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Caution must be used in the elderly in making the diagnosis of complicated migraine, since transient ischemic attacks (TIAs), other cerebrovascular dysfunction, or structural lesions also can produce prolonged neurologic deficits with headache. Although hypertensive headache itself has no specific diagnostic features, patients who do complain of headache with episodes of hypertension usually localize the pain to the occipital region. This headache is most pronounced on awakening in the morning, usually diminishing 2 to 3 hours after arising.

Headaches, although common occurrences in the elderly, can be the symptoms of a serious problem. Specific headaches found in this population need careful consideration and diagnosis. When the diagnosis is elusive, or the headache is sudden, severe, and incapacitating, a neurologist or neurosurgeon should be consulted.

Anamnestic data and clinical features were accurately investigated in 180 patients with cluster headache; 161 were episodic sufferers and 19 were chronic. A significantly high familial incidence of coronary heart disease was found. The patients' medical history revealed a significantly high incidence of peptic ulcer disease and head injury with brain concussion. It is stressed that the side on which head injury took place is very frequently the same side on which cluster headache is located, although the latency between the two events appears to be a long one. The study of timing of cluster periods suggests, for some patients, a constant, typical temporal pattern not necessarily related to seasons or the months of of the year. Cluster attacks frequently occur during certain periods of the day (onset being most frequent between 1 and 3 p.m.). Cluster headache cannot be considered as a nocturnal headache.

A patient with necrosis of the tongue was found to have Horton's disease. The other typical manifestations of this disease, though present, were overshadowed by the lingual necrosis. Recovery occurred after relatively high doses of corticoids.

Chronic headache pain has many causes but is generally attributed to one of three mechanisms: muscular contraction, vascular inflammation, or traction or inflammation of pain-sensitive structures. Because of the wide variety of headache types and the often-confusing terminology and classification systems in use, evaluation of headache can be difficult. A step-by-step approach to patient workup, including patient history, physical examination, and appropriate tests, can help the physician pinpoint the underlying problem and determine appropriate therapy. Long-term drug therapy is effective for most patients with vascular headaches. For headaches of psychogenic origin, therapy includes psychotropic drugs, biofeedback training, counseling, and behavior modification. More research in the area of mind-body interactions will lead to improved management of chronic headache of nonorganic origin.

59 patients with cluster headache are discussed. Treatment can be divided into treatment of the acute attack, and prophylactic treatment. The acute attack can be interrupted in most cases by ergotamine, either sublingually or in the form of suppositories. A number of patients respond to the inhalation of pure oxygen. Most patients with the episodic type of cluster headache do well on prophylactic treatment with methysergide. If they prove refractory to this drug, treatment with lithium salts can be instituted. Most patients with the chronic type of cluster headache respond favourably to lithium therapy.

Causes of headache requiring urgent and specific treatment must not be overlooked. Headache due to cervical spinal root irritation, like migraine, is common and responds well to appropriate treatment. When headache is chronic or recurrent, a good care provider-patient relationship can be critical.

A case of cluster-tic syndrome is presented. A 51-year-old man developed pain attacks corresponding to the second branch of the trigeminal nerve. After treatment with 1200 mg carbamazepine daily, the attacks disappeared. Full remission was achieved, and carbamazepine therapy was continued. Pain attacks of a quite different character then appeared; their clinical picture corresponded to cluster headache. After treatment with cyproheptadine, the cluster headache attacks ceased, but 2 days later, before the discontinuation of the treatment, the attacks of trigeminal neuralgia reappeared. Treatment with carbamazepine was started again, and there was remission of the trigeminal neuralgia after several weeks.

The clinical definition of carotidynia is not a controversial one, whereas how its etiology should be interpreted is still uncertain. The study of the clinical features and the therapeutical results in 12 patients suffering from carotidynia reveals a marked resemblance to migraine. In particular, the case history reported points out a significant incidence of migraine as a familial disease, its special localization and the type of pain, the possible presence of a prodromal stage and the favourable response to the drugs that are known to be effective in migraine treatment. The theory that carotidynia should be ascribed to the group of vascular headaches is therefore suggested.

Eleven patients were examined thermographically during spontaneous cluster headaches and 22 during attacks induced by nitroglycerin or alcohol. In cluster headache, heat loss increased from the affected orbital region, and in some patients, this spread above and below the eye, down the nose, and to the affected temple. Inhalation of 100% oxygen reduced or abolished cluster pain in 22 of 25 instances, and asymmetry of heat loss then disappeared. Since the unilateral increase in blood flow usually followed the onset of pain in affected areas, the vascular changes of cluster headache are probably secondary phenomena, initiated by a vasodilator pathway, with the trigeminal nerve as the afferent and the greater superficial petrosal nerve as the efferent limb.

The authors analysed the clinical pattern of manifestations and electroencephalographic findings in 120 patients with vasomotor headache, who were attending the Migraine Treatment Centre at the Department of Neurology, Medical Academy in Lódź. During 5 years of observation these patients accounted for 20% of all cases of idiopathic headaches treated in this Centre. It was observed that the clinical manifestations and electroencephalographic findings in vasomotor headaches were non-characteristic. The diagnosis of this headache must be reached after ruling out all other idiopathic and symptomatic headaches.