Value of neuroimaging in the evaluation of neurologically normal children with recurrent headache.

Alehan FK.

Division of Child Neurology, Baskent University School of Medicine, Ankara, Turkey. falehan hotmail.com

Headache is one of the most frequent physical complaints in children. Although headaches in children are generally benign, neuroimaging studies are frequently performed in clinical practice for the fear of missing a serious underlying disease. Despite this, limited data exist about the utility of neuroimaging in recurrent headache of children with a normal neurologic examination. This prospective study was planned to determine the value of neuroimaging in neurologically normal children with migraine and tension-type headache. Among 95 consecutive patients presenting with headache, 72 patients receiving a diagnosis of migraine or tension-type headache were included in the study. Neuroimaging procedures were performed in 83%. Magnetic resonance imaging (MRI) was abnormal in 11 of 49 cases. Abnormalities consisted of foci of gliosis in four, sinusitis in two, pineal cyst in one, periventricular leukomalacia in one, arachnoid cyst in one, old traumatic changes in one, and cervical syrinx in one. Two of the 11 computed tomographic (CT) scans revealed sinus disease. The percentage of findings causally related to headache was about 10. None of the patients had undergone surgery because of neuroimaging results. In conclusion, the yield of neuroimaging in recurrent headaches of children with a normal neurologic examination is low, and neuroimaging should not be part of a routine initial examination of these patients.

Online source: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12585718&dopt=Abstract headache medicine




Headache in the Diagnosis-Related Groups (DRG) era: management and appropriateness of admission.

Sances G, Sandrini G, Costa A, Antonaci F, Citterio A, Nappi G.

University Centre for Adaptive Disorders and Headache, University of Pavia, IRCCS C. Mondino Institute of Neurology, Via Palestro 3, 27100 Pavia, Italy.

Headache is an extremely common disorder which has a marked impact on the utilisation of healthcare resources and constitutes a considerable socio-economic burden. The related costs, both direct and indirect, are especially high in developed countries, since headache predominantly affects an economically-active section of the population. The Diagnosis-Related Groups (DRG) system, a method for reimbursing healthcare structures for patient admissions, was introduced in Italy in 1995. The aim of the system was to control public health expenditure and to promote better distribution of financial resources. Here, we report the results of the application of the DRG system to headache patients admitted to the Department of Neurology of the University of Pavia in 1996 and 1998. The financial analysis revealed high fixed costs (hospital running costs per days of hospitalisation); by contrast, the impact of the variable costs (those relating to the direct management of the individual patient, i.e. examinations, therapeutic interventions etc.) was low. It was found that reducing the number of days of hospitalisation increases the hospital's income and reduces the mean loss incurred in each DRG. It is therefore suggested that a complete approach to the management of headache must include educational programmes for patients and general practitioners, and that access to headache centres and to hospital care should be restricted to cases of acute, severe headache, or recurrent, chronic headache with/without drug abuse or dependence.

Online source: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11200796&dopt=Abstract headache medicine




Severe episodic headache as the sole presenting ictal event in patients with a solitary cysticercus granuloma.

Rajshekhar V.

Department of Neurological Sciences, Christian Medical College and Hospital, Vellore, India. rajshekhar cmcvellore.ac.in

OBJECTIVES: Most patients with a solitary cysticercus granuloma present with seizures and severe episodic headache as the sole presenting symptom is rare in these patients. We report the clinical features, evolution and outcome of the disease in patients with a solitary cysticercus granuloma who had severe headache alone without seizures as the sole presenting event. MATERIAL AND METHODS: This was a prospective study which included all patients who presented with severe episodic headache alone and had a diagnosis of a solitary cysticercus granuloma based on CT imaging and follow-up and were managed in our department between June 1, 1991 and May 31, 1998. RESULTS: Out of nearly 550 patients diagnosed to have a solitary cysticercus granuloma during the period of the study, 15 patients (2.5%) presented with severe episodic headache alone. While 9 patients had 1 episode of headache, 6 patients had 2 to 5 episodes. Patients were managed with conservative symptomatic therapy (13 patients) and albendazole therapy (2 patients). Follow-up scans showed complete or partial resolution of the granuloma in 8 patients and a lesion of the same size in 4 patients. None of the patients with complete resolution of the granuloma reported further episodes of headache. CONCLUSIONS: It is important to recognize this presentation of a solitary cysticercus granuloma as it could be confused clinically with other acute central nervous system illnesses such as subarachnoid haemorrhage and meningitis. In regions endemic for cysticercosis a contrast enhanced CT scan of the brain should be performed in patients presenting with sudden onset of severe headache when a plain scan does not reveal intracranial haemorrhage as only a contrast enhanced scan will reveal the granuloma.

Online source: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10893062&dopt=Abstract headache medicine




[Chronic daily headache: clinical presentation]

[Article in Portuguese]

Krymchantowski AV, Moreira Filho PF.

Centro de Avaliacao e Tratamento da Dor de Cabeca do Rio de Janeiro, Brazil. abouchkrym openlink.com.br

Chronic daily headache (CDH) represents a group of any headache disorder that occurs on a daily or near daily basis, for longer than 6 months. Even though it is a common problem, it is not a well defined disorder, resulting in controversies regarding its identification, description and approach. Three hundred patients, 232 women and 68 men, ages 16 to 86 (mean 38 years old for the women and 42 for the men), attending a headache center and fulfilling the proposed criteria for CDH (Silberstein et al.) and presenting headache 28 days per month were retrospectively studied. The clinical features allowed the primary headache diagnosis, before the transformation into daily presentation as: transformed migraine (TM ) in 271 patients (90,3%), chronic tension-type headache (CTTH) in 26 patients (8,7%) and new daily persistent headache (NDPH) in 3 patients (1%). Among the TM patients, the most observed presentation was pressure or tightening, bilateral fronto-temporal, moderate non-continuous headache, with a progressive onset. The association with nausea and phonophobia was demonstrated in 60% and 32% of the patients respectively. The association with photophobia and sleep disturbances, as well as the occurrence of intermittent headache attacks, was different among male and female patients. With regard to the CTTH patients, pressure or tightening, bilateral fronto-temporal, moderate non-continuous headache, with sleep disturbances and no associated symptoms, was the predominant presentation.

Online source: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10920405&dopt=Abstract headache medicine




Headaches in patients with radiosurgically treated occipital arteriovenous malformations.

Kurita H, Ueki K, Shin M, Kawamoto S, Sasaki T, Tago M, Kirino T.

Department of Neurosurgery, Graduate School of Medicine, University of Tokyo, Japan. hkurita-tky umin.ac.jp

OBJECT: The goal of this study was to determine the prevalence, characteristics, and radiosurgical outcomes of headaches associated with occipital arteriovenous malformations (AVMs). METHODS: The authors reviewed the medical records of 37 consecutive patients with occipital AVMs who had been treated by radiosurgery to identify the radiological features of the AVMs before and after treatment and the clinical features and outcomes of headaches described in accordance with the criteria of the International Headache Society (IHS). Thirty-six patients (97.3%) were followed for a mean period of 46.6 months. The median volume of the AVMs was 1.9 cm3, to which a mean radiation dose of 21.6 Gy was delivered. In the entire study group, periodic headaches were found in 17 patients (45.9%), of whom seven (18.9%) suffered from migraines with the characteristic visual aura. Migraine was predominantly found in patients with right-sided (p = 0.038) or laterally located (p = 0.025) AVMs. Factors associated with a higher incidence of any type of headache included larger nidus volume (p = 0.02), tortuous change of feeding artery (p = 0.036), and cortical drainage with reflux in the superior sagittal sinus (p = 0.032). The actuarial rate of angiographic obliteration was 71.6% at 3 years. Headaches resolved or improved in 12 (70.6%) of 17 patients, including six (85.7%) of seven with migraine. The outcome of headache closely correlated with the obliteration results of the AVM (p = 0.002). CONCLUSIONS: A portion of occipital AVMs do cause headaches that satisfy the current IHS criteria for migraine, and the prevalence varies by the topography of the lesion. Radiosurgery can resolve headaches in the majority of treated patients.

Online source: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10930007&dopt=Abstract headache medicine




Chronic post-traumatic headache associated with minor cranial trauma: a description of cephalalgic patterns.

Bettucci D, Aguggia M, Bolamperti L, Riccio A, Mutani R.

Department of Neurology, Novara, University of Torino, Hospital Maggiore della Carita, Italy.

We studied a group of 93 patients who had not previously suffered headache and who were consecutively admitted to the Emergency Department of the hospitals of Novara and Borgomanero, Italy because of a cranial trauma definable as minor according to the current International Headache Society (IHS) criteria. Two weeks after admission, all patients underwent a semi-structured interview which revealed that 24 (25.8%) had headache; 21 of these (22.5% of the original 93 patients) also had headache when they underwent a second interview eight weeks after the traumatic event. These 21 patients were diagnosed as having chronic post-traumatic headache associated with minor cranial trauma (5.2.2 of the IHS classification), and the prevalent clinical pattern of headache presentation was examined with the aim of attributing the fourth IHS classification code number. Eighteen of the 21 patients were found to have a tension-type pattern (5.2.2.2), and the remaining three had migraine (5.2.2.1); none had cluster headache (5.2.2.3). These data demonstrate a large prevalence of tension-type headache in patients with class 5.2.2 post-traumatic headache, and confirm the results of previously published studies that were not based on the diagnostic criteria of the current classification.

Online source: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10935855&dopt=Abstract headache medicine




Interobserver reliability in physical examination of the cervical spine in patients with headache.

Van Suijlekom HA, De Vet HC, Van Den Berg SG, Weber WE.

Pain Management and Research Center, Departments of Anesthesiology and Neurology, University Hospital of Maastricht, The Netherlands.

OBJECTIVE: To assess interobserver reliability of two expert headache neurologists when examining the cervical spine of patients with headache. BACKGROUND: The diagnosis of cervicogenic headache involves the physical examination of the cervical spine. METHODS: Twenty-four patients diagnosed as having migraine, tension-type headache, or cervicogenic headache were included in the study. After interview, each patient's cervical spine was examined in a structured way. Reliability was assessed by Cohen's kappa. RESULTS: Reduced range of motion in the cervical spine showed kappa scores indicating moderate agreement. Provocation of headache revealed moderate-to-substantial agreement. Assessment of zygapophyseal joint pressure pain showed slight-to-fair agreement. The kappa values of the circumscribed characteristic tender points showed agreement ranging from "not better than chance" to "substantial agreement." CONCLUSIONS: Our study showed that the interobserver reliability of expert headache neurologists was satisfactory in the majority of the physical examination tests of the cervical spine in patients with different headache syndromes. However, standardization of the clinical tests in order to improve their reliability is recommended.

Online source: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10940097&dopt=Abstract headache medicine




Cranioplasty in acoustic neuroma surgery.

Wazen JJ, Sisti M, Lam SM.

Department of Otolaryngology--Head and Neck Surgery, Columbia-Presbyterian Medical Center, New York, New York 10032, USA.

OBJECTIVES: To measure the incidence of postoperative headaches after retrosigmoid resections of acoustic neuromas and to evaluate the impact of cranioplasty on the prevention and management of these headaches. STUDY DESIGN: A prospective evaluation was performed on 30 consecutive patients who underwent a cranioplasty after retrosigmoid excision of their acoustic neuroma. The results were compared with 30 historical control patients who underwent the same procedure but did not have reconstruction with a cranioplasty. The patients were evaluated by review of office records and via telephone questionnaire. METHODS: One group of patients (30 patients) had no cranioplasty, and the other group of 30 patients had primary reconstruction with a titanium mesh-acrylic cranioplasty. All 60 patients were asked to report on the duration and severity of their headaches by means of a standard questionnaire, grading their symptoms on a scale of 1 to 4. The data were subjected to chi2 and Student t test statistical analyses. RESULTS: New-onset, postoperative headaches occurred in 27% of patients, 23% in the cranioplasty group compared with 30% in the group without cranioplasty (a difference that was not statistically significant [P = .158]). However, there was a statistically significant difference in the severity of the headaches (P<.03). The headaches in the cranioplasty group were less severe and were not disabling. There were no complications, infections, or extrusions related to the cranioplasty. CONCLUSIONS: Cranioplasty has not been able to eliminate postoperative headaches. However, the use of cranioplasty has significantly decreased the severity of postoperative headaches after retrosigmoid excision of acoustic neuromas.

Online source: www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10942129&dopt=Abstract headache medicine