David J. Capobianco

Hypnic headache: Another indomethacin-responsive headache syndrome?

Hypnic headache syndrome is a benign, recurrent, late‐onset headache disorder that occurs exclusively during sleep. Lithium has been reported to be an effective treatment, but the side effects of this medication are sometimes prohibitive, particularly in the elderly. Other drugs have been reported to be effective in this disorder, including caffeine, flunarizine, and verapamil. Recently, indomethacin has been reported to effectively suppress hypnic headaches. We report the response of seven patients with hypnic headache who were treated with indomethacin. Hypnic headache syndrome appears to represent yet another headache disorder in which there is sometimes an impressive response to indomethacin.

Occipital Condyle Syndrome

Objective.—Review the clinical features of occipital condyle syndrome.

Idiopathic Intracranial Hypertension and Seventh Nerve Palsy

Patients with idiopathic intracranial hypertension may occasionally present with coexisting lower motor neuron facial weakness. This study reviews a 6‐year experience at Mayo Clinic. The aim of this study was to determine the possible association of idiopathic intracranial hypertension and facial paresis. Two cases were identified. Both fulfilled the modified Dandys diagnostic criteria for idiopathic intracranial hypertension. Treatment consisted of steroids in one, and emergent optic nerve sheath fenestration in the other. The cranial nerve palsies resolved in both cases.

Facial Pain as a Symptom of Nonmetastatic Lung Cancer

Patients with nonmetastatic lung cancer may rarely experience facial pain as a presenting symptom, during the course of the disease or upon recurrence of the disease. This study reviews a 10‐year experience at Mayo Clinic. The aim of this study was to (1) further characterize the clinical features of facial pain as a symptom of nonmetastatic lung cancer, and (2) assist clinicians in recognizing this association. Ten cases were identified. All patients complained of severe, aching, facial pain typically aural‐temporal in location, ipsilateral to the lung cancer. Six of the 10 cases involved the left side. Recent weight loss was present in 7 of 10 patients, with an elevated sedimentation rate in 6. Digital clubbing was documented in three. Neurologic examinations and neuroimaging were normal in all patients. Lumbar puncture, when performed, was normal. Facial pain preceded the diagnosis of lung cancer by 1 to 24 months. In three patients, facial pain was the initial symptom of tumor recurrence. Four of the 10 tumors were adenocarcinoma; radiation with or without chemotherapyappears to be the treatment of choice for the facial pain. The presumed mechanism is local invasion of the vagus nerve. In suspected cases, a chest x‐ray and chest CT are indicated.

An Overview of the Diagnosis and Pharmacologie Treatment of Migraine

Migraine, an episodic headache disorder, is one of the most common complaints encountered by primary-care physicians and neurologists. Nevertheless, it remains underdiagnosed and undertreated. Rational migraine treatment necessitates an accurate diagnosis, identification and removal of potential triggering factors, and, frequently, pharmacologic intervention. Effective management also includes establishing realistic expectations, patient reassurance, and education. The choice of medication (abortive, symptomatic) for an acute attack depends on such factors as the severity of the attack, presence or absence of vomiting, time of onset to peak pain, rate of bioavailability of the drug, comorbid medical conditions, and side-effect profile. Effective agents for acute attacks include simple or combination analgesics, nonsteroidal anti-inflammatory drugs, ergot derivatives, selective serotonin agonists, and antiemetics. Opioid analgesics are unnecessary for most patients. The choice of preventive (prophylactic, interval) medication depends primarily on comorbid medical conditions and side-effect profile. Useful preventive agents include beta-adrenergic blockers, calcium channel blockers, tricyclic antidepressants, anticonvulsant medications, and serotonin antagonists.

Facial Pain as the Presenting Symptom of Lung Carcinoma With Normal Chest Radiograph

Facial pain is a rare presenting symptom of nonmetastatic lung carcinoma. Referred pain from tumor invasion and compression of the vagus nerve was the presumed cause in the 31 cases published to date. We report 2 additional cases having an unusual clinical feature, namely, both had radiographic evidence of malignancy absent on initial chest films. Severe facial pain in both cases was explained by pulmonary carcinoma detected only through further investigations. From these cases follows the notable conclusion that referred facial pain of malignant origin can occasionally precede the appearance of neoplasm on routine chest films. It is therefore important for physicians to be familiar with the clinical features of this syndrome in order to choose appropriate further diagnostic testing in patients who may be at risk.

A review of intractable facial pain secondary to underlying lung neoplasms.

We describe a 63-year-old smoker who suffered from intractable facial pain secondary to an underlying lung neoplasm. Data from 30 previously reported and similar cases are also summarized. The clinical triad of a smoker suffering from periauricular pain and an elevated ESR should alert the clinician to the possibility of an occult lung mass. In these cases a computed tomography of the chest should always be obtained. Previously refractory pain typically responds to surgical resection of the mass and/or radiation therapy.

Clinical review: the differential diagnosis of pain in the quiet eye.

BACKGROUND–Eye pain, periorbital and retro-orbital pain, and headache or facial pain referred to the orbital region are common presenting complaints. REVIEW SUMMARY–In this review, we discuss the etiologies of eye pain in the quiet eye, which is defined clinically as one with a clear cornea without redness or irritation of the conjunctiva or sclera. CONCLUSIONS–The causes of eye pain may be divided into two groups: (1) those associated with abnormal localizing ophthalmologic and neuro-ophthalmologic findings (including trigeminal neuropathies); and (2) those with a normal ophthalmologic and neurologic examinations. The latter group is further divided into the following subgroups: (1) specific short-lasting or long-lasting headache or eye pain syndromes; (2) pain referred to the eye from other pathologic processes (secondary eye pain) sometimes distant from structures concerned with vision; and (3) pain from orbital, superior orbital fissure, cavernous sinus, or intracranial infiltrative, neoplastic, or inflammatory disease processes with normal ophthalmologic and neuro-ophthalmologic exam. Unfortunately, in some patients, no etiology for the pain syndrome is discerned and one is left with a diagnosis of idiopathic eye pain, eye strain, or atypical facial pain.

Medication-Induced (Analgesic Rebound) Headache: Historical Aspects and Initial Descriptions of the North American Experience

A review of the initial descriptions of medication‐induced (misuse) headache in the North American literature indicates that this disorder was first identified in the mid‐1950s. It was not until the early 1980s that this phenomenon became well established.

ACGME competencies in neurology Web-based objective simulated computerized clinical encounters

Objective: The American Headache Society developed an innovative Web-based neurology resident educational program to 1) meet the objectives of the Accreditation Council for Graduate Medical Education Outcomes Project; 2) provide measurable improvement of a neurology resident’s understanding of headache and the performance within each core competency; 3) assist residents and program directors in identifying knowledge gaps; and, ultimately, 4) improve the quality of patient care through enhanced educational initiatives. Methods: Quantitative analysis focused on pretest and post-test results, level attainment on case-based simulations, competency achievement, and interactions between cases. One of four validated global scores was related to each resident response on all competency learning opportunities and was measured, from one case to another, to determine improvement and understanding. The pretest and post-test each consisted of 50 randomized questions that tested baseline and improvement on specific core competencies and understanding of headache. Results: The pretest mean score was 30.08, and the post-test mean score was 34.79. A paired sample t test analysis showed a significant difference from pretest to post-test scores (M = −4.72, SD = 4.88, t[91] = −9.269, p < 0.001). There was significant improvement in the competencies as the residents moved through the cases as well as in each of the competencies from the pretest to the post-test. Results showed that residents increased their knowledge and performance by synthesizing the content. Conclusions: This outcomes analysis demonstrates the effectiveness of the American Headache Society Neurology Resident’s Program in improving the resident’s knowledge of headache medicine and Accreditation Council for Graduate Medical Education core competencies. ACGME = Accreditation Council for Graduate Medical Education; AHS = American Headache Society; GME = graduate medical education; NS = not significant; OSCCE = objective simulated computerized clinical encounter; PGY = postgraduate year.