Clinical Neuroscience

[Trigeminovascular hypothesis of cluster headache]

TAJTI János1, SZOK Délia1, VÉCSEI László1

SEPTEMBER 20, 1996

Clinical Neuroscience - 1996;49(09-10)

[Cluster headache is a rare, very severe disorder which is clinically well characterized with a relatively poorly defined pathomechanism. Concerning the pathomechanism of cluster type headache, from the clinical symptoms three things can be inferred. The fact that head pain is centred dominantly around the eye and fore head makes it probable that the unilateral trigeminal nociceptive pathways are involved. Lacrimation and rhinorrhoea suggest the activation of the parasympa thetic, while ptosis and miosis suggest the sympathetic innervation of the region. There is a reflex connection within the brainstem that may be activated when the Gasserion ganglion is stimulated. The afferent of the reflex circle comes from the central branch of the ophthalmic division as the sensory trigeminal nerve. The parasympathetic nuclei of the seventh and ninth cranial nerves are the centre. The efferents are the parasympathetic peripheral branches of the VIlth and IXth cranial nerves. During spontaneous and nitroglycerin induced cluster attacks the levels of CGRP and VIP increased in the blood of external jugular vein. Oxygen inhalation or subcutaneous administration of sumatriptan reduced the CGRP concentration to normal. This observation supports the function of the trigeminovascular reflex in cluster headache.]

AFFILIATIONS

  1. Szent-Györgyi Albert Orvostudományi Egyetem, Ideg- és Elmegyógyászati Klinika Szeged

COMMENTS

0 comments

Further articles in this publication

Clinical Neuroscience

[Hemodynamic adaptation of fetal brain]

JAKOBOVITS Ákos, HENDRIK Jörn

[Doppler color ultrasonography of the middle cerebral and umbilical arteries was performed on 104 fetuses born at term. A total of 254 investigations were carried out. Of the 104 fetuses studied, 52 infants had birth weights appropriate for gestational age (mean 3409.2 g) and 52 infants were small for gestational age (mean 2272.1 g). Cerebral hemodynamic adaptation was observed in growth retarded fetuses due to placenta! insufficiency. ln these cases the elevated umbilical vascular resistance evidenced the placenta! insufficiency. At the same time the decrease of the cerebral vascular velocimetry indexes indicated the improving cerebral blood supply. Only the systolic/diastolic ratio was significantly reduced in growth retarded fetuses when compared with normal controls. ln the umbilical artery the pulsatility index and systolic/diastolic ratio were raised significantly in growth retarded fetuses. The ratio of the cerebral arterial to umbilical cord artery index values proved a better indicator of the difference between growth retarded and normal controls than the index of the cerebral or umbilical artery alone. The ratios of all three index values of the growth retarded fetuses were significantly smaller than those of the normal controls (pulsatility index 1.03 versus 1. 60, resistance index 0.84 versus 1.19 and systolic/diastolic ratio 1.01 versus 2.02). The ratios of the small for date fetuses due to other, nonplacental causes were simi­ lar to the normal controls. The blood circulation disorder evokes hemodynamic adaptation in the feta! brain. The intrauterine growth restriction is a consequence of this disturbed blood supply. The cerebral circulatory adaptation failed in the small for date fetuses non associated with decreased blood supply.]

Clinical Neuroscience

[Distal Ulnar Neuropathies]

KISS Gábor, KÓMÁR József

[Compression of the distal part of the ulnar nerve is an uncommon entrapment neuropathy. Depending on the site of compression it may result in pure motor symptoms. The atrophy of the small hand muscles without sensory deficit may mimic motor neuron disease. Correct clinical examination and electrophysiology including measurement of ulnar distal motor latency to the first dorsal interosseous muscle can reveal the correct diagnosis. 46 surgically treated cases of distal ulnar neuropathy are reported. 12 patients had only muscle weakness without sensory abnormalities. 6 of them showed motor deficit restricted to the first dorsal interosseous and adductor pollicis muscles. 34 patients were followed up 31 of them improved, 3 cases should be reoperated because of recidive lipoma.]

Clinical Neuroscience

[Importance of sociological and psychological factors in pathogenesis of ischaemic stroke]

MENDE Lilla, JÓRI Birkás Adrien, FAZEKAS Gábor, FAZEKAS András

[The authors investigate sociological and psychological factors in the pathogenesis of ischaemic stroke, as a follow up of their earlier study. In the first part of the recent study patients and control subjects are compared in terms of frequency, severity, type and the temporal distribution of life events within the 5 years preceding the stroke. In the second part the importance of coping-style and psychological characteristics are studied. It is shown that the likely factors leading to stroke are: lower life events score in the more distant period, but higher life events score preceding the stroke, poor coping, greater emotional instability, trait-anxiety, hostility, and decreased job involvement. The type of life events, global Type-A behaviour, "speed and impatience", "hard driving and competitiveness” seem indifferent. On the basis of these results a successful stroke-programme should consider the complexity of somatic, sociological and psychological factors.]

Clinical Neuroscience

[Transoesophageal echocardiography after stroke]

NAGY Lajos, SÁMOCYI Marianna, TARJÁN Jenő, GARZULY Ferenc

[40 stroke patients were studied by both transoesophageal and transthoracic echocardiography. The diagnosis of stroke was based on medical history, physical examination and computerized tomographic brain scan. 39 patients underwent carotid duplex scan as well. Transoesphageal echocardiography was used to examine 40 patients of whom 19 had cardiac source of embolism. Out of these, 7 patients had definitive, whereas 12 had possible cardiac source of embolism. Transthoracic echocardiography was diagnostic only in 8 cases. Using carotid duplex scan, carotid stenosis was detected in 8 patients and sclerosis without significant stenosis in 8 others. From each of these two groups 4 patients had coexistent cardiac source of embolism as well. In the 8 patients with atrial fibrillation the left atrial thrombus and spontaneous echo contrast were more frequent than in patients with sinus rhythm. The transoesophageal echocardiography altered the management of antico agulation in 3 patients. The authors concluded that transoesophageal echocardiography is necessary in stroke patients.]

Clinical Neuroscience

[Prognosis of neuroepithelial tumours by means of cell proliferation studies]

GYÖMÖRI Éva, MÉSZÁROS István, MÉHES Gábor, DÓCZI Tamás, PAJOR László

[Cell-kinetic analysis of tumours has recently been widely used in clinical oncology for prognosis of patients treated with malignant neoplasms and for controlling the efficiency of treatment protocols. Definition of biological nature of neuroepithelial tumours was based on grading depending on the severity of cellular anaplasia. Neuroepithelial tumours can be characterized not only by the histological features but also by the DNA content and abnormalities of the cell proliferation – though the relationship between histological malignancy, proliferative activity and cellular aneuploidity was found to be rather controversial according to the literature. In this review article the clinical value of cell cycle analysis such as distribution of DNA content, DNA index; S-phase fraction; proliferation-markers [MIB 1 antibody, bromdeoxy uridin labelling index, mitotic index, definition of nucleolar organization region) are discussed on the basis of personal experience and review of the appropriate literature. Flow cytometry and examination of proliferation markers have a significant role in the definition of prognosis of patients suffering from WHO grade II and III neuroepithelial tumours. Gliomas giving rise to recidivism have a rapid cell cycle already at their first occurrence, which is characterized by raised proliferation indices, and occurrence of aneuploid cell clones. An unfavourable outcome can be prognosed in patients suffering from a WHO grade II or III glioma if the DNA index is above or below 1+0.1 if the value of the S phase fraction is above 6%, if more than 1 mitosis is found in 10 large magnification field, and if the number of cells labelled with MIB 1 antibody exceeds 3 in 1 large magnification field. The literature confirms our notion that further studies of proliferation characteristics may help in the production of a malignity score of gliomas that could support the efficiency of traditional histological grading in prognosis and control of complex therapy of these tumours.]

All articles in the issue

Related contents

Clinical Neuroscience

[The quality of life of the cluster headache patients during the active phase of the headache]

DIÓSSY Mária, BALOGH Eszter, MAGYAR Máté, GYÜRE Tamás, CSÉPÁNY Éva, BOZSIK György, ERTSEY Csaba

[Introduction - Cluster headache (CH), which affects 0.1% of the population, is one of the most painful human conditions: despite adequate treatment, the frequent and severe headaches cause a significant burden to the patients. According to a small number of previous studies, CH has a serious negative effect on the sufferers’ quality of life (QOL). In the current study, we set out to examine the quality of life of the CH patients attending our outpatient service between 2013 and 2016, using generic and headache-specific QOL instruments. Methods - A total of 42 CH patients (16 females and 26 males; mean age: 39.1±13.5 years) completed the SF-36 generic QOL questionnaire and the headache- specific CHQQ questionnaire (Comprehensive Headache- related Quality of life Questionnaire), during the active phase of their headache. Their data were compared to those of patients suffering from chronic tension type headache (CTH) and to data obtained from controls not suffering from significant forms of headache, using Kruskal-Wallis tests. Results - During the active phase of the CH, the patients’ generic QOL was significantly worse than that of normal controls in four of the 8 domains of the SF-36 instrument. Apart from a significantly worse result in the ‘Bodily pain’ SF-36 domain, there were no significant differences between the CH patients’ and the CTH patients’ results. All the dimensions and the total score of the headache-specific CHQQ instrument showed significantly worse QOL in the CH group than in the CTH group or in the control group. Conclusion - Cluster headache has a significant negative effect on the quality of life. The decrease of QOL experienced by the patients was better reflected by the headache-specific CHQQ instrument than by the generic SF-36 instrument. ]

Clinical Neuroscience

[A prospective study evaluating the clinical characteristics of cluster headache]

ERTSEY Csaba, VESZA Zsófia, BANGÓ Márta, VARGA Tímea, NAGYIDEI Diána, MANHALTER Nóra, BOZSIK György

[Introduction - Although cluster headache (CH) is one of the most severe human pain syndromes, its symptoms and therapeutic possibilities may be suboptimally recognised in current medical practice in Hungary. Aim - To present the clinical characteristics of CH based on a prospective study of patients attending the Headache Service of the Department of Neurology, Semmelweis University. Methods - We collected information about the symptoms, diagnosis and previous treatment of CH patients by filling in a 108-item questionnaire during outpatient visits. Results - In the 5-year period between 2004 and 2008 we obtained data from 78 CH patients (57 males and 21 females; mean age: 44.6±14.6 years). The male:female ratio did not change in subgroups based on disease onset (calendar years). Ninety-three percent considered CH the most severe pain state of their life. The pain was strictly unilateral, affecting the territory of the 1st trigeminal division in all patients. The attacks were accompanied by signs of ipsilateral cranial parasympathetic activation (lactimation 83%, conjunctival injection 67%, rhinorrhea 56%, nasal congestion 43%); less frequently, signs of sympathetic dysfunction (ptosis 48%, miosis 7%) were also present. Two patients had attacks showing the typical localisation, severity and time course of CH attacks, but not accompanied by autonomic phenomena. A considerable part of the patients also observed symptoms that are usually ascribed to migraine (nausea 41%, vomiting 18%, photophobia 68%, phonophobia 58%). This may have been instrumental in the fact that, regardless of the characteristic clinical symptoms, the diagnosis of CH took 10 years on average. At the time of their examination 63% of patients were not using adequate abortive medications and 59% did not have an adequate prophylactic measure. Discussion - Cluster headache is characterised by attacks of devastating pain that warrant an early diagnosis and adequate treatment. Our study underlines that information about the diagnosis and therapy of CH should be emphasized on occasions of neurology specialty training and continuing medical education.]

Clinical Neuroscience

[Cluster headache and its treatment]

JELENCSIK Ilona

[Cluster headache, one of the most painful conditions known, is encountered infrequently in clinical practice. It is characterized by recurrent, unilateral attacks of severe intensity, brief duration and often accompanied by signs and symptoms of autonomic dysfunction. The actual cause of the pain has not been fully elucidated, but most authors believe that the pain arises as a result of a local vasodilatation with a release of certain neuropeptides to the perivascular tissues, resulting in sterile neurogenic inflammation and oedema. Aetiology is absolutely unknown. Treatment can be given as prophylaxis and/or as a symptomatic acute therapy for individual attacks. In the prophylaxis of episodic cluster headache ergotamine, calciumentry blockers, serotonin inhibitors and steroids are used. In chronic cluster headache lithium is the drug of choice, but verapamil may also be tried. Acute therapy has included ergotamine, oxygen inhalation and sumatriptan. Rarely, surgical intervention may be considered.]

Clinical Neuroscience

[Experiences with sumatriptan in the treatment of Cluster headache]

JELENCSIK Ilona, BOZSIK György, ÁFRA Judit, ERTSEY Csaba

[Subcutaneously administered sumatriptan 6 mg is rapid, effective and well-tolerated for the acute treatment of cluster headache. Efficacy is maintained in long-term use. The authors report the results of the 5HT1 receptor agonist sumatriptan autoinjector in the treatment of 350 attacks in 20 cluster patients. After 20 minutes post injection the complete dissolution of headache was reported in 95% of the attacks. Slight and transient side-effects were experienced therefore non of the patients were discouraged from using the autoinjector device again. It is essential in the improvement of the quality of life of patients suffering from cluster headache.]

LAM Extra for General Practicioners

[HEADACHE IN EVERYDAY MEDICAL PRACTICE]

ERTSEY Csaba

[Headache is one of the most common complaints in clinical practice. The International Headache Society’s current classification distinguishes two major categories of headache: primary and secondary (symptomatic) headache types. The former types, which account for the majority of headaches, are caused by a functional disorder in a structurally intact nervous system and are characterised by stereotypical attacks that resolve - in most cases - spontaneously after a certain period, the duration of which is characteristic for each headache type. The diagnosis of primary headaches is based on a detailed history of the attacks and negative results on a neurological examination. At the first presentation of the patient, it should be determined whether a potentially serious or life-threatening condition might be present, whether the type of the patient’s headache can be ascertained according to the IHS’s criteria, and what kind of examinations are needed to establish the correct diagnosis. A detailed history is the cornerstone of the diagnosis of primary headaches and it cannot be substituted by instrumental examinations. The use of imaging and other examination methods is necessary for the diagnosis of secondary headaches, but if the patient’s history and the results of the neurological investigation are fully consistent with a primary headache type, instrumental examinations are unlikely to provide any additional information. Although establishing the correct diagnosis is often time-consuming, it is necessary for the efficient treatment.]