Sinus venous stenosis, intracranial hypertension and progression of primary headaches

Authors: De Simone R, Ranieri A, Montella S, Marchese M, Persico P, Bonavita V.

The recently advanced hypothesis that idiopathic intracranial hypertension without papilledema (IIHWOP) is a powerful risk factor for the progression of pain in individuals prone to episodic primary headache implies that IIHWOP is much more prevalent than it is believed to be in the general population and that it can run almost asymptomatic in most of the affected individuals. In this review, we discuss the evidence available supporting that: (a) sinus venous stenosis-associated IIHWOP is much more prevalent than believed in the general population and can run without symptoms or signs of raised intracranial pressure in most of individuals affected, (b) sinus venous stenosis is a very sensitive and specific predictor of intermittent or continuous idiopathic intracranial hypertension with or without papilledema, even in asymptomatic individuals, (c) in primary headache prone individuals, a comorbidity with a hidden stenosis-associated IIHWOP represents a very common, although largely underestimated, modifiable risk factor for the progression and refractoriness of headache.

Posttraumatic headache

Authors: Vargas BB, Dodick DW.

PURPOSE OF REVIEW: Posttraumatic headache (PTH) is a commonly occurring and potentially disabling consequence of concussion and mild traumatic brain injury (mTBI). This brief review highlights recent advances in the epidemiology, evaluation, and management of concussion, mTBI, and PTH.
RECENT FINDINGS: Current epidemiological studies suggest that previous estimates of concussion and mTBI incidence are grossly underestimated and have also helped to identify specific activities and demographic groups that might be more susceptible. Concussion results in profound metabolic derangements during which the brain is potentially vulnerable to repeat injury and permanent damage. Imaging studies such as magnetic resonance (MR) spectroscopy and diffusion tensor imaging have proven to be effective at identifying these abnormalities both acutely and also weeks after symptoms resolution. To date, there have been no randomized, placebo-controlled studies supporting the efficacy of any treatment for PTH and current therapeutic decisions are guided only by expert opinion and current evidence-based guidelines for the treatment of specific primary headache phenotypes, the most commonly occurring of which is migraine.
SUMMARY: Despite numerous advances in the awareness, pathophysiology, and diagnostic workup of concussion, mTBI, and PTH, there is a paucity of evidence-based guidance regarding treatment.

Sinus Venous Stenosis-Associated Idiopathic Intracranial Hypertension Without Papilledema as a Powerful Risk Factor for Progression and Refractoriness of Headache

Authors: De Simone R, Ranieri A, Montella S, Marchese M, Bonavita V.

Data from two recent studies strongly support the hypothesis that idiopathic intracranial hypertension without papilledema (IIHWOP) could represent a powerful risk factor for the progression of pain in primary headache individuals. The first study highlights that an asymptomatic IIHWOP is much more prevalent than believed in the general population and occurs only in central venous stenosis carriers. In the second study, about one half of a large consecutive series of unresponsive primary chronic headache patients shows significant sinus venous stenosis. A continuous or intermittent IIHWOP was detectable in 91% of this subgroup and in no patient with normal venography. Moreover, after the lumbar puncture, a 2- to 4-week improvement in headache frequency was observed in most of the intracranial hypertensive patients. These findings strongly suggest that patients prone to primary headache who carry central venous outflow abnormalities are at high risk of developing a comorbid IIHWOP, which in turn is responsible for the progression and the unresponsiveness of the pain. Based on the available literature data, we propose that central sinus stenosis-related IIHWOP, although highly prevalent among otherwise healthy people, represents an important modifiable risk factor for the progression and refractoriness of pain in patients predisposed to primary headache. The mechanism could refer to up to one half of the primary chronic headache patients with minimal response to treatments referring to specialized headache clinics. Due to the clinical and taxonomic relevance of this hypothesis further studies are urgently needed.

Sinus venous stenosis-associated IIHWOP is a powerful risk factor for progression and refractoriness of pain in primary headache patients: a review of supporting evidences

Authors: Roberto De Simone, A. Ranieri, S. Montella, R. Erro, C. Fiorillo and V. Bonavita

From the issue entitled "7th International Headache Seminar, Stresa, Italy, 26-28 May 2011"

Reported prevalence of idiopathic intracranial hypertension without papilledema (IIHWOP) in series of patients with chronic or transformed migraine is significantly higher than expected; yet, IIHWOP is not included among the risk factors for migraine progression. However, several studies provided evidences suggesting that IIHWOP could represent a possible, largely underestimated, risk factor for progression of pain in migraine and, possibly, in other primary headaches. Data from two recent studies, albeit aimed to different end-points, strongly support this hypothesis. In the first study, conducted on a large series of neurological patients without any sign or symptom of raised intracranial pressure (ICP), including chronic headache, the prevalence of bilateral central venous stenosis at magnetic resonance venography (MRV) was 23% and an IIHWOP at opening pressure was found in 48% of this subgroup (11% of the whole sample) while it was not detected in any of the subjects with normal MRV. This indicates that IIHWOP may be much more prevalent than believed in general population and that it can run without any symptom or sign of raised ICP in most of affected subjects. In the second paper, sinus venous stenosis-associated IIHWOP has been found in about one half of a large chronic primary headache patients series with poor response to treatments and in none of those with normal MRV. Moreover, after the diagnostic lumbar puncture, a transient improvement of headache frequency has been observed in the majority of intracranial hypertensive chronic headache subjects. Taken together, the data of these two recent papers rise the following hypothesis: (1) asymptomatic IIHWOP is much more prevalent than expected in general population; (2) IIHWOP is a powerful and largely unrecognized risk factor for progression of pain in primary headache patients; (3) sinus venous stenosis at MRV is a reliable predictor of raised intracranial hypertension also in asymptomatic patients; (4) sinus venous stenosis has a causative role in IIH pathophysiology. These assumptions share a potential high clinical impact and need to be urgently tested in adequately designed controlled studies.

Approach to Headache in Emergency Department

Authors: Nallasamy K, Singhi SC, Singhi P.

Headache remains a frequently encountered neurological symptom in Emergency department. Secondary causes of headache outnumber the primary entities such as migraine. Most of the secondary headaches have benign etiologies. The goal of emergent evaluation is to detect those with serious or life threatening causes. Identifying the pattern of headache helps in narrowing down the possible etiological diagnosis. A single episode of acute headache usually results from an acute infection ranging from viral URI to acute meningitis. Acute recurrent headaches are typically a feature of migraine. Chronic progressive headaches often indicate a serious underlying pathology such as a brain tumor and warrant a detailed neurological examination for signs of raised intracranial pressure (ICP) and focal deficits. Children with abnormal neurological findings require a neuroimaging. CT scan usually detects most of the abnormalities. Initial stabilization and management of raised ICP takes precedence in sick children. While simple analgesics like paracetamol and ibuprofen are used for symptomatic therapy, identification and appropriate treatment of underlying conditions is necessary for complete resolution of headache.


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