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Background and Purpose Methods Results Conclusions Patients presenting at the emergency room (ER) with headache often encounter a hostile atmosphere and experience delays in diagnosis and treatment. The aim of this study was to design a protocol for the ER with the goal of optimizing the care of patients with urgent headache to facilitate diagnosis and expedite treatment.A narrative literature review was conducted via a MEDLINE search in October 2021. The “Code Headache” protocol was then developed considering the available characteristics and resources of the ER at a tertiary care center within the Spanish National Public Health system.The Code Headache protocol comprises three assessments: two scales and one checklist. The assessments identify known red flags and stratify patients based on suspected primary/secondary headaches and the need for pain treatment. Initial assessments, performed by the triage nurse, aim to first exclude potentially high morbidity and mortality etiologies (HEAD1 scale) and then expedite appropriate pain management (HEAD2 scale) based on scoring criteria. HEAD1 evaluates vital signs and symptoms of secondary serious headache disorders that can most benefit from earlier identification and treatment, while HEAD2 assesses symptoms indicative of status migrainosus, pain intensity, and vital signs. Subsequently, ER physicians employ a third assessment that reviews red flags for secondary headaches (grouped under the acronym ‘PEACE’) to guide the selection of complementary tests and aid diagnosis.The Code Headache protocol is a much needed tool to facilitate quick clinical assessment and improve patient care in the ER. Further validation through comparison with standard clinical practice is warranted. [ABSTRACT FROM AUTHOR]

Background: Acute Disseminated Encephalomyelitis (ADEM) is an acute demyelinating disorder of the central nervous system, characterize by multiple white matter hyperintensities on T2 MRI. Patients usually present with subacute progressive encephalopathy and polyfocal neurological deficits. Possible treatments are corticosteroids, immunoglobulins and plasma exchange. Full clinical recovery is seen in more than half of the cases. Case: We describe a case of a 62-year-old patient presenting with thunderclap headache as the first symptom, two weeks after an upper respiratory tract infection. The clinical course was complicated by progressive coma and intracranial hypertension mandating external ventricular drainage and sedation. Initial treatment with methylprednisolone was unsuccessful but clinical resolution and radiological regression was achieved after plasma exchanges and cyclophosphamide. Conclusion: To our knowledge, this is the first reported case of ADEM presenting with thunderclap headache. Intracranial hypertension with the need for invasive neuromonitoring and pressure management is also a very rare complication of ADEM. In this report, we describe the findings of the literature review concerning ADEM, thunderclap headache and intracranial hypertension. [ABSTRACT FROM AUTHOR]

Myelin oligodendrocyte glycoprotein antibody disease (MOGAD) is characterized by multiple phenotypic conditions such as acute disseminated encephalomyelitis, optic neuritis, and myelitis. MOGAD's spectrum is expanding, with potential symptoms of increased intracranial pressure that are similar to idiopathic intracranial hypertension (IIH). We report a boy with new-onset continuous headache and a brain MRI at onset suggesting idiopathic intracranial hypertension (IIH). The patient showed resistance to treatment with acetazolamide and, after one month, developed optic neuritis in the left eye. Laboratory tests documented positive MOG antibodies (anti-MOG) in the serum. The final diagnosis was MOGAD, with the initial symptoms resembling IIH. [ABSTRACT FROM AUTHOR]

Abstract Background Acute Disseminated Encephalomyelitis (ADEM) is an acute demyelinating disorder of the central nervous system, characterize by multiple white matter hyperintensities on T2 MRI. Patients usually present with subacute progressive encephalopathy and polyfocal neurological deficits. Possible treatments are corticosteroids, immunoglobulins and plasma exchange. Full clinical recovery is seen in more than half of the cases. Case We describe a case of a 62-year-old patient presenting with thunderclap headache as the first symptom, two weeks after an upper respiratory tract infection. The clinical course was complicated by progressive coma and intracranial hypertension mandating external ventricular drainage and sedation. Initial treatment with methylprednisolone was unsuccessful but clinical resolution and radiological regression was achieved after plasma exchanges and cyclophosphamide. Conclusion To our knowledge, this is the first reported case of ADEM presenting with thunderclap headache. Intracranial hypertension with the need for invasive neuromonitoring and pressure management is also a very rare complication of ADEM. In this report, we describe the findings of the literature review concerning ADEM, thunderclap headache and intracranial hypertension.

Background: Sturge–Weber syndrome (SWS) is a neurocutaneous disorder for which the neurological aspects, particularly headaches, remain poorly understood, despite significantly affecting morbidity. The present study aimed to elucidate the prevalence, characteristics and treatment strategies, as well as explore the pathogenesis of headaches, in SWS. Methods: Using Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines, we systematically reviewed observational studies, case reports and series from eight databases (Cochrane Library, EBSCO, Embase, Medline, PubMed, Science Direct, Scopus and Web of Science), published from 1978 to 2023, to investigate the prevalence, characteristics, medication response and pathogenic theories of headaches in SWS. Results: The review analyzed 48 studies, uncovering headache prevalence between 37% and 71%. Migraine-like headache affected up to 52% of individuals. Prophylactic and acute treatments included non-steroidal anti-inflammatory drugs, triptans and antiepileptic drugs, despite the lack of established guidelines. Life-threatening headaches in SWS are uncommon, typically accompanied by other neurological symptoms. The pathogenesis of headaches in SWS is considered to involve venous congestion and neuronal hyperexcitability linked to leptomeningeal angiomas. Conclusions: Headaches occur more frequently in individuals with SWS than in the general population. Despite symptoms meeting migraine criteria, these headaches should be considered secondary to vascular conditions. Implementing acute and prophylactic treatment is advised to reduce the impact on patients' lives. [ABSTRACT FROM AUTHOR]

Objectives Sellar pathologies are frequently found on imaging performed to investigate headache. However, both headache and incidental sellar lesions are common. Hence, this study prospectively examined headache prevalence, phenotype, and severity in patients with sellar pathologies and the impact of transsphenoidal surgery on headache. Methods Patients undergoing transsphenoidal resection of sellar lesions were consecutively recruited. At baseline, participants were defined as having headache or not and headache phenotype was characterized using validated questionnaires. Headache severity was assessed at baseline and 6 months postoperatively using the Headache Impact Test-6 (HIT-6) and Migraine Disability Assessment Score (MIDAS). Tumor characteristics were defined using radiological, histological, and endocrine factors. Primary outcomes included baseline headache prevalence and severity and headache severity change at 6 months postoperatively. Correlation between headache and radiological, histological, and endocrine characteristics was also of interest. Results Sixty participants (62% female, 47.1 ± 18.6 years) were recruited. Sixty-three percent possessed baseline headache. HIT-6 scores were higher in patients with primary headache risk factors, including younger age (R 2 = −0.417, p = 0.010), smoking history (63.31 ± 7.93 vs 54.44 ± 9.21, p = 0.0060), and family headache history (68.13 ± 7.01 vs 54.94 ± 9.11, p = 0.0030). Headaches were more common in patients with dural invasion (55.70 ± 12.14 vs 47.18 ± 10.15, p = 0.027) and sphenoid sinus invasion (58.87 ± 8.97 vs 51.29 ± 10.97, p = 0.007). Postoperative severity scores improved more with higher baseline headache severity (HIT-6: R 2 = −0.682, p < 0.001, MIDAS: R 2 = −0.880, p < 0.0010) and dural invasion (MIDAS: −53.00 ± 18.68 vs 12.00 ± 17.54, p = 0.0030). Conclusion Headaches in sellar disease are likely primary disorders triggered or exacerbated by sellar pathology. These may respond to surgery, particularly in patients with severe headache and dural invasion. [ABSTRACT FROM AUTHOR]

Abstract Background Nummular headache (NH) is categorized as a primary headache in the International Classification of Headache Disorders, Third edition (ICHD-3) diagnostic criteria, but there are secondary etiologies as well. We present a case of secondary NH that associated with vascular lesion. Case presentation We report on a 40-year-old man with a medical history of symptomatic intracranial arterial stenosis who developed a headache after percutaneous transluminal angioplasty and stenting because of Intracranial atherosclerotic stenosis(ICAS). This new-onset headache was a pinprick headache confined to the parietal part of the head and 5 cm in size. This headache most closely resembled the phenotype of a NH. And other causes of secondary headache were excluded. Thus, the diagnosis of NH was highly speculated. This patient represents a rare headache phenomenon after intracranial arterial stent placement. Conclusion This is the first report of NH after stent placement treatment in a patient with ICAS.

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The article discusses research which investigated the effectiveness of a screening tool for the differential diagnosis of secondary headaches in acute care. Topics explored include the key questions regarding neurological symptoms and systemic features that admitting medical staff need to ask, the reasonable sensitivity and specificity demonstrated by the screening tool, and the secondary headache diagnoses accounted which range from primary brain tumour to venous sinus thrombosis.

Background: Nummular headache (NH) is categorized as a primary headache in the International Classification of Headache Disorders, Third edition (ICHD-3) diagnostic criteria, but there are secondary etiologies as well. We present a case of secondary NH that associated with vascular lesion. Case presentation: We report on a 40-year-old man with a medical history of symptomatic intracranial arterial stenosis who developed a headache after percutaneous transluminal angioplasty and stenting because of Intracranial atherosclerotic stenosis(ICAS). This new-onset headache was a pinprick headache confined to the parietal part of the head and 5 cm in size. This headache most closely resembled the phenotype of a NH. And other causes of secondary headache were excluded. Thus, the diagnosis of NH was highly speculated. This patient represents a rare headache phenomenon after intracranial arterial stent placement. Conclusion: This is the first report of NH after stent placement treatment in a patient with ICAS. [ABSTRACT FROM AUTHOR]

Headache stands out as one of the prevalent symptoms affecting the nervous system,significantly impacting the quality of life,particularly in elderly individuals.The recurrent nature of headaches poses a substantial challenge for the well-being of the elderly,and the management of head pain in this demographic requires a distinctive approach owing to their underlying health conditions and unique characteristics.This article endeavors to comprehensively review both primary and secondary headaches commonly observed in elderly patients.Additionally, it delves into the diagnostic methodologies and treatment strategies specific to this age group.The overarching objective is to establish a theoretical foundation for the secure,efficacious,and systematic diagnosis and management of headaches in the elderly,thus contributing to improved overall patient care.

Background & Aims: Headache has been a common problem for humans since ancient times. The aim of this study was to investigate the prevalence of ear, nose, and throat diseases in patients with headache. Materials & Methods: In this descriptive cross-sectional study, we reviewed medical records of 100 patients presenting with headache to the ENT clinic of Imam Khomeini Hospital in Urmia, Iran, between 2019 and 2021. The type of headache (primary or secondary) was diagnosed based on medical history, clinical examinations, and paraclinical examinations (CT scan) and completion of a checklist for each patient. Chi-square and independent t-tests were used to analyze data. The p value < 0.05 was considered significant. Results: Of 100 patients, 58 (58%) had primary headaches with a mean age of 1.72 ± 4.77 years, and 42 (42%) had secondary headaches with a mean age of 5.57 ± 1.43 years (p < 0.01). There was a significant difference in the type of headache and location of pain in patients except for the back of the head and the top of the head (p < 0.05). Of the 58 patients with primary headaches, 26 (44.8%), and of the 42 patients with secondary headaches, 10 (23.8%) woke up from sleep due to headache (p < 0.03). Of the 58 patients with primary headaches, 38 (65.5%), and of the 42 patients with secondary headaches, 12 (28.6%) had their headache worsened by light and noise (p < 0.001). Conclusion: Of all patients, 42% had secondary headaches, which most commonly had symptoms of sinus pain. These patients were treated by an otolaryngologist. Patients with non-sinus headaches were referred to a neurologist.

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: The current International Classification of Headache Disorders, 3rd edition (ICHD-3) diagnostic criteria for cardiac cephalalgia were established according to previous case reports and the opinion of experts. We aimed to assess the ICHD-3 diagnostic criteria for cardiac cephalalgia. Methods: We conducted a series of cases study and evaluated these criteria in 54 patients with cardiac cephalalgia. Next, we assessed whether the ICHD-3 diagnostic criteria B, C and D for migraine without aura were fulfilled by these patients. Results: ICHD-3 criteria A, B, C1, C2 and D for cardiac cephalalgia were met by 100% of patients, whereas criterion C3 was fulfilled by 81.5%. The least frequently fulfilled sub-criterion was C3b (accompanied by nausea) (18.5%). Moreover, we found that ICHD-3 criteria B, C and D for migraine without aura were met by a low proportion of patients: 11.1%, 46.3% and 25.9%, respectively, and no patient fulfilled the three criteria simultaneously. Conclusion: Based on our results, we propose revised diagnostic criteria for cardiac cephalalgia. We suggest removing criterion C3 and C4. We also suggest removing the word "migraine-like" from its description. [ABSTRACT FROM AUTHOR]

Headache during pregnancy can be due to primary causes such as migraine but can also be a presenting symptom of secondary causes including life threatening conditions. This is a minireview of secondary causes of headache during pregnancy and the puerperium. Unique alterations in physiological and vascular functions as well as in the coagulation pathway which occur during pregnancy increase the risk of most of these secondary conditions which include preeclampsia, eclampsia, hemorrhagic stroke, cerebral venous, sinus thrombosis, reversible cerebral vascular syndrome, and posterior reversible encephalopathy. Marked increase in progesterone level in pregnancy is also associated with the growth of tumors such as meningiomas, as 70% of these tumors are positive for progesterone receptors and increase in size can lead to headache along with other neurological symptoms. Hemodynamic changes can lead to the growth of meningiomas as well. Although hormone producing pituitary tumors are usually not conducing to pregnancy, women with known pituitary tumors who do get pregnant may become symptomatic during pregnancy and develop secondary headache. Another rare cause of secondary headache during pregnancy is pituitary apoplexy. Although its occurrence is uncommon, it needs to be properly recognized and treated to avoid endocrine and visual complications. Other rare entities with increased incidence during the puerperium such postdural puncture headache will be also discussed. In summary, new onset headache during pregnancy deserves special attention because in the absence of proper recognition and treatment, secondary headache disorders can endanger the life of the mother and the fetus. [ABSTRACT FROM AUTHOR]

The article presents a case study of a 73-year-old male patient with daily headaches triggered by various activities and fluctuations in blood pressure, with a focus on distinguishing between primary and secondary headache causes based on clinical characteristics and the International Classification of Headache Disorders, 3rd edition (ICHD-3) criteria.

Headaches can be nociplastic, neuropathic, and nociceptive. Pain related to the latter two categories occurs in the presence of nerve lesions and nociceptive stimuli; attributing pain to the last category requires a list of potential causes and arguments supporting the causal claim. Taking a history and examining patients serves to assess diagnostic criteria and screen for disorders whose diagnosis requires additional examinations. Screening information occurs in two types: one indicates that patients have a headache due to another condition; the other suggests they are at risk. Aspiring to make causal claims for a headache is reasonable because if underlying disorders appear independently and randomly, it is probable that there is only one cause. Thus, having found a cause often implies having found the cause. The prerequisites for causal claims are temporal sequencing, correlation, and elimination of alternate causes. Mechanistic, manipulative, and probabilistic evidence supports the second criterion. The importance of headaches lies in their frequent appearance as an early symptom of an incipient disorder ("sentinel symptom"). Hence, they provide the opportunity to diagnose early diseases with potentially deleterious consequences. Thus, it is sensible to assess each attack carefully and systematically. [ABSTRACT FROM AUTHOR]

Background: This multicenter cross-sectional study aimed to determine the frequency and characteristics of secondary headaches in different geographic regions, including Turkey, the Middle East, Asia, and Africa. Methods: Patients were admitted to the study on a particular day each week for five consecutive weeks between 1 April and 16 May 2022. Before the study, all researchers underwent a constructed briefing about the use and code of the ICHD-3 criteria. The study was conducted in two stages. In the first stage, data on secondary headaches were compared between the regions. In the second stage, the sub-diagnoses of secondary headaches were analyzed only in Turkey. Results: A total of 4144 (30.0%) of the 13,794 patients reported headaches as the main symptoms at admission. A total of 422 patients were excluded from the study. In total, 1249 (33.4%) of 3722 patients were diagnosed as having secondary headaches (Turkey [n = 1039], Middle East [n = 80], Asia [n = 51], Africa [n = 79]). The frequency of secondary headaches (Turkey 33.6%, Africa 30.1%, Middle East 35.5%, Asia 35.4%) did not differ significantly between the regions (p > 0.05). The most common subtype of secondary headaches was headache attributed to substances or their withdrawal in all the studied regions. There was a female predominance in all regions, but it was lower in Africa than in Turkey. The severity and density of headaches differed significantly between the regions, with patients from Africa reporting milder pain than patients from other regions. In Turkey, the most common sub-diagnoses of secondary headaches were medication overuse headache, idiopathic intracranial hypertension, and cervicogenic headache. Conclusion: In the present study, one in three patients with a headache had a secondary headache. Headache attributed to substances or their withdrawal was the most common subtype of secondary headaches in all the studied regions. The female predominance of secondary headaches was lower in Africa than in Turkey. The severity and density of headaches differed significantly between regions, with patients from Africa reporting milder pain. [ABSTRACT FROM AUTHOR]

Medication-overuse headache (MOH) can develop from primary headaches. MOH is usually the result of overuse of symptomatic medications. It is a noteworthy personal and societal burden. The identification and treatment of patients at risk for MOH is an essential component of MOH management. Medication overuse can be modifiable and can advance from episodic to chronic migraine. Treatment for MOH is complex, and experts in the field have varied views on the most appropriate strategy for MOH treatment. The objective of this review is to give a comprehensive synopsis of the literature for the management of MOH. Treatment strategies, such as detoxification and prevention, are the debatable issues. Medication withdrawal is the foundation for management. The available literature suggested abrupt withdrawal with preventive approaches for early management. Bridging therapy could be useful to get relief from withdrawal symptoms. Multidisciplinary choices proved beneficial in supporting withdrawal and preventing relapse. Worldwide, the termination of overused medications has been observed as a standard treatment strategy; however, patient-specific approaches should be taken.

Headache during pregnancy can be due to primary causes such as migraine but can also be a presenting symptom of secondary causes including life threatening conditions. This is a minireview of secondary causes of headache during pregnancy and the puerperium. Unique alterations in physiological and vascular functions as well as in the coagulation pathway which occur during pregnancy increase the risk of most of these secondary conditions which include preeclampsia, eclampsia, hemorrhagic stroke, cerebral venous, sinus thrombosis, reversible cerebral vascular syndrome, and posterior reversible encephalopathy. Marked increase in progesterone level in pregnancy is also associated with the growth of tumors such as meningiomas, as 70% of these tumors are positive for progesterone receptors and increase in size can lead to headache along with other neurological symptoms. Hemodynamic changes can lead to the growth of meningiomas as well. Although hormone producing pituitary tumors are usually not conducing to pregnancy, women with known pituitary tumors who do get pregnant may become symptomatic during pregnancy and develop secondary headache. Another rare cause of secondary headache during pregnancy is pituitary apoplexy. Although its occurrence is uncommon, it needs to be properly recognized and treated to avoid endocrine and visual complications. Other rare entities with increased incidence during the puerperium such postdural puncture headache will be also discussed. In summary, new onset headache during pregnancy deserves special attention because in the absence of proper recognition and treatment, secondary headache disorders can endanger the life of the mother and the fetus.

A small percentage of patients suffer from a secondary headache syndrome. It is imperative that clinicians are able to differentiate primary headache syndromes from secondary headache syndromes, as failure to do so significantly worsens morbidity and mortality. Recent advances in our understanding of pathobiological mechanisms offer useful information on these enigmatic disorders. We now understand that the causes of secondary headache syndromes can vary significantly – these may be infectious, inflammatory, vascular, traumatic or structural in origin.A well-taken history and targeted physical examination coupled with appropriate investigations can enable these syndromes to be recognized consistently and thus allow their timely and appropriate treatment. Along with their epidemiology, some of their key characteristics shall thus be discussed in this review so as to aid the busy clinician at the bedside. Red flags including sudden onset, high pain intensity, pattern of change of a preexisting headache, focal neurological signs or seizure, systemic signs and precipitation by physical activity can guide the clinician to suspect a secondary headache. Importantly a preexisting headache is not an exclusion of a secondary headache – it might even be a predisposition in certain cases.

Abstract Background Cardiac cephalalgia is an unusual condition that occurs during an episode of myocardial ischemia. Information about cardiac cephalalgia is scarce and its characteristics and physiopathology remain unclear. Our aim is to provide a narrative review of clinical characteristics and physiopathology of cardiac cephalalgia and to evaluate the current diagnostic criteria. Methods A search through PubMed was undertaken for studies on cardiac cephalalgia published until 20th September 2022. We summarized the literature and provide a comprehensive review of the headache characteristics and possible mechanisms. We also evaluated current International Classification of Headache Disorders third edition diagnostic criteria based on prior reported cases. Results In total, 88 cases were found. Headache characteristics were variable. Occipital location and throbbing pain were the most frequently reported. Headache was accompanied in most cases by cardiac symptoms. Criterion B was fulfilled by 98% of cases, criterion C1 by 72%, and criteria C2a and C2b by 37 and 93.2%, respectively. Regarding headache features described in diagnostic criterion C3, ‘moderate to severe intensity’, ‘accompanied by nausea’, ‘not accompanied by photophobia or phonophobia’ and ‘aggravated by exertion’, were reported in 75, 31, 55 and 55% of cases, respectively. Conclusion Cardiac cephalalgia characteristics are variable and the headache features described in the diagnostic criterion C3 might not be adequate. Given that cardiac cephalalgia can be the manifestation of a life-threatening condition it is important to increase the knowledge about this entity.

Abstract: Co-occurring pain conditions that affect overlapping body regions are complicated by the distinction between primary vs secondary pain conditions. We investigate the occurrence of headache and painful temporomandibular disorder (TMD) in a community-based, cross-sectional study of US adults in the Orofacial Pain: Prospective Evaluation and Risk Assessment (OPPERA-II) study. A specific goal was to determine whether headache attributed to TMD is separable from primary headache. Using DC/TMD and International Classification of Headache Disorders-third edition criteria, 3 groups of individuals were created: (a) headache without TMD; (b) headache comorbid with TMD; and (c) headache attributed to TMD. Regression models compared study groups according to demographic and comorbid characteristics, and post hoc contrasts tested for differences. Descriptive statistics and Cohen d effect size were computed, by group, for each predictor variable. Differences in continuous predictors were analyzed using one-way analysis of variance. Nearly all demographic and comorbid variables distinguished the combined headache and TMD groups from the group with headache alone. Relative to the reference group with primary headache alone, markers related to headache, TMD, somatic pain processing, psychosocial, and health conditions were substantially greater in both headache comorbid with TMD and headache attributed to TMD, attesting to their qualitative similarities. However, effect sizes relative to the reference group were large for headache comorbid with TMD and larger again for headache attributed to TMD, attesting to their separability in quantitative terms. In summary, the presence of overlapping painful TMD and headache adds substantially to the biopsychosocial burden of headache and points to the importance of comprehensive assessment and differential management. [ABSTRACT FROM AUTHOR]

Background: The prevalence of cardiac cephalalgia is unknown and there is limited information about its clinical features. We aimed to assess the prevalence of cardiac cephalalgia, its clinical characteristics and associated factors. Methods: We conducted a prospective study of patients with suspected acute coronary syndrome admitted to the Cardiology Service at Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain, over a one-year period. We interviewed patients within the first 24 hours of admission using a standardized case-report form to assess the presence of headache in relation to the acute coronary syndrome and its characteristics. Results: We included 438 patients, 381 with confirmed myocardial ischemia. Prevalence of cardiac cephalalgia was 14.2% (n=54). The most common features were frontal location, pressing quality and moderate intensity. Pain referred to the jaws (aOR 2.61; 95% CI 1.33-5.12; p=0.005), palpitations (aOR 3.65; 95% CI 1.57-8.50; p=0.003) and circumflex coronary artery as the culprit artery for the myocardial ischemia (aOR 3.8; 95% CI 1.07-13.74; p=0.021) were related to cardiac whereas history of hypertension was inversely associated (aOR 0.37: 95% CI 0.18-0.74; p=0.005). Conclusion: The prevalence of cardiac cephalalgia was 14.2%. Our study provides valuable information about cardiac cephalalgia characteristics that suggest revision of current diagnostic criteria. [ABSTRACT FROM AUTHOR]

Background: Persistent headache/facial/neck pain attributed to past cervicocephalic arterial dissection is under-documented in literature. Our main goal was to evaluate clinical characteristics and contributors to this persistence. Methods: A retrospective cohort study which included patients with a radiologically confirmed cervicocephalic arterial dissection (2015–2020) in a Portuguese tertiary hospital. Headache persistence was identified through clinical records. A questionnaire aimed to characterize headache in three moments: previous, persistent, and headache at the time of the interview (on average 2.5 years post-event). Results: Ninety-two patients were identified; 24 (26.1%) had headache persistence ≥3 months, and 20 (22.2%) on average after 2.5 years post-event. There were no differences regarding demographics and vascular risk factors among patients with (n = 22) and without (n = 68) headache persistence. The first group had higher previous headache history (68.2% vs 4.4%, p < 0.001), delay in diagnosis (3.6 vs 1.9 days, p < 0.001), and headache/cervicalgia as the first symptom (81.8% vs 41.2%, p < 0.001). At the time of the interview, 20% still reported daily headache. A logistic regression model depicted headache history (OR = 59.8, p < 0.001), acute headache/cervicalgia (odds ratio, OR = 25.4, p = 0.005), posterior circulation dissection (OR = 7.6, p < 0.001), and less than 4 points by National Institutes of Health Stroke Scale score (OR = 5.0, p = 0.025) as contributors to headache persistence. Conclusion: Headache persistence post-cervicocephalic arterial dissection is common, and frequently affects patients daily. As it potentially affects functional outcomes and quality of life, the contributors identified in this study may help clinicians manage patients after the acute event. [ABSTRACT FROM AUTHOR]

Abstract Background Defining the relationship between a headache and stroke is essential. The current diagnostic criteria of the ICHD-3 for acute headache attributed to ischemic stroke are based primarily on the opinion of experts rather than on published clinical evidence based on extensive case-control studies in patients with first-ever stroke. Diagnostic criteria for sentinel headache before ischemic stroke do not exist. The present study aimed to develop explicit diagnostic criteria for headache attributed to ischemic stroke and for sentinel headache. Methods This prospective case-control study included 550 patients (mean age 63.1, 54% males) with first-ever ischemic stroke and 192 control patients (mean age 58.7, 36% males) admitted to the emergency room without any acute neurological deficits or severe disorders. Standardized semi-structured interview forms were used to evaluate past and present headaches during face-to-face interviews by a neurologist on admission to the emergency room in both groups of patients. All headaches were diagnosed according to the ICHD-3. We tabulated the onset of different headaches before a first-ever ischemic stroke and at the time of onset of stroke. We divided them into three groups: a new type of headache, the previous headache with altered characteristics and previous unaltered headaches. The same was done for headaches in control patients within one week before admission to the hospital and at the time of entry. These data were used to create and test diagnostic criteria for acute headache attributed to stroke and sentinel headache. Results Our previous studies showed that headache at onset of ischemic stroke was present in 82 (14.9%) of 550 patients, and 81 (14.7%) patients had sentinel headache within the last week before a stroke. Only 60% of the headaches at stroke onset fulfilled the diagnostic criteria of ICHD-3. Therefore, we proposed alternative criteria with a sensitivity of 100% and specificity of 97%. Besides, we developed diagnostic criteria for sentinel headache for the first time with a specificity of 98% and a sensitivity of 100%. Conclusions We suggest alternative diagnostic criteria for acute headache attributed to ischemic stroke and new diagnostic criteria for sentinel headache with high sensitivity and specificity.

Background: Cardiac cephalalgia is an unusual condition that occurs during an episode of myocardial ischemia. Information about cardiac cephalalgia is scarce and its characteristics and physiopathology remain unclear. Our aim is to provide a narrative review of clinical characteristics and physiopathology of cardiac cephalalgia and to evaluate the current diagnostic criteria. Methods: A search through PubMed was undertaken for studies on cardiac cephalalgia published until 20th September 2022. We summarized the literature and provide a comprehensive review of the headache characteristics and possible mechanisms. We also evaluated current International Classification of Headache Disorders third edition diagnostic criteria based on prior reported cases. Results: In total, 88 cases were found. Headache characteristics were variable. Occipital location and throbbing pain were the most frequently reported. Headache was accompanied in most cases by cardiac symptoms. Criterion B was fulfilled by 98% of cases, criterion C1 by 72%, and criteria C2a and C2b by 37 and 93.2%, respectively. Regarding headache features described in diagnostic criterion C3, 'moderate to severe intensity', 'accompanied by nausea', 'not accompanied by photophobia or phonophobia' and 'aggravated by exertion', were reported in 75, 31, 55 and 55% of cases, respectively. Conclusion: Cardiac cephalalgia characteristics are variable and the headache features described in the diagnostic criterion C3 might not be adequate. Given that cardiac cephalalgia can be the manifestation of a life-threatening condition it is important to increase the knowledge about this entity. [ABSTRACT FROM AUTHOR]

Headache is a commonly encountered symptom in urgent care and the emergency department. Headache syndromes are classified a primary headache and do not require neuroimaging; however, patients should be assessed at each encounter for changes in their headache symptoms. This case highlights a patient who was suffering from a new headache type, characterized as different from her previous attacks and unyielding to her current acute and preventive treatment methods. The patient was sent for neuroimaging and found to have a mass within her sella turcica that required surgical intervention and removal. Assessing headache patients for red flag symptoms can uncover significant alterations in the patient's symptomatology and indicate a need for further evaluation. By evaluating for red flag symptoms, clinicians can ensure the delivery of high-quality care and better health care outcomes for patients with headache disease. [ABSTRACT FROM AUTHOR]

Headache is one of the most common diagnoses in neurology. A thorough understanding of the clinical presentation of secondary headache, which can be life-threatening, is critical. This review provides an overview of the diagnostic approach to a patient with headache, including discussion of "red," "orange," and "green" flags. We emphasize particular scenarios to help tailor the clinical workup to individual circumstances such as in pregnant women, when particular attention must be paid to the effects of blood pressure and hypercoagulability, as well as in older adults, where there is a need for higher suspicion for an intracranial mass lesion or giant cell arteritis. Patients with risk factors for headache secondary to alterations in intracranial pressure, whether elevated (e.g., idiopathic intracranial hypertension) or decreased (e.g., cerebrospinal fluid leak), may require more specific diagnostic testing and treatment. Finally, headache in patients with COVID-19 or long COVID-19 is increasingly recognized and may have multiple etiologies. [ABSTRACT FROM AUTHOR]

This article will identify common causes of pain following traumatic brain injury (TBI), discuss current treatment strategies for these complaints, and help tailor treatments for both acute and chronic settings. We will also briefly discuss primary and secondary headache disorders, followed by common secondary pain disorders that may be related to trauma., Competing Interests: Disclosure The authors have nothing to disclose., (Published by Elsevier Inc.)

Abstract Background Cluster headache is a primary condition characterized by severe headache accompanied by trigeminal autonomic signs. By definition, it is not attributed to underlying etiologies; however, under certain clinical characteristics, secondary etiologies must be ruled out. Case presentation We present the case of a 48-year-old Hispanic man with a history of episodic right orbital pain, lasting 30 minutes, associated with ipsilateral tearing, who prior to the onset of his symptoms reported loss of appetite, weight loss, and paresthesias in the right chin region. After work-up studies, high-grade lymphoma with infiltration to the right submental nerve was diagnosed, in which numb chin syndrome was the initial presentation. Despite initiation of treatment, the patient died 3 weeks after the diagnosis. Conclusions In the study of cluster headache, underlying etiologies must be considered when there are atypical clinical manifestations. Within these etiologies, metastases to pericranial nerves must be included, which, besides generating localized symptoms, can activate the trigeminal vascular system simulating headaches of primary etiology.

Headaches can be nociplastic, neuropathic, and nociceptive. Pain related to the latter two categories occurs in the presence of nerve lesions and nociceptive stimuli; attributing pain to the last category requires a list of potential causes and arguments supporting the causal claim. Taking a history and examining patients serves to assess diagnostic criteria and screen for disorders whose diagnosis requires additional examinations. Screening information occurs in two types: one indicates that patients have a headache due to another condition; the other suggests they are at risk. Aspiring to make causal claims for a headache is reasonable because if underlying disorders appear independently and randomly, it is probable that there is only one cause. Thus, having found a cause often implies having found the cause. The prerequisites for causal claims are temporal sequencing, correlation, and elimination of alternate causes. Mechanistic, manipulative, and probabilistic evidence supports the second criterion. The importance of headaches lies in their frequent appearance as an early symptom of an incipient disorder (“sentinel symptom”). Hence, they provide the opportunity to diagnose early diseases with potentially deleterious consequences. Thus, it is sensible to assess each attack carefully and systematically.

WHO estimates that the prevalence of headaches worldwide in the adult population is approximately 50 %. Globally, half to three­quarters of people aged 18 to 65 have complained of headaches in the past year, and more than 30 percent have suffered from migraines. At the same time, 1.7 to 4 % of the adult population suffers from head­aches that last 15 or more days a month. Undoubtedly, cephalgia constitutes a global problem. However, it is worrying that the causes of headaches are not always correctly diagnosed. The main clinical barrier pointed out by WHO is the lack of knowledge of health pro­fessionals about headache management. Thus, the broad coverage of issues related to the management of patients with cephalgia does not lose its relevance, and even more: it needs to be supplemented with current data. In particular, the mechanisms of headache can be associated with several pathophysiological processes that are triggered by the in­fluence of professional activities, specific physical activity, active leisure, or amateur sports. Recreational diving has become a popular form of active leisure for the past 20 years. It is noteworthy that headache is a common symptom in divers and, although it is usually benign, it can sometimes signal the serious consequences of high pressure. Proper diagnostic tactics require specialists to carefully collect the anamnesis and examine the patient, as well as to understand the unique physiological changes in the human body that occur under the influence of under­water environmental factors.

Background: Defining the relationship between a headache and stroke is essential. The current diagnostic criteria of the ICHD-3 for acute headache attributed to ischemic stroke are based primarily on the opinion of experts rather than on published clinical evidence based on extensive case-control studies in patients with first-ever stroke. Diagnostic criteria for sentinel headache before ischemic stroke do not exist. The present study aimed to develop explicit diagnostic criteria for headache attributed to ischemic stroke and for sentinel headache. Methods: This prospective case-control study included 550 patients (mean age 63.1, 54% males) with first-ever ischemic stroke and 192 control patients (mean age 58.7, 36% males) admitted to the emergency room without any acute neurological deficits or severe disorders. Standardized semi-structured interview forms were used to evaluate past and present headaches during face-to-face interviews by a neurologist on admission to the emergency room in both groups of patients. All headaches were diagnosed according to the ICHD-3. We tabulated the onset of different headaches before a first-ever ischemic stroke and at the time of onset of stroke. We divided them into three groups: a new type of headache, the previous headache with altered characteristics and previous unaltered headaches. The same was done for headaches in control patients within one week before admission to the hospital and at the time of entry. These data were used to create and test diagnostic criteria for acute headache attributed to stroke and sentinel headache. Results: Our previous studies showed that headache at onset of ischemic stroke was present in 82 (14.9%) of 550 patients, and 81 (14.7%) patients had sentinel headache within the last week before a stroke. Only 60% of the headaches at stroke onset fulfilled the diagnostic criteria of ICHD-3. Therefore, we proposed alternative criteria with a sensitivity of 100% and specificity of 97%. Besides, we developed diagnostic criteria for sentinel headache for the first time with a specificity of 98% and a sensitivity of 100%. Conclusions: We suggest alternative diagnostic criteria for acute headache attributed to ischemic stroke and new diagnostic criteria for sentinel headache with high sensitivity and specificity. [ABSTRACT FROM AUTHOR]

Background: Diagnosing headache disorders comprises the collection and interpretation of information. This study estimates agreement and bias in the latter. Methods: Physicians and medical students diagnosed eight patients' headaches using the International Classification of Headache Disorders. We calculated Cohen's Kappa for all participants and subgroups (board-certified neurologists, physicians working in a neurology department). Moreover, we asked how sure they felt about their diagnoses. Finally, participants estimated the number of different headache diagnoses a patient receives when consulting many physicians for the same headache and indicated the highest acceptable number. Results: The data of 63 participants entered the analysis, of whom 18 were neurologists (18/63, 28.6%), and 41 were currently working at a neurology clinic (41/63, 66.7%). Cohen's Kappa decreased (0.706, 0.566, and 0.408) with increasing levels of the classification hierarchy. Interrater agreement was highest among neurologists. Physicians not working in a neurology clinic tended to diagnose secondary headaches more often were less confident about their diagnoses. Conclusions: Physicians with less experience in headache disorders struggle more to diagnose headaches than neurologists do; they suspect secondary headaches, disagree, and feel insecure more often. Thus, interpreting a headache history is prone to error and bias. [ABSTRACT FROM AUTHOR]

Introduction: This study was conducted to provide detailed information about clinical characteristics and short-term treatment outcome of childhood headache. Materials and Methods: This prospective observational study was done over a period of 15 months (January 2013 to March 2014) at a rural tertiary care center in North India. Detailed history, clinical examination, specialty review, and follow-up details were maintained on pretested structured proforma. Final diagnosis of headache type was made as per International Classification of Headache Disorders, 2nd edition. Results: Out of 100 (45 boys) children aged 8–18 years, 52% were diagnosed with migraine, 23% with tension-type headache, and 25% with secondary headache. Diffuse headache was the commonest (41%), and photophobia, phonophobia, and dizziness were the commonest symptoms in all headache subtypes. Sixty-five percentage of migraine headache were triggered by exertion. Lack of sleep and anxiety were triggers in most (65%) of tension type headache. Of 52 migraine children, 21 were started on prophylaxis for migraine and 14 of them reported significant improvement. Secondary causes for headache were found in 25% of children and half of them were having refractive errors. Conclusions: Results of the study show migraine being the commonest type of headache in children followed by secondary headache. This study also highlights the need for long-term follow-up of childhood headache. [ABSTRACT FROM AUTHOR]

Headache is a common complaint and is often benign. When patients with cancer describe new headaches, it is important to ensure that there are no emergent or concerning etiologies, including metastatic disease. This review article details primary and secondary headaches. Red flags—the do‐not‐miss warning signs—are described. An initial approach to the evaluation, including suggestions for imaging, features to look for in a targeted examination, and when to request a consultation, is outlined. An overview of headache etiologies is described with a particular emphasis on the most common types: migraine and tension. The classification of headaches, based on criteria from the International Classification of Headache Disorders (3rd edition; beta version), is reviewed. Medications used for treatment, including newer biological agents, are described, and there are details about both abortive and preventive medication therapies. Suggestions for complementary and integrative therapies, some of which may be synergistic in treating other cancer symptoms, are outlined; they include mindfulness therapies, which are gaining traction in treating a variety of medical conditions. Readers should have an understanding of headache evaluation in patients with cancer and should know how to formulate a plan for a diagnosis. In addition, readers will gain familiarity with common treatments, both pharmacological and complementary/integrative. This article describes the evaluation and management of patients with cancer who develop headaches. Red flags, the initial workup, and headache descriptions and treatments, as well as when to refer patients to a headache specialist, are reviewed. [ABSTRACT FROM AUTHOR]

Aim: Headache attributed to temporomandibular disorders and myalgia are two diagnoses included in the diagnostic criteria for temporomandibular disorders (DC/TMD). However, it is not clear if these two diagnoses are different clinical entities given their similar presentation and way in which they are diagnosed, when the myalgia is within the temporalis muscle. The purpose of this retrospective study was to assess the overlap between headache attributed to temporomandibular disorders and myalgia of the temporalis muscle. Methods: The charts of 671 patients seeking treatment at the Section of Orofacial Pain and Jaw Function, Aarhus University, Denmark, between January 2015 and February 2020 were screened for a diagnosis of headache attributed to temporomandibular disorders, myalgia of the temporalis muscle, or both. Results: A total of 89 patients fulfilled the DC/TMD criteria for either headache attributed to TMD, myalgia of the temporalis or both. Of these, two had a diagnosis of headache attributed to TMD, 16 of myalgia of the temporalis, and 71 were diagnosed with both. In 97.3% of the times that headache attributed to temporomandibular disorders was diagnosed, the patient was also diagnosed with myalgia of the temporalis. The Jaccard index was 0.8, indicating a substantial overlap between the two diagnoses. Finally, the overlap of pain location between the two diagnoses was substantial, with a Jaccard index of 0.9. Conclusions: In the present study, headache attributed to temporomandibular disorders was almost exclusively diagnosed together with myalgia of the temporalis. Therefore, we propose that headache attributed to temporomandibular disorders and myalgia of the temporalis muscle have more clinical similarities than differences and as such could be considered one single clinical entity. Further studies will be needed to address the clinical consequences of this proposal. [ABSTRACT FROM AUTHOR]

Objective: This study aims to investigate the demographic, clinical features of children and adolescents with headaches which is one of the most common reason for referral to pediatric neurology clinics in addition to elucidating the frequency of primary and secondary headaches as well as their management. Material and Methods: We retrospectively reviewed the medical reports of children and adolescents who were referred to Ankara City Hospital, Department of Pediatric Neurology between December 2019 and December 2020. Results: During the study period, 236 (86.8%) children, and adolescents were diagnosed with primary headaches and 36 (13.2%) were diagnosed with secondary headaches. Tension headaches were the most frequent (71.2%) type of primary headaches while headache or facial pain attributed to disorders of the cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cervical structure were the most frequent (38.8%) type of secondary headaches. All patients with secondary headaches had at least one red flag while 23 (63.8%) patients had 2 or more red flags. Magnetic resonance imaging was diagnostic in 58.3% of the patients while EEG was diagnostic in 6% of the patients. Conclusion: Pediatric patients presenting with headaches should be carefully examined to diagnose and treat the causes of secondary headaches which can be life-threatening and require urgent treatment. On the other hand, accurate diagnosis is very important in primary headaches which constitute more than 80% of all headaches and have detrimental effects on life quality as a result of refraining from daily activities. [ABSTRACT FROM AUTHOR]

Abstract Background Calcitonin gene-related peptide (CGRP) has recently been implicated in the pathogenesis of post-traumatic headache (PTH), which raises the prospect for therapeutic use of monoclonal antibodies targeting CGRP or its receptor. Therefore, we decided to assess the efficacy, tolerability, and safety of erenumab for prevention of persistent PTH attributed to mild traumatic brain injury. Methods A single-center, non-randomized, single-arm, open-label study of erenumab for adults aged 18–65 years with persistent PTH. Patients were assigned to receive 140-mg erenumab monthly by two subcutaneous 1-mL injections, given every 4 weeks for 12 weeks. The primary outcome measure was the mean change in number of monthly headache days of moderate to severe intensity from baseline (4-week pretreatment period) to week 9 through 12. Tolerability and safety endpoints were adverse events (i.e. number and type). Results Eighty-nine of 100 patients completed the open-label trial. At baseline, the mean monthly number of headache days of moderate to severe intensity was 15.7. By week 9 through 12, the number was reduced by 2.8 days. The most common adverse events were constipation (n = 30) and injection-site reactions (n = 15). Of 100 patients who received at least one dose of erenumab, two patients discontinued the treatment regimen due to adverse events. Conclusions Among patients with persistent PTH, erenumab resulted in a lower frequency of moderate to severe headache days in this 12-week open-label trial. In addition, erenumab was well-tolerated as discontinuations due to adverse events were low. Placebo-controlled randomized clinical trials are needed to adequately evaluate the efficacy and safety of erenumab in patients with persistent PTH. Trial registration ClinicalTrials.Gov, NCT03974360 . Registered on April 17, 2019 - Retrospectively registered