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PubMed1996

Pneumatized superior turbinate as a cause of referred migraine headache.

Three patients with typical (common) migraine unresponsive to conventional therapy were evaluated with complete otolaryngologic examination, diagnostic nasal endoscopy, and coronal sinus computed tomography (CT). Enlargement of the superior turbinate due to pneumatization, with accompanying mucosal contact, was found in each case. Application of topical or injected anesthetic to the superior turbinate lessened or relieved headache, and subsequent endoscopic sinonasal surgery succeeded in providing significant headache relief (follow-up of 6 to 14 months). This is the first report of superior turbinate variations/abnormalities causing migraine, or indeed any type of headache. A discussion of the mechanism of referred pain from mucosal contact is offered after a discussion of each case.

Adolescent↗

PubMed1978

Sternoclavicular joint involvement in ankylosing spondylitis.

Two patients with sternoclavicular joint involvement in ankylosing spondylitis are described, both of whom presented with referred pain syndromes which delayed diagnosis. The anatomy of the sternoclavicular joint and the salient features of this entity are reviewed.

Adult↗

PubMed1997

Primary cardiac lymphoma: initial symptoms suggestive of gastrointestinal disease.

We report a case of primary cardiac lymphoma in a patient who was not infected with human immunodeficiency virus and had symptoms suggestive of upper gastrointestinal (GI) disease. Examination revealed no GI abnormalities. Echocardiography, prompted by sudden development of congestive heart failure, revealed a large right atrial mass. Cardiac biopsy followed by staging evaluation indicated primary cardiac non-Hodgkin's lymphoma. After chemotherapy was begun, the tumor shrunk and GI symptoms resolved, suggesting an etiologic relationship by a referred pain mechanism. Unusual features of our case include the initial predominance of GI symptoms and the circumstances that led to diagnosis antemortem. The case also underscores the importance of considering intrathoracic disease in patients with upper abdominal symptomatology.

Aged↗

PubMed1996

Spinal stenosis and neurogenic claudication.

Neurogenic claudication is diagnosed from a classical history and complementary spinal imaging. The abnormal signs may be few. It should be distinguished from intermittent claudication (peripheral vascular disease), referred pain from the back or root pain that is aggravated by walking, and psychological distress. Pathologically, a developmentally small canal is usually affected by multiple levels of segmental degenerative change, with venous pooling in the cauda equina between two levels of low pressure stenosis. There is probably then a failure of arterial vasodilatation of the congested roots in response to exercise, with symptoms in the legs when walking. Once established, symptoms tend neither to improve nor deteriorate. Conservative management is reasonable. Otherwise decompression at the most significant stenotic level is probably adequate to obtain a good surgical result.

Diagnosis, Differential↗

PubMed1997

Radiologic prevalence of advanced lateral C1-C2 osteoarthritis.

STUDY DESIGN: The lateral C1-C2 (atlantoaxial) joints were evaluated retrospectively in 355 patients referred for radiographs of the paranasal sinuses. OBJECTIVES: To determine the radiologic prevalence of advanced lateral atlantoaxial osteoarthritis. SUMMARY OF BACKGROUND DATA: Previous studies have shown a relation between atlantoaxial osteoarthritis and referred pain in the suboccipital region. However, the radiologic prevalence of this degenerative disorder is unknown. METHODS: Five hundred radiographs of the paranasal sinuses were evaluated retrospectively. Both lateral atlantoaxial joints were clearly visible on occipitofrontal projections in 355 examinations. Each lateral atlantoaxial joint was considered severely degenerated when advanced narrowing or obliteration of the joint space, subchondral sclerosis, and/or osteophytosis were present. RESULTS: Atlantoaxial osteoarthritis was found in 4.8% of the patients. The radiologic prevalence of advanced degenerative changes at the lateral atlantoaxial joint(s) was found to increase with age, ranging from 5.4% in the sixth decade to 18.2% in the ninth decade of life. CONCLUSION: Because advanced degenerative changes at the lateral atlantoaxial joints can cause suboccipital neck pain, these findings should be included in the differential diagnosis in older patients with this symptom.

Aged↗

PubMed2000

Electrical stimulation of the rat lumbar spine induces reflex action potentials in the nerves to the lower abdomen.

STUDY DESIGN: The distribution of the nerve action potentials reflexively elicited by electrical stimulation of the lumbar spine was investigated in rats. OBJECTIVES: To elucidate the relation between the lumbar spine and other body regions that compose the spinal reflex. SUMMARY OF BACKGROUND DATA: The hypothesis was that the ventral portion of the L5-L6 disc spatially corresponds to the groin. METHODS: In Experiments 1 and 2, wire electrodes were placed 1) in the ventral and dorsal portions of the disc, facet joint, and muscle fascia at L5-L6, and 2) in the ventral portions of L3-L4, L4-L5, L5-L6, and L6-S discs. A needle electrode was inserted in the L5-L6 disc by 0.4-mm increments, and action potentials were serially recorded from the genitofemoral nerve. RESULTS: Experiments 1 and 2: Reflex action potentials were elicited in the iliohypogastric (T13 and L1), ilioinguinal (L1), and genitofemoral (L2) nerves. Experiment 1: Stimulation of the disc induced reflex discharges significantly more frequently than stimulation of the facet joint and muscle fascia. Experiment 2: The more cranial the disc stimulated, the more frequently the reflex discharge was induced in the iliohypogastric nerve. Experiment 3: The depth of stimulation did not influence the size of the reflex action potential. CONCLUSIONS: Electrical stimulation of the lumbar disc and facet joint induced reflex discharges in the nerves to the lower abdominal regions. It was postulated that the reflex discharges are related to muscle contraction resulting in referred pain in the loin and groin.

Abdominal Muscles↗

PubMed2005

Surgical treatment of patients with refractory migraine headaches and intranasal contact points.

Contact point headaches have been attributed to intranasal contact between opposing mucosal surfaces, resulting in referred pain in the distribution of the trigeminal nerve. In subjects with primary headaches, contact points may be associated with treatment refractoriness. We aimed to assess the benefits of surgical correction in patients with refractory migraine or transformed migraine, and radiographic evidence of contact points in the sinonasal area. We reviewed charts of patients who underwent endoscopic sinus surgery and septoplasty for contact point in the same surgical facility, from October 1998 through August 2003. Subjects eligible for surgery had: (i) refractory migraine (failed to standard pharmacological headache treatments) or refractory transformed migraine; (ii) contact points demonstrated by computed tomography scan; (iii) reported significant headache improvement after topical anaesthesia to the contact area. Headache characteristics were assessed preoperatively and at follow-up (6-62 months after surgery) using a standardized questionnaire. A total of 21 subjects (72.5% women) were assessed. Mean headache frequency was reduced from 17.7 to 7.7 headache days per month (P = 0.003). Mean headache severity was reduced from 7.8 to 3.6 on a 0-10 scale (P = 0.0001). Headache-related disability was reduced from 5.6 (10-point scale) to 1.8 (P < 0.0001). A total of 16 subjects (76.2%) had their headache scores improved by 50% or more; nine (42.9%) were pain free at the last follow-up. A total of 18 (95.8%) had at least a 25% reduction in their headache scores. Two patients (9.5%) had increase in their headache score by less than 25%. For selected patients with refractory headaches, demonstrable contact points, and positive response after topical anaesthesia, surgical approach toward the triggering factor may be useful. Prospective studies are necessary to confirm our results.

Adult↗

PubMed2006

Myofascial trigger points, neck mobility and forward head posture in unilateral migraine.

This paper describes the differences in the presence of myofascial trigger points (TrPs) in the upper trapezius, sternocleidomastoid, temporalis and suboccipital muscles between unilateral migraine subjects and healthy controls, and the differences in the presence of TrPs between the symptomatic side and the non-symptomatic side in migraine subjects. In addition, we assess the differences in the presence of both forward head posture (FHP) and active neck mobility between migraine subjects and healthy controls and the relationship between FHP and neck mobility. Twenty subjects with unilateral migraine without side-shift and 20 matched controls participated. TrPs were identified when there was a hypersensible tender spot in a palpable taut band, local twitch response elicited by the snapping palpation of the taut band and reproduction of the referred pain typical of each TrP. Side-view pictures were taken in both sitting and standing positions to measure the cranio-vertebral angle. A cervical goniometer was employed to measure neck mobility. Migraine subjects showed a significantly greater number of active TrPs (P<0.001), but not latent TrPs, than healthy controls. Active TrPs were mostly located ipsilateral to migraine headaches (P<0.01). Migraine subjects showed a smaller cranio-vertebral angle than controls (P<0.001), thus presenting a greater FHP. Neck mobility in migraine subjects was less than in controls only for extension (P=0.02) and the total range of motion in flexion/extension (P=0.01). However, there was a positive correlation between the cranio-vertebral angle and neck mobility. Nociceptive inputs from TrPs in head and neck muscles may produce continuous afferent bombardment of the trigeminal nerve nucleus caudalis and, thence, activation of the trigeminovascular system. Active TrPs located ipsilateral to migraine headaches might be a contributing factor in the initiation or perpetuation of migraine.

Adolescent↗

PubMed1993

Focal headache during balloon inflation in the vertebral and basilar arteries.

BACKGROUND AND PURPOSE: Headache may be seen in acute cerebrovascular disease. The significance of localized headache in association with vertebrobasilar disease has not been recognized. SUMMARY OF REPORT: We describe a patient with a cerebellar arteriovenous malformation who underwent intravascular balloon occlusion of the vertebral and basilar artery. He developed reproducible patterns of referred pain with balloon inflation at specific sites. CONCLUSIONS: Well localized head pain in the setting of acute stroke should alert physicians to the possibility of localized arterial injury. The pattern seen in this patient has been documented in experimental situations, and should be of use in the setting of acute stroke.

Basilar Artery↗

PubMed1993

Headache as a presentation of angina: reproduction of symptoms during angioplasty.

We report a case of angina presenting as headache in a 59-year-old man. Headaches were relieved by nitroglycerin and were reproduced by occlusion of the first obtuse marginal artery during angioplasty. Headaches resolved after successful angioplasty. The temporal relationship between coronary artery occlusion and the headache suggests that headache angina is due to referred pain rather than a generalized vasospastic disorder.

Angina Pectoris↗

PubMed2005

Surgical management of contact point headaches.

INTRODUCTION: Contact point headaches are caused by contact between the nasal septum and the lateral nasal wall by a mechanism of referred pain involving the trigeminal nerve. Our goal was to investigate headaches caused by the contact between the septum and the superior turbinate or medial wall of the ethmoid sinuses and not the middle turbinate. MATERIALS AND METHODS: A retrospective chart review was performed on patients who underwent septoplasty and sinus surgery for headache. The total number of patients who opted for surgery was 23. Only 12 patients met the criteria of having a contact point between the septum and medial wall of the ethmoid sinus, or septum and superior turbinate, which were demonstrated via CT scan of the sinuses. These patients underwent surgical intervention in order to relieve the contact points. RESULTS: According to the same pain questionnaire given pre- and postoperatively, 83% no longer complained of headaches, while 8% had significant relief. Forty-one percent of our patients were previously diagnosed with migraines; 80% of these patients were successfully treated by surgery. DISCUSSIONS: Contact point headaches and migraine without aura (MWOA) have similar symptoms (eg, photophobia, phonophobia, nausea and vomiting, pulsating nature). We believe contact point headaches should be considered in the patient with a diagnosis of MWOA headaches.

Diagnosis, Differential↗

PubMed1983

Somatic and visceral inputs to the thoracic spinal cord of the cat: effects of noxious stimulation of the biliary system.

1. Single unit electrical activity has been recorded extracellularly from 133 neurones in the grey matter of the 8th and 9th thoracic segments of the spinal cord in chloralose anaesthetized cats. The responses of these neurones to electrical stimulation of the ipsilateral splanchnic nerve, to natural stimulation of the skin and to distension of the biliary system have been studied.2. Of the neurones studied, 75% responded to electrical stimulation of the splanchnic nerve and had a cutaneous receptive field in the costal region (viscero-somatic neurones). Twenty-three per cent of the neurones had a cutaneous receptive field but no visceral input (somatic neurones) and 2% had a visceral input but no cutaneous field.3. Somatic neurones had well-localized receptive fields from which they could be driven by innocuous stimulation of the skin (52%), by noxious (7%) or by both forms of stimulation (41%). No somatic neurones projected to supraspinal levels via the contralateral ventro-lateral funiculus.4. Viscero-somatic neurones were excited by small myelinated and non-myelinated afferent fibres in the splanchnic nerve. Most viscero-somatic neurones had cutaneous inputs from nociceptors either exclusively (38%) or in addition to non-noxious inputs (53%).5. The recording sites of somatic neurones were located almost exclusively in laminae II and IV and dorsal V of the dorsal horn. In contrast, viscero-somatic neurones were located in lamina I and in laminae V-IX of the grey matter. No differential distribution of recording sites according to type of cutaneous receptive field has been found within the viscero-somatic group of neurones.6. About one-third of all viscero-somatic neurones could be excited by distensions of the biliary system. In all cases, intensities of visceral stimulation above physiological levels were necessary to activate the neurones. Most units driven by biliary afferents were located in or ventral to lamina V of the dorsal horn. The excitation of these units by biliary distension was found to be specifically mediated by receptors in the biliary system.7. Sixteen per cent of the neurones were found to project to supraspinal levels via crossed ventro-lateral pathways. All of these neurones were viscero-somatic with axonal conduction velocities between 12 and 68 m sec(-1).8. These results are discussed in relation to the postulates of the ;Convergence-projection' theory of referred pain.

Action Potentials↗

PubMed1985

Morphology of ambulatory ST segment changes in patients with varying severity of coronary artery disease. Investigation of the frequency of nocturnal ischaemia and coronary spasm.

The frequency and magnitude of objectively determined myocardial ischaemia during normal daily activities of patients with varying severity of coronary artery disease are unknown. Furthermore, the incidence of nocturnal resting myocardial ischaemia and frequency of coronary spasm in patients with normal coronary arteries and chest pain are also not known. One hundred consecutive patients with chest pain referred for coronary angiography were therefore investigated with exercise testing and ambulatory ST segment monitoring. Fifty two of 74 patients with significant coronary artery disease and six of 26 with no significant coronary narrowing had episodes of ST segment change during 48 hours of ambulatory monitoring. Two patients, one with normal coronary arteries and localised spasm and one with three vessel disease, had episodes of ST segment elevation, whereas all other patients had episodes of ST segment depression. The frequency, duration, and magnitude of ST segment changes were greater in patients with more severe types of coronary artery disease. Thus more than six episodes of ST segment change per day occurred in patients with two or three vessel disease or left main stem stenosis and in the only patient with coronary spasm and normal coronary arteries. Nocturnal ischaemia occurred in 15% of patients with coronary artery disease and was almost an invariable indicator of two or three vessel coronary artery disease or left main stem stenosis. Episodes of ST segment change occurred most commonly during the morning hours and least commonly during the night, in parallel with changes in basal hourly heart rates. The heart rate at the onset of ST segment change tended to be lower in patients with coronary artery disease than in those with normal coronary arteries. The duration of exercise to ST segment depression tended to be shorter in patients with more severe disease, but it could not predict patients with nocturnal myocardial ischaemia, left main stem stenosis, or coronary spasm, whereas ambulatory ST segment monitoring was able to identify most of these patients.

Activities of Daily Living↗

PubMed1995

Hand ischemia in patients with hemodialysis access grafts: angiographic diagnosis and treatment.

PURPOSE: To determine the cause of symptoms and efficacy of transcatheter therapy in a series of patients with dialysis grafts and hand pain referred for arteriography. MATERIALS AND METHODS: Thirteen patients with 14 hemodialysis grafts underwent arteriography for possible hand ischemia. The sites of proximal graft anastomosis were the distal radial artery (n = 6) and the mid- to distal brachial artery (n = 6). Transcatheter therapy was performed via the graft or by antegrade brachical puncture. RESULTS: The cause of symptoms was ischemia from obstructive arterial disease in seven cases (three with superimposed steal), graft steal alone in three, ischemic monomelic neuropathy in two, and carpal tunnel syndrome in two. Five arterial stenoses were treated with angioplasty, with improvement or resolution of symptoms in four patients. CONCLUSION: In this group, symptoms were usually the result of inflow or outflow arterial disease, alone or in combination with graft steal. Transcatheter therapy (angioplasty or embolization) is effective in selected cases.

Adult↗

PubMed1996

Massive hemoptysis due to pulmonary tuberculosis: control with bronchial artery embolization.

PURPOSE: To determine the efficacy of bronchial artery embolization in the control of massive hemoptysis due to pulmonary tuberculosis. MATERIALS AND METHODS: Between 1988 and 1994, 140 patients (125 men and 15 women; mean age, 31.5 years) who presented with massive hemoptysis (more than 300 mL of blood in 24 hours) underwent bronchial artery embolization. Fifty-one patients had received no antituberculosis drugs. Bronchial artery embolization was performed on the side with the greater abnormality on the chest radiograph. Catheters (4 F) and a gelatin sponge were used for embolization. Inflammatory hypervascularity was seen in all patients (five patients had contrast material extravasation and 10 patients had pseudoaneurysms). RESULTS: Almost complete control of hemoptysis was achieved in 102 patients. Of the remaining 38 patients with a notable amount of bleeding after the procedure, 29 were treated successfully with conservative measures and nine underwent re-embolization. Seven patients who underwent re-embolization had recurrent bleeding; four of these patients underwent successful surgery, and three died of aspiration. Two patients developed transient paraparesis 6 hours after the procedure. Nine patients reported transient referred pain to the ipsilateral orbit during injection of the gelatin sponge. One patient had transient dysphagia. CONCLUSION: Patients with massive hemoptysis due to pulmonary tuberculosis should first be treated with bronchial artery embolization.

Adult↗

PubMed1980

Effects of coronary artery occlusion on thoracic spinal neurons receiving viscerosomatic inputs.

Action potentials of single cells in the gray matter of the T2 to T4 spinal segments of chloralose-anesthetized cats were recorded during occlusion of the anterior descending branch of the left coronary artery. Only cells responding both to visceral and somatic afferent inputs were examined. In 53% of the cells the discharge frequency was unaffected by coronary artery occlusion (CAO). The remaining 47% could be classified by four response patterns: 1) in 18% frequency increased immediately following the onset of CAO; 2) in 22%, frequency increased 13.6 +/- 3.3 (SE) s after CAO and the increased frequency usually was associated with changes in the configuration of the electrocardiogram; 3) in 3%, frequency increased at the onset of CAO and then increased more approximately 11 s later; 4) in 4%, inhibition of spontaneous activity occurred during CAO. A noxious pinch applied to the somatic receptive field maximally excited 94% and inhibited 6% of the cells. Since viscerosomatic convergence provides a basis for referred pain, these cells could potentially be involved with transmission of nociceptive information to regions of the brain that integrate pain sensations.

Action Potentials↗

PubMed2000

Intrapericardiac injections of algogenic chemicals excite primate C1-C2 spinothalamic tract neurons.

Extracellular potentials of 38 C1-C2 spinothalamic tract (STT) neurons in anesthetized monkeys (Macaca fascicularis) were examined for responses to intrapericardiac injections of an algogenic chemical mixture (adenosine, 10(-3) M; bradykinin, prostaglandin E(2), serotonin, histamine, each 10(-5) M). Chemical stimulation of cardiac/pericardiac receptors increased activity of 21 cells, decreased activity of 5 cells, and did not change activity of 12 cells. Cells excited by chemical stimuli received input from noxious mechanical stimulation of somatic fields; most receptive fields included the neck, inferior jaw, or head areas. Nerve ablations in 11 cells excited by intrapericardiac chemicals showed that cardiac input activated by algogenic chemicals traveled primarily in vagal afferent fibers to C1-C2 segments; phrenic or cardiopulmonary sympathetic inputs were predominant in 2 of 11 cells. These results supported the concept that activation of cardiac vagal afferents might lead to the production of referred pain sensation in somatic fields innervated from high cervical segments.

Afferent Pathways↗

PubMed1984

Responses of thoracic spinothalamic and spinoreticular cells to coronary artery occlusion.

Spinothalamic and spinoreticular neurons in the C8-T5 spinal segments were examined for responsiveness to occlusion of the left main, left circumflex (CX), or left anterior descending (LAD) coronary artery in monkeys and cats. Four types of cell response to occlusion were observed, as follows: 1) cell activity increased (6 responses) or decreased (1 response) to myocardial ischemia produced by the occlusion; 2) cell activity increased at the onset of occlusion, adapted, and then increased again as ischemia developed (6 responses); 3) cell activity increased at the onset or release of occlusion, and rapidly adapted (13 responses) or remained elevated throughout the occlusion (2 responses); and 4) no response to occlusion (14 tests). Among the types of responses to occlusion, both the magnitude of increased cell activity as well as the spontaneous discharge rates were similar. There were no differences in types of response according to coronary artery ligated. Fourteen cells were tested for responses to separate occlusions of the LAD and CX. Ten cells responded differently to the two occlusions, and four cells exhibited similar responses. C-fiber input onto a neuron was significantly related to whether a cell exhibited a response to cardiac ischemia. Since every cell with C-fiber input did not respond to ischemia, however, this input was not sufficient to predict whether a cell would respond to ischemia. All cells had somatic fields, and all cells responded to noxious stimulation of the somatic field. Some cells also received input from hair movement. The modality of the effective somatic stimulus was not related to type of response to coronary artery occlusion. Spinothalamic and spinoreticular neurons responded similarly to occlusion. Type of response was neither related to cell location in spinal cord nor to projection site in brain. We conclude that spinothalamic and spinoreticular neurons respond to coronary artery occlusion. Different neurons may receive input from different regions of the heart as well as from different types of visceral afferents, resulting in various responses to occlusion. The population of cells excited from ischemia of a given portion of myocardium may determine how the brain interprets the noxious information and refers pain to different somatic structures.

Afferent Pathways↗