Time to retire ‘New daily persistent headache’: Mode of onset of chronic migraine and tension-type headache

New daily persistent headache is described as an enigmatic condition with daily headache from onset. It has posed challenges diagnostically and therapeutically. Methods: We conducted a study of patients referred to headache services based in Central and North-East London, United Kingdom, meeting the International Classificaiton of Headache Disorders – 3 criteria for New daily persistent headache. Information on demographics, phenotype and treatment responses were collected. The syndrome of the daily headache was also classified according any other ICHD-3-defined syndrome. Results: Of 162 patients, females comprised 68.5% with median age of onset 35 years. The daily headache experienced was chronic migraine in 89.7% and tension-type headache in 8.8%. Thunderclap-onset New daily persistent headache occurred in 14.8%. More than one headache syndrome was experienced in 15.4%, including cough, hypnic, sexual and stabbing headache. All aura types were experienced, most commonly brainstem aura in 39%. Prior headache was reported 53.7%. A persisting sub-form was present in 51.2%, relapsing remitting in 12.3% and 14.0% reported improvement; 19.8% were lost to follow-up. Only 11.1% reported an antecedent trigger. The most common premorbid disorders were psychiatric in 35.7%. A fifth improved on preventative medication, most commonly amitriptyline, propranolol and topiramate. Conclusion: Our cohort of New daily persistent headache is consistent with a mode of onset of migraine and tension-type headache which occurs in predisposed individuals.

Acute HSV and anti-NMDA encephalitis occurring as a neurosurgical complication

We present a 24-year-old man with a 2-year history of progressive right-sided monocular vision loss with no other symptoms. An MRI showed a meningioma compressing the right optic nerve and the cavernous sinus. The tumour was partially resected. Eight days after discharge the patient was admitted with fever, a severe stabbing headache, insomnia, nausea and vomiting. A FilmArray panel and a cerebral biopsy were performed which were positive for herpes simplex virus 1 (HSV-1). An MRI of the brain showed asymmetric bilateral lesions in the frontobasal region with predominance of the right side. Acyclovir was started and continued until completing 21 days. A month after discharge, he started experiencing insomnia, trichotillomania, limb tremor, persistence of abulia, apathy and emotional lability. An HSV-1 encephalitis relapse was suspected, acyclovir and foscarnet were started. Due to the poor response to antiviral therapy CSF was tested, which was positive for anti-NMDA receptor encephalitis. A treatment course of intravenous immunoglobulin was started with a favourable outcome.

Stabbing facial pain reminiscent of primary stabbing headache

Primary stabbing headache (PSH) is a transient and localized headache disorder. Facial variants of this rare pain syndrome have not been previously described. Four patients (n = 2 female, 2 male) presented themselves to our headache and facial pain outpatient clinic. They suffered daily from several dozen to several hundred short-lasting stabbing pain paroxysms primarily in the second and third trigeminal branches (V2 and V3) without lateral predominance. These non-neuralgic pain paroxysms did not strictly follow dermatomes, were not accompanied by trigeminal autonomic features and could not be triggered but occurred exclusively spontaneously. They did not fulfill any existing ICHD-3 criteria but appeared clinically to have similarities to primary stabbing headache syndromes. Indomethacin showed no efficacy. Exclusive facial variants of stabbing pain paroxysms should be classified as separate entities and tentatively be called stabbing facial pain.

Primary stabbing headache

Primary stabbing headache is a unique headache disorder, also known as idiopathic stabbing headache, ice pick headache, and jabs and jolts syndrome. The headache is described as a sharp, stabbing pain, lasting seconds to minutes, with no associated symptoms, including any autonomic features. It is more common in women by a 3:1 ratio and is comorbid with migraine, with some studies reporting that up to 40% of migraineurs also have primary stabbing headache. Performing magnetic resonance imaging of the brain is reasonable in patients who present with stabbing headache, as there are secondary causes. Meningiomas, hemorrhages, and giant cell arteritis have all been reported to present in this manner. As primary stabbing headache is a benign disorder, infrequent attacks do not require treatment and patients can be counselled accordingly. For more frequent attacks, indomethacin is the prophylactic drug of choice. Other treatment options include melatonin and cyclooxygenase-2 inhibitors.