HASH(0x48eff90)

ABSTRACT: Cluster headache (CH) is a primary headache disease characterized by recurrent short-lasting attacks (15 to 180 minutes) of excruciating unilateral periorbital pain accompanied by ipsilateral autonomic signs (lacrimation, nasal congestion, ptosis, miosis, lid edema, redness of the eye). It affects young adults, predominantly males. Prevalence is estimated at 0.5-1.0/1,000. CH has a circannual and circadian periodicity, attacks being clustered (hence the name) in bouts that can occur during specific months of the year. Alcohol is the only dietary trigger of CH, strong odors (mainly solvents and cigarette smoke) and napping may also trigger CH attacks. During bouts, attacks may happen at precise hours, especially during the night. During the attacks, patients tend to be restless. CH may be episodic or chronic, depending on the presence of remission periods. CH is associated with trigeminovascular activation and neuroendocrine and vegetative disturbances, however, the precise causative mechanisms remain unknown. Involvement of the hypothalamus (a structure regulating endocrine function and sleep-wake rhythms) has been confirmed, explaining, at least in part, the cyclic aspects of CH. The disease is familial in about 10% of cases. Genetic factors play a role in CH susceptibility, and a causative role has been suggested for the hypocretin receptor gene. Diagnosis is clinical. Differential diagnoses include other primary headache diseases such as migraine, paroxysmal hemicrania and SUNCT syndrome. At present, there is no curative treatment. There are efficient treatments to shorten the painful attacks (acute treatments) and to reduce the number of daily attacks (prophylactic treatments). Acute treatment is based on subcutaneous administration of sumatriptan and high-flow oxygen. Verapamil, lithium, methysergide, prednisone, greater occipital nerve blocks and topiramate may be used for prophylaxis. In refractory cases, deep-brain stimulation of the hypothalamus and greater occipital nerve stimulators have been tried in experimental settings.The disease course over a lifetime is unpredictable. Some patients have only one period of attacks, while in others the disease evolves from episodic to chronic form.

A 54 year-old female has a clinical diagnosis of chronic paroxysmal hemicrania (CPH) according to IHS-criteria (2004) three years ago. Six months after that, she developed symptoms compatible with trigeminal neuralgia (TN) involving the second and third trigeminal territories also at the left side. Cranial and cervical spine resonance magnetic images showed extensive cervical syringomyelia that included nucleus caudalis (C2 level) region and a posterior fossa Chiari I malformation without hydrocephalus. The association between CPH and TN is called chronic paroxysmal hemicrania-tic syndrome (CPH-tic). This is the first clinical description of a secondary cause of CPH-tic syndrome in the literature.

In the Vågå study of headache epidemiology, 1838 parishioners in the age group 18-65 years were included (88.6% of the relevant population). Each individual was questioned in a face-to-face situation. In this population, a search of rare unilateral headaches was also made, in spite of their presumed rarity. Trigeminal neuralgia was present in two cases. Two individuals with SUNCT traits were observed. Hemicrania continua may have been present in one individual. Also observed were: optic neuritis (n=1), herpes zoster (n=4); a case of unilateral headache upon neck rotation (chronic paroxysmal hemicrania variant? or "forme fruste" of the neck-tongue syndrome?); masseter muscle spasm (n=1); temporo-mandibular joint dislocation (n=1); and possible carotidynia (n=3). A particularly intriguing form of headache was a unilateral, neuralgiform (?) pain, associated with ipsilateral, regular jabs and allodynia, a combination observed in eight females. A couple of conditions that entirely defy rubrication are also reported.

Objectives - To describe a unilateral headache that in addition to the typical shortlasting unilateral neuralgiform headache attacks with conjunctival injection, tearing, sweating and rhinorrhea (SUNCT) syndrome - traits with excessive and ipsilateral autonomic phenomena - had circumscribed eyelid erythema and adjacent ocular redness. Observations - A 60-year-old female had excessive, right-sided lacrimation and local pain at 15 years of age. Due to steadily increasing discomfort, with lacrimation and swelling over the outer part of the upper eyelid, the right lacrimal gland was removed at 20 years of age, with a suspicion of lacrimal gland adenoma. Preoperatively, symptomatic side mild-degree eyelid erythema/rhinorrhea were integral parts of the attack. After years with minor complaints, she, in the mid-twenties, experienced more long-lasting pain attacks, and pain soon became the main problem. A marked, distinct erythema on the lateral part of the right-sided eyelids and marked, localized 'eye redness' in the adjacent area were main ingredients of the attacks together with eyelid edema and viscous rhinorrhea. There were visible vessels below the eye, and telangiectasia of the upper eyelid. Conclusions - This headache has many similarities with SUNCT - but has several, grossly deviating traits: the temporal aspects, excruciatingly intense pain attacks, and above all marked, lateral eye-lid erythema, and adjacent, massive ocular reddening. This constellation probably alienates it from SUNCT.

The trigeminal autonomic cephalalgias (TACs) are a group of primary headache disorders characterized by unilateral pain in the somatic distribution of the trigeminal nerve and ipsilateral autonomic signs, which reflect activation of the cranial parasympathetic pathway. The group includes cluster headache, paroxysmal hemicrania, and short-lasting unilateral neuralgiform headache with conjunctival injection and tearing. Hemicrania continua was previously classified as one of the TACs. Despite their common elements, individually these headaches differ with respect to attack duration, frequency, and response to indomethacin.

Styrene-butadiene copolymers were analyzed by static secondary ion mass spectrometry (S-SIMS) and laser ablation Fourier transform ion cyclotron resonance mass spectrometry (LA-FTICRMS) to obtain quantitative information based on specific ions. Silver deposition was performed on polystyrene, butadiene rubber and styrene-butadiene rubber. Under these experimental conditions, new secondary ions were detected, in particular silver-cationized butadiene [M(butadiene)- Ag](+) and styrene [M(styrene)- Ag](+) monomers. In contrast, LA-FTICRMS experiments did not require pretreatment. At high laser power density, UV photons (193, 266 and 355 nm) allowed the detection of styrene and butadiene monomers at m/z 104 and 54, respectively. The use of the observed ions by SIMS or LA-FTICRMS ensures that quantitative information on the relative distribution of each monomer is obtained. However, the silver coating thickness in the SIMS experiment seems to have an important influence on the quantitative information obtained. For LA-FTICRMS experiments, the best results are obtained at a wavelength of 355 nm.

For more accurate and objective pressure sore risk assessment various risk assessment tools were developed mainly in the USA and Great Britain. The Braden Scale for Predicting Pressure Sore Risk is one such example. By means of a literature analysis of German and English texts referring to the Braden Scale the scientific control criteria reliability and validity will be traced and consequences for application of the scale in Germany will be demonstrated. Analysis of 4 reliability studies shows an exclusive focus on interrater reliability. Further, even though examination of 19 validity studies occurs in many different settings, such examination is limited to the criteria sensitivity and specificity (accuracy). The range of sensitivity and specificity level is 35-100%. The recommended cut off points rank in the field of 10 to 19 points. The studies prove to be not comparable with each other. Furthermore, distortions in these studies can be found which affect accuracy of the scale. The results of the here presented analysis show an insufficient proof for reliability and validity in the American studies. In Germany, the Braden scale has not yet been tested under scientific criteria. Such testing is needed before using the scale in different German settings. During the course of such testing, construction and study procedures of the American studies can be used as a basis as can the problems be identified in the analysis presented below.

The clinical presentation, risk factors, laboratory data, and neuroimaging and neuropathological findings in 26 patients with autopsy proved central nervous system (CNS) aspergillosis are reviewed. Eleven patients had hematological malignancies (8 underwent bone marrow transplantation), 8 patients underwent liver transplantation, and 3 patients had acquired immunodeficiency syndrome. Four had illnesses resulting in immunosuppression (systemic lupus erythematosus, infected aortic graft, neuroblastoma, and fulminant hepatic failure). The most common presenting clinical symptoms of CNS aspergillosis were fever and a strokelike syndrome. Risk factors for developing CNS aspergillosis included neutropenia, immunosuppressive therapy, low CD4 counts, and retransplantation. Spinal fluid findings were nondiagnostic. Computed tomograms and magnetic resonance scans of the head showed low-density lesions or hemorrhagic infarctions. Most aspergillosis cases occurred in the setting of widely disseminated disease commonly arising from the lung. Pathologically, multiple areas of necrosis throughout the brain were seen. Aspergillus invasion of blood vessel walls was seen microscopically. Amphotericin B with or without flucytosine was not effective treatment.

As can be learned from the literature, bovine serum may contain antibodies directed against human immunoglobulin allotypes. This gave rise to the question of what the origin of those antibodies is. We tested bacteria (E. coli) by means of the haemagglutination inhibition assay, which is used to type either Gm or Km factors. Anti-G1m(2) and anti-G3m(10)-specific antibodies were inhibited by the bacteria in a clear-cut manner, as was anti-Km(1), albeit less significantly. In contrast, the bacteria tested almost totally failed to inhibit anti-G3m(21) serum. The results lead to the assumption that E. coli may carry both Gm- and Km-like antigenic structures, which are presumably the antigenic material leading to immunization of cattle. Furthermore, new attention is drawn to a mechanism for immunization which is discussed regarding the genesis of either AB0 isoagglutinins in man or other "naturally occurring" antibodies.

The utility of the differences between cluster headache (CH) and paroxysmal hemicrania (PH) is limited by the considerable overlap of their clinical characteristics. We compared 54 patients with CH and eight patients with PH in terms of demographic features, characteristics of headache attacks, associated autonomic features, temporal forms of disorders, and response to verapamil. According to our results, clinical features that distinguished CH and PH patients were: maximal pain localization, ocular in CH patients and extra-ocular in PH group; mean attack duration was longer and mean attack frequency was lower in CH patients in comparison with PH patients. Conjuctival injection was the only autonomic sign seen more frequently in CH patients. There were more CH patients with episodic and more PH patients with unremitting form of the disorder in examined groups. Although statistical analysis pointed out a significant difference between these clinical features, there was no clinical characteristic that exclusively belonged to one of these headache entities. Demographic characteristics (age, gender, social background), the other headache attack features (nocturnal attacks, interattack tenderness), the other autonomic signs, as well as the response to verapamil did not differ significantly between two groups.

The International Classification of Headache Disorders 2nd Edition (ICHD-II), published in 2004, marks an unquestionable progress from the preceding 1988 edition, but the in-depth analysis it offers is not immune from drawbacks and shortcomings. First of all, it is still basically a classification of attacks and not of syndromes. For the migraine group, while the revised classification more accurately characterises migraine with aura, it fails to provide a sufficiently structured description of those forms of migraine without aura that over the years evolve to so-called daily chronic forms. These forms are not adequately recognised as chronic migraine, which ICHD-II includes among the complications of migraine. The inclusion of short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) in the cluster headache group is bound to generate some perplexity, while the recognition of new daily persistent headache (NDPH) included in the group of other primary headaches as a separate clinical entity appears somewhat premature. Doubts are also raised by the actual existence of triptan-overuse headache, which ICHD-II includes in Group 8 among medication-overuse headaches. Finally, the addition of headache attributed to psychiatric disorder, which is certainly a good option in perspective, is not yet supported by an adequate systematisation.

Given the range of disorders that produce headache, a systematic approach to classification and diagnosis is an essential prelude to clinical management. For the last 15 years, the diagnostic criteria of the International Headache Society (IHS) have been the accepted standard. The second edition of The International Classification of Headache Disorders (January 2004) reflects our improved understanding of some disorders and the identification of new disorders. Neurologists who treat headache should become familiar with the revised criteria. Like its predecessor, the second edition of the IHS classification separates headache into primary and secondary disorders. The four categories of primary headaches include migraine, tension-type headache, cluster headache and other trigeminal autonomic cephalalgias, and other primary headaches. There are eight categories of secondary headache. Important changes in the second edition include a restructuring of these criteria for migraine, a new subclassification of tension-type headache, introduction of the concept of trigeminal autonomic cephalalgias, and addition of previously unclassified primary headaches. Several disorders were eliminated or reclassified. In this article, the authors present an overview of the revised IHS classification, highlighting the primary headache disorders and their diagnostic criteria. They conclude by presenting an approach to headache diagnosis based upon these criteria.

OBJECTIVE To investigate if the McGill Pain Questionnaire confirms the distinction between chronic migraine and chronic tension-type headache. BACKGROUND It has been suggested that different categories of chronic daily headache should be distinguished; in particular, chronic migraine and chronic tension-type headache. METHODS The McGill Pain Questionnaire and a visual analog scale were administered to 40 patients with chronic daily headache, 85 patients with migraine, and 47 patients with episodic tension-type headache. The patients with chronic daily headache were subdivided, according to criteria described by other authors, into those with chronic migraine (n=29) and those with chronic tension-type headache (n=11). Weighted McGill Pain Questionnaire item scores, subscales, total pain rating indexes, and choice frequency of the descriptors were calculated. The data of chronic migraine and chronic tension-type headache were compared and tested for significant differences (Student t test). The same was done for migraine and episodic tension-type headache. Data were also processed through the Self-organizing Map, a system based on a counter-propagation neural network. RESULTS In the chronic migraine group, compared with the chronic tension-type headache group, scores were higher in 17 of 20 McGill Pain Questionnaire items (significantly in 5) and for the sensory and affective subscales (significantly). In the migraine group, compared with the episodic tension-type headache group, scores were higher for 18 McGill Pain Questionnaire items (significantly in 7), and for the sensory, affective, and mixed affective-evaluative subscales, total pain-rating index, and visual analog scale (all significantly). The coincidence of descriptors of first choice was low between chronic migraine and chronic tension-type headache, but it was high between chronic migraine and migraine and between chronic tension-type headache and episodic tension-type headache. After Self-organizing Map analysis, chronic migraine and chronic tension-type headache were prevalently distributed in 2 different areas of the map. CONCLUSIONS In the disorders characterized by a daily and near-daily headache, the McGill Pain Questionnaire consistently can discriminate between those evolving from migraine and those evolving from tension-type headache, indirectly confirming the validity of a distinction between these 2 clinical conditions. The differences are similar to those observed between patients with migraine and patients with episodic tension-type headache. This seems to be independent of the pain level since the difference of the total pain-rating index and the visual analog scale between chronic migraine and chronic tension-type headache was not statistically significant.

In the International Headache Society (IHS) classification of 1988, chronic daily headache (CDH) forms are not exhaustively categorized. The forthcoming revision of the classification will include a number of CDH forms that had been reported prior to 1988 or have been identified after that date. In particular, chronic migraine will be added to the classification as a complication of migraine, provided that use of symptomatic drugs does not exceed 10 days per month. In addition to chronic cluster headache and chronic paroxysmal hemicrania, short-lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT) and hemicrania continua will be comprised among CDH forms with short-lived attacks. Hypnic headache will be included in Group 4 ("Other primary headaches"). No additions will be made to the new IHS classification for forms such as new daily persistent headache (NDPH) and cervicogenic headache as proposed by Sjaastad.

Paroxysmal hemicrania has been described as an excruciating unilateral pain, which is usually ocular and frontotemporal with short-lasting (2-45 min), frequent attacks (usually more than five per day); with marked autonomic features (rhinorrhoea, nasal congestion, conjunctival injection, lacrimation) and unilateral to the pain. A response to indomethacin is essential using the current criteria for the diagnosis. It is a rare condition but when it occurs it is misdiagnosed as being due to sinusitis. A retrospective analysis of 11 patients seen in the period 1995-2001 suggests that there is an overlap between paroxysmal hemicrania and cluster headache. Four patients had all the characteristics of paroxysmal hemicrania and responded to indomethacin. Four other patients fulfilled the criteria except for the frequency and length of the attacks. They only had one attack per day and these lasted more than 2 h. Another patient had all the symptoms of paroxysmal hemicrania and did not respond to indomethacin, but responded to triptans and pizotifen. Patients with cluster headache typically respond to these. Two patients were unable to continue taking indomethacin owing to severe gastrointestinal upset. In the same period, we also had 30 patients with cluster headaches. There is increasing evidence that paroxysmal hemicrania and cluster headache share a similar pathogenesis and that they may not always be so discrete in either their response to indomethacin or their periodicity.