Higgins JN, Cousins C, Owler BK, Sarkies N, Pickard JD. Idiopathic intracranial hypertension: 12 cases treated by venous sinus stenting . J Neurol Neurosurg Psychiatry. 2003;74:1662-1666. Background: The high pressures documented in the intracranial venous sinuses in idiopathic intracranial hypertension (IIH) could be the result of focal stenotic lesions in the lateral sinuses obstructing cranial venous outflow. Objective: To explore the relation between venous sinus disease and IIH. Methods: 12 patients with refractory IIH had dilatation and stenting of the venous sinuses after venography and manometry had shown intracranial venous hypertension proximal to stenoses in the lateral sinuses. Intrasinus pressures were recorded before and after the procedure and correlated with clinical outcome. Results: Intrasinus pressures were variably reduced by stenting. Five patients were rendered asymptomatic, two were improved, and five were unchanged. Conclusions: The importance of venous sinus disease in the aetiology of IIH is probably underestimated. Lateral sinus stenting shows promise as an alternative treatment to neurosurgical intervention in intractable cases. Comment: This is one of the hot topics, that is, whether idiopathic increased intracranial pressure is usually due to a cortical sinus thrombosis, stenosis, or other anomaly. When more advanced techniques in magnetic resonance venography become more widely available and utilized, answers on the frequency of secondary idiopathic intracranial hypertension should become available. SJT Bastin ME, Sinha S, Farrall AJ, Wardlaw JM, Whittle IR. Diffuse brain oedema in idiopathic intracranial hypertension: a quantitative magnetic resonance imaging study. J Neurol Neurosurg Psychiatry. 2003;74:1693-1696. Objectives: To investigate the hypothesis that idiopathic intracranial hypertension is associated with diffuse brain oedema, using quantitative magnetic resonance imaging. Methods: Values for the mean diffusivity of water (<D>) and the proton longitudinal relaxation time (T1) were measured for various brain regions in 10 patients with idiopathic intracranial hypertension and 10 age, sex, and weight matched controls. Results: No significant differences in < D> and T1 values were found between patient and control groups in any of the brain regions investigated. Conclusions: The results suggest that idiopathic intracranial hypertension is not associated with abnormalities of convective transependymal water flow leading to diffuse brain oedema. Afridi S, Goadsby PJ. New onset migraine with a brain stem cavernous angioma. J Neurol Neurosurg Psychiatry. 2003;74:680-682. A case of new onset migraine is described following a pontine bleed from a cavernous angioma. Polmear A. Sentinel headaches in aneurysmal subarachnoid haemorrhage: what is the true incidence? A systematic review. Cephalalgia. 2003;23:935-941. The aim of this systematic review was to determine the incidence of sentinel headache reported by patients with aneurysmal subarachnoid haemorrhage, and whether they are likely to be due to recall bias or to misdiagnosis of a previous haemorrhage. Nine studies of good quality, which reported the number of patients with aneurysmal subarachnoid haemorrhage with a history of sentinel headache, gave rates of 10% to 43%. Two case-control studies, in which the frequency of a history of sentinel headache in patients with aneurysmal subarachnoid haemorrhage was compared with that in controls with non-aneurysmal subarachnoid haemorrhage or with stroke, gave an incidence of 5% (95% confidence interval 0.5, 16) in controls, suggesting that only a small number of apparent sentinel headaches are due to recall bias. Sentinel headaches appear to be a real entity. Their true incidence may vary from near zero to about 40% according to the rate of misdiagnosis in the community under consideration. Plus an editorial: Demaerschalk B, Dodick DW. Recognizing sentinel headache as a premonitory symptom in patients with aneurysmal subarachnoid haemorrhage. Cephalalgia. 2003; 23:933-934. Comment: Drs. Demaerschalk and Dodick's editorial notes that Dr. Polmear's study is a systematic review and a meta-analysis, since it is not possible to design a randomized controlled trial (RCT) to answer questions on the nature of sentinel headaches before subarachnoid hemorrhage (SAH). They comment on this article meeting appropriate standards as described in the evidence-based literature of: "1. defining the question, 2. conducting a literature search, 3. identifying relevant studies, 4. applying inclusion and exclusion criteria, 5. appraising the studies, 6. abstracting data and 7. conducting analysis by combining results if appropriate" (Oxman A, Guyatt G, Cook D, Montori V. Summarizing the evidence. In: Guyatt G, Drummond R, eds. Users' Guide to the Medical Literature, A Manual for Evidence-Based Clinical Prctice. Chicago: American Medical Association; 2002:155-173). Finally, they point out that even if the lower number of sentinel headaches precede SAH, "Given the morbidity and mortality of ...[SAH], the finding that sentinel headaches occur in at least 10% of these patients underscores the opportunity... to identify...patients...early." SJT

INTRODUCTION: The revised International Headache Society (IHS) criteria for cluster headache are: attacks of severe or very severe, strictly unilateral pain, which is orbital, supraorbital, or temporal pain, lasting 15 to 180 minutes and occurring from once every other day to eight times daily. METHODS AND OUTCOMES: We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of interventions to abort cluster headache? What are the effects of interventions to prevent cluster headache? We searched: Medline, Embase, The Cochrane Library, and other important databases up to June 2009 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations, such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS: We found 23 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions. CONCLUSIONS: In this systematic review, we present information relating to the effectiveness and safety of the following interventions: baclofen (oral); botulinum toxin (intramuscular); capsaicin (intranasal); chlorpromazine; civamide (intranasal); clonidine (transdermal); corticosteroids; ergotamine and dihydroergotamine (oral or intranasal); gabapentin (oral); greater occipital nerve injections (betamethasone plus xylocaine); high-dose and high-flow-rate oxygen; hyperbaric oxygen; leuprolide; lidocaine (intranasal); lithium (oral); melatonin; methysergide (oral); octreotide (subcutaneous); pizotifen (oral); sodium valproate (oral); sumatriptan (oral, subcutaneous, and intranasal); topiramate (oral); tricyclic antidepressants (TCAs); verapamil; and zolmitriptan (oral and intranasal).

La cefalea es un problema de salud pública y plantea grandes desafíos en diagnóstico y tratamiento. La epidemiología de cefalea en niños y adolescentes, presenta una prevalencia de 30 por ciento entre los 3 y 15 años y de migraña de un 3-4 por ciento. La clasificación de la Sociedad Internacional de Cefaleas incorpora criterios para el diagnóstico de migraña infantil. Las principales diferencias con el adulto son: la duración, lateralidad y síntomas asociados como foto y/o fonofobia. La clasificación temporal de cefalea, diferencia la cefalea aguda, aguda recurrente, crónica no progresiva y crónica progresiva. La cefalea mixta, combina más de un tipo de cefalea. En la fisiopatología, se describen las vías involucradas en la activación del dolor como también los sistemas moduladores. Se analizan las teorías (muscular, vascular y neurogénica) que intentan explicar el fenómeno. El diagnóstico se basa en la historia clínica, examen físico y pruebas complementarias. En tratamiento se consideran medidas no farmacológicas, (educación, prevención, control ambiental de gatillantes) y farmacológicas. El uso de profilaxis continua es según frecuencia de eventos. Si bien faltan estudios en niños, la creación de unidades de cefalea que aborden en forma multidisciplinaria esta morbilidad, tendrán éxito si se usan protocolos ordenados, interactuando con las consultas de especialidad en aquellos casos de mayor complejidad, que no responden a intervenciones básicas, definidas éstas de acuerdo a la realidad local de cada unidad de cefalea.

ObjectivesTo identify the most effective treatments for chronic tension-type headache relief.Material and methodsA systematic review was conducted in MEDLINE, PEDro, Cochrane and CINAHL databases. It included randomized controlled trials and meta-analysis with adult patients and a minimum of 15 subjects, with tension-type headache that were not migraines or headache secondary to other conditions. We selected studies published from January 1998 to October 2008, in English, including the terms Effectiveness, Tension-type headache, and Treatment. In this first search, 81 studies were found and reviewed. Subsequently, specific terms related to treatment--Pharmacology, Botulinum toxin A, Manual therapy, Physiotherapy, Physical therapy, Psychological, Osteopathy, Chiropractic and Acupuncture were included in our search. After this second search, 80 more studies were found and reviewed. Finally, 15 studies were found to meet the inclusion criteria and were selected to be analyzed in the present study.ResultsThe 15 studies analyzed include treatments with botulinum toxin, antidepressants, antidepressants and stress control therapy, kinesitherapy, kinesitherapy and massage or relaxation therapy, massage, kinesitherapy and manipulative physiotherapy, connective tissue therapy, massage and heat therapy, osteopathy muscular relaxation, cranial osteopathy, chiropractic and acupuncture.ConclusionsTreatment with botulinum toxin is the most frequently used among doctors, although there is significant controversy about its effectiveness. The most effective physiotherapy treatment consists of spinal manipulation, combined with cervical muscle stretching and massage. Tricyclic antidepressants are the most effective pharmacological treatment.

OBJECTIVE: Gabapentin (GBP), originally an antiepileptic drug, is more commonly used in the treatment of pain, including headache disorders. Off-label GBP is used in headache disorders with some success, some failure, and much debate. Due to this ambiguity, a clinical evidence literature review was performed investigating GBP's efficacy in headache disorders. METHODS: Bibliographic reference searches for GBP use in headache disorders were performed in PUBMED and OVID Medline search engines from January 1, 1983 to August 31, 2014. Based on abstracts read by two reviewers, references were excluded if: GBP was not a study compound or headache symptoms were not studied. The resulting references were then read, reviewed, and analyzed. RESULTS: Fifty-six articles pertinent to GBP use in headache disorders were retained. Eight headache clinical trials were quality of evidence Class 2 or higher based on American Academy of Neurology criteria. Seven of the eight clinical trials showed statistically significant clinical benefit from GBP in various headache syndromes (though modest affects at times). One study, Mathew et al., had concerns about intention-treat analysis breaches and primary outcomes. CONCLUSION: Despite the conflicting evidence surrounding select studies, a significant amount of evidence shows that GBP has benefit for a majority of primary headache syndromes, including chronic daily headaches. GBP has some efficacy in migraine headache, but not sufficient evidence to suggest primary therapy. When primary headache treatments fail, a GBP trial may be considered in the individual patient.

All papers on cluster headaches were reviewed according to preset criteria under the following headings: classification, epidemiology, aetiology, pathophysiology, and clinical features. The management review used the Cochrane systematic review guidelines and so is based on randomized controlled trials wherever possible. A meta-analysis was not done. Other treatments are discussed and their drawbacks are highlighted and guidelines proposed based on the evidence of this review.

One third of patients with aneurysmal subarachnoid haemorrhage (ASAH) present with headache only. A prompt diagnosis is crucial, but these patients must be distinguished from patients with non-haemorrhagic benign thunderclap headache (BTH). The headache characteristics and associated features at onset in subarachnoid haemorrhage and benign thunderclap headache were studied to delineate the range of early features in these conditions. In this prospective study, one of two observers interviewed 102 patients with acute severe headache by means of a standard questionnaire. The patients were alert on admission and had no focal deficits. ASAH was subsequently diagnosed in 42 patients, non-aneurysmal perimesencephalic haemorrhage (PMH) in 23 patients, and BTH in 37 patients. Headache developed almost instantaneously in 50% of patients with ASAH, 35% of patients with PMH, and 68% of patients with BTH and within 1 to 5 minutes in 19%, 35%, and 19%, respectively. Loss of consciousness was reported in 26% of patients with ASAH, 4% of patients with PMH and 16% of patients with BTH, and transient focal symptoms in 33%, 9%, and 22% respectively. Seizures and double vision had occurred only in ASAH. Vomiting and physical exertion preceding the onset of headache were more frequent in patients with ASAH (69% and 50%) and those with PMH (83% and 39%) than in those with BTH (43% and 22%). Headache developed almost instantaneously in only half the patients with aneurysmal rupture and in two thirds of patients with benign thunderclap headache. In patients with acute severe headache, female sex, the presence of seizures, a history of loss of consciousness or focal symptoms, vomiting, or exertion increases the probability of ASAH, but these characteristics are of limited value in distinguishing ASAH from BTH. Aneurysmal rupture should be considered even if focal signs are absent and the headache starts within minutes.

INTRODUCTION: Chronic tension-type headache (CTTH) is a disorder that evolves from episodic tension-type headache, with daily, or very frequent, episodes of headache lasting hours or they may be continuous. It affects up to 4% of the general population, and is more prevalent in women (up to 65% of cases). METHODS AND OUTCOMES: We conducted a systematic overview, aiming to answer the following clinical questions: What are the effects of drug treatments for CTTH? What are the effects of non-drug treatments for CTTH? We searched: Medline, Embase, The Cochrane Library, and other important databases up to December 2013 (Clinical Evidence overviews are updated periodically; please check our website for the most up-to-date version of this overview). RESULTS: At this update, searching of electronic databases retrieved 125 studies. After deduplication, 77 records were screened for inclusion in the overview. Appraisal of titles and abstracts led to the exclusion of 56 studies and the further review of 21 full publications. Of the 21 full articles evaluated, three systematic reviews and one RCT were included at this update. We performed a GRADE evaluation for 15 PICO combinations. CONCLUSIONS: In this systematic overview, we categorised the efficacy for 12 interventions based on information about the effectiveness and safety of non-drug treatments acupuncture and cognitive behavioural therapy (CBT), as well as the drug treatments amitriptyline, anticonvulsant drugs (sodium valproate, topiramate, or gabapentin), benzodiazepines, botulinum toxin, noradrenergic and specific serotonergic antidepressants (mirtazapine), NSAIDs (e.g. ibuprofen); opioid analgesics (e.g. codeine), paracetamol, serotonin re-uptake inhibitor antidepressants (SSRIs, SNRIs), and tricyclic antidepressants (other than amitriptyline).

BACKGROUND: This is an updated version of the original Cochrane review published in Issue 4, 2010 (Law 2010). Cluster headache is an uncommon,severely painful, and disabling condition, with rapid onset. Validated treatment options are limited; first-line therapy includes inhaled oxygen. Other therapies such as intranasal lignocaine and ergotamine are not as commonly used and are less well studied. Triptans are successfully used to treat migraine attacks and they may also be useful for cluster headache. OBJECTIVES: To assess the efficacy and tolerability of the triptan class of drugs compared to placebo and other active interventions in the acute treatment of episodic and chronic cluster headache in adult patients. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL),MEDLINE, EMBASE, ClinicalTrials.gov, and reference lists for studies from inception to 22 January 2010 for the original review, and from 2009 to 4 April 2013 for this update. SELECTION CRITERIA: Randomised, double-blind, placebo-controlled studies of triptans for acute treatment of cluster headache episodes. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed study quality and extracted data. Numbers of participants with different levels of pain relief,requiring rescue medication, and experiencing adverse events and headache-associated symptoms in treatment and control groups were used to calculate relative risk and numbers needed to treat for benefit (NNT) and harm (NNH). MAIN RESULTS: New searches in 2013 did not identify any relevant new studies.All six included studies used a single dose of triptan to treat an attack of moderate to severe pain intensity. Subcutaneous sumatriptan was given to 131 participants at a 6 mg dose, and 88 at a 12 mg dose. Oral or intranasal zolmitriptan was given to 231 participants ata 5 mg dose, and 223 at a 10 mg dose. Placebo was given to 326 participants.Triptans were more effective than placebo for headache relief and pain-free responses. By 15 minutes after treatment with subcutaneous sumatriptan 6 mg, 48% of participants were pain-free and 75% had no pain or mild pain (17% and 32% respectively with placebo). NNTs for subcutaneous sumatriptan 6 mg were 3.3 (95% CI 2.4 to 5.0) and 2.4 (1.9 to 3.2) respectively. Intranasal zolmitriptan 10mg was of less benefit, with 12% of participants pain-free and 28% with no or mild pain (3% and 7% respectively with placebo). NNTs for intranasal zolmitriptan 10 mg were 11 (6.4 to 49) and 4.9 (3.3 to 9.2) respectively. AUTHORS' CONCLUSIONS: Based on limited data, subcutaneous sumatriptan 6 mg was superior to intranasal zolmitriptan 5 mg or 10 mg for rapid (15 minute)responses, which are important in this condition. Oral routes of administration are not appropriate.

Post-traumatic headache (PTH) is a very controversial disorder, particularly when it comes to chronic PTH following mild closed head injury and headache attributed to whiplash injury. Nevertheless, mild traumatic brain injury is very common in Western societies, affecting approximately 1.8 million individuals in the USA. Between 30 and 90% of patients develop PTH. Generally, this headache resolves within the first 3 weeks after the accident without any specific therapy or long-term complications but in a minority of patients chronic PTH develops and can be associated with serious neurological and neuropsychological deficits. Sufficient psychological or neurobiological markers for PTH do not exist, thus treatment can be very challenging and should always be multidisciplinary, even in the early stages of disease, to make every reasonable effort in preventing the development of chronic pain.