Great occipital nerve blockade for cluster headache in the emergency department: case report.

A 44-year-old man with a past medical history of episodic cluster headache presented in our ED with complaints of multiple daily cluster headache attacks, with cervico-occipital spreading of pain from May to September 2004. The neurological examination showed no abnormalities as well as brain and spine MRI. Great Occipital Nerve (GON) blockade, with Lidocaine 2% (5 ml) and betamethasone (2 mg), were performed in the right occipital region (ipsilaterally to cluster headache), during attack. GON blockade was effective immediately for the attack and the cluster period resolved after the injection. We suppose that the action of GON blockade may involve the trigemino-cervical complex and we moreover strongly suggest to use GON blockade in emergency departments for cluster headache with cervico-occipital spreading as attack abortive therapy, especially in oxygen and sumatriptan resistant cluster headache attacks, in patients who complaints sumatriptan side-effects or have contraindications to use triptans.

Primary headache in Emergency Department: prevalence, clinical features and therapeutical approach.

Headache is one of the most common reported complaints in the general adult population and it accounts for between 1% and 3% of admissions to an Emergency Department (ED). The overwhelming majority of patients who present to an ED with acute primary headache (PH) have migraine and very few of them receive a specific diagnosis and then an appropriate treatment. This is due, in part, to a low likelihood of emergency physicians diagnosing the type of PH, in turn due to lack of knowledge of the IHS criteria, and also the clinical condition of the patients (pain, border type of headache, etc.) In agreement with the literature, another interesting aspect of data emerging from our experience is that few of the ED PH patients are referred to headache clinics for diagnosis and treatment, especially if they present with high levels of disability. This attitude promotes the high-cost phenomenon of repeater patients that have already been admitted to the ED for the same reason in the past. This is statistically important because it involves about 10% of the population with PH.

Migraine in the Emergency Department: a psychometric study of a migraine "repeaters" sample.

To evaluate the influence of psychometric variables on the "repeater" phenomenon in an emergency department, 15 "repeaters" and 27 outpatient migraineurs were recruited. All patients were submitted to the Beck Depression Inventory (BDI), State and Trait Anxiety Inventory, Toronto Alexithymia Scale-20 (TAS-20), Tridimensional Personality Questionnaire and Migraine DIsability Assessment Scale (MIDAS). The "repeater" group showed higher MIDAS total scores (p=0.02) and higher scores in TAS-20 (p=0.02) than the outpatients. A higher frequency of alexithymic trait (p=0.02) and higher BDI scores (p=0.07) have also been observed in the "repeater" group than the outpatients. Alexithymia and depressive mood associated with high disability may be a specific psychosocial pattern of "repeater" migraineurs. The psychometric evaluation of this population may be important to explain the "repeaters" phenomenon.

Tolosa-Hunt syndrome in a patient with systemic lupus erythematosus.

We report a case of Tolosa-Hunt syndrome (THS) in a patient with systemic lupus erythematosus studied with MRI. Magnetic resonance showed enlargement of the cavernous sinus and compression of the carotid syphon by enhancing tissue. In particular, fat-suppressed T1-weighted images before and after contrast agent injection and MR angiography showed extension of the abnormal tissue to the apex of the orbit and narrowing of the internal carotid artery. A presumptive diagnosis of THS was made and steroid treatment was started with rapid relief of symptoms. Follow-up MR study after steroid therapy demonstrated sub-total resolution of the neuroradiological findings. Neuroradiological findings in THS are quite typical but they may be subtle; furthermore, the presence of a systemic disease may suggest secondary involvement of the cavernous sinus. Utilization of the appropriate MR techniques and follow-up exams may contribute to the diagnosis of THS even in the presence of other systemic diseases.