Jonathan P. Gladstone

Migraine and cerebral white matter lesions: When to suspect cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL)

Background:Patients with migraine are at an increased risk for white matter lesions, typically multiple, small, punctate hyperintensities in the deep or periventricular white matter, best observed on magnetic resonance imaging utilizing T2-weighted or FLAIR sequences. The underlying pathogenesis of white matter lesions in migraineurs is unknown, and the lesions are usually nonspecific and of unclear clinical significance. Review Summary:Often the presence of white matter lesions causes uncertainty for physicians and anxiety for patients and may lead to a variety of diagnostic tests and treatments. Occasionally, white matter lesions may represent a secondary cause for headaches such as CADASIL (cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy). CADASIL is underrecognized and underdiagnosed; it should be suggested by (i) 1 or more of recurrent subcortical ischemic strokes (especially before age 60 and in the absence of vascular risk factors), migraine (especially with aura, including atypical or prolonged auras) and/or early cognitive decline or subcortical dementia; (ii) bilateral, multifocal, T2/FLAIR hyperintensities in the deep white matter and periventricular white matter with lesions involving the anterior temporal pole, external capsule, basal ganglia, and/or pons; and (iii) an autosomal-dominant family history of migraine, early-onset stroke, or dementia. The clinical spectrum of CADASIL is broad, and there is a poor genotype-phenotype correlation. In certain individuals or families, migraine may be the only clinical manifestation. Conclusions:While the prevalence of nonspecific white matter lesions in migraineurs is increased, the white matter lesions may occasionally represent a secondary cause for headache such as CADASIL. Greater awareness of the unique clinical, neuroimaging, and pathologic features, as well as the availability of diagnostic genetic testing, should enhance the recognition and diagnosis of this fascinating condition.

Spontaneous CSF leak treated with percutaneous CT-guided fibrin glue

Gladstone et al.1 advocate sealing CSF leaks with CT-guided, targeted fibrin glue injections in patients with spontaneous intracranial hypotension (SIH). We agree that the injection should be made at the site of the leak as a distant epidural blood patch may often give only temporary relief. In our SIH patients, we obtained permanent sealing of the leak in 13 of 16 cases in which the CSF loss at a spinal root level was approached either by direct surgery (three successful cases) or by targeted percutaneous …

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.

Management of Chronic Daily Headache: Challenges in Clinical Practice

Chronic daily headache (CHD) refers to a category of headache disorders that are characterized by headaches occurring on more than 15 days per month. This category is subdivided into long‐ and short‐duration (>4 or <4 hours) CDH disorders based on the duration of individual headache attacks. Examples of long‐duration CDH include transformed migraine (TM), chronic migraine (CM), new daily persistent headache (NDPH), acute medication overuse headache, and hemicrania continua (HC). The goal of this review is to enable clinicians to accurately diagnose and effectively manage patients with long‐duration CDH. Patients with CDH often require an aggressive and comprehensive treatment approach that includes a combination of acute and preventive medications, as well as nondrug therapies.

From Hemicrania Lunaris to Hemicrania Continua: An Overview of the Revised International Classification of Headache Disorders

The International Headache Societys (IHS) Classification of Headache Disorders, published in 1988, is largely responsible for stimulating the rapid scientific and therapeutic advances that have revolutionized the field of headache. By establishing consistent operational diagnostic criteria for primary and secondary headache disorders, the IHS Classification has facilitated epidemiological and genetic studies as well as the multinational clinical trials that provide the basis for our present treatment guidelines. Fifteen years after its original release, a revised 2nd edition has been unveiled. Modifications are small but significant. We hope to introduce clinicians to the salient changes in the 2nd edition by highlighting the newly included headache types, acknowledging the renamed headache types, and reviewing the modifications in diagnostic criteria for existing headache types. Physicians involved in the care of headache patients need to be aware of these changes and should continue to consult the IHS criteria to ensure accurate diagnosis, to continue to refine the diagnostic criteria, and to contribute to the body of knowledge necessary to make further advances in the classification as well as in the field of headache.

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.

Revised 2004 International Classification of Headache Disorders: new headache types.

In 1988, the International Headache Society created a classification system that has become the standard for headache diagnosis and research. The International Classification of Headache Disorders galvanized the headache community and stimulated nosologic, epidemiologic, pathophysiologic, and genetic research. It also facilitated multinational clinical drug trials that have led to the basis of current treatment guidelines. While there have been criticisms, the classification received widespread support by headache societies around the globe. Fifteen years later, the International Headache Society released the revised and expanded International Classification of Headache Disorders second edition. The unprecedented and rapid advances in the field of headache led to the inclusion of many new primary and secondary headache disorders in the revised classification. Using illustrative cases, this review highlights 10 important new headache types that have been added to the second edition. It is important for neurologists to familiarize themselves with the diagnostic criteria for the frequently encountered primary headache disorders and to be able to access the classification (www.i-h-s.org) for the less commonly encountered or diagnostically challenging presentations of headache and facial pain.

The Young Woman With Postpartum “Thunderclap” Headache

A 19-year-old female completed her first ever pregnancy without complication. On the fourth postpartum day, she abruptly developed a severe and unremitting headache while sitting at home. At the time of her evaluation 6 hours later, her headache persisted and was described as severe (“the worst of my life”), diffuse, nonlateralized, nonpulsatile, and not affected by positional change. She denied associated neck stiffness. Her past medical history was notable for episodic migraine with and without visual aura since age 11. During her pregnancy, she had experienced only occasional and relatively mild headaches. Vital signs were stable. Blood pressure was 130/78, heart rate was 76 beats per minute, and she was afebrile. Her general and neurologic examinations were normal. Her neck was supple and there was no evidence of papilledema. Noncontrast brain CT was performed 6 hours following headache onset and was normal. Lumbar puncture was performed and demonstrated an elevated opening pressure (320 mm/H2O); the CSF obtained was rust colored, and laboratory analyses demonstrated 250 000 RBC/mm3, 255 WBC/mm3 (80% polys, 20% mononuclear cells), glucose 77 mg/dL, and protein 185 mg/dL. Brain MRI demonstrated findings suggestive of acute thrombosis within the superior sagittal sinus, and on MRV the distal two-thirds of the sinus was not visualized.

Current and emerging treatment options for migraine and other primary headache disorders

Primary headache disorders are highly prevalent worldwide. The impact of primary headaches to the individual is significant and reflects physical suffering and decreased social and occupational functioning. The economic burden to society is enormous and represents direct healthcare costs and the indirect costs associated with decreased workplace productivity and work absences. The last decade has witnessed tremendous advances both in our understanding of the biology of headache and in our therapeutic armamentarium. This review outlines how these developments may be rationally implemented by highlighting individual treatment options and general treatment strategies. The state-of-the-art methods for the abortive and prophylactic treatment of tension-type headache, migraine and cluster headache are reviewed.

Acute Migraine: Which Triptan?

INTRODUCTION Primary headache disorders are the most frequent reason for referral to neurologists worldwide, and most of these patients have migraine (Menken 1996; Sempere et al. 2002; Rajput et al. 1988). Migraine is a common and frequently incapacitating headache disorder characterized by episodic attacks of moderate-to-severe headache, along with various combinations of neurological, gastrointestinal and autonomic symptoms (Goadsby et al. 2002). The one-year prevalence of migraine is 11% in the United States and Western Europe (6% for males and 15–18% for females) and one quarter of migraine patients experience one or more attacks per week (Goadsby et al. 2002; Hamelsky et al. 2001). A recent report by the World Health Organization ranks migraine as one of the most disabling chronic conditions and equates a day with severe migraine to the disability associated with a day with quadriplegia, psychosis or dementia (Menken et al. 2000). The aggregate impact of migraine