OCT). All patients had comprehensive neuro-ophthalmological examinations including automated perimetry., Results: Forty-four patients were included. Thirty-five patients completed the 12-month follow-up. Dramatic improvement in headache occurred within the first weeks after diagnosis. After 1 year, 15 patients reported no or only infrequent headache. However, 15 of the remaining 20 patients reported sustained chronic headache. Early age of onset and high diagnostic intracranial pressure (ICP) were associated with better headache outcome (≤1 headache days/month) after a year. Papilledema decreased rapidly within the first 2 months of diagnosis. After 1 year, OCT measures had normalized. Visual outcome was excellent in most patients., Conclusions: Although headache in 43% of patients responded well to ICP management, sustained long-term headache was seen in the remaining patients, despite resolution of papilledema. Headache in IIH may thus be attributed to more complex mechanisms than ICP elevation alone. High ICP and young age were associated with better headache outcome. Early treatment according to standard guidelines seems sufficient to ensure excellent visual outcome in the vast majority of patients., (© 2014 EAN.)

Objective: Our aim was to investigate CO(2) laser-evoked potential (LEP) habituation to experimental pain in a group of patients affected by medication-overuse headache, with a history of episodic migraine becoming chronic, before and after treatment, consisting in acute medication withdrawal and a preventive treatment cycle., Background: One of the main features of LEPs in migraineurs is a lower habituation to repetitive noxious stimuli during the interictal phase., Methods: LEPs were recorded to stimulation of both the right hand and the right perioral region in 14 patients and in 14 healthy subjects. The habituation of both the N1 and the vertex N2/P2 components was assessed by measuring the LEP amplitude changes across 3 consecutive repetitions of 30 trials each., Results: In the 8 patients who had clinically improved after treatment, the N2/P2 amplitude habituation was significantly higher after treatment than before treatment following both hand (F = 43.2, P < .0001) and face stimulation (F = 6.9, P = .01). In these patients, the N2/P2 amplitude habituation after treatment was not different from that obtained in healthy controls (P = .18 and P = .73 for hand and face stimulation, respectively). On the contrary, in the patients who did not improve, the N2/P2 amplitude still showed reduced habituation after both hand (F = 3.1, P = .08) and face (F = 0.7, P = .4) stimulation., Conclusion: The deficient habituation of the vertex N2/P2 complex was partly restored after successful treatment of medication-overuse headache, reflecting a modification in pain-processing pathways., (© 2012 American Headache Society.)

Objective: To determine the prevalence and characteristics of, and factors associated with, chronic daily headache (CDH) in U.S. soldiers after a deployment-related concussion., Methods: A cross-sectional, questionnaire-based study was conducted with a cohort of 978 U.S. soldiers who screened positive for a deployment-related concussion upon returning from Iraq or Afghanistan. All soldiers underwent a clinical evaluation at the Madigan Traumatic Brain Injury Program that included a history, physical examination, 13-item self-administered headache questionnaire, and a battery of cognitive and psychological assessments. Soldiers with CDH, defined as headaches occurring on 15 or more days per month for the previous 3 months, were compared to soldiers with episodic headaches occurring less than 15 days per month., Results: One hundred ninety-six of 978 soldiers (20%) with a history of deployment-related concussion met criteria for CDH and 761 (78%) had episodic headache. Soldiers with CDH had a median of 27 headache days per month, and 46/196 (23%) reported headaches occurring every day. One hundred seven out of 196 (55%) soldiers with CDH had onset of headaches within 1 week of head trauma and thereby met the time criterion for posttraumatic headache (PTHA) compared to 253/761 (33%) soldiers with episodic headache. Ninety-seven out of 196 (49%) soldiers with CDH used abortive medications to treat headache on 15 or more days per month for the previous 3 months. One hundred thirty out of 196 (66%) soldiers with CDH had headaches meeting criteria for migraine compared to 49% of soldiers with episodic headache. The number of concussions, blast exposures, and concussions with loss of consciousness was not significantly different between soldiers with and without CDH. Cognitive performance was also similar for soldiers with and without CDH. Soldiers with CDH had significantly higher average scores on the posttraumatic stress disorder (PTSD) checklist compared to soldiers with episodic headaches. Forty-one percent of soldiers with CDH screened positive for PTSD compared to only 18% of soldiers with episodic headache., Conclusions: The prevalence of CDH in returning U.S. soldiers after a deployment-related concussion is 20%, or 4- to 5-fold higher than that seen in the general U.S. population. CDH following a concussion usually resembles chronic migraine and is associated with onset of headaches within the first week after concussion. The mechanism and number of concussions are not specifically associated with CDH as compared to episodic headache. In contrast, PTSD symptoms are strongly associated with CDH, suggesting that traumatic stress may be an important mediator of headache chronification. These findings justify future studies examining strategies to prevent and treat CDH in military service members following a concussive injury., (© 2012 American Headache Society.)

Objective: To determine the prevalence of headaches and their influencing factors among pregnant women., Methods: A cross-sectional study was conducted from January 3 to April 29, 2005, with 1357 women receiving routine pregnancy check-ups at the obstetric clinics of the community health institutions of Kayseri, Turkey. A structured questionnaire and the Zung Depression Scale were used to collect data., Results: Overall, 24.6% (95% confidence interval, 22.3%-26.9%) of the participants had headaches before pregnancy, whereas only 17.9% (95% confidence interval, 15.9%-20.1%) had headaches during pregnancy. Although the headache prevalence was lower during than before pregnancy, it was high among the participants aged 35 years or older, those who received help in their housework, and those who were multiparous. Moreover, the Zung depression score was significantly high among those experiencing headaches., Conclusion: The significant decrease in headache prevalence observed during pregnancy may be the result of a pregnancy-specific hormonal status. However, the most significant factors influencing the frequency of headaches in the participants were related to their socioeconomic status and the severity of depression., (Copyright © 2012 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.)

Background: Based on our encounters with patients who have been treated for unruptured intracranial aneurysms by endovascular coil embolization using bioactive coils, we observed that such patients often present with headaches and fever., Objective: The purpose of this study was to evaluate the incidence of headache and fever after coil embolization using bioactive coils., Methods: A database of 92 intracranial unruptured aneurysm patients (88 patients who did not have chronic headaches or migraines before treatment) on whom coil embolization had been performed between July 2007 and October 2010 was retrospectively assessed. Forty-five aneurysms (43 patients) were treated using bioactive coils and the other aneurysms were treated using bare coils. We analyzed the incidence and duration of headache, temperature, C-reactive protein, and white blood cell count before and after coil embolization and compared the 2 groups., Results: Forty-one patients (46.6%) reported onset of headaches just after treatment. Headache incidences were significantly greater in the patients treated with bioactive coils (bioactive coil group: 62.8% [27/43] vs bare coil group: 31.1% [14/45], P = .003), and the duration of headaches was significantly longer in the bioactive coil group (bioactive coil group: 3.44 ± 1.22 days vs bare coil group: 2.40 ± 1.17 days, P = .027). Seventy-one patients (80.7%) had incidences of fever (over 37°C) after treatment (bioactive coil group: 83.7% [36/43] vs bare coil group: 77.8% [35/45], P = .663). The duration of fever was significantly longer in the bioactive coil group (bioactive coil group: 2.9 ± 1.4 days vs bare coil group: 1.9 ± 1.1 days, P = .0017), and temperatures at 1, 2, or 3 days after treatment were significantly higher in the bioactive coil group (respective temperatures at 1, 2, 3 days after treatment: bioactive coil group: 37.42 ± 0.49, 37.19 ± 0.45, 37.00 ± 0.49 vs bare coil group: 37.14 ± 0.38, 36.96 ± 0.41, 36.63 ± 0.51, P = .009, P = .0246, P = .0032). There were no significant differences in C-reactive protein level and white blood cell count 1 and 3 days after treatment between 2 groups., Conclusions: Bioactive coils induce headache and fever after coil embolization for intracranial aneurysms due to the inflammatory effects of polyglycolic acid used to accelerate aneurysm fibrosis and neointimal formation., (© 2011 American Headache Society.)

Occipital nerve neuralgia is a rare cause of severe headache, and may be difficult to treat. We report the case of a patient with occipital nerve neuralgia caused by pathological contact of the nerve with the occipital artery. The pain was refractory to medical treatment. Surgical decompression yielded complete remission., (© 2010 American Headache Society.)

Background: Chronic headache is one of the most prominent symptoms among subjects with traumatic head injury (THI). Despite the relatively high prevalence of chronic post-traumatic headache (CPTHA) and its enormous effect on the already poor quality of life of subjects with THI, its mechanisms has not been studied in depth., Objective: To conducted quantitative somatosensory testing in THI subjects with and without chronic post-traumatic headache (CPTHA) in order to shed light on the yet, unknown pathophysiology of CPTHA., Methods: THI subjects with and without CPTHA and healthy controls underwent thermal and mechanical threshold measurements in painful and pain-free regions in the head and in their hands (a remote pain-free region) and filled out and the post-traumatic stress disorder (PTSD) inventory. In addition, the THI and CPTHA filled out the Mc'Gill pain questionnaire (MPQ)., Results: THI subjects with CPTHA had significantly higher thermal thresholds in both the head and hand indicating central damage to the pain and temperature system and in addition, a significantly lower pressure-pain threshold in the head as well as more severe PTSD symptomatology than the pain-free THI subjects and healthy controls., Conclusions: The sensory profile of subjects with CPTHA suggests that CPTHA may be a form of central pain. The cranial mechanical hyperalgesia may originate from peripheral tissue damage accompanying the THI. Psychological factors may contribute to the development, and maintenance of CPTHA in susceptible individuals., (Copyright © 2010 European Federation of International Association for the Study of Pain Chapters. Published by Elsevier Ltd. All rights reserved.)

Giant cell arteritis (GCA) should be considered in the differential diagnosis of any new onset headache occurring in individuals over the age of 50 years. Headache is the most common complaint in GCA patients but the clinical characteristics of the headache itself does not help in making a diagnosis as the headache can occur anywhere on the head, not just the temples, be mild to severe in intensity and be dull to throbbing in quality. As other things can cause new onset headache in older individuals, additional clinical symptoms or signs that may suggest GCA as a diagnosis would be useful to clinicians. Two cases are presented that suggests that new onset stabbing headache associated with a new daily persistent headache is a possible diagnostic sign for a diagnosis of GCA. Nothing in the literature to date has mentioned new onset stabbing headache as part of the presenting symptom complex for GCA.

Spontaneous intracranial hypotension (SIH) is typically characterized by orthostatic headache; however, various atypical manifestations of SIH have been reported recently. We report here the case of a 46-year-old man with headache secondary to SIH, which was nonorthostatic, triggered only when the patient shook his head. We suggest that SIH should be suspected in patients with headache induced by head-shaking, even without orthostatic features, especially when the headache is accompanied by other symptoms commonly associated with SIH.

Background: Some types of headaches with sinonasal origin may be present in the absence of inflammation and infection. The contact points between the lateral nasal wall and the septum could be the cause of triggering and sustained pain via trigeminovascular system., Objective: The aim of this study was to evaluate the feasibility and effectiveness of endoscopic surgery in the sinonasal region for treatment of headache with special attention paid to specific diagnostic methods and patient selection., Methods: This was a prospective, non-randomized and semi-quasi experimental research study. Thirty-six patients with chronic headaches who had not previously responded to conventional treatments were evaluated by rhinoscopy and/or endoscopy, local anesthetic tests and computed tomography scans as diagnostic criteria. These patients were divided into 4 groups based on the diagnostic methods utilized. The intensity of headaches pre- and post-operatively were recorded by utilizing the visual analog scale scale and performing analysis with analysis of variance test comparison and Statistical Package for Social Sciences. Average follow-up was 30 months., Results: Our overall success rate approximated 83% while the complete cure rate was 11%. Patients in group 4 achieved the best results. In this group all diagnostic criteria were positive. In addition, patient responses were statistically significant in groups with more than one positive criteria compared with group 1 who only had positive examination. The positive response of 14 migrainous patients diagnosed with migraine prior to treatment was 64%., Conclusion: Surgery in specific cases of headaches with more positive evidence of contact point could be successful, particularly if medical therapy has failed.

Acquired cerebellar tonsillar herniation is a known complication of lumboperitoneal shunt (LPS) for any indication, including idiopathic intracranial hypertension (IIH), also known as pseudotumor cerebri.(1) While the underlying pathophysiology of IIH remains unknown, increasing body mass index is a clear risk factor for the development of IIH. We describe an obese patient with IIH unresponsive to LPS who developed symptoms of intracranial hypotension and cerebellar tonsillar herniation after bariatric surgery and a 50-kg weight loss.

There are several ways in which stress may interact with migraine in those predisposed to migraine attacks. These interactions may result from biochemical changes related to the physiological stress response, as, for example, the release of corticotrophin releasing hormone, or from changes induced by the psychological response to stressors. Stress is the factor listed most often by migraine sufferers as a trigger for their attacks, but in addition there is evidence that stress can help initiate migraine in those predisposed to the disorder, and may also contribute to migraine chronification. Migraine attacks themselves can act as a stressor, thereby potentially leading to a vicious circle of increasing migraine frequency. Since the important factor in the stress-migraine interaction is likely the individual's responses to stressors, rather than the stressors themselves, the acquisition of effective stress management skills has the potential to reduce the impact of stressors on those with migraine.

The prevalence of tension-type headache and vitamin D deficiency are both very high in the general population. The inter-relations between the two have not been explored in the literature. We report 8 patients with chronic tension-type headache and vitamin D deficiency (osteomalacia). All the patients responded poorly to conventional therapy for tension headache. The headache and osteomalacia of each of the 8 patients responded to vitamin D and calcium supplementation. The improvement in the headache was much earlier than the improvements in the symptom complex of osteomalacia. We also speculate on the possible mechanisms for headache in the patients with vitamin D deficiency.

Objective: To investigate both concurrent and prospective relationships between daily frustration, cognitive coping and coping efficacy on the one hand and daily headache occurrence on the other., Methods: Eighty-nine adolescents aged 13-21 completed an online daily diary for 3 weeks. Data were analyzed using multilevel modeling., Results: Daily frustration of goal pursuits was significantly related to both same day and next day headache occurrence. Coping efficacy beliefs were significantly related to lower next day headache occurrence (no same day relationship was found). None of the cognitive coping strategies used in response to daily frustration were related to headache occurrence on the same or next day., Conclusions: Daily frustration to goal pursuit is suggested to be an important stressor contributing to concurrent and prospective headache occurrence. Furthermore, the extent to which adolescents believe in their ability to cope also appears to influence experience of subsequent headache. Further prospective studies are necessary to confirm these findings and to further unravel the possibly reciprocal relations between these factors. These findings offer useful insights into the dynamic interplay between daily stressful experiences and headache in youths.

Objectives: To assess whether family history for chronic headache (CH) and drug overuse could represent a risk factor for headache chronification., Background: Among factors investigated as risk factors for chronification of headache disorders, familial liability for CH and drug overuse has been rarely investigated., Patients and Methods: A total of 105 consecutive patients with daily or nearly daily headache, and 102 consecutive patients with episodic headache matched by age, sex, and type of headache at onset, underwent a structured direct interview about family history for episodic headache, CH with and without medication overuse, substance abuse/dependence, and psychiatric disorders., Results: In total, 80 out of 105 patients with CH received a diagnosis of medication overuse headache (MOH), 21 patients were classified as chronic migraine (CM), and 4 as chronic tension-type headache (CTTH) without drug overuse. Some 38.1% of CH patients reported family history for CH vs only 13.7% of episodic headaches (P = .001). Familiality for CH with medication overuse was reported by 25.7% of cases vs 9.8% of controls (P = .0028). A familial history of substance abuse was reported by 20% of patients vs 5.9% of controls (P = .0026). In all, 28.7% of MOH patients reported family history for CH with medication overuse (P = .0014) and 21.2% for substance abuse (P = .002). Relatives of patients with MOH were more likely than control relatives to suffer from CH (OR = 4.19 [95% CI 2.05-8.53]), drug overuse (OR = 3.7 [95% CI 1.66-8.24]), and substance abuse (OR = 4.3 [95% CI 1.65-11.19]). No differences regarding family history for episodic headache and for psychiatric disorders were found. No differences in family history for CH with drugs overuse and for substance abuse were found between CH patients without overuse and controls. Fifteen CH patients reported family history for alcohol abuse (P = .0003)., Conclusions: The significantly increased familial risk for CH, drug overuse, and substance abuse suggests that a genetic factor is involved in the process of headache chronification.

Objective: The object of this study is to investigate the prevalence and characteristics of headache in Korean professional women breath-hold divers, including their overuse of analgesics., Background: Headache is a common problem encountered in clinical practice, and undersea divers exhibit unique causes of headache in addition to other common primary headaches. Many scuba divers are known to use various types of drugs to overcome dive-related symptoms or to enhance their underwater performance., Methods: The target population of this study was women divers in the northern district of Jeju Island who were registered in the divers' union. Data were collected using telephone interviews with a structured questionnaire. Headache was diagnosed and classified according to criteria of the International Headache Society., Results: Nine hundred and eleven (80.3%) divers responded to the telephone interview. The prevalence rates of headache were 21.4% for tension-type headache and 9.1% for migraine. One hundred and four divers (11.4%) fulfilled the criteria for chronic daily headache (CDH). Overuse of combination analgesics was reported by 70.7% of divers. Women divers with CDH were significantly older and they complained more of tinnitus and dizziness, and had a greater history of hypertension than divers without headache., Conclusion: The prevalence of CDH is high in Korean professional women breath-hold divers, with many of them being combination-analgesics overusers.

Chronic daily headaches (CDH) affect between 3 and 4% of the Western population and is one of the most common problems seen in the neurology clinic. It is often difficult to delineate where CDH began and medication overuse headache (MOH) supervenes. The current study analyses the development of MOH in people taking regular analgesia for reasons other than headache, namely patients attending rheumatology clinics. The aim of this study was to assess, for the first time in an Irish population of patients, whether CDH was more common in such patients as previously reported. We also wanted to see how often rheumatology patients were taking non-prescribed analgesics. The results show that, in a cohort of 114 rheumatology patients, 32% reported that they suffer from headaches regularly. Of these, 38% fulfilled criteria for CDH (or 12% of the whole cohort). Of the 14 patients with CDH, 11 also fulfilled the International Classification of Headache Disorders criteria for MOH. Seventy per cent of the patients fell under the category of medication overuse (>15 days a month for > 3 months) but only 9% fulfil criteria for MOH. Contrary to the previous work in this area, we found a very low (< 2 %) incidence of previous migraine in our patients with CDH. We conclude that headaches (both CDH and MOH) are common in this patient population. We suggest that here should be greater awareness amongst all doctors caring for these patients of the potential for creating a second chronic problem when using excessive analgesia to treat the first.

Background: Stress, one of the most commonly identified triggers for primary headache in the workplace, usually leads to inefficient work during attacks. Stress-related primary headaches in the nursing staff of hospitals have received little attention., Objective: To realize the association between stress and headache, and the means of coping with this kind of headache., Methods: A cross-sectional, hospital-based study using a semi-structured questionnaire was administered to 900 nursing staffers in a tertiary medical center in southern Taiwan. Thirty-two items, including basic information, headache- and stress-related questions, work satisfaction, and coping strategies were measured. Headache sufferers with either migraine or episodic tension headache (attacks <15 days per month) based on International Headache Society (IHS) criteria were enrolled for analysis. The Student's t-test, one-way analysis of variance (ANOVA), and chi-square test were used for statistical analysis., Results: Three hundred eighty-six out of 779 responders (49.6%) had experienced primary headaches in the previous year, and 374 (48.1%) had had episodic-type headaches (<15 days/month). A careful neurological interview of the latter group revealed that 222 (28.5%) had migraine, 104 (13.4%) had tension headache, 37 (4.8%) had mixed migraine and tension headache, and 11 (1.4%) had other causes of headache. There were no demographic differences between the sufferers and nonsufferers, although a statistically significant difference was noted in self-reported sources of stress (individual P values ranged from .021 to < .001). Headache sufferers had more stress at work than non-headache sufferers (P < .001). The youngest and least experienced of the nursing staff, the unmarried, and those with a lower level of education had a higher level of stress. The methods used to deal with headaches were sleep, taking medicine, taking a rest, visiting the doctor, and seeking psychological help. Nurses commonly used acetaminophen (panadol--500 mg) to relieve their pain., Conclusion: These results indicate that stress at work is associated with primary headaches among nursing staff, and that nurses rarely seek help in the beginning. Therefore, nursing staff education aimed at ameliorating the stress and coping with the headaches, thus allowing the nurses to provide better patient care, may be warranted.

We describe an interesting case of a 40-year-old lady who developed a spontaneous low-pressure headache whilst playing the bag-pipes. Playing wind instruments requires the generation of significant intra-thoracic pressure, which may have contributed to this musician's condition.

Headache is a chronic disease that occurs with varying frequency and results in varying levels of disability. To date, the majority of research and clinical focus has been on the role of biological factors in headache and headache-related disability. However, reliance on a purely biomedical model of headache does not account for all aspects of headache and associated disability. Using a biopsychosocial framework, the current manuscript expands the view of what factors influence headache by considering the role psychological (i.e., cognitive and affective) factors have in the development, course, and consequences of headache. The manuscript initially reviews evidence showing that neural circuits responsible for cognitive-affective phenomena are highly interconnected with the circuitry responsible for headache pain. The manuscript then reviews the influence cognitions (locus of control and self-efficacy) and negative affect (depression, anxiety, and anger) have on the development of headache attacks, perception of headache pain, adherence to prescribed treatment, headache treatment outcome, and headache-related disability. The manuscript concludes with a discussion of the clinical implications of considering psychological factors when treating headache.

Objective: To assess and contrast the relative frequency of a past history of physical and/or sexual abuse in patients with chronic daily headache (CDH) versus migraine., Background: A number of risk factors have been identified as risk factors for chronification of headache disorders. Limited data exist regarding the influence of physical and/or sexual abuse on primary headache disorders., Methods: This was a retrospective chart review of 183 consecutive new headache patients seen from December 2004 through August 2005 at an outpatient tertiary-care center. Patients were included in the study if they had chronic daily headache (with criteria for medication over-use headache or chronic migraine), or migraine with or without aura. A history of physical and/or sexual abuse was systematically asked of all headache patients at their first visit in the clinic. This information was then transferred to a semi-standardized form and the relative frequency of abuse in both groups contrasted., Results: Of the 161 patients included in the study, 90.1% were female with a mean age of 36.4 +/- 12.0. A total of 59.0% of the patients were diagnosed with CDH and 41.0% were diagnosed with migraine. Overall, 34.8% of all patients, 40.0% of CDH patients, and 27.3% of migraine patients had a history of physical and/or sexual abuse. The relative frequency of a history of physical and/or sexual abuse was higher in the CDH group as compared to the migraine group (P = .048)., Conclusion: The relative frequency of abuse is higher in CDH sufferers than migraineurs, suggesting that physical and sexual abuse may be risk factors for chronification.

Objective: The aim was to evaluate whether preventive treatment with topiramate in patients with episodic migraine reduces the risk of developing chronic forms of headache., Background: Chronic forms of headache, including chronic migraine or medication overuse headache (MOH), are characterized by 15 or more headache days per month. Acute medication overuse has been shown to be a risk factor for developing chronic headache, but it is not known whether preventive treatment can reduce the risk of developing chronic forms of headache or the development of MOH., Methods: Pooled data from 3 trials in patients with episodic migraine randomized either to treatment with 100 mg topiramate per day (n = 384) or with placebo (n = 372) were analyzed with regard to the number of headache days during a prospective 4-week baseline period and the individual final 4 weeks of each patient's treatment during the planned 26-week double-blind treatment period., Results: The number of headache days per month in the topiramate versus the placebo-treated groups was 7.3 +/- 3.0 versus 7.3 +/- 3.1 during baseline and 4.1 +/- 4.2 versus 5.6 +/- 4.9 during the final 4 weeks, respectively (P < .001). At the end of the study, 8 versus 16 patients fulfilled International Headache Society criteria of chronic headache (odds ratio: 2.11, P= .082). Moreover, a significantly lower number of patients receiving topiramate treatment reported an increase in headache days per month by the end of the study when compared to placebo (66 vs 88 patients, respectively; odds ratio: 1.49, P < .05). Finally, the number of days with usage of acute medication was significantly lower in the topiramate arm compared with placebo (3.3 +/- 3.7 vs 4.3 +/- 3.6, respectively; P < .001)., Conclusion: Preventive treatment with topiramate in patients with episodic migraine may reduce the risk of developing chronic forms of headache.