Headache in giant cell arteritis and other arteritides.

Giant cell arteritis remains the most common systemic vasculitis in patients over the age of 50. Headache is the most common symptom, but is not invariably present. The headache may take almost any form, and may resemble any of the primary headaches, even cluster. Prompt diagnosis is important to prevent the well known serious complications. Accurate diagnosis allows appropriate therapy. Other forms of vasculitis may also cause headaches so correct diagnosis is essential as therapies may differ.

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.

Providing relief from headache pain. Current options for acute and prophylactic therapy.

The sometimes debilitating pain of migraine and other types of primary headache can be difficult to control with acute drug therapy alone. Often patients need both acute and prophylactic treatment to keep headache pain at bay. Dr Ward discusses the current treatment options for migraine with and without aura, tension-type headache, and cluster headache. He also provides practical pointers for use of the various formulations of specific drugs, including the newer "triptan" medications.

Case reports: 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.

Management of an acute primary headache.

Effective management of primary (benign) headaches generally depends upon proper diagnosis and rational use of medications. Successful treatment requires adequate dosing plus choosing the optimal route for drug delivery. When oral remedies fail, transnasal, rectal, or parenteral therapy may succeed. While cure of headaches is not currently possible, control is possible for the majority of sufferers. Most patients can adequately treat their headaches without resorting to the doctor's office or emergency room. Many therapies may not only relieve head pain, but also alleviate associated symptoms.

Familial paroxysmal dystonic choreoathetosis revisited.

A case of familial paroxysmal dystonic choreoathetosis (PDC) documented by video/EEG monitoring is described. The father of the proband is affected by exertional cramping but not PDC, lending support to the previous hypothesis that exertional cramping may represent a "forme fruste" or the incomplete expression of PDC. Other family members affected by PDC are women, with exercise-induced cramping alone found in two men. Two of the women report prolonged exertion as a precipitant of lengthy spells consistent with typical PDC rather than the previously described "intermediate," exercise-induced form of PDC. Exertional cramping in families affected by PDC may represent the variable expression of the "dystonia gene" in male members. Conversely, exercise-induced PDC, both of the intermediate and longer form described here, may have a predilection to manifest in women.

Headache and electroconvulsive therapy.

While headache is a documented side effect of electroconvulsive therapy (ECT), there is little information on this phenomenon. Studies of the mechanisms of ECT as a treatment for depression indicate that alterations in serotonergic neurotransmission appear to be related to its efficacy. While ECT and many of the antidepressant drugs have similar effects on serotonergic transmission, they are notably different in the changes they induce in type 2 receptors for 5-hydroxytryptamine (5-HT). ECT upregulates 5-HT2, and antidepressants down regulate the receptor's expression. 5-HT2 receptor sensitization has been associated previously with headache genesis, which may explain why ECT induces headache, and amitriptyline relieves headache. In our study we surveyed 98 patients retrospectively about their experiences with headache prior to and following ECT. Of the 54 patients who submitted properly completed questionnaires, five reported new onset of headaches following ECT, four reported exacerbation of a previous headache problem, and two reported their headaches improved. The patients experienced changes in the character or location of pain, with a tendency to progress from tension-type to migrainous headache. In all but two cases these developments persisted at least eight months after ECT. We discuss the possible reasons and significance of our findings.

MRI findings in a case of ophthalmoplegic migraine.

MRI using gadolinium contrast material can demonstrate lesions in cranial nerves. Tumors and inflammatory lesions have been described. There is little published information on MRI of cranial nerves in patients with migraine headaches with ophthalmoplegia. We present a case of ophthalmoplegic migraine with a cranial nerve abnormality which was subsequently shown to improve as the patient clinically improved. Implications from this finding are discussed in relation to the pathophysiology of ophthalmoplegic migraine.

Dihydroergotamine suppositories in a headache clinic.

Dihydroergotamine (DHE) is available in the United States for parenteral use. We report a preliminary trial of DHE suppositories in an outpatient headache clinic setting. Dihydroergotamine suppositories may be appropriate for patients with catamenial migraine and classic migraine in particular.