Tag Archives: headache

New Form of Headache Taking Off

The pilot announces your plane will be landing soon. Then it comes without warning: a severe, debilitating pain in your head that resolves ‑ spontaneously – only once you arrive at the terminal.

Dr. Frederico Mainardi first heard about such a sudden attack from a patient, and together with seven other case reports devised “Headache Attributed to Airplane Travel” criteria in 2007. Shortly thereafter, he started receiving e-mails from people around the world who described very similar headaches.

Source: Wikimedia/Creative Commons user Todd Neville

Dr. Mainardi sent a questionnaire to these 69 contacts, and answers returned from 63 people revealed some common, peculiar characteristics:

Strict unilaterality (occurs on only one side of the head).

Quality of the pain.

Severe intensity.

Short duration of attack.

Absence of companion symptoms (some headaches come with nausea, vomiting, sensitivity to light, etc.).

Appearance during landing phase (53 of the 63 reports)

The headaches are so bad that 44 people (69%) said their experience negatively influences their decisions to fly again, Dr. Mainardi said at a congress of the International Headache Society in Berlin.

Strangely, 46 people reported flying multiple times without incident before their in-flight attack.

The good news is acute pain medication such as sodium naproxen taken before (or during, if it’s a long flight) can prevent an attack in a patient with a history of this headache type, said Dr. Mainardi, a neurologist at the Headache Centre at the Giovanni e Paolo Hospital in Venice, Italy.

Importantly, only two people reported sinusitis at the time of their attack. MRI scans and sinus CT scans in a subset of patients ruled out any other physical explanations for the headaches, Dr. Mainardi said.

All patients denied drinking alcohol before their attack, and the duration of their flights was not a factor.

Dr. Mainardi proposes “Headache Attributed to Airplane Travel” be considered a new entity for the next edition of the International Classification of Headache Disorders or ICHD, the leading reference used by headache specialists worldwide.

In the meantime, Dr. Mainardi has collected 74 individual case reports so far.

–Damian McNamara

@MedReporter on twitter


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The Top-Viewed Posts of 2010

Well, it’s that time of year: A time for reflection, a time for too much fattening food and drink, and probably way too much togetherness with relatives you spend the rest of the year trying to avoid. Here at Notes From the Road, we’d like to take a moment to reflect on the bounty that medicine has provided us in 2010 by sharing our most-viewed posts, as nearest as we can determine.

Via Flickr Creative Commons user yoppy

10. Would an Artificial Pancreas be a Diabetes “Cure?” By Miriam E. Tucker

The Juvenile Diabetes Research Foundation’s announcement yesterday of a partnership with Animas Corp. and DexCom Inc. to develop a first-generation automated insulin delivery system brought to my mind a question that is often debated in diabetes circles: Would a fully automated “artificial pancreas” represent a “cure” for type 1 diabetes? (Read more.)

9. Placebos vs. Antidepressants: Not Quite a Draw By Bob Finn

There’s a fascinating study in today’s Journal of the American Medical Association. It’s a meta-analysis of randomized controlled trials comparing antidepressants vs. placebo. And it showed that the placebo effect is so strong in depression that placebos work as well as paroxetine (Paxil) and imipramine (Tofranil) for all patients except those with major depressive disorder that’s classified as “very severe.” Placebo tied active medication for “mild,” “moderate,” and even “severe” depression. (Read more.)

8. Tocilizumab Approval Causes Buzz by Diana Mahoney

One year after asking the Roche group to submit additional data for its monoclonal antibody tocilizumab, the FDA has approved the biologic agent for the treatment of moderate to severe rheumatoid arthritis. (Read more.)

7. Head Injuries Predict Persistent, Bad Headaches by Sherry Boschert

Like many of the neurologists attending the annual meeting of the American Headache Society, I slipped into the hotel lobby during breaks in the program to watch World Cup soccer in bits and pieces. The images of players heading the ball caught my eye in a new way after hearing a couple of presentations about the associations between head injuries and persistent, more frequent, and disabling headaches. (Read more.)

6. Using Hemoglobin A1C to Diagnose Diabetes: What’s Your Take? By Miriam E. Tucker

The American Diabetes Association’s decision earlier this month to officially endorse hemoglobin A1c as a diagnostic test for diabetes is either timely, inappropriate, or long overdue, depending on whom you talk to. (Read more.)

5. Can Hemoglobin A1C Go Too Low? By Miriam E. Tucker

A new study showing increased mortality among type 2 diabetes patients at hemoglobin A1c levels below 7.5% raises a new question: Should diabetes guidelines be revised to include a minimum hemoglobin A1c level? (Read more.)

4. New Clues to the Root of Basal Cell Carcinoma by Doug Brunk

Findings from a novel investigation published in the Jan. 5, 2010, edition of Cancer Prevention Research are helping researchers better understand what causes basal cell carcinoma tumors. (Read more.)

3. Rheumatoid Arthritis 5.0 by Mitchel Zoler

Rheumatologists have remade rheumatoid arthritis, a pretty big deal for them if only because it’s “the major systemic rheumatic disease that we as a specialty treat,” said Dr. Michael E. Weinblatt, a Harvard rheumatologist, at the end of a 90-minute session on Sunday afternoon that unveiled a new definition of rheumatoid arthritis to the world. (Read more.)

2. Doctors Attend to Burning Man by Sherry Boschert

Next week more than 40,000 people from around the world will migrate to Black Rock Desert in Nevada to create a week-long community where clothing is optional, illicit drugs are common, and fantastical artwork is everywhere. Dr. Marc Nelson will be one of them at an event called Burning Man. (Read more.)

1. Doctors: Help Them Understand That “It Gets Better” By Mark Lesney

Any growing tolerance of a person’s right to his or her own sexuality that is evidenced in the mainstream culture has yet to impact the Lord of the Flies scenarios that exist for gay, lesbian, bisexual, transgendered, or questioning students in many schools across the country—something that is comically but bitingly portrayed in the Fox hit series “Glee.” (Read more.)

Thanks for following us in 2010. We hope you’ll be back for more in 2011.

— Alicia Ault (on Twitter @aliciaault)

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Filed under Dermatology, Endocrinology, Diabetes, and Metabolism, Family Medicine, IMNG, Pediatrics, Primary care, Psychiatry, Rheumatology

Now tell me where ELSE it hurts…

When it comes to managing chronic pain, have physicians been looking in the wrong places? Physical findings in peripheral tissues rarely match up with patients’ reports of pain, or vice versa. Yet, clinicians typically examine only the area where the patient reports the pain, rather than looking at the whole body and considering that the patient’s perception of persistent pain may have a more central origin, according to pain expert Dr. Daniel J. Clauw.

Image by Kira.Belle via Flickr Creative Commons

“There is no chronic pain state where degree of damage or inflammation in the periphery correlates well with level of pain. Yet, the diagnostic algorithms or paradigms that everyone uses for treating chronic pain still assume that all pain is nociceptive. What we see in the peripheral tissues is not necessarily what our patients are experiencing,” Dr. Clauw said at last week at a 2-day scientific workshop on pain and musculoskeletal disorders, sponsored by the University of Michigan and held on the Bethesda, Md., campus of the National Institutes of Health.

That narrow focus has led many medical professionals to assume that when there is a disparity between peripheral findings and pain, the pain must be caused primarily by psychological factors. A prime example is fibromyalgia, still a somewhat controversial diagnosis. But as the first chronic pain syndrome identified as NOT being caused by peripheral inflammation or damage, fibromyalgia is “a metaphor for the centrality of chronic pain,” Dr. Clauw said.

So what should clinicians do differently? First, look beyond the immediate area the patient is complaining about. Has the patient had pain in other parts of the body? Experience frequent headaches? Have irritable bowel? Previous chronic neck pain, and now pain in the hip? “To me as a pain researcher, this is a blinking neon light that the person has a problem with pain processing. It may be that the particular symptom they’re coming in with is due to increased volume control setting rather than a pathologic problem in that part of the body,” Dr. Clauw told me.

And treatment? Ensuring adequate exercise and sleep and reducing stress are important yet underemphasized. Cognitive behavior therapy also has been shown to help. Pharmacologic therapy that acts centrally, rather than peripherally, may also be effective. The antidepressant duloxetine (Cymbalta), for example, is a serotonin/norepinephrine reuptake inhibitor that has been recently approved to treat osteoarthritis of the hip and low back pain, in addition to fibromyalgia and diabetic peripheral nerve pain.

A major challenge, Dr. Clauw believes, might be in getting clinicians to change their approach to pain. “It takes a long time for people trained in one way of thinking to think differently. This isn’t just a new drug or a new device. It’s a major paradigm shift.”

-Miriam E. Tucker (@MiriamETucker on Twitter)

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Head Injuries Predict Persistent, Bad Headaches

Like many of the neurologists attending the annual meeting of the American Headache Society, I slipped into the hotel lobby during breaks in the program to watch World Cup soccer in bits and pieces. The images of players heading the ball caught my eye in a new way after hearing a couple of presentations about the associations between head injuries and persistent, more frequent, and disabling headaches.

Soccer cupcakes image by flickr user Ana_Fuji (CC license)

The studies didn’t single out head injuries from soccer or even sports in general. But the National Electronic Injury Surveillance System gives a sense of their numbers, as reported on the American Association of Neurologic Surgeons website. Among the 351,922 sports-related head injuries treated in U.S. emergency rooms in 2008, soccer injuries ranked sixth (19,252 injuries) behind head injuries from cycling (70,802), U.S.-style football (40,825), basketball (27,583), baseball or softball (26,964), and powered recreational vehicles (25,970).

At the meeting, Dr. Sylvia Lucas of the University of Washington, Seattle and her associates reported on prospective 1-year follow-up on 377 patients after acute rehabilitation for moderate to severe traumatic brain injury. Sports or pedestrian accidents caused the injuries in 4% each, with most injuries due to vehicular accidents (56%), falls or flying objects (28%), or violence (9%).

Image courtesy of flickr user Jo Madonna (CC).

What surprised Dr. Lucas was not just the high prevalence of headache after injury but that the prevalence held steady during the year of follow-up after discharge from rehabilitation. Compared with 18% of patients who reported having headaches before their head injury, headache prevalence was 46% soon after injury, 48% at 3 months after rehab, 44% at 6 months, and 46% at 12 months. A greater proportion of patients who reported pre-injury headaches had post-traumatic headache (48%) than did patients with no pre-injury headaches (23% with post-traumatic headache). Women were significantly more likely than men with head injury to report headaches at each time point.

Dr. Gretchen E. Tietjen of the University of Toledo, Ohio and her associates took a different approach. Surveys of 1,348 adults with migraines seen at 11 U.S. and Canadian headache centers found that the 28% of patients with a history of head or neck injury had more frequent and disabling headaches and more comorbid conditions that started at younger ages compared with patients without head and neck injuries.

Chronic headaches were a problem for 42% of the head/neck injury group and 31% of the noninjured migraineurs. Higher scores on the Headache Impact Test reflected more disabling headaches in the injured patients.

“One thing I wasn’t expecting” was the persistent difference between groups in rates of comorbidities, Dr. Tietjen said. Irritable bowel syndrome: 30% in the head/neck injury group compared with 21% in the noninjured. Fibromyalgia: 16% vs. 7%. Interstitial cystitis: 9% vs. 5%. Arthritis: 37% vs. 21%. Depression: 52% vs. 35%. Anxiety: 40% vs. 27%. Sleep apnea: 11% vs. 6%. Uterine fibroids: 17% vs. 10%.

These studies shed some light on the interplay between headache and head injury — sports-related or not — that constitutes a game-changer in ways we haven’t realized before.

— Sherry Boschert (Twitter @SherryBoschert)
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