Francisco J. Barriga

Nonconvulsive status epilepticus associated with cephalosporins in patients with renal failure

PURPOSE Nonconvulsive status epilepticus is an unusual complication of cephalosporin therapy, with only a few isolated cases reported. SUBJECTS AND METHODS We reviewed the clinical and electroencephalographic (EEG) characteristics of 10 patients with renal failure in whom developed alteration of consciousness without convulsions associated with continuous epileptiform EEG activity while being treated with cephalosporins. RESULTS Nonconvulsive status epilepticus developed in 5 men and 5 women, with a mean (+/- SD) age of 69 +/- 14 years, while receiving intravenous cephalosporins (ceftriaxone, 2 patients; ceftazidime, 2; and cefepime, 6). All patients had renal failure; 1 also had hepatic failure. Patients presented with progressive disorientation or agitation, sometimes associated with mild facial or limb myoclonus, that had begun 1 to 10 days (mean, 5 +/- 2 days) after starting cephalosporin treatment. The EEG showed continuous or intermittent bursts of generalized, high-voltage, 1 to 2 Hz sharp wave activity or sharp and slow wave activity that resembled, but could be differentiated from, the triphasic waves seen in metabolic encephalopathies. Intravenous clonazepam suppressed the epileptiform activity completely in 5 patients and partially in the other 5. Cephalosporins were withdrawn, and antiepileptic therapy was started for all patients. All patients improved, 2 in less than 24 hours and the remainder within 2 to 7 days. CONCLUSIONS Cephalosporins can cause nonconvulsive status epilepticus in patients with renal failure. The clinical picture is difficult to differentiate from a that of metabolic encephalopathy unless an EEG is obtained. Physicians should be aware of this potentially dangerous complication.

Nummular Headache: A Prospective Series of 14 New Cases

Objective.—To study the clinical features of nummular headache (NH) and get an approach to its epidemiology.

Objective assessment of autonomic signs during triggered first division trigeminal neuralgia

A total of 26 episodes of V-1 trigeminal neuralgia attacks have been recorded in two female patients. Autonomic phenomena were assessed according to a semiquantitative scale. Attacks lasted 17 ± 5 s. Mild lacrimation without conjunctival hyperaemia, rhinorrhea or ptosis was observed, even in relatively long lasting episodes. This is in clear contradiction with SUNCT (shortlasting, unilateral, neuralgiform headache with conjunctival injection, tearing and rhinorrhea) attacks that are always dramatically accompanied by both lacrimation and conjunctival injection of the symptomatic side from the very onset of symptoms. Carbamazepine provided complete and sustained relief of symptoms in both patients. Herein we will show differential autonomic features of V-1 trigeminal neuralgia vs. SUNCT that will both aid the clinician to distinguish both syndromes and stress that both entities are nosologicaly different.

Nummular Headache Secondary to An Intracranial Mass Lesion

Nummular headache is a coin-shaped, chronic cephalalgia usually considered to stem from epicranial tissues. We describe a patient complaining of circumscribed pain in the head as the only symptom of a subtentorial meningioma. This observation underlines the need to revise the concept of circumscribed, referred pains in the head arising from pain-sensitive intracranial structures.

Duration of attacks of first division trigeminal neuralgia.

Objective measurements of duration of attacks have been performed in 8 (5 female and 3 male) patients suffering from primary first division (V-1) trigeminal neuralgia. The mean age of the patients was 67.5 ± 11.4 years, and the mean age at onset 64.0 ± 9.7 years. During the study the patients were off treatment. A total of 192 attacks were witnessed by the authors and exactly timed by a stop-watch. The duration of attacks ranged from 2 to 32 s, with a mean of 6.5 ± 6.1 s. The unweighted mean was 8.8 ± 5.7 s, with a range of 2.4-17.5 s. With the present data the duration of attacks of V-1 neuralgia has been exactly determined, and the clinical distinction of V-1 neuralgia from other shortlasting headaches, particularly from SUNCT, has been substantially clarified.

Local Decrease of Pressure Pain Threshold in Nummular Headache

Background.—Nummular headache (NH) is a primary disorder presenting with localized pain that is circumscribed to a coin‐shaped area of the head surface.

Nummular headache associated to arachnoid cysts.

A 52-year-old woman suffered a subarachnoid haemorrhage (SH) that caused cephalalgia without focal neurological abnormality. A four-vessel angiography revealed no vascular malformations but a right posterior parietal AC was found. High blood pressure was demonstrated and treated. Shortly after the SH, she started feeling a sore pain over a circumscribed area of the right parietooccipital scalp (Fig. 1a), where a 2.5 cm, coin-shaped area of tenderness and dysesthesia was detected, while neurological examination was normal. A MRI confirmed a 3 9 2.5 9 3 cm parieto-occipital AC (Fig. 1b). Several treatments, including gabapentin, indomethacin and amitriptyline were unsuccessful. She refused to be treated with botulinum toxin injections and rejected the cyst’s surgical removal. After 4 years no changes have occurred in her clinical, neurological or imaging findings.

Bifocal nummular headache: the first three cases.

Nummular headache (NH) has been defined as a focal head pain that is exclusively felt in a small area of the head surface. Here we describe three patients who presented with focal head pain in two separate areas. This finding seems to be consistent with bifocal NH and further enlarges the clinical diversity of this headache disorder. The pathogenic mechanisms of NH may be active in multiple cranial areas in some particular patients.

Pericranial Tenderness is Not Related to Nummular Headache

The aim of the present study was to investigate whether nummular headache (NH) patients show increased pericranial tenderness in relation to healthy subjects, and to compare pericranial tenderness between both NH and chronic tension-type headache (CTTH) patients. Three tenderness (total, cephalic and neck) scores were objectively and blinded assessed in 10 NH patients, 10 CTTH subjects and 10 healthy matched controls. No significant differences were found in any tenderness score between the symptomatic and non-symptomatic sides in NH, or between right and left sides in either CTTH or control groups. All tenderness scores were significantly greater in CTTH patients compared with both NH patients and controls (P < 0.001), but not significantly different between NH patients and controls. Therefore, NH patients had lower tenderness than patients with CTTH and did not show increased tenderness when compared with healthy subjects. In addition, tenderness in NH patients was quite symmetrical between both the symptomatic and the non-symptomatic sides. The absence of increased pericranial tenderness could be clinically useful in distinguishing NH from CTTH. Current findings expand the evidence supporting the notion that NH is a non-generalized and rather limited disorder, marking the presence of a well-delimited painful zone.

Manual Therapies in the Management of Tension‐Type Headache

Patients suffering from tension‐type headache (TTH) are often treated with manual therapies. We have analyzed the quality and the outcomes of published trials and have not found any rigorous evidence that manual therapies are effective in TTH. Further research is required before manual therapies can be considered useful in the management of TTH.