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Calcitonin gene-related peptide (CGRP) probably has a role in migraine pathophysiology, and antagonism of its receptors might provide treatment without the vasoconstrictor effects of triptans. We aimed to assess the clinical profile of MK-0974 (telcagepant), an orally bioavailable antagonist of CGRP receptor. In a randomised, parallel-treatment, placebo-controlled, double-blind, trial at 81 sites in the Europe and the USA, adults with migraine diagnosed by International Headache Society criteria treated moderate or severe attacks with either oral telcagepant 150 mg or 300 mg, zolmitriptan 5 mg, or placebo. The five co-primary endpoints were pain freedom, pain relief, or absence of photophobia, phonophobia, or nausea at 2 h after treatment. Analysis was by the full analysis set and multiplicity was controlled for with a step-down closed-testing procedure. This trial is registered with ClinicalTrials.gov, number NCT00442936. 1380 patients were randomly assigned to receive telcagepant 150 mg (n=333) or 300 mg (354), zolmitriptan (345), or placebo (348). Telcagepant 300 mg was more effective than placebo for pain freedom (95 [27%] of 353 patients vs 33 [10%] of 343 [p<0·0001]), pain relief (194 [55%] of 353 vs 95 [28%] of 343 [p<0·0001]), and absences of phonophobia (204 [58%] of 353 vs 126 [37%] of 342 [p<0·0001]), photophobia (180 [51%] of 353 vs 99 [29%] of 342 [p<0·0001]), and nausea (229 [65%] of 352 vs 189 [55%] of 342 [p=0·0061]). Efficacy of telcagepant 300 mg and zolmitriptan 5 mg were much the same, and both were more effective than telcagepant 150 mg. Adverse events were recorded for 31% taking telcagepant 150 mg, 37% taking telcagepant 300 mg, 51% taking zolmitriptan 5 mg, and 32% taking placebo. Telcagepant 300 mg is effective as an acute treatment for migraine with efficacy comparable to that of zolmitriptan 5 mg, but with fewer associated adverse effects. Merck Research Laboratories.

Spontaneous intracranial hypotension (SIH) is caused by spinal leakage of cerebrospinal fluid (CSF) and typically causes orthostatic headache which is relieved by lying in a recumbent position. We describe the case of a 44-year-old male suffering from orthostatic headaches accompanied by symptomatic cervical disc herniation, for which he had an anterior cervical discectomy and fusion (ACDF). Computerized tomography of the brain at the emergency department 1 week after this procedure showed bilateral subacute subdural hematomas. In retrospect, the positional headache had been present for 3 months prior to the ACDF, and magnetic resonance imaging of the cervical spine prior to the ACDF already showed signs of an extradural CSF collection indicating intracranial hypotension. This case highlights the possibility of SIH caused by a spinal dural leak due to cervical disc herniation.

Background Sport as a migraine trigger has been reported, but extensive information on these triggered attacks and the patients experiencing these attacks is lacking. Goal of this study was to investigate the lifetime prevalence of exercise triggered migraine attacks in migraine patients and if patients with exercise triggered attacks experience specific prodromal or ictal migraine symptoms. Methods 103 consecutive migraine patients seen during their first visit at a Dutch headache clinic were administered an interview during their first visit to the outpatient headache clinic in which they were asked about their normal life migraine characteristics and if exercise had ever triggered a migraine attack within 48 hours after stopping exercise. Those reporting exercise triggered migraine attacks, were asked if these migraine attacks were typical or atypical compared to their normal life attacks and which kind of exercise in particular could provoke migraine attacks. Results Among migraineurs lifetime prevalence of exercise-triggered migraine attacks was 38%, regardless of migraine type (with or without aura) or gender. Neck pain as the initial migraine symptom during normal life migraine attacks, was more frequent in those experiencing exercise-triggered migraine attacks. More than half of the patients reporting exercise-triggered migraine attacks abandoned the offending sport due to migraine. As our study population was drawn from a headache clinic, result can not be generalized to the general population. Conclusions Life time prevalence of exercise-triggered migraine attacks was high. Those experiencing exercise-triggered migraine attacks, more frequently had neck pain as initial migraine symptom during normal life attacks.

[...]studies in the future have further determined whether it is safe to treat those patients, it seems that recent MI (in the previous 7 weeks) should still be considered a contraindication for rt-PA treatment. Acetylsalicyl acid 100 mg 1dd1, clopidogrel 75 mg 1dd1, and clexane 0.8 mL 2dd1 were initiated. Because chest pain on admission was absent, no acute percutanous coronary intervention was done.

We report the case of a 4-year-old girl with acute subdural hematoma who presented to the emergency department after an unwitnessed fall of the balcony. The hematoma was hyperdense along the left convexity of 9 mm thickness with a consequent mass effect with obliteration of the adjacent sulci, left lateral ventricle compression and a midline shift of 7 mm. During her stay in the emergency department while waiting for transfer to the children intensive care unit elsewhere she slightly deteriorated neurologically. Repeat CT scan of the brain 4 h after initial presentation remarkably showed that the subdural hematoma had now largely disappeared, with a decrease in volume and density. Consequently, the mass effect diminished with a near normalization of the midline shift.

Temporal bone osteomyelitis has been recognized for decades as a complication of otitis externa, specifically in elderly patients with diabetes. A much less prevalent form is skull base osteomyelitis. We report a 70-year-old man with diabetes who presented to our outpatient clinic with severe chronic daily complaints of headache. The headache was located frontoparietally and kept him awake at night. Imaging (nonenhanced computed tomography [CT], magnetic resonance imaging, and positron emission tomography/CT) showed a hypermetabolic mass on the right side of the skull base, in the middle ear, and in the mastoid process, with invasion and partial destruction of the surrounding elements of the petrous bone, the occipital bone, and the sphenoid bone on the right, with extension by way of the clivus into the apex of the left petrous bone. Diagnostic puncture revealed Streptococcus pneumoniae.The final diagnosis was severe daily headache due to central skull base osteomyelitis. Our case emphasizes the need for proper clinical and radiological investigation keeping the diagnosis of skull base osteomyelitis in mind with patients with diabetes or otherwise immunocompromised status who present with chronic daily headache and otalgia.

We present the case of a woman who developed severe nightly thoracic pain during pregnancy without neurological deficits upon examination. Spontaneously after childbirth, the pain was markedly reduced. Further investigation showed that her pain was caused by an ependymoma in the cervicothoracic spinal cord. Gross total resection was accomplished, and the patient has been free of pain ever since. With this case, we want to draw attention to a rare, but possibly very disabling, cause of increasing nightly thoracic pain during pregnancy. Spontaneous improvement after childbirth could erroneously cause postponement of further investigation.

Headache caused by subdural empyema is usually associated with fever and symptoms and/or clinical signs of meningeal irritation and increased intracranial pressure. We describe a patient with headache with absence of these signs or symptoms of meningeal irritation or intracranial pressure, who turned out to have a parafalcine subduralempyema. A 28-year-old man had headache for 2 weeks, which had started with visual symptoms with duration of 5 minutes. Two days later, he developed fever. During these 2 weeks, he had recurrence of visual symptoms for 4 times, with duration of several minutes.Neurologic examination at presentation on the emergency department showed no meningeal irritation or papilledema. However, on closer examination, a limited homonymous hemianopsia on the left side and a drift of the left leg were found. Magnetic resonance imaging showed parafalcine subdural empyema on the right side of the falx and a small brain abscess right occipitally. Neuronavigated craniotomy was performed, which confirmed the presence of empyema and allowed culture of the specimens. Streptococcus milleri group was cultured,which allowed narrowing of the antibiotic therapy to Benzylpenicillin12 million entities per 24 hours. Headache and subdural empyema diminished during treatment, and at follow-up 12 weeks after start of treatment, patient had no remaining complaints. Parafalcine-located subdural empyema can present without presence of clear localizing symptoms or signs like meningeal irritation and increased intracranial pressure. When headache is accompanied with fever, one should extensively question neurologic symptoms, and a thorough neurologic examination should be done.

D) showing thickening of the meninges close to the lytic bone lesion on the left side, with pathological contrast enhancement of the subdural mass. [...]3 intracerebral lesions were seen, suspect for metastases. Laboratory findings showed an elevated C-Reactive Protein level of 308 mg/l (normal <1 mg/L) and a white blood cell count of 14.5 × 109/L (normal 4-10 × 109/L). Most cases of subdural empyema occur in the second decade of life in patients who are otherwise healthy. [...]there is a marked predisposition in males [10-12].