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Medication overuse headache (MOH) is defined as headache occurring on 15 or more days per month developing as a consequence of regular overuse of acute or symptomatic headache medication (on 10 or more, or 15 or more days per month, depending on the medication) for more than three months. Triptans, NSAIDs, acetaminophen, ergotamine, barbiturates, and opioids can all cause MOH. Although the optimal treatment strategy for MOH is debated, treatments include discontinuing the overused medications and treating with preventive migraine medications. In the ED, it is important to recognize patients who have MOH to provide appropriate treatment recommendations for MOH and to avoid perpetuating the patient’s medication overuse. In general, ED treatment of the patient with frequent headaches should not include narcotics or butalbital-containing medications as they are associated with the highest risk of developing MOH as well as the potential to create drug-seeking behavior. Proper follow-up should be arranged prior to discharge from the ED.
SUNCT is a rare primary headache disorder that is associated with activation of the posterior hypothalamus and often poorly responsive to medication. Recently, a relationship between between pituitary microadenoma and SUNCT has been suggested, and reports of both amelioration and exacerbation by dopamine-agonists have been published. These findings suggest a functional role for the hypothalamic-pituitary axis in SUNCT.
We report the long-term 4 year follow-up of a 35 year-old patient with a 14-year history of medically and surgically intractable SUNCT who experienced immediate and complete resolution of symptoms after resection of a 6 mm pituitary microadenoma.
This patient was first seen at the age of 28 years with a 10-year history of attacks of right retro-orbital pain satisfying the IHS criteria for SUNCT. Many medical and surgical treatments were attempted without success. An MRI demonstrated a 6 mm microadenoma without compression of surrounding structures. A trial of bromocriptine caused marked exacerbation of his pain. The patient underwent a trans-sphenoidal resection of the pituitary lesion. SUNCT attacks worsened for the first 24h post-operatively, then disappeared. He has been completely headache-free, without medication, for the past 43 months with the last follow-up being January 2006.
This case emphasizes the relationship between pituitary microadenomas and SUNCT, supports the role of the hypothalamic-pituitary axis in the genesis of SUNCT, and illustrates the importance of careful imaging of the pituitary region in patients with SUNCT.
Headache is the most common presenting symptom in neurology and constitutes more than one-third of primary care consultations. Organized according to the presenting features of the headache (acute, episodic and chronic), this handbook provides diagnostic and treatment information for both common and uncommon causes of headache. Making maximum use of lists, bullet points, summary boxes and illustrations, it allows the reader fast access to essential information where it is needed most. Each topic is dealt with succinctly, using up-to-date knowledge and experience of the authors, all of whom are headache experts from leading clinical centers in the USA and Canada. Providing comprehensive and detailed coverage to satisfy the needs of the busy neurologist, residents in neurology, neurosurgery, psychiatry and other fields of internal medicine, this book will also be a valuable guide to practising clinicians who do not deal with headache on a regular basis.