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.     

TRH stimulation as an attempt at demonstration of the induction and involution of prolactin-secreting pituitary cells in pregnancy and puerperium and in pathological hyperprolactinemia

The present paper discusses the relationship between functional hypertrophia or hyperplasia of the prolactin secreting cells in the pituitary and actual pituitary prolactin reserves in pregnant and post partum women. 35 randomly selected post partum patients from the 3rd to 12th day p.p. and 14 women in their 11th to 14th weeks of pregnancy volunteered to undergo a standard TRH-test. The control group consisted of 60 normoprolactinemic patients. Eleven pathologically hyperprolactinemic patients were compared to the normoprolactinemic and physiologically hyperprolactinemic groups. In all cases, plasma prolactin showed a linear decrease from the 3rd to 12th days post partum. The TRH induced increase became correspondingly greater as the basal prolactin levels decreased, i.e. an inverse relationship between these two parameters was seen. The TRH-induced increase was also always greater than the increase caused by suckling. A connection between prolactin and parity was not found. The inverse relationship between basal prolactin levels and the actual reserves which could be released by TRH stimulation can be explained in that there are two regulatory systems for prolactin. The estrogens stimulate basal prolactin and inhibit prolactin reserves. The actual prolactin reserve is, on the one hand, directly dependent on the degree of endogenous neurohormonal stimulation and, on the other hand, indirectly dependent on the endogenous estrogens through a feedback mechanism. The TRH-stimulation test is not suitable for determining a functional hypertrophia or hyperplasia of lactotropic pituitary cells.     

Relationship between endocrine, immune, and clinical variables in patients with systemic lupus erythematosus

OBJECTIVE: To assess the frequency of increased plasma prolactin (PRL) in patients with systemic lupus erythematosus (SLE) and to evaluate its relationship to other hormonal and immune variables. METHODS: Thirty-five patients with SLE with various levels of disease activity were studied. Plasma PRL, cortisol, growth hormone (GH) were determined by radioimmunoassay and interleukin 6 (IL-6) by ELISA: SLE activity was evaluated using the European Consensus Lupus Activity Measurement (ECLAM). RESULTS: Increased plasma PRL concentration (> 20 ng/ml) was recorded in 11 patients (31%). No correlation was found between plasma PRL and GH, IL-6, cortisol, or C-reactive protein, nor was any significant correlation observed between plasma PRL and the ECLAM score. Patients with hyperprolactinemia were, however, found to have been treated with higher doses of prednisone therapy than patients with normal plasma PRL. Further analysis of the relationship of plasma PRL and therapy showed that patients with SLE selected by the attending physician for prednisone therapy in doses > or = 10 mg/day were more frequently hyperprolactinemic. CONCLUSION: Our findings that patients with SLE with a more active form of the disease and who are less responsive to therapy had increased plasma PRL levels more frequently may be indicative of a potential relationship of hyperprolactinemia to severity of disease.     

The effect of combined estrogen/progestogen treatment in women with hyperprolactinemic amenorrhea

Eleven women with hyperprolactinemic amenorrhea were treated with a combined estrogen/progestogen preparation (Loestrin 30) for 3 months as hormone replacement therapy because of estrogen deficiency, with a view to protection against osteoporosis. Serum prolactin levels rose during the 1st month of treatment (p < 0.05) but did not rise significantly further during the 2nd and 3rd months. The levels rose in proportion to pretreatment levels by 28% (median), and fell significantly but not completely during the 1-week treatment-free intervals. After the study period, prolactin values appeared to remain stable in those women who continued longer on treatment, and returned to around pretreatment values in those who stopped. In one woman there was radiological evidence of pituitary tumor growth during treatment. This study shows that estrogen/progestogen treatment in standard contraceptive dosage usually leads to only moderate and non-progressive stimulation of pituitary activity in women with hyperprolactinemic amenorrhea, but occasional excessive growth of a prolactinoma can occur and treatment needs to be monitored. Women with relatively high prolactin levels seem to be at particular risk. Safer variations of estrogen therapy such as lower dosage or combination with a protective low dose of a dopamine agonist should also be considered.     

Different sensitivity to sodium valproate in healthy, non-tumoral and tumoral hyperprolactinemic subjects

GABAergic drugs affect PRL secretion in both rat and man. Sodium valproate (SV) inhibits GABA transaminase so increasing the endogenous GABAergic tone. The aim of this study was to evaluate the effects of SV at low and high doses on PRL release in healthy subjects and hyperprolactinemic patients. Fifteen patients with prolactinomas, 8 patients with non-tumoral hyperprolactinemia and 10 healthy subjects were studied: in non consecutive days, all subjects received placebo and SV at the dose of 400 and 800 mg po. Serum PRL levels were assessed 30, 15 and 5 min before and every 30 min for 4 hours after administration. SV at the dose of 400 mg induced a significant decrease of serum PRL in healthy subjects (p < 0.05), whereas no effect was noted in both tumoral and non-tumoral hyperprolactinemia. The administration of 800 mg SV induced a significant decrease of PRL levels in healthy subjects and in patients with non-tumoral hyperprolactinemia (p < 0.05). Conversely, in prolactinomas a paradoxical increase of serum PRL concentration (p < 0.05) was observed 120 min after the administration of the drug. These data confirm the inhibitory activity of SV on PRL release in healthy subjects, and suggest the existence of a partial resistance to GABA in non-tumoral hyperprolactinemia. In prolactinomas, the paradoxical PRL increase after high dose of SV suggests the existence of a complete pituitary resistance to GABA. This finding might be explained by the appearance of the stimulatory effect of GABA at hypothalamic level that could have been unmasked by the lack of pituitary GABA effects on adenomatous lactotrophs.     

Methylergonovine maleate as a cluster headache prophylactic: a study and review

Methylergonovine maleate (Methergine), an ergot derivative with vasoconstrictive properties, has been cited as an effective treatment for vascular headaches. Few studies are available to support its use in headache management. An uncontrolled pilot study of 20 episodic cluster headache patients confirmed its effectiveness and tolerability as an adjunct cluster headache prophylactic. Decreased headache frequency was reported by 19 of 20 patients (95%), and 15 of 20 patients (75%) reported decreased intensity of headaches within 1 week of initiating therapy. A review of methylergonovine's pharmacokinetic, molecular, and tolerability profile clarifies its mechanisms and clinical role in headache management.     

Galactorrhea

Galactorrhea syndromes are mainly caused by hyperprolactinemia, which has been defined by the basal prolactin level more than 15 ng/ml. However, normoprolactinemia can not be proved only by the basal prolactin level less than 15 ng/ml, which required the assessment of prolactin secreting capacity. Occulted hyperprolactinemia has be well known as the same syndrome as hyperprolactinemia, which shows basal prolactin level less than 15 ng/ml and the exceed response of prolactin to prolactin secreting stimulation like as thyroid releasing hormone. Women with occulted hyperprolactinemiais show temporary and intermitted hyperprolactincmia responding to a lot of atimulous states like as stress, sleep or elevated E2 level, which resulted in galactrrhea, menstrual disturbances or infertility. The elevated prolactin not only suppress the pituitary ganadotropin secretion, but also disturb follicular development and luteal function in the ovary. Dopamine agonists, bromocriptine and teruguride an usually indicate in the treatment of hyperptolactinemia and have brought the good results.     

Hyperprolactinemia

The ability to measure serum prolactin levels has led to the characterization of hyperprolactinemia as a clinical entity. In women galactorrhea and amenorrhea are symptoms of elevated prolactin levels; in men, impotence seems to be a clinical correlate. In the differential diagnosis, concern about the presence of a pituitary adenoma is preeminent. Management of microadenomas is controversial; both active therapy and conservative follow-up have been advocated. For larger lesions, neurosurgery or radiation becomes necessary. Drug therapy to reduce prolactin levels is now available.     

Ocular adnexal oncocytoma: a case series and clinicopathologic review of the literature

OBJECTIVE: Headache is a common complaint in children and brain imaging has become widely used to evaluate this clinical condition. We studied the value of neuroimaging in children with chronic headaches. PATIENTS AND METHODS: A retrospective chart review was conducted of all children referred to the pediatric outpatient clinic for evaluation of headache over a 3-year period. The charts were reviewed for headache characteristics, clinical indications for performing neuroimaging, and imaging results. Special attention was paid to evidence of space-occupying lesions. RESULTS: A total of 160 records were studied, with subjects ranging in age from 4 to 14 years. Most patients were diagnosed as having migraine headaches (60%) or chronic tension headaches (29.5%). Other diagnoses were post-traumatic (6%) and unclassified (4%). Sixty-six patients (41%) had computed tomography imaging performed. In most cases, brain imaging studies were performed because of clinical data (41%) like atypical pattern, sleep-related headache or increase of headache, because of the parents' concerns about brain lesions (38%) and because of an age less than 5 years (14%). Structural changes were found on brain imaging in 4 patients, but none indicated the presence of a treatable space-occupying lesion and all were deemed unrelated to the headache. Our findings of no relevant abnormalities in a series of 66 neuroimaging studies indicate that the maximal rate at which such abnormalities might appear in this population is 4.4%. CONCLUSIONS: These results indicate that neuroimaging studies have very limited value in the clinical evaluation of pediatric patients with chronic headache and should be reserved for those patients with clinical evidence suggestive of underlying structural lesion.     

Clinical relapses and disease activity on magnetic resonance imaging associated with viral upper respiratory tract infections in multiple sclerosis

Inflammatory lesions of the hypophysis include lymphocytic hypophysitis, pituitary abscess, and granulomatous inflammation, with or without specific infections (i.e., sarcoidosis, mycobacteria). These lesions are known to mimic pituitary neoplasms. We report the clinical and pathologic findings in three patients who underwent transsphenoidal resection for presumed pituitary adenoma. Two were women aged 30 years (one with a 5-month history of headache, the other with a 1-year history of menstrual irregularity) and one was a 12-year-old girl with headache, nausea, and diabetes insipidus. Preoperative endocrinologic studies showed increased prolactin in one patient and normal serum thyroid stimulating hormone and prolactin levels in another. By magnetic resonance imaging (MRI), the first case had a 1.2-cm mass with increased signal on T1 and isointensity on T2, ring enhancement after gadolinium, and lateral deviation of the pituitary stalk. The second patient had a 1.1-cm "cystic" mass seen during magnetic resonance imaging with adjacent bony changes seen during computed tomography. In the third, computed tomography showed a hypodense pituitary mass that enlarged during 1-month observation. At surgery, abnormal soft tissue surrounded liquefied material in the anterior pituitary in all cases. Histologic studies showed fragments of intact normal anterior pituitary with preserved vascular and reticulin network and regions of anterior pituitary infiltrated by foamy histiocytes. Other fragments resembled granulation tissue, and some consisted of acellular debris. Histiocytes were immunoreactive for the macrophage marker CD68 and negative for S-100 and CD1a. Ultrastructurally, the normal adenohypophysis was permeated by lipid-laden macrophages. There were no well-formed granulomas or giant cells, hemosiderin, acid-fast bacilli, or fungi. Serial sections and keratin immunostains failed to identify an epithelial cyst lining or keratin among the debris. We propose the term "xanthomatous hypophysitis" for this lesion.     

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.     

Clinical features of daily chronic headache

INTRODUCTION: Although the International Headache Society considers chronic tension headache to be a chronic headache, patients with daily chronic headache may have pain which is not only due to tension but also has migrainous features. OBJECTIVE: To evaluate the clinical differences and abuse of drugs in a group of patients with chronic daily headache who were consecutively evaluated in the Neurology Clinic. MATERIAL AND METHODS: We consider the patients to have daily chronic headache when they have had pain at least 6 days a week for the past 6 months. Using this criterion, we studied 112 patients, of whom 90 (80.4%) were women and 22 (19.6%) men. Results. Sixty nine (61.6%) had transformed migraine and 43 (38.4%) tension headache. There were no differences in their current ages but the age of onset of the headaches varied (p = 0.000,t). Unilateral pain, trigger factors and a family history were more frequent in the cases of transformed migraine. Eighty four patients (75%) abused analgesics. Although we found different pain intensities (p = 0.000, chi 2) there was no difference in the weekly consumption of analgesics (p = 0.64, t) in the mg/week of ergotamine (p = 0.96, t) nor in absence from work between the two types of headache. CONCLUSIONS: In spite of clinical differences between transformed migraine and tension headache, which may help diagnosis, in our series abuse of analgesics (including ergotamine) was a common characteristic.     

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.     

Interosseous muscles in claw finger

The amenorrhea-galactorrhea syndrome which occurs at a time other than the post-partum period is most often seen in association with a tumor of the pituitary gland; the symptoms are caused by a hypersecretion of prolactin. Among a series of 19 patients in Tel Aviv who underwent surgery for treatment of pituitary tumors, 2 presented with the amenorrhea-galactorrhea syndrome. The first patient, a 16 year old, presented with headaches, nausea, and diplopia; she underwent a series of 3 surgical procedures and died of a respiratory arrest in the third post-operative period. The second patient was a 39 year old woman who had borne 5 children; she presented with loss of vision, underwent surgery, and did well post-operatively. The authors point out that whereas either amenorrhea or galactorrhea alone may be associated with a number of disorders, the combination of the two symptoms is characteristic of pituitary tumors. Both patients who were presented in this article had chromophobe adenomas of the pituitary. The authors also discuss the various biologic actions of prolactin and its interrelationships with other hormones.     

Beyond global oxygen supply-demand relations: in search of measures of dysoxia

Variations in serum molecular forms of prolactin (PRL) from an adolescent woman presenting amenorrhea-galactorrhea are reported. Persistent hyperprolactinemia and hypoestrogenism were demonstrated as well as the presence of a pituitary tumor with suprasellar extension. Bromocriptine was given at progressive doses up to 37 mg daily, decreasing the hyperprolactinemia and galactorrhea. After 2 years of treatment the patient noticed symptoms of gastric intolerance, bromocriptine was discontinued and a rebound of hyperprolactinemia was observed. Lisuride was administered instead resulting in a new decrease in PRL serum levels, disappearance of galactorrhea and beginning of regular menses. Serum gel chromatographic analysis was carried out before and during lisuride treatment. The first chromatographic analysis showed a predominance of high molecular weight (approximately 66 KD) PRL, accounting for more than 90% of the immunoreactive PRL. The second chromatography showed the major peak of immunoreactive PRL displaced to the right (molecular weight of 22 KD), which was eluted near the PRL standard. With these chromatographic patterns it is concluded that the pituitary macroprolactinoma secreted different molecular forms of PRL and treatment with lisuride appeared to exert some effect on the PRL molecular size secreted by the pituitary.     

Treatment of women with the galactorrhea-amenorrhea syndrome with pyridoxine (vitamin B6)

Three women with the galactorrhea-amenorrhea syndrome and elevated prolactin concentrations experienced a return of regular ovulatory menses within 37-94 days after starting pyridoxine treatment (200-600 mg/day). In each the galactorrhea ceased and serum prolactin levels were maintained in the normal range while taking pyridoxine. In two other women with prolonged secondary amenorrhea but without hyperprolactinemia or galactorrhea, pyridoxine at dosages up to 600 mg/day did not restore ovulatory menses. Pyridoxine treatment was also ineffective in decreasing profuse galactorrhea in one woman with normal prolactin levels and regular ovulatory menses. In the three women effectively treated with pyridoxine, the galactorrhea returned, serum prolactin levels increased, and the menses ceased after discontinuing pyridoxine. These results imply that pyridoxine, by decreasing the excessive secretion of prolactin, may be useful in the long-term medical management of women with hyperprolactinemia and the galactorrhea-amenorrhea syndrome.     

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.     

Effects of feeding fresh garlic and garlic oil on detoxifying enzymes and micronuclei formation in rats treated with azoxymethane

Two studies were conducted during which 23 patients with chronic migraine were exposed to pulsing electromagnetic fields over the inner thigh. In an open study, 11 subjects kept a 2-week headache log before and after 2 to 3 weeks of exposure to pulsing electromagnetic fields for 1 hour per day, 5 days per week. The number of headaches per week decreased from 4.03 during the baseline period to 0.43 during the initial 2-week follow-up period and to 0.14 during the extended follow-up which averaged 8.1 months. In a double-blind study, 9 subjects kept a 3-week log of headache activity and were randomly assigned to receive 2 weeks of real or placebo pulsing electromagnetic field exposures as described above. They were subsequently switched to 2 weeks of the other mode, after which they kept a final 3-week log. Three additional subjects in the blind study inadvertently received half-power pulsing electromagnetic field exposures. The 6 subjects exposed to the actual device first showed a change in headache activity from 3.32 per week to 0.58 per week. The 3 subjects exposed to only half the dose showed no change in headache activity. Large controlled studies should be performed to determine whether this intervention is actually effective.     

A study on sexual dysfunction in female patients with alcoholics

Few investigations have been made concerning hormonal changes and dyspareunia in fertile aged women with alcoholics experiencing sexual dysfunction. Twenty-seven Japanese woman with alcoholics under 40 years of age excluded with liver cirrhosis were studied to describe alcohol drinking related to sexual dysfunction. Among 21 sexually active women, 20(95.2%) had both symptoms of dyspareunia and vaginal dryness, and only one had neither symptom. Most of patients have lower estradiol levels and 92.0% of patients have the moderately elevated prolactin levels. Eleven of them were having the second grade amenorrhea associated with hyperprolactinemia and hypergonadotropic hypogonadism and 14 were having the first grade amenorrhea. In this study alcoholic abuse women may have deeply related to the hyperprolactinemia, dyspareunia, amenorrhoea, vaginal dryness, ovarian dysfunction and fetal alcohol syndrome.     

The primary empty sella an endocrine study on 12 cases

Twelve patients (10 women and 2 men) with a primary empty sella turcica were studied. Endocrine function tests were performed as follows: growth hormone (GH) was measured after insulin-induced-hypoglycaemia, luteinizing hormone (LH) and follicle-stimulating hormone (FSH) after LH-releasing hormone, thyrotrophin (TSH) and prolactin after thyrotrophin-releasing hormone; pituitary reserve of adrenocorticotrophin (ACTH) was determined by measurement of plasma cortisol after lysine-vasopressin and 11 deoxycortisol after metyrapone. Five of the patients (group A) had no endocrine disturbance. Seven patients (group B) had a hypothalamo-pituitary disorder. Two of them had panhypopituitarism which appeared in one case after meningoencephalitis and in the other after a severe cranial trauma. In two cases an amenorrhoea-galactorrhoea syndrome with increased prolactin level (68 and 230 ng/ml) led to a diagnosis of a prolactin producing adenoma, which was confirmed by surgery. Finally three cases of amenorrhoeagalactorrhoea, with normal prolactin level, and/or diabetes insipidus remained unexplained. However, no causal relationship could be demonstrated between the pituitary disturbance and the "empty sella". Primary empty sella turcica is therefore a neuroanatomical and neuroradiological entity with no endocrine implication. A pituitary disorder might suggest a microadenoma or an incidentally associated disease.