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Hemicrania continua (HC) is an indomethacin-responsive primary headache disorder which is currently classified under the heading of trigeminal autonomic cephalalgias (TACs). It is a highly misdiagnosed and underreported primary headache. The pooled mean delay of diagnosis of HC is 8.0 ± 7.2 years. It is not rare. We noted more than 1000 cases in the literature. It represents 1.7% of total headache patients attending headache or neurology clinic. Just like other TACs, it is characterized by strictly unilateral pain in the trigeminal distribution, cranial autonomic features in the same area and agitation during exacerbations/attacks. It is different from other TACs in one aspect. While all other TACs are episodic, HC patients have continuous headaches with superimposed severe exacerbations. The central feature of HC is continuous background headache. However, the patients may be worried only for superimposed exacerbations. Focusing only on exacerbations and ignoring continuous background headache are the most important factors for the misdiagnosis of HC. A large number of patients may have migrainous features during exacerbation phase. Up to 70% patients may fulfill the diagnostic criteria for migraine during exacerbations. Besides migraine, its exacerbations can mimic a large number of other primary and secondary headaches. The other specific feature of HC is a remarkable response to indomethacin. However, a large number of patients develop side effects because of the long-term use of indomethacin. A few other medications may also be effective in a subset of patients with HC. Various surgical interventions have been suggested for patients who are intolerant to indomethacin. Several aspects of HC are still not defined. There is a great heterogeneity in types of patients or articles on the HC in the literature. Diagnostic criteria have been modified several times over the years. The current diagnostic criteria are too restrictive in some aspects. We suggest a more accommodating type of criteria for the appendix of International Classification of Headache Disorder (ICHD).

The author, a sufferer of tension-type headache (TTH), believes that the word \"tension\" in \"tension-type headache\" carries a social stigma and that patients do not accept a diagnosis of TTH readily. TTH is the most common primary headache disorder. The disability of TTH as a burden of society is greater than that of migraine. Absenteeism because of TTH is higher than that due to migraine. However, patients with TTH do not go for consultation. Even the prevalence of new daily persistent headache (NDPH) is 12 times higher at the headache clinic than that of chronic TTH (CTTH). These points hint that TTH patients probably do not want to visit the clinic. The author believes that it could be because of the stigma attached to \"tension.\" Herein, the author has noted the first responses given by 50 consecutive patients with TTH when they were told that they had been suffering from TTH. The first answer of 64% of patients with TTH was \"I do not have any tension/stress.\" This denial is similar to the denial declared by patients with depression. Depression and tension are similar in the sense that both are considered as a signs of personal weakness. Such a preconception in the society creates a stigma, and patients deny the diagnosis, conceal symptoms, and become reluctant to seek help and treatment.

Background Migraine chronification is associated with increased disability and central sensitization, yet potentially modifiable metabolic contributors remain incompletely understood. Vitamin D deficiency has been implicated in neuroinflammatory and neuromuscular pathways relevant to migraine, but its relationship with migraine chronicity and objective musculoskeletal tenderness has not been systematically evaluated. Methods In this cross-sectional, three-arm observational study, 50 patients with chronic migraine (CM), 50 with episodic migraine (EM), and 50 age- and sex-matched healthy controls were enrolled. Serum 25-hydroxyvitamin D levels were measured, and deficiency was defined as <30 ng/mL. Muscle and bone tenderness were assessed using a standardized 4-point scale. Group comparisons were performed using ANOVA with post-hoc testing. Multivariable logistic and modified Poisson regression models estimated adjusted odds ratios (aOR) and relative risks (aRR). Trend analysis across chronicity (control → EM → CM) and Pearson correlations were conducted. Results Vitamin D levels declined progressively across chronicity (CM 18.7 ± 11.1; EM 26.3 ± 11.6; controls 35.7 ± 12.7 ng/mL; p < 0.001). Deficiency was present in 78% of CM, 60% of EM, and 46% of controls. CM was independently associated with deficiency (aOR 3.57; aRR 1.54). A significant linear trend was observed (β = −7.41 ng/mL per step; p < 0.001). Muscle and bone tenderness were significantly higher in CM. Vitamin D levels inversely correlated with muscle tenderness ( r = −0.41, p < 0.001). Conclusions Vitamin D deficiency is associated with CM and increased musculoskeletal tenderness. Given the cross-sectional design, causality cannot be inferred, and reverse causation remains a plausible explanation. It warrants further longitudinal and interventional investigation .

Background and Aims: Serotonin syndrome (SS) is a highly underdiagnosed drug-induced clinical syndrome. Under diagnosis is partly due to the unawareness of this syndrome by physicians. The aim of this study is to assess the knowledge, attitude and practice of SS among neuro physicians in India. Methods: A cross-sectional survey using a self-administered questionnaire was carried out among neuro physicians in India. Neuro physicians attending the various neurological conferences and meetings were approached to participate in the study. Result: A total of 150 neuro physicians responded to the survey. About 31% of participants correctly recognized the criteria for SS. Only 17% of the neuro physicians considered clonus as the most important feature in SS. Very few physicians correctly identified serotonergic agents causing serotonin syndrome. Similarly, a very low percentage of neuro physicians correctly identified the drugs used in the management of SS. Drugs used for the treatment of SS were incorrectly recognized as drugs causing SS. Clonus is the most specific feature for SS. However, examination for clonus is not a routine phenomenon in clinical practice among neuro physicians. Conclusion: This study shows great deficiencies in all domains of SS among neuro physicians. There is a need to make every doctor aware of SS by educational programs.

Introduction: Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) and short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms (SUNA) are rare primary headache disorders. Aim: The aim of the study is to describe and compare the clinical characteristics of patients with SUNA and SUNCT. Methods: Patients with SUNCT or SUNA observed in a neurology clinic of a tertiary hospital in India between January 2017 and December 2022 were evaluated. Results: Thirteen patients with SUNA (seven female, 54%) and 16 patients with SUNCT (nine female, 56%) were identified for the evaluation. The mean ages at the onset of SUNA and SUNCT were 36.8.5 ± 8.1 years and 37.2 ± 8.4 years, respectively. The age of onset in our patients was somewhat younger than that of other large series. The demographic and clinical features of SUNA patients were comparable to those of SUNCT patients. Orbital/retro-orbital area was the most common site of pain in both types of headaches. The pattern of pain was noted as single stab (in all patients), repetitive stabs (SUNA vs. SUNCT: 77% vs. 75%), and sawtooth patterns (SUNA vs. SUNCT: 23% vs. 25%). The majority of attacks in both groups lasted less than two minutes. Conjunctival injection and tearing were present in all SUNCT patients (as a part of the diagnostic criteria). The prevalence of conjunctival injection and tearing in SUNA was 46% and 31%, respectively. All patients reported spontaneous attacks. Triggers were reported in seven (54%) patients with SUNA and nine (56%) with SUNCT. Only one patient in each group had a refractory period following a trigger-induced episode. Two patients in the SUNCT group had compression of the trigeminal nerve by a vascular loop. Conclusion: This is the largest case series from India. There were no significant differences between patients with SUNA and SUNCT.