Headache secondary to haemorrhagic stroke resembling paroxysmal hemicrania

Abstract

The association between hemicrania and autonomic phenomena is the main aspect shared by a group of headaches called trigemino autonomic cephalalgias (TAC's) 1 . Their pathophysiology is not entirely known. Trigeminal and intermediary nerves of Wrisburg are involved as well as structures and brainstem connections and posterior hypothalamus 2 . Belonging to TAC's, paroxysmal hemicrania (PH) was described by Sjaastad and Dale 3 , in 1974, as a variant of cluster headaches, characterized by similar crises with a lower duration, higher frequency and dramatic response to indomethacin. Associations of structural lesions with paroxysmal hemicranias, other trigemino autonomic cephalalgias and migraine-like headaches have been described. Such reports corroborate the view according to which posterior hypothalamus and brainstem play a major role in the pathophysiology of these groups of headaches 4 . We report a case of a patient with a headache resembling TAC's but secondary to intraparenchymatous hematoma in brainstem, with an expressive response to indomethacin. CASEMale, 51 years old, caucasian, reported having shown three to four attacks a week for three months of strictly high intensity right hemicrania, mostly around the ocular globe, with sharp pains and average duration of 20 minutes. The crises of headache occurred four to six times a day, predominantly at night, but rarely awakening because of pain. The headache was associated with lacrimation, conjunctival hyperemia, palpebral edema and nasal congestion, ipsilateral to hemicrania. In his personal history he had severe artery hypertension, smoking, and haemorrhagic stroke (HCVA), clinically treated, occurring ten days before the onset of headache. He denied having previous headaches or familial history of headache.Neurological examination showed right hypertonic and hyper-reflex hemiparesia. Magnetic scanning (MRI) was compatible to intraparenchymatous hematoma in brainstem, in pons topography, mostly in anterior and left regions, and midbrain (Figs 1, 2 and 3).The patient was first treated with amitriptyline, 50 mg/day, and reevaluated a month later. No clinical improvement was obtained. At that occasion, indomethacin was administered orally

Paroxysmal hemicrania associated to carotid artery dissection: a case report

“…Our patient had no signs or symptoms on the same side as the dissection. Between 26 to 36% of patients who have carotid dissection have no head, face or neck pain 5 and 25.5% of these patients have no local signs or symptoms. 6 There are descriptions of headache compatible with paroxysmal hemicrania associated with intracranial secondary lesions such as expansive lesions in the sella turcica, pituitary apoplexy, intraparenchymal pontomesencephalic hemorrhage, type I Chiari malformation and giant cell arteritis.…”

Paroxysmal hemicrania masquerading as a stroke in an elderly gentleman: case report

“…There are many diseases that are initially diagnosed as PH and subsequently revised, based on subsequent neuroimaging evidence, as other diagnoses. These includes strokes involving the brainstem, arterio-venous malformations, meningiomas, bulking pituitary lesions, vascular loops encompassing the trigeminal nerve and Moya-Moya disease [4][5][6][7][8][9][10][11][12][13]. Strokes are known to be more common in the geriatric population, whom constitute 53.4% of all adult strokes [14].…”