16th European Headache Congress

Chair

Headache is a common aura in patients with generalized seizures at a younger age of onset

Secondary headaches

Epidemiology

Abstract text (incl. figure legends and references) Question: Although the pathophysiology of headache as an epileptic aura is frequently attributed to the excessive neocortical cellular excitability of the parieto-occipital cortex in patients with focal seizures, several studies have documented headache may occur as an aura or isolated epileptic symptom in patients with generalized seizures. Currently, there is limited information on the headache as an aura in patients with generalized seizures. Methods: We performed a 14-year retrospective study of patients with generalized seizures who received at least 6 months of treatment in our epilepsy clinic. Information on the characteristics of aura and seizure semiology were obtained through review of medical records. The proportion of patients who experienced an aura including headache and the demographic and clinical characteristics of the patients with and without headache as an aura were further analyzed. Results: We included 102 patients diagnosed with generalized seizures and received treatment for at least 6 months. The patients were 44 males and 58 females. The most frequent seizure types were absence seizures in 8 patients, myoclonic seizures in 54 patients, and generalized tonic clonic seizures in 40 patients. Aura was documented in 45 patients (45/102, 44.1%) and headache was the most common aura in 26 patients (26/102, 25.5%). There was no differences in gender, seizure type, and presence or absence of aura other than headache but patients with headache as an aura had a significantly younger age of onset of seizures than patients without headache (14.8±3.8 vs 24.7±16.2, p=0.003). Conclusion: Our study shows that headache is the most frequent aura in patients with generalized seizures. Patients with a younger age of onset of seizures are more likely to experience headache as an aura, which may be due to differences in pathophysiology or cortical neuronal network according to the age of onset of seizures in patients with generalized seizures.

ePoster

Headache phenotypes in Idiopathic Intracranial Hypertension and its short-term outcomes

Multidisciplinary clinical assessments

Abstract text (incl. figure legends and references) Question: Is there any relationship between demographic factors, clinical pattern of headache, treatment response, and headache outcome with the headache phenotype of IIH? Methods: Retrospective analysis of demographic and clinical characteristics of patients with IIH presenting with headache between 01/01/2008-31/12/2021, with the evaluation of headache outcomes in the first 12 months following IIH treatment. Statistical analysis was made using descriptive and non-parametric tests. Results: Headache was present in 32 of 40 patients (80%) with IIH (90% female; mean age 32 years; mean BMI 32,9Kg/m2; 88% with papilledema; mean CSF opening pressure 37cmH20). Patients presented commonly with migraine (n=11, 34.4%) and tension-type headache (n=7, 28.1%). A not-classifiable phenotype was present in 12 patients (37.5%). Associated symptoms included photophobia (47%), worsening with Valsalva/recumbency (25%), nausea/vomiting (19%), and phonophobia (9%). 72% of patients had daily pain, but only 9% had a medication-overuse headache; 41% had previous primary headache (mostly migraine). Regarding treatment and short-term follow-up (12months), there was a failure to medical treatment in 44% and a reduction of headaches (≥50%) in 63% of the patients. Among headache phenotypes, there were no significant differences regarding age, race, BMI, or clinical features (symptoms associated with IIH, CSF opening pressure, clinical pattern of headache, time until diagnosis). Also, there were no differences regarding response to treatment or headache outcomes in 12 months follow-up. Conclusions: Headache phenotype does not appear to be an essential factor in allowing clinical distinction, treatment response, or predicting the short-term headache outcome of this intriguing entity.

Prof.

Outcome of epidural blood patch for imaging-negative spontaneous intracranial hypotension

Abstract text (incl. figure legends and references) Background: Spontaneous intracranial hypotension (SIH) is diagnosed based on at least one of abnormal findings in brain MRI, spinal imaging, and lumbar puncture. However, the sensitivity of brain MRI, spinal myelography, and lumbar puncture is low. We questioned if patients with suspected SIH would respond to epidural blood patch (EBP) although they do not have imaging abnormalities. Methods: We prospectively registered patients with suspected SIH admitted to Samsung Medical Center from 2017 January and 2021 July. For patients whose brain MRI and CT or MR myelography were normal and received EBP for the first time in our hospital, we analyzed their treatment outcome at discharge and 3 months after EBP which was defined as the remission of orthostatic headache and 50% response in maximal headache intensity. Results: A total of 22 treatment-naïve patients with orthostatic headache and negative brain and spinal imaging who received EBP were identified and included in this study. Spinal imaging was performed with CT myelography in 6 (27%) and MR myelography in 16 (73%). Out of 9 (41%) patients who underwent lumbar puncture, none had an opening pressure lower than normal range (median 13.8 cmH2O, interquartile 9.8 – 16.6). After EBP (mean 1.4 times, range 1–3), orthostatic headache was remitted in 77% and 95% of patients, and 50% response was achieved in 77% and 91% of patients, respectively at discharge and 3 months after treatment. Conclusion: Our study shows that EBP yielded a high rate of treatment response in imaging-negative patients with suspected SIH. We suggest that the empirical EBP should be considered for the treatment of new onset orthostatic headache although brain and spinal imaging are negative. The necessity of lumbar puncture is questionable in such patients considering the high response rate of EBP and low detection rate of &quot;low pressure&quot;.

Unusual Presentation of Headache Attributed to Airplane Travel - Case Report

Cluster headache 

Abstract text (incl. figure legends and references) BACKGROUND: According to ICHD-3 Headache Attributed to Airplane Travel is described as a severe headache, usually unilateral and periocular and without autonomic symptoms, occurring during and caused by aeroplane travel. A recent study reveals some differences in the clinical presentation and suggests a need for refining the criteria. AIM: To describe a case of headache attributed to airplane travel, accompanied by autonomic symptoms and longer duration. CASE PRESENTATION: A 34y woman with severe headache, which developed first on an aeroplane travel during landing and repeats ever since during landing. Pain is of shock-like nature, VAS=10, localized periocularly on the left, accompanied by nausea, vomiting, tearing of the right eye, followed by subsequent tearing of the left one. A discharge of clear secretion from the right nostrail is also present. Headache improves after landing but does not subside. It might contunue 1-3 days with a milder intensity. It is so unpleasant, the patient does not want to travel by plane. Apart from that, a classical clinical characteristics of migraine with visual aura (black dots in the vision field) is reported again on the left side with photo-, phonophobia, and nausea, no other autonomic symptoms, restlessness or aggitation. Patient had concurrent bronchial asthma. Neurological exam-normal. MRI showed small tempo-parietal lesions of a vascular nature; without any sinus pathology. The case most likely refers to both: 1) headache associated with airplane travel and 2) migraine with visual aura. However, the presence of autonomic symptoms is not alligned with the ICHD-3 definition for airplane headache. Additionally, the headache does not remit after landing wich is another discrepancy. The migraine with aura is co-existing. CONCLUSION: Based on the described clinical characteristics, it seems that headache attributed to airplane travel might present also with accompanying autonomic symptoms like lacrimation and rhinorhea.

Impact of migraine on the presentation of reversible cerebral vasoconstriction syndrome

Migraine

Abstract text (incl. figure legends and references) Question― Prevalence of migraine among patients with reversible cerebral vasoconstriction syndrome (RCVS) considerably exceeds prevalence in the general population. However, its impact on the clinical and radiological presentation of RCVS remains unknown. We aimed to compare clinical characteristics and complications in RCVS patients with and without a history of migraine. Methods― In a pooled cohort of 345 French patients with RCVS, we compared patients with and without a history of migraine regarding the clinical presentation, rates of neurological complications, and the functional outcome at 3 months. Results― Among 345 patients, 92 (27%) reported a history of migraine. Migraine was independently associated with the absence of thunderclap headache at onset (OR 1.8, 95% CI 1.0-3.3; p=0.049) and with absence of recalled sexual triggers (OR 2.4, 95% CI 1.3-4.7; p=0.008). History of migraine with aura was an independent risk factor for aura during the course of RCVS (OR 6.4, 95% CI 2.0-20.4; p=0.002), while history of migraine without aura was independently associated with the occurrence of subarachnoid hemorrhage (SAH; OR 2.0, 95% CI 1.0-3.7; p=0.037) and multiple cervical artery dissections (mCAD; OR 4.1, 95% CI 1.1-14.6; p=0.032). The functional outcome was equal in both groups, with a modified Rankin scale score of 0-1 in ≥90% of patients. Conclusions― Migraine seems to influence clinico-radiological features of RCVS, predisposing for an atypical clinical presentation and an elevated risk for SAH and mCAD. Larger multi-centric studies are warranted to confirm these findings.

Extreme intracranial hypertension and severe headache in a immunocompetent man with Cryptococcal meningitis

Neuroimigang in headache disorders

Abstract text (incl. figure legends and references) Cryptococcusis is an infection caused by the fungi Cryptococcus neoformans and gatii.1 Cryptococcal meningitis is generally occurred in immunocompromised patients. It may be seen rarely in immunocompetent individuals with nonspecific and more subtle symptoms.2 case: A 47 Years old man with history of 6 months headache, diplopia and blurred vision Presented to emergency department because of the worsening of his symptoms. The Headache was severe, generalized with nausea, the characteristics were dullness and postural that the patient could not lay down. Examination was revealed a papillary edema, and decreased visual acuity. Magnetic resonance imaging of brain showed bilateral basal ganglia signal change. Lumbar puncture was done, and the opening pressure was 120 cmH2O. The analysis results were as follow: Appearance semi-clear, white blood cell: 130 (80% lymphocyte), red blood cell: 580, and the CSF biochemistry results were: Glucose: 28 mg/dl and total protein: 59 mg/dl. The study of CSF showed a positive Cryptococcus neoformans PCR. The patient admitted and treatment with Amphotericin B was started. HIV Ab was negative and patient&quot;s immune system was intact. He just had close-contact with pigeon. After 30 days of treatment, Cryptococcus neoformans PCR was negative in secound SCF study. Patient discharged with oral Fluconazole and the headache was completely resolved but the ophtalmic symptoms had partially improved. Cryptococcusis Should be considered in the differential diagnosis of immunocompetent patients, presenting with prolonged headache.2 Early diagnosis is important, because late treatment may lead to some residual symptoms and sometimes death of patients. 1. Cryptococcal meningitis: epidemiology, immunology, diagnosis and therapy. P.R. Williamson, et al. Nat Rev Neural, 13(2017) 2. Cryptococcus meningitis presented with multiple cerebral infarcts in an immunocompetent patient. Buket Erturk Sengel, et al. IDCases,vol.24(2021)

The features of the course of traumatic brain disease in persons with combat traumatic brain injury

Abstract text (incl. figure legends and references) This article is devoted to the problem of survival and prognosis of treatment outcomes of patients with traumatic brain injury who have sustained craniocerebral trauma according to changes in neurospecificity protein (S100β) levels during the acute period of trauma. An analysis of the course and results of treatment of patients who had sustained severe craniocerebral trauma was carried out. Patients underwent routine biochemical examinations, neuroimaging studies and protein (S100β) levels examination in the acute period of trauma. On the basis of the data obtained, it was found that the level of neurospecificity protein S100β in the blood serum takes a great role in predicting the course and outcome of the disease. Objective: to elucidate the relationship between changes in the level of neurospecific protein (S100β) in the acute period of injury, data from neuroimaging methods (CT and / or MRI) of the study, the course and results of treatment and consequences of traumatic brain injury in combat zone Environmental protection in the East of Ukraine on the basis of the analysis of retrospective research (injury follow-up was 1 year, 3 years, 5 years). Materials and methods of research. 250 participants of hostilities and invalids, after the received craniocerebral trauma in the zone of carrying out anti-terrorist operation, on the basis of neurological department of Regional hospital of war veterans were observed. Patients were divided into groups depending on the severity of the injury (mild, moderate and severe), treatment in the acute period, the course and outcome of the disease. Observations have been conducted since 2015. by 2021, the follow-up was 1 year, 3 years, 5 years. Conclusions. Based on the data we conducted on the basis of the Hospital retrospective analysis of medical documents of the military who received severe trauma in the area of anti-terrorist operation, we can say that the level of neuronspecific protein S100β in serum plays an important role in predicting the course and outcome of the disease.

Epicrania fugax secondary to multiple sclerosis

Pathophysiology others than migraine and cluster

Abstract text (incl. figure legends and references) Background Epicrania fugax (EF) is a primary headache of recent description. EF essentially consists of brief paroxysms of pain describing a linear or zigzag trajectory across the surface of one hemicranium, beginning and terminating in the territories of different nerves(1). Materials and methods We present a case report that illustrates the possibility of presenting a headache with the characteristics of EF, but which is presumably produced secondary to demyelination plaques due to multiple sclerosis. Results Patient with a history of multiple sclerosis receiving treatment with glatiramer acetate, with periventricular, subcortical and infratentorial white matter lesions (Figure 1), who reports that for 6 days he has presented pain in the territory of the three branches of the right trigeminal nerve of short duration and electrical characteristic, which is becoming more frequent and longer (4-5 seconds). There is no trigger point. By expressly delimiting the area, he refers that it begins at the level of the vertex, with a rapid path towards the chin. Normal neurological examination. With these data, a forward EF diagnosis is made. Anesthetic blockade with bupivacaine was performed on both major suboccipital nerves and Lamotrigine 75 mg/day was prescribed (with progressive dose escalation over six weeks). At the check-up after three months, the patient reports the complete resolution of his symptoms Conclusions The correct characterization of a secondary headache can improve our management. In the previous case, an anesthetic block is performed and lamotrigine is prescribed. Despite the scant evidence collected to date, this management would be correct for a primary EF, and in the same way it has been useful for the patient. References Square ML, Guerrero AL, Couple JA. Epicrania Fugax. Curr Pain Headache Rep. 2016 Apr;20(4):21. doi: 10.1007/s11916-016-0557-9. PMID: 26893151.

A Case of Spontaneous Intracranial Hypotension in a Third-trimester Pregnant Woman Resolved by Delivery

Abstract text (incl. figure legends and references) Spontaneous intracranial hypotension (SIH) is characterized by a low cerebrospinal fluid (CSF) volume because of leakage, resulting in an orthostatic headache.1 Little is known about SIH during pregnancy, especially in a third-trimester is very rarely reported.2 We report a SIH case in a third-trimester pregnant woman, which was resolved by delivery.This is the first report to our knowledge. A 30-year-old woman at 33+6 weeks&quot; gestation presented to our hospital with a headache. She had felt a tearing pain in the upper back while mopping 4 days ago, then an orthostatic headache occurred. Diffuse pachymeningeal thickening/enhancement and fluid collection near the dura showed on brain and spine MRI. (Fig. 1 &amp; 2) We diagnosed her with SIH clinically. She had been treated with bed rest, hydration, and analgesics, but did not improve. We inquired obstetricians about fetal safety for the CT-guided epidural blood patch (EBP), and they recommended a procedure after delivery because the fetus was mature. She had a cesarean section. The headache rapidly improved after the delivery. On the third day after delivery, the patient could stand for more than an hour. She was discharged on the fifth day after delivery without a headache. Although the risk or physiologic factors for SIH during pregnancy are unknown, the point that SIH was resolved through delivery in this case suggests that SIH might be related to pregnancy itself. If the symptom does not improve with known treatment, delivery might be considered as the next option for treatment when the fetus matures allow delivery. 1. Mokri B. Spontaneous intracranial hypotension.Continuum.2015;21:1086-108 2. Ferrante E, et al. Management of Spontaneous Intracranial Hypotension During Pregnancy: A Case Series.Headache.2020;60:1777-87 Figure 1. Brain MRI show diffuse pachymeningeal thickening and enhancement. Figure 2. Spine MRI show diffuse fluid collection in the epi and subdural space, posterior to the C7-T7 cord. (arrows)

Post-traumatic headache responds well to suboccipital block

Headache in the elderly

Abstract text (incl. figure legends and references) Background: Post-traumatic headache, defined as the one that occurs after a traumatic brain injury, can adopt the characteristics of other primary headaches (especially tension-type headache or migraine), and traditionally its management has been that of these headaches. This clinical management lacks solid scientific evidence and is rather based on expert opinions(1). Materials and methods: Through the exposure of two cases reports, treatment by anesthetic blocks is suggested as a useful therapeutic tool for these cases. Results: The first patient is a 73-year-old woman, who reported that after a mild head injury, she had intermittent headache of varying intensity, oppressive type, of greater intensity at times of greater psychological stress, and of left parieto-occipital location. Normal examination and CT. Subcutaneous infiltration with bupivacaine is performed in both major suboccipital and supraorbital nerves, and amitriptyline is prescribed. The patient only consumed one container of amitriptyline by mistake, presenting complete resolution of her symptoms since the blockade was performed. Secondly, we have a 70-year-old man who had a pulsating right hemicranial headache for 30 years, at which time he suffered a trauma in that area. The headache, in the last months had been accentuated. Normal examination and CT. Amitriptyline was prescribed, and after two months, the patient reported only a slight improvement, proceeding to perform a bupivacaine blockade of both major suboccipital nerves, giving complete resolution of the condition. Conclusion: Anesthetic blocks have been positioned as a therapeutic weapon in some types of headaches (migraine, cluster headache, suboccipital neuralgia,...), as we believe that in post-traumatic headache may be. Ashina H, Eigenbrodt AK, Seifert T, et al. Post-traumatic headache attributed to traumatic brain injury: classification, clinical characteristics, and treatment. Lancet Neurol. 2021 Jun;20(6):460-469.

Headache in intracranial arachnoid cysts: implications for management

Abstract text (incl. figure legends and references) Question: With a prevalence of 1.4%, intracranial arachnoid cysts are a frequent incidental finding on MRI and CT. Whilst most cysts are benign in the long term, clinical practice and imaging frequency does not necessarily reflect this. Is headache a useful symptom in stratification of this pathology? Method: A literature review was conducted searching the Medline database with MESH terms. This literature was condensed into an article, edited by a consultant Neurosurgeon. This was further condensed, presented to the Neurosurgery department at Princess Alexandra Hospital for final feedback and editing. Results: Headache remains a non specific symptom in relation to cysts, however case reports do exist of post traumatic bleed and spontaneous cyst growth. The minority of symptomatic patients or those with cysts in sensitive areas may require referral to a neurosurgeon for clinical follow up, imaging or intervention. This review outlines a treatment algorithm to guide clinicians. Conclusion: Greater than 94% of patients are asymptomatic, practitioners can be confident in reassuring patients of the benign nature of a potentially worrying finding. Headaches should be thoroughly explored and cysts in atypical locations or with atypical features may benefit from surgical intervention.

Poster session 3

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