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Background & Objective: Studies have shown that the most common neurologic symptom in patients with COVID-19 is headache, which may even be the first and only symptom. This study aimed to determine headache characteristics such as frequency, duration and localization, as well as the relationship of systemic inflammation with headaches in patients with COVID-19. Methods: A total of 202 patients hospitalized for COVID-19, consisting of 101 patients with headaches and 101 patients with no headache, were included in the study. Demographic characteristics, symptoms, clinical findings, and laboratory results were evaluated. In the group with headaches, visual analog scale (VAS) scores, duration, severity, and localization of pain were recorded. Results: One hundred nineteen (58.9%) of the patients had no headache in their previous medical history, whereas 21.3% (43/202) had a migraine history. Most of the patients with headache experienced short-term attacks of moderate-severity headaches (47.1%) that were pressing in nature (59%), and generalized (32.4%). We divided our patients into two groups according to pain severity: one of patients with mild-to-moderate headache and one of those with severe headache.. Pain characteristics were compared between the groups, and it was observed that the pain duration was longer in the group with severe pain (p

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.

Rheumatoid meningitis is a rare complication of long-standing rheumatoid arthritis. We present the case of a 39-year-old Bolivian woman with a history of seropositive rheumatoid arthritis of 12 years of evolution without extra-articular manifestations that develops a severe headache with vomiting. The diagnosis of rheumatoid meningitis was performed based on clinical history, blood count and biochemistry results, cerebrospinal fluid analysis and cranial magnetic resonance imaging findings. High-dose intravenous glucocorticoids were started, followed by rituximab. After treatment, a significant clinical improvement was observed and repeat magnetic resonance imaging scan confirmed an improvement of the meningeal lesions.

The paper presents a case of a 35-year-old woman with a history on the COVID-19. This disease was confirmed by PCR test. The woman’s medical history revelated endometriosis, cardiac arrhythmia and hypercholesterolemia. The first symptoms of COVID-19 were lower abdominal pain and diarrhoea, and in the next days — severe headache, muscle and joint pain, body weakness, dry cough, chest pains and many others. On the thirteenth day, the infection occurred to skin lesions on the face. The treatment applied resulted in clinical improvement.

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

Arterial gas embolism is a well-described and frequently seen injury encountered in both civilian and military diving operations. It is becoming increasingly reported and potentially increasingly more common in the hospital environment as a complication of more frequent gastroenterology procedures. We present a case of a 49-year-old, active-duty female who developed significant left-sided neurological deficits manifesting as diffuse left-sided weakness, subjective confusion, and severe headache following esophagogastroduodenoscopy. With increased clinical suspicion for arterial gas embolism, the patient was evaluated by the hyperbaric medicine team at our facility and subsequently treated to near-resolution of symptoms by multiple hyperbaric oxygen treatments. This case highlights the importance of considering this rare complication during or following common invasive procedures. Furthermore, the unique training and experience of physicians with expertise in diving medicine and their ability to recognize these types of injury in the hospital setting highlights the importance of continued training in these fields within Military Medicine in addition to civilian Undersea and Hyperbaric Medicine fellowships.

Background Colloid cysts are benign and rare tumors of the brain. The growth rates of these tumors are unpredictable. These cysts can increase in size and obstruct the cerebrospinal fluid pathways producing obstructive hydrocephalus. Consequently, this can manifest as acute severe headaches followed by deterioration in consciousness, or even sudden death in patients. Such remarkable episodes occurring in patients during air travel have been reported sparsely in the literature. Case Description In this report, we narrate the ordeal of a patient who had severe headache followed by loss of consciousness during his air travel. After his arrival, he was taken to a referral center where the diagnosis of a colloid cyst obstructing the cerebrospinal fluid pathway resulting in acute obstructive hydrocephalus was revealed. We analyze the physiologic effects of cabin pressure and high altitude on the intracranial pressure and present a brief review of the literature. Conclusions Changes in cabin pressure during flight may play a role in worsening of intracranial pressure in patients with colloid cyst with marginal brain compliance.

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

A 50-year-old woman presented to the emergency room complaining of severe headache. A non-contrasted head CT was obtained, which demonstrated a hyperdense image compatible with an intracerebral hemorrhage in the posterior region of the left temporal lobe. The patient displayed no neurological deficit during the consultation and a subsequent MRI showed a temporoinsular bleeding lesion that was suggestive of an atypic meningioma or a metastatic lesion. Afterwards, neck, chest and abdomen CT scans were performed, and the imaging ruled out a secondary neoplasm. The patient underwent surgical resection of the lesion, and a solid tumor was found with no bleeding associated. The pathology reported a WHO I fibroblastic meningioma.

Slit ventricle syndrome (SVS) is a well-known complication of long-standing shunts. Patients develop intermittent severe headache, vomiting with other symptoms of increased intra-cranial pressure. Brain computed tomography (CT) usually reveals slit-like ventricles with nearly obstructed proximal catheters. Treatment for SVS usually involves upgrading the shunt valve pressure setting. Currently, many patients carry programmable shunts and pressure setting can be adjusted noninvasively. However, when the programmable valve pressure setting is upgraded, some patients with SVS experience worsened symptoms. This is caused by the time gap between ICP increase and real ventricular expansion (and freeing proximal catheter) after shunt upgrading. Therefore, it is important to control a patient’s symptoms during the transition period. We report our experience in controlling ICP in a patient with SVS using external ventricular drainage.

Reversible cerebral vasoconstriction syndrome (RCVS) is characterized by acute and usually severe headache related to multifocal vasoconstriction of cerebral arteries, reversible within 3 months. About 10% of RCVS are pregnancy-related, but only three cases of antepartum RCVS have been described. We report the case of a 26-year-old pregnant woman who presented at 36 weeks gestation with antepartum RCVS. Delivery was managed by cesarean section under general anesthesia. Though she developed focal neurologic deficits on the first postoperative day, these resolved at hospital discharge. This case highlights pre- and post-partum multidisciplinary management including cesarean section under general anesthesia.

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.

BACKGROUND Third epidermoid tumors are a rare finding. The appearance of these tumors often makes them difficult to diagnose, and thus they require multimodality imaging. CASE SUMMARY A 48-year-old male patient reported to our hospital with complaints of vomiting and severe headache. The patient also complained of involuntary micturition for the past five days. We used a combination of computed tomography (CT) and magnetic resonance imaging (MRI) imaging modalities to confirm the presence of a malignant epidermoid cyst arising from the third ventricle. A contrast-enhanced CT of the head demonstrated minimal perilesional enhancement while an MRI revealed a large, lobulated and septated T2 hyperintense mass arising from the third ventricle. The maximum size of the lesion measured 73 mm × 65 mm × 64 mm in size. CONCLUSION Malignant epidermoid arising from the third ventricle in an adult male was reported using a combination of CT, MRI, and MR spectroscopy.

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.

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.

A 62 years old man presented to his GP with a severe right temporal headache. He was diagnosed with temporal arteritis and treated with systemic steroids. Five days later, he presented to the Emergency department of a tertiary care centre and admitted with confusion, severe headache and a “swollen” right eye. The patient was initially admitted to the stroke unit with a suspected carotico-cavernous fistula.

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.

A 60-year-old caucasian woman was transferred from an outside hospital with one week history of severe headache, intermittent nausea, vomiting, and a one day history of episodes of dizziness, ataxia, and falls. An initial non-contrast computed tomographic of head demonstrated diffuse cerebral edema prompting transfer to our institution for further evaluation and management.

A 12-year-old girl presented with complaint of severe headache lasting 10 days, nausea and vomiting for 1 day. The headache was localized in the right fronto-occipital region with spread to the neck and shoulders. In her medical history, tympanostomy tubes were inserted in her ears due to frequent otitis media with effusion before 2 years. She had recurrent reactive airway, asthma attacks, and allergic rhinitis. Before the definitive diagnosis could be established, she had received systemic antihistamine, nasal steroid, leukotriene antagonist, inhaler steroid, and salbutamol. She was treated with sefaclor per orally due to acute sinusitis for 5 days. The patient was admitted to our hospital with symptoms of severe headache. Physical examination showed that she was alert with an axillary temperature of 36.3 °C, weight of 60 (95th percentile) kg, height of 155 (65th percentile) cm, blood pressure of 150/100 mmHg (> 95th/> 95th percentile), and heart rate of 98 beats/min.

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.

This case is intended to serve as a learning tool for all clinicians working in primary care. Headache is a commonly encountered problem in primary care and most cases do not mandate urgent transfer to secondary care. However, in this particular patient, there was focal neurology as well as a coital history of headache, both of which collectively mandated further investigation. She was diagnosed with a spontaneous parieto-occipital haemorrhage. On reflection, it is important to note that, despite this haemorrhage, the patient remained well enough to present to primary care and was still able to maintain a Glasgow Coma Scale score of 15/15. This case highlights two important areas of learning which could be useful to all healthcare professionals evaluating headaches. Firstly, any new focal neurology such as blurring of vision should prompt further investigation. Secondly, all healthcare professionals evaluating a sudden-onset headache should ask about whether the headache was coital or not, as this is very easy to ask and may prove to be very diagnostically useful. ### Presenting complaint A 44 year old woman presented to her GP on a morning walk-in clinic, complaining of an 18-hour history of severe headache which was spreading from the posterior to the anterior aspect of her head. She mentioned that this …

At times, more restricted lesions of the brain areas may lead to involvement of so-called provincial hubs or more localized or confined brain regions. Several typical brain images are presented in Fig. 12.1. The parietal and temporal lobes are often involved with such lesions and both have been reported as relatively “silent” areas of the brain when restricted lesions affect these areas. A case in point is that of image 1 in figure. The middle-aged woman presented as a so-called “stroke alert” to our emergency room with her main presenting symptom a sudden severe headache with otherwise normal neurological examination and normal NIH stroke score of 0. With administration of analgesics, a rapid improvement of her headache ensued and she was cleared for discharge with a presumptive diagnosis of migraine to which she was prone to. Just prior to her discharge, the fasttracked MRI scan became available and revealed a small left parietal hemorrhage. Given the location, she was evaluated for left parietal syndromes including a Gerstmann’s syndrome and angular gyrus syndrome, the former which was her ultimate clinical diagnosis. In emergent as well as most routine stroke presentations, Gerstmann’s syndrome is rarely specifically tested for, and indeed in our case it was the only discernible neurological deficit. This brief case report underscores the value of cognitive and behavioral neurological syndrome evaluation. In emergent cases, neuroimaging is often revealing and can guide the examination. Given a lesion, what specific syndromes may be present?

A 29-year-old primipara woman (162 cm, 78 kg) at 36-week gestation was admitted from the ER with the complaint of severe headache localized to the left frontal area for 3 months, accompanied by nausea/vomiting of 1 week duration.

This chapter focuses on the importance of the Observation Unit (OU) in management of patients with syncope/collapse. The designation “OU” applies to a dedicated area, generally located near the Emergency Department (EDOU), devoted to the evaluation of patients, including those with transient loss of consciousness (T-LOC) in whom a diagnosis has not been made during the Emergency Department (ED) process but in whom the clinical findings do not suggest an immediate life-threating condition, such as chest pain, severe headache, abdominal pain. In some hospital organizations, the OU can admit patients with diseases that need only a short acute treatment (e.g., acute asthma). In some countries the OU are also termed Short Intensive Observation Unit, meaning that during the observation time an intense and in-depth clinical observation could be done. The OUs dedicated to the management of patients with syncope/collapse are called Syncope Observation Units (SOU). SOU can admit patients with unexplained syncope/collapse at intermediate risk and many of those at high risk and, combined with the in-hospital Syncope Unit (SU), plays a strategic role in the modern efficient management of syncope/collapse patients. The SOU should have a defined syncope management protocol and a well-established organization and essential equipment for an intensive management of unexplained syncope.

Excessive daytime sleepiness (EDS) is a prevalent sleep-related complaint across the general population and has been reported to be associated with headache. Tension-type headache (TTH) is the most commonly encountered headache and accounts for a significant amount of disease burden. However, the association between EDS and TTH is currently scarce. In the present study, we investigated the impact of EDS on the prevalence and clinical presentation of TTH. We utilized data from the Korean Headache-Sleep Study, a national survey that sought to identify headache and sleep characteristics in Korean adults. Participants with an Epworth sleepiness scale score greater or equal to 11 were considered as having EDS. Of the 2,695 participants enrolled, 570 (21.2%) and 313 (11.6%) had TTH and EDS, respectively. EDS was highly prevalent in individuals with chronic tension-type headache (CTTH) than in those without headache (35.7 vs. 9.4%, p < 0.001). The prevalence of EDS in episodic tension-type headache (ETTH) individuals with a headache frequency

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.

To discuss the clinical syndrome, review common imaging findings of pituitary apoplexy (PA) and role of imaging in therapy and follow-up. Also, to review other acute clinical scenarios with similar clinical and/or imaging findings as PA. PA is a severe and potentially life-threatening medical emergency, characterized by constellation of symptoms/signs that occur as a result of acute hemorrhage and/or infarction in pituitary gland. Patients present with acute and sudden onset of symptoms/signs, most commonly with severe headache, vision deficits/ophthalmoplegia, altered mental status, and possible pan hypopituitarism. Pre-existing macro adenoma (65–90%), especially non-functioning and prolactinomas, are most susceptible to apoplexy, which undergoes hemorrhage or infarct, but PA can occur with normal pituitary or microadenoma. Because of the probable grave prognosis of PA, imaging characteristics of PA and other acute clinical scenarios with similar clinical and/or imaging findings should be familiar to radiologists. PA is potentially a life-threatening clinical syndrome, however, imaging and clinical findings can lead the radiologist towards appropriate diagnosis, and rule out other clinical mimics. When hemorrhage is secondary to an underlying lesion, regrowth of the pituitary tumor years after a PA episode is possible and patients require long-term clinical and imaging surveillance.

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.

Background The biopsychosocial model claims that illness is generated by both biological and psychosocial factors. Accordingly, several studies have shown that both factors contribute to the generation of pain. Aims The aim of the present study is to manipulate biological, psychological, and social factors in hypobaric hypoxia headache in order to understand their relative contribution to the generation of headache pain. Methods Healthy subjects were subdivided into three groups and brought to our high-altitude labs for the assessment of hypoxia-induced headache, blood oxygen saturation (SO2), prostaglandins, and cortisol during the first 24 h after arrival. The first group did not undergo any manipulation. The second group (negative expectation) was told that severe headache would occur if SO2 dropped to less than 80% and their oximeters were set to display a saturation of 75%, even though real SO2 was much higher. The third group (negative expectation and social interaction) underwent the same manipulation as the second group, but these subjects spent the night together with people experiencing headache and insomnia. Results Although none of the three groups differed significantly for SO2, the second group, compared to the first, experienced more severe headache and showed an increase in prostaglandins and cortisol. The third group, compared to the second group, showed a further increase of headache as well as of prostaglandin (PG) E2 and cortisol. Conclusions These findings indicate that biological, psychological, and social factors are additive not only in the generation of headache but also for the biochemical changes related to hypoxia.

Background: Migraine is a public health problem and it is the third most common cause of disability among individuals below the age of 50. In spite of the multiplicity of the studies concerned with exploring the disease epidemiology and nature worldwide, data from Saudi Arabia are lacking. The aim of this study was to study the prevalence of migraine in Taif city, Saudi Arabia. Methods: This was a cross-sectional study conducted on 354 individuals in Taif city. Data were collected via a self-administered questionnaire including demographic variables, clinical variables, and therapeutic variables. Data were fed into the computer and analyzed using SPSS software. Results: Among the 354 recruited participants, 54% were females, and 46% were males. Migraine occurred in 89.9% of urban inhabitants. About 24% of migraineurs were unemployed, and 16% were non-working students. Headache occurred in 86.9% of females and 71.6% of males (P = 0.002). Gender was significantly correlated with migraine prevalence (odds ratio (OR) = 0.28). About 47% reported pain score of 4 - 6. Seeking medical advice was encountered in 32.4% of females and 26.6% of males. Nausea occurred in more than one-third of patients before and during headache. Only 31.4% of participants knew about migraine triggers. Family history was found in 64% of participants. Conclusions: Migraine is prevalent in Taif city. It is more prevalent among females, and among urban areas. Migraine is associated with high rates of unemployment. Most Saudi migraineurs encounter throbbing, moderately severe headache, that does not awake them from sleep. Females report more severe headaches, whereas more men take medications. Nausea is the most common associated symptom with migraine. Only one-third of Saudi migraineurs know about migraine triggers. Family history of migraine is very common among Saudi migraineurs. J Clin Med Res. 2018;10(2):125-133 doi: https://doi.org/10.14740/jocmr3277w

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.

Notable in Neurology This Week This issue features an article that investigates the association between early neurologic recovery, practice pattern variation, and endotracheal intubation during status epilepticus; another describes the development of a new quality of life measure for boys and men with Duchenne muscular dystrophy. A featured Contemporary Issues discusses the ethics of searching for covert consciousness. ### Association of Refractory Pain in the Acute Phase After Subarachnoid Hemorrhage With Continued Outpatient Opioid Use Patients with aneurysmal subarachnoid hemorrhage (aSAH) have severe headache at onset and during the following weeks; they often receive opioids while in the hospital. This retrospective study found that continued outpatient opioid use was common after aSAH …

Objetivo: Investigar o nível de conhecimento dos leigos acerca da identificação dos sinais e sintomas e dos fatores de risco referentes ao AVC. Materiais e métodos: Foi realizada pesquisa bibliográfica em bases de dados internacionais, sendo selecionados 9 estudos publicados entre os anos de 2017 e 2021, compreendendo os idiomas inglês e português. Resultados: Ao analisar os artigos elencados, percebeu-se que a maioria fez uso de questionário como instrumento de coleta de dados (88,9%) e entrevistas presenciais (66,7%). Com relação aos sinais e sintomas, os principais abordados pelos estudos foram: fraqueza ou formigamento na face, no braço ou na perna; confusão, alteração da fala ou compreensão da linguagem; alteração na visão e dor de cabeça súbita, intensa e sem causa aparente. Quanto aos fatores de risco, os mais abordados foram hipertensão e tabagismo. Conclusões: Percebeu-se que o nível de conhecimento dos leigos acerca da identificação dos sinais e sintomas e fatores de risco do AVC não é satisfatório, devido ao baixo nível educacional dos participantes, poucas campanhas educativas e diminuto vínculo entre os usuários e as equipes interdisciplinares de saúde.

We are reporting a case of 16-year-old boy presented with severe headache and blurred vision. MRI showed a pineal region mass that was initially thought to be a germinoma. Endoscopic biopsy revealed tuberculoma which is an exceedingly rare and unusual location for CNS tuberculoma. The patient was treated successfully with anti-tuberculous therapy.

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.

A 24-year-old non-obese, but slightly overweight, female presented with a two-week history of progressive severe headache associated with two days of blurry vision. Clinical exam was significant for bilateral papilledema and an enlarged blind spot on visual field testing. Contrast enhanced MRI head revealed no space occupying lesion. A lumbar puncture revealed an elevated opening pressure of 38 cm H2O with normal cerebrospinal fluid composition leading to a diagnosis of pseudotumor cerebri syndrome (PTCS). The patient lacked the typical risk factors of high body mass index or obvious antecedent medications; however, on subsequent questioning, she was chronically ingesting a high vitamin A containing weight loss dietary supplement (Thrive W® – Table 1), which we believe had caused intracranial hypertension. Discontinuation of the diet pill and treatment with acetazolamide led to marked improvement of her PTCS. This case highlights the fact that non-traditional products or medications with high vitamin A may cause pseudotumor cerebri, which treating physicians should assess for while dealing with non-obese PTCS patients.

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.

Neurocysticercosis (NCC) is considered a common infection of the nervous system caused by the Taenia solium and is known to be the primary cause of preventable epilepsy in many developing countries. NCC is commonly resulted by the ingestion of Taenia solium eggs after consuming undercooked pork, or contaminated water. The parasite can grow in the brain and spinal cord within the nervous system, causing severe headache and seizures beside other pathological manifestations. People in North Eastern hilly areas of Bangladesh are very much fond of Pork meat. Here in this case report, an elderly indigenous male was found to be presented with weakness and sleep deprivation initially. During subsequent conversation with the patient for obtaining his medical history, he started complaining of dizziness, which eventually led to generalized convulsions lasting for about one minute. Though his neurological system examination was inconclusive, stool routine microscopic examination showed ova of T. solium. IgG antibody against T. solium was positive. Later, the patient was advised to have contrast MRI of brain which revealed multiple Ring enhancing T2 hyperintense cystic lesion with tiny central in different parts of the brain.Bangladesh Journal of Infectious Diseases 2016;3(1):24-27

Secondary hemorrhage occurs as a complication of central nervous system (CNS) following acupuncture has been reported in few cases. The present study reports a case of a 70-year-old woman who presents medulla oblongata hemorrhage after acupuncture. The patient suffered severe headache, neck pain, vomiting, and weakness after the neck acupuncture. The purpose of presenting this case report is to raise awareness among clinicians of fateful CNS complications during acupuncture. More importantly, qualified training of acupuncturists is anticipated and standardized processes of clinical acupuncture operations needs to be developed, in order to avoid the occurrence of acupuncture accidents. Keywords: Secondary hemorrhage, Medulla oblongata, Acupuncture, Complication

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.

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

The occurrence of Tolosa-Hunt syndrome (THS) in the setting of discoid lupus erythematosus (DLE) has not been previously reported. We report a case of a 55-year-old Chinese man with established cutaneous lupus who presented with 1 week of worsening blurry vision and ptosis of the left eye with severe headache 2 weeks prior to presentation. His cranial nerve examination was significant for left afferent pupillary defect, red desaturation, ptosis, and oculomotor nerve palsy. He also presented with active DLE lesions. Magnetic resonance imaging brain demonstrated asymmetric thickening and enhancement of the left cavernous sinus consistent with THS. After a 4-week gradual steroid taper his ophthalmoplegia resolved. The unusual occurrence of THS and DLE prompts consideration of nonsystemic autoimmune disorders in diagnosis of THS.

Bezold’s abscess is a suppurative complication of mastoiditis rarely seen in the current era of antimicrobials. It can lead to seriously sequelae if not diagnosed and treated early. We describe a patient with recurrent bilateral otalgia who had received multiple courses of antimicrobials who presented with severe headache, neck pain and right sided hearing loss. Imaging studies showed chronic mastoiditis and formation of a Bezold’s abscess. Drainage was performed but symptoms persisted. Our report highlights the need for further evaluation of patients presenting with complicated mastoiditis and the need for prolonged antimicrobial therapy. Keywords: Bezold’s abscess, Suppurative mastoiditis, Skull base osteomyelitis

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.

Post-dural puncture headache (PDPH), a condition commonly caused by inadvertent dural puncture with a large-bore epidural needle, may also occur as a result of uncomplicated small-bore spinal needle insertion. The condition is characterized by a severe headache exacerbated in the upright position and relieved when the patient is supine but may involve nausea, vomiting and occasionally cranial nerve symptoms. Presented are the clinical findings, diagnosis, prevention and treatment of PDPH.

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.

Quantifying pain intensity using a numerical rating scale is a well validated means for assessing the subjective perception of pain. A cognitive framework to interpret and characterize a concept is referred to as a schema. The schema used to conceptualize pain rating can vary, potentially through assimilation of new experiences and information. Thus, whether pain-rating schema differ systematically between those with chronic pain and pain-free individuals is unknown. Secondary analysis of a survey dataset were used to compare pain rating schema across individuals with various forms of chronic pain (n= 785) and pain-free adults (n=451). Schema were assessed using 6 items from the Pain Severity Questionnaire (Frey Law, et al 2014), as part of a larger study. Mean ratings (0 – 10 scale, allowing 0.5 intervals) for 2 common hypothetical pain conditions: mild, moderate, and severe headache and joint pain. Differences and percent reduction between severities were assessed between subgroups, based on type nad number of pain co-morbidities. Patients with FM, with or without multiple pain co-morbidities reported higher pain ratings than pain-free individuals across mild, moderate and severe conditions by approximately 1 out of 10 (p