Headaches. Part 2

Now I’m going to go through some cases.This is a case, sad case, of a 61-year-old male who came in with a six-week history of headaches. The pain awakened him out of sleep and would get better as the day went on. When he would strain at stool, the pain would get worse, and when he would sit up he developed something called visual obscuration. This is a classic brain tumor history. Every neurology book you ever pick up will say, “Brain tumors cause early morning headaches, wake you up out of sleep, get worse if you cough or sneeze.” I think we all learned this in school. Three-quarters of these people with brain tumors had headaches that sounded like tension headaches, and about 9% had migraine-like headaches. About 14% of these people had kind of unclassifiable headaches. But look at this, 8% of all the people with brain tumors had what every neurology book you ever pick up says they are supposed to have. So, so much for that rule.

The other thing is, it seems that if you have a previous history of headaches and you develop a brain tumor, you are more likely to develop headaches than if you didn’t have a previous history of headaches. It’s very common that what you’ve got now, with your brain tumor, is simply more of what you used to have. What I mean by that is, if you have a history of migraine and you develop a brain tumor, you are likely to develop more, more severe, more persistent migraines than you had before but not necessarily a new headache. If you had cluster headaches, or you had tension headaches, you are more likely to develop more to those, but again, not necessarily a new headache.

Let me talk about another case. This is a case of a 22-year-old woman, came in with new frontal headaches which would increase when she strained at stool and began awakening her out of sleep, and her periods had become abnormal. Now if you look at this lady – she’s a little on the heavy side -if you look at her optic nerve, she has papilledema. What’s wrong with her? Anyone know? Pseudotumor, that’s right. Now we call this idiopathic intracranial hypertension or pseudotumor. Again, most of these are women, most of them are obese, most of them have menstrual irregularities. They have generally non-focal neurological exams, except for papilledema. They have papilledema. Although some don’t, which is spooky. Many of them have a recent weight gain. Some have endocrinopathy’s, and up where I live – I live in the New York area – actually infectious disease is really easy in New York because we actually have only one disease, which is Lyme disease. Everybody either has Lyme disease or thinks they have Lyme disease, and that includes the people who bring them into the office. Actually Lyme disease can cause pseudotumor, so it actually is a fairly important cause.

So how do you treat these people? Generally we use carbonic and hydrase inhibitors, that’s probably the agent of choice. When I was a resident we used to do lumbar punctures, serially. You need to do one to diagnose these people, you show that their protein is either normal or low, they don’t have cells, their pressure is very, very high. And then we used to do these serial lumbar punctures. We basically used to do one or two a day, every day, until they signed out against medical advice. Which usually didn’t take very long. We came to realize that that is kind butcherous. Furthermore, when you start doing that you actually have a chance of implanting an epidermoid tumor into their spine. So you have to be very careful. If they are getting into trouble, if they have papilledema and they are losing their vision, we recommend doing optic nerve fenestrations and occasionally ventricular shunts.

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