Headache attributed to airplane travel

Headache attributed to airplane travel, also named ‘airplane headache’ (AH) is a recently described clinical entity characterized by the sudden onset of a severe head pain, which appears exclusively in relation to airplane flights, mainly during the landing phase. Secondary causes, such as upper respiratory tract infections or acute sinusitis, must be ruled out. Although its pathophysiology is not completely understood, a causative role is attributed to an imbalance of the intrasinus pressure, consequent to a change of external air pressure not paralleled with an adequate compensation inside the cranial sinuses. In the International Classification of Headache Disorders, second edition (ICHD-2) AH is not mentioned. On the basis of an extended investigation, AH diagnostic criteria were proposed, which have been introduced for the first time in the recently published ICHD-3B version. Its formal recognition will favour further studies aimed at improving knowledge about AH and implementing preventative measures.

Headache and sport

Headache is prevalent within the community and can have an impact on sport in both the amateur and the elite player. Initiatives to increase activity levels in the population make this an important area. Against a background of a limited evidence base, this chapter suggests how headache can be classified within this context and offers guidance for treating both the amateur and the elite athlete. The impact of headache in sport may be unrecognized and undertreated, and further research is needed in this area.

Headache associated with systemic infection, intoxication, or metabolic derangement

This chapter discusses headaches attributed to exposure to a substance, disorders of homeostasis, high altitude, airplane travel, diving, sleep apnoea, dialysis, cardiac cephalalgia, hypertension, metabolic derangement, and systemic infection.

Cranial neuralgias and persistent idiopathic facial pain

Orofacial pain is a complex problem and affects up to 7% of the population. Although trigeminal neuralgia has been considered the prime neuralgic condition in the facial region, other forms of neuropathic pain are now being more frequently recognized and require recognition and a different management approach. Many patients with chronic orofacial pain report numerous comorbidities, such as psychiatric or personality disorders, which significantly affect management. Various pain conditions present in the facial region. Some of them rarely present extra-orally (unless as radiating pain) such as atypical odontalgia or persistent dento-alveolar pain disorder and burning mouth syndrome, whereas others will present in both areas such as classical trigeminal neuralgia, post-traumatic trigeminal neuropathy, trigeminal neuropathy attributed to multiple sclerosis, and persistent idiopathic facial pain. Myofascial pain syndrome related to the muscles of mastication is very common and may also be associated with temporomandibular joint problems. Trigeminal neuralgia and the rarer glossopharyngeal neuralgia are similar in quality and characteristics with specific treatment modalities, but differ in pain location. Trigeminal neuropathic pain is caused most frequently by trauma. If no other diagnostic criteria are fulfilled, a diagnosis of persistent idiopathic facial pain is made. It is crucial for these patients to be managed by multidisciplinary teams.

Cough headache

Cough headache exists in a primary and secondary form. The latter is due to tonsillar descent or, more rarely, to other space-occupying lesions in the posterior fossa/foramen magnum. Up to 40% of patients have an underlying structural lesion. Most patients with primary cough headache respond to indomethacin and suboccipital craniectomy with posterior fossa reconstruction can relieve cough headache in Chiari type I malformation.

Hemicrania continua

Hemicrania continua is an uncommon primary headache characterized by continuous, unilateral cranial pain of moderate intensity, more painful exacerbations with cranial autonomic features, and an absolute response to indomethacin. It is considered one of the trigeminal autonomic cephalalgias. Activation of the trigeminal–autonomic reflex and the contralateral posterior hypothalamic grey is thought to play an important role in its pathophysiology. The mean age of onset is in the third decade and there is a female preponderance of 2:1. Hemicrania continua can be divided into a remitting and an unremitting type; most patients suffer from the unremitting type. Any part of the head or neck can be affected, and pain is mainly described as throbbing. Many patients experience migrainous features during exacerbations. Physical and supplementary investigations are mostly normal. Other trigeminal autonomic cephalalgias and migraine are the main differential diagnostic alternatives for consideration.

Classification, diagnostic criteria, and epidemiology

The trigeminal autonomic cephalalgias (TACs), including cluster headache, paroxysmal hemicrania, SUNCT (short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing), SUNA (with cranial autonomic symptoms), and hemicrania continua, belong to the primary headaches. They are characterized by severe unilateral headache attacks in association with ipsilateral cranial autonomic features. Cluster headache is the most frequent of the TACs. The other TACs are rare, but epidemiological data are scarce and variable. The various types of TAC are distinguished not only by differences in attack frequency and duration, but also by differences with respect to treatment response. The typical headache syndromes, fulfilling the International Classification of Headache Disorders-3 criteria, have also been described in association with other disorders and imaging is required to exclude intracranial pathology in all newly diagnosed patients.

Headache mechanisms

Headache disorders involve widespread disturbances in nervous system function, resulting in a broad array of symptoms in addition to head pain. A general understanding of these disorders requires not only an understanding of the mechanisms underlying the pain, but also of those causing symptoms that may precede, accompany, or follow the pain. Imaging and clinical electrophysiological studies provide strong evidence that rather than being primarily vascular disorders, the major primary headaches disorders are fundamentally disorders of brain excitability. Changes in the activity of the thalamus and cortex appear to be particularly important in migraine, and alterations in hypothalamic function likely play a critical role in both migraine and cluster headache. Migraine aura involves propagated waves of activity in the cortex; cortical spreading depression (CSD) in animal models provides insight in the mechanisms of these waves. Elevations of extracellular potassium and release of the excitatory transmitter glutamate appear to be critical in the initiation of CSD, whereas sustained uncoupling of the normal relationship between neural and vascular activity occurs in the wake of CSD. Headache pain may be transmitted not only by trigeminal nerves, but also by the upper cervical nerves. The trigeminal nucleus caudalis, dorsolateral pons and midbrain, periaqueductal gray, thalamus, and sensory cortex may all play important roles in headache. Increasing evidence implicates the release of neuropeptides, particularly calcitonin gene-related peptide as a primary mediator of headache. Each of these and other basic mechanisms of headache may represent distinct therapeutic targets

Diagnostic neuroimaging in migraine

This chapter focuses on diagnostic clinical neuroimaging in migraine. In most migraine cases, patient history, details of symptoms, and careful clinical neurological examination are together the most important tools in diagnosing and treating migraine, and, consequently, there is mostly no need for further laboratory tests or neuroimaging. In selected non-acute headache cases, neuroimaging is warranted, and recommendations are provided. Good understanding of the migraine pathophysiology allows better interpretation of neuroimaging findings, notably when patients present acutely, in or outside an attack. The neuroradiological findings relevant in understanding the complex relationship between migraine and stroke will therefore be discussed. Similarly, knowledge of the epidemiological findings that have set migraine as a risk factor for (progressive) subclinical brain lesions is relevant in everyday neuroradiological practice.

Reversible cerebral vasoconstriction syndrome

Reversible cerebral vasoconstriction syndrome (RCVS) is a term used to describe a group of conditions characterized by reversible segmental narrowing and dilatation of multiple intracranial arteries. Most patients present with an explosive-onset, severe (thunderclap) headache. Thunderclap headaches frequently recur over days to weeks. Recent studies suggest that RCVS and primary thunderclap headache belong to the same spectrum of disorders, justifying the inclusion of RCVS in this textbook of headache syndromes. Up to one-third of patients do not have any identifiable trigger; however, most cases have been associated with exposure to vasoconstrictive medications, illicit drug use, over-the-counter agents, sexual activity, and childbirth.