Treatment of hemicrania continua with radiofrequency ablation and long-term follow-up.

OBJECTIVE: The objective of this research is to describe novel procedural treatments for hemicrania continua that allow patients to remain off indomethacin. METHODS: Case reports are presented. RESULTS: We describe four distinct patients with indomethacin-responsive hemicrania continua who were unable to discontinue the use of indomethacin without headache recurrence. No other medications were effective for their syndrome. Secondary causes of headache were ruled out in each case. Each patient underwent diagnostic blockade of either the atlanto-axial joint, C2 dorsal root ganglion or sphenopalantine ganglion depending on their clinical examination and presence of cranial autonomic symptoms. A positive response led to a radiofrequency ablation of the C2 ventral ramus, C2 dorsal root ganglion or sphenopalantine ganglion, which provided headache relief in all case patients as complete as indomethacin. Long-term follow-up of these patients has shown that all have remained essentially headache free without the need for indomethacin. One patient has needed repeat radiofrequency procedures with consistent response. CONCLUSION: Hemicrania continua is defined by its sensitivity to indomethacin but very few patients are able to discontinue the medication without headache recurrence. As the risks of chronic indomethacin use are substantial, alternative treatments are necessary to protect patient health. We are now able to suggest several radiofrequency ablation procedures as effective as indomethacin with long-term follow-up.

A case of post-traumatic LASH syndrome responsive to indomethacin and melatonin (a man with a unique triad of indomethacin-responsive trigeminal autonomic cephalalgias).

OBJECTIVE: The objective of this article is to present the first post-traumatic/secondary case of LASH syndrome and the first melatonin-responsive case of LASH. METHODS: We present a case report. RESULTS: A 44-year-old man developed three distinct headache syndromes in progression over a 2.5-year time period after a motor vehicle accident. He initially had paroxysmal hemicrania, which he experienced for 15 months, then transitioned to hemicrania continua for 3.5 months, then LASH syndrome, which he endured until he was treated with indomethacin and became pain free. Then after an inability to taper off indomethacin he was placed on melatonin and achieved a pain-free state. CONCLUSION: This is the first post-traumatic/secondary case of LASH syndrome, the first male patient to be documented with LASH, and the first LASH case to show complete alleviation with melatonin. This patient's unique case history provides another example of how multiple trigeminal autonomic cephalalgias can occur in a single individual. This may be one of the first cases of three distinct trigeminal autonomic cephalalgias developing after trauma.

New daily persistent headache with a thunderclap headache onset and complete response to nimodipine (a new distinct subtype of NDPH).

At present new daily persistent headache is just a group of conditions that are connected based on the temporal profile of their mode of onset. If new daily persistent headache is a true distinct syndrome like migraine then we need to start to define subtypes that have specific effective treatments such has been noted for migraine sub-forms. We present what we believe is the first recognized subtype of new daily persistent headache that which starts with a thunderclap headache onset. A patient presented with a 13 month history of a daily headache from onset which initiated as a thunderclap headache along with persistent acalculia. All neuroimaging studies for secondary causes were negative. Nimodipine rapidly and completely alleviated her headache and associated neurologic symptoms. We propose that this subtype of new daily persistent headache is caused by a very rapid increase in CSF tumor necrosis factor alpha levels leading to cerebral artery vasospasm with a subsequent thunderclap headache, then continuous or near continuous cerebral artery vasospasm leading to a persistent daily headache. Nimodipine which not only inhibits cerebral artery vasospasm but also tumor necrosis factor alpha production appears to be a specific treatment for this distinct subtype of new daily persistent headache.

Two young women with chronic daily headache and cognitive impairment: why we need to ask about headache in the postpartum period.

Headache, which has a variety of causes, is a common and disabling complaint following childbirth. An important aetiology not to be missed is headache from epidural spinal anaesthesia, known as postdural puncture headache (PDPH), which has been reported in upwards of 85% of pregnant women and is a manifestation of intracranial hypotension from leakage of cerebrospinal (CSF) fluid through a dural tear. The common presenting symptom of PDPH is head pain occurring when a patient is in an upright position that resolves with recumbency. Other neurological issues associated with intracranial hypotension can include cranial nerve palsies, encephalopathy and Parkinsonism. We present two cases of persistent PDPH after pregnancy with secondary cognitive impairment. A review of the clinical manifestations, neuroimaging findings and treatment for PDPH will be presented. Better recognition of this disorder by obstetricians, physicians and anaesthetics will help to reduce the considerable morbidity this syndrome can produce in young mothers.

Paroxysmal hemicrania as the clinical presentation of giant cell arteritis.

Head pain is the most common complaint in patients with giant cell arteritis but the headache has no distinct diagnostic features. There have been no published reports of giant cell arteritis presenting as a trigeminal autonomic cephalalgia. We describe a patient who developed a new onset headache in her fifties, which fit the diagnostic criteria for paroxysmal hemicrania and was completely responsive to corticosteroids. Removal of the steroid therapy brought a reemergence of her headaches. Giant cell arteritis should be considered in the evaluation of secondary causes of paroxysmal hemicrania; in addition giant cell arteritis needs to be ruled out in patients who are over the age of 50 years with a new onset trigeminal autonomic cephalalgia.