Stroke incidence, prevalence and mortality in women worldwide.

BACKGROUND: The study of sex differences on stroke incidence, prevalence and mortality is an emerging field of stroke epidemiology and care. AIMS: This study sought to determine the information available on stroke epidemiology in women worldwide and possible sex differences in stroke epidemiology, and, if so, describe the nature of these differences and whether they are consistent across countries/groups of countries. SUMMARY: We searched the available literature in English published between 1 January 2008 and 5 May 2015. Out of 17.789 papers only 56 peer-reviewed papers (29 community-based studies, 17 retrospective studies, 6 reviews, and 4 cross-sectional studies) have been included in the study. This review adopted the epidemiologic transition theory, which classifies countries into four stages according to their levels of industrialization and economy. For the first and second stages, reliable registries and health certification are lacking, and therefore our sought after data were very limited.In the third stage, specifically for Eastern Europe (post-socialist countries), the burden from stroke in women was on the rise, while in the fourth stage, despite an aging population, decreases in stroke incidence, prevalence and mortality have been observed, even in subjects older than 80 years for both sexes. However, regarding studies of US populations, these trends for women were less pronounced for African Americans, and Hispanics as well as Indians. This suggests a "gender-gap" regarding access to treatment and care.In conclusion, identifying the presence of differing global burden between the sexes will allow us to better understand how to prevent, treat, and manage both men and women.

Headache.

Headache can be a symptom of vast pathologies, and common secondary headache including head or neck trauma, cranial or cervical vascular disorder, non-vascular intracranial disorders headache related to a substance or its withdrawals, infection, disorders of homeostasis, disorders of cranium or facial mouth or cranial disorders, and headache attributable to psychiatric. Stroke-related headache has been reported between 7 and 65% and headache is also the most frequent symptom of cerebral venous thrombosis, which is present in nearly 90% of patients.

Great careers: Cornil, Bouchard, Bourneville and Proust.

Several French physicians of the 19th century are considered to be the pioneers of modern neurology, especially Jean-Martin Charcot. Later, the pupils of Charcot--interns at La Salpêtrière Hospital in Paris, including Cornil, Bouchard and Bourneville--went on to make great contributions to the field of neurology with their own discoveries. Specifically, with their mentor, they made the following contributions: Bouchard is responsible for first-ever description of cerebral hemorrhage pathogenesis; Bourneville arranged for the publication of Charcot's works; Cornil demonstrated histological evidence that supported Guillaume Duchenne's hypothesis regarding the cause of paralysis in poliomyelitis and he made the first diagnosis of chronic childhood arthritis. Besides these physicians, Adrien Proust, the father of the novelist Marcel, who had met Charcot at the Salpêtrière during the early part of his career, was a renowned physician, who also contributed greatly to research through his published works on stroke, aphasia, hysteria and neurasthenia.

Update on hemicrania continua.

Hemicrania continua (HC) is a rare primary headache syndrome, characterized by unilateral pain and an absolute response to indometacin. Since the term was first coined in 1984, more than 100 cases have been described worldwide. Most recently, detailed case series that provide more detailed information concerning the sometimes complex clinical presentation of HC have been reported. Functional imaging studies suggest a unique pattern of subcortical involvement in HC: contralateral to the pain posterior hypothalamic region, ipsilateral dorsal pons and ipsilateral ventral midbrain, which, along with the particular effect of indometacin, probably justifies its classification as a unique entity. Increasing the awareness of this primary headache form among clinicians will aid in its diagnosis while further work is being undertaken to characterize the syndrome.

Hemicrania continua: a clinical study of 39 patients with diagnostic implications.

Hemicrania continua is an uncommon primary headache disorder, characterized by continuous unilateral pain, where pain exacerbations are associated with cranial autonomic features. The hallmark of this condition is the absolute response to indometacin. We describe the phenotype of this condition in a large series of patients. Thirty-six (92%) patients had side-locked pain and 3 (8%) had side-alternating pain. The majority (82%) of the patients had the chronic (unremitting) form and the severity range of background pain was 1-10 out of 10 on verbal rating scale, with a mean of 6.5. Thirty-eight (97%) of the patients rated the painful exacerbations between 6.5 and 10 with a mean of 9 and 28 (71%) described their severe pain as excruciating. Of the cohort, 97% had at least one cranial autonomic feature during exacerbations: 73% had lacrimation, 51% nasal congestion, 46% conjunctival injection and 40% ptosis and facial flushing. Other cranial autonomic features included rhinorrhoea, forehead/facial sweating, itching eye, eyelid oedema, sense of aural fullness and periaural swelling, miosis, mydriasis and swelling of the cheek and face. Thirty-one (79%) had phonophobia, which was unilateral in 14 (48%); 29 (74%) had photophobia, which was unilateral in 14 (48%); and 27 (69%) had motion sensitivity. In addition, about two-thirds were agitated or restless, or both, and about one-quarter were aggressive, mainly verbally, with severe pain. All patients had a positive placebo-controlled indometacin test (100-200 mg intramuscularly) or a positive oral indometacin trial, or both. We suggest the International Headache Society criteria be revised to remove the absence of side-shift pain as a criterion. Furthermore, revised criteria should encompass a more extensive range of cranial autonomic features and consider pain as fluctuating with moderate, severe and very severe intensity. Currently the sine qua non for hemicrania continua is a response to indometacin. Since there is no reliable clinical marker of that response, we recommend an indometacin test, either orally or by injection, for any patient with unilateral pain, with or without cranial autonomic symptoms.

Trigeminal autonomic cephalalgias: paroxysmal hemicrania, SUNCT/SUNA, and hemicrania continua.

The trigeminal autonomic cephalalgias (TACs) are a group of primary headache disorders that include cluster headache (CH), paroxysmal hemicrania (PH), and short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing/cranial autonomic features (SUNCT/SUNA). Hemicrania continua (HC) is often included with this group, although the second edition of The International Classification of Headache Disorders did not link the entities. Trigeminal autonomic cephalalgias are generally characterized by relatively short-lasting attacks of severe pain and lateralized associated features including the pain, cranial autonomic symptoms, and where present, migrainous symptoms, such as photophobia. Paroxysmal hemicrania has intermediate duration and intermediate attack frequency. Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing has the shortest attack duration and the highest attack frequency. Hemicrania continua has a continuous pain with exacerbations that can include cranial autonomic symptoms as part of the phenotype. The syndromes share much in their pathophysiology and investigation paths; however, their treatment is distinct, so that the accurate differentiation is important for optimal management.

Symptomatic trigeminal autonomic cephalalgias.

BACKGROUND: The trigeminal autonomic cephalalgias (TACs) are a group of primary headache syndromes characterized by strictly unilateral head pain that occurs in association with ipsilateral cranial autonomic features. The group includes cluster headache, paroxysmal hemicrania, and short lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing. These syndromes differ in attack duration and frequency as well as the response to therapy. Most of the cases of these syndromes are primary headaches, though numerous symptomatic cases have been described albeit that it is difficult to establish a causal relationship with the underlying pathology in most cases. REVIEW SUMMARY: We reviewed the literature to identify the cases of symptomatic TACs that were likely to be secondary to the reported underlying lesion. We also attempted to identify any clinical features that may be pointers for distinguishing these cases from primary cases and thereby inform the diagnostic workup of these disorders. CONCLUSION: Forty cases of symptomatic TACs were identified. These symptomatic headaches were associated with atypical phenotypes, abnormal examination, and poor treatment response though a significant minority had a typical presentation. A relatively high proportion of all TACs were secondary to pituitary tumors. It is difficult to draw up guidelines for the diagnostic workup required on the basis of this small retrospective case series. It remains unclear whether every TAC patient requires neuroimaging, though if it is considered then magnetic resonance imaging is the preferred modality. In addition, we suggest that all TAC patients should be carefully assessed for pituitary disease related symptoms but further investigations with magnetic resonance imaging of the pituitary gland and pituitary hormonal profile should only be undertaken in patients with atypical features, abnormal examination, or those resistant to the appropriate medical treatment.

Trigeminal autonomic cephalalgias: diagnostic and therapeutic developments.

PURPOSE OF REVIEW: The review was designed to summarize recent research relevant to the trigeminal autonomic cephalalgias, which include cluster headache, paroxysmal hemicrania, short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing/cranial autonomic features (SUNCT/SUNA). Hemicrania continua is included for completeness. RECENT FINDINGS: Cluster headache has the longest attack duration and relatively low attack frequency. Paroxysmal hemicrania has intermediate duration and intermediate attack frequency. Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing have the shortest attack duration and the highest attack frequency. Hemicrania continua has a continuous pain with exacerbations that can include cranial autonomic symptoms as part of the phenotype. The importance of diagnosing these syndromes resides in their excellent but highly selective response to treatment. SUMMARY: Considerable advances have been made in the diagnostic and therapeutic approaches to trigeminal autonomic cephalalgias and these are important for neurologists to consider.

Paroxysmal hemicrania: a prospective clinical study of 31 cases.

Paroxysmal hemicrania is a rare syndrome characterized by repeated attacks of strictly unilateral, severe, short-lasting pain occurring with cranial autonomic features. The hallmarks of this syndrome are the relatively short attacks and the exquisite response to indometacin. We describe the phenotype of this condition in a series of 31 patients. The mean duration of attack was 17 min. The mean attack frequency was 11. The distribution of the pain was orbital and temporal in 77% of the patients, retro-orbital in 61%, frontal in 55%, occipital in 42%; although pain was also reported in the vertex, second division of trigeminal nerve, neck, nose, jaw, parietal region, ear, teeth, eyebrow, shoulder (ipsilateral and bilateral), arm and third division of trigeminal nerve. Of the cohort, 87% had lacrimation, 68% had conjunctival injection, 58% rhinorrhoea, 54% nasal congestion, ptosis and facial flushing. Other cranial autonomic features include eyelid oedema, forehead/facial sweating, sense of aural fullness and periaural swelling, miosis, mydriasis and swelling of the cheek. The majority of the patients (80%) were agitated or restless, or both, with the pain and 26% were aggressive. All patients had positive placebo control indometacin test (100-200 mg intramuscularly), or a positive oral indometacin trial or both. We suggest the International Headache Society criteria be revised to remove specification of attack site, and to include the full range of cranial autonomic features. Currently, the sine qua non for paroxysmal hemicrania is a response to indometacin. Since there is no reliable clinical marker of that response we recommend an indometacin test, either orally or by injection for any patient with lateralized discrete attacks of head pain with associated cranial autonomic symptoms.

Application of the 1988 International Headache Society diagnostic criteria in nine Italian headache centers using a computerized structured record.

BACKGROUND: The actual application of the current International Headache Society (IHS) diagnostic criteria in clinical practice has not been investigated thoroughly. OBJECTIVES: To develop a computerized, structured, medical record based exclusively on the IHS classification system. DESIGN AND METHOD: We tested the computerized structured record by entering and analyzing data reported on the case sheets of 500 consecutive patients attending nine headache centers in Italy. All clinical diagnoses in the study were made according to current IHS criteria. The rate of concordance between the diagnosis provided by the computerized structured record and that reported by clinicians on the case sheets was calculated, and reasons for any discrepancies between the two diagnoses were analyzed. RESULTS: Concordance between the two diagnoses was found in 345 of 500 cases examined (69%). In the remaining 155 cases, diagnoses reached with the computerized structured record and case sheets were impossible or discordant with respect to the diagnoses made by the clinician. In 144 of these cases (28.8%), this was due to missing information or errors in the diagnosis recorded by the clinicians on the patient case sheet. In particular, the diagnosis could not be reached using the computerized structured record in 105 cases (20.6%) because of a lack of one or more data needed in formulating a correct diagnosis according to the IHS operational criteria for one of the primary headache disorders. In the remaining 41 cases some data were missing, but the data available were sufficient to reach a diagnosis according to the IHS criteria. Moreover, the diagnoses reached using the computerized structured record were not in agreement with those made by the clinicians in another 39 cases (7.9%) due to an incorrect interpretation by the clinicians of the data reported on the patients' case sheets. In only 2.2% of the cases (n = 11) misdiagnoses were due to errors of the program that were promptly corrected. CONCLUSIONS: The present study suggests that incorrect application of IHS criteria for the diagnosis of primary headache may occur in as many as one third of patients attending headache centers and that use of a computerized structured record based exclusively on current IHS criteria may overcome this deficiency.