Carlo Lisotto

Headache attributed to airplane travel (“airplane headache”: first italian case

A new form of headache, whose attacks seem to be stereotyped, has been recently reported; because of the peculiarity of its onset, strictly related to airplane travel, the name of “Airplane headache” was proposed. A total of 7 cases have been published. Here we present the first Italian one. Furthermore the revision of the clinical characteristics of each patient leads us to propose provisional diagnostic criteria.

Episodic hypnic headache

Hypnic headache is a primary headache disorder, which occurs exclusively during sleep and usually begins after the age of 60 years. It was first described by Raskin in 1988 (1), as a sleep-related headache, that regularly awakened patients at a consistent time of night; the pain was diffuse, persisting for 30–60 min, without autonomic symptoms. Hypnic headache was not included in the first edition of the International Headache Society (IHS) classification. In the second edition this headache was classified in section 4.5, included in the group of ‘Other primary headaches’ (2). At the time of this writing 82 patients with this disorder have been described (3–29). The possible pathophysiology and the pharmacological treatment of this headache have been recently discussed and analysed (30, 31), as well as its relationship with REM sleep (14, 27, 28). A symptomatic case that developed after an ischaemic stroke in the pontine reticular formation was also reported (29). The natural history of hypnic headache is not well known. The review of the published cases suggests that hypnic headache tends to be a chronic unremitting disorder. To better understand the natural history of hypnic headache, we have prospectively followed 4 patients with this disorder since 1998. The first two cases, diagnosed in 1998 and 1999, respectively, were published previously (13, 17); the other two cases, of new description, were first seen in 2000. Hypnic headache was the main diagnosis in 0.09% of all headache patients and notably in 1.4% of geriatric patients (above the age of 65 years) seen in our Headache Centre from 1998 to 2002.

Headache attributed to airplane travel ('airplane headache'): clinical profile based on a large case series.

Background: The ‘headache attributed to airplane travel’, also named ‘airplane headache’ (AH), is a recently described headache disorder that appears exclusively in relation to airplane flights, in particular during the landing phase. Based on the stereotypical nature of the attacks in all reported cases, we proposed provisional diagnostic criteria for AH in a previously published paper. Up to now 37 cases have been described in the literature. Methods: After our paper was disseminated via the Internet, we received several email messages from subjects around the world who had experienced such a peculiar headache. Their cooperation, by completing a structured questionnaire and allowing the direct observation of three subjects, enabled us to carry out a study on a total of 75 patients suffering from AH. Results: Our survey confirmed the stereotypical nature of the attacks, in particular with regard to the short duration of the pain (lasting less than 30 minutes in up to 95% of the cases), the clear relationship with the landing phase, the unilateral pain, the male preponderance, and the absence of accompanying signs and/or symptoms. It is conceivable to consider barotrauma as one of the main mechanisms involved in the pathophysiology of AH. The observation that the pain appears inconstantly in the majority of cases, without any evident disorder affecting the paranasal sinuses, could be consistent with a multimodal pathogenesis underlying this condition, possibly resulting in the interaction between anatomic, environmental and temporary concurrent factors. Conclusions: This is by far the largest AH case series ever reported in the literature. The diagnostic criteria that we previously proposed proved to be valid when applied to a large number of patients suffering from this condition. We support its recognition as a new form of headache, to be included in the forthcoming update of the International Headache Society Classification, within ‘10. Headache attributed to disorder of homoeostasis’. Its formal validation would favour further studies aimed at improving the understanding of its pathophysiology and implementing preventative measures.

Rofecoxib for the Treatment of Chronic Paroxysmal Hemicrania

Chronic paroxysmal hemicrania (CPH) is an uncommon but well-known primary headache disorder with more than 100 cases reported in the literature. CPH was first described in 1974 (1) but officially named 2 years later (2). In many aspects, the clinical features of CPH and cluster headache are similar, and they are grouped together in Chapter 3 of the 1988 International Headache Society (IHS) classification (3). The diagnosis for CPH includes temporal (at least 50 attacks with a frequency above five per day for more than half of the time); clinical (severe unilateral orbital/supraorbital and/or temporal pain always on the same side lasting 2–45 min, associated with at least one of the following vegetative signs: conjunctival injection, lacrimation, nasal congestion, rhinorrhoea, ptosis, eyelid oedema); and pharmacological (absolute effectiveness of indomethacin £150 mg/day) criteria. Thus, for the first time a pharmacological response to a drug is included among the major diagnostic requirements for the diagnosis of a primary headache. However, this operative criterion was recently subjected to criticism, and other drugs have been shown of some benefit in the treatment of CPH, even if indomethacin remains the most effective. Indomethacin is usually well tolerated; nevertheless, gastrointestinal side-effects should always be considered for those patients who require long-term therapy. Adverse events are observed in about 23% of chronically treated patients, whereas a good persistence of efficacy is described (4). Therefore, the use of new cyclo-oxygenase-2 (COX-2) inhibitors should be of interest, since their mechanism of action reduces the incidence of the gastroenteric adverse effects (5); and the anti-inflammatory activity of rofecoxib is comparable to indomethacin both in vivo and in vitro (6). Indeed, some reports in the literature indicate the usefulness of the COX-2 inhibitors in the treatment of CPH, hemicrania continua and idiopathic stabbing headache (7–10), the so-called indomethacin-responsive headaches (11–13).

Focus on therapy of the Chapter IV headaches provoked by exertional factors: primary cough headache, primary exertional headache and primary headache associated with sexual activity

Primary cough headache, primary exertional headache and primary headache associated with sexual activity are distinct entities, even though they share several features: acute onset, the absence of structural brain disease and exertional factors as precipitating events. In this short review, we illustrate the possible treatment strategies on the basis of information collected from a systematic analysis of the international literature.

Headache in the elderly: a clinical study

AbstractAlthough the prevalence of headache in the elderly is relevant, until now few studies have been conducted in patients over the age of 65 years. We analyzed the clinical charts of 4,417 consecutive patients referred to our Headache Centre from 1995 to 2002. There were 282 patients over 65 years of age at the first visit, corresponding to 6.4% of the study population. Primary headaches were diagnosed in 81.6% of the cases, while secondary headaches and non-classifiable headaches represented, respectively, 14.9% and 3.5% of the cases. Among primary headaches, the prevalence was almost the same for migraine without aura (27.8%), transformed migraine (26.1%) and chronic tension- type headache (25.7%). The most frequent secondary headaches were trigeminal neuralgia and headache associated with cervical spine disorder.

Headache in Sturge–Weber syndrome: a case report and review of the Literature

Sturge–Weber syndrome, defined also as encephalotrigeminal or leptomeningeal angiomatosis, is a nonhereditary congenital neurocutaneous disorder, characterized by a facial vascular nevus (port-wine stain) that follows the distribution of the trigeminal nerve, associated with an ipsilateral leptomeningeal angioma. Neurological manifestations include seizures (in 80% to 90% of cases), mental retardation (in 40% to 50% of cases) and focal signs, such as hemiplegia, aphasia or hemianopia, that are often fluctuating (1, 2). In previous isolated studies the association of the syndrome with headache, in particular migraine with aura, was reported, but poorly documented (3). In a series of 23 epileptic patients with Sturge–Weber syndrome it was noted that 7 cases had episodes of throbbing unilateral headache with autonomic symptoms and transient hemiparesis. None of these episodes was preceded or accompanied by loss of consciousness or ictal phenomena such as clonic jerks. It was suggested that these attacks were most likely episodes of hemiplegic migraine rather than epileptic seizures (2). The prevalence of migraine in Sturge– Weber syndrome was seen to be higher than in normal population (4). A patient with this syndrome, free of epileptic seizures for 10 years, started suffering from hemiplegic migraine attacks, without a family history for this disorder (5). Conversely, no case of headache was reported in a long-term outcome study regarding 52 adults with Sturge–Weber syndrome (1). The headache secondary to encephalotrigeminal angiomatosis was not included in the first edition of the International Headache Society (IHS) classification. In the second edition this headache was finally classified in group 6 (section 6.3.5), which includes the secondary headaches attributed to cranial or cervical vascular disorders (6). Case report

A case of posterior scleritis: differential diagnosis of ocular pain

Posterior scleritis is a rare cause of ocular pain, due to scleral inflammation, presenting with periocular pain, pain on movement and decreased vision. Although anterior scleritis may be associated with this condition, ocular signs may be absent. We report a case of posterior scleritis, presenting with right-sided ocular and periocular pain, exacerbated by ocular movements, irradiating to the ipsilateral temple and zygoma, not associated with visual disturbances at onset. Diagnosis was made with ultrasonography and confirmed by brain and orbital MRI. Differential diagnosis of facial pain, in particular, affecting the periorbital region, is discussed. In the presence of ocular pain, even in the absence of ocular signs, an ophthalmologic consultation should be performed.

Focus on the management of thunderclap headache: from nosography to treatment

Thunderclap headache (TCH) is an excruciating headache characterized by a very sudden onset. Recognition and accurate diagnosis of TCH are important in order to rule out the various, serious underlying brain disorders that, in a high percentage of cases, are the real cause of the headache. Primary TCH, which may recur intermittently and generally has a spontaneous, benign evolution, can thus be diagnosed only when all other potential underlying causes have been excluded through accurate diagnostic work up. In this review, we focus on the management of TCH, paying particular attention to the diagnostic work up and treatment of the condition.

Cluster-like headache after surgical crystalline removal and intraocular lens implant: a case report.

Cluster headache (CH) is a well characterized primary headache disorder. Nevertheless, symptomatic CH has been reported in association with various underlying diseases. Symptomatic cluster headache related to ocular pathologies have been rarely described. We report a case consequent to a surgical operation for cataract.