Faculty Bibliography

Post-dural puncture headache (PDPH) is a frequent complication of lumbar puncture, performed for diagnostic or therapeutic purposes or accidentally, as a complication of epidural anesthesia. As PDPH can be disabling, clinicians who perform these procedures should be familiar with strategies for preventing this disorder. Since the best preventative measures sometimes fail, clinicians should also be familiar with the therapeutic approaches for PDPH. Herein, we review the procedure-related risk factors for PDPH, the prognosis of PDPH and the studies of PDPH treatment. We divide the therapeutic approach to PDPH into 4 stages: conservative management, aggressive medical management, conventional invasive treatments, and the very rarely employed less conventional invasive treatments and provide management algorithm to facilitate treatment.

Migraine and tension-type headache (TTH) can increase in frequency and transform from episodic to chronic forms. The process of transformation of these primary headaches is complex and involves multiple risk factors. In this cross-sectional and longitudinal population study, we aimed to investigate the relation of clinical characteristics of primary headaches to poor outcome: new-onset or persistent chronic headache (> or =180 days/year). Individuals who had migraine + / - TTH and those who had pure TTH were studied separately. Of 740 individuals who entered this study in 1989, 673 were eligible for follow-up in 2001, and a total of 549 individuals participated in the follow-up study. At baseline in 1989, no difference was found between episodic and chronic migraine headache ( + / - TTH). Duration of headache episodes >72 hours (p = .002) was associated with pure chronic TTH at baseline in 1989 whereas aggravation of headache by physical activity (p = .045) was associated with pure frequent episodic TTH. Of 64 subjects with migraine + / - TTH, 12 had a poor outcome in 2001. For pure TTH, of 116 subjects at baseline, 11 had a poor outcome in 2001. Using multivariate logistic regression analysis with adjustment for medication overuse and use of preventive medications, poor outcome of migraine + / - TTH tended to be associated with a baseline pulsating quality and severe intensity of migraine, photophobia and phonophobia, as well as longer duration of an individual headache attack. For pure TTH, unilateral headache, nausea and individual headache attack duration greater than 72 hours was associated with poor outcome. Pooled data univariate analysis revealed that nausea, daily use of acute headache medications, use of headache preventive medications and coexistent headaches were significant predictors of chronic headache in 2001(p<.05). In conclusion, our study demonstrates that certain clinical characteristics of headaches are associated with poor outcome but alone may not predict the chronification of migraine or TTH.

Post-dural puncture headache (PDPH) is a frequent complication of dural puncture whether performed for diagnostic purposes or accidentally, as a complication of anesthesia. Because both procedures are common, clinicians interested in headache should be familiar with this entity. The differential diagnosis of PDPH is broad and includes other complications of dural puncture as well as headaches attributable to the condition which lead to the procedure. The patterns of development of PDPH depend on a number of procedure- and nonprocedure-related risk factors. Knowledge of procedure-related factors supports interventions designed to reduce the incidence of PDPH. Finally, despite best preventive efforts, PDPH may still occur and be associated with significant morbidity. Therefore, it is important to know the management and prognosis of this disorder. In this review, we will highlight diagnosis and clinical characteristics of PDPH, differential diagnosis, frequency, and risk factors as well as pathophysiology of PDPH.

Headache is one of the most common neurological symptoms reported by patients with thrombotic thrombocytopenic purpura (TTP). Reports of headache characteristics in patients with TTP are rare. We report 2 cases of headache in a setting of TTP and review previous reports. Headache in TTP can have features in common with both migraine and tension-type headache. Although the pathophysiology of headache in TTP is not certain, platelet aggregation and activation may play a key role.

The objective of this study was to estimate and contrast the occurrence of ictal and interictal cutaneous allodynia (CA) in individuals with migraine with and without temporomandibular disorders (TMD). Both TMD and CA are common in migraine and may be associated with migraine transformation from episodic into a chronic form. Herein we hypothesize that TMD contributes to the development of CA and to more severe headaches. In a clinic-based sample of individuals with episodic migraine, the presence of TMD was assessed using the research diagnostic criteria for myofascial or mixed (myofascial and arthralgic) TMD. Ictal CA was quantified using the validated Allodynia Symptom Checklist (ASC-12). The ASC-12 measures CA over the preceding month by asking 12 questions about the frequency of allodynia symptoms during headaches. Interictal CA was assessed in the domains of heat, cold and mechanical static allodynia using quantitative sensory testing. Our sample consists of 55 individuals; 40 (73%) had TMD (23 with myofascial TMD and 17 with the mixed type). CA of any severity (as assessed by ASC-12) occurred in 40% of those without TMD (reference group), 86.9% of those with myofascial TMD (P = 0.041, RR = 3.2, 95% CI = 1.5-7.0) and in 82.3% of those with mixed TMD (P = 0.02, RR = 2.5, 95% CI = 1.2-5.3). Individuals with TMD were more likely to have moderate or severe CA associated with their headaches. Interictally (quantitative sensory testing), thresholds for heat and mechanical nociception were significantly lower in individuals with TMD. Cold nociceptive thresholds were not significantly different in migraine patients with and without TMD. TMDs were also associated with change in extra-cephalic pain thresholds. In logistical regression, TMD remained associated with CA after adjusting for aura, gender and age. TMD and CA are associated in individuals with migraine.

Headache associated with moyamoya disease (HAMD) is common in moyamoya disease. However, the characteristics and classification of HAMD are largely unknown. We present a case of a 39-year-old woman with HAMD. To characterize and classify the features of this syndrome, the patient was asked to complete a 4-month diagnostic headache diary. There was a total of 15 ictal days. All episodes were without aura. The headache was more commonly pressing (10/15), mild to moderate in severity (14/15), unchanged by physical activity (11/15), and associated with photophobia (10/15). The International Headache Society Classification was utilized to determine that eight episodes met criteria for probable migraine without aura, while seven episodes met criteria for probable frequent episodic tension-type headache. We identified four other case reports of HAMD with partial descriptions of the characteristics. When combined with our patient, the median age was 34 years old (range 6-49, SD 16). Four were female, while the patient with cluster headache was male. The median time from headache onset to diagnosis with moyamoya disease was 9.5 months (range 0-192, SD 88.0). Headaches were described as migraine with aura in two of five cases, hemiplegic migraine in one of five, and cluster headache in one of five. The highest intensity was described as severe in three of three cases, in which headache intensity was reported. Meanwhile, nausea, vomiting, and photophobia were present in two of three cases, where these features were reported, while nausea without vomiting was seen in one of three cases. In all five cases, patients had other neurological symptoms, such as paresis, seizures, visual disturbances, dysarthria, allodynia, ptosis, and unilateral restless leg syndrome. In conclusion, HAMD can present as migraine without aura. It can be the first presenting symptom of moyamoya disease. The headache features are not diagnostic; hence, early neurovascular imaging should be considered in patients with new onset, refractory migraine-like headache, especially in the setting of other neurological symptoms to exclude underlying moyamoya disease. Further reports using headache diaries are needed to better characterize HAMD as well as to determine whether headache with tension-type features is also part of this condition.