Mark Weatherall

The diagnosis and treatment of chronic migraine

Migraine is the most common disabling brain disorder. Chronic migraine, a condition characterized by the experience of migrainous headache on at least 15 days per month, is highly disabling. Patients with chronic migraine present to primary care, are often referred for management to secondary care, and make up a large proportion of patients in specialist headache clinics. Many patients with chronic migraine also have medication overuse, defined as using a compound analgesic, opioid, triptan or ergot derivative on at least 10 days per month. All doctors will encounter patients with chronic headaches. A basic working knowledge of the common primary headaches, and a rational manner of approaching the patient with these conditions, allows a specific diagnosis of chronic migraine to be made quickly and safely, and by making this diagnosis one opens up a substantial number of acute and preventive treatment options. This article discusses the current state of management of chronic migraine.

Idiopathic trigeminal neuropathy may respond to greater occipital nerve injection

Trigeminal neuropathy is a condition characterized by sensory disturbance in the distribution of the trigeminal nerve (1). It can be caused by a wide variety of conditions, including trauma, tumours, connective tissue disorders, infections or neurovascular conflict. In many cases, however, no obvious cause is found. A case is presented in which a patient with idiopathic trigeminal neuropathy underwent ipsilateral greater occipital nerve injection with significant improvement in symptoms.

Intracerebral multifocal Rosai–Dorfman disease

We report a rare occurrence of intracranial Rosai-Dorfman disease (RDD), in a young patient with multiple bilateral intracerebral lesions, and discuss her management. RDD is an histiocytic proliferative disorder, which seldom presents with intracranial pathology. Intraparenchymal RDD without concurrent systemic features is rare. This 31-year old woman presented with two focal seizures, but no peripheral lymphadenopathy, and no significant systemic abnormalities. Preoperative imaging showed intrinsic space-occupying lesions in the left frontal lobe, and right parietal and right inferior frontal white matter. She underwent excision of the peripherally located left frontal lesion, and aside from a five-day course of postoperative dexamethasone, received no further active treatment. Histopathological analysis revealed the characteristic features of RDD. Postoperative imaging, taken at 10 weeks and 12 months, demonstrated resolution of all three lesions. This patient had a rare multifocal, bilateral, intracerebral RDD, illustrating that although a histological diagnosis is necessary, further treatment may not be required.

A report of the natural history of leptomeningeal gliomatosis

Primary leptomeningeal gliomatosis (PLG) is a rare condition, with fewer than 50 patients reported. Our report illustrates the natural history of PLG in full, from the prodromal phase of subacute meningitis to the final stages characterised by extensive nerve root infiltration, cranial nerve palsies and widespread peripheral neurogenic muscle wasting. We provide correlative neuroimaging with serial MRI, and present the first published positron emission tomography imaging of this condition. We emphasise the importance of considering PLG in the differential diagnosis of chronic aseptic meningitis, the difficulties of making the diagnosis ante mortem, and the utility and potential limitations of early meningeal biopsy in this condition.

Familial hemicrania continua

There are now three known causative genes for familial hemiplegic migraine and increasing evidence to support a genetic predisposition to the more common types of migraine with and without aura, and for cluster headache. We present the first reported case of familial hemicrania continua. A mother and daughter developed hemicrania continua at the same time of life. Both showed an absolute response to indometacin and at similar doses. Both also suffered from migraine with aura. We discuss the increasing support for a genetic predisposition to dysfunction of the pain system within the brain manifesting as primary headache.

The migraine theories of Liveing and Latham: a reappraisal

This article discusses the leading 19th century British contributions to theories of migraine pathogenesis: Edward Liveings theory of nerve storms and Peter Wallwork Lathams vasomotor theory, providing a detailed accounts of their origin, and their rise and fall in the latter decades of the century, emphasizing the central role of William Gowers in their ultimate downfall. The article concludes by discussing the reasons behind the rising reputation of Liveings work, demonstrating how history may be made to serve contemporary ends.

Post market pilot programme with single pulse transcranial magnetic stimulation (sTMS) for acute treatment of migraine: SpringTMS™ use in migraine

Some patients suffer disabling, frequent migraine without effective treatment as current pharmacological options are either contra-indicated, poorly tolerated or overused. A post market pilot programme with the sTMS device was initiated for patients with migraine.

Drug therapy in headache

All physicians will encounter patients with headaches. Primary headache disorders are common, and often disabling. This paper reviews the principles of drug therapy in headache in adults, focusing on the three commonest disorders presenting in both primary and secondary care: tension-type headache, migraine and cluster headache. The clinical evidence on the basis of which choices can be made between the currently available drug therapies for acute and preventive treatment of these disorders is presented, and information given on the options available for the emergency parenteral treatment of refractory migraine attacks and cluster headache.

Narouze SN (ed) Interventional management of head and face pain. Nerve blocks and beyondNarouzeSN (ed)Interventional management of head and face pain. Nerve blocks and beyond.New York: Springer, 2014 (ISBN: 978-1-4614-8951-1, hbk, £72)

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