Biomedical subjects
Publications and source records attributed to J A Pareja.
Numular headache is a chronic, mild to moderate, pressurelike pain in a circumscribed cranial area of approximately 2 to 6 cm in diameter. Pain usually is limited to the parietal region, although it may appear in any cranial site. It is a benign process of usually unknown origin.
A total of 26 episodes of V-1 trigeminal neuralgia attacks have been recorded in two female patients. Autonomic phenomena were assessed according to a semiquantitative scale. Attacks lasted 17 +/- 5 s. Mild lacrimation without conjunctival hyperaemia, rhinorrhea or ptosis was observed, even in relatively long lasting episodes. This is in clear contradiction with SUNCT (shortlasting, unilateral, neuralgiform headache with conjunctival injection, tearing and rhinorrhea) attacks that are always dramatically accompanied by both lacrimation and conjunctival injection of the symptomatic side from the very onset of symptoms. Carbamazepine provided complete and sustained relief of symptoms in both patients. Herein we will show differential autonomic features of V-1 trigeminal neuralgia vs. SUNCT that will both aid the clinician to distinguish both syndromes and stress that both entities are nosologicaly different.
We report a SUNCT patient who showed both a precipitation and worsening of symptomatic periods after treatment with L-type calcium channel blockers. This pharmacological response may provide us with important clues for understanding the pathophysiology of SUNCT, and hopefully to find a remedy for the victims of this syndrome. This observation could also support a verapamil trial in SUNCT patients as a precipitating of attacks.
PURPOSE: Nonconvulsive status epilepticus is an unusual complication of cephalosporin therapy, with only a few isolated cases reported. SUBJECTS AND METHODS: We reviewed the clinical and electroencephalographic (EEG) characteristics of 10 patients with renal failure in whom developed alteration of consciousness without convulsions associated with continuous epileptiform EEG activity while being treated with cephalosporins. RESULTS: Nonconvulsive status epilepticus developed in 5 men and 5 women, with a mean (+/- SD) age of 69 +/- 14 years, while receiving intravenous cephalosporins (ceftriaxone, 2 patients; ceftazidime, 2; and cefepime, 6). All patients had renal failure; 1 also had hepatic failure. Patients presented with progressive disorientation or agitation, sometimes associated with mild facial or limb myoclonus, that had begun 1 to 10 days (mean, 5 +/- 2 days) after starting cephalosporin treatment. The EEG showed continuous or intermittent bursts of generalized, high-voltage, 1 to 2 Hz sharp wave activity or sharp and slow wave activity that resembled, but could be differentiated from, the triphasic waves seen in metabolic encephalopathies. Intravenous clonazepam suppressed the epileptiform activity completely in 5 patients and partially in the other 5. Cephalosporins were withdrawn, and antiepileptic therapy was started for all patients. All patients improved, 2 in less than 24 hours and the remainder within 2 to 7 days. CONCLUSIONS: Cephalosporins can cause nonconvulsive status epilepticus in patients with renal failure. The clinical picture is difficult to differentiate from a that of metabolic encephalopathy unless an EEG is obtained. Physicians should be aware of this potentially dangerous complication.
A series of 18 patients suffering from supraorbital neuralgia have been studied through a seven year period. Appropriate investigations ruled out other headaches. There was a female (67%) preponderance. Mean age at onset was 51.6 years. The mean headache duration was 5.9 years. Five patients had a history of ipsilateral forehead trauma. The main areas of pain were the forehead and orbit. The pain was dull with short sharp or burning exacerbations. The temporal pattern was either remitting (n = 7) or chronic continuous (n = 11). Autonomic accompaniments were generally lacking. Neurological assessment was normal in all but 4 patients who were found to have signs/symptoms of sensory dysfunction in the forehead of the symptomatic side. Trials of different drugs, including migraine and anti-neuralgic drugs, only provided slight relief. Anaesthetic nerve blocks of the supraorbital nerve provided an absolute but transitory relief of pain. Although aetiology and pathogenesis of supraorbital neuralgia is largely unknown, entrapment of the supraorbital nerve at its outlet and successful decompressive surgery have been previously reported. This and other pathogenic hypotheses are discussed.
Proposals for the diagnostic criteria for hemicrania continua (HC) and also for the nosological status of HC are set forth. The clinical constellation of symptoms and signs making up HC consists of: unilaterality without side shift; absolute indomethacin effect; and long-lasting repetitive attacks of varying duration, eventually with a chronic pattern, the pain being mild to severe. For the typical clinical picture of HC, including a positive 'indotest', we propose the term hemicrania continua vera. More or less analogous, but 'indotest-negative' clinical pictures have provisionally been termed hemicrania generis incerti (of undetermined nature). At the present level of knowledge, the diagnosis of hemicrania generis incerti should be made mostly by exclusion. HC may possibly best be classified along with chronic paroxysmal hemicrania (CPH) as this is the only other headache absolutely responsive to indomethacin. The bond between these two headaches on the one hand and cluster headache on the other should, at most, be a loose one. Interrelationships of these four classifiable headaches are briefly discussed.
Indomethacin has consistently been proven to provide complete and sustained relief of symptoms in hemicrania continua (HC) and chronic paroxysmal hemicrania (CPH), but is not devoid of side-effects. The goal of this retrospective study is to assess the dose and side-effects of prolonged indomethacin treatment of HC and CPH. Twenty-six patients with either HC or CPH were followed during an average of 3.8 years after onset of treatment with indomethacin. Relief of symptoms occurred within 3 days of treatment, with 84 +/- 32 mg/day of indomethacin. With time, 42% of patients experienced a decrease of up to 60% in the dose of indomethacin required to maintain a pain-free state. Six (23%) patients showed adverse events, mostly gastrointestinal and relieved with ranitidine. No major side-effects were observed. These results indicate that prolonged indomethacin treatment of HC or CPH has a good safety and tolerability profile with a reduction of up to 60% in the initial dose.
More than 16 years after the first description of hemicrania continua (HC), its aetiology and pathogenesis remain obscure. Clinically, HC is considered a syndrome with two pivotal characteristics: (i) strictly unilateral (moderate, fluctuating, relatively long-lasting) headache; and (ii) absolute response to indomethacin. HC is further characterized by some ancillary, but mostly "negative", features such as: (iii) relative paucity of accompaniments; and (iv) lack of precipitating factors. The female preponderance is also remarkable, although not diagnostic in the solitary case. Finally, a non-specific, but remarkable feature is the temporal pattern. HC may present as a remitting or chronic (continuous) headache. In HC, unilaterality and absolute response to indomethacin are considered crucial diagnostically. Existing controversy, such as regarding atypical features, particularly the so-called "HC resistant to indomethacin", is discussed. The nature of hemicrania with negative indomethacin response remains most unclear; it may not belong to the HC cycle at all. Accordingly, we propose that the typical clinical picture of HC, including an absolute response to indomethacin, be termed Hemicrania continua vera. More or less analogous, but indomethacin-resistant, clinical pictures can provisionally be termed Hemicrania generis incerti (of undetermined nature), provided other diagnostic possibilities have been ruled out. The differential diagnosis of HC vs. other unilateral headaches is commented on. Previous attempts at classification of HC into the group chronic daily headache (CDH) are discussed. The only acceptable "link" of HC with the other headaches classified as CDH is the temporal pattern (which is a non-specific feature). HC is probably pathophysiologically different from the others disorders classified under CDH. Conversely, HC and chronic paroxysmal hemicrania share many common features, including the absolute response to indomethacin. HC should probably be included in the IHS group 3.
A study was made of the personality profiles of a sample of 51 patients with chronic tension-type headache (CTH) employing the Minnesota Multiphasic Personality Inventory (MMPI). Two clusters were obtained by applying multivariate classification techniques: cluster 1 (with elevations on scales Hy, D and Hs only) and cluster 2 (exhibiting elevations on most scales except Pd, Mf and Si). Fifty subjects without chronic pain or known psychiatric disorders, and extracted from the same social setting as the patients, completed the MMPI as a control group. Fluoxetine treatment was started in the CTH group, with follow-up over a 1-year period. Chi-squared analysis correlating the clusters obtained to different pain-related variables and epidemiological parameters revealed a significant association to sex only. There were no differences in therapeutic response between the two clusters. However, the patients belonging to the less perturbed cluster who exhibited profiles analogous to those of the control population showed significant improvement with respect to the global sample and their own cluster.
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Cerebral cortical activity is constant throughout the entire human life, but substantially changes during the different phases of the sleep-wake cycle (wakefulness, non-REM sleep and REM sleep), as well as in relation to available information. In particular, perception of the environment is closely linked to the wake-state, while during sleep perception turns to the internal domain or endogenous cerebral activity. External and internal information are mutually exclusive. During wakefulness a neuronal mechanism allows attention to focus on the environment whereas endogenous cortical activity is ignored. The opposite process is provided during sleep. The function external attention-internal attention is coupled with the two modes of brain function during wakefulness and during sleep, providing two possible cortical status: thinking and dreaming. Several neurological processes may influence the declaration of the three states of being or may modify their orderly oscillation through the sleep-wake cycle. In addition, endogenous information and its perception (dreams) may be modified. Disturbances of dreaming may configurate in different general clinical scenarios: lack of dreaming, excess of dreaming (epic dreaming), paroxysmal dreaming (epileptic), nightmares, violent dreaming, daytime-dreaming (hallucinations), and lucid dreaming. Sensorial deprivation, as well as the emergence of internal perception may be the underlying mechanism of hallucinations. The probable isomorphism between hallucinations and dreaming is postulated, analyzed and discussed.
STUDY OBJECTIVES: To assess language used during episodes of sleeptalking in bilingual children. DESIGN: The investigation was accomplished through the parents who, after having received appropriate information, participated by filling out a survey on sleeptalking. SETTINGS: The study was performed in three bilingual schools of the Basque country, a region in northern Spain in which two completely different official languages are spoken. PATIENTS: A total of 1000 parents agreed to participate, and 681 children were studied. MEASUREMENTS AND RESULTS: Sleeptalking was reported by 383 (56.3%) of children (mean age 9 years; range: 3-17). Most individuals used their dominant (i.e., native) language during sleep. However, a minority (< 4%) were found to use their non-dominant language persistently during episodes of sleeptalking. CONCLUSIONS: Balanced bilinguals (those who have equal proficiency in both languages) may sleeptalk in either of the two languages. Dominant bilinguals (i.e., having greater proficiency in one language) may preferentially sleeptalk in their dominant language, with immediate past events probably influencing language use in individual subjects on particular nights. Several considerations are postulated as an explanation for the group who systematically exhibited a dominance shift during sleep.
Both SUNCT syndrome and idiopathic stabbing headache (ISH) (jabs and jolts syndrome) have to be considered when encountering shortlasting headaches. Since there are no specific tests for these headaches, the differential diagnosis depends entirely upon assessment of the clinical features. These headaches are generally easily distinguishable clinically. There seem to be symptomatic forms of SUNCT.
We report the coexistence of both chronic paroxysmal hemicrania (CPH) and trigeminal neuralgia (tic douloureux) in a female patient. The clinical features combined to make a configuration of CPH-tic syndrome. The two components of the syndrome appeared synchronously in the same orbital region--first branch of the trigeminal nerve--with a latency of several years after the onset of isolated tic attacks of the second and third trigeminal divisions. The concurrence of both types of pain in the same symptomatic area may have some significance for pathogenic, clinical, and pharmacological aspects of such a syndrome. We discuss all these and postulate a provisional distinction between CPH-V2,3 tic and CPH-V1 tic.
Quantitative measurement of sound-induced discomfort and pain thresholds showed that migraineurs (n = 65) were significantly more sensitive than headache-free controls (n = 80), both during and outside attack (p < 0.0001). Patients tested with head pain had lower thresholds than those tested without pain (p < 0.01). Migraine with and without aura did not differ as to sound sensitivity. There were no significant differences in thresholds between the symptomatic and nonsymptomatic sides (p > or = 0.78). Patients with unilateral headache or pain of pulsating character were more sensitive than those with bilateral headache or pressing pain (p < 0.05). Phonophobia did not correlate significantly with duration, frequency, or severity of attacks. The main results were in accordance with a questionnaire study concerning subjective evaluation of sound sensitivity. Similarities between phonophobia and photophobia in migraine provide evidence that both phenomena share a common pathophysiological mechanism in this condition.
In order to evaluate photophobia and phonophobia in cluster headache (CH), light and sound-induced discomfort and pain thresholds were measured quantitatively in 50 patients and 50 sex-matched and age-matched headache-free controls. During bout (i.e., during the active period with attacks), CH patients were more sensitive to light and sound than controls (p < 0.001). Outside bout they did not differ significantly from controls except for binaural stimulation. Patients were more photophobic and phonophobic during bout than in the remission period (p < or = 0.05). However, for those tested during bout, the sensitivity to light and sound was not related to the presence of pain during test, usual pain intensity, or pain laterality. In response to a questionnaire about their sensitivity, a significantly higher proportion of patients considered themselves sensitive during bout than outside (91% vs 46% for light [chi 2 = 5.9, p < 0.05] and 89% vs 49% for sound [chi 2 = 4.7, p < 0.05]). These results indicate that photophobia and phonophobia are important accompanying phenomena of cluster bouts.
Thermal thresholds were measured in the face (first and second trigeminal area), over the mastoid process (C2-3 area), and in the hands in patients with migraine (n=17), cluster headache (n=22), and cervicogenic headache (n=20). Significant symptomatic versus nonsymptomatic side differences were generally not found for any headache group. Cluster headache patients had significantly higher warm thresholds than controls (n=24) for most of the cephalic points. Cervicogenic headache patients had significantly higher warm and cold thresholds than controls (n=56) at several cephalic and noncephalic points. Warm thresholds over the mastoid process on the symptomatic side were higher in cervicogenic headache patients compared to the other groups. In migraine patients, thermal thresholds were similar to those in controls. Thus, we found no evidence of focal or unilateral peripheral somatic nerve dysfunction involving C or A-delta fibers in any of the studied headache groups, although a C2-3 root dysfunction in cervicogenic headache could not be excluded. A bilateral central sensory dysfunction in cluster headache and cervicogenic headache may be hypothesized but a generalized peripheral dysfunction can also explain our results.
The interval between indomethacin administration and clinical response may be clinically relevant in the assessment of chronic paroxysmal hemicrania and hemicrania continua and other unilateral headache disorders with which they can be confounded. Eight patients with chronic paroxysmal hemicrania (6 women and 2 men) and 12 patients with hemicrania continua (8 women and 4 men) were entered into the study. The patients were given 50 mg of indomethacin intramuscularly (i.m.) on day 1 and some of them 100 mg IM on day 2 in an open fashion. The usual attack pattern was reestablished prior to the second test. The mean interval between attacks before the two injections (51 +/- 18 minutes) in chronic paroxysmal hemicrania was significantly shorter than the mean after each of the two indomethacin injections (50 mg = 493 +/- 251 minutes; 100 mg = 668 +/- 211 minutes; P < 0.001; Mann-Whitney test). In every patient, there was a clear refractory period after indomethacin. Since the first "expected" attack after indomethacin administration did not occur, it can, with reasonable certainty, be assumed that the protective phase was initiated already prior to the time of the next "anticipated" attack. The mean attack duration was 22 minutes (last three attacks prior to test). The mean interval between the onset of two consecutive pretest attacks was 73 minutes. Since the interval between attacks was rather stable, one is, therefore, probably allowed to assume that the absolute protective effect of indomethacin on average had begun somewhere between 22 (mean attack duration) and 73 minutes after indomethacin injection. Similarly, in hemicrania continua, the time between 50-mg indomethacin injection and complete pain relief was 73 +/- 66 minutes. The pain-free period after indomethacin injection was around 13 hours (i.e., 13 +/- 8 hours after 50 mg and 13 +/- 10 hours after 100 mg). The use of a test dosage of 50 mg of indomethacin IM ('indotest') gives a clear-cut answer and may be a useful tool in the diagnostic arsenal in every unilateral headache for a proper clinical assessment. A diagnosis of chronic paroxysmal hemicrania or hemicrania continua is a serious matter because it may imply life-long treatment with a potentially noxious drug. It is, therefore, of the utmost importance that an 'indotest' is carried out in a standard fashion. In the future, the rules set forth in the present context should be followed, at least in scientific studies. Pain pressure thresholds at cranial and extracranial levels were not significantly modified after indomethacin injection in any of the headaches.