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Headache-Adviser Newsletter, Issue #26 Rare Headaches
November 21, 2010

Rare Types Of Headaches

In this newsletter I wanted to talk about some rare types of headaches. These are headaches that I see only about once or twice a year in our clinic but I feel they are worth mentioning if you are not quite sure your headaches are responding to usual treatments.

Paroxsysmal Hemicrania

This is a rare type of headache related to cluster headaches. It occurs mostly in men, like cluster and has some of the same symptoms. It begins in adulthood. It is accompanied by severe boring or stabbing pain that is always 100% of the time on one side of the head. Like cluster, it has the following symptoms:

  • Severe boring pain on side of head or behind the eye
  • Redness and tearing in the eye, same side as headache
  • Nasal congestion, same side as headache
  • Drooping of eyelid, same side as headache

Unlike cluster, the timing is a bit different. Cluster headaches have a circadian rhythm; they occur the same time every day or with changes of the seasons. They last a few minutes up to 180 minutes. Paroxsysmal hemicranias headaches last only up to 45 minutes. They also occur many times a day randomly.

Treatment in the acute phase should include IV steroids for 3-5 days in a row followed by a course of prednisone. We also place patients on verapamil 240 mg 2-3 times per day. If they fail on this, then the treatment is indomethacin daily for 2-3 months.

When chronic it is also known as Sjaastad Syndrome.

Ice Pick Headache

Ice pick headaches are a very short lived stabbing headache. They occur on one or both sides of the head and last only a few seconds. They are associated with migraine, but at the present time we are unsure as to why.

Clinically (since I see severe migraine cases) I have seen this headache show up as a migraine profile improves. It may occur after a severe migraine is over.

If they occur only once or twice a day, generally we do not treat them. If occurring several times a day, then they respond to indomethacin, similar to the paroxsysmal hemicranias.

I should note, that while on indomethacin, patients must be on an H2 blocker such as Pepcid or Prilosec to protect the stomach. This anti-inflammatory can be hard on the stomach and if taken alone, may cause ulcers. As long as the stomach is protected, I have not had a problem when patients are on it for a few months.

Post-Partum Headaches

I bring this one up as many women are unaware of the fact just how serious this can become. Many times women will develop a headache after having a baby and this is most often than not an epidural headache. It happens if there is a small CSF (cerebrospinal fluid) leak at the base of the spine. It is treated with a blood patch which seals the leak.

Ok fine..but what if it doesn’t work? There is another type of headache than can occur that is more serious.

Remember that blood clots are associated with pregnancy. It is what we call a hypercoagulable state. A severe headache that occurs during labor and delivery or just after may be a blood clot in the brain. (Yes, they can occur there too!) The actual name is a sinus venous thrombosis. These clots occur in the veins surrounding the brain and the headache is excruciating.

Unfortunately, many doctors miss this, especially if the patient has a past history of migraine. Imaging such as a CT will not show it and the only imaging that is appropriate is an MRI and MRV to show the veins.

The treatment is blood thinners and just wait until the body reabsorbs the clot. In this case, opiods are appropriate for the pain.

Newly Persistent Daily Headache

This one is new on the horizon. It was just discovered within the last few years and is what it sounds like. Usually the person has no previous history of headache of any type, and then it just occurs one day and never goes away.

It can be difficult to diagnosis and basically it thought of when all other diagnoses have been excluded, and treatments have failed.

Usually occurring in adult women, many of these patients can remember the headache and how it started. It may occur after a very stressful event such as an infection, surgery or even a stressful life event. The pain is throbbing and associated with migraine symptoms such as photophobia and nausea. Movement makes it worse, just like migraine.

The quality of the headache mimics cerebrospinal fluid leaks and cerebral thrombosis so those headaches must be ruled out first.

Some patients have shown a response to gabapentin or topiramate, both of which are anti-seizure drugs.

New Book Project

Well enough for now. I just wanted to mention that I am now working on a home study course for headache sufferers. It will include a book and DVDs to help people chart their way through your headaches…more on that later!

For those of you in the US...Happy Thanksgiving!

Here's To Headache Free Days

Take care..

Mary Kay Betz MS RPA-C
Physician Assistant

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