Neurol Sci (2015) 36 (Suppl 1):S153–S155 DOI 10.1007/s10072-015-2170-9
BRIEF COMMUNICATION
Persistent orthostatic headache without intracranial hypotension: which treatment? M. Curone • A. Proietti Cecchini L. Chiapparini • D. D’Amico
•
Ó Springer-Verlag Italia 2015
Abstract Orthostatic headache can be the leading symptom of intracranial hypotension, however, not all orthostatic headaches are due to cerebrospinal fluid leaks and these forms can be a clinical problem, especially for treatment. Aim of this study was to review patients with persistent orthostatic headache in whom a detailed head and spinal MRI follow-up did not reveal any sign of intracranial hypotension and to evaluate which treatment can be considered the first choice. Patients admitted to our headache center for evaluation of persistent orthostatic headache and followed after first admission with clinical and neuroradiological controls were systematically reviewed. 11 patients (7 M, 4 F) followed in a period lasted from 10 months up to 2 years were studied. Six patients (54, 5 %) reported a MRI performed previously elsewhere with a suspect diagnosis of intracranial hypotension which was not confirmed at MRI at our hospital such as during the radiological follow-up. Three patients (27.2 %) had developed orthostatic headache short after a neck or head trauma with no evidence of neuroradiological pathological signs and two patients (18 %) had a previous history of psychiatric disorder. We administrated antidepressants in five patients, atypical neuroleptic in three patients, association of antidepressant and antipsychotic in one patient and muscle relaxants in two cases. All patients showed a certain improvement of headache in the weeks after M. Curone (&) A. P. Cecchini D. D’Amico Headache and Neuroalgology Unit, Department of Clinical Neurosciences, Neurological Institute C. Besta, IRCCS Foundation, Via Celoria 11, 20133 Milan, Italy e-mail: [email protected] L. Chiapparini Neuroradiology Unit, Neurological Institute C. Besta, IRCCS Foundation, Via Celoria 11, 20133 Milan, Italy
introduction of the pharmacological treatment; six (54, 5 %) had pain relief during the follow-up and five (45, 5 %) were pain free at the last clinical control. We found out that patients with the best outcome were the ones treated with antidepressants. Persistent orthostatic headache without any neuroradiological sign of intracranial hypotension is a challenging problem for clinicians. Although the International Classification of Headache Disorders (ICHD-3 beta version) criteria suggests the possibility of epidural blood patch in orthostatic headache without causes, we believe that a pharmacological treatment tailored on each patient should be always considered and antidepressants can be the first choice. Keywords Intracranial hypotension Orthostatic headache Antidepressants
Introduction Orthostatic headache can be the leading symptom of intracranial hypotension, however, not all headaches caused by cerebrospinal fluid (CSF) leaks are orthostatic and not all orthostatic headaches are due to CSF leaks. Moreover, orthostatic headaches can occur without head and spinal MRI evidence of intracranial hypotension [1]. This headache forms, when persistent and with no response to acute therapies, can be a clinical problem particularly as far as treatment.
Objective Aim of this study was to review patients with persistent orthostatic headache and normal head and spine MRI to evaluate which treatment can be considered the first choice.
123
S154
Patients and methods We reviewed the charts of patients admitted to our Headache Center for persistent orthostatic headache followed with several clinical and neuroradiological controls after first admission in whom a detailed head and spine MRI study did not reveal signs of intracranial hypotension or any other causes of secondary headache.
Neurol Sci (2015) 36 (Suppl 1):S153–S155 Table 1 Headache attributed to spontaneous intracranial hypotension: diagnostic criteria of the International Headache Society (ICHDIII beta version) and comments Diagnostic criteria A. Any headache fulfilling criterion C B. Low CSF pressure (\60 mm CSF) and/or evidence of CSF leakage on imaging C. Headache has developed in temporal relation to the low CSF pressure or CSF leakage, or has led to its discovery D. Not better accounted for by another ICHD-3 diagnosis
Results 11 patients (7 M, 4 F) mean age 37.4 years (range 18–58 years) followed in a period lasted from 10 months up to 2 years were studied. All patients complained at admission a moderate to severe daily/near daily non pulsating diffuse headache with a dull pressure occipital and/ or frontal, the longer they were upright with improving in a variable time frame of 5 min to 3 h after lying down. Past medical history was positive for chronic migraine in 2 on 11 (18 %). All patients considered this headache disabling. In six patients (54.5 %) headache was partially relieved by analgesics while in five (45.4 %) was acute-drugs resistant. Two patients (18 %) reported constriction in the neck area without worsening after sitting or standing. No nausea, fullness, dizziness or vomiting was described by patients. Six patients (54, 5 %) showed a brain MRI performed previously elsewhere with a suspect diagnosis of intracranial hypotension which was not confirmed at brain and spine MRI performed at our Hospital such as during the radiological follow-up. Three patients (27.2 %) had developed orthostatic headache short after a neck or head trauma with no evidence of neuroradiological pathological signs and two patients (18 %) had a previous history of psychiatric disorder. All these 11 patients received medical treatment with different drugs for at least 4 months to 1 year. We administrated antidepressants in five patients, atypical neuroleptic in three patients, association of antidepressant and antipsychotic in one patient and muscle relaxants in two cases. Two patients were treated with amitriptyline 25 mg/day and one with association of amitriptyline and chlordiazepoxide, respectively, at daily dose of 25 and 10 mg. One patient was treated with escitalopram 10 mg per day, and one with duloxetine up to 60 mg/day. Three patients were treated with tiapride administrated orally 100 mg three times a day and one patient with association of escitalopram 10 mg/day and olanzapine 5 mg/day. Two patients were treated with an increasing dosage of cyclobenzaprine (from 10 mg/day up to 30 mg/day). All patients showed a certain improvement of headache in the weeks after introduction of the pharmacological treatment; six (54, 5 %) had pain relief during the follow-up (at 4, 8, 12 and 24 months) and five (45, 5 %)
123
Comments In patients with typical orthostatic headache and no apparent cause, after exclusion of postural orthostatic tachycardia syndrome (POTS) it is reasonable in clinical practice to provide autologous lumbar EBP. It is not clear that all patients have an active CSF leak, despite a compelling history or brain imaging signs compatible with CSF leakage. Cisternography is an outdated test, now infrequently used; it is significantly less sensitive than other imaging modalities (MRI, CT or digital subtraction myelography). Dural puncture to measure CSF pressure directly is not necessary in patients with positive MRI signs such as dural enhancement with contrast
were pain free at the last clinical control. We found out that patients with the best outcome were the ones treated with antidepressants.
Discussion Persistent orthostatic headache without neuroradiological signs of intracranial hypotension is a challenging problem for clinicians. The International Classification of Headache Disorders (ICHD-3 beta version) criteria for ‘‘headache attributed to spontaneous intracranial hypotension’’ [2] (Table 1) specify in comments that in patients with typical orthostatic headache and no apparent cause, it is reasonable in clinical practice to provide autologous lumbar epidural blood patch (EBP) but the choice of an invasive surgical treatment without specific indication raises some ethical issues. Moreover, a psychiatric evaluation should be performed to exclude a comorbid psychiatric condition underlying headache [3]. We believe that a pharmacological treatment tailored on each patient should be always taken into account in these cases. Considering their efficacy in several headache forms [4, 5] antidepressants may be the first choice. Conflict of interest
The authors declare no conflict of interest.
References 1. Leep Hunderfund AN, Mokri B (2008) Orthostatic headache without CSF leak. Neurology 71:1902–1906
Neurol Sci (2015) 36 (Suppl 1):S153–S155 2. Classification Committee of the International Headache Society (2013) The international classification of headache disorders, 3rd edition (beta version). Cephalalgia 33:629–808 3. Ferrante E, Rubino F (2014) Orthostatic headache without intracranial hypotension: a headache due to psychiatric disorder? Headache 54(6):1056–1057
S155 4. Punay NC, Couch JR (2003) Antidepressants in the treatment of migraine headache. Curr Pain Headache Rep 7(1):51–54 5. Smitherman TA, Walters AB, Maizels M, Penzien DB (2011) The use of antidepressants for headache prophylaxis. CNS Neurosci Ther 17(5):462–469
123
Copyright of Neurological Sciences is the property of Springer Science & Business Media B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
BRIEF COMMUNICATION
Persistent orthostatic headache without intracranial hypotension: which treatment? M. Curone • A. Proietti Cecchini L. Chiapparini • D. D’Amico
•
Ó Springer-Verlag Italia 2015
Abstract Orthostatic headache can be the leading symptom of intracranial hypotension, however, not all orthostatic headaches are due to cerebrospinal fluid leaks and these forms can be a clinical problem, especially for treatment. Aim of this study was to review patients with persistent orthostatic headache in whom a detailed head and spinal MRI follow-up did not reveal any sign of intracranial hypotension and to evaluate which treatment can be considered the first choice. Patients admitted to our headache center for evaluation of persistent orthostatic headache and followed after first admission with clinical and neuroradiological controls were systematically reviewed. 11 patients (7 M, 4 F) followed in a period lasted from 10 months up to 2 years were studied. Six patients (54, 5 %) reported a MRI performed previously elsewhere with a suspect diagnosis of intracranial hypotension which was not confirmed at MRI at our hospital such as during the radiological follow-up. Three patients (27.2 %) had developed orthostatic headache short after a neck or head trauma with no evidence of neuroradiological pathological signs and two patients (18 %) had a previous history of psychiatric disorder. We administrated antidepressants in five patients, atypical neuroleptic in three patients, association of antidepressant and antipsychotic in one patient and muscle relaxants in two cases. All patients showed a certain improvement of headache in the weeks after M. Curone (&) A. P. Cecchini D. D’Amico Headache and Neuroalgology Unit, Department of Clinical Neurosciences, Neurological Institute C. Besta, IRCCS Foundation, Via Celoria 11, 20133 Milan, Italy e-mail: [email protected] L. Chiapparini Neuroradiology Unit, Neurological Institute C. Besta, IRCCS Foundation, Via Celoria 11, 20133 Milan, Italy
introduction of the pharmacological treatment; six (54, 5 %) had pain relief during the follow-up and five (45, 5 %) were pain free at the last clinical control. We found out that patients with the best outcome were the ones treated with antidepressants. Persistent orthostatic headache without any neuroradiological sign of intracranial hypotension is a challenging problem for clinicians. Although the International Classification of Headache Disorders (ICHD-3 beta version) criteria suggests the possibility of epidural blood patch in orthostatic headache without causes, we believe that a pharmacological treatment tailored on each patient should be always considered and antidepressants can be the first choice. Keywords Intracranial hypotension Orthostatic headache Antidepressants
Introduction Orthostatic headache can be the leading symptom of intracranial hypotension, however, not all headaches caused by cerebrospinal fluid (CSF) leaks are orthostatic and not all orthostatic headaches are due to CSF leaks. Moreover, orthostatic headaches can occur without head and spinal MRI evidence of intracranial hypotension [1]. This headache forms, when persistent and with no response to acute therapies, can be a clinical problem particularly as far as treatment.
Objective Aim of this study was to review patients with persistent orthostatic headache and normal head and spine MRI to evaluate which treatment can be considered the first choice.
123
S154
Patients and methods We reviewed the charts of patients admitted to our Headache Center for persistent orthostatic headache followed with several clinical and neuroradiological controls after first admission in whom a detailed head and spine MRI study did not reveal signs of intracranial hypotension or any other causes of secondary headache.
Neurol Sci (2015) 36 (Suppl 1):S153–S155 Table 1 Headache attributed to spontaneous intracranial hypotension: diagnostic criteria of the International Headache Society (ICHDIII beta version) and comments Diagnostic criteria A. Any headache fulfilling criterion C B. Low CSF pressure (\60 mm CSF) and/or evidence of CSF leakage on imaging C. Headache has developed in temporal relation to the low CSF pressure or CSF leakage, or has led to its discovery D. Not better accounted for by another ICHD-3 diagnosis
Results 11 patients (7 M, 4 F) mean age 37.4 years (range 18–58 years) followed in a period lasted from 10 months up to 2 years were studied. All patients complained at admission a moderate to severe daily/near daily non pulsating diffuse headache with a dull pressure occipital and/ or frontal, the longer they were upright with improving in a variable time frame of 5 min to 3 h after lying down. Past medical history was positive for chronic migraine in 2 on 11 (18 %). All patients considered this headache disabling. In six patients (54.5 %) headache was partially relieved by analgesics while in five (45.4 %) was acute-drugs resistant. Two patients (18 %) reported constriction in the neck area without worsening after sitting or standing. No nausea, fullness, dizziness or vomiting was described by patients. Six patients (54, 5 %) showed a brain MRI performed previously elsewhere with a suspect diagnosis of intracranial hypotension which was not confirmed at brain and spine MRI performed at our Hospital such as during the radiological follow-up. Three patients (27.2 %) had developed orthostatic headache short after a neck or head trauma with no evidence of neuroradiological pathological signs and two patients (18 %) had a previous history of psychiatric disorder. All these 11 patients received medical treatment with different drugs for at least 4 months to 1 year. We administrated antidepressants in five patients, atypical neuroleptic in three patients, association of antidepressant and antipsychotic in one patient and muscle relaxants in two cases. Two patients were treated with amitriptyline 25 mg/day and one with association of amitriptyline and chlordiazepoxide, respectively, at daily dose of 25 and 10 mg. One patient was treated with escitalopram 10 mg per day, and one with duloxetine up to 60 mg/day. Three patients were treated with tiapride administrated orally 100 mg three times a day and one patient with association of escitalopram 10 mg/day and olanzapine 5 mg/day. Two patients were treated with an increasing dosage of cyclobenzaprine (from 10 mg/day up to 30 mg/day). All patients showed a certain improvement of headache in the weeks after introduction of the pharmacological treatment; six (54, 5 %) had pain relief during the follow-up (at 4, 8, 12 and 24 months) and five (45, 5 %)
123
Comments In patients with typical orthostatic headache and no apparent cause, after exclusion of postural orthostatic tachycardia syndrome (POTS) it is reasonable in clinical practice to provide autologous lumbar EBP. It is not clear that all patients have an active CSF leak, despite a compelling history or brain imaging signs compatible with CSF leakage. Cisternography is an outdated test, now infrequently used; it is significantly less sensitive than other imaging modalities (MRI, CT or digital subtraction myelography). Dural puncture to measure CSF pressure directly is not necessary in patients with positive MRI signs such as dural enhancement with contrast
were pain free at the last clinical control. We found out that patients with the best outcome were the ones treated with antidepressants.
Discussion Persistent orthostatic headache without neuroradiological signs of intracranial hypotension is a challenging problem for clinicians. The International Classification of Headache Disorders (ICHD-3 beta version) criteria for ‘‘headache attributed to spontaneous intracranial hypotension’’ [2] (Table 1) specify in comments that in patients with typical orthostatic headache and no apparent cause, it is reasonable in clinical practice to provide autologous lumbar epidural blood patch (EBP) but the choice of an invasive surgical treatment without specific indication raises some ethical issues. Moreover, a psychiatric evaluation should be performed to exclude a comorbid psychiatric condition underlying headache [3]. We believe that a pharmacological treatment tailored on each patient should be always taken into account in these cases. Considering their efficacy in several headache forms [4, 5] antidepressants may be the first choice. Conflict of interest
The authors declare no conflict of interest.
References 1. Leep Hunderfund AN, Mokri B (2008) Orthostatic headache without CSF leak. Neurology 71:1902–1906
Neurol Sci (2015) 36 (Suppl 1):S153–S155 2. Classification Committee of the International Headache Society (2013) The international classification of headache disorders, 3rd edition (beta version). Cephalalgia 33:629–808 3. Ferrante E, Rubino F (2014) Orthostatic headache without intracranial hypotension: a headache due to psychiatric disorder? Headache 54(6):1056–1057
S155 4. Punay NC, Couch JR (2003) Antidepressants in the treatment of migraine headache. Curr Pain Headache Rep 7(1):51–54 5. Smitherman TA, Walters AB, Maizels M, Penzien DB (2011) The use of antidepressants for headache prophylaxis. CNS Neurosci Ther 17(5):462–469
123
Copyright of Neurological Sciences is the property of Springer Science & Business Media B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
