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Malaria is a febrile and potentially fatal infection. It is typically transmitted to humans through the bite of Anopheles mosquitoes and less frequently can be contracted through blood transfusions, sharing contaminated needles and syringes, mother-to-child transmission, or after solid organ transplantation. Posttransplant malaria has rarely been reported in the literature, even in endemic areas. We report the cases of three solid organ recipients in which Plasmodium vivax infection was documented during postsurgical evaluation 30 days after transplant surgery. The diagnosis of donor-derived malaria was confirmed in all patients by demonstrating Plasmodium in a peripheral blood smear and by polymerase chain reaction (PCR). All recipients had symptoms. The liver transplant recipient had myalgia, arthralgia, and thrombocytopenia; the kidney transplant recipient developed acute renal failure; and the heart transplant recipient had fever, cephalalgia, and tonic-clonic seizures. Pre-transplant screening of donors and recipients from endemic regions may not be sufficient to safely rule out persistent malaria. In Colombia, according to legislation, no mandatory testing is required for the diagnosis of malaria in organ donors in nonendemic areas. Therefore, donor screening by questionnaire is the only tool for preventing transplant-borne malaria. The migratory trend from Venezuela to Colombia has increased the number of imported cases of malaria, and the infection may be present in endemic and nonendemic regions. Although donor evaluation is not standardized in current guidelines, we suggest that donors be tested for malaria with a peripheral blood smear, detection of specific IgG antibodies against Plasmodium, and techniques such as PCR, if possible.

Introduction Malaria is an endemic infection in tropical circles. It can be transmitted from mosquitoes bite, but exceptional cases have been attributed to multiorgan transplantation. Case report This is a 34 years-old woman who received a heart transplant for final stage dilated cardiomyopathy. Over the hospitalization, she developed fever, cephalalgia, and tonic-clonic seizures with MRI findings compatible with posterior reversible encephalopathy. A thick blood smear revealed hemoparasitic forms of Plasmodium vivax. Afterward, malaria was also diagnosed in recipients of one kidney and liver of the same organ-donor. First-line treatment with artesunate was prescribed for three days and chloroquine with primaquine thereafter for fourteen days. The patient was discharged and returned to the emergency department five days later, complaining of gastrointestinal symptoms and develop multiorgan failure that led to death. Conclusion We report a case of malaria transmission through heart transplantation. Despite adequate and supervised treatment, it can be related to a fatal outcome. Malaria screening in organ donors should be considered in regions where endemicity can lead to rare cases of transmission by transplantation.

Microvascular brain injury is well recognized in neuropsychiatric systemic lupus erythematosus (SLE), but cerebral large artery involvement is being debated. Three females with SLE, aged 9 to 14 years, had immunosuppressive treatment intensification because of lupus nephritis. Within the following days or weeks, they presented with intense cephalalgia - isolated or associated with neurological symptoms - and no or mild hypertension. Magnetic resonance angiography showed multiple stenoses within the circle of Willis. One patient had subsequent small subcortical cerebral infarction. Two patients were treated for neuropsychiatric SLE; one patient was treated for reversible cerebral vasoconstriction syndrome (RCVS). Angiography normalized within a few weeks in all three patients. Retrospectively, clinical and radiological features suggest that RCVS was the most likely diagnosis in all patients. Multidisciplinary analysis of clinical and angiographic features is recommended, as RCVS is rare in children and its recognition may help to adjust treatment. WHAT THIS PAPER ADDS: Reversible vasoconstriction syndrome was observed in paediatric systemic lupus erythematosus. Thorough imaging analysis was necessary to address this diagnosis in paediatric patients.

We present the first mnemonic in Spanish, "PPIENSENLo," for alarm criteria in secondary headaches in children in order to facilitate their identification, diagnosis, and treatment. A search was performed across different electronic databases for a mnemonics that applied to clinical alarm criteria in secondary headaches in children. None were found in English or Spanish. This tool is perhaps useful both for clinical and teaching purposes.

In order to effectively study and manage headache disorders, diagnosis is essential. In both research and clinical arenas, separating secondary causes from primary headache disorders is a crucial first step, followed by further specificity within these broader categories. Historical approaches to classifying headache disorders culminated in the International Classification of Headache Disorders (ICHD), completed and published in 1988. This was revised as the International Classification of Headache Disorders, 2nd Edition (ICHD II) in 2004. The International Headache Society's Subcommittee on Classification began work on the 3rd edition in 2010, and has just published this online and in the journal Cephalalgia. The diagnostic criteria for more than 200 causes of headaches are based upon evidence when available, and fortunately, recent research in the field of headache medicine has produced data applicable to the refinement of classification of a number of primary and secondary headache disorders. Some areas, however, await further study, making classification more challenging. This article will attempt to provide an overview of the rationale behind the ICHD, a guide to its use, and a summary of important diagnostic features of the primary and secondary headaches, particularly where these have changed significantly in the ICHD III from ICHD II.

Cephalalgia alopecia is a rare and recently described headache syndrome in which recurrent, burning head and neck pain is associated with hair loss from areas of scalp affected by the pain. We here report the case of a 33-year-old woman with continuous unilateral occipital pain and colocalized alopecia, only responsive to onabotulinumtoxin A injections. We hypothesize whether this clinical phenotype may correspond to either cephalalgia alopecia or nummular headache with trophic changes, conditions that might represent 2 manifestations of the same spectrum of disorders.

This headache type has had many different names in the past including ciliary neuralgia, erythroprosopalgia of Bing, hemicrania periodic neuralgiforms, histaminic cephalalgia, Horton’s headache, migrainous neuralgia, Sluder’s neuralgia, and sphenopalatine neuralgia. Kunkle and colleagues observed the tendency of the headaches to cluster in time and

The practice of headache medicine is challenging, and excluding secondary causes of headaches is essential for proper diagnosis and treatment. The evaluation of secondary headaches often leads to investigations involving organ systems other than the nervous system. As such, headache, which is typically thought to be neurologic in origin, can be a manifestation of cardiac pathology in the form of cardiac cephalalgia. Conversely, chest pain, which is typically thought to be cardiac in origin, could be a manifestation of a neurologic disease process in the form of atypical migraine aura. In the presented cases, we demonstrate headaches that involve cardiac and neurologic pathology with atypical presentations.

Andrasik F, Grazzi L, Usai S, Kass S & Bussone G. Disability in chronic migrainewith medication overuse: treatment effects through 5 years. Cephalalgia 2009.London. ISSN 0333-1024Chronic migraine accompanied by medication overuse is particularly difficult totreat. The number of treatment investigations is limited, few have includedfollow-up beyond 6 months and almost none has examined whether treatmentleads to concurrent improvements in disability and functional impairment. Thisopen-label study addresses these limitations. We have been prospectively fol-lowing an initial cohort of 84 chronic migraine patients with medication overuse,who at the time of this evaluation had been reduced to 58, for an extendedperiod to assess longer-term maintenance of effects, using measurement proce-dures identical to those in the original investigation. Thus, the specific aim wasto determine the clinical status, with respect to pain indices and disability level,of chronic migraine patients with medication overuse who were treated andfollowed prospectively for 5 years. All patients completed a brief inpatienttreatment programme, in which they were withdrawn from their offendingmedications and subsequently placed on more appropriate preventive antimi-graine medications. Both end-point, wherein missing data points were estimated,and continuer analyses, wherein data analysis was limited to the 58 individualswith complete datasets, revealed significant improvement on all measuresstudied—headache days per month, analgesic consumption and Migraine Dis-ability Assessment (MIDAS) total score. The percentage reduction from baselineto 5 years for the MIDAS total score was 76.0%, while the percentage ofindividuals revealing improvements of clinically significant magnitude ( 50%)on the MIDAS was 91.9%. MIDAS total scores were lower at 5 years than at someof the intervening follow-up intervals. Comparisons of those who completed the5-year follow-up (

The aim of the study is to evaluate the efficacy and tolerability of the five triptans that are commercially available in Italy (zolmitriptan 2.5 mg, rizatriptan 10 mg, sumatriptan 100 mg, almotriptan 12.5 mg and eletriptan 40 mg). The study was conducted in single-blind versus placebo and its duration was 18 months. At the Headache Centre of the 'Agostino Gemelli' Hospital in Rome we selected 42 patients, suffering from headache with and without aura (International Headache Society Committee on Headache Classification, 1988 Cephalalgia 8:1-96), whose headache frequency ranged between 1- and 4-monthly crises. For a total of 25 crises, for every five consecutive crises, a different triptan was taken. The end-points of the study were as follows: response at 2 h, 'pain free' at 2 h and 'sustained pain free' (at 24 h). The intra-patient consistency and the tolerability were also evaluated. Thirty patients completed the study and the statistical analysis was only applied to these patients. No substantial difference in terms of the efficacy of the triptans was noted; all triptans were well tolerated. These results suggest the possibility of testing different triptans in the same patient in order to identify the ideal drug for every patient.

BACKGROUND A high cure rate may be attained for locally advanced, undifferentiated nasopharyngeal carcinoma (NPC) in children, provided that a combined modality of treatment is employed. Both local and systemic therapies are necessary. Results at a single pediatric institution were analyzed. METHODS From November 1988 to December 1997, 16 consecutive patients were treated with NPC at the Hospital Garrahan in Buenos Aires, Argentina. The authors were able to evaluate 11 patients (9 boys and 2 girls); their median age was 12 (range, 8–14) years. Chemotherapy consisted of 3 courses, every 3 weeks, of 5-fluorouracil (500 mg/m2) plus bleomycin (15 mg/m2) daily for 4 days, with cisplatin (100 mg/m2) added the last day. External beam radiotherapy was delivered over a median of 52 (range, 45–63) days, to a median cumulative dose to the primary site of 55 (range, 50–61.2) grays (Gy). The median dose for the lower neck area was 45 (range, 45–55.8) Gy. All patients received radiotherapy to the primary site and to the initially involved lymphoid areas, with daily single doses of 1.8 Gy (5 of 7 days per week). RESULTS The main symptoms at onset were cervical mass (100%), epistaxis (54%), cephalalgia (36%), and trismus (36%). All cases were Stage IV (American Joint Committee on Cancer and International Union Against Cancer TNM system). Complete response was achieved in 45% of patients after initial chemotherapy. With a median follow-up of 63 (range, 23–119) months, disease free survival (with standard error [SE]) and overall survival estimates were 61% (16%) and 91% (9%), respectively, at 75 months. Acute toxicity due to therapy was tolerable. Chronic sinusitis (73%), hypothyroidism (73%), and mild (64%) or moderate (9%) neck fibrosis were detected at follow-up. CONCLUSIONS Although this series is small, the authors concluded that NPC patients have a good chance of survival in the setting described, in spite of locally advanced disease. Chemotherapy might be useful in preventing the development of systemic metastases. Cancer 2000;89:690–5. © 2000 American Cancer Society.

A 72-year-old man presented with a 7-week history of a new onset constant severe right-sided headache associated with redness and tearing of the right eye, which resolved on indomethacin due to nonmetastatic small cell carcinoma producing a large suprahilar mass. This is the first case report of a hemicrania continua-like headache with autonomic features due to lung cancer. I propose the term "vagal cephalalgia" to include headache and/or facial pain due to nonmetastatic lung cancer and cardiac cephalalgia which result from vagal afferent stimulation.

In all papers published up to now it is stated or surmised that in cervicogenic headache, described by Sjaastad and collaborators (Cephalalgia, 3(4):240–256, 1983), the painful stimulus is carried mainly or exclusively by the greater occipital nerve. As a contribution to the study in this modality of headache, the authors made 16 dissection in eight cadavers looking for the anatomical relations of the lesser occipital nerve. The results showed that the head and face pain originating from the ventral ramus of the second cervical nerve (C2) can be explained in three different ways: (1) through anatomical regional peculiarities which make it vulnerable to mechanisms of compression and stretching; (2) through the relationship between C2 ventral ramus, the superior cervical ganglion, and the ophthalmic branch of the trigeminal nerve; (3) through clinical evidence related to painful sensibility. The authors emphasize the possible role of the lesser occipital nerve on the genesis of cervicogenic headache. It is expected that the conclusions reached will be of help to clinical studies of headache. © 1994 Wiley-Liss, Inc.

Curr Pain Headache. Rep 2002 Feb;6(1):52-56 The design and execution of clinical trials poses special problems for cluster headache. Although there is less inter-individual and intra-individual variability of attacks than seen with migraine, the brevity of attacks, spontaneous remissions unrelated to treatment, and the relative rarity of cluster headaches challenge investigators. The International Headache Society has developed guidelines that represent a compromise between scientific rigor and practicality. Only injectable sumatriptan for acute attacks and verapamil for prophylaxis have demonstrated a robust therapeutic effect in controlled clinical trials. Comment: Kenneth Moore raises important methodological considerations. It is possible to undertake crossover trials comparing different active treatments? He is correct in his assertion that few agents show robust efficacy. A major issue relates to the proportion of patients with episodic versus chronic cluster headache where efficacy of active treatments can vary. For example, oral zolmitriptan was effective against placebo only in those patients with episodic disease (Bahra A, Gawel MJ, Hardebo JE, Millson DS, Breen SA, Goadsby PJ. Oral zolmitriptan is effective in the acute treatment of cluster headache. Neurology. 2000;54:1832-1839). And a set of small studies on melatonin and cluster demonstrate the problems Dr. Moore describes. In one study (Leone M, D'Amico D, Moschiano F, Fraschini F, Busonne G. Metalonin versus placebo in the prophylaxis of cluster headache: a double-blind pilot study with parallel groups. Cephalalgia. 1996;16:494-496), the melatonin worked only in episodic, not chronic cluster patients. In the second study (Prinsheim T, Magnoux E, Dobson CF, Hamel E, Aube M. Melatonin as adjuctive therapy in the prophylaxis of cluster headache: a pilot study. Headache. 2002;42:787-792), melatonin did not work better than placebo in either episodic or chronic cluster patients. Furthermore, the paper abstracted above by Torelli and Manzoni suggests that episodic cluster may progress to chronic cluster as a result of extrinsic factors such as smoking. Finally, there are ethical issues in placebo-controlled cluster studies, given the severity of the pain and the availability of effective acute and chronic treatments. As noted above, Dr. Peter Goadsby points out the need to persevere with these studies to find nonvasoactive treatments for patients with cluster headache. DSM and SJT

The purpose of this investigation was to evaluate the long-term course of non-invasively treated chronic headache. A total of 1015 adult patients with primary diagnosis of vascular/migraine or muscle contraction headache participated in the study investigating symptom frequency and severity over a 36 month period after receiving treatment. Treatment consisted of either: relaxation training (stepwise relaxation/hypnosis/autogenic training/cognitive behavior therapy); biofeedback (thermal/photoplethysmograph/EMG); micro-electrical therapy (TENS/Neurotransmitter Modulation) or multimodal treatment (combination of any of the above two treatments). Seven hundred and ninety-three patients returned sufficient data to be included in the analysis. Patients were randomly assigned to treatment groups and received either short term intervention (15 or less treatments) or long term intervention (greater than 15 treatments). Results indicate that all treatment conditions significantly reduced frequency and intensity of cephalalgia. Repeated measure analysis of variance indicated that grouping variables of Biofeedback treatment, symptoms being evidenced less than 2 years and receiving over 15 treatment sessions best predicted successful intervention.

SYNOPSIS The migraine subject exhibits a dopaminergic vascular hypersensitivity on the brain level (CBF increase) as well as on the peripheral level (BP decrease). A dopaminergic agonist, piribedil, was administered by intravenous infusion (0,1 mg/kg over 30 minutes) to 150 patients known to suffer from migraine or other kinds of headache. 94% of migraine patients developed nausea or vomiting and 69% a decrease of BP, severe enough to discontinue the infusion. In non migraine headaches, the piribedil infusion had no effects in 61% of patients and provoked a decrease of BP in 16% of cases only. The piribedil test could be used to distinguish genuine migraine from other cephalalgia in patients prone to headache.