Au-delà des algies vasculaires de la face (AVF), d’autres céphalées trigémino-autonomiques « primaire » ont été définies par la classification ICHD3 telle que l’hémicrânie paroxystique, l’hémicrania ...continua ainsi que le SUNCT (Short lasting Unilateral Neuralgiform headache attacks with Conjonctival injection and Tearing) et le SUNA (Short lasting Unilateral Neuralgiform headache attacks with cranial Autonomic symptoms). Celles-ci sont encore plus rares que l’AVF mais ont en commun des crises de céphalées sévères unilatérales, de topographie périorbitaire, pluriquotidienne et associées à des signes ipsilatéraux végétatifs. Elles diffèrent par leur fréquence, leur durée mais aussi leurs traitements. L’hémicrânie paroxystique et l’hemicrania continua répondent exclusivement à l’indométacine alors que le SUNCT et SUNA restent souvent réfractaires à de nombreux traitements.
Certaines céphalées trigémino-autonomiques peuvent être associées à des névralgies du trijumeau comme dans le Cluster-Tic syndrome ou Paroxysmal hemicrania-Tic syndrome, souvent peu connus.
Enfin, plus récemment, d’autres types de céphalées trigémino-autonomiques ont été décrites mais pas encore intégrées dans l’ICHD3 : Il s’agit principalement du Red Ear syndrome, du syndrome d’Harlequin ou encore du LASH (Long lasting Autonomic Symptoms with Hemicrania). Leur survenue doit conduire à la réalisation d’un bilan approfondi afin de rechercher une cause secondaire, notamment locale.
The collection of lead seals of the Pera Museum consists of 17 unpublished pieces, except for three lead seals (nos.1, 8, and 10) which are dated from the second half of the 7th century to the 13th ...century. Ten of the seventeen Byzantine lead seals of the Pera Museum collection mention the dignities and the offices of their owners. These offices range from the lower rank of a simple notary (no. 5) up to the highest office of the emperor himself (no. 9). There is only one seal related to the ecclesiastical administration, issued by a bishop (no. 2). Noteworthy are the seals of Georgios (no. 6), who has the uniquely attested office of an imperial apothekarios, as well as the 11th-century seal of Pharasmanes Apokapes, member of a notable Byzantine family of Armenian origin, by whom no other seals have been published so far. Another group of seals consists of the specimens (nos. 11-14 and possibly also no. 17) where only the name or the surname of their owner is mentioned. All these pieces are dated to the period between the second half of the 11th century and the 13th century. In the collection, there are two more iconographic seals (nos. 15-16) depicting on both sides holy figures without any inscription that mentions their owner, and finally, an unidentified seal (no. 17) (dated to the end of the 11th century).
Si un grand nombre de traitements ont été essayés pour prendre en charge l’hémicrânie paroxystique (HP), l’hémicrania continua (HC) et les « short lasting neuralgiform headaches attacks » (SUNCT et ...SUNA) celle-ci demeure particulièrement difficile du fait de la méconnaissance de leur physiopathologie et de leur rareté, ce qui limite les études cliniques. L’indométhacine reste le traitement pharmacologique de référence pour HP et HC, réponse obligatoire pour valider le diagnostic selon les critères de l’ICHD-3 Pour l’HP derrière l’indométhacine un autre anti-inflammatoire non stéroïdien (AINS) le piroxicam semble légèrement émerger dans les publications tant pour le traitement aigu que prophylactique, mais pour ce dernier il est suivi de près par le vérapamil, la gabapentine et le topiramate Pour l’HC piroxicam et colecoxib ont donné de bons résultats en aigu, tandis que gabapentine et topiramate se partagent la prophylaxie toujours bien sur derrière l’indométhacine. Pour le SUNCT et le SUNA si la lamotrigine semble donner quelques résultats positifs en traitement préventif, pour la phase aiguë la lidocaïne en intraveineux ou sous-cutanée est la plus efficace. Sur le plan non pharmacologique aucun traitement n’émerge réellement si ce n’est peut-être la stimulation du nerf occipital et/ou son infiltration par des corticoïdes dans le SUNCT ou le SUNA.
A significant proportion of patients with short-lasting unilateral neuralgiform headache attacks (SUNHA) are refractory to medical treatments. Neuroimaging studies have suggested a role for ...ipsilateral trigeminal neurovascular conflict with morphological changes in the pathophysiology of this disorder. We present the outcome of an uncontrolled open-label prospective single centre study conducted between 2012 and 2020, to evaluate the efficacy and safety of trigeminal microvascular decompression in refractory chronic SUNHA with magnetic resonance imaging evidence of trigeminal neurovascular conflict ipsilateral to the pain side. Primary endpoint was the proportion of patients who achieved an "excellent response", defined as 90-100% weekly reduction in attack frequency, or "good response", defined as a reduction in weekly headache attack frequency between 75% and 89% at final follow-up, compared to baseline. These patients were defined as responders. The study group consisted of 47 patients of whom 31 had SUNCT and 16 had SUNA (25 females, mean age ± SD 55.2 years ± 14.8). Participants failed to respond or tolerate a mean of 8.1 (±2.7) preventive treatments pre-surgery. Magnetic resonance imaging of the trigeminal nerves (n = 47 patients, n = 50 symptomatic trigeminal nerves) demonstrated ipsilateral neurovascular conflict with morphological changes in 39/50 (78.0%) symptomatic nerves and without morphological changes in 11/50 (22.0%) symptomatic nerves. Post-operatively, 37/47 (78.7%) patients obtained either an excellent or a good response. Ten patients (21.3%, SUNCT = 7 and SUNA = 3) reported no post-operative improvement. The mean post-surgery follow-up was 57.4 ± 24.3 months (range 11-96 months). At final follow-up, 31 patients (66.0%) were excellent/good responders. Six patients experienced a recurrence of headache symptoms. There was no statistically significant difference between SUNCT and SUNA in the response to surgery (p = 0.463). Responders at the last follow-up were however more likely not to have interictal pain (77.42% vs 22.58%, p = 0.021) and to show morphological changes on the magnetic resonance imaging (78.38% vs 21.62%, p = 0.001). The latter outcome was confirmed in the Kaplan Meyer analysis, where patients with no morphological changes were more likely to relapse overtime compared to those with morphological changes (p = 0.0001). All but one patient who obtained an excellent response without relapse, discontinued their preventive medications. Twenty-two post-surgery adverse events occurred in 18 patients (46.8%) but no mortality or severe neurological deficit was seen. Trigeminal microvascular decompression may be a safe and effective long-term treatment for short-lasting unilateral neuralgiform headache attacks patients with magnetic resonance evidence of neurovascular conflict with morphological changes.
SEE LEONE AND PROIETTI CECCHINI DOI101093/AWW233 FOR A SCIENTIFIC COMMENTARY ON THIS ARTICLE: Short-lasting unilateral neuralgiform headache attacks are primary headache disorders characterized by ...short-lasting attacks of unilateral pain accompanied by autonomic features. A small minority are refractory to medical treatment. Neuroimaging studies have suggested a role of the posterior hypothalamic region in their pathogenesis. Previous case reports on deep brain stimulation of this region, now understood to be the ventral tegmental area, for this disorder are limited to a total of three patients. We present a case series of 11 new patients treated with ventral tegmental area deep brain stimulation in an uncontrolled, open-label prospective observational study. Eleven patients with refractory short-lasting unilateral neuralgiform headache attacks underwent ipsilateral ventral tegmental area deep brain stimulation in a specialist unit. All patients had failed, or been denied access to, occipital nerve stimulation within the UK's National Health Service. Primary endpoint was change in mean daily attack frequency at final follow-up. Secondary outcomes included attack severity, attack duration, headache load (a composite score of attack frequency, severity and duration), quality of life measures, disability and affective scores. Information was also collected on adverse events. Eleven patients (six male) with a median age of 50 years (range 26-67) were implanted between 2009 and 2014. Median follow-up was 29 months (range 7-63). At final follow-up the median improvement in daily attack frequency was 78% (interquartile range 33%). Response rate (defined as at least a 50% improvement in daily attack frequency) was 82% and four patients were rendered pain-free for prolonged periods of time. Headache load improved by 99% (interquartile range 52%). Improvements were observed in a number of quality of life, disability and affect measures. Adverse events included mild incision site pain, subcutaneous displacement of the implantable pulse generator, transient oscillopsia and minor wound infection. One patient required removal of the system due to wound infection. Ventral tegmental area deep brain stimulation may be an effective treatment option for refractory short-lasting unilateral neuralgiform headache attack patients who have failed other therapies.
Abstract
Objective
To look at cigarette smoking history (personal and secondary exposure as a child) in non-cluster headache trigeminal autonomic cephalalgias seen at a headache clinic and to ...determine smoking exposure prevalence utilizing previously published data.
Methods
Retrospective chart review and PubMed/Google Scholar search
Results
Forty-eight clinic patients met ICHD-3 criteria for non-cluster headache trigeminal autonomic cephalalgias. Four had paroxysmal hemicrania, 75% were smokers and secondary exposure was noted in all. 16 patients had short lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) or short lasting unilateral neuralgiform headache attacks with autonomic symptoms (SUNA), 12.5% were smokers and secondary exposure was noted in 91%. Twenty-eight patients had hemicrania continua, 21% were smokers and secondary exposure was found in 62.5%.
Since 1974 there have been 88 paroxysmal hemicrania, 50 SUNCT or SUNA and 89 hemicrania continua patients with a documented smoking exposure history. From current data and previous studies, a smoking history was noted in 60% paroxysmal hemicrania, 18% SUNCT and SUNA and 21% hemicrania continua patients.
Conclusion
A cigarette smoking history appears to be connected to paroxysmal hemicrania (personal and secondary exposure) and possibly to SUNCT/SUNA (secondary) and hemicrania continua (secondary).
Koç University Libraries established in 1993 is celebrating the 30th anniversary of its opening. This article exhibits the different phases of this 30-year long journey including the initial ...planning, the constant growth and the response to the social and technological transformation dominating the future of libraries worldwide. The Libraries constitutes a model in Türkiye with its rich collections, diverse services and qualified human resources. It also attaches importance to being part of the international library community and supports global development in every way. In addition, this article covers the institutionalization of higher education in the Republic of Türkiye which is celebrating its centenary.
Emerging data-points towards a possible aetiological and therapeutic relevance of trigeminal neurovascular contact in short lasting unilateral neuralgiform headache attacks with conjunctival ...injection and tearing (SUNCT) and perhaps in short lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms (SUNA). We aimed to assess the prevalence and significance of trigeminal neurovascular contact in a large cohort of consecutive SUNCT and SUNA patients and evaluate the radiological differences between them. The standard imaging protocol included high spatial and nerve-cistern contrast resolution imaging acquisitions of the cisternal segments of the trigeminal nerves and vessels. MRI studies were evaluated blindly by two expert evaluators and graded according to the presence, location and degree of neurovascular contact. The degree of contact was graded as with or without morphological changes. Neurovascular contact with morphological changes was defined as contact with distortion and/or atrophy. A total of 159 patients (SUNCT = 80; SUNA = 79) were included. A total of 165 symptomatic and 153 asymptomatic trigeminal nerves were analysed. The proportion of neurovascular contact on the symptomatic trigeminal nerves was higher (80.0%) compared to the asymptomatic trigeminal nerves (56.9%). The odds on having neurovascular contact over the symptomatic nerves was significantly higher than on the asymptomatic nerves odds ratio (OR): 3.03, 95% confidence interval (CI) 1.84-4.99; P < 0.0001. Neurovascular contact with morphological changes were considerably more prevalent on the symptomatic side (61.4%), compared to the asymptomatic side (31.0%) (OR 4.16, 95% CI 2.46-7.05; P < 0.0001). On symptomatic nerves, neurovascular contact with morphological changes was caused by an artery in 95.0% (n = 77/81). Moreover, the site of contact and the point of contact around the trigeminal root were respectively proximal in 82.7% (67/81) and superior in 59.3% (48/81). No significant radiological differences emerged between SUNCT and SUNA. The multivariate analysis of radiological predictors associated with the symptomatic side, indicated that the presence of neurovascular contact with morphological changes was strongly associated with the side of the pain (OR: 2.80, 95% CI 1.44-5.44; P = 0.002) even when adjusted for diagnoses. Our findings suggest that neurovascular contact with morphological changes is involved in the aetiology of SUNCT and SUNA. Along with a similar clinical phenotype, SUNCT and SUNA also display a similar structural neuroimaging profile, providing further support for the concept that the separation between them should be abandoned. Furthermore, these findings suggest that vascular compression of the trigeminal sensory root, may be a common aetiological factor between SUNCT, SUNA and trigeminal neuralgia thereby further expanding the overlap between these disorders.
Aims
We conducted a cross-sectional study to re-examine the clinical profile of patients with a clinical diagnosis of classical trigeminal neuralgia (CTN).
Methods
Inclusion criteria consisted of the ...International Headache Society’s published classification of CTN. For the specific purposes of the study, features such as autonomic signs, persistent background pain, attack durations of >2 minutes and reports of pain-related awakening were included. The demographic and clinical phenotype of each patient were carefully recorded for analysis.
Results
The study cohort consisted of 81 patients and based on reported attack duration these were divided into short (≤ 2 minutes, n = 61) and long (> 2 minutes, n = 20) groups for further analysis. The group with short attack duration neatly fit most of the criteria for CTN while the long attack group presents a more challenging diagnosis. There were no significant differences in pain severity, quality and location between the short and long attack groups. The frequency of persistent background pain was significantly higher in the long (70%) compared to the short attack group (29.5%, p = 0.001). There were significantly more reports of pain-related awakenings in the long (55%) than in the short attack groups (29.5%, p = 0.04). There were no significant differences in the frequency of autonomic signs between the short (21.3%) and long attack groups (40%, p = 0.1). In the short attack group, the presence of autonomic signs was significantly associated with longer disease duration, increased pain-related awakenings, and a reduced prognosis.
Conclusion
There are clear diagnostic criteria for CTN but often patients present with features, such as long pain attacks, that challenge such accepted criteria. In our cohort the clinical phenotype of trigeminal, neuralgiform pain with or without autonomic signs and background pain was observed across both short and long attack groups and the clinical implications of this are discussed.
Background
Non-invasive vagus nerve stimulation has initial evidence of efficacy in migraine and cluster headache. However, little is known about its role in the management of refractory chronic ...headaches.
Methods
We evaluated the preventive and abortive effects of non-invasive vagus nerve stimulation in 41 consecutive patients with refractory primary chronic headaches in an open-label prospective clinical audit. Headache diaries were used to collect clinical information. Those who obtained at least 30% reduction in headache days/episodes after three months of treatment were considered responders and were offered treatment continuation.
Results
Twenty-three patients with chronic migraine, 12 with chronic cluster headache, four with hemicrania continua and two with short-lasting unilateral neuralgiform headache attacks with autonomic symptoms (SUNA) were treated. Two of 23 chronic migraine patients, one of 12 chronic cluster headache patients, and two of four hemicrania continua patients were considered responders. None of the patients with SUNA benefited from the therapy. Two chronic migraine patients were able to reduce the pain severity of moderate migraines with non-invasive vagus nerve stimulation.
Conclusion
Non-invasive vagus nerve stimulation may not constitute an effective acute nor preventive treatment in refractory chronic primary headaches. The encouraging effect in hemicrania continua warrants further evaluation in larger studies.
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