Thomas N. Ward

Exploding vs. imploding headache in migraine prophylaxis with Botulinum Toxin A

&NA; Migraine headache is routinely managed using medications that abort attacks as they occur. An alternative approach to migraine management is based on prophylactic medications that reduce attack frequency. One approach has been based on local intramuscular injections of Botulinum Toxin Type A (BTX‐A). Here, we explored for neurological markers that might distinguish migraine patients who benefit from BTX‐A treatment (100 units divided into 21 injections sites across pericranial and neck muscles). Responders and non‐responders to BTX‐A treatment were compared prospectively (n = 27) and retrospectively (n = 36) for a host of neurological symptoms associated with their migraine. Data pooled from all 63 patients are summarized below. The number of migraine days per month dropped from 16.0 ± 1.7 before BTX‐A to 0.8 ± 0.3 after BTX‐A (down 95.3 ± 1.0%) in 39 responders, and remained unchanged (11.3 ± 1.9 vs. 11.7 ± 1.8) in 24 non‐responders. The prevalence of aura, photophobia, phonophobia, osmophobia, nausea, and throbbing was similar between responders and non‐responders. However, the two groups offered different accounts of their pain. Among non‐responders, 92% described a buildup of pressure inside their head (exploding headache). Among responders, 74% perceived their head to be crushed, clamped or stubbed by external forces (imploding headache), and 13% attested to an eye‐popping pain (ocular headache). The finding that exploding headache was impervious to extracranial BTX‐A injections is consistent with the prevailing view that migraine pain is mediated by intracranial innervation. The amenability of imploding and ocular headaches to BTX‐A treatment suggests that these types of migraine pain involve extracranial innervation as well.

A Retrospective, Comparative Study on the Frequency of Abuse in Migraine and Chronic Daily Headache

Objective.—To assess and contrast the relative frequency of a past history of physical and/or sexual abuse in patients with chronic daily headache (CDH) versus migraine.

EVALUATION AND MANAGEMENT OF HEADACHE IN THE EMERGENCY DEPARTMENT

In the ED, correct diagnosis is the necessary foundation on which specific therapy is based. There is no substitute for obtaining a thorough history and examining the patient competently. Patients with a past history of primary headaches, such as migraine, also may be afflicted with (new) secondary headaches. Although efficiency is desirable from the perspective of ED management, a thoughtful approach complemented by the judicious selection of tests is compatible with that goal as well as achieving the desired outcome of accurate diagnosis and relief of pain. Arrangements for long-term follow-up are important.

Sex Matters: Evaluating Sex and Gender in Migraine and Headache Research

(Headache 2011;51:839‐842)

Pharmacological prevention of migraine

#### Summary points People who have migraine experience intermittent attacks of unilateral, pulsating, and moderate to severe headache with associated nausea or photophobia and phonophobia (or all these symptoms). These attacks typically start before the age of 40, often in childhood or teenage years, and occur most commonly from the second to the fourth decade of life.1 Attacks may be infrequent or frequent. Chronic migraine is diagnosed when attacks regularly occur on more than 15 days a month. Box 1 shows the International Headache Society’s classification criteria for migraine without aura. #### Box 1 International Headache Society’s classification criteria for migraine without aura1 At least five attacks fulfilling criteria A-C Recent population studies have shown the worldwide prevalence of migraine to be greater than 10%. The prevalence of migraine in the United States has been estimated at 18% for women, 6% for men, and 12% overall.2 3 Migraine clearly affects women more than men, and its aetiology also seems to have a hereditary component. The World Health Organization ranks migraine 19th on the list of diseases worldwide that cause disability.w1 In spite of recent advances in treatment options for migraine, both acute and preventive, these treatments continue …

Psychosocial factors of relevance to sex and gender studies in headache.

(Headache 2011;51:923‐931)

Ictal Adiponectin Levels in Episodic Migraineurs: A Randomized Pilot Trial

To assess ictal adiponectin (ADP) levels before and after acute abortive treatment in women episodic migraineurs.

Laughing Headache: A Novel Type of Triggered Headache With Response to Divalproex Sodium

A number of headache precipitants have been described, including weather changes, menstrual periods, missed meals, sunlight, sleep derangement, various foods, perfume, and stress.1 Many triggered headaches fulfill diagnostic criteria for migraine. Exertion and sexual activity have also been reported as trigger factors for headache, and these have been categorized separately by the International Headache Society (Table).2 Symonds, in 1956, described 21 patients with headaches induced by coughing, as well as straining, sneezing, laughing, or stooping, in whom no evidence of intracranial pathology could be found, and postulated that traction on painful intracranial structures due to transient increased intracranial pressure (on the basis of reduced venous flow during Valsalva) might explain symptoms.3 An even larger series of exertional headaches was reported by Rooke in 1968, which included 93 patients without any detectable intracranial pathology.4 He was unable to find a common mechanism to explain the syndrome, but noted that a number of his patients (approximately 25%) had an antecedent upper respiratory syndrome, leading to his speculation of an inflammatory etiology. The following is a summary of a case of severe, recurrent, brief, nonmigrainous, head pain precipitated only by mirthful laughing, without any other

Headache Caused by a Spinal Cord Stimulator in the Upper Cervical Spine

We report persistent headaches developing in a patient subsequent to the placement of a spinal cord stimulator in the upper cervical spine. These persistent headaches responded to dihydroergotamine and sumatriptan. Headaches ceased upon repositioning of the stimulator lower in the cervical spine. We postulate an effect of the device on the trigeminovascular system via the nucleus caudalis trigeminalis and/or spinal trigeminal tract.

Migraine–tic syndrome: a case report of a new headache type

Trigeminal neuralgia has been described in patients with other concomitant headache disorders. Striking examples are the so-called ‘Cluster–Tic Syndrome’ (1, 2) and Chronic Paroxysmal Hemicrania–Tic Syndrome (3). This report documents a previously undescribed paired association in a patient with migraine who described consistent recurring trigeminal neuralgia symptoms at the time of her migraines, with excellent response to gabapentin.