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Introduction: Real-life headache presentations may fit more than one ICHD3 diagnosis. This project seeks to exhaustively list all logically consistent “co-diagnoses” according to the ICHD3 criteria. We limited our project to cases of two concurrent diagnoses. Methods: We included the criteria for “Migraine” (1.1, 1.2, 1.3), “Tension-type headache” (2.1, 2.2, 2.3, 2.4), “Trigeminal autonomic cephalalgias” (3.1, 3.2, 3.3, 3.4, 3.5), and “Other primary headache disorders.” We also excluded “probable” diagnosis criteria. Each characteristic in the above criteria is assigned a unique prime number. We then encoded each ICHD3 criteria into integers through multiplication in a list format; we called these criteria representations. “Codiagnoses representations” were generated by multiplying all possible pairings of criteria representations. We then manually encoded a list of logically inconsistent characteristics through multiplication. All co-diagnoses representations divisible by any inconsistency representations were filtered out, generating a list of co-diagnoses representations that were logically consistent. This list was then translated back into ICHD3 diagnoses. Results: We used a total of 103 prime numbers to encode 578 ICHD3 criteria. Once illogical characteristics were excluded, we obtained 145 dual diagnoses. Of the dual diagnoses, two contained intersecting characteristics due to subset relationships, 14 contained intersecting characteristics without subset relationships, and 129 contained dual diagnoses as a result of non-intersecting characteristics. Conclusion: Analysis of dual diagnosis in headaches offers insight into “loopholes” in the ICHD3 as well as a potential explanation for the source of a number of controversies regarding headache disorders. The existence of dual diagnoses and their identification may carry implications for future developments and testing of machine-learning diagnostic algorithms for headaches. [ABSTRACT FROM AUTHOR]

Background: Headache burden is substantial in idiopathic intracranial hypertension. The classification of idiopathic intracranial hypertension headache by the International Classification of Headache Disorders (ICHD) is an important tool for research and clinical purposes. Methods: We phenotyped headaches and tested sensitivity and specificity of the ICHD-3 criteria for idiopathic intracranial hypertension headache in a prospective cohort of patients suspected of idiopathic intracranial hypertension at two tertiary headache centers. Results: Sensitivity was 93% and specificity was 100% of ICHD-3 criteria for idiopathic intracranial hypertension-related headache validated in idiopathic intracranial hypertension (n = 140) and patients in whom idiopathic intracranial hypertension was suspected but disproven (n = 103). The phenotype of new/worsened headaches related to idiopathic intracranial hypertension suspicion was equally migraine-like (p = 0.76) and tension-type-like (p = 0.08). Lumbar puncture opening pressure was higher (p < 0.0001) and pulsatile tinnitus more frequent (p < 0.0001) in idiopathic intracranial hypertension patients, but neither improved the applicability of the headache criteria, nor did papilledema. Conclusion: Headache phenotype is not distinct in idiopathic intracranial hypertension. ICHD-3 criteria for idiopathic intracranial hypertension headache are sensitive and specific, but simplicity can be improved without compromising accuracy. We propose that a new or worsened headache temporally related to active idiopathic intracranial hypertension is a sufficient criterion for idiopathic intracranial hypertension headache regardless of headache phenotype or accompanying symptoms, and that elements of idiopathic intracranial hypertension diagnostics (papilledema and opening pressure) be segregated from headache criteria. Trial Registration: ClinicalTrials.gov Identifier: NCT04032379 [ABSTRACT FROM AUTHOR]

Objective: To assess the prevalence or relative frequency of paroxysmal hemicrania and its clinical features in the adult general population and among adult patients evaluated for headache in tertiary care. Background: Paroxysmal hemicrania is a rare trigeminal autonomic cephalalgia with characteristic attacks of headache, associated cranial autonomic symptoms and signs, and an absolute response to indomethacin. Its epidemiological burden remains unknown in both the adult general population and among adult patients evaluated for headache in a tertiary care setting. Moreover, the frequencies of the clinical features associated with paroxysmal hemicrania have not been well established. Methods: A literature search of PubMed and Embase was conducted from January 1, 1988, to January 20, 2023. Eligible for inclusion were observational studies reporting the point prevalence or relative frequency of paroxysmal hemicrania or its clinical features in the adult general population or among adult patients evaluated for headache in tertiary care. Two independent investigators (M.J.H. and J.G.L.) performed the title, abstract, and full‐text article screening. Each included study's risk of bias was critically appraised using the Joanna Briggs Institute Critical Appraisal Checklist for Studies Reporting Prevalence Data. Estimates of prevalence or relative frequency were calculated using a random‐effects meta‐analysis. The between‐study heterogeneity was assessed using the I2 statistic and further explored with meta‐regression. This study was pre‐registered on PROSPERO (identifier: CRD42023391127). Results: A total of 17 clinic‐based studies and one population‐based study met the eligibility criteria. Importantly, an overall high risk of bias was observed across the eligible studies. The relative frequency of paroxysmal hemicrania was estimated to be 0.3% (95% CI, 0.2%–0.5%) among adult patients evaluated for headache in tertiary care with considerable heterogeneity (I2 = 76.4%). No cases with paroxysmal hemicrania were identified among 1,838 participants in a population‐based sample. Moreover, the most prevalent cranial autonomic symptoms were lacrimation (77.3% [95% Cl, 62.7%–87.3%]), conjunctival injection (75.0% [95% Cl, 60.3%–85.6%]), and nasal congestion (47.7% [95% Cl, 33.6%–62.3%]). Conclusions: Our findings suggest that paroxysmal hemicrania is a rare disorder among adults evaluated for headache in tertiary care, while its prevalence in the general population remains unknown. Further studies focusing on the clinical features of paroxysmal hemicrania are warranted. [ABSTRACT FROM AUTHOR]

Background: The distinction between a pre-existing primary headache and a secondary headache at the onset of a disorder is important and has not been taken into account in the International Classification of Headache Disorders-3. This study aimed to improve the general diagnostic criteria for secondary headaches using results of our previous studies. Materials and methods: We analyzed characteristics of headaches including their changes in intensity, duration, frequency, localization and side, development of new accompanying symptoms, and therapeutic response at the onset of transient ischemic attacks (TIA) (n = 120, mean age 56.1, 55% females) and ischemic stroke (n = 550, mean age 63.1, 56% females) compared to the control group (n = 192, mean age 58.7, 64% females). Results: Headache of a new type occurred in 8.4% of ischemic stroke patients and 5% of TIA patients on the day of admission but did not occur at all in the control group. Pre-existing headache with a change of at least one characteristic occurred significantly more often in stroke (5.4%) and TIA (7.5%) than in the control group (1%) (p = 0.01 and p = 0.003 respectively). Conclusion: The presence of a new type of headache and a pre-existing headache with altered characteristics in close temporal relation to a disorder indicates causality. Based on these data we propose revised general diagnostic criteria for secondary headaches. [ABSTRACT FROM AUTHOR]

Background: Hypnic headache is a neurological disorder characterized by recurrent headache attacks that occur exclusively during sleep, leading to awakening. Synthesizing the available epidemiological data might inform clinical decision-making. Methods: We searched PubMed and Embase for observational studies on hypnic headache published between 1 May 2004, and 22 December 2022. Two investigators independently screened titles, abstracts, and full-text articles. We performed a random-effects meta-analysis with meta-regression to estimate the prevalence of hypnic headache and its clinical features based on epidemiologic data from population-based and clinic-based studies. Results: Fourteen studies, one population-based and 13 clinic-based, met our eligibility criteria. The population-based study did not identify any people with hypnic headache. From 11 clinic-based studies, the pooled relative frequency of hypnic headache was 0.21% (95%CI, 0.13 to 0.35%; I2 = 87%) in adult patients evaluated for headache. The pooled mean age of onset was 60.5 years, with a slight female predisposition. Hypnic headache was typically bilateral (71%), pressing (73%), of moderate (38%) or severe (44%) pain intensity, and lasted about 115 minutes per attack. Conclusions: Our data should be cautiously interpreted due to between-study heterogeneity. The identified clinical presentation of hypnic headache can guide clinical diagnosis, in addition to the International Classification of Headache Disorders. [ABSTRACT FROM AUTHOR]

Abstract Tension-type headache (TTH) and migraine are two common primary headaches distinguished by clinical characteristics according to the 3rd edition of the International Classification of Headache Disorders. Migraine is identified by specific features such as being more prevalent in females, being aggravated by physical activity, certain genetic factors, having photophobia, phonophobia, nausea, vomiting, or aura, and responding to specific drugs. Nonetheless, TTH and migraine share some common characteristics, such as onset occurring in the 20 s, and being triggered by psychological factors like stress, moderate pain severity, and mild nausea in chronic TTH. Both conditions involve the trigeminovascular system in their pathophysiology. However, distinguishing between TTH and migraine in clinical practice, research, and epidemiological studies can be challenging, as there is a lack of specific diagnostic tests and biomarkers. Moreover, both conditions may coexist, further complicating the diagnostic process. This review aims to explore the similarities and differences in the pathophysiology, epidemiology, burden and disability, comorbidities, and responses to pharmacological and non-pharmacological treatments of TTH and migraine. The review also discusses future research directions to address the diagnostic challenges and improve the understanding and management of these conditions. Graphical Abstract

Introduction: Real-life headache presentations may fit more than one ICHD3 diagnosis. This project seeks to exhaustively list all logically consistent “co- diagnoses” according to the ICHD3 criteria. We limited our project to cases of two concurrent diagnoses. Methods: We included the criteria for “Migraine” (1.1, 1.2, 1.3), “Tension-type headache” (2.1, 2.2, 2.3, 2.4), “Trigeminal autonomic cephalalgias” (3.1, 3.2, 3.3, 3.4, 3.5), and “Other primary headache disorders.” We also excluded “probable” diagnosis criteria. Each characteristic in the above criteria is assigned a unique prime number. We then encoded each ICHD3 criteria into integers through multiplication in a list format; wecalled these criteria representations. “Codiagnoses representations” were generated by multiplying all possible pairings of criteria representations. We then manually encoded a list of logically inconsistent characteristics through multiplication. All co-diagnoses representations divisible by any inconsistency representations were filtered out, generating a list of co- diagnoses representations that were logically consistent. This list was then translated back into ICHD3 diagnoses. Results: We used a total of 103 prime numbers to encode 578 ICHD3 criteria. Once illogical characteristics were excluded, we obtained 145 dual diagnoses. Of the dual diagnoses, two contained intersecting characteristics due to subset relationships, 14 contained intersecting characteristics without subset relationships, and 129 contained dual diagnoses as a result of non-intersecting characteristics. Conclusion: Analysis of dual diagnosis in headaches offers insight into “loopholes” in the ICHD3 as well as a potential explanation for the source of a number of controversies regarding headache disorders. The existence of dual diagnoses and their identification may carry implications for future developments and testing of machine-learning diagnostic algorithms for headaches. [ABSTRACT FROM AUTHOR]

Migrainous infarction (MI) is a rare disorder. The precise diagnostic criteria for this diagnosis have been available in the International Classification of Headache Disorders (ICHD) since 1988, but many cases do not fulfil these criteria. This paper describes a good example of MI and analyzes previously published case reports. We report a very special case of MI in an 18-year-old woman who had a recurrent episode of migraine with a similar aura with numbness of the right arm and speech disturbances which had an unusually long duration (>120 min). On admission to the headache centre "Europe-Asia", she complained of slowness of speech and problems with choice of words. An MRI showed acute lacunar infarcts in the left parietal subcortical area. Ischemic infarcts were localized in a relevant area on the left side and the aura symptoms were right-sided. The patient, therefore, fulfilled the ICHD-3 diagnostic criteria for "Migrainous infarction". An analysis of 35 previously published articles with case reports about MI showed that 22 did not meet the diagnostic criteria of the ICHD for migrainous infarction. Using all this, we developed diagnostic recommendations for migrainous infarction which can help to improve the quality of diagnosis when used together with the diagnostic criteria of the ICHD for migrainous infarction. [ABSTRACT FROM AUTHOR]

Tension-type headache (TTH) and migraine are two common primary headaches distinguished by clinical characteristics according to the 3rd edition of the International Classification of Headache Disorders. Migraine is identified by specific features such as being more prevalent in females, being aggravated by physical activity, certain genetic factors, having photophobia, phonophobia, nausea, vomiting, or aura, and responding to specific drugs. Nonetheless, TTH and migraine share some common characteristics, such as onset occurring in the 20 s, and being triggered by psychological factors like stress, moderate pain severity, and mild nausea in chronic TTH. Both conditions involve the trigeminovascular system in their pathophysiology. However, distinguishing between TTH and migraine in clinical practice, research, and epidemiological studies can be challenging, as there is a lack of specific diagnostic tests and biomarkers. Moreover, both conditions may coexist, further complicating the diagnostic process. This review aims to explore the similarities and differences in the pathophysiology, epidemiology, burden and disability, comorbidities, and responses to pharmacological and non-pharmacological treatments of TTH and migraine. The review also discusses future research directions to address the diagnostic challenges and improve the understanding and management of these conditions. [ABSTRACT FROM AUTHOR]

Background. Although persistent headaches are a common post-stroke pain syndrome, the epidemiology and clinical features of persistent headache after first-ever ischemic stroke have not been considered previously. There is no exact data on how often headache attributed to stroke persists for more than 3 months, i.e. meets the criteria for persistent headache after stroke and what are their distinctive clinical features. The tasks of our study were: to analyze the occurrence/incidence of persistent headaches after the first-ever ischemic stroke; to determine clinical characteristics and types of persistent headaches in comparison with headaches at the onset of stroke. Materials and methods. The study included 550 patients (mean age 63.1 years, 54% men) with first-ever ischemic stroke, of which 529 patients were followed up for at least three months after the stroke. Standardized semi-structured interview forms were used to assess these headaches during professional face-to-face interviews at the onset of stroke and 3 months after the stroke using telephone interview by neurologist. Results. Among 529 follow up patients 55 (10.4%) had persistent headaches after first-ever ischemic stroke. Among these 55 patients 34 patients had persistent new-type headaches which arose for the first time during the onset of stroke, they included predominated migraine-like headaches (n=20), tension-type-like headaches (n=9) and thunderclap-like headaches (n=5). 21 patients had persistent headaches with altered characteristics: predominated tension-type-like headaches (n=16), and less common migraine-like headaches (n=5). Persistent headaches after stroke had the following characteristics compared to headaches at onset of stroke: severe headache intensity, a gradual decrease of occurrence of accompanying symptoms (photo- and phonophobia; p=0.03), the transition of unilateral headaches in bilateral (p=0.004), the presence of headaches 15 days per month in 30.9% of the patients. Conclusion. Persistent post-stroke headaches represent a persistent pain syndrome with severe intensity and frequency of attacks, which requires their further study and creation of guidelines for their management.

Abstract Background Observational studies on the prevalence of premonitory symptoms in people with migraine, preceding the headache pain (or aura) phase, have shown conflicting results. We conducted a systematic review and meta-analysis to estimate the prevalence, and relative frequency among clinic populations, of premonitory symptoms in people with migraine, overall and of the multifarious individual symptoms, and to review the methodologies used to assess them. Methods We searched PubMed and Embase for studies published from database inception until 31st of May 2022. Two investigators independently screened titles, abstracts, and full texts. We retrieved observational studies that reported the prevalence/relative frequency of one or more premonitory symptoms in people with migraine. Two investigators independently extracted data and assessed risk of bias. Results were pooled using random-effects meta-analysis. Our main outcomes were the percentage of people with migraine who experienced at least one premonitory symptom and the percentages who experienced different individual premonitory symptoms. To describe our outcomes, we used the terms prevalence for data from population-based samples and relative frequency for data from clinic-based samples. We also descriptively and critically assessed the methodologies used to assess these symptoms. Results The pooled estimated prevalence in population-based studies of at least one premonitory symptom was 29% (95% CI: 8–63; I2 99%) and the corresponding pooled estimated relative frequency in clinic-based studies was 66% (95% CI: 45–82; I2 99%). The data from clinic-based studies only supported meta-analysis of 11 of 96 individual symptoms, with relative frequency estimates ranging from 11 to 49%. Risk of bias was determined as high in 20 studies, moderate in seven, and low in two. Conclusions The substantial between-study heterogeneity demands cautious interpretation of our estimates. Studies showed wide methodological variations, and many lacked rigor. Overall, the evidence was insufficient to support reliable prevalence estimation or characterization of premonitory symptoms. More data are needed, of better quality, to confirm the existence of a distinctive premonitory phase of migraine, and its features. Methodological guidelines based on expert consensus are a prerequisite.

Abstract Background It is poorly described how often headache attributed to stroke continues for more than 3 months, i.e. fulfils the criteria for persistent headache attributed to ischemic stroke. Our aims were: 1) to determine the incidence of persistent headache attributed to past first-ever ischemic stroke (International headache society categories 6.1.1.2); 2) to describe their characteristics and acute treatment; 3) to analyse the prevalence of medication overuse headache in patients with persistent headache after stroke; 4) to evaluate factors associated with the development of persistent headache after stroke. Methods The study population consisted of 550 patients (mean age 63.1, 54% males) with first-ever ischemic stroke, among them 529 patients were followed up at least three months after stroke. Standardized semi-structured interview forms were used to evaluate these headaches during professional face-to-face interviews at stroke onset and telephone interviews at 3 months. Results At three months, 61 patients (30 women and 31 men, the mean age 60.0) of 529 (11.5%) follow-up patients had a headache after stroke: 34 had a new type of headache, 21 had a headache with altered characteristics and 6 patients had a headache without any changes. Therefore 55 (10.4%) patients had a persistent headache attributed to ischemic stroke. Their clinical features included: less severity of accompanying symptoms, slowly decreasing frequency and development of medication overuse headache in one-third of the patients. The following factors were associated with these headaches: lack of sleep (29.1%, p = 0.009; OR 2.3; 95% CI 1.2–4.3), infarct in cerebellum (18.2%, p = 0.003; OR 3.0; 95% CI 1.4–6.6), stroke of undetermined etiology (50.9%, p = 0.003; OR 2.3; 95% CI 1.3–4.1), less than 8 points by NIHSS score (90.9%, p = 0.007; OR 3.4; 95% CI 1.4–8.6) and low prevalence of large-artery atherosclerosis (12.7%, p = 0.006; OR 0.3; 95% CI 0.2–0.80). Conclusion Persistent headache attributed to ischemic stroke is not rare and frequently leads to medication overuse. The problem is often neglected because of other serious consequences of stroke but actually, it has a considerable impact on quality of life. It should be a focus of interest in the follow-up of stroke patients.

Objective: To estimate the relative frequencies of hemicrania continua and its clinical features in adult patients who were evaluated for headache in a clinic-based setting. Methods: PubMed and Embase were searched for observational, clinic-based studies published between 1 January 2004 and 1 February 2022, that reported on the relative frequencies of hemicrania continua and its clinical features. Two independent investigators (HMA and SA-K) screened titles, abstracts, and full text-articles. A random-effects meta-analysis was conducted to estimate pooled relative frequencies of hemicrania continua and its clinical features across clinic-based studies. Results: Eleven clinic-based studies were deemed eligible for inclusion. Of these, eight studies reported on the relative frequency of hemicrania continua among adult patients (n = 9854) who were evaluated for headache in a tertiary care unit. The pooled relative frequency of hemicrania continua was found to be 1.8% (95% CI; 1.0–3.3). Considerable heterogeneity was noted across studies (I2 = 89.8%). The three most common symptoms associated with hemicrania continua were lacrimation (72.3%), conjunctival injection (69.8%), and restlessness/agitation (60.2%). Conclusion: The findings of this meta-analysis suggest that there is limited epidemiologic data on the relative frequencies of hemicrania continua and its clinical features. Standardized data acquisition and reporting are needed to estimate prevalence rates more accurately and to better understand epidemiologic patterns. This, in turn, should increase awareness of the impact that hemicrania continua has in clinical practice. [ABSTRACT FROM AUTHOR]

Background: Observational studies on the prevalence of premonitory symptoms in people with migraine, preceding the headache pain (or aura) phase, have shown conflicting results. We conducted a systematic review and meta-analysis to estimate the prevalence, and relative frequency among clinic populations, of premonitory symptoms in people with migraine, overall and of the multifarious individual symptoms, and to review the methodologies used to assess them. Methods: We searched PubMed and Embase for studies published from database inception until 31st of May 2022. Two investigators independently screened titles, abstracts, and full texts. We retrieved observational studies that reported the prevalence/relative frequency of one or more premonitory symptoms in people with migraine. Two investigators independently extracted data and assessed risk of bias. Results were pooled using random-effects meta-analysis. Our main outcomes were the percentage of people with migraine who experienced at least one premonitory symptom and the percentages who experienced different individual premonitory symptoms. To describe our outcomes, we used the terms prevalence for data from population-based samples and relative frequency for data from clinic-based samples. We also descriptively and critically assessed the methodologies used to assess these symptoms. Results: The pooled estimated prevalence in population-based studies of at least one premonitory symptom was 29% (95% CI: 8–63; I2 99%) and the corresponding pooled estimated relative frequency in clinic-based studies was 66% (95% CI: 45–82; I2 99%). The data from clinic-based studies only supported meta-analysis of 11 of 96 individual symptoms, with relative frequency estimates ranging from 11 to 49%. Risk of bias was determined as high in 20 studies, moderate in seven, and low in two. Conclusions: The substantial between-study heterogeneity demands cautious interpretation of our estimates. Studies showed wide methodological variations, and many lacked rigor. Overall, the evidence was insufficient to support reliable prevalence estimation or characterization of premonitory symptoms. More data are needed, of better quality, to confirm the existence of a distinctive premonitory phase of migraine, and its features. Methodological guidelines based on expert consensus are a prerequisite. [ABSTRACT FROM AUTHOR]

Background: The current knowledge on the epidemiology and clinical manifestation of airplane headache is mostly derived from case series and small cohort studies without evidence from large populations. Methods: This cross-sectional study was conducted over a five-month period in the arrival area of two international airports in Germany. 50,000 disembarking passengers were addressed about headaches during their flight to determine headache prevalence, and those confirming and willing to participate underwent a structured interview. Results: Headache during travel was reported by 374 passengers (0.75%), and 301 underwent a structured interview. One hundred and one (0.2%) met the diagnostic criteria of airplane headache. Six passengers suffered from migraines and 134 from tension-type headaches. The differences in the age and gender distribution between the airplane headache and non-airplane headache groups were not statistically significant. The onset (79.2%), duration (82.2%), and location (73.3%) of airplane headache mostly complied with current diagnostic criteria but pain intensity (42.6%) and quality (42.6%) did less so. Conclusion: Our data suggest a substantially lower prevalence of airplane headaches than previously reported. The pain intensity and quality seem less characteristic than assumed, suggesting a need to refine the current diagnostic criteria. [ABSTRACT FROM AUTHOR]

Migrainous infarction (MI) is a rare disorder. The precise diagnostic criteria for this diagnosis have been available in the International Classification of Headache Disorders (ICHD) since 1988, but many cases do not fulfil these criteria. This paper describes a good example of MI and analyzes previously published case reports. We report a very special case of MI in an 18-year-old woman who had a recurrent episode of migraine with a similar aura with numbness of the right arm and speech disturbances which had an unusually long duration (>120 min). On admission to the headache centre “Europe-Asia”, she complained of slowness of speech and problems with choice of words. An MRI showed acute lacunar infarcts in the left parietal subcortical area. Ischemic infarcts were localized in a relevant area on the left side and the aura symptoms were right-sided. The patient, therefore, fulfilled the ICHD-3 diagnostic criteria for “Migrainous infarction”. An analysis of 35 previously published articles with case reports about MI showed that 22 did not meet the diagnostic criteria of the ICHD for migrainous infarction. Using all this, we developed diagnostic recommendations for migrainous infarction which can help to improve the quality of diagnosis when used together with the diagnostic criteria of the ICHD for migrainous infarction.

Background: It is poorly described how often headache attributed to stroke continues for more than 3 months, i.e. fulfils the criteria for persistent headache attributed to ischemic stroke. Our aims were: 1) to determine the incidence of persistent headache attributed to past first-ever ischemic stroke (International headache society categories 6.1.1.2); 2) to describe their characteristics and acute treatment; 3) to analyse the prevalence of medication overuse headache in patients with persistent headache after stroke; 4) to evaluate factors associated with the development of persistent headache after stroke. Methods: The study population consisted of 550 patients (mean age 63.1, 54% males) with first-ever ischemic stroke, among them 529 patients were followed up at least three months after stroke. Standardized semi-structured interview forms were used to evaluate these headaches during professional face-to-face interviews at stroke onset and telephone interviews at 3 months. Results: At three months, 61 patients (30 women and 31 men, the mean age 60.0) of 529 (11.5%) follow-up patients had a headache after stroke: 34 had a new type of headache, 21 had a headache with altered characteristics and 6 patients had a headache without any changes. Therefore 55 (10.4%) patients had a persistent headache attributed to ischemic stroke. Their clinical features included: less severity of accompanying symptoms, slowly decreasing frequency and development of medication overuse headache in one-third of the patients. The following factors were associated with these headaches: lack of sleep (29.1%, p = 0.009; OR 2.3; 95% CI 1.2–4.3), infarct in cerebellum (18.2%, p = 0.003; OR 3.0; 95% CI 1.4–6.6), stroke of undetermined etiology (50.9%, p = 0.003; OR 2.3; 95% CI 1.3–4.1), less than 8 points by NIHSS score (90.9%, p = 0.007; OR 3.4; 95% CI 1.4–8.6) and low prevalence of large-artery atherosclerosis (12.7%, p = 0.006; OR 0.3; 95% CI 0.2–0.80). Conclusion: Persistent headache attributed to ischemic stroke is not rare and frequently leads to medication overuse. The problem is often neglected because of other serious consequences of stroke but actually, it has a considerable impact on quality of life. It should be a focus of interest in the follow-up of stroke patients. [ABSTRACT FROM AUTHOR]

New daily persistent headache is described as an enigmatic condition with daily headache from onset. It has posed challenges diagnostically and therapeutically. Methods: We conducted a study of patients referred to headache services based in Central and North-East London, United Kingdom, meeting the International Classificaiton of Headache Disorders – 3 criteria for New daily persistent headache. Information on demographics, phenotype and treatment responses were collected. The syndrome of the daily headache was also classified according any other ICHD-3-defined syndrome. Results: Of 162 patients, females comprised 68.5% with median age of onset 35 years. The daily headache experienced was chronic migraine in 89.7% and tension-type headache in 8.8%. Thunderclap-onset New daily persistent headache occurred in 14.8%. More than one headache syndrome was experienced in 15.4%, including cough, hypnic, sexual and stabbing headache. All aura types were experienced, most commonly brainstem aura in 39%. Prior headache was reported 53.7%. A persisting sub-form was present in 51.2%, relapsing remitting in 12.3% and 14.0% reported improvement; 19.8% were lost to follow-up. Only 11.1% reported an antecedent trigger. The most common premorbid disorders were psychiatric in 35.7%. A fifth improved on preventative medication, most commonly amitriptyline, propranolol and topiramate. Conclusion: Our cohort of New daily persistent headache is consistent with a mode of onset of migraine and tension-type headache which occurs in predisposed individuals. [ABSTRACT FROM AUTHOR]

Introduction: The most frequently reported neurological adverse event of ChAdOx1 nCoV-19 (AZD1222) vaccine is headache in 57.5%. Several cases of cerebral venous thrombosis (CVT) have developed after vaccination. Headache is the leading symptom of CVT. For the differential diagnosis of headaches attributed to this vaccine and headaches attributed to CVT, it is of central clinical importance whether and, if so, how the phenotypes and course of these headaches can be differentiated. The study aims to examine in detail the phenotype of headache attributed to this vaccine. Methods: Data on the clinical features and corresponding variables were recorded using a standardized online questionnaire in this multicenter observational cohort study. The primary outcomes of this study are the clinical features of headaches after vaccination. Findings: A total of 2464 participants reported headaches after vaccination with the ChAdOx1 nCoV-19 (AZD1222) vaccine. On average, headaches occurred 14.5 ± 21.6 h after vaccination and lasted 16.3 ± 30.4 h. A bilateral location was described by 75.8% of participants. This is most often found on the forehead (40.0%) and temples (31.4%); 50.4% reported a pressing and 37.7% a dull pain character. Headache intensity was most often severe (38.7%), moderate (35.2%), or very severe (15.5%). Accompanying symptoms were most commonly fatigue (44.8%), chills (36.1%), exhaustion (34.9%), and fever (30.4%). Conclusion: Headaches attributed to COVID-19 vaccination with the ChAdOx1 nCoV-19 (AZD1222) vaccine demonstrate an extensive and characteristic complex of symptoms. The findings have several important clinical implications for the differentiation of post-vaccinal headache and other primary as well as secondary headaches. [ABSTRACT FROM AUTHOR]

The article discusses clinical practice one day more or less of headache might not significantly change the burden of disease for individual patients and high frequency episodic migraine (HFEM; 8–14 headache days/month) may well affect a patient's life in a similar way as CM with 15–23 days of headache/ month.

Headache is one of the leading symptoms often associated with brain tumours. Secondary headaches attributed to intracranial neoplasias have been included in subchapter 7.4 of the third edition of the International Classification of Headache Disorders (ICHD-3). According to ICHD-3, the headache may be attributed to a brain tumour if it has developed in close temporal relation with the development of the neoplasia, has significantly worsened in parallel with the worsening of the tumour, and/or has significantly improved following the successful treatment of the neoplasia. Brain tumour headache was traditionally thought to display some specific clinical characteristics, including worsening in the morning and/or when lying down, being aggravated by Valsalva-like manoeuvres and accompanied by nausea and/or vomiting; however, the studies performed after the advent of modern neurodiagnostic techniques have pointed out that the "classic" brain tumour headache is uncommon, particularly at the time of clinical presentation. Therefore, it becomes critical to seek some specific factors associated with the presence of an intracranial mass (the so-called "red flags") that can guide the physician to establish an accurate diagnosis. [ABSTRACT FROM AUTHOR]

Background: Vestibular migraine (VM) is a relatively recently acknowledged vestibular syndrome with a very relevant prevalence of about 10% among patients complaining of vertigo. The diagnostic criteria for VM have been recently published by the Bárány Society, and they are now included in the latest version of the International Classification of Headache Disorders, yet there is no instrumental test that supports the diagnosis of VM. Objective: In the hypothesis that the integration of different vestibular stimuli is functionally impaired in VM, we tested whether the combination of abrupt vestibular stimuli and full-field, moving visual stimuli would challenge vestibular migraine patients more than controls and other non-vestibular migraineurs. Methods: In three clinical centers, we compared the performance in the functional head impulse test (fHIT) without and with an optokinetic stimulus rotating in the frontal plane in a group of 44 controls (Ctrl), a group of 42 patients with migraine (not vestibular migraine, MnoV), a group of 39 patients with vestibular migraine (VM) and a group of 15 patients with vestibular neuritis (VN). Results: The optokinetic stimulation reduced the percentage of correct answers (%CA) in all groups, and in about 33% of the patients with migraine, in as many as 87% of VM patients and 60% of VN patients, this reduction was larger than expected from controls' data. Conclusions: The comparison of the fHIT results without and with optokinetic stimulation unveils a functional vestibular impairment in VM that is not as large as the one detectable in VN, and that, in contrast with all the other patient groups, mainly impairs the capability to integrate different vestibular stimuli. [ABSTRACT FROM AUTHOR]

Objective: To systematically identify risk factors for the development of post‐traumatic headache (PTH) attributed to traumatic brain injury (TBI) as defined in the International Classification of Headache Disorders (ICHD). Background: PTH is a common sequela of TBI and a leading cause of injury‐related disability worldwide. However, little is known about risk factors for the development of PTH attributed to TBI. Methods: We searched PubMed and Embase for literature on risk factors for the development of acute and/or persistent PTH attributed to TBI in accordance with any version of the ICHD. Original studies published in English and of prospective, cross‐sectional or retrospective design were considered for the review. Data extraction was performed independently by 2 investigators. Results: Of 1993 potentially relevant articles identified, 3 articles met the inclusion criteria. The following risk factors were assessed for the development of acute PTH: age, sex, type of injury, loss of consciousness, previous TBIs, history of primary headache disorders, history of chronic pain condition other than headache, current treatment for depression/anxiety, attention or learning disorders, body mass index, and other diseases (not further specified). None of the included studies assessed risk factors for the development of persistent PTH. Conclusions: We found that there is little evidence for any risk factors involved in the development of acute PTH, whereas no study had assessed risk factors for the development of persistent PTH. Further studies are warranted and should be powered to examine possible risk factors for the development of PTH. Rigorous methodology and standardized monitoring should be prioritized to support high‐quality research and validate potential findings. [ABSTRACT FROM AUTHOR]

Aim: This basic review is intended to summarize the current knowledge of methemoglobinemia as an important cause of secondary headache with the hope of generating a growing interest in studying this phenomenon. Background: We describe the pathological underpinnings of headaches generated by hypoxia. Possible mechanisms include cerebral vasodilation‐associated stretching of the vessel nociceptors, sensitization of perivascular nociceptors mediated by nitric oxide, cerebral calcitonin gene‐related peptide, activation of the cyclic adenosine monophosphate pathway, cortical spreading depression, disruption of the blood‐brain barrier, and neurogenic inflammation. We review the clinical features, pathophysiology, and management of methemoglobinemia. We conducted a literature review of reports of symptomatic methemoglobinemia with headache. In addition, we describe a case report of a patient who presented with an acute onset of severe holocranial headache associated with rapidly progressive perioral paresthesia, cyanosis in lips and hands, nausea, and mild dyspnea on exertion. These features can be misinterpreted as an acute attack of migraine with pain‐related hyperventilation syndrome and anxiety leading to clinically detrimental delay in the management of the progressive hypoxia. Her symptoms resolved following treatment with methylene blue. The complex relationship of migraine and hypoxia‐related headaches is also reviewed. We propose that methemoglobinemia‐associated headaches are possibly generated by stretching of the nociceptor nerve endings during cerebral vasodilation and hypoxia‐mediated oxidative stress. Conclusions: The case highlights the need to broaden the formulated differential diagnosis of an acute onset severe holocranial headache and pay careful attention to other signs and symptoms that may provide hints on potential mechanism(s) for secondary headaches. We provide justification for the need to incorporate "Headache attributed to Methemoglobinemia" as a subtype under the section "Headache attributed to hypoxia and/or hypercapnia" of the International Classification of Headache Disorders to support clinical decision making. [ABSTRACT FROM AUTHOR]

Objective: To determine headache diagnosis and treatment patterns in the outpatient setting, focusing on documentation of the International Classification of Headache Disorders (ICHD) criteria., Design, Setting, and Participants: Retrospective cohort data were collected from electronic medical records of adults aged 18-35 who presented to resident-staffed family medicine outpatient clinics in the Midwest, USA, for a new or worsening headache between 2015 and 2016. Diagnosis codes were used to summarize the overall nature and prevalence of headaches. A random subset of 30 patients each for migraine headache (MGH) with and without aura and tension-type headache (TTH) were reviewed to determine how many of the five possible ICHD criteria were documented. Demographics/clinical characteristics, ICHD criteria, number and type of medications, and healthcare utilization (imaging, primary and emergency department care) through one year following the initial visit were summarized and compared across headache types., Results: There were 716 unique patients during the study period (414 MGH, 227 unspecified headaches, 75 TTH, or others). Complete ICHD criteria were documented for two patients in total. There was partial documentation (e.g., one to four of the possible five) for 30% of TTH, 63% of MGH without aura, and 77% of MGH with aura (p<0.05). Across headache types, patients were prescribed an average of 2.3 to 3.3 medications over one year, with MGH patients generally trying more medications (up to eight for those with aura and up to 12 for those without). Abortive or rescue medications were prescribed to nearly all patients; prophylactics were prescribed for 50% of MGH with aura, 66.7% of MGH without aura, and 53.3%. Non-pharmacologic interventions were less prescribed: 33.3% of TTH patients and 3.3% of MGH types combined (p<0.05). Healthcare utilization was highest for MGH with aura (ED visits) and without aura (clinic visits) patients compared to TTH (p<0.001)., Conclusion: Headache-related documentation is often incomplete, which may limit interpretation and associations between diagnoses, prescribing patterns, and healthcare utilization. Future studies should evaluate the use of electronic medical records (EMR)-based templates to improve documentation, and additional detailed studies are needed in the local setting to determine whether treatment, including the use of non-pharmacologic and prophylactic methods of treatment, is optimal., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2024, Pershing et al.)

Background: To assess the prevalence of headache attributed to aeroplane travel (AH) in patients referred to Italian Headache Centres.Material and Method: 869 consecutive patients visiting six Italian headache centres during a 6 month-period (October 2013 to March 2014) were enrolled in the survey. Among them, 136 (15.6%) had never flown and therefore were excluded from the study. The remaining 733 patients (f = 586, m = 147; age 39.1 ± 17.3) were asked about the occurrence of headache attacks during flight; those who answered the question positively filled in a detailed questionnaire that allowed the features of the attacks to be defined.Results: Headache attacks during the flight was reported by 34/733 subjects; four presented attacks fulfilling ICHD-3 beta (1) criteria for migraine without aura and therefore were not further considered. The features of the remaining 30 (4.0%; m = 18, f = 12, age 36.4 ± 7.3) completely fulfilled the ICHD-3 beta criteria for AH. In more detail, the pain was unilateral (fronto-orbital: n = 23; fronto-parietal: n = 7; without side-shift: n = 25, with side-shift: n = 5), lasting up to 30 min in 29 subjects. All the patients reported the pain as very severe or unbearable and landing as the phase of travel in which the attack appeared. In four cases, a postictal, milder, dull headache could last up to 24 hours. Accompanying symptoms were present in eight cases (restlessness: n = 5; conjunctival injection and tearing: n = 2; restlessness + ipsilateral conjunctival injection and tearing: n = 1). The fear of experiencing further attacks negatively affected the propensity for future flights in 90.0% of subjects (n = 27). In all the patients, AH onset did not coincide with the first flight experience. Concomitant migraine without aura was diagnosed in 24, tension-type headache in four, migraine without aura + tension-type headache in two cases; none suffered from cluster headache. Five subjects reported AH on each flight, 20 in > 50% of flights, five occasionally. Despite the severe intensity of the pain, only one third of this sample spontaneously reverted to a pharmacological treatment; the most useful strategy combines a decongestant nasal spray plus the intake of a simple analgesic 30 min before the estimated attack. Spontaneous manoeuvres were applied by 18 patients (Valsalva-like: n = 12; compression: n = 2; both manoeuvres: n = 4), more often without significant improvement. These data confirm our previous finding on the clinical features of AH.Conclusion: AH was found in 4.0% of a multicentre, large sample of patients with flight experiences. Although limited to a sample of patients followed in six Italian headache centres, to the best of our knowledge these are the first epidemiological data on AH gathered by direct interview. If properly investigated, AH seems to be a not infrequent condition, which, when diagnosed, could probably be prevented in many cases. [ABSTRACT FROM AUTHOR]

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