Seymour Solomon

Headache in cerebrovascular disease.

Two hundred fifteen consecutive patients with cerebrovascular events were evaluated pro- spectively for the incidence and characteristics of headache. Of 163 patients able to communicate, headache occurred in 29% with bland infarcts, 57% with parenchymal hemorrhage, 36% with transient Lschemic attacks and 17% with lacunar infarcts. Patients with a history of recurrent throbbing headache were significantly more likely to have headache, usually throbbing in quality, during the present illness. Women developed headache significantly more often than men. Headache began prior to the vascular event in 60% of patients and at its onset in 25%. The quality, onset and duration of the headache varied widely among patients. Headache in cerebrovascular disease is common, though neither its occurrence nor characteristics predict lesion type or location. Though the pathogenesis of the headache is unknown, its association with prior throbbing headache suggests that similar factors may operate in both. Stroke Vol 15, No 6, 1984

Hemicrania continua: ten new cases and a review of the literature.

We describe 10 new patients and review the 24 prior reports of hemicrania continua, an uncommon, unilateral headache disorder. The disorder is characterized by a continuous baseline headache of moderate severity with superimposed exacerbations of more severe pain. These exacerbations are sometimes associated with ipsilateral autonomic disturbances. There are three temporal patterns: a chronic, nonremitting headache from onset; a remitting variety consisting of distinct phases of continuous unilateral headaches that persist for weeks to months followed by pain-free remissions; and an evolving form in which initially remitting headaches transform into the chronic, non-remitting pattern. Accurate diagnosis is important as all forms are characterized by a dramatic and selective response to indomethacin.

Retinal migraine reappraised

Retinal migraine is usually characterized by attacks of fully reversible monocular visual loss associated with migraine headache. Herein we summarize the clinical features and prognosis of 46 patients (six new cases and 40 from the literature) with retinal migraine based upon the International Classification of Headache Disorders-2 (ICHD-2) criteria. In our review, retinal migraine is most common in women in the second to third decade of life. Contrary to ICHD-2 criteria, most have a history of migraine with aura. In the typical attack monocular visual features consist of partial or complete visual loss lasting <1 h, ipsilateral to the headache. Nearly half of reported cases with recurrent transient monocular visual loss subsequently experienced permanent monocular visual loss. Although the ICHD-2 diagnostic criteria for retinal migraine require reversible visual loss, our findings suggest that irreversible visual loss is part of the retinal migraine spectrum, perhaps representing an ocular form of migrainous infarction. Based on this observation, the authors recommend migraine prophylactic treatment in an attempt to prevent permanent visual loss, even if attacks are infrequent. We also propose a revision to the ICHD-2 diagnostic criteria for retinal migraine.

Guidelines for controlled trials of drugs in cluster headache.

The present guidelines were developed under the auspices of the International Headache Society (IHS) to facilitate high quality controlled clinical trials (CCT) in cluster headache. Quality CCT are the only way to convincingly establish the efficacy of any drug treatment. These guidelines for CCT are designed mainly to test drug efficacy. For general issues in clinical trials, the reader should consult works on clinical trial methodology (1-4). Here, issues of specific relevance to cluster headache will be emphasized. Previous discussions of related issues, as they pertain to migraine, have been reported (5-9). This paper was modeled after the IHS guidelines for controlled trials of drugs in migraine (10).

Anterograde transneuronal degeneration in the limbic system: clinical-anatomic correlation.

A 64-year-old man with diffuse atherosclerosis developed an organic mental syndrome, followed by hypothalamic symptoms. Autopsy showed an old large cystic infarct involving the left temporal lobe including the hippocampus, and atrophy of the ipsilateral fornix, mammillary body, hypothalamus, mammillothalamic tract, and the anterior thalamic nucleus. The clinical deterioration and pathologic findings may be explained by anterograde transneuronal degeneration within the limbic system following the infarction.

Episodic paroxysmal hemicrania Two new cases and a literature review

Episodic paroxysmal hemicrania (EPH) is a rare disorder characterized by discrete bouts of hemicranial headache separated by headache-free remissions. Although EPH resembles episodic cluster headache in the location and quality of pain as well as the pattern of associated autonomic features, it is distinguished by the greater frequency and shorter duration of individual headaches. Differentiation of these disorders is important because EPH almost invariably responds to treatment with indomethacin but not to standard cluster headache therapy.

Apoplectic headache and oculomotor nerve palsy: An unusual presentation of multiple sclerosis

A patient with a history of facial myokymia presented with apoplectic headache and a 3rd nerve palsy. Initial CT, lumbar puncture, and cerebral angiogram were unremarkable, but subsequent CSF examination revealed oligoclonal bands. MRI displayed over 30 white matter lesions. This case demonstrates that multiple sclerosis may present with severe headache and a 3rd nerve palsy, simulating the clinical picture of a posterior communicating artery aneurysm.

A headache clinic-based approach to field trials of the International Headache Society criteria

Criteria for the diagnosis of headache disorders have recently been developed but require empirical validation. We present an approach to the evaluation of headache criteria in a headache clinic: define the group of headache sufferers to be studied, obtain data used in establishing the diagnosis, apply the diagnostic criteria and assess their usefulness. In applying this method to a group of patients with chronic daily headache, we found that approximately one-third would not fit the current criteria for chronic tension-type headache. We conclude that empiric validation of headache criteria based on subjective data is a complex and iterative process. Operational criteria for headache diagnosis to be used by primary care physicians should be validated in that setting and ideally should be relatively simple.

A randomized controlled trial of a comprehensive migraine intervention prior to discharge from an emergency department.

OBJECTIVESnPatients who use an emergency department (ED) for acute migraine headaches have higher migraine disability scores, lower socioeconomic status, and are unlikely to have used a migraine-specific medication prior to presentation to the ED. The objective was to determine if a comprehensive migraine intervention, delivered just prior to ED discharge, could improve migraine impact scores 1u2003month after the ED visit.nnnMETHODSnu2002 This was a randomized controlled trial of a comprehensive migraine intervention versus typical care among patients who presented to an ED for management of acute migraine. At the time of discharge, for patients randomized to comprehensive care, the research team reinforced their diagnosis, shared a migraine education presentation from the National Library of Medicine, provided them with six tablets of sumatriptan 100u2003mg and 14 tablets of naproxen 500u2003mg, and if they wished, provided them with an expedited free appointment to the institutions headache clinic. Patients randomized to typical care received the care their attending emergency physicians (EPs) felt was appropriate. The primary outcome was a between-group comparison of the Headache Impact Test (HIT-6) score, a validated headache assessment instrument, 1u2003month after ED discharge. Secondary outcomes included an assessment of satisfaction with headache care and use of migraine-specific medication within that 1-month period.nnnRESULTSnu2002 Over a 19-month period, 50 migraine patients were enrolled. One-month follow-up was successfully obtained in 92% of patients. Baseline characteristics were comparable. One-month HIT-6 scores in the two groups were nearly identical (59 vs. 56, 95% confidence interval [CI] for difference of 3u2003=u2003-5 to 11), as was dissatisfaction with overall headache care (17% vs. 18%, 95% CI for difference of 1%u2003=u2003-22% to 24%). Patients randomized to the comprehensive intervention were more likely to be using triptans or migraine-specific therapy (43% vs. 0%, 95% CI for difference of 43%u2003=u200320 to 63%) 1u2003month later.nnnCONCLUSIONSnA comprehensive migraine intervention, when compared to typical care, did not improve HIT-6 scores (a validated measure of the effect of migraine on ones daily life) 1u2003month after ED discharge. Future work is needed to define a migraine intervention that is practical and useful in an ED, where many underserved patients, of necessity, present for care.

Complications of pneumoencephalography associated with internal carotid thrombosis.

REPORTED SERIES of more than 500 cases reviewing the morbidity and mortality of pneumoencephalography attest to the safety of this procedure. The mortality rate has ranged from 0.2 to 1.6 per cent.’-’ A large majority of the reported deaths have occurred in cases of brain tumor, and deaths of patients with cerebral vascular disease are rarely mentioned.2.s If the common but transient symptoms following pneuomencephalography are excluded, the morbidity resulting from air studies is so slight that such statistics were not even tabulated in the series noted above. Serious cerebral complications such as confusion and stupor were occasionally mentioned, but only three instances of focal cerebral sequelae were reported in the above reviews, which include a combined total of 7,604 cases. (The latter compilation excludes those series3v0 which confined their observations to the mortality rate of pneumoencephalography. ) It is of interest that two of the three cases were reported in Schuleman’s7 review of 572 pneumoencephalograms. The two cases to be reported were observed within a short span of time and suggest that significant morbidity may be greater than has been realized. Specific evaluation of the hazards of pneumoencephalography in the presence of cerebral vascular disease is not to be found in the literature. Statements can be found, however, which set forth the belief that air studies are more hazardous in individuals with cerebral arterios c l e r ~ s i s . ~ ~ ~ ~ ~ ~ ’ ~ “Air studies in the face of carotid thrombosis” have been cited” as “carrying an impressive risk,” and o thed2 have warned of similar danger. Although these views are held and taught by most neurologists and neurosurgeons, except for an occasional single case report, the specific basis for these