Migraine Case Example Research Paper

Chronic migraines and tension-type headaches are debilitating diseases affecting 1.4 to 2.2% of the population with both quality of life and economic implications. To date, the pain associated with migraine and tension-type headaches has been controlled with a range of medications, with varying levels of success. In addition, the side-effect profile of these medications, as well as their potential for addiction, has been a cause for concern for both patients and physicians.Migraine Case Example Research Paper

Chronic daily headaches (CDHs) refers to primary headaches that happen on at least 15 days per month, for 4 or more hours per day, for at least three consecutive months. The differential diagnosis of CDHs is challenging and should proceed in an orderly fashion. The approach begins with a search for “red flags” that suggest the possibility of a secondary headache. If secondary headaches that mimic CDHs are excluded, either on clinical grounds or through investigation, the next step is to classify the headaches based on the duration of attacks. If the attacks last less than 4 hours per day, a trigeminal autonomic cephalalgia (TAC) is likely. TACs include episodic and chronic cluster headache, episodic and chronic paroxysmal hemicrania, SUNCT, and hypnic headache. If the duration is ≥4 h, a CDH is likely and the differential diagnosis encompasses chronic migraine, chronic tension-type headache, new daily persistent headache and hemicrania continua. The clinical approach to diagnosing CDH is the scope of this review.

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Case presentations

Four women with long histories of migraine or frequent tension-type headache that meet the International Classification of Headache Disorders criteria for Chronic Migraine or Tension-type Headaches were given a systemic treatment(s) of autologous stromal vascular fraction or autologous ‘StroMed’ isolated from lipoaspirate. StroMed is stromal vascular fraction cells prepared by ultrasonic cavitation. Two of the four patients, both of whom are Arab women aged 40 and 36 years, ceased having migraines after 1 month, for a period of 12 to 18 months. The third patient, a Slavic woman aged 43 years, had a significant decrease in the frequency and severity of migraines with only seven migraines over 18 months. The fourth patient, an Asian woman aged 44 years, obtained a temporary decrease for a period of a month and was retreated 18 months later and has been free of migraines to date for 1 month. Pain medication was typically reduced from prescribed opioid analgesia to non-steroidal anti-inflammatory drugs and paracetamol.Migraine Case Example Research Paper

Do brain tumours cause headaches?
Headaches are one of the most common symptoms of a brain tumour, but they are also common in healthy people, and can be due to many everyday causes.

The headaches are not caused directly by the tumour itself, as the brain has no pain receptors, but by a build-up of pressure on pain-sensitive blood vessels and nerves within the brain.

The build-up of pressure can be due to the tumour pressing on these vessels/nerves or by the tumour blocking the flow of cerebrospinal fluid (CSF) within the brain.

Headaches are rarely the only symptom of a brain tumour.

Doctors do NOT generally worry if your headache is:

occasional
mild
doesn’t last long
has an identifiable cause, such as a hangover, lack of sleep, flu-like illness, sinus infection or if you have been ‘fasting’ (not eating) or overusing medication.
However, people often worry whether their headache is due to something more serious, such as a brain tumour, particularly if they have frequent or severe headaches causing a lot of pain.

If you’re worried, you should speak to your doctor, who can undertake a neurological examination. This involves testing your vision, hearing, balance, reflexes, arm and leg strength, and coordination. If this examination does not show anything outside the normal range and you have no other symptoms, you are unlikely to have a brain tumour.Migraine Case Example Research Paper

What kind of headaches do brain tumours cause?
Headaches associated with brain tumours (tumors) are usually:

worse in the morning (you may wake with one)
aggravated by straining, coughing, shouting or bending over – their intensity and pain may reduce when you are stood upright and the build-up of CSF begins to drain
not managed by pain killers
What do brain tumour headaches feel like?
Headaches associated with brain tumours:

can be throbbing or a dull ache, depending on where they are in the brain
occur intermittently starting gradually, but fading over a few hours
tend to get worse over time
can resemble common migraine or tension-type headaches.
Other signs and symptoms of a brain tumour
Other features of headaches have been identified as “red flags,” which may suggest a brain tumour. These include:

a change in previous headache pattern
if your headaches are associated with:
prolonged/repeated vomiting
any new muscle weakness, sensory symptoms (e.g. numbness or speech difficulties), or visual symptoms, especially on one side of the body
a change in memory, personality, or thinking
seizures (fits) – this does not have to be a full convulsive seizure, but could be a twitching of the hand, arm or leg, or an ‘absence’.

Once considered rare, spontaneous intracranial hypotension (SIH) is now more commonly diagnosed and recognized as an important cause of headaches. SIH is typically the result of spontaneous cerebral spinal fluid (CSF) leak at the spine level; orthostatic headaches, low CSF pressure, and diffuse pachymeningeal enhancement on MRI are diagnostic hallmarks. However, SIH has a broad spectrum of clinical and imaging manifestations, and atypical cases are increasingly seen.Migraine Case Example Research Paper

“The variability in just about every aspect of this disorder is substantial,” says Bahram Mokri, M.D., an emeritus professor of neurology at Mayo Clinic in Rochester, Minnesota. “It can be difficult to diagnose and treat this syndrome.”

Sophisticated imaging and experience with the vast clinical presentations of this disorder are keys to the diagnosis. When the source of the leak is accurately identified and if surgical repair is deemed the best management, complete and lasting relief of symptoms can be achieved. “The outcome can be dramatic for most of these patients,” says David G. Piepgras, M.D., a consultant in Neurologic Surgery at Mayo Clinic in Rochester, Minnesota.

Spectrum of presentation
Mayo Clinic has been at the forefront of advances in SIH diagnosis and treatment. Over the past 25 years, Dr. Mokri and Dr. Piepgras have seen an estimated 700 patients with SIH. Articles summarizing many of the outcomes of Dr. Mokri’s work were published in the May 2014 edition of Neurologic Clinics and September 2014 edition of Headache.

Initially, it wasn’t uncommon for patients to be referred after misdiagnosis and treatment for conditions such as migraine or tension headache.

Based on work at Mayo Clinic, it now appears that the core pathogenic factor in SIH is decreased CSF volume rather than decreased CSF opening pressure. “Patients can have normal CSF pressure and yet have this syndrome,” Dr. Mokri says. “MRI findings and clinical features seem to be variables that are dependent on the CSF volume.”Migraine Case Example Research Paper

Even orthostatic headache, the most common symptom of SIH, appears to vary. The time from change in the patient’s posture from recumbent to standing and appearance of headache, or relief upon lying down — usually assumed to be a few minutes — can be much longer. The headache might be throbbing, but often is not, and pain can range from dull to severe. The headache is often but not always bilateral, and can be frontal, fronto-occipital, holocephalic or occipital.

Indeed, Dr. Mokri notes that not all patients with orthostatic headache have CSF leaks, and headaches related to CSF leaks are not all orthostatic: “Sometimes, orthostatic features may dampen, and the pain transform into a lingering, chronic daily headache.”

The nonheadache manifestations of CSF leak also vary greatly, including but not limited to:

Neck or interscapular pain
Tinnitus, change in hearing and dizziness
Nausea and emesis
Gait unsteadiness
Diplopia
Trouble with memory or cognitive function
Movement disorders, such as chorea or parkinsonism
A case series of movement disorders associated with spontaneous CSF leaks was published in the December 2014 issue of Cephalagia.

“Patients can be profoundly affected,” Dr. Piepgras says. “The headache might be so disabling that the patient can’t be up and working.” He cites one patient seen at Mayo Clinic with a spinal CSF leak and brain sag so severe that a syrinx developed in the patient’s spinal cord — which resolved after identification and repair of the leak.

Images of a woman with orthostatic headaches and pain in the posterior neck and shoulder muscles
Woman with orthostatic headaches and pain in the posterior neck and shoulder muscles
A significant minority of patients with SIH display clinical signs of heritable disorders of the connective tissue matrix. Although the etiology of spontaneous CSF leaks remains unknown in many patients, connective tissue weakness may play a role in the formation of meningeal diverticula and zones of dural weakness, resulting in CSF leaks.Migraine Case Example Research Paper

Sealing CSF leaks
At Mayo Clinic, patients who haven’t responded to initial conservative treatment — bed rest, hydration and time — are usually first treated with an epidural blood patch. Many require more than one patch. Although the overall success rate with each patch is about 30 percent, Dr. Mokri notes that, in his clinical experience, patients acknowledge the cumulative improvement when asked after several treatments to compare their symptoms with those before treatment started. Another treatment option is epidural injections of fibrin glue or blood and fibrin glue.

Surgery is considered if these less invasive treatments fail, and the source of the CSF leak is located. Mayo Clinic neuroradiologists have experience with CT myelogram and MRI with gadolinium contrast in these cases. Pinpointing a slow-flow leak remains a challenge; radioisotope cisternography can be helpful in providing evidence of slow-flow CSF leak but is less helpful in determining the precise site.

“The surgery itself may be difficult, particularly if the repair must be in front of the spinal cord, often in the thoracic area,” Dr. Piepgras says. “But if you find the tear and stitch it up, the patient is cured.”

Images of man with orthostatic headaches, dizziness, nausea, and bowel and bladder incontinence
Man with orthostatic headaches, dizziness, nausea, and bowel and bladder incontinence
Successful treatment can sometimes result in rebound intracranial hypertension. Patients may re-present with headache that isn’t necessarily orthostatic, and occasionally with papilledema. “The hypertension usually settles down in a matter of months,” Dr. Mokri says. Acetazolamide may help ease symptoms.Migraine Case Example Research Paper

Dr. Mokri notes that when he began practicing, a diagnosis of low CSF volume headache was largely unknown. Once MRI with contrast became available, he and Dr. Piepgras began seeing patients with diffuse meningeal enhancement and orthostatic headache often referred to Mayo Clinic with diagnoses such as chronic meningitis.

“But to me, it didn’t make sense that fixed meningeal pathology would cause such an intermittent position-related headache,” Dr. Mokri says. “And so we began researching and publishing

Orthostatic hypotension — also called postural hypotension — is a form of low blood pressure that happens when you stand up from sitting or lying down. Orthostatic hypotension can make you feel dizzy or lightheaded, and maybe even faint.

Orthostatic hypotension may be mild and last for less than a few minutes. However, long-lasting orthostatic hypotension can signal more-serious problems, so it’s important to see a doctor if you frequently feel lightheaded when standing up.

Occasional (acute) orthostatic hypotension is usually caused by something obvious, such as dehydration or lengthy bed rest, and is easily treated. Chronic orthostatic hypotension is usually a sign of another health problem, so treatment varies.

Symptoms
The most common symptom is lightheadedness or dizziness when you stand up after sitting or lying down. Symptoms usually last less than a few minutes.Migraine Case Example Research Paper

Orthostatic hypotension signs and symptoms include:

Feeling lightheaded or dizzy after standing up
Blurry vision
Weakness
Fainting (syncope)
Confusion
Nausea
When to see a doctor
Occasional dizziness or lightheadedness may be fairly minor — triggered by mild dehydration, low blood sugar or overheating. Dizziness or lightheadedness may also happen when you stand after sitting for a long time. If these symptoms happen only occasionally, there’s likely no cause for concern.

It’s important to see your doctor if you experience frequent symptoms of orthostatic hypotension because they can signal serious problems. It’s even more urgent to see a doctor if you lose consciousness, even for just a few seconds.

Keep a record of your symptoms, when they occurred, how long they lasted and what you were doing at the time. If these occur at dangerous times, such as while driving, discuss this with your doctor.

Request an Appointment at Mayo Clinic
Causes
When you stand up, gravity causes blood to pool in your legs and abdomen. This decreases blood pressure because there’s less blood circulating back to your heart.Migraine Case Example Research Paper

Normally, special cells (baroreceptors) near your heart and neck arteries sense this lower blood pressure. The baroreceptors send signals to centers in your brain, which signals your heart to beat faster and pump more blood, which stabilizes blood pressure. These cells also narrow the blood vessels and increase blood pressure.

Orthostatic hypotension occurs when something interrupts the body’s natural process of counteracting low blood pressure. Many different conditions can cause orthostatic hypotension, including:

Dehydration. Fever, vomiting, not drinking enough fluids, severe diarrhea and strenuous exercise with excessive sweating can all lead to dehydration, which decreases blood volume. Mild dehydration can cause symptoms of orthostatic hypotension, such as weakness, dizziness and fatigue.
Heart problems. Some heart conditions that can lead to low blood pressure include extremely low heart rate (bradycardia), heart valve problems, heart attack and heart failure. These conditions prevent your body from responding rapidly enough to pump more blood when standing up.
Endocrine problems. Thyroid conditions, adrenal insufficiency (Addison’s disease) and low blood sugar (hypoglycemia) can cause orthostatic hypotension, as can diabetes — which can damage the nerves that help send signals regulating blood pressure.
Nervous system disorders. Some nervous system disorders, such as Parkinson’s disease, multiple system atrophy, Lewy body dementia, pure autonomic failure and amyloidosis, can disrupt your body’s normal blood pressure regulation system.
After eating meals. Some people experience low blood pressure after eating meals (postprandial hypotension). This condition is more common in older adults.
Risk factors
The risk factors for orthostatic hypotension include:

Age. Orthostatic hypotension is common in those who are age 65 and older. Special cells (baroreceptors) near your heart and neck arteries that regulate blood pressure can slow as you age. It also may be harder for an aging heart to beat faster and compensate for drops in blood pressure.
Medications. These include medications used to treat high blood pressure or heart disease, such as diuretics, alpha blockers, beta blockers, calcium channel blockers, angiotensin-converting enzyme (ACE) inhibitors and nitrates.Migraine Case Example Research Paper

Other medications that may increase your risk of orthostatic hypotension include medications used to treat Parkinson’s disease, certain antidepressants, certain antipsychotics, muscle relaxants, medications to treat erectile dysfunction and narcotics.

Using medications that treat high blood pressure in combination with other prescription and over-the-counter medications may cause low blood pressure.

Certain diseases. Some heart conditions, such as heart valve problems, heart attack and heart failure; certain nervous system disorders, such as Parkinson’s disease; and diseases that cause nerve damage (neuropathy), such as diabetes, increase the risk of low blood pressure.
Heat exposure. Being in a hot environment can cause heavy sweating and possibly dehydration, which can lower your blood pressure and trigger orthostatic hypotension.
Bed rest. If you have to stay in bed a long time because of an illness, you may become weak. When you try to stand up, you may experience orthostatic hypotension.
Pregnancy. Because your circulatory system expands rapidly during pregnancy, blood pressure is likely to drop. This is normal, and blood pressure usually returns to your pre-pregnancy level after you’ve given birth.
Alcohol. Drinking alcohol can increase your risk of orthostatic hypotension.
Complications
Persistent orthostatic hypotension can cause serious complications, especially in older adults. These include:

Falls. Falling down as a result of fainting (syncope) is a common complication in people with orthostatic hypotension.
Stroke. The swings in blood pressure when you stand and sit as a result of orthostatic hypotension can be a risk factor for stroke due to the reduced blood supply to the brain.
Cardiovascular diseases. Orthostatic hypotension can be a risk factor for cardiovascular diseases and complications, such as chest pain, heart failure or heart rhythm problems.Migraine Case Example Research Paper

What is Spontaneous Intracranial Hypotension (SIH)?
In the simplest of terms, SIH is a low-pressure headache. Intracranial hypotension literally means that there is low spinal fluid pressure in the brain. In SIH, there is a leak of spinal fluid from the spine, either in the neck (cervical) or mid-back (thoracic) area. Spinal fluid bathes the brain, cushioning it from impact against the skull when the head moves. The brain makes spinal fluid continuously, and absorbs it at the same rate, creating a delicate balance that keeps the spinal fluid volume and pressure normal.

What are the Symptoms of SIH?
The most common symptom of SIH is a “typical” headache, located in the back of the head, often with neck pain. It is worse when standing or sitting and improves or goes away within 20-30 minutes of lying down, called “orthostatic” or “postural” headache. The pain is often very severe. The next most common variation is a headache that is not present (or mild) upon awakening but develops in the late morning or afternoon and worsens throughout the day.
The location of the headache varies – it may be in the front, affect the entire head or be one-sided. It may resemble migraine with sensitivity to light and noise, nausea or vomiting. There is no specific character of the pain, which may be aching, pounding, throbbing, stabbing, or pressure-like, as examples.Migraine Case Example Research Paper

Another common feature of the headache is marked worsening with coughing, sneezing, straining (lifting, bearing down during a bowel movement), exercise, bending over and sexual activity. Other symptoms include hearing changes (muffled hearing, ringing in the ears, hearing loss), dizziness, impaired concentration, back or chest pain, and double vision. Rarely loss of consciousness, coma, or a Parkinson-like state may occur.

SIH is one cause of New Daily Persistent Headache, which is a headache that starts “out of the blue” one day and never goes away.

Who Gets SIH?
Although anyone can get SIH, it seems to occur more often in people who have a weak “connective tissue matrix”. These people are often tall and thin, have a slender neck, are double-jointed or unusually flexible. Their dura is probably thinner and prone to tearing than in most people.

How is SIH Diagnosed?
If you think that have the symptoms of SIH, it’s important to consult your doctor to conduct a series of tests. From the Trendelenburg test, where the patient lies flat and the exam is tilted to lower the head, imaging studies such as an MRI scan, CT scan or cisternogram, can help to determine if SIH is the cause of the headaches. Still, even through diagnostic testing, a substantial minority of patients may have normal results.

How is SIH Treated?
Many patients with long-standing SIH discover that virtually all of the standard medications used for headache treatment are ineffective. The medical management is similar to what is used for the headache that occurs immediately after a spinal tap, including caffeine, hydration and lying flat. Sometimes an abdominal binder or a medication called theophylline (which acts similar to caffeine) are helpful but rarely make the headache go away permanently.Migraine Case Example Research Paper

Because epidural blood patches are usually successful, they are often the first line of treatment. The patient’s own blood is drawn from the arm and injected in the low spine into the epidural space, which is the space immediately outside the dura. The procedure is performed under fluoroscopy (x-ray) or CT as an outpatient. The most common complication is lower back pain that generally resolves within a week. Occasionally, the back pain lasts weeks or months; rarely there may be scarring (arachnoiditis) causing persistent back pain, or a rebound high pressure state which usually resolves on its own. There is a potential risk of infection. The blood patch often brings instant relief. Sometimes the effect wears off and additional blood patches are needed.

Spontaneous intracranial hypotension (SIH) is characterized by postural headaches secondary to low CSF pressures, which are not attributable to lumbar puncture (LP), trauma, surgery or any other inciting event. SIH is typically due to spontaneous spinal CSF leaks, and are an important and often misdiagnosed cause of new onset headache in young and middle‐aged individuals, especially women.

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Case
This is a case of a 31‐year‐old female with no significant past medical history, and no history of oral contraceptive use, who came to the emergency department complaining of sudden onset intense 10/10 frontal headache worsened by sitting upright and/or standing, and alleviated by lying supine, associated with nausea and vomiting.Migraine Case Example Research Paper

On exam, vital signs were found to be blood pressure 101/70 mmHg, heart rate 61/min, respiratory rate 20/min, and temperature 98.7°F. Laboratory findings were found to be as follows: Hb 14.3 g/dL, Hct 42.3%, WBC 9.5 K/μL, Plt 297 K/μL, glucose 91 mg/dL, BUN 15 mg/dL, Cr 0.8 mg/dL, Na 138 mEq/L, K 4.4 mEq/L, Cl 101 mEq/L, and CO2 25 mEq/L. The rest of the physical exam, including neurological exam, was within normal limits. This patient denies any history of lumbar puncture in the past. Upon arrival to the emergency department, a lumbar puncture was offered to the patient; however, she refused at that time. A CT scan of the head without contrast was done in the ED as well and showed no acute intracranial processes.

The patient’s headache was being treated with fioricet as needed for pain scale 2‐5/10 and with morphine 1 mg IV as needed for pain scale 7‐10/10. An MRA was done to rule out the possibility of Berry aneurysm, which was found to be unremarkable. An MRI with and without contrast showed dilatation of the right transverse sinus (Figs. (Figs.11 and and2)2) and paucity of CSF fluid in both optic nerve sheaths, compatible with intracranial hypotension.

What is a mixed tension migraine?
Scientists believe that there is a continuum of headaches, with tension headache at one end and migraine at the other. A mixed tension migraine is a headache that has characteristics of both a tension headache and a migraine headache. They occur more commonly in women than in men.

Pain-producing inflammatory substances surrounding blood vessels and nerves in the brain are thought to cause migraines. Millions of people worldwide experience regular migraine headaches.

A tension headache is caused by muscle tension. It’s the most common type of headache, according to the World Health OrganizationTrusted Source.

Because mixed tension migraines have symptoms of both migraine and tension headaches, they fall somewhere in the middle of the headache continuum. It’s believed that the migraine comes first, and it causes tension that triggers a tension headache.Migraine Case Example Research Paper

For most people, this type of headache can be managed with medication and by avoiding headache triggers.

Migraine vs. headache: How to tell them apart »

What are the symptoms of mixed tension migraines?
Mixed tension migraines have symptoms of both tension headaches and migraines. However, symptoms may vary from person to person. In other words, you may have more symptoms associated with a migraine than a tension headache or vice versa.

The pain of a mixed tension migraine can vary from dull to throbbing and from mild to severe. Mixed tension migraines typically last 4 to 72 hours.

Symptoms of a mixed tension migraine include:

pain on one or both sides of your head that may get worse with activity
nausea or vomiting
sensitivity to light, sound, or both
neck pain
fatigue
irritability
depression
numbness, tingling, or weakness in your limbs
How is a mixed tension migraine diagnosed?
There is no test for mixed tension migraine. Your doctor can form a diagnosis based on your symptoms and by ruling out other causes of your symptoms.

If you’re experiencing symptoms of a mixed tension migraine, your doctor will begin by taking your health history. They’ll ask you about your symptoms, including where you feel the pain, what the pain feels like, and how often the headaches occur.Migraine Case Example Research Paper

Your doctor will also ask you about your family’s history with headaches. This is because migraines may have a genetic link. Most people who experience migraines have a family member who also experiences migraines.

Your doctor may perform a neurological exam to rule out neuropathy and neurological disorders that can cause similar symptoms. During this exam, your doctor will test your reflexes and muscle tone. They’ll also test your response to different kinds of stimuli like light touch, temperature, and vibration. The results will tell your doctor if your nervous system is functioning normally.

Your doctor may order a CT scan or MRI scan of your head and neck. These tests will provide your doctor with an image of your brain and brain stem to see if your symptoms are being caused by a problem in your brain.

Your doctor may also order blood work to determine if underlying conditions are causing your headaches.

If your doctor suspects a more serious problem like bacterial meningitis or hemorrhage, they may order a lumbar puncture, also known as a spinal tap. This test uses a needle to collect fluid from your spine. They’ll analyze the fluid, which is called cerebrospinal fluid, for evidence of problems.

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What are the treatment options for mixed tension migraines?
Treatment options for mixed tension migraine can include treatments for both tension headaches and migraines. The treatment will depend on your symptoms.

Drugs and medication
Medications for treating mixed tension migraines include the following:Migraine Case Example Research Paper

triptans: cause blood vessels to constrict and ease migraine pain
analgesics: ease pain of less severe migraines and tension headaches, and include acetaminophen (Tylenol)
combination analgesics: often contain caffeine to ease migraine and tension headache pain
ergot derivative drugs: help decrease pain signals transmitted along the nerves
nonsteroidal anti-inflammatory drugs: reduce pain and inflammation, and include ibuprofen (Advil), and aspirin (Bufferin), which are also analgesics
anti-nausea drugs: ease nausea and vomiting caused by mixed tension migraine
A number of medications can be taken to prevent mixed tension migraines. These medications include:

beta-blockers: designed to treat high blood pressure, but can also prevent migraines
calcium channel blockers: help the blood vessels remain the same size and promote good blood flow
antidepressants: work on neurotransmitters in the brain and can prevent headaches
Nutrition and complementary therapy
Along with medications, there are several other methods that can help relieve mixed tension migraines. Magnesium and vitamin B2 deficiencies have been noted in people with migraines. Increasing your intake of those vitamins may help prevent your migraines.

Eating regularly throughout the day, staying hydrated, and getting regular exercise and enough sleep might also be helpful. Relaxation training, meditation, massage or physical therapy, and moist heat applied to the back of your neck may provide relief.

CBT and biofeedback
Some people find cognitive behavioral therapy (CBT) and biofeedback helpful. Both therapies will teach you to be aware of what causes stress and how to control your response to those stressors.Migraine Case Example Research Paper

In CBT, a therapist will help you understand the thoughts that cause you stress. They’ll teach you ways to change those thoughts and lower your stress.

Biofeedback uses special equipment to teach you to monitor and control responses to stress like muscle tension.

Headache hacks: 9 Simple tricks for fast relief »

Are there ways to prevent a mixed tension migraine?
Although the exact cause of migraines isn’t understood, it’s clear that some things can trigger a migraine. Avoiding your headache triggers can help prevent mixed tension migraines.

Try keeping a log of your headaches, what you ate or drank, and your surroundings before you felt a mixed tension migraine. Use this record to figure out what triggers your headaches.

Common headache triggers include:

alcohol, especially beer and red wine
bright or flashing lights
skipping meals
certain odors
particular foods or food additives like nitrates
not enough sleep or too much sleep
menstruation and other changes in hormone levels
overuse or withdrawal from certain medications

Diffuse meningeal enhancement on MRI with gadolinium contrast can confirm the diagnosis of intracranial hypotension when a patient presents with orthostatic headaches, said Todd J. Schwedt, M.D., a neurology fellow at the Mayo Clinic in Scottsdale, Ariz.

Patients who present with ongoing severe, diffuse, pressure headache that is worse when standing and relieved upon lying down may have intracranial hypotension due to a cerebrospinal fluid (CSF) leak. They may also experience very intense pain whenever they sneeze or cough, or with Valsalva maneuvers. The headaches may also be accompanied by vomiting and diminished hearing. Caffeinated beverages provide some relief from the headaches.Migraine Case Example Research Paper

On MRI of the brain with gadolinium contrast, the classic sign of intracranial hypotension due to a CSF leak is contiguous, pachymeningeal enhancement, Dr. Schwedt said. Spontaneous CSF leaks also can cause generalized sagging of the brain with downward displacement of the cerebellar tonsils that is clearly visible on MRI with gadolinium.

MRI of the spine with and without contrast may not be as helpful. Despite the presence of a CSF leak, spinal MRIs may appear normal, with no visible collection of CSF. On occasion, spinal MRI may show pooling of extraarachnoid CSF, but this rarely identifies the exact location of the leak.

Autologous epidural blood patch is used to treat the CSF leak, even when MRI has not located the exact site of the leak. A history of minor trauma, orthostatic headaches, hearing changes, and MRI findings are considered reason enough to perform the blood patch.

For an epidural blood patch, 10–20 mL of autologous blood is injected into the epidural space. “Injection into the lumbar region can be adequate since the blood may travel to the site of the dural leak and injection will result in elevated CSF pressure,” Dr. Schwedt said.Migraine Case Example Research Paper

Although the exact mechanism by which an epidural blood patch provides relief of symptoms is controversial, pain relief may be due to the formation of a gelatinous tamponade that stops the CSF leak and provides an immediate elevation of CSF pressure. Alternatively, the patch may increase CSF pressure by compression of the thecal sac, effectively reducing the volume of the intrathecal space. Relief usually occurs fairly quickly–within 30 minutes in many cases. The technique is typically performed by anesthesiologists.

Performing a lumbar puncture to see if a patient with such symptoms has a low opening pressure is an option. The CSF pressure may or may not be low, and the CSF may contain increased levels of protein and erythrocytes. However, given the diffuse meningeal enhancement seen on MRI and the clinical presentation, a clinical diagnosis can be made and a lumbar puncture avoided, as it has the potential to worsen the patient’s symptoms.

Headaches don’t have to be debilitating or life-threatening when you can identify the cause. For so many patients, once the initial workup to rule out major pathology has been completed, it can be difficult to feel like their symptoms are important to anyone but themselves. After being labeled as “migraine with aura,” “cluster headache” or “atypical tension headache,” there is little incentive to hunt up another diagnosis which might fit the symptom set more completely and offer additional insight. In addition to this being frustrating, it can be deeply dangerous, as these headaches can be life-threatening.

Symptoms that Worsen with Postural Change
One of the headache red flags that healthcare providers may be less familiar with is the presence of an orthostatic component to a patient’s symptoms. These symptoms may be subtle, slowly increasing throughout the day as a person spends more time erect, or they may be dramatic, worsening when standing and improving quickly when laying down. While the dramatic symptoms may be easier to identify, both versions can be indicative of a unique headache cause: cerebrospinal fluid leak.Migraine Case Example Research Paper

While far less common than the other worst-case headache scenarios, a CSF leak can have a range of presentations and outcomes. It can last a long time without worsening or can become life-threatening in an instant. When CSF leaks out of the dura through a small tear or hole, this can cause pressure changes in the brain that cause the symptoms of orthostatic headache. The staggering variance of these symptoms from this increased intracranial pressure are part of what makes this diagnosis so difficult, and can include:

❏ Neck pain
❏ Nausea
❏ Sinus leakage
❏ Dizziness
❏ Tinnitus
❏ Fatigue
❏ Confusion

These symptoms can also include vague neurological changes like unusual smells without a source, visual disturbances, areas of numbness or tingling on the skin, and metal tastes in the mouth.

Causes and More Confusion
Frustratingly, this CSF leak can occur for many reasons, some of them silent. The most commonly known and easily diagnosed cause is a known piercing of the dura, such as would occur during surgery of the brain or spine, or with an epidural or lumbar puncture. Another common cause is a bone spur or bony change such as occur during spinal damage via trauma or long-term degenerative disk disease. A third known cause is connective tissue disease, which may contribute to the dura being less resistant to damage or stretching from minor trauma. This third cause may be particular difficult for patients, as they may not know they suffer from this connective tissue disease until these symptoms present.Migraine Case Example Research Paper

For patients concerned that they may be suffering from these debilitating symptoms as a result of a CSF leak, an expert in the newly growing field, Dr. Ian Carroll at Stanford, recommends spending an entire day laying down. Those with a CSF leak may find that they are symptom free all day as a result, and if the experience is dramatic, it’s a sign of a possible leak. Once diagnosed, these leaks can be repaired with specific patches and even dural glue that are specifically designed to seal these leaks. Dr. Carroll is actively searching for patients who may be suffering from these headaches, and has identified 26 such patients in the last six months alone. In his words, “Having lives derailed by intractable headaches is a tragedy, but it is a much greater tragedy when the person has an undiagnosed CSF leak that could be fixed easily if only recognized. We can help them be back at work and live life more fully.”

❏ Neck pain
❏ Nausea
❏ Sinus leakage
❏ Dizziness
❏ Tinnitus
❏ Fatigue
❏ Confusion

These symptoms can also include vague neurological changes like unusual smells without a source, visual disturbances, areas of numbness or tingling on the skin, and metal tastes in the mouth.

Headache is a common problem that results in over 2 million visits to the emergency department (ED) every year.1 Most headaches are benign, self-limiting conditions or manifestations of chronic headache syndromes.2 Even among patients presenting with the “worst headache of my life,” benign causes far exceed life-threatening causes.3

Nevertheless, several serious and potentially life-threatening etiologies of headache can and do cause patients to present to the ED. Physicians are tasked with differentiating the benign causes from the more serious, and imaging often plays a major role in making this distinction.

Noncontrast head computed tomography (NCT) is the most common initial imaging test ordered for headache patients presenting to the ED.1 In most cases, this initial NCT will be normal. However, several potentially life-threatening causes of headache do appear as abnormalities on NCT, and these manifestations can range from subtle to highly conspicuous. In light of the high prevalence of normal CT examinations for headache, maintaining vigilance when reviewing these studies can be a challenge. An active search pattern may help radiologists to avoid missing subtle but potentially serious diagnoses.Migraine Case Example Research Paper

This 2-part series aims to review an approach to imaging patients presenting with severe headaches using a method that mirrors the everyday experience of radiologists. This first part focuses on potentially life-threatening diseases that commonly produce positive findings on the initial NCT. The goal of this article is to facilitate development of an active search pattern for NCT, which is encountered most frequently when evaluating headaches.

Part 2 will discuss diseases that often do not show findings on NCT. Because NCT may appear normal in these patients, these conditions require a heightened level of clinical suspicion to make the diagnosis, as well as a solid knowledge of the strengths and limitations of various imaging techniques. The goal of the second part is to explain how imaging modalities other than NCT may be used to review particular elements of the clinical presentation that may prompt radiologists to suggest such further imaging and make an accurate diagnosis.

Subarachnoid hemorrhage
Subarachnoid hemorrhage (SAH) is often the first diagnosis considered when evaluating a severe headache. However, most patients with this complaint do not have SAH. In one prospective investigation, 78% of patients presenting with the “worst headache of my life” did not have subarachnoid hemorrhage.4 Among unselected patients with headaches of varying severity who present to the emergency department, SAH is even less common, with several studies reporting an incidence of 1% or less.1,3,5

Despite these facts, SAH is a frequently pursued diagnosis because of its high rates of rebleeding and poor outcomes associated with untreated hemorrhage.6 Stated differently, the negative consequences of failure to detect SAH far outweigh the costs of screening every such patient. Perhaps because of the sheer volume of patients who present with headache, clinical misdiagnosis remains a problem, with initial misdiagnosis of SAH seen in 25% to 51% of cases.5 Even in the ED, one of every 20 cases of SAH may fail to be diagnosed. Migraine Case Example Research Paper

One literature review found CT to be highly sensitive for detecting SAH, with rates of 91% to 98% within the first 12 to 24 hours.8 Significantly, after 12 hrs to 24 hrs, CT’s sensitivity for SAH declined 82% to 84%, and the sensitivity of unenhanced CT at 1 week fell to 50%.8 Because of the potentially catastrophic consequences of missing SAH and the inability of imaging to detect all cases of SAH, lumbar puncture is still recommended in cases of clinically suspected SAH with a negative CT.6,9 Nonetheless, by focusing on certain imaging features on unenhanced CT, the diagnostic yield of unenhanced CT can be increased even several days after initial presentation. In particular, the dependent portions of the subarachnoid space and ventricular system should be carefully examined, as these areas may reveal subtle levels of SAH that have settled in the cerebrospinal fluid (CSF). Because patients are usually scanned in the supine position, particularly important locations include the interpeduncular cistern, the occipital horns of the lateral ventricles, the quadrigeminal plate cistern, and the dependent portions of the Sylvian fissures (Figure 1).

Once SAH is detected, the cause must be sought. In 80% of cases, the etiology is a ruptured aneurysm.10 In these patients, the pattern of hemorrhage on the initial NCT can help predict the site of the ruptured aneurysm, as indicated in Table 1.11 In some cases, the aneurysm itself can be seen as a filling defect against a background of subarachnoid blood (Figure 2). Imaging with conventional angiography, CT angiography (CTA), or less commonly, magnetic resonance angiography (MRA) is mandatory for definitively localizing the aneurysm.

In the remaining 20% of cases, a nonaneurysmal cause is responsible. Roughly half of such cases are due to nonaneurysmal perimesencephalic hemorrhage, which is thought to result from venous bleeding.10,12 In these patients, the hemorrhage is located in the interpeduncular cistern and immediately anterior to the brainstem (Figure 3).13 Recognizing this pattern is important, as it helps to determine prognosis and to guide subsequent imaging.Migraine Case Example Research Paper

Patients with isolated perimesencephalic hemorrhage almost always have no evidence of aneurysm on angiography, fare much better clinically than patients with aneurysmal hemorrhage, and are not at risk for recurrent hemorrhage.14 Other causes of angiogram-negative SAH include trauma, drug abuse (especially cocaine abuse), sickle cell disease, and coagulopathy.15

When adequate clinical information is available, CT diagnosis of SAH does not suffer from high rates of false-positive interpretations.Nevertheless, several mimics of SAH can manifest on CT as increased density in the subarachnoid space. Pseudo-subarachnoid hemorrhage is one such mimic; it can occur in the setting of markedly increased intracranial pressure, such as diffuse cerebral edema (Figure 4). The increased density in the subarachnoid space in pseudo-subarachnoid hemorrhage has been postulated to be due to engorgement of pial vasculature combined with heightened vascular conspicuity due to decreased parenchymal attenuation.16

Leptomeningeal spread of tumor may cause increased attenuation of the subarachnoid space on CT, particularly in neoplasms with highnuclear-to-cytoplasmic ratios, such as lymphoma (Figure 5). Finally, myelographic contrast material can mimic subarachnoid blood. Although one might expect a history of recent myelogram to be readily available from patients presenting with headache, the authors’ experience is that such details occasionally may not be immediately available when the myelogram has been performed at another medical facility.

Parenchymal hemorrhage
Many entities can cause brain parenchymal hemorrhage. An in-depth discussion of the pathophysiology and imaging of brain hemorrhageis beyond the scope of this article; a number of excellent review articles are available to explore this topic further.17,18 The major question faced by clinicians and radiologists is whether an underlying brain lesion, commonly vascular in nature, exists as a cause of hemorrhage. The answer to this question can often be quickly provided noninvasively by CTA or MRA (Figure 6). Clinicians can best select patients for angiographicimaging by considering several demographic, historical, and anatomical factors, most notably age, blood pressure, and hemorrhage location. In one study, CTA defined a vascular cause in 15% of unselected patients presenting with parenchymal hemorrhage.19 The incidence of a vascular cause of spontaneous parenchymal hemorrhage in this study rose to 47%, however, among patients < 46 years old.19 In addition to patients under the age of 50, other factors associated with a vascular etiology include absence of hypertension, presence of subarachnoid or intraventricular hemorrhage, and hemorrhage location in either the temporal or frontal lobes.Migraine Case Example Research Paper

Hydrocephalus
Hydrocephalus should be considered as a potential etiology in patients presenting with severe headache. In some cases, especially when acute, untreated hydrocephalus can be fatal. Therefore, evaluation of any brain imaging study must focus on the caliber of the ventricularsystem. If prior imaging studies are available, clinicians should carefully compare ventricular for interval changes that might signal new onset of hydrocephalus.

Deciding if the ventricular size is abnormally increased in a given patient often requires the subjective judgment of the radiologist. In earl yhydrocephalus, or in patients with brain volume loss due to aging or parenchymal disease, correctly identifying hydrocephalus may be difficult.Focusing on one particular location, the temporal horn of the lateral ventricle may prove helpful. Disproportionate enlargement of the temporal horns often indicates hydrocephalus, and can be useful in distinguishing ex vacuo dilation of the ventricles (ie, dilation due to parenchymal volume loss) from true hydrocephalus.20

Once hydrocephalus is detected, the next step is to determine whether the hydrocephalus is communicating or noncommunicating. Noncommunicating hydrocephalus results from a lesion in the ventricular system that obstructs flow of CSF. Its presence is suggested by the coexistence of a dilated proximal ventricular system and a decompressed distal ventricular system. The point of transition between the dilated and decompressed ventricles should be carefully scrutinized for the presence of a mass. Because the anatomic “choke points” of the ventricular system are located near the midline, one must be careful to scrutinize midline structures, including the foramen of Monro, the aqueduct of Sylvius, and the inferior fourth ventricle (Figure 7). Communicating hydrocephalus, by contrast, shows dilation of the entire ventricular system. In these cases,current or prior diseases affecting the CSF, such as subarachnoid hemorrhage, meningitis, and CSF dissemination of tumor, should be investigated.Migraine Case Example Research Paper

Ischemia
Arterial infarction is relatively often accompanied by headache, particularly in young patients or those with history of migraine.21 Detecting arterial infarction on NCT depends on the duration and severity of vascular occlusion. In general, most patients show ischemic changes on NCT within 6 hours of symptom onset.22 Once arterial ischemia is recognized, the etiology should be sought to help gauge the risk of recurrence and determine optimal treatment.23 Fortunately, the neurologic deficits associated with arterial ischemia generally help distinguish these patients from patients with benign headaches.24

PRES
Posterior reversible encephalopathy syndrome (PRES) is a neurological syndrome that manifests on imaging studies as multifocal areas of edema usually involving the parieto-occipital white matter, but often also involving other areas, including cortical and subcortical watershed distributions, and occasionally the cerebellum, basal ganglia, or brainstem (Figure 8).25 Headache is often a clinical feature of PRES, although usually not the only presenting feature. Typically, patients with PRES will also exhibit seizures, visual disturbances, and alteration of consciousness.26 Furthermore, PRES is most commonly observed in conjunction with particular disease states, especially hypertension, eclampsia/preeclampsia, immunosuppression, chemotherapy, and autoimmune diseases.27 The combination of suggestive imaging patterns, typical clinical presentation, and predisposing conditions should suggest the diagnosis.Migraine Case Example Research Paper

Although PRES abnormalities are best seen and characterized on MRI, they are usually visible on CT. One study compared CT and MR detection of PRES, and found that CT showed abnormalities in most cases of PRES (78%), but that MRI provided diagnosis with greater specificity.28 In that study, CT provided a specific diagnosis in only 45% of cases. In situations where the clinical findings are suggestive but initial CT is negative or equivocal, MRI should be performed for confirmation.

Brain tumor
Headache is common in patients with brain tumors.29 As in the case of PRES, however, headache usually is not the only presenting clinical feature in patients with newly diagnosed intracranial tumors; patients usually have coexistent neurologic deficits. In one study of 183 patients presenting with a brain tumor, isolated headache was the clinical presentation in only 8% of patients.30 Because primary headaches are much more common than tumors as a cause of headache, brain tumors overall are not a common cause of acute headache, with an incidence of < 1% among patients undergoing imaging for headache.31 Although full characterization may require further imaging, brain tumors of sufficient size to cause headache are often readily visible on NCT.

Patients presenting with severe headaches can present a diagnostic challenge due to the wide variety of causes that can range from benign to self-limiting to life threatening. Noncontrast CT plays a major role in the initial work-up of these patients. Therefore, awareness of the diseases that commonly show abnormalities on the initial CT is critical to development of an active search pattern.Migraine Case Example Research Paper

The Case
A 48-year-old woman with a history of migraine headaches and hypertension presented to her outpatient clinic with a 4-day history of headache. While shopping 4 days earlier, she experienced sudden onset of a severe diffuse headache—”maybe the worst headache I’ve ever had.” She sat down because of the pain and associated nausea.

She had presented to clinic later that day, where a nurse practitioner assessed her symptoms as consistent with her prior migraines, and recommended that she simply start the regimen that she had used in the past (ibuprofen and ergotamine tartrate/caffeine [Cafergot®]).

When her symptoms remained severe, she returned the following day to the urgent care center. A staff physician agreed with the nurse’s diagnosis and reassured the patient that there simply had not been enough time for the medications to take effect. He administered intramuscular ketorolac and oral prochlorperazine, with substantial improvement in her symptoms. An appointment was made for her to follow-up with her primary care physician 3 days later in case symptoms persisted, and also to discuss initiation of a medication for migraine prophylaxis.

When the patient returned for her clinic visit in the late afternoon 3 days later, she initially stated that her symptoms had resolved. On closer questioning, however, she stated that she continued to experience headaches when straining (eg, during bowel movements) or bending over. Her physical exam, including visualization of both retinas, was normal.Migraine Case Example Research Paper

The physician regarded the initial acute presentation as very worrisome for subarachnoid hemorrhage (SAH). However, her subsequent clinical course seemed too benign, even with the lingering headaches. Given that he had not completely ruled out the possibility of hemorrhage, he arranged for her to have a CT scan and asked the radiologist to page him immediately with the results. He also gave the patient clear instructions to call him if her symptoms worsened.

The radiologist paged the primary physician later that evening to inform him that the head CT was normal. Knowing that the CT is not 100% sensitive for subarachnoid hemorrhage, the physician telephoned the patient the next morning to see how she was doing. She had just woken up, but thanked him for calling and stated that she felt much better—then the phone went dead. At first, the physician thought she had simply hung up, but since it was rather abrupt he called back and received a busy signal. He called 911.

EMTs found the patient on the floor, arousable only to painful stimuli. MR angiography in the emergency department demonstrated a posterior circulation aneurysm (Figure 1), which was clipped later that day. The patient required a ventriculoperitoneal shunt, but her postoperative course went well, with complete neurologic recovery.
The Commentary
Even in this age of ready access to sophisticated neuro-imaging modalities, misdiagnosis of patients with non-traumatic subarachnoid hemorrhage occurs in roughly 20%-30% of cases (1-3) and results in an inordinate number of malpractice claims.(4) Why is this? Three recurring explanations may account for this high rate of misdiagnosis: (i) not considering the diagnosis, (ii) not understanding the limitations of computed tomography (CT), and (iii) not performing or correctly interpreting the results of lumbar puncture (LP).Migraine Case Example Research Paper

Failure to Consider the Diagnosis
In the ambulatory setting, headache accounts for about 4% of office visits and 2% of emergency department (ED) visits.(1,2) Even in the acuity-skewed ED population, less than 1% of headache patients have SAH, and only an additional 3%-4% have some other serious condition that is life, limb, vision, or brain threatening if untreated (Table 1). The clinician’s principal goal is to distinguish between the 95% of patients with self-limiting headache syndromes, who require pain control, and the other 5%, who require emergent diagnosis and treatment.

The clinician’s task may seem sufficiently similar to finding a needle in a haystack that high rates of misdiagnosis ought to be expected. However, clinicians operate with a number of misconceptions about patients with headaches in general and SAH in particular. First, because migraine and tension headache are so common, patients with a history of headaches sometimes develop other types of headache, as occurred in the present case. Since almost everyone has had a headache at some point, clinicians must carefully distinguish the index headache from prior ones.

We are not told how the nurse practitioner “assessed her symptoms as consistent with her prior migraines.” A simple battery of questions will quickly distinguish “familiar” or chronic headaches from unusual ones. In general, relevant questions include:

Are the quality, duration, severity, and onset of pain the same?
Are any associated symptoms the same?
How often and under what circumstances have headaches occurred in the past?
Has there been any kind of work-up for the headaches?
Is the current headache responding to treatment as in the past?
Many clinicians have the mistaken impression that patients with SAH invariably exhibit at least one of the following: severe, acute illness; hard neurological findings such as cranial nerve palsies; or meningismus. This is simply not true. As with most diagnoses in medicine, there is a bell-shaped curve of presentations, and well-appearing patients with normal neurological examinations represent approximately 30%-40% of patients with SAH.(1) Reliance on the classic presentation of any disease opens the door to misdiagnosis. Moreover, these mildly affected patients, who may lack classic symptoms and signs, have the most to gain by prompt correct diagnosis and therapy.Migraine Case Example Research Paper

Another misconception is that symptoms begin with strenuous activity. In fact, in one large study, roughly 50% of patients with SAH developed their initial symptoms during relaxed activity or were awakened from sleep.(5) Similarly, many patients will not describe their pain as “10 out of 10” in severity or characterize it as the “worst headache of my life.” Moreover, some patients report their symptoms as gradual in onset, rather than describing a “thunderclap” (sudden) onset headache. However, almost all patients will describe their headache as unusual or distinctive in terms of severity and/or character. Even when neck pain dominates the clinical picture, it too tends to be unusual and distinctive, reinforcing the importance of carefully characterizing the patient’s symptoms, especially when there is a prior history of headache. Table 2 lists common misdiagnoses given to SAH patients.

Another common misconception is that reduction of pain with analgesics excludes severe intracranial pathology. Pathophysiologically, a limited number of pathways mediate head pain. Since medications of any class (ie, non-steroidals, opiate analgesics) may blunt or eradicate headache, no diagnostic information should be ascribed to this response. Adding further to the challenge, the pain from a small SAH can resolve spontaneously.

With regard to history, there are two other important and related factors, at least one of which may have played a role in this case. The first is that patients will often use the words “migraine” and “sinus-headache” imprecisely. Some use “migraine” to mean any severe headache, whereas in fact, it has particular characteristics that are well-defined by the International Headache Society.(6) Therefore, if a patient says “I had two migraines last week,” the clinician should proceed as if the patient used the word “headache” until more questions confirm the headaches are indeed migraines.Migraine Case Example Research Paper

The second phenomenon is that of “anchoring.” The patient in this case is diagnosed (incorrectly) with migraine, which then becomes part of her (recent) past history. Psychologically, this limits the open-mindedness of subsequent clinicians evaluating the same problem. Remember that definitive diagnosis of either tension or migraine headache requires multiple episodes of typical symptoms (5 for migraine, 10 for tension headache). Therefore, one should be very cautious of making these diagnoses in patients presenting with their first or worst headache.

Physical examination in patients with SAH is often normal. Only 10%-15% of patients exhibit a third-nerve palsy—85% of aneurysms are located in the anterior circulation and are therefore unlikely to produce any cranial nerve findings.(2) Meningismus and ocular hemorrhages also occur only in a minority of patients.

For all these reasons, not considering SAH in the differential diagnosis remains the most common reason for misdiagnosis.(1,3) Failure to consider the diagnosis commonly results in failure to obtain relevant investigations—specifically, computed tomography and lumbar puncture. Even when these tests are performed, however, clinicians sometimes fail to interpret the results correctly, prematurely terminating the work-up in the face of an initial negative result.

The Limitations of CT Scanning
CT is a powerful diagnostic tool in SAH, but has important limitations. Putting aside misinterpretation, the two most serious issues are spectrum bias and timing from onset of headache.(1,2) In spectrum bias, less severely affected patients (on the left side of the bell-shaped curve of severity) have smaller bleeds and therefore are more likely to have a negative CT scan.(7,8) Timing is also crucial. During the first 12 hours after onset of the headache, CT sensitivity approaches 98%. However, the 95% confidence intervals around this number are wide, and therefore most still recommend a negative CT be followed by a lumbar puncture (LP).(8,9) Three days after onset of the headache, the CT is only 85% sensitive, and at 7 days, it is only 50% sensitive.(10)Migraine Case Example Research Paper

In this case, the patient’s CT was on the fourth day after onset of headache. The negative study at this stage (which would have a sensitivity of about 80%) should not have reassured the clinician and the correct next step would have been to perform an LP. Because this is often viewed as overly aggressive in these well-appearing patients, clinicians often forego this step.(11)

Interpreting the LP Results
The LP in patients with SAH may show blood, xanthochromia, or elevated opening pressure. Blood can be from a traumatic tap or from true SAH; there are many methods of distinguishing between the two, although none is entirely foolproof.(12) Xanthochromia is probably the best method (Figure 2). Many believe that xanthochromia must be measured by spectrophotometry; however this technique is not used in 99% of hospital laboratories in North America.(13) In addition, it may be overly sensitive, with many false positives.(11) Experimentally, CSF with red blood cell counts above 10,000 RBCs/µL or samples that have sat for a period of time prior to analysis may show xanthochromia in the absence of SAH.(14) An elevated opening pressure is found in roughly two thirds of patients with SAH and will occasionally suggest the alternative diagnoses of idiopathic intracranial hypertension and cerebral venous thrombosis.(1)

The best way to avoid misdiagnosis of patients with SAH is to take a very detailed history of the current headache, and to compare it with prior headaches. In patients with abnormal physical examinations, the decision to further evaluate the patient with CT, followed by LP if the CT is negative, equivocal or technically inadequate, is clear-cut. In patients with normal exams, clinicians should stay open to the possibility of SAH and have a very low threshold for pursuing the same evaluation (CT followed by LP) if this life-threatening disorder remains in the differential diagnosis based on the history.

Subarachnoid hemorrhage (SAH) refers to bleeding within the subarachnoid space, which is the area between the brain and the tissues that cover the brain.Migraine Case Example Research Paper

The subarachnoid space is the space where the cerebrospinal fluid circulates, and it’s responsible for protecting your brain from injury by serving as a cushion. A hemorrhage in this space can cause a coma, paralysis, and even death.

This condition can occur quickly, and is often the result of head trauma. The key to survival is immediate medical intervention. Call a doctor or 911 as soon as possible if you or someone you know has the symptoms of SAH.

This life-threatening condition is also rare. According to the Brain Aneurysm Foundation, SAH accounts for between 0.01 and 0.08 percent of visits to the emergency room.

Symptoms of SAH
When SAH develops, it has several symptoms. The main symptom is a sudden, severe headache, which is more intense at the base of the skull. It is often described as the worst headache people have ever experienced. Some people may even feel a popping sensation in their head before the hemorrhage begins.

You may also have:

neck pain
numbness throughout your body
shoulder pain
seizures
confusion
irritability
sensitivity to light
decreased vision
double vision
nausea
vomiting
rapid loss of alertness
The symptoms of SAH come on suddenly, and you may lose consciousness quickly. Seek emergency medical attention right away if you experience any of these symptoms combined with a severe headache.Migraine Case Example Research Paper

Causes of SAH
SAH can occur spontaneously, or as a result of head trauma. Spontaneous SAH is often related to brain aneurysms, which are abnormalities within the brain’s arteries. The most common cause of primary SAH is a berry aneurysm. It’s called a berry aneurysm because it forms a cluster of sac-like pouches in a cerebral vessel that looks like a cluster of berries. These aneurysms swell up and weaken the walls of the arteries over time.

When an aneurysm erupts, it quickly bleeds and forms a clot. This condition is responsible for most SAH cases. Aneurysmal hemorrhage may occur at any age, but it’s most common between age 40 and 65. Brain aneurysms are more common in women, in smokers, and in those with high blood pressure. In some cases, trauma to the brain during an injury can cause aneurysms and result in a subarachnoid hemorrhage.

Other causes of SAH include:

bleeding from an arteriovenous malformation (AVM)
bleeding disorders
use of blood thinners
A serious head injury, such as one that occurs in a car crash or when an older person falls and hits their head, can also lead to an SAH.

Risk factors for SAH
SAH can occur at any age, and some people are even born with cerebral aneurysms that can lead to this condition. According to the Internet Stroke Center, women are more likely than men to develop brain aneurysms, and thus SAH. Smoking and high blood pressure can also increase your risk of developing an aneurysm. Drug use, particularly methamphetamine and cocaine, dramatically increase the risk of not only developing an aneurysm, but having SAH.Migraine Case Example Research Paper

One in 50 people is estimated to have an unruptured aneurysm in the United States. You should talk to your doctor about your risk if you have a history of brain aneurysms.

If you have aneurysms, it’s important to see your doctor regularly to determine your risk for hemorrhaging — before SAH develops.

Diagnosing SAH
SAH is often detected during a physical exam. Your doctor may notice that you have a stiff neck and vision problems. The history of the sudden worst headache of your life also makes SAH more likely. This combination often leads to a diagnosis of SAH. You’ll need more testing to find out the severity of the hemorrhage so that you can get proper treatment.

First, your doctor may conduct a CT scan of the head to look for bleeding in your skull. If the results are inconclusive, the doctor may use a contrast dye during the procedure.

Other tests include:

an MRI scan, which uses radio waves to get clear, detailed images of the brain
a cerebral angiography, which uses an X-ray and injected dye to detect blood flow in the brain
a transcranial ultrasound, which detects blood flow in the arteries within the brain
lumbar puncture to see if blood cells are found in the cerebrospinal fluid
This condition is often misdiagnosed because 73 percent of people don’t get scans.

Treating SAH
Rapid treatment is important to save your life and reduce the possibility and extent of brain damage. Bleeding and pressure may build up in the brain, leading to coma and additional brain damage. This pressure needs to be alleviated by medications or a procedure to drain some of the cerebrospinal fluid. Second, the cause of the bleeding needs to be identified and treated, as new bleeding from the same aneurysm can frequently occur without treatment. Surgery is performed to clip, or close, the aneurysm and stop future bleeding.Migraine Case Example Research Paper

If your aneurysm is being clipped, a craniotomy is performed and the aneurysm is closed. A craniotomy involves opening the skull to expose the area of involvement. A technique called endovascular coiling may also be used to reduce the risk of further bleeding.

If SAH causes a coma, treatment will include appropriate life support with artificial ventilation, protection of the airways, and placement of a draining tube in the brain to relieve pressure.

If you don’t lose consciousness from the SAH, you’ll still be given strict instructions to prevent post-treatment coma. Bed rest is standard for people recovering from this condition. Your doctor will also ask you to refrain from straining your body or bending over. These actions can increase the pressure on your brain.

Your doctor may prescribe medications to:

regulate blood pressure with medication through an IV
prevent artery spasms with nimodipine
relieve severe headaches with painkillers and antianxiety medications
What are the complications of SAH?
Even after SAH treatment, you may be at risk for related complications. The most common complication is called repeated bleeding. This happens when a rupture that has healed itself ruptures again. Repeated bleeding can increase your risk of death. Comas due to SAH can also eventually lead to death.

In some cases, people may experience seizures or strokes following treatment.

How can I prevent SAH?
The only way to prevent this condition is to identify potential problems within the brain. Early detection and, in some cases, treatment of a brain aneurysm can prevent a subsequent hemorrhage in the subarachnoid space.

What is the long-term outlook for SAH?
SAH is a serious condition that can frequently be fatal. The recovery period is long, and you may be at a higher risk of complications if you’re older or have poor overall health.

The earlier you seek emergency medical care, the better your chances of survival.

What is an acute headache?
An acute headache is pain or discomfort that starts suddenly and gets worse quickly. You may have an acute headache only when you feel stress or eat certain foods. Other acute headache pain can happen every day, and sometimes several times a day.Migraine Case Example Research Paper

What are the most common types of acute headache?
Tension headache is the most common type of headache. These headaches typically occur in the late afternoon and go away by evening. The pain is usually mild or moderate. You may have problems tolerating bright light or loud noise. The pain is usually across the forehead or in the back of the head, often only on one side. These headaches may occur every day.
Migraine headaches cause moderate or severe pain. The headache generally lasts from 1 to 3 days and tends to come back. Pain is usually on only one side, but it may change sides. Migraines often occur in the temple, the back of the head, or behind the eye. The pain may throb or be sharp and steady.
A migraine with aura means you see or feel something before a migraine. You may see a small spot surrounded by bright zigzag lines. Other signs or symptoms may follow the aura.
Cluster headache pain is usually only on one side. It often causes severe pain, and can last for 30 minutes to 2 hours. These headaches may occur 1 or 2 times each day, more often at night. The pain may wake you.
What causes acute headaches?
The cause of your headache may not be known. The following conditions can trigger a headache:

Stress or tension, hours or even days after stressful events
Fatigue, a lack of sleep or changes in your usual sleep pattern, or a nap during the day
Menstruation, especially after pregnancy, or use of birth control pills or hormone replacement therapy
Food such as cured meats, artificial sweeteners, alcohol, dark chocolate, and MSG
Suddenly not having caffeine if you usually have larger amounts
A medical problem, such as an infection, tooth pain, neck or sinus pain, thyroid problems, or a tumor
A head injury

How is the type of acute headache diagnosed and treated?
Your healthcare provider will ask you to describe your pain and rate it on a scale from 1 to 10. Tell the provider how often you have headaches and how long they last. Also describe any other symptoms you have along with headaches, such as dizziness or blurred vision.Migraine Case Example Research Paper

Medicines may be given to manage or prevent headaches. The medicine will depend on the type of acute headache you have. Do not wait until the pain is severe before you take your medicine. You may be able to take over-the-counter pain medicines as needed. Examples include NSAIDs and acetaminophen. Ask your healthcare provider which medicine is right for you. Ask how much to take and when to take it. Follow directions. These medicines can cause stomach bleeding or kidney or liver damage if not taken correctly.
Biofeedback may be used to help you manage stress. Electrodes (wires) are placed on your body and attached to a monitor. You will learn how to change stress reactions. For example, you learn to slow your heart rate when you become upset.
Cognitive behavior therapy, or stress management, may be used with other therapies to prevent headaches.
What can I do to manage my symptoms?
Apply heat or ice on the headache area. Use a heat or ice pack. For an ice pack, you can also put crushed ice in a plastic bag. Cover the pack or bag with a towel before you apply it to your skin. Ice and heat both help decrease pain, and heat also helps decrease muscle spasms. Apply heat for 20 to 30 minutes every 2 hours. Apply ice for 15 to 20 minutes every hour. Apply heat or ice for as long and for as many days as directed. You may alternate heat and ice.
Relax your muscles. Lie down in a comfortable position and close your eyes. Relax your muscles slowly. Start at your toes and work your way up your body.
Keep a record of your headaches. Write down when your headaches start and stop. Include your symptoms and what you were doing when the headache began. Record what you ate or drank for 24 hours before the headache started. Describe the pain and where it hurts. Keep track of what you did to treat your headache and if it worked.
What can I do to prevent an acute headache?
Avoid anything that triggers an acute headache. Examples include exposure to chemicals, going to high altitude, or not getting enough sleep. Create a regular sleep routine. Go to sleep at the same time and wake up at the same time each day. Do not use electronic devices before bedtime. These may trigger a headache or prevent you from sleeping well.
Do not smoke. Nicotine and other chemicals in cigarettes and cigars can trigger an acute headache or make it worse. Ask your healthcare provider for information if you currently smoke and need help to quit. E-cigarettes or smokeless tobacco still contain nicotine. Talk to your healthcare provider before you use these products.
Limit alcohol as directed. Alcohol can trigger an acute headache or make it worse. If you have cluster headaches, do not drink alcohol during an episode. For other types of headaches, ask your healthcare provider if it is safe for you to drink alcohol. Ask how much is safe for you to drink, and how often.
Exercise as directed. Exercise can reduce tension and help with headache pain. Aim for 30 minutes of physical activity on most days of the week. Your healthcare provider can help you create an exercise plan.
Eat a variety of healthy foods. Healthy foods include fruits, vegetables, low-fat dairy products, lean meats, fish, whole grains, and cooked beans. Your healthcare provider or dietitian can help you create meals plans if you need to avoid foods that trigger headaches.

This case series is the first to provide evidence of the efficacy of autologous StroMed and stromal vascular fraction in the treatment of migraine and tension-type headache. The treatment of this disease by stromal vascular fraction adds a new dimension to its clinical applicability and suggests a relatively simple treatment that may help address the symptoms of the disease. Given what is known about the components of the stromal vascular fraction and how they act, the information presented in this case series may also further our knowledge of the etiology and pathophysiology of migraine and tension-type headaches. This treatment is simple, looks to be extremely effective and has been life changing for these patients.Migraine Case Example Research Paper

Primary headache disorders
Primary headaches refer to headaches without an anatomical or physiological explanation. Although their cause is unknown, they involve the neurovascular system of the brain. Such headaches include migraine without or with an aura and tension and cluster headaches. Patients with primary headache disorders often present to the allergist/immunologist to rule out an allergic cause for their headache and for possible treatment. Patients also present for evaluation and treatment of rhinitis and/or rhinosinusitis, and during their history it is revealed that they also have a primary headache disorder. Therefore, it behooves the allergist to be knowledgeable about the evaluation, diagnosis, and treatment of primary headache disorders.

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.Migraine Case Example Research Paper

Acute Headache accounts for about 3% of acute medical unit admissions1and up to 8% of Emergency Room attendances2. What follows is an approach to this problem based on the characteristics of the presenting headache type. For each type of acute headache there is a fairly well defined differential diagnosis. If you appreciate the clinical features that are associated with different headache disorders, then you are more likely to identify the correct cause and manage your patient effectively. You should also appreciate that non-neurological disorders, such as carbon monoxide poisoning3 can present with acute headache.

Acute Headaches, that present for hospital assessment are usually one of five types:

Thunderclap Headache – an abrupt severe headache which is maximal at onset

Headache and Fever – a new onset headache with fever

Headache with Focal Neurology – a new onset headache with ‘soft’ focal symptoms such as sensory, visual or motor (weakness) symptoms

New Onset Persistent Headache – a person with no prior history of headache who presents with several days or weeks of a new headache

Chronic Headache presenting for Pain Relief – a person with a known previous headache diagnosis who is in distress because their treatment is not working.

It goes without saying that the assessment of a patient with an acute headache requires a history, (including past medical history, medication history, social history, family history). The headache history must pay attention to the exact timing and severity of headache (“From the start of the headache, until it reached its worst, how long did it take?”). The recording and reading of vital signs (temperature, pulse rate, blood pressure, respiratory rate and Glasgow Coma Scale), a targeted screening neurological examination and a general medical examination are all essential. Arguably, an ECG could also form part of the initial assessment of acute headache4.Migraine Case Example Research Paper

Thunderclap headache is a headache of abrupt onset which is also maximal at onset. It is still not known how long such a headache has to last to have prognostic significance. Neuralgic head pains are also sudden, intense and maximal at onset but they would only last for seconds, and are usually repetitive or recurrent. A potentially serious headache would usually cause significant distress and persist. An unproven assumption is that a thunderclap headache should last for at least an hour to be significant, but no single clinical feature is pathognomic of a serious underlying cause5.

The priority in a first presentation of thunderclap headache is to exclude a ruptured intracranial berry aneurysm causing acute subarachnoid haemorrhage6. An urgent CT brain performed within 24 hours is the initial investigation of choice for the detection of subarachnoid haemorrhage (Fig. 1). Some recent evidence, which requires further validation in settings other than tertiary referral centres, suggests that a CT within 6 hours of an index thunderclap headache is completely sensitive and specific7. If an initial CT Brain is normal, lumbar puncture is required to exclude xanthochromia – which is best performed using CSF spectrophotometry

Headache, or cephalalgia, is defined as diffuse pain in various parts of the head, with the pain not confined to the area of distribution of a nerve. Headache is among the most common pain problems encountered in family practice. One epidemiologic study1 found that 95 percent of young women and 91 percent of young men experienced headache during a 12-month period; 18 percent of these women and 15 percent of these men consulted a physician because of their headache.Migraine Case Example Research Paper

The direct and indirect costs of migraine have been estimated at approximately $17 billion per year. Missed workdays and medical benefits associated with headache cost American industry approximately $50 billion annually.2

In 1988, the International Headache Society published a classification system for headache disorders.3 This extensive system is not convenient to apply in the clinical setting. However, it is diagnostically and therapeutically useful to consider headaches as being divided into two categories: primary and secondary. Primary headaches, which include migraine, tension-type headache and cluster headache, are benign; these headaches are usually recurrent and have no organic disease as their cause4 (Table 1).3 Secondary headaches are caused by under-lying organic diseases ranging from sinusitis to subarachnoid hemorrhage

Tension-type headache (TTH) imposes a heavy burden on the global population but remains incompletely understood and poorly managed. This is the most common type of primary headache: its lifetime prevalence in the general population ranges in different studies from 30 to 78%. At the same time, it is the least studied of the primary headache disorders, despite the fact that it has the highest socio-economic impact.

Tension-type headache is a neurological disorder characterized by a predisposition of attacks from mild to moderate headache with few associated symptoms that you can find in the subtitle ‘Characteristics’ (2).
The criteria for tension-type headache are based on the IHS classification. They are mentioned in the subtitle ‘Diagnostic Procedures’.

The exact mechanisms of tension-type headache are not known. Peripheral pain mechanisms are most likely to play a role in Infrequent episodic tension-type headache and frequent episodic tension-type headache, whereas central pain mechanisms play a more important role in Chronic tension-type headache. Migraine Case Example Research Paper

Tension-type headaches are divided into:
Infrequent episodic
The infrequent subtype has episodes less than once per month and has very little impact on the individual. The pain is typically bilateral, pressing, or tightening in quality and mild to moderate intensity. It is not worsened with physical activity. There is no nausea, but photophobia or phonophobia may be present.(3)(4)

Frequent episodic
Frequent sufferers (between one and fifteen days a month) can encounter considerable disability that sometimes needs expensive drugs and prophylactic medication. This frequent form is a physiologic response to stress, anxiety, depression, emotional conflicts, fatigue or repressed hostility.(3)(4)

Chronic tension-type headaches
The chronic subtype evolves over time from episodic tension-type headache. It is a serious disease, causes greatly decreased quality of life and high disability. It is diagnosed if headaches occur 15 days a month (180 or more days a year). (3)(4)

Probable tension-type headache
Some tension type headaches could be classified only as probable tension-type headache.

Clinically Relevant Anatomy
The brain itself is insensitive to pain, so that is not what hurts when a headache arises.

The pain, instead, occurs in the following locations:
– The tissues covering the brain.
– The attaching structures at the base of the brain.
– Muscles and blood vessels around the scalp, face, and neck.Migraine Case Example Research Paper

The pain is commonly described as a tight feeling, as if the head were in a vise. It usually occurs on both sides of the head and is often experienced in the forehead, in the back of the head and neck, or in both regions. Soreness in the shoulders or neck is common. The muscles who are tight in the frontal and temporal regio are: the masseter, pterygoid, sternocleidomastoid, splenius and trapezius muscles.

Headache is one of the most common physical complaints. Because less than 1% of all headaches are life-threatening, the challenge is to reassure and appropriately treat patients with benign headaches while finding the rare, life-threatening headache without excessive evaluation.

Headaches are classified as primary or secondary. Primary headaches are syndromes unto themselves rather than signs of other diseases. Although potentially disabling, they are reliably not life-threatening. Secondary headaches are symptoms of other illnesses. Unlike primary headaches, secondary headaches are potentially dangerous.

The distinction of primary and secondary headaches is useful diagnostically. Primary headaches, such as tension headaches, are diagnosed clinically, sometimes using diagnostic criteria (the most commonly used are published by the International Headache Society, IHS). Traditional diagnostic studies (laboratory studies, radiology, pathology) cannot verify the diagnosis. Secondary headaches, such as headaches caused by central nervous system (CNS) tumors, often can be definitively diagnosed by identifying the underlying disease.

Clinically, primary and secondary headaches can be difficult to distinguish. The single most important question when developing a differential diagnosis for a headache is, “Is this headache new or old?” Chronic headaches tend to be primary, while new-onset headaches are usually secondary. This is the first and most important pivotal point in diagnosing headaches. This distinction is not perfect. There are some chronic headaches that are secondary headaches (headaches caused by cervical degenerative joint disease for example) and even classic, primary headaches (such as migraines) can present as a new headache. The differentiation of old versus new also depends on how rapidly a patient brings his or her symptoms to medical attention. This being said, the classification of headaches as primary vs secondary and new vs old provides not only a memorable framework for the differential diagnosis but also a clinically useful structure by which the differential can be organized by pivotal points. The differential diagnosis appears below. Figure 20-1 shows the potential diagnoses in a more algorithmic form as they are often considered clinically.Migraine Case Example Research Paper

Migraine headache
Migraine is a chronic neurologic disorder characterized by recurrent moderate-to-severe headaches often accompanied by associated symptoms such as nausea, vomiting, photophobia, and phonophobia.1 It is one of the most frequent neurologic disorders, affecting up to 12.6% of the population (6% men, 18% women) and costs billions of dollars in direct medical costs as well as indirect costs such as lost productivity at work because of absenteeism.2 More than 30 million Americans, 75% of whom are women, are affected by this kind of headache.3 The World Health Organization considers migraine to be 1 of the top 20 most disabling diseases worldwide.4 Migraines can be subclassified into those with episodic and chronic types, primarily differentiated by frequency. Episodic migraine is defined as having <15 days per month with migraine episodes, whereas chronic is defined as the following: (1) headaches of any kind on ≥15 days per month; (2) ≥8 days per month with migraine; (3) headaches have migraine characteristics; (4) headaches are aborted by use of a triptan or ergot; and (5) no history of medication overuse.5, 6 Patients with chronic migraine may experience medication overuse or rebound headaches from various prescribed treatments.7 A genetic link is apparent because >50% of patients with migraine have affected family members.8
The International Headache Society (IHS) classifies headaches in The International Classification of Headache Disorders (www.ihs-headaches.org). Migraine with aura and migraine without aura are used for diagnosis and coding purposes, not terms such as common migraine or classic migraine. An aura is the complex of focal neurologic symptoms that initiate or accompany migraine attacks. Seventy percent to 85% of migraineurs have attacks without an aura, some have both, and 15% to 30% experience an aura.9
Migraine without aura
Migraine without aura is an idiopathic, recurring headache disorder that manifests with attacks lasting 4 to 72 hours (Table I). Typical characteristics of this headache include a unilateral and an occasion bilateral headache with a pulsatile quality, of moderate-to-severe intensity, aggravated by routine physical activity, and associated with nausea and photophobia and phonophobia. The prodrome or premonitory phase, which can occur hours to several days before a migraine, with or without an aura, occurs in 60% of patients.10 It may consist of hyperactivity, hypoactivity, depression, craving for certain foods, repetitive yawning, and other atypical symptoms, such as sensitivity to certain smells and stiff muscles, often of the neck. Common triggers include stress, fasting, sleep disturbances, menstrual periods, weather, alcohol, and foods that contain monosodium glutamate, tyramine, and nitrates.11 Migraine Case Example Research Paper

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