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.

Intracranial hypotension headache after uncomplicated caudal epidural injection

Authors: Thomas R, Thanthulage S.

A caudal epidural injection was performed on a middle-aged woman for pain in her right foot. Although the procedure was uncomplicated and a good epidurogram was obtained, the patient went on to develop an orthostatic headache with generalised weakness and syncopal episodes that were treated successfully by epidural blood patching. We describe the aetiology, presentation and treatment of spontaneous intracranial hypotension and review the similarities with our patient's clinical presentation. We hypothesise as to how our intervention may have resulted in a dural tear.

Idiopathic intracranial hypertension as a significant cause of intractable headache in patients with systemic lupus erythematosus: a 15-year experience

Authors: Kim JM, Kwok SK, Ju JH, Kim HY, Park SH.

Objective: To evaluate the occurrence of idiopathic intracranial hypertension (IIH) in patients with systemic lupus erythematosus (SLE) and to describe the manifestations, treatments and outcomes in these patients. Methods: We reviewed the medical records of 1084 patients with SLE followed up from January 1997 to June 2011 in our unit. We identified patients with IIH and analyzed the demographic, clinical and laboratory characteristics of these patients. Results: Among the 1084 SLE patients, 47 underwent cerebrospinal fluid studies because of their intractable headache and eight (17%) of these were diagnosed as IIH. All were females aged 14 to 32 years. Nobody belonged to the obesity group. Headache, nausea, vomiting and blurred vision were the most common presenting symptoms. All patients had active SLE at the time of admission (SLE disease activity index ≥6). Five patients had lupus nephritis. In eight patients, there were two with antiphospholipid antibodies, two with anti-ribosomal P antibodies and six with anti-Ro antibodies. All subjects recovered without any complication after high dose steroid therapy. Conclusions: IIH accounts for a considerable part of the causes of intractable headache in SLE patients and steroids should be considered as a first-line treatment.

Headache management in concussion and mild traumatic brain injury

Authors: Lucas S.

Headache is one of the most common symptoms after traumatic brain injury (TBI), and posttraumatic headache (PTH) may be part of a constellation of symptoms that is seen in the postconcussive syndrome. PTH has no defining clinical features; currently it is classified as a secondary headache based on its close temporal relationship to the injury. A growing number of studies are characterizing PTH by using primary headache classifications. Moderate to severe PTH that is often disabling may be classified as migraine or probable migraine and is found in substantial numbers of individuals. Recent data from civilian adult, pediatric, and military populations all find that PTH may be more of a chronic problem than previously thought, with a prevalence of close to half of the injured population. In addition, if PTH definitions are strictly adhered to, then many cases of PTH may be missed, thus underestimating the scope of the problem. New headaches may be reported well after the 7 days required for diagnosis of PTH by the guidelines of the International Classification of Headache Disorders, 2nd edition. A history of headache before a head injury occurs and female gender are possible risk factors for headache after TBI. Treatment of PTH may be acute or preventive, and recommendations are made for the use of migraine-specific acute therapy when indicated. Preventive therapy may be considered when PTH is frequent, disabling, or refractory to acute therapies. Comorbid conditions should be considered when choosing an appropriate preventive therapy. The symptom of headache as a "return to play" or "return to duty" barrier must be viewed in the context of other symptoms of mild TBI.

Headache Attributable to Nonvascular Intracranial Disorders

Authors: Mark Obermann, Dagny Holle, Steffen Naegel and Hans-Christoph Diener.

Headache attributable to nonvascular intracranial disorder is a basket of multiple, partly complex, and very diverse idiopathic or secondary disorders. By definition, the headache has to occur in a close temporal relationship to the intracranial disorder. Some of these headache disorders are caused by high or low cerebrospinal fluid pressure; noninfectious inflammatory diseases such as neurosarcoidosis, aseptic (noninfectious) meningitis, and lymphocytic hypophysitis; or intracranial neoplasm. Other nonvascular headaches, including hemicrania epileptica and postseizure headache, Chiari malformation type I, and the syndrome of transient headache and neurological deficits with cerebrospinal fluid lymphocytosis, are attributed to hypothalamic or pituitary hyper- or hyposecretion, intrathecal injection, or epileptic seizures. The clinical presentation of all these disorders can be diverse and often mimics the characteristics of primary headaches, which may delay the diagnosis.

Cough headache secondary to spontaneous intracranial hypotension complicated by cerebral venous thrombosis

Authors: T. Ferrante, L. Latte, G. Abrignani, M. Russo, G. C. Manzoni and P. Torelli.

Cough headache may be the clinical manifestation, sometimes isolated, of an intracranial disease. There are several possible causes of secondary cough headache. The hypothesis that cough headache may be the expression of spontaneous intracranial hypotension has been advanced only recently. In fact, this would represent an exception to the rule that cough headache is generally secondary to conditions leading to an increase in intracranial pressure and/or volume. We report and discuss a case of cough headache secondary to spontaneous intracranial hypotension in an otherwise healthy 59-year-old man. The condition was complicated by cerebral venous thrombosis.


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