Pathological Laughter Prodromal to a Stroke of the Head of the Left Caudate Nucleus

A 38-year-old right-handed female with a past history of intermittent painful rash, dizzy spells, and chronic daily headaches as well as episodic migraines experienced an episode of transient involuntary pathological laughter, right arm weakness, and expressive dysphasia. She was found on MRI to have multiple strokes in multiple vascular distributions, including one in the head of the left caudate. A cardiac ECHO found an atrial myxoma, with extensive evaluation for other causes of stroke unrevealing. The differential diagnosis for pathological laughter in this patient is discussed. The most plausible cause in this patient is an infarct to the head of the left caudate nucleus caused by an embolus of the atrial myxoma.

Primary Headache Disorders: Migraine, Tension-Type, and Chronic Daily Headaches

Primary headache disorders are those in which the headache is the primary feature of the disorder and is not otherwise explained by a structural, genetic, or metabolic cause. This chapter reviews the clinical features, diagnosis, and treatment of common primary headache disorders, including migraine, tension-type, and chronic daily headaches. Migraine usually starts during adolescence, and 90% of patients with migraine have their first attack by age 40 years. In childhood, there is a slight male predominance, but after puberty, a 3:1 female predominance is established. The highest reported prevalence of migraine is in patients who are 30 to 39 years old.

Higher frequency of medication overuse headache in patients attended by neurologists in Lima, Peru

BackgroundThe type of medical care received (self-medication and/or medical care provided by a general practitioner or a neurologist) may be associated with differences in the frequency of medication overuse headaches.MethodThis cross-sectional analytical study included 222 records of patients with chronic daily headaches seen at the National Institute of Neurological Sciences Outpatient Unit in Lima, Peru. A pre-designed questionnaire was used to assess and categorize patients with frequent and chronic headaches.ResultsNinety-four patients (42.34% of those with chronic daily headaches) met the criteria for medication overuse headache. Of these, 19 (28%) self-medicated, 22 (36%) consulted with the general practitioner, and the highest proportion of subjects, 53 (58%), consulted with a neurologist. On bivariate analysis, subjects who had received care from a general practitioner and self-medicated were 38% and 51% less likely to have MOH than the subjects whoreceived medical care from the neurologist (p=0.012; 95% CI 0.42-0.90 and p=0.001; 95% CI 0.32-0.74). On multivariate analysis adjusting by sociodemographic and clinical factors, the association remained significant in regards to self-medication, but became marginal (p=0.055) in regard to being seen by a general practitioner.ConclusionIn this study, the frequency of the headache due to overuse of medication was higher in patients attending a neurologist than those attending a general practitioner or self-medicated. This cross-sectional design cannot assess whether this reflects more severe cases looking for specialized care or more medication overuse headaches as a result of inappropriate management.

EPIDERMOID CYST OF THE FOURTH VENTRICLE: AN UNUSUAL LOCATION

Epidermoid cysts are slow-growing congenital tumors developed from ectodermal inclusions. They usually sit at the cerebellopontine angle or basal cistern, their location in the fourth ventricle are exceptional.We report the case of a 44-year-old patient admitted to the Neurosurgery department for chronic daily headaches with visual impairment recently aggravated by cerebellar stato-kinetic syndrome.The diagnosis of epidermoid cyst of the fourth ventricle was suspected on MRI especially in diffusion sequence and then confirmed by the anatomopatological studies. Subtotal surgical excision was performed. The evolution was marked by the disappearance of clinical signs. Radiological and clinical follow up were indicated.

Reassessment of Pediatric Tension-Type Headaches

A retrospective multicenter chart review was conducted with the objective of evaluating the hypothesis that certain cases diagnosed as tension-type headache (TTH) in pediatric neurology are not stress-related or central sensitization-related conditions but may mimic an autoimmune disorder of the dura mater. Of the 29,642 patient charts reviewed, 12,424 charts (42%) were excluded because of incomplete data and 17,218 cases were analyzed. For all the 29,642 charts, TTH or chronic daily headaches were diagnosed in 29.2% of cases. Among the 17,218 cases subjected to detailed diagnostic procedures, TTH was diagnosed in only 5%. In 7,044 cases, the initial diagnosis of TTH was changed to headache attributed to infection (87.4%), which was supported by the presence of meningeal signs, high antistreptolysin-O titers, and, in 46% of cases, magnetic resonance imaging (MRI)-detected thickening of the cranial dura mater. The initial diagnosis of migraine was confirmed in 87.7% of cases (8,034/9,162). In some cases of treatment-resistant pediatric recurrent headaches, which are initially diagnosed as TTH, a secondary type of headache may be suspected as the underlying cause. Usually this type of headache has streptococcal infection-related laboratory findings, the meninges as the site of the lesion, and meningism as the clinical presentation.

Headache

Key Points Most headaches in children, in the absence of neurologic or systemic findings, require only symptomatic relief with ibuprofen or acetaminophen. Neuroimaging is indicated only with abnormal neurologic features, systemic symptoms, an abrupt change in pattern, or with chronic daily headaches. With recurrent headaches the 1st step in management is promoting healthy lifestyle habits—nutrition, sleep, exercise, hydration, etc. With migraine, DON’T WAIT—medication works best the earlier it is given. Ibuprofen is the initial treatment of choice. If needed, triptans are safe and can be effective.

OnabotulinumtoxinA injections: treatment of reversible cerebral vasoconstriction syndrome chronic daily headaches

Reversible cerebral vasoconstriction syndrome (RCVS) is a rare condition characterised by repetitive, multifocal, vasofluctuations of cerebral arteries. A key symptom is chronic, disabling ‘thunderclap’ headaches, which are extremely difficult to treat as established medications may exacerbate the pathophysiology of RCVS. OnabotulinumtoxinA (OBT-A) injections are used for the prophylaxis of chronic daily headaches (CDH). The mechanism of action of OBT-A significantly differs from oral headache treatments. Thus, OBT-A may be an effective, safe treatment of RCVS-CDH. A 51-year-old woman with RCVS-CDH presented to outpatient clinic. This case report describes the first, believed, documented treatment of RCVS-CDH by OBT-A injections. In 2018, the consented patient received a total of 200 units of OBT-A, 155 units to the 31 approved U.S. Food and Drug Administration (FDA) sites and 45 units injected into the bilateral occipital belly of occipitofrontalis muscles. The patient reported 3 months of excellent pain relief (60% reduction). Three rounds of OBT-A injection, each 3 months apart, resulted in 80% reduction. OBT-A injections may prove a successful, novel treatment for RCVS-CDH.