Pleasure and Displeasure: Thunderclap Headache in a 13-Year-Old Boy

Primary headache associated with sexual activity (PHASA) is a rare headache syndrome characterized by an acute, maximally intense headache during sexual activity and/or orgasm. While rare, it is a diagnosis that is widely accepted in adults; but, scarcely documented in children and adolescents. We aim to highlight the diagnostic process of this interesting headache syndrome in the pediatric population and add to the small list of reported cases in this group. Herein, we describe the case of a 13-year-old boy who presented with thunderclap headaches (TCH) associated with sexual activity. While more commonly diagnosed in adults, PHASA should be considered in sexually active children, though more ominous diagnoses should also be contemplated prior to establishing this diagnosis.

A rare case of short-lasting unilateral neuralgiform headache with conjunctival injection and tearing with progression to neuromyelitis optica spectrum disorder

Short-lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT) is a rare primary headache syndrome. However, some cases of secondary SUNCT are attributed to underlying diseases such as demyelination. We herein report a case of SUNCT with progression to neuromyelitis optica spectrum disorder (NMOSD). A 43-year-old woman developed headaches; 6 weeks later, she developed bilateral visual loss and numbness on the left side of her body. She was ultimately diagnosed with NMOSD.

Symptoms and Clinical Findings in Primary Headache Syndrome Versus Chronic Rhinosinusitis

Background Primary headache syndrome (PHS) patients frequently present to otolaryngologists with sinonasal complaints and diagnosis of chronic rhinosinusitis (CRS) due to symptomatic overlap. In this study, we compare demographic, subjective, and objective clinical findings of patients with PHS versus CRS. Methods We retrospectively reviewed a database of patients presenting to a single tertiary care Rhinology clinic from December 2011—July 2017. Sino-Nasal Outcome Test-22 (SNOT) scores and Lund-Kennedy endoscopy scores were obtained. Lund-MacKay CT scores were calculated, if available. Requirement of headache specialist management was compared between PHS and CRS groups. Patients with both CRS and PHS (CRScPHS) that required headache specialist management were compared to patients with CRS without PHS (CRSsPHS) and patients with PHS alone using Kruskal-Wallis analysis of variance. Receiver operating characteristic (ROC) analyses were carried out to determine significant diagnostic thresholds. Results One-hundred four PHS patients and 130 CRS patients were included. PHS patients (72.1%) were more likely than CRS patients to require headache specialist management (6.9%, p<0.0001). CRSsPHS patients had significantly higher Nasal domain scores compared to PHS patients ( p = 0.042) but not compared to CRScPHS patients ( p>0.99). CRScPHS ( p = 0.0003) and PHS ( p<0.0001) subgroups of patients had significantly higher Aural/Facial domain scores compared to CRSsPHS patients. PHS patients also had significantly higher Sleep domains scores compared to CRSsPHS patients ( p<0.0001). Both CRScPHS and CRSsPHS subgroups had significantly higher nasal endoscopy scores ( p<0.0001) and CT scores ( p = 0.04 & p<0.0001, respectively) compared to the PHS group. Aural/Facial domain score of 4, nasal endoscopy score of 4, and CT score of 2 were found to be reliable diagnostic thresholds for absence of CRS. Conclusions The SNOT-22 may be used to distinguish PHS from CRS based upon the Aural/Facial and Sleep domains. Patients with CRS have more severe Nasal domain scores and worse objective endoscopy and CT findings.

Taking a headache history

The first tip is to take a full medical history. The trick is to interpret it. Around 400 bc Hippocrates described exertional and sex headaches with no aid other than a reed pen and papyrus or parchment. The second tip is to let patients tell the story in their own words as much as possible. The trick is to extract the salient features of the headache syndrome from what is often a cascade of irrelevancies while still trying to let the patient do most of the talking. This is a form of guided democracy. The final tip is to regard the headache as a pain problem to be analysed and hopefully solved by including a traditional pain history as taught in medical school. The trick is not to take shortcuts unless the patient is in extremis on being brought to the Emergency Department, when leaping straight to testing for neck rigidity and looking for signs of infection, a dilating pupil, and other warning signs is preferable.

Borrelia lusitaniae Infection Mimicking Headache, Neurologic Deficits, and Cerebrospinal Fluid Lymphocytosis

Headache with neurologic deficits and cerebrospinal fluid lymphocytosis (HaNDL) is a rare headache syndrome included in the Classification of Headache of the International Headache Society as a “headache attributed to non-infectious inflammatory intracranial disease.” We report one 15-year-old patient with clinical history and cerebrospinal fluid findings compatible with the diagnosis of HaNDL in whom Borrelia lusitaniae was identified in cerebrospinal fluid by polymerase chain reaction.

Syndrome of transient headache and neurologic deficits with cerebrospinal fluid lymphocytosis (HaNDL)

The authors make a narrative review on "headache syndrome and transient neurological deficits with cerebrospinal fluid lymphocytosis (CRL)," a rare, underdiagnosed disorder of little knowledge by physicians specializing in care in the emergency room. Aspects of the clinical picture, diagnosis, prognosis, and treatment are discussed