Imploding and Exploding Migraine Headaches: Comparison of Methods to Diagnose Pain Directionality

Abstract

Background The study aims to compare methods of determining headache directionality (imploding, exploding, and/or ocular headaches) in women with migraine, investigate the concordance between physician assignment and patient self-assignment of pain directionality, and evaluate whether patients assigned their headaches to the same direction when queried using different methods. Directionality of migraine headache pain (imploding, exploding, or ocular) may reflect differences in the underlying pathogenesis of individual migraine attacks among and within individuals. Emerging evidence suggests that directionality of pain in migraine sufferers may predict response to onabotulinumtoxin A. The best method of determining headache directionality in migraine sufferers has not been systematically explored. Methods We conducted a prospective cross-sectional survey study of 198 female patients with migraine presenting to a Women’s Health Clinic. Patients determined the directionality (imploding, exploding, and/or ocular) of their own migraine pain by choosing among 3 pictures graphically representing directionality and also by responding to a written question regarding directionality. Clinicians then classified directionality of migraine pain using structured interviews. Concordance between clinician assignment of directionality and patient self-assignment was determined with Kappa coefficients. Results Subjects were females between the ages of 18 and 77 years (mean 48 years). According to patient selection of representative pictures, 62 (31.6%) had imploding headaches with or without ocular pain, 36 (18.4%) had exploding headaches with or without ocular pain, 78 (39.8%) had ocular pain only, and 20 (10.2%) had imploding and exploding headaches with or without ocular pain. Two subjects did not respond. According to patient responses to a written question, 80 (41.0%) had imploding headaches with or without ocular pain, 53 (27.2%) had exploding headaches with or without ocular pain, 46 (23.6%) had ocular pain only, and 16 (8.2%) had imploding and exploding headaches with or without ocular pain. Three subjects did not respond. For physician assignment, 69 (34.9%) subjects had imploding headaches with or without ocular pain, 89 (45%) had exploding headaches with or without ocular pain, 14 (7.1%) had ocular pain only, and 26 (13.1%) had imploding and exploding headaches with or without ocular pain. The concordance (Kappa coefficient) between physician assignment of headache directionality with patient response to the written question was 0.33 (weak agreement), between physician assignment and patient assignment via selection of representative pictures was 0.35 (weak agreement), and between patient assignment via written question and via selection of representative pictures was 0.35 (weak agreement). Conclusions The assignment of headache directionality varied substantially depending upon the method of determination. The concordance between clinician assignment, patient-self assignment via answering a written question, and...

Entrapment of the Greater Occipital Nerve with Chronic Migraine and Severe Facial Pain: A Case Report

“…23 The role of peripheral sensitization in migraine headache is based on the perception of imploding headache that hurts outside the cranium, 18 the existence of a network of sensory fibers that bifurcate from the parent axons of intracranial meningeal nociceptors and reach extracranial tissues such as periosteum and pericranial muscles by crossing calvarial bones through the sutures, 20 the discovery of upregulated proinflammatory genes and down-regulated anti-inflammatory genes in the extracranial tissue of chronic migraine patients, 22 and the reduction of headache frequency by administration of Onabotulinum toxin A in the peripheral tissues outside the calvarium. 21,23 In line with these findings, the long-term results of occipital nerve decompression surgery for relief of chronic headache with or without features were reported. 24 Among seven patients with chronic refractory occipital headache, occipital nerve decompression surgery resulted in compete elimination of new daily persistent headache and posttraumatic headache, and partial elimination of chronic headache/migraine in two patients.…”

“…The author did not attempt GON decompression for chronic migraine, but rather in terms of referred facial pain due to GON entrapment. This case suggests that peripheral sensitization may be related to pathophysiology, [18][19][20][21][22][23][24] especially when the referred facial pain is accompanied by migraine without aura.…”

“…We attempted decompression of the bilateral GON due to the unique and stereotypical temporal correlation between the patient's headache and peripheral sensitization, which has recently been highlighted in migraine without aura. 21,23,24 We did not perform decompression surgery as a treatment for chronic migraine.…”

Extracranial origin of headache

“…There has been a novel distinction between migraine attacks in which the headache is perceived as exploding, as in a pressure buildup inside the head, and those in which the headache is perceived as imploding, like deformed, crushed or broken calvarial bones, with the pain often described as being inflicted from the outside (imploding headache) by a sharp knife or a more widely spread like a vise-like squeeze [8, 13]. This distinction gained mechanistic attention when it was demonstrated that extracranial administration of OnabotulinumtoxinA is effective in reducing the number of migraine days per month in patients who testified to having ‘imploding’, but not in those who testified to having ‘exploding’ headache (Figure 1) [8, 14].…”

Quality of online information about migraine headache surgery

“…Traditionally migraine has been considered as a consequence of a neurovascular disorder with involvement of the central nervous system, newly some data support the hypothesis of compression or irritation of peripheral sensory nerves within muscles, fascia, bone and vascular spaces of the head and neck [5][6][7][8][9][10][11][12]. The irritation of extracranial sensory nerves may appear spontaneously or may derive from several factors, such as traumatic and postoperative ones: these can cause an injury to the nerves or their surrounding tissue so as to create a trigger point for the migraine headache [1].…”