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Background Meningiomas arising from the petroclival area remain a challenge for neurosurgeons. Various approaches have been proposed to achieve maximum resection with minimal morbidity and mortality. Also, some articles correlated preservation of adjacent veins with less neurologic deficits. Objective To describe the experiences in using a new technique to achieve maximal resection of petroclival meningiomas and preserving the superior petrosal veins (SPVs) and the superior petrosal sinus (SPS). Methods A retrospective analysis of 26 patients harboring a true petroclival meningioma with a diameter ≥25 mm and undergoing surgery with the modified transpetrosal–transtentorial approach (MTTA) was performed. Results Fifty-four percent of 22 patients complained of severe headache at presentation. There was also complaint of cranial nerve (CN) deficit, with CN VII deficit being the most common (present in 42% of patients). The average tumor size (measured as maximum diameter) was 45.2 mm, and most of the tumors compressed the brainstem. Total resection was achieved in 12 patients (46.2%), whereas the others were excised subtotally (54.8%). Most of the patients had WHO grade I (96.1%) meningioma; only one had a grade II (3.8%) meningioma. In addition, clinical improvement and persistence of symptoms were observed in 17 (65.4%) and 8 (30.7%) patients, respectively, and postoperative permanent CN injury was observed in 3 (11.5%) patients. Conclusion Using the MTTA, maximal resection with preservation of the CNs and neurovascular SPV-SPS complex can be achieved. Therefore, further studies and improvements of the technique are required to increase the total resection rate without neglecting the complications that may develop postoperatively.

BackgroundParagangliomas are rare neuroendocrine tumors, especially in the bladder. Although many paragangliomas are non-functional, functioning paragangliomas present with many non-specific signs and symptoms, such as hypertension and headache, complicating their diagnosis. Here, we report a case of micturition-induced severe headache associated with a bladder paraganglioma. Case description: This report describes a severe headache disorder triggered by micturition and associated with a bladder paraganglioma in a middle-aged woman. Her pain occurred consistently after micturition, beginning from the left side of the nose and gradually extended to the forehead and the parietal and occipital regions. The headaches lasted 5–10 min. Removal of the paraganglioma completely eliminated the patient’s pain syndrome.ConclusionThis case elucidates the association between micturition-triggered headaches and bladder paragangliomas. The presence of a post-micturition severe headache should suggest the possibility of a bladder paraganglioma.

Many clinicians lack experience in managing trigeminal autonomic cephalalgias (TACs) in pregnancy and lactation. In addition to cluster headache, TACs include hemicrania continua, paroxysmal hemicrania, and short-lasting unilateral neuralgiform headache with conjunctival injection and tearing/autonomic symptoms (SUNCT/SUNA). Treating these rare, severe headache conditions often requires off-label drugs that have uncertain teratogenic potential. In the last few years, several new treatment options and safety documentation have emerged, but clinical guidelines are lacking. This narrative review aimed to provide an updated clinical guide and good clinical practice recommendations for the management of these debilitating headache disorders in pregnancy and lactation. publishedVersion

Background Paroxysmal localized hyperhidrosis is a rare disorder of the central autonomic nervous system. No association between paroxysmal hyperhidrosis and severe headache has been previously described in literature. Case description: A 65-year-old woman with idiopathic paroxysmal localized hyperhidrosis combined with severe holocranial headache attacks is described in this case report. Extensive diagnostic testing by means of laboratory examinations, 24-hour urinalyses, chest X-ray, abdominal ultrasound and computed tomography scans, and brain and spinal cord magnetic resonance imaging could not identify an underlying disorder. A diagnosis of idiopathic paroxysmal localized hyperhidrosis was made, and the patient was successfully treated with clonidine 0.075 mg three times a day, without any side effects. Conclusion Paroxysmal localized hyperhidrosis is a rare central autonomic nervous system disorder that can occur in combination with severe headache. Both the headache and paroxysmal hyperhidrosis complaints were treated effectively with clonidine in the patient described in this case-report.

Objective To determine the effectiveness of erenumab in treating headaches in idiopathic intracranial hypertension (IIH) in whom papilledema had resolved. Background Disability in IIH is predominantly driven by debilitating headaches with no evidence for the use of preventative therapies. Headache therapy in IIH is an urgent unmet need. Methods A prospective, open‐label study in the United Kingdom was conducted. Adult females with confirmed diagnosis of IIH now in ocular remission (papilledema resolved) with chronic headaches (≥15 days a month) and failure of ≥3 preventative medications received erenumab 4‐weekly (assessments were 3‐monthly). The primary end point was change in monthly moderate/severe headache days (MmsHD) from baseline (30‐day pretreatment period) compared to 12 months. Results Fifty‐five patients, mean (SD) age 35.3 (9) years and mean duration of headaches 10.4 (8.4) years with 3.7 (0.9) preventative treatment failures, were enrolled. Mean baseline MmsHD was 16.1 (4.7) and total monthly headache days (MHD) was (29) 2.3. MmsHD reduced substantially at 12 months by mean (SD) [95% CI] 10.8 (4.0) [9.5, 11.9], p

Previous work has not examined how the association of sexual orientation and severe headache/migraine may be explained by differences between sexual minorities and heterosexuals in sociodemographic and health-related characteristics. Using data from the 2013–2018 National Health Interview Survey, regression decomposition was used to identify determinants of disparities in headache/migraine between sexual minorities collectively and heterosexuals, as well as between bisexual men and gay men, and bisexual women and lesbians. The prevalence of headache/migraine was the highest among bisexual women (36.8%), followed by lesbians (24.7%), bisexual men (22.8%), heterosexual women (19.7%), gay men (14.8%), and heterosexual men (9.8%). Across all models, the largest percentage of the disparity between sexual orientation/gender groups was attributable to age (range, 18.3%–42.2%), serious psychological distress (range, 6.6%–14.0%), and hours of regular sleep (range, 1.7%–8.2%). Although age accounted for the largest part of the disparity in headache/migraine by sexual orientation, several modifiable risk factors also played a role.

In today’s world, migraine is one of the most frequent disorders with an estimated world prevalence of 14.7% characterized by attacks of a severe headache making people enfeebled and imposing a big socioeconomic burden. The pathophysiology of a migraine is not completely understood however there are pieces of evidence that epigenetics performs a primary role in the pathophysiology of migraine. Here, in this review, we highlight current evidence for an epigenetic link with migraine in particular DNA methylation of numerous genes involved in migraine pathogenesis. Outcomes of various studies have explained the function of DNA methylation of a several migraine related genes such as RAMP1, CALCA, NOS1, ESR1, MTHFR and NR4A3 in migraine pathogenesis. Mentioned data suggested there exist a strong association of DNA methylation of migraine-related genes in migraine. Although we now have a general understanding of the role of epigenetic modifications of a numerous migraine associated genes in migraine pathogenesis, there are many areas of active research are of key relevance to medicine. Future studies into the complexities of epigenetic modifications will bring a new understanding of the mechanisms of migraine processes and open novel approaches towards therapeutic intervention.

INTRODUCTION Coronavirus disease 2019 (COVID-19) is associated with significant risk of acute thrombosis. We present a case report of a patient with cerebral venous sinus thrombosis (CVST) associated with COVID-19 and performed a literature review of CVST associated with COVID-19 cases. CASE REPORT A 38-year-old woman was admitted with severe headache and acute altered mental status a week after confirmed diagnosis of COVID-19. Magnetic resonance imaging brain showed diffuse venous sinus thrombosis involving the superficial and deep veins, and diffuse edema of bilateral thalami, basal ganglia and hippocampi because of venous infarction. Her neurological exam improved with anticoagulation (AC) and was subsequently discharged home. We identified 43 patients presenting with CVST associated with COVID-19 infection. 56% were male with mean age of 51.8±18.2 years old. The mean time of CVST diagnosis was 15.6±23.7 days after onset of COVID-19 symptoms. Most patients (87%) had thrombosis of multiple dural sinuses and parenchymal changes (79%). Almost 40% had deep cerebral venous system thrombosis. Laboratory findings revealed elevated mean D-dimer level (7.14/mL±12.23 mg/L) and mean fibrinogen level (4.71±1.93 g/L). Less than half of patients had prior thrombotic risk factors. Seventeen patients (52%) had good outcomes (mRS

OBJECTIVE: To describe the patterns of opioid use in patients presenting to the emergency department (ED) with nontraumatic headache by severity and geography. BACKGROUND: International guidelines recognize opioids are ineffective in treating primary headache disorders. Globally, many countries are experiencing an opioid crisis. The ED can be a point of initial exposure leading to tolerance for patients. More geographically diverse data are required to inform practice. METHODS: This was a planned, multicenter, cross-sectional, observational substudy of the international Headache in Emergency Departments (HEAD) study. Participants were prospectively identified throughout March 2019 from 67 hospitals in Europe, Asia, Australia, and New Zealand. Adult patients with nontraumatic headache were included as identified by the local site investigator. RESULTS: Overall, 4536 patients were enrolled in the HEAD study. Opioids were administered in 1072/4536 (23.6%) patients in the ED, and 386/3792 (10.2%) of discharged patients. High opioid use occurred prehospital in Australia (190/1777, 10.7%) and New Zealand (55/593, 9.3%). Opioid use in the ED was highest in these countries (Australia: 586/1777, 33.0%; New Zealand: 221/593, 37.3%). Opioid prescription on discharge was highest in Singapore (125/442, 28.3%) and Hong Kong (12/49, 24.5%). Independent predictors of ED opioid administration included the following: severe headache (OR 4.2, 95% CI 3.1-5.5), pre-ED opioid use (OR 1.42, 95% CI 1.11-1.82), and long-term opioid use (OR 1.80, 95% CI 1.26-2.58). ED opioid administration independently predicted opioid prescription at discharge (OR 8.4, 95% CI 6.3-11.0). CONCLUSION: Opioid prescription for nontraumatic headache in the ED and on discharge varies internationally. Severe headache, prehospital opioid use, and long-term opioid use predicted ED opioid administration. ED opioid administration was a strong predictor of opioid prescription at discharge. These findings support education around policy and guidelines to ensure adherence to evidence-based interventions for headache.

A High-Risk VITT Prodrome A group of 11 patients had elements of VITT (thrombocytopenia, high d-dimer levels, and positivity for anti-PF4 antibodies) associated with severe headache but no other ev...

Rationale: Severe tension pneumocephalus can lead to drowsiness, coma, and even brain hernia and death. The occurrence of delayed pneumocephalus after spinal surgery is rarely reported and often ignored. Herein, we report a case of delayed pneumocephalus after repeated percutaneous aspiration following spinal surgery. Patient concerns: A 55-year-old man was admitted in October 2020 because of aggravation in bilateral lower limb weakness and dysuria for seven days. He was diagnosed with liver cancer a year ago, and he underwent several operations because of tumor recurrence. The patient underwent thoracic vertebrae tumor excision on this admission, and no cerebrospinal fluid leakage was discovered during surgery. After the third drainage by percutaneous aspiration, the patient complained of severe headache and vomiting on postoperative day 16. Diagnosis: Emergency brain computed tomography revealed massive pneumocephalus. Interventions: Thereafter, suction drainage was discontinued, and he was placed on bed rest and administered intravenous mannitol. Outcomes: Repeated computed tomography showed complete resolution of the pneumocephalus after five days. Lessons: Wound exudates and cystic fluid after spinal surgery should be differentiated from cerebrospinal fluid leakage. Reckless percutaneous aspirations can form pneumocephalus in patients with an occult dural injury, and pneumocephalus can occur up to 16 days after surgery. Early diagnosis of pneumocephalus is crucial to avoid severe consequences.

Rationale: Persistent primitive hypoglossal artery (PPHA) is a rare and permanent carotid-vertebrobasilar anastomoses. Patients with PPHA usually have higher changes of developing intracranial aneurysms due the high intracranial hemodynamics. Although cases of PPHA alone and PPHA with aneurysms have been reported in literature, cases of fenestrated PPHA harboring a ruptured aneurysm have seldomly be reported in literature. We present a rare occurrence of a fenestrated PPHA harboring a reputed aneurysm. Patients concerns: A 43-year-old woman was presented with a sudden-onset severe headache and nausea. Diagnosis: Computerized tomography scan showed third, fourth, and bilateral ventricular hemorrhages. Computed tomographic angiogram showed a PPHA with fenestration malformation and a cystic protrusion consistent with an aneurysm. Intervention: The patient underwent a successful stent-assisted coil embolization via the trans-arterial route under general anesthesia. Outcomes: Two years follow-up revealed no recurrence of her symptomatology and she is currently well and go about her normal daily life. Conclusion: Fenestrated PPHAs harboring aneurysms may be more prone to rupture because of the fenestration and connective tissue weakness of the artery as well as changes in hemodynamics of the already malformed and weak artery.

Guillain-Barré syndrome (GBS) is an acute inflammatory demyelinating polyneuropathy that leads to sensory, motor and autonomic symptoms. We report a 26-year-old female patient with GBS revealed headache and limbs weakness. Treatment with gammaglobulin and corticosteroids led to a rapid improvement of muscle strength. However, she developed more severe headache and increased intracranial pressure which can be relieved by ventricular drainage during recovery period of GBS. Headache and increased intracranial pressure in GBS was relatively rare. This report reviews some literatures about this disorder and analyses possible pathophysiological mechanisms of intracranial hypertension in GBS. We should pay attention to patients who exhibit atypical presentations.

In recent decades, diagnostic imaging became an important generator of large increases in medical spending. Inappropriate head CT referrals also increase population irradiation and unnecessarily burden and frighten patients. To validate previously proposed clinical criteria for referral to head imaging (age > 55 years, focal neurological deficit, changed mental state, nausea or vomiting, coagulation disorder, cancer) in a setting of emergency neurological service. We retrospectively analyzed electronic records of 500 consecutive referrals to neurological emergency and 500 referrals to emergency head imaging. In patients with several referrals, only results of the first evaluation were further analyzed. We calculated relations between clinical predictors, referrals, and findings of head imaging. Of 486 first referrals of consecutive patients, 216 (44%) were referred to the emergency, and 100 (21%) to non-emergency head imaging. Remaining 170 (35%) were not referred to head imaging. Clinical predictors of pathologic head imaging fulfilled 77%, 41%, and 43% of patients, respectively. Pathologic head imaging had 153 of 490 (31%) referred patients. Referral criteria fulfilled 146 (sensitivity 95%) of them. Intracranial pathology was found in 7 of 125 patients not fulfilling referral criteria (negative predictive value 94%): 3 reported transient neurological symptoms, 2 sudden headache, and 2 headache with nausea and vomiting. We confirmed utility of previously proposed clinical criteria for referral to head CT in emergency neurological setting. In addition, we found transient neurological symptoms, sudden severe headache, and headache with nausea or vomiting as additional independent indications for emergency head imaging.

Kingella kingae is the leading cause of osteoarticular infections between 6 and 48 months, a well-known cause of pediatric bacteremia and endocarditis and has been rarely associated with meningitis. We report a case of a healthy 10-year-old boy with meningitis due to Kingella kingae who presented with a history of severe headache, vomiting and prostration.

We herein report a case of chemical meningitis that developed after cervical transforaminal steroid injection. A 49-year-old man presented with symptoms of meningitis (severe headache and neck stiffness) after cervical transforaminal steroid injection at the right C5–6 level. The injection solution was a mixture of lidocaine (0.3 mL), hyaluronidase (1 mL), placenta hydrolysate (2 mL), and normal saline (1 mL). The patient developed symptoms of meningitis 2.5 hours after the cervical epidural injection. Cerebrospinal fluid (CSF) analysis was performed 1 day after the injection, and the results showed an elevated white blood cell count at 7106 cells/µL. The patient’s CSF analysis findings and symptoms did not differ from those of bacterial meningitis. However, considering that his symptoms developed 2.5 hours after the epidural injection, we believe that the patient developed chemical meningitis; therefore, he was symptomatically treated with an analgesic. Three days after the cervical transforaminal epidural injection, the patient experienced complete relief from the headache and neck stiffness. A Gram stain of the CSF revealed no organisms. Hence, the diagnosis of chemical meningitis was confirmed. Clinicians should be knowledgeable about the risk of this complication.

Introduction: Headache is the fifth most common reason to visit an emergency department (ED). In most of the cases, headache is benign and has a primary origin, with migraine as the most common dia...

Background. Migraine is a common neurological disorder characterized by severe headache attacks that may be debilitating. The objective of this study is to determine the knowledge and attitudes of general practitioners in the hospital districts of the city of Ouagadougou on migraine. Methods. This cross-sectional study was carried out in hospital districts of Ouagadougou. The data were collected during three months from February 1 to April 30, 2020. Results. The study included 116 general practitioners. Thirteen percent of them were suffering from migraine. All participants had previous experience with migraine diagnosis before the survey. Eighty percent of general practitioners had a good level of knowledge of ICDH-3 criteria (knowing 6-7 criteria). The most widely recognized IHS criteria were pulsatility quality (93.1%), photophobia or sonophobia (80.2%), and mild-to-moderate intensity (80%). Ninety-five (81.9%) general practitioners rarely ordered brain imaging. The most common acute treatments were nonsteroidal inflammatory drug (39.47%), paracetamol (44.74%), and derivate of ergot (3.95%). The most common preventive treatments were amitriptyline (27.8%), derivate of ergot (18.9%), and NSAID (16.7%). The majority of general practitioners (56.9%) have referred headache patients to a colleague or specialist. Conclusions. Our study found that diagnostic criteria and acute treatment of migraine were well known by the majority of general practitioners, in contrast of preventive treatment.

Objectives To empirically address how thunderclap headache (TCH) is described in a relevant real-world setting. Background TCH refers to a highly recognizable description of a severe headache that reaches maximum severity within 1 minute and endures for at least 5 minutes. The use of a numerical rating scale (NRS) to appraise TCH severity, as well as assessment of TCH progression in patients with pre-existing headache at the time of TCH onset has not been previously evaluated. Methods This was a retrospective case series of adults with a diagnosis of reversible cerebral vasoconstriction syndrome (RCVS), identified through a search of the electronic health record. Individuals meeting International Classification of Headache Disorders, 3rd Edition criteria for acute headache attributed to RCVS were included. Attacks described using a verbal descriptor scale (VDS), NRS, or both were recorded to evaluate acute headache characteristics. Results In all, 56 individuals with available descriptions of 120 acute headaches were included in the study analysis. Patients were female (35, 62.5%) with a median age of 46 (range: 19-67). The majority of patients reported a RCVS trigger (39, 69.6%). Acute headaches were characterized using a VDS (52, 43.3%), NRS (51, 42.5%), or both (17, 14.1%). Acute headaches were always described as severe when a VDS was utilized, and with a median NRS of 10 (range: 4-10). Four patients (7%) did not have a single headache characterized as either severe or with a NRS 8 or greater. In the 10 cases for which there was a pre-TCH baseline headache, it was either rated as mild or with a median NRS of 3 (range: 2-6). Conclusions TCH in RCVS can be recognized using either VDS or NRS, with a broader range of peak intensities than previously recognized. TCH remains recognizable despite pre-existing baseline headache.

OBJECTIVE To determine the Prevalence and factors associated with pregnancy-related complications among reproductive-aged women in northwest Ethiopia. METHODS A community-based retrospective cross-sectional study was conducted among 2367 mothers who delivered from November 2018 to April 2019. Two-stage stratified random sampling technique was employed in clustered villages from three districts out of 10. Pretested and semi-structured interviewer-administered questionnaire was used to collect information on pregnancy-related complications. A binary logistic regression model was fitted to identify the associated factors. RESULTS Overall, 2335 (98.6%) women participated in the study. Mean age of respondents was 15.4 (SD ±3.2) years and 1763 (75.5%) of the women were below 18 years of age. The number of pregnancy-related complications was 372 (15.9%). Severe headache and high fever were the most frequently reported complications. Having a history of known health problem (adjusted odds ratio [aOR] 10.0, 95% confidence interval [CI] 7.10-14.10), history of hypertension (aOR 3.90, 95% CI 1.10-14.20), heart problems (aOR 1.90, 95% CI 1.10-3.30), and living in urban areas (aOR 1.40, 95% CI 1.10-1.81) were the factors associated with pregnancy-related complications. CONCLUSION The number of pregnancy-related complications was high. Having a history of a known health problem, having a hypertension problem, having a heart problem, and being an urban resident were contributing factors.

Background Short-lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT) is a severe headache disorder characterized by clustered episodes of extreme pain. Refractory to most interventions, ipsilateral unilateral ventral tegmental area (VTA) deep brain stimulation (DBS) has been previously reported to be efficacious in 14 cases. Methods and results Herein, we report the first case of an individual with medically refractory SUNCT who underwent bilateral VTA DBS. The patient experienced better improvement of his headaches with bilateral stimulation compared to unilateral stimulation. He also had a return of severe headaches within a few hours after his stimulator was switched off during sleep, with rebound worsening of his headaches over several days. The main side effects were double vision and difficulty focusing while reading, which were observed primarily with unipolar stimulation that required high voltages, high frequencies, and multiple negative contacts to control the headaches. The side effects were minimized with bipolar and interleaving stimulation with comparable control of his headaches. Conclusion Bilateral VTA DBS may be effective in alleviating medical refractory SUNCT.

To evaluate the efficacy of the non-drug therapy based on neurofeedback as a part of multimodality treatment of tension headache.Neurofeedback trainings, which were supported by sensory room sessions, were performed. Two equal groups, with 40 patients in each group, with clinical manifestations of tension headache received pharmacotherapy and non-drug therapy (main group) or pharmacotherapy (comparison group).A decrease in the amplitude of enveloped electromyogram from 6,22±0,73 to 3,85±0,44 (Pharmacotherapy combined with the complex "Neurofeedback-sensory room" significantly increases the efficacy of treatment of tension headache.Оценка эффективности немедикаментозной терапии с применением комплекса биологической обратной связи (БОС) и сенсорной комнаты у пациентов с головной болью напряжения (ГБН).Для выполнения работы использовали БОС-тренинг с последующей релаксацией с помощью элементов сенсорной комнаты. Были исследованы 2 группы пациентов с клиническими проявлениями ГБН, получавших фармакотерапию и комплексную немедикаментозную коррекцию (основная группа,В основной группе после комплексных тренингов отмечены снижение амплитуды огибающей электромиограммы с 6,22±0,73 до 3,85±0,44 мкВ (Выявлено статистически значимое повышение эффективности терапии ГБН при использовании фармакотерапии в сочетании с комплексом «БОС — сенсорная комната».

We hereby report a puzzling case of multiple sclerosis (MS) relapse presenting as Takotsubo syndrome (TTS). Female, 42-years old, who presented herself to the Emergency Room of University Hospital “ASST Spedali Civili” of Brescia, Italy, for a severe headache and a non-ST-segment elevation acute coronary syndrome. Coronary angiogram showed no signs of coronary atherosclerosis. Upon further neurological evaluation, a diagnosis of MS relapse, related to TTS, was made, and treatment was started accordingly. The patient was discharged after 12 days after the admission, free of symptoms, and without signs of neurological and cardiological active disease. A hallmark of TTS is its association with a preceding stressful event. It may also be connected to a wide variety of diseases, including neurological ones, such as stroke, intracranial bleeding, head trauma, migraine, and seizures. However, up to our knowledge, only few cases of MS-induced TTS were previously described. Whether it is plausible to consider TTS as an uncommon extra-neurological manifestation of MS is still debated, however all the evidence points in that direction, considering the central role of catecholamines in TTS pathogenesis. With this case report the authors hope to encourage research on this field and on the intricate topic of brain-heart connections.

We describe the case of a 25-year-old parturient who presented sudden onset and short-lived severe headache caused by reversible cerebral vasoconstriction syndrome (RCVS) during an emergency caesarean section. The syndrome was triggered by phenylephrine administered intravenously to correct arterial hypotension following spinal anaesthesia. RCVS is a clinical and radiological syndrome attributed to transient disturbance in the control of cerebral arterial tone resulting in vasospasms. The syndrome can be precipitated by several triggers, including vasoactive drugs, often used during spinal anaesthesia, illicit drugs, pregnancy and postpartum state. Diagnosis and management can be challenging during pregnancy, peripartum or post partum, since many medications commonly used during these periods must be avoided to prevent triggering RCVS. The aim of this report is to raise the awareness, particularly for anaesthesiologists and obstetricians, of this rare and potentially serious syndrome. We discuss diagnosis, triggers, pathogenesis, clinical course and complications, as well as coordinated multidisciplinary management plans.

The differential diagnosis of the patient with encephalopathy is broad and remains a common yet challenging problem for critical care physicians. A case is presented of contrast-induced encephalopathy in an 81-year-old man undergoing a left heart catheterisation after receiving iopamidol, a low-osmolar contrast agent. Immediately after receiving contrast, our patient experienced severe headache, agitation, altered mentation and significant skin hypersensitivity. This rare, acute and reversible neurological disturbance can be associated with administration of intra-arterial, osmotic, iodinated contrast. Although uncommon, it is important to recognise the various presentations, risk factors and treatment of this condition.

Presentation of Case – Ane Skaare Sjulstad, MD, Adult Neurology Resident, Nordland Hospital, Bodø, Norway A 48‐year‐old man with no previous medical history suddenly experienced severe intense retro‐bulbar pain of pulsating character on the right side, and was seen in the emergency department 7 hours later. He was then alert and oriented, but in excruciating pain. There was no neck stiffness and no fever. The blood pressure was 141/80 mm Hg, and the pulse regular with a frequency of 48. Neurological examination was normal.

Purpose The purpose of this study was to describe new mothers' knowledge related to maternal mortality. Study design and methods Using a cross-sectional design, new mothers were recruited from a postpartum unit of an academic health sciences center where the population was predominately low-income women. Before hospital discharge, they answered questions on their knowledge of potential postpartum complications that could lead to maternal mortality. Questions were based on recommendations from an expert nursing panel. Descriptive statistics were used for data analysis. Results One hundred twenty new mothers participated. Results indicated that most new mothers knew that they should watch for heavy bleeding, a severe headache, and swelling after hospital discharge. However, fewer participants knew that a new mother could experience feelings that she could harm herself or her baby, have blood clots larger than a baby's hand, a temperature of 100.4 °F or higher, and odor with vaginal discharge. Courses of action new mothers would take if experiencing any of the warning signs included 18% of mothers would take no action, 76.7% would tell their boyfriend/husband/partner, 72.5% would inform their mother. Only 60% who would call the labor and delivery unit. Only 38% of the sample knew that pregnancy-related complications can occur for up to 1 year after birth, and 13% of mothers reported not knowing that complications can occur for up to 6 weeks postpartum. Clinical implications Our findings provide a foundation to enhance postpartum education for new mothers and their families and to potentially decrease rates of maternal mortality in the United States.

Diffuse hyperdense cerebral vasculature is sometimes encountered on non-enhanced computed tomography, and polycythemia is one of the conditions which appears the same. The current case report is of a case of 37-year-old female patient arrived with a complaint of feeling severe headache for the past 3 days which was insidious in onset, diffuse in nature and it did not respond to any medication. NECT brain study showed the hyperdense circle of Willis and cerebral venous sinuses. Contrast was not administered for computed tomography study of the brain. On blood investigations, the patient had raised hematocrit level (74%). The hyperdense vessel was due to raised hematocrit (Polycythemia Vera).

Current chemistry analyzers measure ion concentration using ion- selective electrodes; however, may differ in the specific technology at the bedside versus the central laboratory. Instruments utilized for point-of-care testing (POCT) at the bedside use direct ion-selective electrodes, whereas central-laboratory analyzers use indirect ion-selective electrodes. Under most circumstances, these instruments will deliver the same result; however, various substances can cause interferences in one or the other. An 18-year-old Hispanic woman with a history of immune thrombocytopenic purpura (ITP) presented at Children's National Medical Center (CNMC) with a severe headache and required intravenous immunoglobulin (IVIG) therapy. Because a discrepancy developed between her point-of-care and central-laboratory sodium values, another instrument was used to retest the central-laboratory plasma specimens. The results were more in agreement with those from the point-of-care instrument and revealed a unique interference in sodium measurement related to IVIG use.

Objective To assess the feasibility, tolerability, and patient acceptability of single-pulse transcranial magnetic stimulation (sTMS) for migraine prevention in adolescents in an open-label pilot study. Background Migraine is common in adolescents and can be disabling. Well tolerated preventative therapies that are safe and effective are needed. Methods This was an open-label prospective pilot feasibility study of sTMS for migraine prevention in adolescents aged 12-17 years. Participants used sTMS twice daily in a preventative fashion, as well as additional pulses as needed acutely. A 4-week baseline run-in period (weeks 1-4) was followed by a 12-week treatment period. Feasibility was the primary outcome. Secondary outcomes included tolerability and acceptability, as well as the change in headache days, number of moderate/severe headache days, days of acute medication use, and PedMIDAS (headache disability) scores between the run-in period (weeks 1-4) and the third month of treatment (weeks 13-16). Results Twenty-one participants enrolled. Nineteen completed the baseline run-in, and 12 completed the study. Using sTMS proved feasible and acceptable with overall high compliance once treatment administration was streamlined. Initially, for preventive treatment, participants were asked to give 2 pulses, wait 15 minutes, then give 2 additional pulses twice daily. This 15-minute delay proved challenging for adolescents, particularly on school days, and therefore was dropped. Study completion rate went from 4/13 (31%) to 7/8 (88%) once this change was made, P = .024. On average, participants used the device preventively between 22 and 24 days over a 28-day block. There were no serious adverse events. Two participants reported mild discomfort with device use. Conclusion sTMS appears to be a feasible, well-tolerated, and acceptable nonpharmacologic preventive treatment for migraine in adolescents. In designing future trials of sTMS for migraine prevention in adolescents, streamlined treatment administration will be essential to minimize drop-out. Efficacy needs to be assessed in a larger trial.

Background Headache is a frequent complaint among the 1.4 million patients who present to US emergency departments (ED) annually following trauma to the head. There are no evidence-based treatments of acute post-traumatic headache. Methods This was an ED-based, prospective study of intravenous (IV) metoclopramide 20 mg + diphenhydramine 25 mg for acute post-traumatic headache. Patients who presented to our EDs with a moderate or severe headache meeting international criteria were enrolled and followed by telephone 2 and 7 days later. The primary outcome was “sustained headache relief” (headache level less than “moderate” in the ED, no additional headache medication, and no relapse to headache worse than “mild”).We also gathered data on associated symptomotology using the validated Post Concussion Symptom Scale (PCSS). Results 21 patients were enrolled. Twelve of 20 (60%) patients with available follow-up data reported sustained headache relief. All but one of the 21 enrolled patients (95%) reported improvement of headache to no worse than mild. Seven of 19 (37%) patients with available data reported moderate or severe headache during the 48 h after ED discharge. One week later, 5/19 patients reported experiencing headaches “frequently” or “always”. The mean Post Concussion Symptom Score improved from 47.5 (SD 29.4) before treatment to 10.9 (SD 14.8) at the time of ED discharge and 11.4 (SD 21.4) at one week after treatment. Conclusion IV metoclopramide 20 mg + diphenhydramine 25 mg is an effective and well-tolerated medication regimen for patients presenting to the ED with acute post-traumatic headache, though 1/3 of patients report headache relapse after ED discharge and 1/4 of patients report persistent headaches one week later.

We report a case of meningeal carcinomatosis that needed to be distinguished from subarachnoid hemorrhage. A 67-year-old female with acute severe headache was admitted to a previous hospital. Since high intensity signal was detected within the parietal cerebral sulci on the right side on brain FLAIR MRI, cerebral angiography was performed due to suspicion of subarachnoid hemorrhage. However, no vascular abnormality was observed. Then, cerebral spinal fluid was collected, which showed an increase in cell count, suggesting meningitis. She was transferred to our hospital for evaluation of neurological disease. After admission to our hospital, there was an episode of hematemesis. Upper gastrointestinal endoscopy was performed, and advanced gastric cancer was found. She was diagnosed as having meningeal carcinomatosis due to gastric cancer. Meningeal carcinomatosis should be considered in addition to subarachnoid hemorrhage when a patient with acute headache shows high intensity signal within the cerebral sulci on brain FLAIR MRI.

A 21-year-old unmarried woman was admitted to our neurology department because of severe headache that lasted for the past 10 days and persistent incoherent speech, repeated seizures lasting for a ...

Reversible cerebral vasoconstriction syndromes (RCVS) have been well recognized recently as one cause of cerebrovascular disease, but the time course of vessel vasoconstriction remains uncertain. We report herein 2 cases with RCVS in which we clarified temporal changes in vessel vasoconstriction in detail using transcranial color-coded sonography (TCCS). The first case involved a 27-year-old woman who developed intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH) after severe headache. TCCS showed peak systolic velocity (PSV) in the left middle cerebral artery (MCA) peaked at 212 cm/s on day 6 and gradually decreased, whereas PSV of the left posterior cerebral artery (PCA) and left anterior cerebral artery (ACA) re-elevated to 190 cm/s on day 15. The second case involved a 53-year-old woman who developed cerebral infarction in the PCA territory 9 days after severe headache. TCCS study showed PSV elevation in the right MCA. Although TCCS seemed to normalize 7 days after admission, PSV of the left PCA, left ACA, and left MCA re-elevated at day 17. Both cases showed bimodal PSV peaks, with the posterior circulation peak preceded by the anterior circulation peak. These findings may be important in clarifying the mechanisms underlying vasoconstriction in patients with RCVS.

Neuropathic pain is maladaptive pain caused by injury or dysfunction in peripheral and central nervous system, and remains a worldwide thorny problem leading to decreases in physical and mental quality of people's life. Currently, drug therapy is the main treatment regimen for resolving pain, while effective drugs are still unmet in medical need, and commonly used drugs such as anticonvulsants and antidepressants often make patients experience adverse drug reactions like dizziness, somnolence, severe headache, and high blood pressure. Thus, in this review we overview the anatomical physiology, underlying mechanisms of neuropathic pain to provide a better understanding in the initiation, development, maintenance, and modulation of this pervasive disease, and inspire research in the unclear mechanisms as well as potential targets. Furthermore, we summarized the existing drug therapies and new compounds that have shown antalgic effects in laboratory studies to be helpful for rational regimens in clinical treatment and promotion in novel drug discovery.

Background The temporal and anatomical features of vasoconstriction in patients with reversible cerebral vasoconstriction syndrome within hours after symptom onset, in the hyperacute phase, are unclear. Case result Herein we report the cases of two patients with acute severe headache who were diagnosed with reversible cerebral vasoconstriction syndrome. Magnetic resonance imaging within hours after symptom onset revealed multiple areas of isolated cortical vasogenic edema and hyperintense vessel signs of the distal cerebral arteries. Follow-up imaging performed four days later in both cases showed diffuse segmental arterial vasoconstriction in the proximal regions of the cerebral arteries. Both patients received antivasoconstrictive therapy shortly after admission, and neither had neurological sequelae at discharge. The magnetic resonance imaging findings improved gradually within three months after symptom onset. Conclusion Isolated cortical vasogenic edema and hyperintense vessel signs, when observed within hours from sudden severe headache onset, may be useful early markers of reversible cerebral vasoconstriction syndrome.

Objective To examine treatment utilization patterns and safety of onabotulinumtoxinA for the prophylactic treatment of chronic migraine in routine clinical practice. Background Clinical trials support onabotulinumtoxinA for the prophylaxis of headache in patients with chronic migraine, but real-world data are limited. Design/methods A prospective, observational, post-authorization study in adult patients with chronic migraine treated with onabotulinumtoxinA. Data were collected at the first study injection and approximately every three months for ≤52 weeks for utilization and ≤64 weeks for safety data, and summarized using descriptive statistics. Results Eighty-five physicians (81% neurologists) at 58 practices in the United Kingdom, Germany, Spain, and Sweden participated and recruited 1160 patients (84.2% female, median age 46.6 years). At baseline, 85.8% of patients had physician diagnoses of chronic migraine/transformed migraine and reported an average of 11.3 (SD = 6.9) severe headache days per 28 days; 50.6% had previously used onabotulinumtoxinA for chronic migraine. A total of 4017 study treatments were observed. The median number of injection sites (n = 31) and total dose (155 U) were consistent across all treatment sessions, with a median 13.7 weeks observed between sessions. At least one treatment-related adverse event was reported by 291 patients (25.1%); the most frequently reported treatment-related adverse event was neck pain (4.4%). Most patients (74.4%) were satisfied/extremely satisfied with onabotulinumtoxinA treatment. Conclusions Patient demographics/characteristics are consistent with published data on the chronic migraine population. Utilization of onabotulinumtoxinA treatment for chronic migraine appears to be consistent with the Summary of Product Characteristics and published PREEMPT injection paradigm. No new safety signals were identified.

Background Some patients with aneurysm exhibit warning headaches without minor bleeding, and this could be caused by stretching of the aneurysm wall. Recently, our pathologic study observed subintimal fibrin deposition in a majority of the ruptured aneurysms. However, these findings also were observed in some unruptured aneurysms. In this report, 2 unruptured aneurysms exhibited subintimal fibrin, and interestingly, one of the patients experienced severe headache within 1 month before neuroimaging. Objective We performed pathologic analysis of unruptured aneurysms and collected their various clinical variables, including severe headache, to clarify the clinical characteristics of “dangerous” unruptured aneurysms. Methods This study included unruptured saccular aneurysm samples (n = 17) that were resected after clipping. We compared the differences in clinical variables, including warning headache, between aneurysms with and without fibrin deposition. Results Fibrin deposition was present in the subintimal layer in 4 patients and in the periouter membrane in 4 patients. Three of the 4 former patients experienced warning headaches, and one presented aneurysm growth. Of the latter 4 patients, one exhibited aneurysm growth, whereas the others presented with relatively large aneurysms. In the remaining 9 aneurysms without fibrin deposition, monocyte infiltration was observed in one, all aneurysms were small, and no patients experienced warning headaches or aneurysm growth. Conclusions Subintimal fibrin deposition is observed frequently in patients with aneurysm with warning headaches. These pathologic findings are clinically inspiring and may suggest that these aneurysms exhibit rapid stretching by newly formed aneurysms, which can result in rupture at an early stage.

Objective The purpose of this study was to evaluate the psychometric properties of the newly developed Headache Triggers Sensitivity and Avoidance Questionnaire (HTSAQ) designed to measure variables relating to the Trigger Avoidance Model of Headaches. Background The Trigger Avoidance Model of Headaches proposes that one pathway to developing a primary headache disorder is through the avoidance of headache triggers, resulting in an increase in trigger potency through sensitization. Conversely, prolonged exposure to certain triggers may reduce a potential trigger's ability to precipitate a headache. This model has led to an alternative approach to trigger management being proposed called Learning to Cope with Triggers, which advocates the desensitization of certain headache triggers through controlled exposure, while supporting avoidance of those triggers that are detrimental to health and wellbeing. To be able to evaluate predictions based on the Trigger Avoidance Model of Headaches and to investigate the effectiveness of Learning to Cope with Triggers, psychometrically sound measures of trigger sensitivity and trigger avoidance are needed. Method A convenience sample of 376 participants (87.5% female; 64.1% European descent) was recruited for the online study which consisted of a battery of measures including the HTSAQ, Brief Headache Screen, Pain Anxiety Symptoms Scale, Pain Sensitivity Questionnaire, Chronic Pain Acceptance Questionnaire, and demographic items. With an interval of 2-6 weeks, a subsample of participants (n = 201) completed the HTSAQ for a second time. The mean age of the sample was 31.4 years (SD = 12.8). The most common headache diagnoses (based on the Brief Headache Screen) were migraine (chronic = 62; episodic = 160), followed by medication-overuse headache (n = 87). The remaining participants (n = 67) were diagnosed as having episodic less severe headache (most likely tension-type headache). Results Reliability was assessed through internal consistency and test-retest reliability over a period of 2-6 weeks, and both were excellent (alpha > .80). Strong construct validity was demonstrated by the measure's scale scores being significantly correlated in theoretically consistent ways with the Pain Sensitivity Questionnaire, Pain Anxiety Symptoms Scale, and Chronic Pain Acceptance Questionnaire. As the Trigger Avoidance Model of Headaches would predict, correlations between the HTSAQ Sensitivity scales and the Avoidance scale were strong (P

A 56-year-old woman presented with severe headache, blurring of vision, hypertensive emergency and severe crushing central chest pain. Extensive evaluation was undertaken to rule out sinister myocardial, pulmonary and mediastinal pathology. Pain relief required intravenous opiates. One week later, persistent complaints of numbness of hands and legs led to a suspicion of dysautonomic inflammatory neuropathy. Nerve conduction studies confirmed a demyelinating Guillain–Barre syndrome. Intravenous immunoglobulin treatment led to rapid resolution of pain, dysautonomia and neuropathic symptoms.

The symptoms of sudden severe headache and/or diminished consciousness characterize the onset of aneurysmal subarachnoid hemorrhage (SAH). However, several studies have suggested that some patients show an atypical presentation at the onset: symptoms lacking sudden headache and diminished consciousness. These atypical symptoms can easily lead to misdiagnosis. This paper reported the death cases of acute aneurysmal subarachnoid hemorrhage with toothache as the first symptom, hoping to provide clinical evidence for the general public doctors to reduce the misdiagnosis and delayed diagnosis of SAH, improve the identification ability of SAH, and prevent such death events from happening again.

The exact mechanism of idiopathic intracranial hypertension (IIH) is unknown. It needs to be treated because of severe headache and impaired vision. For medically refractory patients, cerebrospinal fluid diversion, optic nerve sheath fenestration and dural venous sinus stenting is applied to relieve the symptoms. As a new therapy, the complication of dural venous stenting was a focus for operators. Here, a woman is reported with IIH who suffered from mastoiditis after stenting in the sigmoid sinus for the first time. The special local anatomy of the sigmoid sinus adjacent to the inner structure made it a noteworthy complication.

Chiari malformation type 1 (CM-1) is an ectopia of the cerebellar tonsils below the foramen magnum that causes severe disability due to its neurologic symptoms. The treatment of choice for CM-1 is decompression of the craniovertebral junction (CVJ). In some patients only an extradural decompression by removing the atlanto-occipital ligament may be sufficient. In other patients, duraplasty is necessary. In this case, we report the operative technique used to treat a CM-1 in a 16-year-old male patient who presented with severe headache and gait instability. A micro-decompression of the suboccipital bone and posterior arch osteotomy of C1 through a 2-cm midline incision was performed under surgical microscope magnification. A duraplasty was performed through the same approach. The patient was discharged home after 2 days in the hospital and returned to regular activities at school 3 weeks after surgery. The minimally invasive technique presented here is a viable option for the posterior decompression of the CVJ in patients with CM-1 using a low-cost self-retaining retractor.

An 81-year-old man with unilateral nasolacrimal duct obstruction underwent routine endonasal dacryocystorhinostomy and 2 days postoperatively developed a severe headache and rigors. Subsequent CT and MRI imaging demonstrated a defect in the floor of the right anterior cranial fossa, which possibly was damaged during the operation, and meningoencephalitis of the adjacent frontal lobe gyrus. Following intravenous antibiotic treatment, the patient made a full recovery with no ongoing sequelae, and his epiphora completely resolved. To the authors' knowledge, this is the first report of meningoencephalitis following endonasal dacryocystorhinostomy. This complication should be considered in any patient with a febrile septic presentation or headache following endonasal dacryocystorhinostomy.

Objective: Migraine is a common, disabling condition typically characterized by severe headache, nausea, and/or light and sound sensitivity. This study assessed migraine-related health resource utilization (HRU) occurring in the emergency room/accident & emergency department (ER/A&E) setting among European patients with four or more migraine days per month. Methods: Patient-level clinical and HRU data were collected via chart extraction by ER/A&E physicians in France, Germany, Italy, and Spain. Eligible patients had four or more migraine days in the month prior to a migraine-related ER/A&E visit and a history of migraine, among other criteria. The index date for each patient was defined as the date of an ER/A&E visit for migraine on or after January 1, 2013. Physician and ER/A&E characteristics, patient and disease characteristics, treatment history, migraine-medication used, and migraine-related HRU (i.e., procedures) during the ER/A&E visit were assessed. Descriptive analyses were conducted in the pooled population, and a sensitivity analysis was performed by country. Results: A total of 467 eligible patient’s charts (120 in France, 120 in Germany, 107 in Italy, and 120 in Spain) were provided by 136 physicians (36 in France, 36 in Germany, 28 in Italy, and 36 in Spain). On average, patients spent nearly eight hours in the ER/A&E. Approximately 82% of patients received a blood test, 62% received an electrocardiography, and 46% received a cranial computerized tomography scan. Despite the majority of patients already using acute or prophylactic treatment upon visiting the ER/A&E, almost all patients were administered or prescribed migraine treatment during the visit. Approximately 21% of patients were admitted to the hospital, and over half of patients were referred to a neurologist or headache specialist. Conclusions: European patients who had four or more migraine days in the month prior to a migraine-related ER/A&E visit had high HRU associated with the visit.

A rare case of Mollaret meningitis characterized by four recurrent episodes of aseptic meningitis during a three-year period is reported. The patient showed a high fever and severe headache accompanied by a high level of cerebrospinal fluid (CSF) cytokines, such as interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-alpha). The symptoms and high CSF cytokines were resolved immediately after introducing indomethacin treatment. Reactivation of the latent virus is considered to be the cause of this rare disease, and indomethacin is believed to inhibit the periodic abnormal generation of eicosanoid in the brain, resulting in a reduction in the fever and subsequent inflammation.

Cluster headache is a neurological disorder that presents with unilateral severe headache associated with ipsilateral cranial autonomic symptoms. Cluster headache attacks often occur more than once a day, and typically manifesting in bouts. It has a point prevalence of 1 in 1000 and is the most common trigeminal autonomic cephalalgia. This article aims to guide general neurologists to an accurate diagnosis and practical management options for cluster headache patients.

Objective: To evaluate headache severity, and its correlation with clinical, cerebrospinal fluid, and neuroimaging parameters of tuberculous meningitis (TBM) patients, and its impact on outcome. Methods: This prospective observational study was conducted at King George’s Medical University, Lucknow, India between October 2012 and March 2014. Ninety-five newly diagnosed TBM patients underwent detailed clinical, laboratory, and neuroimaging evaluation. A numeric rating scale was used to assess the headache severity, and patients were grouped into mild, moderate, severe, and intolerable groups. Patient outcome was evaluated at 6-months follow up. Results: Holocranial stabbing type headache (p=0.002), modified Barthel index ≤12 (p2.5 g/l (p2.5g/L, cranial nerve palsies, paraparesis, and infarcts. Patients of the mild and moderate headache group were headache free at 6 months follow up with good outcome. Conclusion: Severity of headache was associated with multiple clinical, CSF protein, and radiological factors. As intolerable and severe headache had an unfavorable impact on outcome, we could prognosticate the TBM patients on the basis of headache severity.