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Studies combining data from digital surveys and electronic health records (EHR) can be used to conduct comprehensive assessments on COVID-19 vaccine safety.We conducted an observational study using data from a digital survey and EHR of children aged 5-11 years vaccinated with Pfizer-BioNTech COVID-19 mRNA vaccine across Kaiser Permanente Southern California during November 4, 2021-February 28, 2022. Parents/guardians who enrolled their children were sent a 14-day survey on reactions. Survey results were combined with EHR, and medical encounters were described for children whose parents or guardians indicated seeking medical care for vaccine-related symptoms. This study describes self-reported reactions (local and systemic) and additional symptoms (chest pain, tachycardia, and pre-syncope).The study recruited 7,077 participants aged 5-11 years who received the Pfizer-BioNTech COVID-19 mRNA vaccine. Of 6,247 participants with survey responses after dose 1, 2,176 (35 %) reported at least one systemic reaction, and 1,076 (32 %) of 3,401 respondents following dose 2 reported at least one systemic reaction. Local reactions were reported less frequently following dose 2 (1,113, 33 %) than dose 1 (3,140, 50 %). The most frequently reported reactions after dose 1 were pain at the injection site (48 %), fatigue (20 %), headache (12 %), myalgia (9 %) and fever (5 %). The most frequently reported symptoms after dose 2 were also pain at the injection site (30 %), fatigue (19 %), headache (13 %), myalgia (10 %) and fever (9 %). Post-vaccination reactions occurred most frequently-one day following vaccination. Chest pain or tachycardia were reported infrequently (1 %). EHR demonstrated that parents rarely sought care for post-vaccination symptoms, and among those seeking care, the most common symptoms documented in EHR were fever and nausea, comprising0.5 % of children. No encounters were related to myocarditis.While post-vaccination reactions to the Pfizer-BioNTech COVID-19 mRNA vaccine were common in children aged 5-11 years, our data showed that in most cases they were transient and did not require medical care.

Masticatory myofascial pain disorders (MMPD) are a common group of orofacial pain conditions affecting the muscles of mastication, with headache and cervical disorders as well as chronic widespread pain and psychosocial disorders being common comorbid conditions. As their pathophysiology is multifactorial in nature, a multimodal and interdisciplinary approach should be considered. Overall treatment goals include decreasing pain and disability, increasing mandibular range of motion, and improving quality of life. This article describes a complex case exhibiting common characteristics of MMPD while additionally reviewing the literature on classification, pathophysiology, and evidence-based treatment planning.

The COVID-19 pandemic has a substantial impact on the physical and mental health status of patients with COVID-19. This study's objective was to evaluate the factors associated with mental health in patients isolated with COVID-19.It is a retrospective, cross-sectional study. One hundred and two patients discharged from COVID-19 hospitalization in Korea were analyzed. The primary outcome was the correlation between psychological problems such as anxiety, depression, and fear of stigma and physical symptoms such as respiratory symptoms, gastrointestinal symptoms, headache, and fever. Mental and physical symptoms were ascertained using closed and multiple-choice questions. The secondary outcome was the correlation between mental issues, demographic factors, and disease severity. Hypoxia and the need for oxygen therapy, a need for remdesivir antiviral treatment, and indications of pneumonia progression on chest x-ray were confirmed through a review of medical records and used to measure disease severity.Patients with COVID-19 indicated feelings of depression (48.1%), anxiety (49.1%), and fear of stigma (60.45%), and some continued to experience physical symptoms even after discharge. Logistic regression revealed that gastrointestinal symptoms positively correlated with depression (p lt; .05) and headache positively correlated with fear of stigma (p lt; .05), while the other factors were not statistically significant (p gt; .05).This study showed that psychological symptoms persisted even after discharge. Gastrointestinal symptoms and headache were influential factors in predicting depression and fear of stigma. Based on this, dedicated COVID-19 hospitals should provide mental health support and preventive management.

Trigeminal neuralgia is a severe facial pain disorder that is difficult to treat. Erenumab, a monoclonal antibody against the calcitonin gene-related peptide (CGRP) receptor, has proven efficacy in migraine. Erenumab modulates sensory processing in peripheral trigeminal pain pathways in mice and was reported to be effective for patients with trigeminal neuralgia in open-label studies. We aimed to evaluate the efficacy of erenumab in patients with trigeminal neuralgia.We did a randomised, double-blind, placebo-controlled trial in adults (aged 18-85 years) with idiopathic or classic trigeminal neuralgia as defined by the 3rd edition of the International Classification of Headache Disorders. The trial was based at the Danish Headache Center, Copenhagen University Hospital. Eligible participants had no clinically significant cerebrovascular or cardiovascular disease, had self-reported pain intensity of at least 4 on the 11-point Numeric Rating Scale (0=no pain, 10=worst pain imaginable), and had at least three daily pain paroxysms. After a 1-week pre-screening period, patients entered a 4-week baseline period. Participants who met pain inclusion criteria at the end of the baseline period were randomly assigned (1:1) to receive subcutaneous injections of either erenumab 140 mg or placebo and entered the 4-week follow-up period. Randomisation was done in blocks of 10 using a computer-generated schedule by a third-party company. Participants and assessors were masked to treatment allocation, and erenumab and placebo were packed in identical prefilled syringes. The primary outcome was the number of responders, defined as patients who had a reduction of at least 30% in mean average daily pain intensity during the follow-up period compared with during the baseline period, analysed in the intention-to-treat population. This trial is registered with the European Union Drug Regulating Authorities Clinical Trials Database, EudraCT number 2019-000848-95.We assessed 860 patients for suitability and excluded 741 between Oct 28, 2019, and Sept 13, 2021. 119 participants entered a 1-week pre-screening period and 26 were excluded, 93 participants entered a 4-week baseline period with 13 excluded before randomisation, and 80 participants were randomly assigned to erenumab 140 mg (n=40) or placebo (n=40). There was no difference between groups in the number of responders at 4 weeks in the intention-to-treat population (14 [35%] of 40 with erenumab vs 18 [45%] of 40 with placebo; estimated effect size -10% [95% CI -31 to 11]; p=0·36). 20 (50%) of 40 participants reported adverse events in each group. The most common adverse events were constipation (28%) and headache (10%) in the erenumab group, and headache (13%), constipation (10%), and abdominal pain (10%) in the placebo group.Erenumab did not reduce pain intensity compared with placebo in patients with trigeminal neuralgia and CGRP probably does not have an important role in paroxysmal pain. Well tolerated, effective treatments in trigeminal neuralgia are still needed.Novartis.

Introduction Manual therapy has been shown to reduce self-reported symptoms in patients with chronic tension-type headache (CTTH). However, simultaneous application of suboccipital muscle inhibition and interferential current has not previously been investigated. This study evaluates the effectiveness of combined treatment with suboccipital muscle inhibition and interferential current compared to standard treatment for pain, disability, and headache impact in patients with CTTH. Methods Patients were randomly allocated to receive either standard treatment (n = 13) or the experimental treatment (n = 12), consisting of 20 minutes of suboccipital muscle inhibition plus interferential current twice weekly for 4 weeks. The primary outcome was improvement in pain, and secondary outcomes included improvement in headache-related disability and reduction in headache impact, which were assessed at baseline and at 4 weeks by a blinded rater. Results Statistical analysis showed improvements in the experimental treatment group at 4 weeks for headache-related disability (Neck Disability Index: Hedges' g = 1.01, P = .001; and Headache Disability Inventory: Hedges' g = 0.48, P = .022) and headache impact (6-item Headache Impact Test: Hedges' g = 0.15, P = .037) but not for self-reported pain (numerical rating scale: Hedges' g = 1.13, P = .18). Conclusions Combined treatment with suboccipital muscle inhibition and interferential current in patients with CTTH did not significantly improve self-reported pain but did reduce disability and the impact of headache on daily life at 4 weeks. These improvements exceed the minimum clinically important difference, demonstrating the clinical relevance of our findings.

Hypophysitis is considered a rare inflammatory disease of the pituitary gland. For a long time, primary autoimmune hypophysitis has stood out as the most relevant type of hypophysitis. However, with the advent of immunotherapy for the treatment of malignancies and identification of hypophysitis as an immune-related adverse event, hypophysitis has garnered increasing interest and recognition. Therefore, awareness, early recognition, and appropriate management are becoming important as the indication for immunomodulatory therapies broaden.In this review, we discuss the epidemiology, diagnosis, and treatment of hypophysitis with a focus on recent data and highlight subtypes of particular interest while recognizing the gaps in knowledge that remain.Regardless of cause, symptoms and signs of hypophysitis may be related to mass effect (headache and visual disturbance) and hormonal disruption that warrant prompt evaluation. In the vast majority of cases, a diagnosis of hypophysitis can be made presumptively in the appropriate clinical context with radiologic findings consistent with hypophysitis and after the exclusion of other causes.Although subtle differences currently exist in management and outcome expectations between primary and secondary causes of hypophysitis, universally, treatment is aimed at symptom management and hormonal replacement therapy.

Yoga therapy may have some potential in treating migraine, and thus this meta-analysis aims to explore the efficacy of yoga therapy for patients with migraine.PubMed, EMbase, Web of science, EBSCO and Cochrane library databases have been systematically searched and we included the randomized controlled trials (RCTs) reporting the efficacy of yoga therapy for migraine patients. The outcomes included.This meta-analysis included six RCTs. The results revealed that compared with control group for migraine, yoga therapy was associated with remarkably decreased pain intensity (SMD = -1.21; 95% CI = -2.17 to -0.25; P = 0.01), headache frequency (SMD = -1.43; 95% CI = -2.23 to -0.64; P = 0.0004), headache duration (SMD = -1.03; 95% CI = -1.85 to -0.21; P = 0.01), HIT-6 score (SMD = -2.28; 95% CI = -3.81 to -0.75; P = 0.003) and MIDAS score (SMD = -0.52; 95% CI = -0.77 to -0.27; P0.0001).Yoga therapy may be effective to treat migraine patients, but it should be recommended with caution because of heterogeneity.

Cerebral proliferative angiopathy (CPA) is a rare cerebrovascular pathology that presents with unique clinical features due to distinct histologic, angiographic, and pathophysiologic characteristics that separate it from classical arteriovenous malformation. The disorder is characterized by uncontrolled angiogenesis in which functional brain parenchyma is interspersed with abnormal vascular channels without a distinct nidus. Common presenting symptoms include headache, seizures, and stroke-like symptoms. Hemorrhagic presentations are rare in contrast to the typical presentations of classical arteriovenous malformation. Here, we report a young woman with a history of a suspected connective tissue disorder who presented to the emergency department with worsening headaches in a delayed fashion after experiencing minor head trauma and was found to have a left-sided subdural hematoma. Angiography confirmed a diagnosis of CPA after abnormal cortical vasculature was noted during the patient's craniotomy. A systematic review of CPA cases described in the literature was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, with the findings discussed.

Headaches following head trauma or craniotomy have multiple causes, each of which has characteristic imaging features. Posttraumatic headaches may relate to intracranial hemorrhage, fracture, shear injury, mass effect, or vascular injury. Various complications of craniotomy and craniectomy may manifest with headache. CT and MRI of the brain play important roles in diagnosing these causes of headache.

To describe the clinical characteristics of children with pseudotumor cerebri syndrome (PTCS) who were diagnosed according to the modified Dandy criteria and to reclassify them according to the newly proposed diagnostic criteria by Freidman.This retrospective study included the period from January 2016-to July 2021.50 patients were included; 34 males and 16 females with a male to female ratio of 2.1:1. The average age at onset of symptoms was 8 years. Obesity was noticed in 6 (12%) patients; 34 (68%) had symptoms upon presentation. The most common presenting symptom was headache (28 patients; 56%), papilledema was present in 33 (66%) patients. Most patients (37; 74%) had an initial cerebrospinal fluid (CSF) pressure ≥280 mmHPTCS is a chronic condition. Managing patients who do not have papilledema or who do not meet the newly proposed higher CSF pressure is challenging. Although, applying the newly proposed criteria captured most of our patients, however, around one quarter were managed based on clinical experience. This study indicates a strong need for future guidelines tailored specifically for children, taking into consideration that the cut-off point of CSF pressure might not be similar for all populations.

Headache represents one of the most common disorders in childhood and leads to nearly half a million visits to the physician's office or emergency department every year. Although the estimated prevalence is around 58.4%, the actual incidence of headache in the pediatric population might be underestimated, given only a percentage of cases seek medical attention. The first step in the evaluation of pediatric headache is a detailed clinical history and relevant clinical examinations. AAN and ACR do not recommend neuroimaging for patients with primary headache. However, neuroimaging becomes mandatory in presence of red flags to rule out the underlying cause.

Imaging is essential in the diagnosis of vascular causes of headaches. With advances in technology, there are increasing options of imaging modalities to choose from, each with its own advantages and disadvantages. This article will focus on imaging pearls and pitfalls of vascular causes of headaches. These include aneurysms, vasculitides, vascular malformations, and cerebral venous thrombosis.

Middle meningeal artery embolization (MMAE) is an effective minimally invasive treatment for chronic subdural hematomas (cSDHs). The authors investigated outcomes of primary, adjunct, and rescue MMAE and primary surgery for the treatment of cSDH using a large-scale national database.A retrospective study of all patients who underwent MMAE and/or surgery to treat cSDH was performed using the TriNetX Analytics Network. Primary MMAE was compared with adjunct and rescue MMAE and primary surgery. Primary outcomes included headache, facial weakness, mortality, and treatment failure, within 6 months.A total of 4274 patients with cSDH met the inclusion criteria. Of these, 209 (4.9%) were treated with primary MMAE, 4050 (94.8%) were treated with primary surgery, 15 (0.35%) were treated using MMAE as an adjunct therapy, and 18 (0.42%) were treated using MMAE as a rescue following a failed surgical intervention. There were no significant differences in headache, facial weakness, and mortality between the groups. Patients who underwent primary MMAE had a significantly higher Charlson comorbidity index (P 0.0001) than those who underwent primary surgery. The need for surgical rescue was not significantly different between primary MMAE, adjunct MMAE, and rescue MMAE (P 0.05). Additionally, patients with primary surgery had significantly higher treatment failure than those with primary MMAE (odds ratio = 2.11, 95% confidence interval = 1.11-4.01, P = 0.020).This analysis suggests no significant difference in the need for surgical rescue, complication, or mortality between primary MMAE, adjunct MMAE, and rescue MMAE. Additionally, primary MMAE is associated with a significantly lower need for surgical rescue than primary surgery.

The primary aim of this study was to review the effect of exercise in comparison with a non-active treatment on pain intensity, frequency of headache episodes, headache duration, quality of life, medication use, and psychological symptoms, in patients with migraine or tension-type headache (TTH). A systematic search was conducted in various electronic databases to identify all relevant studies: Medline (PubMed), PEDro, EBSCO and Google Scholar. Clinical trials assessing the effects of exercise interventions in patients with primary headaches were selected. Methodological quality was evaluated using the Cochrane Risk of Bias Tool and PEDro scale and qualitative analysis was based on classifying the results into levels of evidence according to the GRADE. 19 studies (2776 participants; 85% female) were included. The meta-analysis showed statistically significant differences in pain intensity for aerobic training in patients with migraine (SMD = -0.65; 95% CI = -1.07 to -0.22, very low certainty evidence) and for strength training in patients with TTH (SMD = -0.84; 95% CI = -1.68 to- -0.01, very low certainty evidence). Statistically significant differences were also found in the medication use (SMD = -0.51; 95% CI = -0.85 to -0.17, low certainty evidence). Low transparency, replicability and high risk of bias were found. Aerobic training has a small to moderate clinical effect on pain intensity and medication use on migraine patients, with very low to low certainty of evidence. Strength training showed a moderate clinical effect with very low quality of evidence in patients with TTH. Exercise could be considered as clinically relevant for the management of patients with primary headaches, but the presence of low certainty of evidence and low transparency and replicability limited its clinical application. PERSPECTIVE: This article presents current evidence about exercise interventions in patients with primary headaches, including migraine and tension-type headache. Existing findings are reviewed, and relevant data are provided on the effectiveness of each exercise modality, as well as its certainty of evidence and clinical applicability.

Hemifacial spasm (HFS) can be associated with Chiari malformation type I (CM1), but the treatment paradigm for these concurrent conditions has not been well-defined. We sought demographical differences between patients with HFS with and without CM1 and explored optimal surgical treatments for these patients. A systematic review of peer-reviewed literature identified 8 studies with 51 patients with CM1 and HFS. A patient from the authors' institution is presented as a case illustration. Of the 51 patients, the average age was 39.4 years, 63% (32/51) were female, 73% (37/51) underwent microvascular decompression (MVD) as a primary intervention, and 16% (8/51) underwent suboccipital decompression (SOD). After primary MVD, 83.7% (31/37) had complete resolution of their symptoms and 10.8% (4/37) had either recurrent CM1 symptoms or new-onset CM1 symptoms. Three (8.1%) required reoperation with suboccipital decompression to address new CM1-related symptoms. All patients who underwent SOD first had complete or near-complete resolution of symptoms. In 3 patients (37.5%) with near-complete resolution, the residual symptoms had insignificant impact on their quality of life. These data suggest that concomitant CM1 should be among the differential diagnosis in younger patients who present with HFS, particularly those who are female or who present with history suggesting tussive headaches. For patients who present with HFS and headache with CM1, SOD instead of MVD may be the preferred surgery to address concurrent symptoms. In patients with HFS and CM1 without headache, optimal treatment is less clear, but SOD as initial surgery may obviate the need for future reoperation.

CSF hypotension arises in the context of a leak of CSF which causes negative intracranial pressure. Sacral fractures result from high-energy trauma which are frequently underdiagnosed. A ten-year-old boy presented with hip pain, after a fall. He mobilized both lower limbs, reported no leg pain, irradiation nor lack of sphincter control. The neurological examination was normal. When asked to stand, he began biparietal headache, nausea and vomiting, which improved laying down. CT scan showed an occult intrasacral meningocele; the MRI revealed collections of CSF along the spine, a S3 fracture with potential laceration of the meningocele and opening of a CSF fistula. Our diagnosis was the CSF hypotension, secondary to the fistula opening. The diagnosis was challenging. The child first presented with symptoms of CSF hypotension without evident cause. The discovery of the meningocele led us to hypothesize the opening of a fistula, a rare diagnosis, later confirmed by MRI. info:eu-repo/semantics/publishedVersion

Patients often report symptoms of headache and dizziness concomitantly. Symptoms of dizziness can be explored with a comprehensive vestibular assessment, allowing for the investigation of central and peripheral vestibular system contributions to symptoms of dizziness. Patients who report both symptoms of headache and dizziness demonstrate abnormalities of the vestibular system which can be measured quantitatively. Completion of comprehensive vestibular testing can help to guide diagnosis and strategies for intervention.

Pediatric headache is a common medical complaint managed across multiple subspecialties with a myriad of unique factors (clinical presentation and disease phenotype) that make accurate diagnosis particularly elusive. A thorough understanding of the stepwise approach to headache disorders in children is essential to ensure appropriate evaluation, timely diagnosis, and efficacious treatment. This work aims to review key components of a comprehensive headache assessment as well as discuss primary and secondary headache disorders observed in children, with a particular focus on clinical pearls and "red flag" symptoms necessitating ancillary diagnostic testing.

It has been observed in recent years that levels of such molecules as calcitonin gene-related peptide (CGRP) and, to a lesser extent, the pituitary adenylate cyclase-activating peptide are elevated during migraine attacks and in chronic migraine, both in the cerebrospinal fluid and in the serum. Pharmacological reduction of these proteins is clinically significant, with an improvement in patients' migraines. It therefore seems logical that one of the main lines of migraine research should be based on the role of CGRP in the pathophysiology of this entity. The Spanish Society of Neurology's Headache Study Group decided to draft this document in order to address the evidence on such important issues as the role of CGRP in the pathophysiology of migraine and the mechanism of action of monoclonal antibodies and gepants; and to critically analyse the results of different studies and the profile of patients eligible for treatment with monoclonal antibodies, and the impact in terms of pharmacoeconomics. The clinical development of gepants, which are CGRP antagonists, for the acute treatment of migraine attacks, and CGRP ligand and receptor monoclonal antibodies offer promising results for these patients.

Novel medical devices are emerging as low-risk treatment options for patients suffering from sinus headaches. Early trends for the treatment of sinus headaches using medical devices are following the more established primary headache literature. There are two categories of devices with early data supporting use, which may serve as useful adjuncts to conventional pharmacotherapy in the management of sinus headaches not caused by sinusitis: transcutaneous electrical neurostimulation and acoustic vibration with oscillating expiratory pressure. There is currently a paucity of high-level evidence and further studies are needed. Initial reports suggest these interventions are low risk, but longer follow-up is necessary.

Neurofibromatosis type 1 (NF1) is a progressive multisystem disorder following an autosomal dominant inheritance pattern that presents with multiple neurological manifestations.We reviewed medical histories of patients with NF1 followed up at our hospital's paediatric neurology department from May 1990 to 31 December 2018. We collected data on neurological symptoms.A total of 128 patients with NF1 were identified. Mean age (SD) at NF1 diagnosis was 4.43 (3.38) years (range, 0.5-14.5 years). There was a slight female predominance (53.1%). Macrocephaly (head circumference over 2 SDs above average for age) was present in 37.5% of cases. Attention-deficit/hyperactivity disorder was recorded in 28.9% of patients (37): combined type in 20 patients, predominantly inattentive in 15, and predominantly impulsive/hyperactive in 2. Other manifestations included headache (18.6%), cognitive impairment (7.8%), motor deficit (6.2%), and epilepsy (4.68%). Brain MRI was performed in 85 patients, revealing T2-weighted hyperintensities in the basal ganglia and/or cerebellum in 60 patients (70.5%), Chiari malformation type 1 in 4 cases, and arachnoid cysts in 3. Optic nerve gliomas were identified by MRI in 22 patients (25.8%). Other MRI findings included plexiform neurofibromas (9.3%) and central nervous system gliomas (3.1%).The neurological manifestations identified in our sample are consistent with those reported in the literature. Effective transfer strategies from paediatric neurology departments and subsequent clinical follow-up by adult neurology departments are needed to prevent loss to follow-up in adulthood.

Sodium valproate and ibuprofen are drugs with known efficacy in the treatment of headache associated with acute migraine attacks. In this study, our aim was to compare the efficacy of these two drugs in the treatment of acute migraine attacks when administered as a single intravenous (IV) dose in the emergency department.This study was designed as a prospective, randomized controlled, double-blinded study and included patients aged 18 to 65 years who presented to the emergency department with acute headache and met the criteria of 'migraine without aura' according to the International Classification of Headache Disorders. The patients were randomized into two groups and given a single dose of 800 mg sodium valproate or 800 mg ibuprofen in 150 mL of normal saline by IV infusion over five minutes. Changes in pain levels were assessed using the Numerical Rating Scale (NRS) for pain over a two-hour period.Ninety-nine patients (49 patients in the sodium valproate group and 50 in the ibuprofen group) completed the trial, and their data were included in the statistical analysis. The mean decrease in the post-treatment delta NRS values was statistically significantly higher in the sodium valproate group than in the ibuprofen group. The mean differences were 1.69 [confidence interval (CI): 1.02-2.37, p0.001], the mean difference between N0 and N2 was 3.61 (CI: 2.96-4.26, p0.001), the mean difference between N0 and N3 was 4.11 (CI: 3.54-4.67, p0.001), and the mean difference between N0 and N4 was 3.92 (CI: 3.67-4.46, p0.001). The number of patients who achieved the primary endpoint of pain relief was significantly higher in the sodium valproate group than in the ibuprofen group (p0.001). According to the Kaplan-Meier analysis showing the rates of reaching the targeted endpoint, there was a significant difference in the efficacy of the two-treatment group (χ2 = 79.98, CI: 80.35-99.65; p = 0.000).

The efficacy of yoga therapy for migraine remains controversial. We conduct this meta-analysis to explore the influence of yoga therapy on the treatment efficacy of migraine.We have searched PubMed, EMbase, Web of science, EBSCO and Cochrane library databases through February 2021, and included randomized controlled trials (RCTs) assessing the efficacy of yoga therapy for migraine attack.Five RCTs involving 356 patients were included in the meta-analysis. Overall, compared with control group for migraine, yoga therapy was associated with substantially reduced headache frequency headache frequency (SMD = -1.43; 95% CI = -2.23 to -0.64; P = 0.0004) and HIT-6 score (SMD = -2.19; 95% CI = -4.09 to -0.28; P = 0.02), but revealed no obvious influence on pain intensity (SMD = -1.37; 95% CI = -2.76 to 0.01; P = 0.05) or McGill Pain Questionnaire (SMD = -2.09; 95% CI = -6.39 to 2.22; P = 0.34).Yoga therapy may benefit to reduce the headache frequency of migraine patients.

Background The overall prevalence of headaches decreases with age; however headaches remain frequent in aged individuals who are also affected by other disorders such as cognitive decline. Despite the high frequency of both conditions in these persons, the association between headaches and cognitive decline is underexplored, underdiagnosed and poorly understood. Objective In the present article, we aim to provide a comprehensive review of existing data concerning the link between headache and cognitive decline. Methods We undertook a systematic literature review to report articles that focus on headaches (including all types of headaches) and neurocognitive disorders of degenerative causes. Results Only 9 studies have explored the association between headaches and neurocognitive decline. Methods were highly variable from population-based study to short series of patients using either database or questionnaire during consultation. Studies focusing on Familial Alzheimer's Disease revealed a very high prevalence of headaches in mutation carrier patients compared to non-carrier patients. Conclusion The association between headaches and cognitive decline is underexplored. Future studies are needed to address the pathophysiological mechanisms to improve the treatment of these underestimated headaches.

Managing neurological emergencies is an essential element of emergency physicians' armamentarium, irrelevant of the specific nature of their practice. The combination of evolving literature and advances in imaging fuel the rapidly changing standards of care, especially in high-stakes diagnoses such as stroke. Navigating the emergency neurology literature to stay abreast of the current updates is becoming more challenging with the sheer volume of publications, combined with the recent dominance of COVID-19 on the literature and media attention. This review article summarizes emergency neurology literature updates that can help you improve your care of these high-risk presentations; articles covering stroke, dizziness, intracerebral hemorrhage, head trauma imaging, headache, seizures, and COVID-19 are reviewed.

Objective To describe transcranial Doppler (TCD) findings in a population with clinical probable RCVS . Exploratory objectives included the study of clinical characteristics of probable RCVS patients with and without spasm detected by TCD. Methods Cross-sectional cohort study of patients with thunderclap headache (TCH) without subarachnoid hemorrhage (SAH) of our neurology and headache center between 2010 and 2019, selecting patients with clinical diagnosis of probable RCVS (negative angiography study) by ICHD-3 criteria and with at least two TCD studies. Results From 114 TCH patients, 36/114 had probable RCVS by ICHD-3 criteria and had at least two TCD studies available. The mean age at RCVS onset was 42.9 years (21–72 years); 29/36 (80.6%) were female, 7/28 (25%) had cardiovascular risk factors and 20/36 (55.6%) had history of migraine. Most common triggers were stressful emotion, drugs, valsalva maneuvers and sexual activity. Five/36 (13.9%) had complications and 3/36 (8.3%) had late recurrence. Initial TCD was performed on average of 16 (6–26) days after headache onset. Twenty-nine had vasospasm on TCD, presenting mean flow velocity of MCA (VMCA) of 135.7 ± 17.0 cm/s and mean maximum VMCA of 138.3 ± 17.2. Vasospasm was mild in 21/29 patients (72.4%) and moderate in 8/29 (27.6%). Complete VMCA normalization occurred on average 41 (30–70) days after headache onset and 24 (11–47) days after initial TCD. The group of patients with vasospasm detected by TCD had more female patients (26/29, 89.7% vs. 3/7, 42.8%, P = 0.016), and more TCH attacks (mean of 3.6 vs. 2.14, P = 0.049). Conclusion TCD may be a useful tool in the identification of vasospasm in patients with probable RCVS, supporting the diagnosis of RCVS in patients presenting with recurrent TCH without SAH.

Cerebral venous sinus thrombosis (CSVT) is a rare condition, causing 0.5% of all strokes only, several mechanisms might be involved in forming the thrombosis, including closed head injury.Systematic review was done by using the following databases: PubMed, Google Scholar, Microsoft Academic, Clinical Trials, Cochrane Library, and Web of Science.25 articles met our criteria out of 152 articles, average and standard deviation of the age was 38.2 ± 16.8 years with an age range of 18-82. The majority of cases presented with loss of consciousness or decreased GCS (41%), followed by headache (26%), scalp abrasions/lacerations (21%), paralysis (18%), visual disturbance (18%), nystagmus (15%), and agitation (15%). The most commonly used diagnostic method was angiography. Thrombosis was the most frequently reported radiological finding among all the cases (26/34, 76%). Comparisons of outcomes between patients who underwent surgical intervention and those who did not undergo surgery revealed a significant difference in outcome favoring non-surgical treatment (p 0.005, odds ratio (OR) 0.04, (95% CI) 0.003 - 0.30).Non-surgical outcomes were better than the surgical outcomes. However, no significant difference was seen comparing anti-coagulation versus conservative management (supportive without anticoagulation), single versus multi-sinuses (≥2 sinuses) involvement, and between any of the sinuses involved.

To study the safety and patients' tolerance of transcranial magnetic stimulation (TMS), we conducted a systematic review and meta-analysis of the major depressive disorder population.Our study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched the literature published before April 30th, 2021 and performed a random-effects meta-analyses which included drop-out due to adverse events, serious adverse events and other non-serious adverse events as primary and secondary outcomes.A total of 53 randomized sham-controlled trials with 3,273 participants were included. There was no increased risk of drop-out due to an adverse event (active TMS intervention group=3.3%, sham TMS intervention group=2.3%, odds ratio = 1.30, 95% CI= 0.78-2.16, P = 0.31) or a serious adverse event (active TMS intervention group=0.9%, sham TMS intervention group=1.5%, odds ratio = 0.67, 95% CI= 0.29-1.55, P = 0.35). Our findings suggest that TMS intervention may significantly increase the risk of non-serious adverse events including: headaches (active TMS intervention group=22.6%, sham TMS intervention group=16.2%, odds ratio = 1.48, 95% CI= 1.15-1.91, P = 0.002), discomfort (active TMS intervention group=10.9%, sham TMS intervention group=5.0%, odds ratio 1.98, 95% CI= 1.22-3.21, P = 0.006) and pain (active TMS intervention group=23.8%, sham TMS intervention group=5.2%, odds ratio= 8.09, 95% CI= 4.71-13.90, P0.001) at the stimulation site, but these non-serious events were mostly mild and transient after TMS treatment.These findings provide evidence for the safety and patients' tolerance of transcranial magnetic stimulation technique as an alternative monotherapy or as an add-on treatment for major depressive disorder.

Droperidol is a butyrophenone that has recently been reintroduced after a United States Food and Drug Administration (US FDA) black box warning in 2001. Evidence demonstrates utility in a variety of clinical conditions.This paper provides evidence-based updates concerning the use of droperidol for the emergency clinician.Droperidol received a black box warning by the US FDA in 2001 due to concerns for QT prolongation and torsades de pointes; however, reevaluation of the available data suggests droperidol is a safe and efficacious medication. It can be used in the emergency department (ED) setting for many conditions, including acute agitation, headaches, vertigo, nausea, and vomiting. Extensive literature supports that the QT-prolonging effects are transient and that the risk of torsades de pointes is rare with doses utilized in the ED. An electrocardiogram does not need to be routinely obtained before droperidol use but should be considered in patients at high risk for QT prolongation.Current evidence suggests that droperidol is a safe and effective medication for treating nausea and vomiting, headache, vertigo, and agitation in the ED setting.

Objectives Use of Motivational Interviewing (MI) in education may improve medication-overuse headache (MOH) patients’ ability to cope with pain. In a randomised controlled trial, we evaluated the effect of education focusing on behavioural change among MOH patients. Methods Ninety-eight MOH patients were randomized (1:1) to standard treatment and 12-weeks of MI-based education versus standard treatment alone after detoxification. Outcome of interest was changes in coping strategies measured by the Coping Strategy Questionnaire at four- and nine months. Results The educational program improved patients’ perceived efficacy in the use of their coping strategies to control pain, both at four-and nine months follow-up (mean±SE): ∆:0.84 ± 0.35, 95% CI:0.16;1.52, p = 0.02 and: ∆: 0.90 ± 0.39, 95% CI:0.14;1.66, p = 0.02, respectively. No between-group differences were detected in the other coping subscales. Within the intervention group, the coping strategy subscales Catastrophizing, and Reinterpretation of pain sensation were significantly improved at nine months follow-up (p = 0.003 vs. p = 0.012, respectively). No changes were found in the control group. Conclusion MI-based education focused on behavioural changes improved MOH patients’ perceived efficacy in the use of their coping strategies to control pain. Practice implications Education based on MI could be valuable for MOH patients with respect to behavioural changes and perceived headache control.

Background Data on the long-term impact of SARS-CoV-2 infection in children and young people (CYP) is conflicting. We assessed evidence on long-term post-COVID symptoms in CYP examining prevalence, risk factors, type and duration. Methods: Systematic search of published and unpublished literature using 13 online databases between 01/12/2019 – 31/07/2021. Eligible studies reported CYP ≤19 years with confirmed or probable SARS-CoV-2 with any symptoms persisting beyond acute illness. Random effects meta-analyses examined pooled risk difference in symptom prevalence (controlled studies only) and pooled prevalence (uncontrolled studies also included). Meta-regression examined study characteristics hypothesised to be associated with symptom prevalence. Prospectively registered: CRD42021233153. Findings Twenty two of 3357 unique studies were eligible, including 23,141 CYP. Median duration of follow-up was 125 days (IQR 99-231). Pooled risk difference in post-COVID cases compared to controls (5 studies) were significantly higher for cognitive difficulties (3% (95% CI 1, 4)), headache (5% (1, 8)), loss of smell (8%, (2, 15)), sore throat (2% (1, 2)) and sore eyes (2% (1, 3)) but not abdominal pain, cough, fatigue, myalgia, insomnia, diarrhoea, fever, dizziness or dyspnoea. Pooled prevalence of symptoms in post-COVID participants in 17 studies ranged from 15% (diarrhoea) to 47% (fatigue). Age was associated with higher prevalence of all symptoms except cough. Higher study quality was associated with lower prevalence of all symptoms, except loss of smell and cognitive symptoms. Interpretation The frequency of the majority of reported persistent symptoms was similar in SARS-CoV-2 positive cases and controls. This systematic review and meta-analysis highlights the critical importance of a control group in studi7777es on CYP post SARS-CoV-2 infection.

Introduction: Headache is one of the most common neurological complaints, and is most frequent during reproductive age. As a result, we are routinely faced with pregnant or breastfeeding women with this symptom in clinical practice. It is important to know which pharmacological choices are the safest, which should not be used, and when we should suspect secondary headache. To this end, the Spanish Society of Neurology's Headache Study Grouphas prepared a series of consensus recommendations on the diagnostic and therapeutic algorithms that should be followed during pregnancy and breastfeeding. Development: This guide was prepared by a group of young neurologists with special interest and experience in headache, in collaboration with the Group's Executive Committee. Recommendations focus on which drugs should be used for the most frequent primary headaches, both during the acute phase and for prevention. The second part addresses when secondary headache should be suspected and which diagnostic tests should be performed in the event of possible secondary headache during pregnancy and breastfeeding. Conclusions: We hope this guide will be practical and useful in daily clinical practice and that it will help update and improve understanding of headache management during pregnancy and breastfeeding, enabling physicians to more confidently treat these patients., Introducción: La cefalea es uno de los motivos de consulta más comunes en neurología, siendo más frecuente durante la edad reproductiva. Por ello, es habitual encontrar en nuestras consultas pacientes embarazadas o en periodo de lactancia con dicha queja. Es importante conocer las opciones farmacológicas más seguras, cuáles no se deben emplear, así como cuándo sospechar cefaleas secundarias. Por este motivo, el Grupo de Estudio de Cefaleas de la Sociedad Española de Neurología ha elaborado una guía con las recomendaciones consensuadas acerca de los algoritmos diagnósticos y terapéuticos que se deben emplear durante el embarazo y la lactancia

OBJECTIVES: To evaluate the short-term mortality of adult patients presenting to the emergency department (ED) with altered mental status (AMS) as compared to other common chief complaints. METHODS: Observational cohort study of adult patients (age ≥ 40) who presented to an academic ED over a 1-year period with five pre-specified complaints at ED triage: AMS, generalized weakness, chest pain, abdominal pain, and headache. Primary outcomes included 7- and 30-day mortality. Hazard ratios (HR) were calculated with 95% confidence intervals (CI) using Cox proportional hazards models adjusted for age, acuity level, and comorbidities. RESULTS: A total of 9,850 ED visits were included for analysis from which 101 (1.0%) and 295 (3.0%) died within 7 and 30 days, respectively. Among 683 AMS visits, the 7-day mortality rate was 3.2%. Mortality was lower for all other chief complaints, including generalized weakness (17/1170, 1.5%), abdominal pain (32/3609, 0.9%), chest pain (26/3548, 0.7%), and headache (4/840, 0.5%). After adjusting for key confounders, patients presenting with AMS had a significantly higher risk of death within 7 days of ED arrival than patients presenting with chest pain (HR 3.72, 95% CI 2.05 to 6.76, p

Treatment outcomes for migraine and other chronic headache and pain conditions typically demonstrate modest results. A greater understanding of underlying pain mechanisms may better inform treatments and improve outcomes. Increased GABA+ has been identified in recent studies of migraine, however, it is unclear if this is present in other headache, and pain conditions. We primarily investigated GABA+ levels in the posterior cingulate gyrus (PCG) of people with migraine, whiplash-headache and low back pain compared to age- and sex-matched controls, GABA+ levels in the anterior cingulate cortex (ACC) and thalamus formed secondary aims. Using a cross-sectional design, we studied people with migraine, whiplash-headache or low back pain (n = 56) and compared them with a pool of age- and sex-matched controls (n = 22). We used spectral-edited magnetic resonance spectroscopy at 3T (MEGA-PRESS) to determine levels of GABA+ in the PCG, ACC and thalamus. PCG GABA+ levels were significantly higher in people with migraine and low back pain compared with controls (eg, migraine 4.89 IU ± 0.62 vs controls 4.62 IU ± 0.38; P = .02). Higher GABA+ levels in the PCG were not unique to migraine and could reflect a mechanism of chronic pain in general. A better understanding of pain at a neurochemical level informs the development of treatments that target aberrant brain neurochemistry to improve patient outcomes. Perspective This study provides insights into the underlying mechanisms of chronic pain. Higher levels of GABA+ in the PCG may reflect an underlying mechanism of chronic headache and pain conditions. This knowledge may help improve patient outcomes through developing treatments that specifically address this aberrant brain neurochemistry.

Background Superior semicircular canal dehiscence (SSCD) is an abnormality of the otic capsule, which normally overlies the superior semicircular canal. Surgical management is indicated in patients with persistent and debilitating symptoms. Given the complexity of the disease, there are patients who experience less favorable surgical outcomes and require revision surgery. The purpose of this study was to report to the rate of postoperative symptomatic improvement in patients who required revision surgery. Methods A retrospective analysis of patients undergoing SSCD surgical repair at a single institution was performed. Information on patient demographics, primary and secondary surgical approaches, surgical outcomes, and follow-up length was collected. Results Seventeen patients underwent 20 revision surgeries. There were eleven (65%) females and six (35%) males. Mean age of the cohorts was 50 years (range 30−68 years), and mean follow-up length was 6.8 months (range 0.1−31.1 months). Cerebrospinal fluid leak was noted in 67% of cases. The greatest postoperative symptomatic resolution was reported in oscillopsia (100%), headache (100%), and internal sound amplification (71%), while the least postoperative symptomatic resolution was reported in tinnitus (42%), aural fullness (40%), and dizziness (29%). Conclusions Revision surgery can provide symptomatic improvement in select SSCD patients; however, patients should be cautioned about the possibility of less favorable outcomes than in index surgery. Revision surgeries are associated with a considerably higher rate of perioperative cerebrospinal fluid leak.

The S100ß protein (PS100ß) is a biomarker, which has demonstrated its importance in diagnoses ruling out intracranial hemorrhages in people with light head traumas This study aims to evaluate if the PS100ß presents an interest in the diagnostic strategy for subarachnoid hemorrhages (SAH).Prospective non-randomized multicentric study in three hospitals from October 2018 to January 2020. Every patient who came into the emergency department for an intense non-traumatic headache lasting less than 3 h received an PS100ß assay and a non-injected head computed tomography (CT) scan. The primary endpoint was the number of patients with a diagnosis of SAH on the head CT scan with a PS100ß level of under 0.10 μg/L.60 patients were included and five patients had a SAH. Four patients had an SAH with a PS100ß level lower than 0.10 μg/L and one patient had an SAH with a PS100ß level higher than 0.10 μg/L. The negative predictive value for the PS100ß with a discriminating threshold less than or equal to 0,10 μg/L in the diagnosis ruling out SAH was 93% [IC 95%: 0,86-1].S100ß protein assay with a discriminating threshold of 0,10 μg/L does not demonstrate any interest in the diagnostic strategy for non-traumatic SAH.

Headache has been cited as both a primary symptom and a sequela of infection with the novel coronavirus. Cases of long coronavirus disease (COVID) headache have already been documented in adults, but literature on similar cases in children and adolescents is scant.We present three cases of persistent headache after infection with COVID-19 in pediatric patients presenting to a tertiary headache center.Infection has been suggested as a trigger for chronic headaches, specifically those of the new daily persistent headache type. Although the association between new daily persistent headache and COVID-19 remains unclear, these cases highlight the importance of awareness of the neurological sequelae of novel coronavirus infection in children and adolescents.

Objectives Historically, headache was reported in up to 76% of hemodialysis patients. Some authors suggested that headache resulted from caffeine withdrawal. This study aims to compare the incidence of headache and hypotension between patients drinking regular or decaffeinated coffee during dialysis. Methods One-hundred fifty-six patients were enrolled in this randomized, double-blind, placebo-controlled, multicenter study. Patients with atrial fibrillation were excluded. Group A was given 80 mL of regular coffee and group B 80 mL of decaffeinated coffee (placebo) in the middle of the session for 12 consecutive sessions. Ultrafiltration rate was fixed to a maximum of 13 mL/kg/hour. The primary outcome was the incidence of headache during dialysis. Results A total of 139 patients completed the trial (6.4% vs. 15.4% of withdrawal in Groups A and B, respectively). The number of sessions with headache was not significantly different between Group A and B (33.3% vs. 37.1% respectively, P = .522), nor the number of sessions with hypotension (27% vs. 26% respectively, P = .539). In a subgroup analysis, headache tended to be more frequent in Group B (P = .06) in 2 categories of patients: those with the highest potassium dialysate (K = 2) and the non-hypertensive patients. Conclusions Headache occurred in 35% of patients during their chronic hemodialysis sessions. Caffeine intake did not prevent headache occurrence in these patients.

Introduction The purpose of our work was to study the characteristics of Headache associated with refractive errors (HARE) 1 , and to search for the correlation between headaches characteristics and some risk factors. We aimed also to assess the impact of these headaches on the quality of life of patients. Methods A cross-sectional, retrospective, comparative study including 90 patients followed between August 2019 and January 2020. These patients were divided into two groups: Group 1 including patients presenting headaches due to uncorrected ametropia, and group 2 including control subjects. We studied HARE characteristics, the influence of certain risk factors (profession, triggers factors, characteristics of ametropia, and orthoptic abnormalities) on them, their evolution after one month of treatment, and their impact on patients’ quality of life with the HIT-6 score. Results Headaches due to ametropia were mainly chronic (20.9 ± 15.76 months on average) progressive (100% of cases), daily (90% of cases) predominantly during the second half of the day (82% of cases). They were moderate (64% of cases), with a fronto-orbital topography in 52% of cases. Headaches were compression-type in 36% of cases (18 patients) and pressure-type in 64% (32 patients). The multivariate study retained prolonged screen working (P = 0.013), combined ametropias (P = 0.001), moderate hyperopia (P = 0.01) and astigmatism (P = 0.03) to be risk factors of HARE. Headaches induced a substantial to major impact on the quality of life in 68% (34 patients had a score greater than 55), the latter is significantly influenced by the presence of high myopia. After optical correction and orthoptic treatment, we noted an improvement in headache in 100% of cases. The multivariate analysis did not identify any independent factor that impact the evolution of headache at one month. Conclusion HARE may influence life quality; it needs an appropriate treatment based on risk factor management. A healthy lifestyle in addition to adequate refractive error correction is essential in children and, sometimes in adults. Oculomotor abnormalities treatment leads to improve long term results.

Background Surgeons performing Minimally Invasive Surgery (MIS) report significant neck/shoulder problems and visual symptoms. Headache is another commonly reported symptom but publications about the characteristics and associated risk factors are limited. Purpose of the study To determine the characteristics of headache among MIS surgeons and the associations of headache with neck/shoulder problems, visual symptoms and other associated factors. Design A cross-sectional study. Methods A comprehensive online survey was sent to MIS surgeons inclusive of 63 questions about individual and workplace physical factors, characteristics of headache, neck/shoulder problems and visual symptoms. Binary logistic regression models were conducted to determine the associations of the prevalence and severity of headache with risk factors. The main findings Headaches in the last 7 days were reported by 36% of surgeons, with 37% of these of moderate to severe intensity. Frequent intense headaches were often preceded by neck pain. Surgeons with headache were eight times more likely to also experience visual symptoms and four times more likely to experience neck/shoulder problems. Several factors (frequently adopting forward head movement, surgical specialty, sex and age) were significantly associated with headaches (p ≤ 0.05). Conclusions This study revealed headaches were present in one-third of MIS surgeons. During surgery, surgeons report adopting non-neutral neck/shoulder/head positions, which may explain headaches, neck/shoulder problems and visual symptoms. Evidence based strategies to assist surgeons better manage these symptoms are warranted.

Migraine is characterized by symptoms related to cortical hyperexcitability such as photophobia , phonophobia , osmophobia and allodynia . One-third of migraineurs experience aura, whose neurophysiological substrate is thought to be cortical spreading depression (CSD). Functional magnetic resonance imaging (MRI) has shown the migraine aura to be characterized by cerebral hyperactivity/hyperperfusion followed by hypometabolism/hypoperfusion spreading along the occipital cortex with the same spatiotemporal organization as the experimentally triggered CSD. The link between migraine aura and headache remains undetermined. Neuroimaging studies have failed to show a leakage of the blood–brain barrier, which was suspected to occur during CSD and to cause the stimulation of trigeminal nociceptive receptors. However, recent studies have highlighted the involvement of neuroglial inflammation and other studies have suggested that a common central network plays a role in the link between CSD and migraine pain. Finally, MRI has made it possible to study the contribution of metabolites such as glutamic acid , γ-amino-butyric acid and sodium in the pathophysiology of hyperexcitability in migraine.

Introduction: Tension-type headache is the most common primary headache, with a high prevalence and a considerable socioeconomic impact. Manual physical therapy techniques are widely used in the clinical field to treat the symptoms associated with tension-type headache. This systematic review aims to determine the effectiveness of manual and non-invasive therapies in the treatment of patients with tension-type headache. Development: We conducted a systematic review of randomised controlled trials in the following databases: Brain, PubMed, Web of Science, PEDro, Scopus, CINAHL, and Science Direct. Ten randomised controlled trials were included for analysis. According to these studies, manual therapy improves symptoms, increasing patients’ well-being and improving the outcome measures analysed. Conclusions: Manual therapy has positive effects on pain intensity, pain frequency, disability, overall impact, quality of life, and craniocervical range of motion in adults with tension-type headache. None of the techniques was found to be superior to the others; combining different techniques seems to be the most effective approach. Resumen: Introducción: La cefalea tensional es la cefalea primaria más usual, con una prevalencia elevada y unas consecuencias socioeconómicas de gran impacto. Las técnicas de terapia manual, desde la fisioterapia, son muy utilizadas en el abordaje del conjunto de síntomas que puede provocar. El propósito fue realizar una revisión sistemática sobre la efectividad de las terapias manuales y no invasivas en el tratamiento de pacientes que presentan cefalea tensional en sus actuales formas. Desarrollo: Se llevó a cabo una revisión sistemática de la literatura en busca de ensayos controlados y aleatorizados. Se emplearon las siguientes bases de datos: Brain, PubMed, Web of Science, PEDro, Scopus, CINHAL y Science Direct. Se analizaron 10 estudios, todos ellos ensayos controlados y aleatorizados. Según los estudios individuales, la intervención logra mejorar la clínica, aportando bienestar al paciente y mejorando las distintas medidas de resultado analizadas. Conclusiones: La terapia manual logra efectos positivos sobre la intensidad y la frecuencia del dolor, la discapacidad, el impacto, la calidad de vida y el rango de movimiento craneocervical en adultos con cefalea tensional. No se encuentra superioridad entre una técnica con respecto a otra, siendo más efectivo el tratamiento combinado de estas.

Migraine and epilepsy are distinct neurological diseases with specific clinical features and underlying pathophysiological mechanisms. However, numerous studies have highlighted the complex and multifaceted relationships between the two conditions. The relationships between headache and epilepsy manifest themselves in different ways. Firstly, the clinical diagnosis of these disorders may be challenging in view of possible overlapping. While post-ictal headache is a frequent condition, ictal epileptic headache is a rare but challenging diagnosis. Both situations raise the question of the pathophysiological mechanism of headache triggered by seizures. Migraine aura and epilepsy can also exhibit overlapping symptoms leading to their misdiagnosis, in particular in the case of visual aura. Secondly, migraine with aura and epilepsy can occur as a co-morbid condition, particularly in familial hemiplegic migraine (FHM). From a pathophysiological perspective, the identification of genetic mutations in FHM has brought significant advances in the understanding of dysfunctions of neuronal networks leading to hyperexcitability. The purpose of this review is to present clinical situations encompassing headache and epilepsy that can be challenging in neurological practice and to discuss the underlying pathophysiological mechanism of such interactions.

The French Headache Society proposes updated French guidelines for the management of migraine. The first part of these recommendations is focused on the diagnosis and assessment of migraine. First, migraine needs to be precisely diagnosed according to the currently validated criteria of the International Classification of Headache Disorders , 3d version (ICHD-3). Migraine-related disability has to be assessed and we suggest to use the 6 questions of the headache impact test (HIT-6). Then, it is important to check for risk factors and comorbidities increasing the risk to develop chronic migraine , especially frequency of headaches, acute medication overuse and presence of depression. We suggest to use a migraine calendar and the Hospital Anxiety and Depression scale (HAD). It is also necessary to evaluate the efficacy and tolerability of current migraine treatments and we suggest to systematically use the self-administered Migraine Treatment Optimization Questionnaire (M-TOQ) for acute migraine treatment. Finally, a treatment strategy and a follow-up plan have to be proposed. Guidelines for pharmacological and non-pharmacological treatments are presented in the second and third part of the recommendations.

Around 15% to one-third of migraineurs experience aura. Aura is a fully reversible focal neurological phenomenon involving visual, sensory, speech, and/or motor symptoms that develops gradually and usually precedes the headache phase. The pivotal role of cortical spreading depression (CSD) as a mechanism underlying aura has been widely supported by a large body of studies. The diagnosis is based on the International Headache Classification Disorders III edition criteria. Aura is characterized by gradual development, duration of each symptom no longer than one hour, a mix of positive and negative features, and complete reversibility. Visual aura is the most common type of aura, occurring in over 90% of patients. When aura symptoms are multiple, they usually follow one another in succession, beginning with visual, then sensory, then aphasic; but the reverse and other orders have been noted. The accepted duration for most aura symptoms is one hour, but motor symptoms, which are rare, are often longer lasting. When a patient experiences for the first time a possible aura phase it's sometimes difficult to know if there was gradual or brutal onset of the symptoms. If the patient has no visual aura symptoms or simultaneous neurological symptoms, or presents neurological symptoms corresponding to a cerebral vascular territory, emergency exploration of a possible transient ischemic attack is necessary. Long duration (greater than one hour) of what may or may not be an aura phase, late onset of aura, or a dramatic increase in aura attacks should also be explored. The relative risk of ischemic stroke is significantly increased in migraine with aura. Combined hormonal contraception with estrogens significantly increases the risk of stroke in women with migraine with aura. It is recommended to start non-steroidal anti-inflammatory drugs (NSAIDs) or aspirin as soon as possible during the aura phase, not to treat the aura, but to avoid or to diminish the headache phase. In case of failure of NSAIDs or aspirin it is recommended to use a triptan when the headache begins. The prophylactic treatments for migraine with aura are those used in migraine without aura based on very few randomized clinical trials specifically dedicated to migraine with aura.

Background Severe headache, a hallmark of aneurysmal subarachnoid hemorrhage (aSAH), affects up to 90% of patients during hospitalization. Opioids remain the guideline recommended mainstay of acute therapy despite their significant side effects and potential for tolerance and addiction. We evaluated time trends in opioid prescriptions, hypothesizing a decline with increasing recognition of the opioid crisis. Methods We performed a retrospective review of patients with aSAH admitted to a single tertiary care center between 2012 and 2019 and included patients with Hunt-Hess-Grade ≤ 3 who were able to verbalize pain scores. Collected variables included mean and maximum daily headache scores, aneurysm treatment modality, and daily analgesic medication doses. Results Of 340 patients with aSAH, 114 (86 from 2012–2016 and 28 from 2017–2019) were included. Of the included patients, 86/114 (75.4%) were female. Patients in the 2012–2016 had a median age of 55 compared to 63 in the 2017–2019 group (P = 0.02). Otherwise, there was no significant difference in demographic data including time in hospital, treatment option utilized, or aneurysm characteristics. Maximal daily headache score ranged from 6 to 8 for 2012–2016 and 5 to 8 for 2017–2019 cohorts. Average oral morphine equivalents (in mg) administered during hospitalization were similar between groups (2012–2016: 251 ± 345 95% CI [178,323]; 2017–2019: 207 ± 237 95% CI [119,295]; P = 0.319). When prescribed, doses of opioids provided at discharge were less in the more recent group (2012–2016: 84.4 ± 78.9 95% CI [57.5, 111]; 2017–2019: 38.1 ± 20.2 95% CI [33.7, 42.5]; P = 0.004) Conclusion Despite recognition of important drawbacks of opioid use for headache control, and efforts to reduce opioid use during hospitalization, we found that utilization during hospitalization for SAH did not decrease over time. Maximal headache scores remained similar in the studied time periods, indicative of insufficient pain relief. This points out a pressing need to further investigate alternative opioid and narcotic sparing strategies for patients with SAH.