Eric J. Eross

Clinical, Anatomical, and Physiologic Relationship Between Sleep and Headache

The intimate relationship between sleep and headache has been recognized for centuries, yet the relationship remains clinically and nosologically complex. Headaches associated with nocturnal sleep have often been perceived as either the cause or result of disrupted sleep. An understanding of the anatomy and physiology of both conditions allows for a clearer understanding of this complex relationship and a more rational clinical and therapeutic approach. Recent biochemical and functional imaging studies in patients with primary headache disorders has lead to the identification of potential central generators which are also important for the regulation of normal sleep architecture.

The Sinus, Allergy and Migraine Study (SAMS).

Objective.—The objective of this study is to classify (according to the current International Headache Societys criteria [ICHD‐II]) the headache types that those with self‐diagnosed sinus headache experience and to determine barriers to correct diagnosis.

Sinus headache: a neurology, otolaryngology, allergy, and primary care consensus on diagnosis and treatment.

Sinus headache is a widely accepted clinical diagnosis, although many medical specialists consider it an uncommon cause of recurrent headaches. The inappropriate diagnosis of sinus headache can lead to unnecessary diagnostic studies, surgical interventions, and medical treatments. Both the International Headache Society and the American Academy of Otolaryngology-Head and Neck Surgery have attempted to define conditions that lead to headaches of rhinogenic origin but have done so from different perspectives and in isolation of each other. An interdisciplinary ad hoc committee convened to discuss the role of sinus disease as a cause of headache and to review recent epidemiological studies that suggest sinus headache (headache of rhinogenic origin) and migraine are frequently confused with one another. This committee reviewed available scientific evidence from multiple disciplines and concluded that considerable research and clinical study are required to further understand and delineate the role of nasal pathology and autonomic activation in migraine and headaches of rhinogenic origin. However, this group agreed that greater diagnostic and therapeutic attention needs to be given to patients with sinus headaches.

Orthostatic Headache Syndrome with Csf Leak Secondary To Bony Pathology of the Cervical Spine

The syndrome of orthostatic (low pressure) headaches is well described and most commonly occurs following deliberate violation of the dura (e.g. lumbar puncture). This syndrome can also occur spontaneously and results from the leakage of CSF. We describe three patients who suffered from spontaneous CSF leaks secondary to bony pathology of the cervical spine, and propose that this may be a more common aetiology than originally thought. Often these patients are difficult to manage medically, and surgery may be necessary for symptomatic relief.

Thunderclap headache associated with reversible vasospasm and posterior leukoencephalopathy syndrome

A 46-year-old woman with a past medical history of episodic migraine and benign sexual headache was in good health until she experienced an explosive, sudden and severe occipital headache while having a bowel movement. There was no associated loss of consciousness or awareness. The headache, however, was associated with nausea and neck pain/ stiffness. The headache intensity diminished over several hours. Two days later, she experienced a recurrent more prolonged thunderclap headache, whereupon she was taken immediately to hospital. In the emergency department (ED), she was hypertensive (190–200/110–120) and mildly drowsy. Examination revealed no meningeal, long tract, focal, or lateralizing neurological signs. Furthermore, there was no evidence of hypertensive retinopathy or papilloedema. During her evaluation in the ED, she had a witnessed generalized tonic clonic seizure. A computed tomography (CT) scan of the brain and lumbar puncture were normal. Blood work revealed a mild thrombocytosis (437K), but CBC, electrolytes, ESR (9), ANA (0.4), hypercoagulable profile, TSH, urinalysis, and serum chemistry were normal. A magnetic resonance imaging (MRI) scan of the brain revealed T2 signal abnormalities in the posterior parietooccipital lobes with a small area of increased diffusion-weighted signal in the left occipital lobe (Figs. 1 and 2). There was no evidence of gadolinium enhancement. On the fourth hospital day, a fourvessel cerebral angiogram revealed diffuse multifocal vasospasm involving the posterior and anterior circulation (Fig. 3). There was no evidence of an intracranial aneurysm or arteriovenous malformation. A diagnosis of ischaemic stroke secondary to CNS vasculitis was made and the patient was treated with high-dose intravenous methylprednisolone and warfarin. The patient was transferred to our institution for in-patient video-EEG monitoring because of the generalized tonic-clonic seizure. During her hospitalization at our institution, follow-up MRI scans (on days 6 and 13 after presentation) revealed resolution of the T2 signal abnormalities (Fig. 4). Fifteen days after presentation, a follow-up magnetic resonance angiogram was normal. The patient was treated with lisinopril 5 mg, her blood pressure ranged from 130 to 140 systolic and 80 to 90 diastolic. No further seizures occurred and video-EEG monitoring over 48 h was normal. An evaluation for secondary causes of hypertension was unremarkable. Warfarin was discontinued and the patient was discharged in normal neurological condition and headache free. She remained asymptomatic on lisinopril 4 months later.

An Otolaryngology, Neurology, Allergy, and Primary Care Consensus on Diagnosis and Treatment of Sinus Headache:

While “sinus” headache is a widely accepted clinical diagnosis, many medical specialists consider it to be an uncommon cause of recurrent headaches. Unnecessary diagnostic studies, surgical interventions, and medical treatments are often the result of the inappropriate diagnosis of sinus headache. Both the International Headache Society and the American Academy of Otolaryngology–Head and Neck Surgery have attempted to characterize conditions leading to headaches of rhinogenic origin. However, they have done so from different perspectives and in isolation from the other specialty groups. An interdisciplinary ad hoc committee recently convened to discuss the role of sinus disease and the nose in the etiology of headache and to review recent epidemiologic studies suggesting that sinus headache (headache of rhinogenic origin) and migraine are frequently confused with one another. Clinical trial data are presented which clearly indicate that the majority of sinus headaches can actually be classified as migraines. This committee reviewed scientific evidence available from multiple disciplines and concludes that considerable research and clinical study are needed to further understand and explain the role of nasal pathology and autonomic activation in migraine and headaches of rhinogenic origin. However, there was a consensus from this group that greater diagnostic and therapeutic attention needs to be given to patients complaining of sinus headache that may indeed be due to the nose.

Duration of Migraine Is a Predictor for Response to Botulinum Toxin Type A

Objective.—To identify the clinical characteristics and/or injection parameters that predict a favorable response to botulinum toxin type A in patients with episodic and chronic migraine.

Hemicrania Continua: An Indomethacin-Responsive Case With an Underlying Malignant Etiology

Primary nonmetastatic lung neoplasms have been reported to cause ipsilateral facial pain before the underlying malignancy is diagnosed. 1,2 This pain most commonly is described as an ache affecting the ear, jaw, or temporal region. 2 To our knowledge, however, there has been no previous description of a newly diagnosed, indomethacin-responsive case of hemicrania continua as the initial presentation of an occult lung tumor. First described by Sjaastad and Spierings in 1984, hemicrania continua is a unique primary headache disorder most commonly affecting women (5:1) in their third decade of life. 3 According to the International Headache Society (IHS) criteria, hemicrania continua is characterized by moderately severe unilateral head pain present for over a month in a continuous pattern with fluctuating severity. 4 The headache either must respond completely to indomethacin or must have at least one associated cephalic autonomic feature occurring with exacerbations of pain. 4 The autonomic features of hemicrania continua often are not as prominent as with other trigeminal autonomic cephalgias such as cluster headache or chronic paroxysmal hemicrania (CPH). 5,6 We describe a case of indomethacin-responsive hemicrania continua related to an underlying lung neoplasm, propose a potential pathophysiology, and suggest recommendations for the recognition and management of similar cases.

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.

Migraine in special populations: Treatment strategies for children and adolescents, pregnant women, and the elderly

PREVIEW Although migraine is a common occurrence in children and adolescents, its diagnosis and treatment present unique challenges. Migraine management in pregnant women and the elderly can also be difficult and requires selection of appropriate and safe medications for patients in these special circumstances. In this article, Drs Gladstone, Eross, and Dodick provide pearls for both abortive and prophylactic treatments for migraine in these populations.