Spotlight on Headache in transplant patients

In this article, discusses the approach to headache when presenting in the context of solid organ or hematopoietic stem cell transplant patients, which can include both primary and secondary causes. In this article, Dr. Jeniffer Robblee of Barrow Neurological Institute outlines the epidemiology and etiologies of headache in the transplant population including pharmacotherapies, infection, vascular associations, and miscellaneous causes. Suggestions for management and possible pathophysiological mechanisms are discussed.

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Spotlight on Cyclic vomiting syndrome

In this article, Dr. Shannon Babineau of Goryeb Children’s Hospital discusses cyclic vomiting syndrome, which is considered one of the functional abdominal disorders and migraine variants. It is typified by stereotyped intense bouts of vomiting, at least 4 times per hour, lasting for hours to days followed by stretches of wellness. It has been recognized in children for over 100 years and it is being recognized as a condition that affects adults as well. Its pathophysiology is still not well understood; however, identification of autonomic and mitochondrial dysfunction has helped towards a better understanding.

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Spotlight on Medication overuse headache

Medication overuse headache is a chronic headache that occurs in people with a pre-existing primary headache, such as migraine or tension-type headache, following overuse of any kind of acute headache medications. It is a common and disabling disorder that affects 1% to 2% of the general population, and it is extremely important to recognize and treat this condition. Generally, treatment of medication overuse headache requires a multidisciplinary setting and includes education of patients, discontinuation of the overused medication, and initiation of preventive treatment.

In this recently updated article, Dr. Chia-Chun Chiang of the University of California, San Diego provides an update on the definition, pathophysiology, clinical aspects, and treatment strategies of this headache type.

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Spotlight on Recurrent painful ophthalmoplegic neuropathy

In this article, Dr. Deborah Friedman of the University of Texas Southwestern Medical Center discusses the fascinating and controversial entity of recurrent painful ophthalmoplegic neuropathy, formerly termed “ophthalmoplegic migraine.” The International Classification of Headache Disorders (ICHD-3 beta+) no longer considers the disorder a type of migraine but has reclassified it as a cranial neuralgia.

Although many cases are typical of a cranial neuralgia, with enhancement of the involved cranial nerve on MRI and improvement using corticosteroids, other cases are more suggestive of a migraine variant. The third nerve is the nerve most frequently involved, and most cases appear in childhood or early adulthood. The episodes of ophthalmoplegia appear spontaneously and then resolve. As the etiology for recurrent painful ophthalmoplegic neuropathy is likely multifactorial and remains uncertain, the condition may more appropriately be considered a syndrome rather than a distinct diagnosis.

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Spotlight on Patent foramen ovale

In this article, Dr. Shadi Yaghi and Dr. Shawna Cutting of the Warren Alpert Medical School of Brown University discuss patent foramen ovale, a highly prevalent anomaly occurring in 25% to 30% of the general population.

Patent foramen ovale represents the postnatal persistence of the normally present foramen ovale, a flap valve structure formed by the septum primum and septum secundum in the fetus. Although it is generally asymptomatic, studies have found associations with ischemic stroke and migraine. The best treatment strategy for patent foramen ovale in the setting of ischemic stroke or migraine remains unclear. Randomized controlled trials on patent foramen ovale closure showed no benefit for secondary stroke prevention or migraine improvement.

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Spotlight on Status migrainosus

In this article, Dr. Shuhan Zhu of Jefferson Headache Center discusses status migrainosus, an attack of severe migraine lasting more than 72 hours accompanied by debilitating symptoms that is not attributable to another disorder.

Status migrainosus may occur in migraineurs with or without aura. For patients presenting with the first or worst prolonged headache, a thorough neurologic evaluation with collateral imaging and/or spinal fluid sampling is indicated to assess for secondary causes of pain. In a patient with underlying diagnosis of migraine and without a secondary attributable cause of prolonged headaches, focus should be on swift and effective treatment with the primary aim of aborting the migraine.

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Spotlight on Migraine aura without headache

Migraine is a common neurologic disorder that is prevalent in the younger population. With age, migraine prevalence decreases, but some people continue to experience migraine auras without the subsequent or associated headache pain. In this article, Dr. Shih-Pin Chen of the National Yang-Ming University School of Medicine reviews the clinical manifestations, prevalence, pathophysiology, therapeutic options, and prognosis for this selective group of patients. Breakthroughs in understanding the pathogenesis and clinical manifestations are highlighted.

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Spotlight on Retinal migraine

In this article, Dr. Brian Grosberg and Dr. Seymour Solomon, both of Albert Einstein College of Medicine and Montefiore Headache Center, discuss clinical manifestations, biological basis, and prognosis of retinal migraine.

Retinal migraine is usually characterized by attacks of fully reversible monocular visual loss associated with migraine headache. Retinal migraine is most common in women of childbearing age who have a history of migraine with aura. In the typical attack, monocular visual features consist of partial or complete visual loss lasting less than 1 hour. Although the current diagnostic criteria for retinal migraine require fully reversible visual loss, our findings suggest that irreversible visual loss is part of the retinal migraine spectrum. Nearly half of reported cases with recurrent transient monocular visual loss subsequently experienced permanent monocular visual loss.

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Spotlight on Vestibular migraine

Vestibular migraine presents with attacks of spontaneous or positional vertigo (head motion–induced) and visual vertigo lasting 5 minutes to 3 days. The diagnosis requires a history of migraine, temporal association of migraine symptoms with vertigo attacks, and exclusion of other causes. Because headache is often absent during acute attacks, other migraine features such as photophobia or auras have to be specifically inquired about. The pathophysiology of vestibular migraine is unknown, but several mechanisms link the trigeminal system, which is activated during migraine attacks, and the vestibular system. Treatment includes antiemetics for severe acute attacks, pharmacological migraine prophylaxis, and lifestyle changes.

In this clinical article, Dr. Thomas Lempert of Charité University Hospital and Dr. Michael von Brevern of Humboldt University discuss the manifestations, biological basis, diagnosis, and mananagement of vestibular migraine.

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Spotlight on Transient visual loss

Clarification of the mechanism and cause of transient visual loss first depends on separating monocular and binocular symptoms and signs. Binocular transient visual loss usually reflects cerebrovascular vertebrobasilar circulation thromboembolism, systemic hypoperfusion, or migraine. Monocular transient visual loss is often attributable to arteriostenotic disease of the internal carotid artery in the cervical or intracranial segment or stenosis of the ophthalmic artery or its central retinal artery branch. However, reports show that migrainous vasoconstriction and various nonvascular mechanisms are also common causes of monocular transient visual loss and that familial hemiplegic migraine can be associated with multiple daily episodes of transient monocular vision loss in families with SCN1 mutations. Case reports also document that Whipple disease with bilateral optic disc edema and the use of latanoprost for glaucoma have both been associated with transient monocular vision loss in individual patients.

In this article, Dr. James Goodwin of the University of Illinois at Chicago cites case reports in which acute glaucoma led to transient vision loss in one or both eyes, which is important for the neurologist to include in the differential diagnosis so that an appropriate ophthalmologic referral can be made in order to prevent permanent vision loss.

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