Perioperative ingestion of caffeine and postoperative headache

The interruption of daily consumption of caffeine-containing beverages can cause headache and other symptoms within 8 hours. Resumption of caffeine alleviates these symptoms. Surgical patients routinely fast preoperatively and may have postoperative symptoms from caffeine withdrawal. In the current study, we determined whether perioperative caffeine consumption altered the incidence of postoperative headache. After institutional approval of the study design, 233 surgical outpatients were surveyed about history of headaches, caffeine consumption, and the presence and severity of headaches postoperatively. Of the 233 patients, 190 (82%) drank caffeinated beverages daily (mean daily consumption, 290 mg of caffeine). Postoperative headaches occurred in 22% of patients who routinely drank caffeinated beverages but in only 7% of those who did not (P < 0.03). Other factors associated with postoperative headaches included a history of frequent headaches (P < 0.0001), age of 50 years or younger (P < 0.002), and amount of daily caffeine ingested (P < 0.01). Among daily caffeine drinkers, those who drank caffeinated beverages on the day of the surgical procedure had a lower incidence of postoperative headaches than did those who abstained (17% versus 28%; P < 0.04). Postoperative headaches may be related to several factors. Perioperative intake of caffeine altered postoperative well-being. Caffeine given preoperatively may limit postoperative withdrawal headaches among the millions of daily drinkers of caffeinated beverages. A randomized, prospective, and blinded trial to test this hypothesis is warranted.     

Hyperprolactinemia and headaches

We investigated the frequency of headaches in women with menstrual abnormalities and hyperprolactinemia. Twenty-seven of 46 (58%) women with hyperprolactinemia indicated that headache episodes occur once or more per week; patients with sellar abnormalities (macroadenoma) or previous cranial or pituitary operation were excluded from this group of hyperprolactinemic patients. The headache episodes occurred significantly more frequently than in the control group (N = 56), where 27% indicated one or more headaches per week (p less than 0.01). In the vast majority of the women with hyperprolactinemia, headaches had preceded the finding of elevated prolactin levels for years and had not developed after the patients had become concerned about the pituitary gland. The clinical impression was that the headaches of these patients typically lack features of prodromal signs and unilaterality and resemble, in general, tension headaches; they may last for hours and often require medication. We could not demonstrate a relationship between prolactin levels and frequency or severity of these headache episodes. The etiology of these headaches is unclear. The therapeutic effect of bromocriptine deserves further investigation. In conclusion, we present data to suggest that headaches are commonly an associated finding in hyperprolactinemic women who have no evidence of significant pituitary enlargement.     

Case of the month. August 1996--frontal lobe tumor in 11 year old girl

An 11 year old girl presented with an 8 month history of left temporal headaches with new onset of nausea and vomiting with increased severity of headaches. An MRI scan showed a frontal lobe mass. The tumor was resected and histologic studies demonstrated a central neurocytoma. The clinical, radiologic and pathologic aspects (including immunohistochemistry and electron microscopy) of central neurocytomas are reviewed and the atypical features of this case described.     

Endoscopic sinonasal surgery in the management of primary headaches

Primary headaches (migraine, cluster, tension-type) are common disorders thought to be unrelated to nasal and sinus abnormalities. We present data on 19 patients with refractory primary headaches in the absence of significant sinus symptoms. The majority of patients responded with decreased pain to office application of nasal anaesthesia. A high prevalence of sinonasal abnormalities was found on coronal CT scans. Seventy-nine per cent responded with either decreased pain severity or headache frequency after endoscopic sinonasal surgery. We discuss possible underlying mechanisms to explain these findings.     

A new type of headache of ocular origin: ophthalmotonic headache. Diagnosis and treatment

INTRODUCTION: In some patients it was seen that chronic headaches disappeared after laser iridectomies had been done to prevent glaucoma, in persons with normal intra-ocular pressure (IOP). OBJECTIVE: To make a study of patients with headache, some of whom were treated with topical beta-blockers (carteolol) and others by Yag-laser iridectomies. The effect on headache and IOP was analyzed. MATERIAL AND METHODS: A survey, ophthalmological examination and headache provocation test were carried out in patients with headaches, and the changes in IOP determined by pharmacologically inducing miosis and mydriasis were recorded. Three treatment groups were formed and the results analyzed statistically. RESULTS: In the 12 patients treated pharmacologically, 62% improved and in 14% the headaches disappeared. In the 16 treated using laser 94% were cured and 6% improved. When both types of treatment were used on 9 patients, 22% improved and 78% were cured. The validity of the ocular pressure curve was checked in the diagnosis of blockage of the pupil. CONCLUSIONS: Some headaches of ocular origin (ophthalmotonic), not previously described, occur due to abrupt changes in intraocular pressure, and improve significantly when the IOP is reduced by beta-blockers or Yag-laser iridectomies are done. A valid provocation tests for diagnosis of this type of headache is described. We consider that blockage of the pupil and/or of the angle of the anterior chamber are possible etiopathogenic mechanisms.     

Headaches associated with nasal obstruction due to deviated nasal septum

A deviated nasal septum not only can cause a blocked nose, but may also be associated with headaches. This study evaluates the nature of these headaches, the effect of submucous resection of the nasal septum, and the factors associated with postoperative headache relief. Deviated nasal septa were corrected by submucous resection in 99 men and 17 women. Patients were studied at 4 to 48 months (mean 18 months) postoperatively. Fifty-five of the 116 patients studied (47.4%) had preoperative recurring headaches. Thirty-five of the 55 patients with headaches (63.6%) experienced relief (complete or partial) of their headaches at a mean follow-up period of 18 months. Patients were more likely to be relieved of their headaches following submucous resection if the headaches were most intense over the frontal region, pressurelike in nature, and if the submucous resection resulted in relief of nasal obstruction. It is possible that headaches recur in the long term, and it is postulated that central mechanisms play a role.     

Headache during pregnancy

A questionnaire was submitted to 430 women 3 days after delivery, asking mainly about features of headache before and during pregnancy, and their possible modification or recurrence; moreover, delivery modalities and the condition of the newborn were evaluated. One-hundred-and-twenty-six (29.3%) were found to be primary headache sufferers (IHS criteria, 1988), 81 of whom had migraine without aura (MO), 12 migraine with aura (MA), and 33 tension-type headache (TH). In all three groups, about 80% showed complete remission or a higher than 50% decrease in the number of attacks. The improvement was more evident after the end of the first trimester; this trend was common to the three primary headaches considered. In our series of primary headaches, there was only one case (MO) which began during pregnancy. In a subgroup of pluripara, headache maintained the improvement presented in the first pregnancy also during the following gravidic periods in about 50% of cases, whereas in the remaining 50% a worsening in parallel with successive pregnancies was found. Primary headaches "per se" do not seem to increase the pregnancy or delivery risks, nor the vitality of the newborn. During pregnancy, drug use was very much reduced and was restricted to a limited number of compounds.     

Drug-induced pseudotumor cerebri

Pseudotumor Cerebri (PTC) is an uncommon disorder whose etiology is largely unknown, although its association with steroid withdrawal, hypervitaminosis A, and the use of the tetracycline group of drugs has been well documented. We report here a case in which a patient on chronic divalproex therapy for a seizure disorder developed PTC. Changing his antiepileptic medication from divalproate to topiramate effected a remission of PTC symptoms while maintaining his seizure-free status. It is recommended that physicians treating epilepsy, vascular headaches, or mood disorders with divalproate consider the diagnosis of PTC when their patients complain of new onset of headaches or an increase in frequency or severity of existing headaches--especially those associated with a visual disturbance--to prevent permanent visual loss.     

Postural changes of the cervical spine in patients with nontoxic goiter

PURPOSE: To investigate differences in cervical spine posture and range of motion and self-reported neck pain and headache between patients with nontoxic goiter compared with a matched control group. DESIGN: An observational, controlled, blinded study. SETTING: The ambulatory outpatient facility of a university hospital. PARTICIPANTS: Twenty-five nontoxic goiter patients and 25 matched nongoiterous control subjects from the Department of Endocrinology. INTERVENTION: Participants were X-rayed from a lateral position in neutral, full flexion and full extension, and the radiographs were evaluated by a blinded examiner for anterior head carriage, maximal flexion, maximal extension and the extent and severity of any degenerative changes in the cervical spine. The degree of postural neck muscle tenderness was evaluated by a blinded rheumatologist using a validated Total Tenderness Score system. In addition, the two groups were compared for their self-reported frequency of neck pain and headaches. RESULTS: A significant increase in anterior head carriage was found among the goiter patients (p = .01), together with a corresponding decrease in flexion (p = .01), whereas the corresponding increase in extension was not statistically significant (p = .16). A higher prevalence of headaches was found in the goiter group (p = .06), but there was no difference in neck muscle tenderness (p = .40) or frequency of neck problems (p = .40) between the groups. The severity of degenerative changes in the cervical spine (p = .22) and the number of vertebral levels with degenerative changes (p = .13) were similar in the two groups. CONCLUSIONS: Goiters of > 100 g seem to alter the posture of the cervical spine, possibly resulting in a tendency for more frequent headaches. The changes do not seem to cause more neck pain, muscle tenderness or degeneration of the cervical spine.     

Epidemiology of tension-type headache in Santiago, Chile: a prevalence study

OBJECTIVE: To describe the importance of tension-type headache (TTH) in Santiago, Chile, by analyzing its prevalence, clinical features, and impact by age, gender, and socioeconomic status, using widely accepted international diagnostic criteria. METHODS: In 1993, a representative sample of 1540 adults (older than 14) of the province of Santiago were interviewed using a standard questionnaire. A total of 1385 (89.9% response rate) subjects responded to the survey. Initially, a designated member of each household responded to the questionnaire. Subsequently, each household member with headache was asked to respond to questions about the severity, frequency, location, duration, associated symptoms, and impact in work and social activities of their most frequent headaches. TTH diagnoses were determined in accordance with the International Headache Society criteria of 1988. RESULTS: Total prevalence was found to be 26.9% (95% CI: 24.6-29.3%); 35.2% in females (95% CI: 31.7-38.8%) and 18.1% in males (95% CI: 15.2-21.3%). The prevalence of episodic TTH was 24.3% (95% CI: 22.1-26.7%) and of chronic TTH 2.6% (95% CI: 1.8-3.6%). Overall, and by subtype, prevalence was significantly higher in females (ratio 1:9). There was no significant variation in prevalence by socioeconomic or age group except in chronic TTH, in which there was an increase with age. CONCLUSIONS: TTH is a prevalent condition in a sample of adults of Santiago, similar to that reported in previous studies using similar methodologies. Overall, TTH represents 72.3% of all recurrent headaches.     

The efficacy of RS-25259, a long-acting selective 5-HT3 receptor antagonist, for preventing postoperative nausea and vomiting after hysterectomy procedures

We evaluated the safety and efficacy of RS-25259, a potent and long-acting selective 5-HT3 receptor antagonist, for the prevention of postoperative nausea and vomiting (PONV) in women undergoing hysterectomy procedures. In this randomized, double-blind, placebo controlled, dose-ranging study, 218 healthy, consenting women were assigned to one of the six treatment groups: placebo or RS-25259 0.1, 0.3, 1.0, 3.0, or 30 microg/kg. All patients underwent a standardized general anesthetic technique. The study medication was administered i.v. 20-30 min before the end of surgery. During the initial 24-h period after surgery, the incidence of vomiting, the need for rescue antiemetics, the time to the first episode of emesis, and administration of rescue antiemetic medication, as well as a nausea visual analog scale and verbal categorical scale scores were recorded. In addition, recovery times from the end of anesthesia and the incidences of perioperative side effects were noted. Only 30 microg/kg RS-25259 significantly decreased the incidence of vomiting and the requirement for rescue antiemetics. The largest dose of RS-25259 also delayed the time to the first emetic episode and reduced the number of treatment failures. However, no differences were found in the severity of postoperative nausea (versus saline), and postoperative headaches were more common after the administration of RS-25259 0.3-30 microg/kg i.v. In conclusion, RS-25259 30 microg/kg i.v. was effective in reducing the incidence of PONV after major gynecologic surgery, but the occurrence of headaches with the larger doses of RS-25259 is a concern. Implications: RS-25259, a long-acting 5-HT3 antagonist, was effective in reducing postoperative vomiting only at the largest dose studied (30 microg/kg). However, RS-25259 had no antinausea activity, and the larger doses were associated with an increased incidence of headaches in the postoperative period.     

Headache and neck pain in spontaneous internal carotid and vertebral artery dissections

We studied the characteristics of headaches in 161 consecutive symptomatic patients with spontaneous dissections of the internal carotid artery (n = 135) or the vertebral artery (n = 26). For patients with internal carotid artery dissection (ICAD), the mean age was 47 years and for those with vertebral artery dissection (VAD), 40.7 years. A history of migraine was present in 18% of the ICAD group and in 23% of the VAD group. Headache was reported by 68% of the patients with ICAD and by 69% of those with VAD, and, when present, it was the initial manifestation in 47% of those with ICAD and in 33% of those with VAD. Ten percent of patients with ICAD had eye, facial, or ear pain without headache. The median interval from onset of headache to development of other neurologic manifestations was 4 days for the ICAD group and 14.5 hours for the VAD group. For all dissections, headaches typically were ipsilateral to the side of dissection. In the ICAD group, headaches were limited to the anterior head in 60% of patients and were steady in 73% and pulsating in 25%. In the VAD group, headaches were distributed posteriorly in 83% of patients and were steady in 56% and pulsating in 44%. Neck pain was present in 26% of patients with ICAD (anterolateral) and in 46% of those with VAD (posterior). The median duration of the headache in patients with VAD and ICAD was 72 hours, but headaches became prolonged, persisting for months to years, in four patients with ICAD.     

Clinical-physiological characteristics and hormone therapy of patients with typical form of climacteric syndrome

Clinical and physiological examinations of 76 women in the postmenopause revealed in 64 of them the typical form of the climacteric syndrome, characterized by not only typical symptoms ("flushes", increased exudation, headaches, etc.), but also by various emotional vegetative disturbances detected at profound clinical neurological examination of the autonomic nervous system and the emotional sphere. Individual hormone therapy was associated with an appreciable alleviation of all psychovegetative disorders: "flushes", exudation, irritability, arterial hypertension, severity of vegetative dystonia, hysterical stigmata.     

Response to prophylactic treatment of benign headache in children

INTRODUCTION: Common childhood headaches seldom require prophylactic treatment which, nevertheless, is quite often unsatisfactory. OBJECTIVE: To study drug and non-drug related factors that may influence the therapeutic response. MATERIAL AND METHODS: A four-month follow-up study of all patients attended during a year at the neuropediatric, outpatient hospital-based clinic, with > or = 2 monthly migraine without aura attacks, > or = 10 tension-type headaches, or both types of headaches. Patients were randomized to be treated on an open basis, placebo controlled, with flunarizine or piracetam. Headache frequency was evaluated according to treatment and patients' basal characteristics. RESULTS: 98 patients studied (56 migraine without aura, 24 tension-type headache, 18 mixed). 33% dropped out; they were school underachievers more frequently than those that completed the protocol. Of those completing the protocol and treated with placebo as the first choice of therapy, 27% reported total remission of symptomatology; those not remitting with placebo were high achievers at school significatively more frequently. At the end of the trial, 43% of the initially randomized patients still complained of headaches, regardless of treatment, showing a seasonal relationship. CONCLUSIONS: Prophylaxis of benign childhood headaches is needed in less than half of those reporting a high headache frequency; school achievement should be taken into consideration as another clue to compliance and headache persistence. On a short-term basis only the seasonal influence and the placebo effect can be held responsible for amelioration of symptomatology.     

The management of acute headache in adults in an acute admissions unit

There have been no previously published studies about acute admissions with headaches to a medical admissions ward. In our retrospective case-note study of all patients admitted with headaches to the acute medical admission ward of Ninewells Hospital, Dundee over a six-month period, there were 114 admissions with headache (2.4% of all admissions). CT scans were done in 68 (59.6%) and were abnormal in 21 patients. Twenty four patients (21.1%) had serious underlying causes for headaches. Predictors for CT abnormalities are discussed. Eighteen patients had lumbar punctures and six had abnormal results. Most patients were discharged after one day, nine were transferred to the neurosurgical unit and there were two deaths. Deficiencies in record keeping were identified as was a lack of precision in diagnosis. Changes in practice are needed to improve patient care and perhaps national guidelines are required.     

Chemoselectively addressable HCan building blocks in peptide synthesis: L-homocanaline derivatives

OBJECTIVE: Forty-two persons were exposed to controlled low-speed rear-end automobile collisions to assess the relation between both gender and impact severity and the presence, severity, and duration of whiplash-associated disorders (WAD). Individual measures were also assessed for their potential to predict the onset of WAD. DESIGN: Experimental study subjecting individuals to a speed change of 4 km/h and 8 km/h and utilizing pretest and posttest physical examinations (immediately after and 24 hours after impact) to quantify subjects' clinical response. RESULTS: Approximately 29% and 38% of the subjects exposed to the 4 km/h and 8 km/h speed changes, respectively, experienced WAD symptoms, with cervical symptoms and headaches predominating. Objective clinical deficits consistent with WAD were measured in both men and women subjects at both 4 km/h and 8 km/h. At 4 km/h, the duration of symptoms experienced by women was significantly longer when compared with that in men (p < .05). There were no significant differences in the presence and severity of WAD between men and women at 4 km/h and 8 km/h or in the duration of WAD at 8 km/h. There was also no significant difference in the presence, severity, and duration of WAD between 4 km/h and 8 km/h. No preimpact measures were predictive of WAD. CONCLUSION: The empirical findings in this study contribute to establishing a causal relationship between rear-end collisions and clinical signs and symptoms.     

Idiopathic intracranial hypertension and orthostatic edema may share a common pathogenesis

Our aim was to determine the frequency of orthostatic edema (OE) in patients with idiopathic intracranial hypertension (IIH). We evaluated 30 women with IIH for evidence of OE by comparing sodium and water excretion in the recumbent and standing postures and morning and evening body weights. Data were compared with findings in 30 women with OE, 22 weight-matched obese normal subjects, and 20 lean normal subjects. The effect of treatment with diuretics or diuretics plus sympathomimetic agents was compared. Seventy-seven percent of IIH patients had evidence of peripheral edema and 80% had significant orthostatic retention of sodium or water. Excretion of a standard saline load and of a tap water load was significantly impaired in the upright posture in the IIH and OE patients compared with the lean and obese normal subjects. Diuretic therapy induced weight loss (up to 9 kg) and decreased mean weight gain from morning to evening in 5 of 12 patients treated. In seven patients also treated with diuretics plus sympathomimetic drugs, the diuretic-induced morning weight loss and morning to evening weight gain were both significantly improved with the addition of sympathomimetic agents. Therapy reduced the frequency or severity of headaches in seven patients and reduced papilledema in four patients who received no other concurrent treatment for IIH. The orthostatic retention of sodium and water and the consequent edema is very similar in IIH and OE patients, suggesting a common pathogenesis for both disorders. Diuretic therapy, dietary salt and water restriction, and planned periods of recumbency merit study as a treatment for these patients.     

Incidence of chronic pain following traumatic brain injury

OBJECTIVE: To index the frequency of reported chronic pain in patients with traumatic brain injury (TBI). DESIGN: A case series study was conducted on consecutive patients with TBI. SETTING: TBI patients were recruited from an adult tertiary care center brain injury clinic. PATIENTS: A consecutive sample of 132 patients who attended a brain injury rehabilitation center after TBI. The sample included 53 mild and 79 moderate/severe TBI patients. OUTCOME MEASURES: Patients were administered a protocol that indexed pain site, frequency, severity, and duration. RESULTS: Chronic pain was reported by 58% of mild TBI and 52% of moderate/severe TBI patients. Headaches were the most commonly reported pain problem. Chronic headaches were reported by 47% of mild TBI patients and 34% of moderate/ severe TBI patients. Neck/shoulder, back, upper limb, and lower limb pain were reported similarly by mild and moderate/severe TBI patients. CONCLUSIONS: Findings indicate that chronic pain is a significant problem in mild and moderate/severe TBI patients. More effective diagnosis of TBI patients with chronic pain may facilitate rehabilitation of these patients.     

Bacterial causes of bovine mastitis in Wondogenet, Ethiopia

This community study on headache in Malaysia was based on IHS diagnostic criteria and showed the last-year prevalence of migraine was 9.0%. Migraine with aura accounted for only 10.6% of the migrainous population. The last-year prevalence of tension headache was 26.5% (94.4% episodic, 5.6% chronic) and 28.2% for other types of headache. No case of cluster headache was found. Almost two thirds of the migraine subjects graded their headaches as severe, while almost 60% of the tension headache subjects and almost 70% of the other headache subjects graded their headaches as mild. Overall, there was higher prevalence in females for migraine and tension headache, and in males for the other types of headache. The prevalence of headache was lower among those younger than 15 and older than 65 years of age. No significant differences were found in the prevalence of headache among the different racial groups nor among the urban versus the rural population. All the headache types shared the same triggering factors suggesting that different physiological characteristics are responsible for the type of pain suffered. In the location of this community with its tropical climate, headache was attributed to sun exposure in 51.9% of the migraine subjects, 55.7% of the tension headache subjects, and 36.6% of the group with other headaches.