Wall-eyed bilateral internuclear ophthalmoplegia in posterior circulation stroke-a case report

Internuclear ophthalmoplegia is characterised by restricted ocular motility in lateral gaze in which the affected eye shows impairment of adduction and it results from damage to medial longitudinal fasciculus (MLF). Wall-eyed bilateral internuclear ophthalmoplegia (WEBINO) is an extremely rare neurological manifestation which has typical signs including primary gaze exotropia, vertical gaze palsy, ptosis, abducting nystagmus. The common and serious etiological factor is cerebrovascular accident involving the vessels supplying MLF and many cases have life threatening associated neurological impairment. In this case report we have discussed about a gentleman who presented with bilateral ptosis, primary gaze exotropia and headache. Patient found to have vertical gaze palsy and abducting nystagmus on examination. Computed tomography (CT) imaging shows infarct in pontine region and CT angiography revealed basilar artery occlusion supplying region of pons with involvement of posterior cerebral artery. Patient treated with antiplatelet and diplopia managed. Patient showed improvement on subsequent follow-up visits.

Treatment Realities of Headache Disorders in Rural Germany by the Example of the Region of Western Pomerania

(1) Background: Headache disorders are among the most disabling medical conditions but the supply with experienced providers is outpaced by the demand for service. It is unclear to what extent particularly patients in rural regions are affected by limited access to comprehensive care. Furthermore, it is unknown what role general practitioners (GPs) play in headache care. (2) Methods: First-time consultations to a specialised headache clinic at a tertiary care centre were asked to participate. Their socio-demographic background, general and headache-specific medical history, disability and quality of life (QoL) were assessed. Additionally, 176 GPs in neighbouring districts were contacted regarding headache management. (3) Results: We assessed 162 patients with first-time consultations (age 46.1 ± 17.0 years, 78.1% female), who suffered from migraine (72%), tension type, cluster and secondary headaches (each 5–10%). About 50% of patients received a new headache-diagnosis and 60% had treatment inconsistent with national guidelines. QoL was significantly worse in all domains compared to the general population. About 75% of GPs see headache patients at least several times per week, and mostly treat them by themself. (4) Conclusions: More than every second headache patient was neither correctly diagnosed nor received guideline adherent treatment. Headache-related disability is inferior to what is expected from previous studies. Access to specialised health care is more limited in rural than in urban regions in Germany and GPs request more training.

A Comparative Analysis of Amytripiline, Flunnarazine and Topiramate in the treatment of Primary Headache

Introduction Primary headache disorder, characterized by recurrent headache is the most prevalent disease leading to widespread ill health and impaired quality of life. In Nepal headache is one of the most common cause of patient attending neurology clinic. Amitriptyline, Flunarizine and Topiramate are common drugs in the treatment of primary headache. We conducted this study to compare the efficacy of drugs namely Amitriptyline, Flunarizine and Topiramate in the treatment of primary headache Materials and Methods This is the retrospective data analysis of primary headache patient treated with amitriptyline, flunarizine and topiramate. On their first, second and third subsequent visits, Headache Impact Test 6 Scoring was done by a medical person. Patient were treated clinically. After third follow up data were analyzed using SPSS version 20.0. Categorical variables were compared by chi-square test, paired sample t-test, ANOVA test and Welch test. Results A total of 142 patient data was analyzed. The most common age group were between 20 to 39 years (56.34%) followed by 40 to 59 years (33.80%). Female were predominant in the group 124 (87.32%). All three medication Amitriptyline, Flunarizine and Topiramate were able to significantly lower Headache impact test -17.23 ± 6.643, -14.06 ± 7.155, -15.82 ± 5.907 respectively (P- <0.001). Amitriptyline was found to be better than other two drugs in reducing Headache Impact Test. Conclusion All three drugs namely Amitriptyline, Flunarizine and Topiramate, are significantly effective in the treatment of primary headache. Though tension type of headache is the most common type of headache, amitriptyline seems to be equally effective in treatment with other primary headaches.

Headache and Facial Pain

Headaches are a near-universal experience, with a 1-year prevalence of 90% and a lifetime prevalence of 99%. Headaches and pain to the head account for roughly 3% of visits to US emergency departments annually, making them the fourth most common reason for seeking emergency care. There are numerous types of headaches, and although the majority are benign, types exist that may result from serious and potentially life-threatening causes. As such, it is important for the physician to consider a broad differential diagnosis for every headache patient. This review discusses the classification of headaches, identifies pain-sensitive structures in the head, discusses the history and examination in patients with headache, and describes many of the primary and secondary headaches. Figures show the areas of the brain sensitive to pain; 1-year prevalence of migraine in men, women, and children; frequency of attacks in migraineurs; prevalence of headaches by age group and in patients with cerebrovascular disorders; and symptoms of idiopathic intracranial hypertension. Tables list the major categories of headache disorders, key elements of the headache history, helpful questions to ask, features of selected primary and secondary headaches, reasons to consider neuroimaging, efficacy of selected over-the-counter medications, triptans available in the United States, medication options for urgent or emergency treatment of migraine, selected preventive medications for migraine, generally accepted indications for preventive treatment, general principles for the use of preventive medications, titration schedules for preventive medication, interval or short-term preventive treatment of menstrual migraine, strategies for managing increase in migraines in patients starting estrogen replacement therapy, transition medications for rapid, temporary suppression of headaches, medications possibly effective for cluster and hypnic headaches, differential diagnosis of the acute, severe, new-onset headache, and etiologies of papilledema and headache. This review contains 6 highly rendered figures, 23 tables, and 115 references.

Headache and Facial Pain

Headaches are a near-universal experience, with a 1-year prevalence of 90% and a lifetime prevalence of 99%. Headaches and pain to the head account for roughly 3% of visits to US emergency departments annually, making them the fourth most common reason for seeking emergency care. There are numerous types of headaches, and although the majority are benign, types exist that may result from serious and potentially life-threatening causes. As such, it is important for the physician to consider a broad differential diagnosis for every headache patient. This review discusses the classification of headaches, identifies pain-sensitive structures in the head, discusses the history and examination in patients with headache, and describes many of the primary and secondary headaches. Figures show the areas of the brain sensitive to pain; 1-year prevalence of migraine in men, women, and children; frequency of attacks in migraineurs; prevalence of headaches by age group and in patients with cerebrovascular disorders; and symptoms of idiopathic intracranial hypertension. Tables list the major categories of headache disorders, key elements of the headache history, helpful questions to ask, features of selected primary and secondary headaches, reasons to consider neuroimaging, efficacy of selected over-the-counter medications, triptans available in the United States, medication options for urgent or emergency treatment of migraine, selected preventive medications for migraine, generally accepted indications for preventive treatment, general principles for the use of preventive medications, titration schedules for preventive medication, interval or short-term preventive treatment of menstrual migraine, strategies for managing increase in migraines in patients starting estrogen replacement therapy, transition medications for rapid, temporary suppression of headaches, medications possibly effective for cluster and hypnic headaches, differential diagnosis of the acute, severe, new-onset headache, and etiologies of papilledema and headache. This review contains 6 highly rendered figures, 23 tables, and 115 references.

Headache and Facial Pain

Headaches are a near-universal experience, with a 1-year prevalence of 90% and a lifetime prevalence of 99%. Headaches and pain to the head account for roughly 3% of visits to US emergency departments annually, making them the fourth most common reason for seeking emergency care. There are numerous types of headaches, and although the majority are benign, types exist that may result from serious and potentially life-threatening causes. As such, it is important for the physician to consider a broad differential diagnosis for every headache patient. This review discusses the classification of headaches, identifies pain-sensitive structures in the head, discusses the history and examination in patients with headache, and describes many of the primary and secondary headaches. Figures show the areas of the brain sensitive to pain; 1-year prevalence of migraine in men, women, and children; frequency of attacks in migraineurs; prevalence of headaches by age group and in patients with cerebrovascular disorders; and symptoms of idiopathic intracranial hypertension. Tables list the major categories of headache disorders, key elements of the headache history, helpful questions to ask, features of selected primary and secondary headaches, reasons to consider neuroimaging, efficacy of selected over-the-counter medications, triptans available in the United States, medication options for urgent or emergency treatment of migraine, selected preventive medications for migraine, generally accepted indications for preventive treatment, general principles for the use of preventive medications, titration schedules for preventive medication, interval or short-term preventive treatment of menstrual migraine, strategies for managing increase in migraines in patients starting estrogen replacement therapy, transition medications for rapid, temporary suppression of headaches, medications possibly effective for cluster and hypnic headaches, differential diagnosis of the acute, severe, new-onset headache, and etiologies of papilledema and headache. This review contains 6 highly rendered figures, 23 tables, and 115 references.

A Survey on Probable and Improbable Decisions About Headache Treatment

The treatment of headache disorders is adapted to their severity. It is the aim of this study to evaluate the probability of treatment decisions being taken and to identify underlying principles influencing them. The study was internet-based and cross-sectional; participants completed the EUROLIGHT questionnaire anonymously. Inclusion criterion was the consent to participate. Participants were excluded if diagnostic questions had not been completed. We estimated probabilities based on relative frequencies and built binary logistic regression models to identify factors influencing decision-making. The survey was completed by 976 individuals; 636 completed the diagnostic questions. The probability of a patient to consult a GP or a neurologist was 0.26 and 0.20, respectively. Patients decided by a probability of 0.93 to take acute treatment. These treatment decisions, which were taken by patients alone increased in probability with increasing ictal burden (P < 0.001, P < 0.001 and P < 0.001). The probability of treating migraine with triptans was 0.74; the probability to take a prophylactic treatment was 0.43. Neurologists were more likely than GPs to prescribe these medications (P = 0.006 and P < 0.001, respectively). We identified several principles underlying treatment decisions. Most patients decide to take acute treatment for headache attacks; they are less likely to treat their headache disorder interictally. Treatment decisions are less likely to be taken if more than one decision-maker is involved; if physicians are involved, severity of the headache disorder does not affect the probability of a treatment decision being taken. Overall, the more severely affected a headache patient, the less likely an adequate treatment.

Detection of Migrainous Infarction with Formal Visual Field Testing: A Case Report

Introduction: Cerebrovascular accidents (CVA) of the posterior circulation are a rare complication of migraine, and present with atypical CVA symptomatology. Case Report: A 49-year-old-male presented with complaint of persistent visual aura and resolved mild cephalgia. His exam corroborated his reported incomplete left inferior quadrantanopia, and was confirmed by immediate formal optometry evaluation. Occipital CVA was confirmed on admission. Conclusion: Migrainous strokes of posterior circulation should be considered as a potential diagnosis in any headache patient with persistent visual aura. This case suggests that incorporation of formal visual field testing in the emergent setting can shorten the time required for diagnosis in certain circumstances.

Recommendations for the management of headaches during the COVID-19 pandemic

BackgroundDuring the novel coronavirus - COVID-19 pandemic, health care systems are facing one of its greatest challenges.ResultsSecondary headaches may need urgent care at an emergency department. Primary headaches exacerbations may require intravenous infusion. Treatment optimization is key for a better outpatient management.ConclusionWe give recommendations on when a headache patient should go to the hospital despite the current limited resources, and primary headache management aspects during the outbreak.