Headache associated with changes in intracranial pressure.
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Brain Neoplasms↗
Biomedical subjects
S D Silberstein
Publications and source records attributed to S D Silberstein.
Transcranial Doppler: technique and application to headache.
This article reviews the technique and physics relevant to a functional understanding of transcranial doppler. The frequently contradictory findings in migraine are reviewed. Several studies suggest increased flow velocities are common in the interictal period. There are disparate findings between studies of the ictal period. In cluster headache, there appear to be more easily reproduced changes between and during cluster attacks.
Cerebrovascular Circulation↗
Evaluation and emergency treatment of headache.
Headache is a common complaint in patients presenting to the emergency department. Most such headaches are benign, but some have a more severe organic cause. Occasionally, patients present with a chronic headache disorder with which they can no longer cope. The new International Headache Society Classification of Headache is reviewed along with the differential diagnosis of benign headache disorders. Headache diagnosis by history is examined in detail followed by a discussion of the emergency presentation of headache patients. Causes for concern are presented, along with a detailed discussion of differential diagnosis, including subarachnoid hemorrhage, meningitis, sinusitis, glaucoma, internal carotid artery dissection, and cerebro-vascular disease. Also discussed are medications used for the symptomatic treatment of headache, including analgesics, NSAIDs, narcotics, and ergotamine preparations. Approaches to the treatment of the severe, persistent headache in the emergency department are outlined and treatment options suggested. Headache medication overuse is discussed and guidelines are presented to recognize the condition and prevent its recurrence.
Analgesics↗
Chronic daily headache: long-term prognosis following inpatient treatment with repetitive IV DHE.
We retrospectively studied the long-term (2-year) outcome of 50 consecutive patients admitted to our inpatient headache program because of chronic daily headache (CDH) associated with the overuse of analgesics, ergotamine, or both. They had been detoxified, given repetitive intravenous dihydroergotamine (IV DHE) and prophylactic medications as part of the program, and had become headache-free on this regimen. At the time of admission, 37 of the 50 patients had transformed migraine (TM), 12 had new daily persistent headache (NDPH), and 1 had chronic tension-type headache; 29 of the patients with TM, 7 of those with NDPH, and the single patient with chronic tension-type headache had coexistent migraine. Substances abused, alone or in combination, included: caffeine in 39 patients (av. 441 mg/d), acetaminophen in 32 (av. 2187 mg/d), aspirin in 24 (av. 1807 mg/d), ibuprofen in 9 (av. 1156 mg/d), narcotics in 7 (av. 10.1 mg morphine equivalents/d) and ergotamine in 11 (av. 2.3 mg/d). Twenty patients were using preventive medication at the time of admission. Follow-up evaluations were performed at 3, 6, 12, and 24 months after discharge. Forty-three patients were analyzed at 3 months. Of these, 44% had an excellent or good result and 28% a fair result; 3 were overusing analgesics. At 24 months, 39 patients were analyzed: 59% had a good or excellent result and 28% a fair result; 5 were overusing analgesics, 4 of whom were doing poorly.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
Symptomatic and prophylactic treatment of migraine and tension-type headache.
Pharmacotherapy is the mainstay for patients with persistent headaches. When simple analgesics can no longer be used, combination analgesics are prescribed. Symptomatic medications also include antiemetics, ergot derivatives, corticosteroids, neuroleptics, and narcotics. Nonsteroidal anti-inflammatory drugs are commonly used both symptomatically and prophylactically, and are the treatment of choice for menstrual migraine. Exertional migraine, benign orgasmic cephalalgia, chronic paroxysmal hemicrania, cough headache, and "ice-pick" headache are treated with indomethacin. Ergotamine tartrate is often recommended when simple or combination analgesics do not relieve headaches. Dihydroergotamine (DHE) is effective for treating intractable headache; because it has fewer side effects than ergotamine, it is tolerated by patients unable to tolerate other ergotamine preparations. DHE is administered IM and, for occasional use, patients can be taught self-injection. Repetitive IV DHE therapy for chronic severe headaches requires hospitalization; most patients become headache-free within 3 days. Patients who refuse hospitalization, do not respond to the drug, or are not suitable candidates for DHE therapy may receive a short course of a corticosteroid, a neuroleptic or, rarely, a narcotic. For frequent headaches, prophylactic treatment usually begins with a tricyclic antidepressant or a beta blocker.
Analgesics↗
The role of sex hormones in headache.
Changes in estrogen levels at menarche, menstruation, pregnancy, and menopause may trigger or change the prevalence of migraine. The fall in estrogen that occurs with menstruation is the trigger for menstrual migraine, whereas the sustained high estrogen levels during pregnancy frequently result in headache relief. Estrogen produces changes in prostaglandins, hypothalmic opioids, and prolactin secretion, which may in part account for genesis of headache. The treatment of menstrual migraine and migraine associated with menopause and the use of oral contraceptives is discussed, focusing on standard headache treatment and hormonal manipulation.
Contraceptives, Oral↗
Emergency treatment of headache.
The first approach in the emergency treatment of headache is the use of abortive measures in an attempt to forestall progression of early signs and symptoms. Abortive measures include analgesics, antiemetics, and anxiolytics; nonsteroidal anti-inflammatory drugs; ergots, generally preceded by administration of an antiemetic; conservative use of corticosteroids; major tranquilizers; and even narcotics (in certain extreme and selective situations). If abortive measures fail, IM or IV administration of dihydroergotamine mesylate, preceded by promethazine (IM) or metoclopramide (IM or IV) and followed by dexamethasone (IM or IV), is an effective emergency procedure. Every patient seeking care for headache from an emergency department should be instructed on how and where to obtain definitive follow-up and long-term treatment.
Emergencies↗
Advances in understanding the pathophysiology of headache.
Recent evidence suggests that migraine may not be due to vasoconstriction followed by reactive vasodilation, and tension-type headache may not be due to excess muscle contraction. The prodromes of migraine may have a hypothalamic origin, and the aura and changes in cognition may have a cortical neuronal origin. The pain of migraine and tension-type headache may be generated centrally or enhanced or generated by neurogenic inflammation. Drugs used to treat headache frequently interact with serotonin receptor subtypes: abortive drugs at the 5-HT1 receptor and preventive drugs at the 5-HT2 receptor.
Headache↗
Idiopathic intracranial hypertension without papilledema.
We describe 10 patients with idiopathic intracranial hypertension who did not have papilledema. Idiopathic intracranial hypertension without papilledema, although rarely reported, may well be a clinically important headache syndrome. Historical and demographic features of patients with idiopathic intracranial hypertension without papilledema are similar to those of patients with papilledema. Obese women with chronic daily headache and symptoms of increased intracranial pressure, pulsatile tinnitus, history of head trauma or meningitis, an empty sella on imaging studies, or a headache that is unrelieved by standard therapy should have a diagnostic lumbar puncture. Findings from laboratory and neurologic investigations are normal in most patients with idiopathic intracranial hypertension without papilledema. Initial management should include removal of possible inciting agents, weight loss if applicable, and standard headache therapy. Lumbar puncture and diuretic therapy should precede a trial of corticosteroids. Surgery (lumboperitoneal or ventriculoperitoneal shunt or perhaps optic nerve sheath fenestration) may be indicated for prolonged incapacitating headache that is not responsive to medical management or lumbar puncture.
Adult↗
Review article: migraine and pregnancy.
A 27-year-old woman with no family or personal history of migraine presented with headache associated with unilateral paresthesias and blurred vision. This was her first, and so far only, attack of migraine with aura and led to the diagnosis of her pregnancy and to this review. Migraine can begin for the first time with pregnancy, particularly in the first trimester. Cases of migraine with aura are the most commonly reported. Preexisting migraine usually improves with pregnancy, particularly if it was associated with menstrual migraine. Headache occurs frequently in the post-partum period, particularly in known migraineurs. Migraineurs have no increased risk of complications during pregnancy and their children have no increased incidence of birth defects.
Adult↗
The treatment of cluster headache with repetitive intravenous dihydroergotamine.
We reviewed our experience with 54 cluster headache patients (23 episodic, 31 chronic) admitted to our headache center 64 tines over the past five years and treated with repetitive intravenous dihydroergotamine (IV DHE). DHE therapy was initiated on admission and prophylactic medication regimens were started or adjusted. All 54 patients had complete relief of their cluster headache, usually within two days. Most (82.8%) had no side effects. The average length of hospitalization was 6.7 days. At the three month followup, 92.9% of the episodic cluster patients were headache-free and 7.1% had a 50-74% improvement; at six months, all were headache-free. Of the chronic cluster patients, 44.4% were headache-free at three months and 52.8% had at least 50% improvement. At six months, 75% were headache-free and 22.2% were at least 75% improved, probably as a result of continued prophylactic medication. Repetitive IV DHE safely, rapidly, and effectively controls cluster headache.
Adult↗
Estrogens, progestins, and headache.
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Contraceptives, Oral, Hormonal↗
Spontaneous low cerebrospinal fluid pressure headache.
A 69 year old man presented with headache on arising and relieved with recumbency. His clinical presentation, laboratory data, response to treatment and radiographic evaluation were consistent with spontaneous low cerebrospinal fluid pressure from CSF hyperabsorption. Cisternography showed rapid accumulation in the kidneys and urinary bladder, without evidence of CSF leak. His headache was eventually controlled with two blood patches and oral caffeine.
Aged↗
Repetitive intravenous DHE in the treatment of refractory headache.
We analyzed retrospectively the data for 300 patients with refractory headache who were treated with dihydroergotamine (DHE) at the Comprehensive Headache Center at Germantown Hospital. The patients had either chronic daily headache (with drug rebound -216, without rebound -42), short-duration headache (18), or cluster headache (24). Treatment consisted of withdrawal of overused medications (usually analgesics and ergots), repetitive IV administration of DHE, and use of metoclopramide and prophylactic medications, together with educational and psychological support. Overall, 91% (range, 86% to 100%) of the patients became headache-free, usually within 2 to 3 days. The average duration of hospitalization was 7.4 days. Side effects, reported in 157 (52%) of the patients, consisted primarily of nausea (32%), tightness and burning (8%), leg cramps (7%), vomiting (6%), and increased blood pressure (5%). The side effects generally resolved spontaneously or with adjustment of the DHE dose and/or adjunct medication, and necessitated withdrawal of therapy in only 2 patients (1 with drug-related claudication; 1 with somatic complaints of uncertain origin). We conclude that a regimen of repetitive intravenous DHE and metoclopramide can provide rapid relief of chronic intractable headache, and can ameliorate the effects of analgesic and ergot withdrawal in patients with chronic daily headache and rebound associated with overuse of these drugs.
Chronic Disease↗
Twenty questions about headaches in children and adolescents.
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Adolescent↗