Classifying headaches as primary (migraine, tension-type or cluster) or secondary can facilitate evaluation and management A detailed headache history helps to distinguish among the primary headache disorders. "Red flags" for secondary disorders include sudden onset of headache, onset of headache after 50 years of age, increased frequency or severity of headache, new onset of headache with an underlying medical condition, headache with concomitant systemic illness, focal neurologic signs or symptoms, papilledema and headache subsequent to head trauma. A thorough neurologic examination should be performed, with abnormal findings warranting neuroimaging to rule out intracranial pathology. The preferred imaging modality to rule out hemorrhage is noncontrast computed tomographic (CT) scanning followed by lumbar puncture if the CT scan is normal. Magnetic resonance imaging (MRI) is more expensive than CT scanning and less widely available; however, MRI reveals more detail and is necessary for imaging the posterior fossa. Cerebrospinal fluid (CSF) analysis can help to confirm or rule out hemorrhage, infection, tumor and disorders related to CSF hypertension or hypotension. Referral is appropriate for patients with headaches that are difficult to diagnose, or that worsen or fail to respond to management (+info)
Cluster headaches associated with vascular malformations.
A vascular malformation was demonstrated in a migrainous female who had developed cluster headaches. The patient responded well to oral dihydroergotamine 1 mg twice daily. (+info)
Headache after carotid endarterectomy.
Forty-eight hours after undergoing a successful right carotid endarectomy a patient complained of headache in and behind the right eye radiating to the temple and forehead. The onset of headache was sudden, and the pain was severe and throbbing. After three weeks of regular four- to eight-hour attacks each day the headaches gradually became less frequent. Two months after operation they had disappeared completely. Headache as a complication of endarterectomy is rare, but typically it is vascular and subsides spontaneously in one to six months. If a predisposition to migraine were a precipitating factor many more cases would be expected. No possible explanation for for headache after carotid prearterectomy can account adequately for its apparent rarity. (+info)
Prospective, randomised, double blind, controlled comparison of metoclopramide and pethidine in the emergency treatment of acute primary vascular and tension type headache episodes.
STUDY OBJECTIVE: To compare analgesic effects of metoclopramide (MTP), pethidine (PET), and combination of metoclopramide-pethidine (M-PET) in the treatment of adult patients with acute primary vascular and tension type headache admitted in the emergency department (ED). METHODS: All consecutive adult patients admitted into a university hospital ED in six months with acute vascular and tension type headache were recruited. The patients whose complaints had lasted no longer than seven days were randomised to four groups and thereby received 10 mg MTP intravenously plus placebo intramuscularly (MTP), 10 mg MTP intravenously plus 50 mg PET intramuscularly (M-PET), 50 mg PET intramuscularly plus placebo intravenously (PET); and intramuscular and intravenous placebo (PLC) in a blinded fashion. The patients were asked to report the degree of pain at 0, 15, 30, and 45 minutes on visual analogue scale (VAS) and demographic data and any side effects encountered were recorded. Rescue medication was used if required by the patient because of poor pain relief. RESULTS: Data regarding 336 patients meeting inclusion criteria were analysed. Mean VAS values recorded at 45 minutes were significantly higher in PLC group than in others (p = 0.000). When the PLC group was excluded, VAS scores in MTP and M-PET groups were significantly lower than in PET group (p = 0.038). Though unimportant, the incidence of side effects recorded in PET group was found to be significantly higher than in the other groups (p = 0.003). CONCLUSION: These data suggest that MTP produces more effective analgesia than PET in both vascular and tension type headache in patients with acute primary headache episodes. (+info)
Dissection of bilateral intracranial vertebral artery with basilar artery involvement: a case report of a patient free from neurological deficits.
We report a patient with dissection of the bilateral intracranial vertebral artery (VA) that did not present any symptoms other than occipital headache, which was probably associated with sleeping overnight in a car seat with unsteady head position. Although cerebral angiography revealed extensive dissection of the bilateral VA after branching of the posterior inferior cerebral artery, retrograde flow to the basilar artery (BA) via the right posterior communicating artery contributed to preserved posterior circulation. These findings indicate that even in patients without neurological deficits, the involvement of BA cannot be excluded and that accurate evaluation using radiological techniques should be considered. (+info)
Intravenous administration of metoclopramide by 2 min bolus vs 15 min infusion: does it affect the improvement of headache while reducing the side effects?
OBJECTIVE: To determine the therapeutic effect (alleviation of vascular type headache) and side effects of a slow intravenous metoclopramide infusion over 15 min compared with those effects of a bolus intravenous metoclopramide infusion over 2 min in the treatment of patients with recent onset vascular type headache. MATERIAL AND METHODS: All adults treated with metoclopramide for vascular type headache were eligible for entry into this clinical randomised double blinded trial. This study compared the effects of two different rates of intravenous infusion of metoclopramide over a period of 13 months at a university hospital emergency department. During the trial, side effects and headache scores were recorded at baseline (0 min), and then at 5, 15, 30 and 60 min. Repeated measures analysis of variance was used to compare the medication's efficacy and side effects. RESULTS: A total of 120 patients presenting to the emergency department met the inclusion criteria. Of these, 62 patients (51.7%) were given 10 mg metoclopramide as a slow intravenous infusion over 15 min (SIG group) and 58 patients (48.3%) were given 10 mg metoclopramide intravenous bolus infusion over 2 min (BIG group). 17 of the 58 patients in the BIG group (29.3%) and 4 of the 62 patients (6.5%) in the SIG group had akathisia (p = 0.001). There were no significant differences between the BIG and SIG groups in terms of mean headache scores (p = 0.34) and no adverse reactions in the study period. Metoclopramide successfully relieved the headache symptom(s) of patients in both the BIG and SIG groups. CONCLUSION: Slowing the infusion rate of metoclopramide is an effective strategy for the improvement of headache and reducing the incidence of akathisia in patients with vascular type headache. (+info)
Benign vascular sexual headache and exertional headache: interrelationships and long term prognosis.
There is a definite relationship between the vascular type of benign sexual headache and benign exertional headache. Forty five patients with benign vascular sexual headache were reviewed. Twenty seven (60%) experienced benign vascular sexual headache alone and eighteen (40%) had experienced both benign vascular sexual headache and benign exertional headache on at least one occasion. The mean age was 34.3 years with a male:female ratio of 5.4:1. Thirty patients with a history of benign vascular sexual headache were followed for an average of 74 months. A personal history of migraine was found in 47% of cases and a family history of migraine in 30%. Forty one per cent of patients with benign vascular sexual headache alone had recurrences after diagnosis, and stress and fatigue were considered major contributing factors to the initial and recurrent headache. Nine patients had experienced benign vascular sexual headache and benign exertional headache within 72 hours of each other on at least one occasion, often with a residual headache between the two. Four patients experienced their benign vascular sexual headache and benign exertional headache separated by months to years. The prognosis of benign vascular sexual headache and the clinical and possible pathophysiological relationships between benign vascular sexual headache and benign exertional headache are discussed. Knowledge of the interrelationships of these varieties of headache is valuable in the counselling of patients. (+info)
Cocaine-related vascular headaches.
The records of 21 patients admitted to hospital from January 1985 to December 1988 for acute headache associated with cocaine intoxication were reviewed. Fifteen patients were identified who experienced headaches with migrainous features in the absence of neurological or systemic complications. None of them had a history of cocaine-unrelated headaches or a family history of migraine, and all had a favourable outcome. Three possible mechanisms of cocaine-related vascular headaches are discussed which depend on the interval between cocaine ingestion and development of the headache. We postulate that acute headaches following cocaine use may relate to the sympathomimetic or vasoconstrictive effects of cocaine, while headaches following cocaine withdrawal or exacerbated during a cocaine "binge" may relate to cocaine-induced alteration of the serotoninergic system. (+info)