Arens Taga

Age of onset of episodic and chronic cluster headache – a review of a large case series from a single headache centre

BackgroundIn the largest case series of cluster headache (CH) published in the literature, age of onset varies between 29.6 and 31.6 years. Differences in onset age based on gender and subtype diagnosis are reported, while there are only few data on patients with childhood and elderly onset. We therefore deemed it useful to review our own large case series of CH patients.MethodsThe age of onset of cluster headache was investigated in a consecutive case series of 808 patients (585 men and 223 women), including 686 (503 men and 183 women) with episodic cluster headache (ECH), 103 (66 men and 37 women) with chronic cluster headache (CCH), and 19 with an indeterminate form of CH (16 men and three women).ResultsThe mean age of onset was 30.2 ± 13.8 years (30.1 ± 13.0 in men and 30.4 ± 15.7 in women). The women with primary CCH had a mean onset age of 42.8 ± 21.7 years, while the women with secondary CCH did not differ much from those with ECH. Distribution of the study subjects by decades of onset age showed a peak in the third decade both in men and in women, but when only CCH patients were considered it displayed a more marked bimodal pattern in women (with peaks in the second and the sixth decade) than men (with peaks in the third and the fifth decade). The clear male predominance in cases with onset in the central age groups became attenuated in the extreme age groups. In patients with onset between ≤ 15 years and ≥ 50 years, the traditional male-to-female ratio was actually inverted in CCH.ConclusionsBased on these epidemiological findings, it would be important to investigate the possible role, causative or protective, played by hormonal factors in CH pathogenesis.

Headache as a presenting symptom of glioma: A cross-sectional study:

Objective The objective of this study was to analyse the prevalence and the clinical features of headache as a presenting symptom of glioma. Methods We interviewed 527 consecutive adult patients with histologically confirmed glioma, admitted to the Regina Elena National Cancer Institute between 2010 and 2015. We defined four headache phenotypes: Tension-type-like headache (TTH), migraine-like headache, worsening of a pre-existing headache (WPH) and classic brain tumour headache (BTH). Logistic regression analysis was carried out to investigate potential risk factors for headache at presentation of glioma. Results 12.5% (n = 66) of patients with glioma indicated headache as a presenting symptom of their disease. Of these, 31 patients (47%) had TTH, while BTH and WPH were reported by 28 (42%) and seven (11%) patients, respectively. We did not find any case of migraine-like headache. Infratentorial (p = 0.038) and right-sided tumours (p = 0.013) were more frequently associated with the presence of headache at onset. Patients with TTH were older than patients with BTH and WPH (p = 0.035). BTH was less frequently associated with other neurological signs (p < 0.0001). The multivariate logistic regression analysis showed the localization of the brain tumour in the left hemisphere to be a protective factor for the development of headache. Conclusions Our study includes a very large series of patients with glioma, providing a description of headache phenotype at first presentation of disease and investigating possible factors that may influence the clinical features of headache.

Cluster Headache With Accompanying Migraine-Like Features: A Possible Clinical Phenotype

There are limited literature data on migraine‐like accompanying features (MLF) in patients with cluster headache (CH). These symptoms are frequently reported by patients and may delay CH diagnosis.

Neurobiology of chronicization

In the past few years, research on chronicization of headache has focussed primarily on migraine, even though there are other types of primary headache that over time can turn into chronic forms. Only a minority of migraine sufferers will develop a chronic condition, with attacks that are likely to vary in their clinical features. As a result, in chronic migraine the specific diagnostic criteria for this headache type do not always exhibit the typical features of migraine. Among the factors that play a major role in favouring chronicization are a high frequency of migraine attacks since the beginning, overuse of symptomatic medication and onset of depression or arterial hypertension. Several neurophysiology, biochemistry and functional neuroimaging studies suggest that chronic migraine may be associated with structural, functional and metabolic changes in the brain, especially involving the brainstem.

A case-report of migraine “sine headache”:

Background and objectives We describe a case of a female patient whose otherwise “typical” migraine attacks turned into episodes with a full spectrum of associated symptoms but without headache. Case report We evaluated a 53-year-old woman with a long history of migraine without aura. In concomitance with premenopausal menstrual dysregulation, she reported episodes of nausea and vomiting, associated with photophobia, phonophobia and osmophobia, but without headache; these episodes were responsive to oral triptans. Alternative diagnoses were excluded through extensive examinations. Discussion To date, no reports have been published in the literature on otherwise typical migraine attacks that are not accompanied by headache, nor did our case seem comparable to cases of abdominal migraine and cyclic vomiting syndrome. Conclusion Pathophysiologically, we hypothesize that functional dysregulation of the hypothalamus-brainstem connectivity may generate migraine attacks with a full spectrum of associated symptoms but without pain.

Isolated Third Cranial Nerve Palsy Leading to the Diagnosis of Disseminated Burkitt Lymphoma: A Case Report and Literature Review

Introduction: Dysfunction of the third cranial nerve can result from lesions anywhere along its course between the midbrain and the orbit. Lymphoma is a rare cause of isolated oculomotor nerve palsy (OMP), with only 19 cases reported in the literature. We describe a case of an isolated OMP leading to the diagnosis of disseminated Burkitt lymphoma (BL). Case Report: A 37-year-old man presented with acute onset diplopia and right ptosis and was found to have a right pupillary sparing OMP. The diagnostic workout was unremarkable, including contrast-enhanced brain and orbital magnetic resonance imaging, MR angiography, exhaustive laboratory tests, and cerebrospinal fluid analysis. After a course of high-dose intravenous steroid therapy, the patient recovered almost completely. Three weeks after the discharge, he developed lumbar radicular pain and lower limbs weakness followed by the relapse of the right OMP. A second lumbar puncture revealed the presence of “small monomorphic lymphocytes,” consistent with leptomeningeal lymphomatosis. A whole-body positron emission tomography scan disclosed a mediastinal mass, whose histopathologic “starry sky” appearance was pathognomonic for BL. Conclusions: Reviewing the literature, we were able to find only 3 cases of OMP as the presenting manifestation of BL, all occurring in patients with predisposing HIV infection. Our case of isolated OMP highlights some “red flags” for a lymphomatous etiology, including young age, a progressive course, a response to high-dose steroid therapy, and relapse upon steroid discontinuation; these cases require a comprehensive evaluation, including repeated cytological cerebrospinal fluid analysis and sensitive imaging techniques to detect a possible primary lesion.

Paroxysmal Hemicrania-Like Headache Secondary to Phosphodiesterase Inhibitors Administration: A Case Report.

Phosphodiesterase-5 (PDE-5) inhibitors are well described as triggers of migraine and less often of cluster headache. We report the first observation, to our knowledge, of isolated attacks of headache resembling paroxysmal hemicrania after tadalafil and sildenafil administration in a patient without a personal history of primary headache disorder. A 35-year-old right-handed man was evaluated at the Parma Headache Centre in July 2016. He was a semi-professional cyclist and smoked about one pack-year. His past medical history was unremarkable except for Alcock syndrome (ie, pudendal nerve entrapment) with secondary erectile dysfunction. He had no prior history of headaches. After a consultation with an urologist, he started taking tadalafil 10 mg. The first time he took the pill, about 30-45 min after its ingestion, he experienced six attacks of right periocular pain, with severe intensity and throbbing quality, which were associated with ipsilateral conjunctival injection, nasal congestion, and ptosis. Each attack lasted about 5-6 min, with pain-free intervals of 10-15 min; the complete episode had an overall duration of 2 h. Headache wasn’t temporally related to sexual activity. He used tadalafil two other times and experienced identical headache attacks. He tried different NSAIDs (including ketoprofen and ibuprofen) as symptomatic therapy without clear benefit. Therefore, he consulted his urologist, who confirmed the possibility of headache being triggered by PDE-5 inhibitors, and suggested an evaluation at our headache center due to the atypical headache phenotype. At first assessment, we performed an extensive neurological examination, which was normal. Having considered some clinical “red flags” for an organic etiology (new-onset headache and the temporal relationship with a vasomotor drug), we requested a brain 3-tesla MRI and a MRI angiography, which excluded central nervous system abnormalities. From the Parma Headache Centre, Department of Clinical and Experimental Medicine, University of Parma, Parma, Italy (A. Taga, M. Russo, A. Genovese, G. C. Manzoni, and P. Torelli).

O058. Cluster headache with accompanying migraine-like features

Background There are limited literature data on migraine-like accompanying features (MLF) in patients with cluster headache (CH). These symptoms are frequently reported by patients [1-3] and may delay CH diagnosis [4]. The aim of the present study was to investigate the occurrence of migraine symptoms in an Italian case series of CH patients, and to determine whether these features influence the clinical phenotype of CH.