Hemicrania continua is not a rare disorder. All cases of chronic unilateral daily headaches should receive an indomethacin trial early if not first in treatment.

Objective To describe a standardized methodology for the performance of peripheral nerve blocks (PNBs) in the treatment of headache disorders. Background PNBs have long been employed in the management of headache disorders, but a wide variety of techniques are utilized in literature reports and clinical practice. Methods The American Headache Society Special Interest Section for PNBs and other Interventional Procedures convened meetings during 2010‐2011 featuring formal discussions and agreements about the procedural details for occipital and trigeminal PNBs. A subcommittee then generated a narrative review detailing the methodology. Results PNB indications may include select primary headache disorders, secondary headache disorders, and cranial neuralgias. Special procedural considerations may be necessary in certain patient populations, including pregnancy, the elderly, anesthetic allergy, prior vasovagal attacks, an open skull defect, antiplatelet/anticoagulant use, and cosmetic concerns. PNBs described include greater occipital, lesser occipital, supratrochlear, supraorbital, and auriculotemporal injections. Technical success of the PNB should result in cutaneous anesthesia. Targeted clinical outcomes depend on the indication, and include relief of an acute headache attack, terminating a headache cycle, and transitioning out of a medication‐overuse pattern. Reinjection frequency is variable, depending on the indications and agents used, and the addition of corticosteroids may be most appropriate when treating cluster headache. Conclusions These recommendations from the American Headache Society Special Interest Section for PNBs and other Interventional Procedures members for PNB methodology in headache disorder treatment are derived from the available literature and expert consensus. With the exception of cluster headache, there is a paucity of evidence, and further research may result in the revision of these recommendations to improve the outcome and safety of these interventions.

The results of this study suggest that patients with transformed migraine have a lower health-related quality of life than patients with migraine. These findings indicate that the headache chronicity associated with transformed migraine has a significant influence on quality of life. The results highlight the importance of effective management of headaches to avoid the progression of migraine to the more disabling transformed migraine.

Cluster headache is perhaps the most painful of the primary headache disorders. Its treatment includes acute, transitional, and preventive therapy. Despite the availability of many treatments, cluster headache patients can still be difficult to treat. We treated 14 cluster headache patients with greater occipital nerve block as transitional therapy (treatment initiated at the same time as preventive therapy). The mean number of headache-free days was 13.1+23.6. Four patients (28.5%) had a good response, five (35.7%) a moderate, and five (35.7%) no response. The greater occipital nerve block was well tolerated with no adverse events. Headache intensity, frequency and duration were significantly decreased comparing the week before with the week after the nerve block (P<0.003, P=0.003, P<0.005, respectively). Greater occipital nerve blockade is a therapeutic option for the transitional treatment of cluster headache. u Cluster headache, nerve block, occipital nerve

Objective.—To evaluate the effect of GONB, with or without trigger point injection (TPI), on dynamic mechanical (brush) allodynia (BA) and on head pain in migraine. Background.—Patients with migraine often have cutaneous allodynia that is related to sensitization of central pain neurons. Greater occipital nerve block (GONB) is an effective treatment for migraine headache; however, its effect on cutaneous allodynia in migraine is unknown. Methods.—We studied patients with migraine and BA who were treated with GONB with or without TPI. Demographic data, migraine history, and headache features were documented. Allodynia was evaluated using a structured questionnaire and by applying a 4 × 4‐inch gauze pad to skin areas in the trigeminal and cervical dermatomes. Degree of allodynia (the allodynia score) was measured on a 100‐mm visual analog scale (VAS) before treatment and 10 and 20 minutes thereafter. Headache levels were assessed using an 11‐point verbal scale. Allodynia scores, as well as headache levels, before and after treatment were compared. Results.—Nineteen patients were studied. Mean age was 43.6 ± 11.8 years. Twenty minutes after treatment, headache was reduced in 17 patients (89.5%) and did not change in 2 (10.5%). The average headache level was 6.53 before treatment and 3.47, 20 minutes after it. The average allodynia score decreased after 20 minutes in all patients. Average allodynia score per site was reduced by 18.69 mm and 13.74 mm in the trigeminal and cervical areas, respectively. There was a positive correlation between allodynia index, obtained through the questionnaire, and allodynia score, obtained by examination. Conclusion.—GONB, with or without TPI, reduced both head pain and brush allodynia in this migraine patient group.

Pulsatile tinnitus and obesity suggest possible IIHWOP in patients with CDH. Treatment of patients with increased intracranial pressure was not satisfactory.

Objective-To study the clinical characteristics of cluster headache in women. Cluster headache is a disorder of men (male to female ratio 6-7:1). Methods-Retrospective chart review to identify all women diagnosed with cluster headache at an academic headache centre from January 1995 through July 1998. Results-Thirty two women and 69 men were identified. The mean age of onset of cluster headache was 29.4 years in women versus 31.3 years in men. Two peaks of onset in women (2nd and 5th decade) were identified compared with one in men (3rd decade). Episodic cluster headache was present in 75% of women and 77% of men. Women and men had on average 3 attacks a day, but attack duration was shorter in women (67.2 minutes v 88.2 minutes). Cluster headache period duration (11.1 weeks v 10 weeks) and remission periods (21.1 months v 23.1 months) were similar in women and men. Miosis and ptosis seemed to be less common in women (miosis 13.3% v 24.6%, ptosis 41.9% v 58.1%) whereas lacrimation and nasal congestion/rhinorrhoea were almost equally prevalent in women and men. Women had more nausea than men (62.5% v 43.5%, p=0.09) and significantly more vomiting (46.9% v 17.4%, p=0.003). Photophobia occurred in 75% of women and 81.2% of men, and phonophobia occurred in 50% of women and 47.8% of men. Conclusions-The clinical characteristics of cluster headache in women are very similar to those in men. Women develop the disorder at an earlier age of onset and experience more "migrainous symptoms" with cluster headache, especially vomiting. Both men and women have frequent photophobia and phonophobia with cluster headache attacks. These symptoms are not included in the International Headache Society cluster headache criteria, suggesting the need for possible criteria revision. (J Neurol Neurosurg Psychiatry 2001;70:613-617) Keywords: cluster headache; women; sex; autonomic symptoms Cluster headache is a stereotypic headache disorder characterised by short lasting attacks of severe unilateral head pain with associated autonomic symptoms. Cluster headache has always been identified as a disorder of men, with a male to female ratio of 6-7:1.1 Most of the accepted clinical characteristics of cluster headache have been established through observation of men with this disorder. Very few studies have been dedicated to describing the disorder in women because of its rarity. Manzoni 1 has suggested that the sex ratio for cluster headache is decreasing and that more women are developing or being diagnosed with cluster headache. We attempted to better define the clinical characteristics of cluster headache in women and compare and contrast these manifestations with those in men. Patients and methodsWe carried out a retrospective chart review at the JeVerson Headache Center (a university based academic headache clinic) to identify all women diagnosed with cluster headache from January 1995 to the end of July 1998. Each patient had to satisfy the International Headache Society (IHS) criteria for cluster headache 2 : at least five att...

Allodynia has been described in migraine but has not been fully investigated for the different sensory modalities. The aim of this study was to compare the prevalence of dynamic (brush) and static (pressure) mechanical allodynia in migraine patients and to suggest a practical method of testing them in a clinical setting. Patients with International Headache Society-defined episodic migraine (EM) or with transformed migraine (TM) as defined by Silberstein and Lipton were prospectively recruited from the Jefferson Headache Center out-patient clinic. A questionnaire of migraine features and symptoms of allodynia was administered. Brush allodynia (BA) was tested by cutaneous stimulation with a gauze pad and pressure allodynia (PA) was tested using von Frey hairs (VFH). The prevalence of BA and PA in all patients and in the different subgroups was calculated and correlated with migraine features. We recruited 55 migraine patients. Twenty-five had EM and 30 had TM. BA was present in 18 (32.7±) patients and PA in 18–24 (32.7–43.6±). Allodynia to both brush and pressure was found in 13–17 (23.6–30.9±) patients. If a patient had allodynia to one modality only, it was more likely to be PA than BA. Both BA and PA were more common in patients with TM compared with those with EM [BA 46.7± vs. 16.0±; PA (differences significant for the medium and thick VFHs) 50± vs. 20± and 50± vs. 12±, respectively]. Both types of allodynia were also more common in patients with migraine with aura compared with those with migraine without aura (BA 57.1± vs. 17.6±; PA 57.1–61.9± vs. 17.6–32.7±). There was a positive correlation between allodynia score (as obtained by examination) and allodynia index (as obtained by history) for both BA and PA. The incomplete, although considerable, overlap between BA and PA suggests that allodynia to different sensory modalities is associated with sensitization of different neuronal populations. Because PA was more common than BA, it may be a more sensitive indicator of allodynia in migraine. PA can be tested clinically in a practical and systematic manner.