Mark Obermann

Objective: To collect pairs of nonfactual information and their interpretations and rate their usefulness in distinguishing between primary and secondary headache disorders. Background: Physicians use clinical indicators such as Red Flags and ask about exposure to potential causes to differentiate primary from secondary headaches; however, these approaches have limitations and may result in unnecessary diagnostic procedures. Methods: Using the Delphi process, the participants proposed information-interpretation pairs in the first round and rated them anonymously in two subsequent rounds. The ratings relied on quality estimators to evaluate the reliability, validity, relevance, and frequency on 5-point Likert scales, ranging from 0 to 5. We considered pairs with an average rating of 4.0 or higher to have reached consensus. Results: Four proposals reached consensus, of which two referred to nonfactual information: (i) “A headache that feels familiar indicates a primary headache.” (ii) “A headache that feels completely different from any previous headache raises the suspicion of a secondary headache.” Conclusions: The participants generally found little use for nonfactual information for distinguishing between primary and secondary headache disorders. Solely the presence and absence of patients’ notion of a familiar headache were deemed helpful. While the participants viewed the former as being associated with a primary headache, they felt that the latter pointed towards a secondary headache. Further research is necessary to evaluate their usefulness in clinical practice.

Background and purpose: Previous studies demonstrated cognitive deficits in patients with peripheral vestibulopathy (PVP) with dysfunction of spatial navigation and orientation, but also documented cognitive decline in nonspatial abilities. This study evaluates cognitive deficits in patients with unilateral vestibulopathy (UVP) as well as bilateral vestibulopathy (BVP) in multiple cognitive domains using common screening tests to reliably detect these deficits in clinical practice.Methods: This prospective study compared patients with UVP and BVP to age‐ and sex‐matched healthy controls (HC). Tests included the Alzheimer's Disease Assessment Scale (ADAS), Mini‐Mental Status Examination (MMSE), Trail Making Test Part A and B, Clock Drawing Task, Executive Interview‐25 (EXIT25), Dementia Detection (DemTect), and the Judgment of Line Orientation (JLO). The Montgomery‐Åsberg Depression Rating Scale was used to control for depression. Videonystagmography objectively reconfirmed PVP. The Vertigo Symptoms Scale and the Dizziness Handicap Inventory were used to assess for symptom severity and restrictions of activities of daily living.Results: Eighty‐one patients (65 UVP, 16 BVP) were compared to 55 HC. Patients showed impairment in ADAS, MMSE, DemTect, EXIT25, and JLO. No differences between UVP and BVP were detected. The relative risk (RR) estimates of developing cognitive deficits following PVP were increased. The RR for the ADAS was higher in BVP (RR = 4.91, 95% confidence interval [CI] = 1.87–12.9, p = 0.001) than in UVP (RR = 3.75, 95% CI = 1.65–8.51, p = 0.002), but was similar for the MMSE and DemTect between groups.Conclusions: Patients with PVP showed deficits in multiple cognitive domains including nonspatial cognitive abilities. Vestibulopathy could be a risk factor for the development of cognitive impairment.

Background: Persistent postural-perceptual dizziness (PPPD) is the most common functional vestibular disorder. A multisensory mismatch altered by psychological influences is considered to be an important pathophysiological mechanism. Increased cortical and subcortical excitability may play a role in the pathophysiology of PPPD. We hypothesized that decreased motion perception thresholds reflect one mechanism of the abnormal vestibular responsiveness in this disorder. We investigated the vestibular perception thresholds and the vestibular ocular reflex with a rotatory chair experiment to gain insights in the processing and adaption to vestibular provocation. Methods: In this cross-sectional study 26 female PPPD patients and 33 healthy female age matched controls (HC) were investigated sitting in a motorized rotary chair shielded regarding visual and acoustic stimuli. The chair was rotated for 20 minutes with slowly increasing velocity to a maximum of 72°/s. We functionally tested motion perception thresholds and vegetative responses to rotation as well as vestibular-ocular reflex thresholds. We additionally investigated several psychological comorbidities (i.e. depression, anxiety, somatosensory amplification) using validated scores. Conventional dizziness scores were obtained to quantify the experienced dizziness and impact on daily life. Results: PPPD patients showed a significant reduced vestibulo-perceptual threshold (PPPD: 10.9°/s vs. HC: 29.5°/s; pp=0.043). No significant difference was measured regarding nystagmus parameters between both groups. Conclusion: PPPD patients showed increased vegetative response as well as decreased vestibulo-perceptual thresholds which are related to disease duration. This is of interest as PPPD might be sustained by increased vestibular excitability leading to motion intolerance and induction of dizziness when exposed to movement.

Sekundäre Kopfschmerzen, die auf die Exposition, den Übergebrauch oder den Entzug einer Substanz zurückzuführen sind, sind in Kapitel 8 der 3. Auflage der Internationalen Klassifikation von Kopfschmerzerkrankungen (ICHD-3) aufgeführt. Es werden 3 Unterkapitel unterschieden: 8.1. Kopfschmerz zurückzuführen auf Substanzgebrauch oder Substanzexposition, 8.2. Kopfschmerz zurückzuführen auf einen Medikamentenübergebrauch und 8.3. Kopfschmerz zurückzuführen auf den Entzug einer Substanz. Ersterer – Kopfschmerz zurückzuführen auf Substanzgebrauch oder Substanzexposition – bezieht sich auf einen Kopfschmerz mit Beginn unmittelbar oder innerhalb von Stunden nach der Exposition. Hingegen ist der „Kopfschmerz zurückzuführen auf einen Medikamentenübergebrauch“ (MOH) definiert als ein Kopfschmerz, der an 15 oder mehr Tagen pro Monat bei Patienten mit einer vorbestehenden primären Kopfschmerzerkrankung auftritt und sich als Folge der regelmäßigen Einnahme akuter Kopfschmerzmedikamenten über einen Zeitraum von mehr als 3 aufeinanderfolgende Monate entwickelt hat. Bezüglich letzterem, ist der Entzug von Koffein, Östrogen und Opioiden am häufigsten mit der Entwicklung von Kopfschmerzen assoziiert. Der vorliegende Artikel soll einen Überblick über die neuesten Erkenntnisse zur Klassifikation, Pathophysiologie und zu Behandlungsstrategien dieser sekundären Kopfschmerzentitäten geben und legt den Schwerpunkt dabei auf die Unterkapitel 8.1 und 8.2. der ICHD-3-Klassifikation. Secondary headaches attributed to exposure, overuse or withdrawal of a substance are listed in chapter eight of the 3 rd edition of the International Classification of Headache Disorders (ICHD-3). Three sub-chapters are distinguished: 8.1 Headache attributed to use of or exposure to a substance, 8.2 Medication-overuse headache (MOH) and 8.3 Headache attributed to substance withdrawal. Headache attributed to substance use or substance exposure refers to a headache that begins immediately or within hours after exposure. Medication-overuse headache (MOH) is defined as a headache that occurs on 15 or more days per month in patients with a pre-existing primary headache disorder and develops as a result of regular use of acute headache medication for more than three consecutive months. Regarding the latter, withdrawal of caffeine, estrogen and opioids is most commonly associated with the development of headache. This article aims to provide an overview of the latest knowledge on the classification, pathophysiology and treatment strategies for these secondary headache disorders, focusing on subchapters 8.1 and 8.2 of the ICHD-3 classification. Publication Date: 09 March 2021 (online) © 2021. Thieme. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

This case describes a middle-aged man with anti-dipeptidyl-peptidase-like protein 6 (DPPX) encephalitis who exhibited the triad of memory loss, diarrhea, and tremor. The progression of his disease resembled neurodegenerative disease, and his first presentation at our department was 2 years after the first onset of symptoms. Antibodies against DPPX were positive in both serum and cerebrospinal fluid. No related tumor was found. The patient was initially treated with corticosteroid therapy and plasmapheresis. Despite moderate response to this treatment, corticosteroids were ceased because of adverse effects such as Cushing syndrome, deep vein thrombosis, and osteoporosis. After five cycles of treatment with rituximab, the patient experienced no further progression of neurologic symptoms and no adverse effects. The case adds to the understanding of the diagnosis, treatment, and potential prognosis of anti-DPPX encephalitis.

Despite recent advances in understanding and treating trigeminal neuralgia, its management remains a considerable challenge. Better classification of different types of facial pain and the identification of prognostic factors for different treatment options lead the way toward better quality of life for the individual patient. Although the principles of treating trigeminal neuralgia remain basically the same, antiepileptic drugs, muscle relaxants, and neuroleptic agents are widely used medical treatment options. They were not originally developed for treating trigeminal neuralgia. Carbamazepine was studied in adequate placebo-controlled clinical trials in the 1960s and is still considered the most effective drug. Among emerging treatment options currently under clinical investigation are local botulinum neurotoxin type A injections and a novel sodium channel blocker (CNV1014802) that selectively blocks the Nav1.7 sodium channel. Non-pharmacological treatment options are non-invasive electrical stimulation with either transcranial direct-current stimulation or repetitive transcranial magnetic stimulation which both require further evaluation in regard to applicability. Surgical options remain a valid choice for patients not responding to medical treatment and include Gasserian ganglion percutaneous techniques, gamma knife surgery, and microvascular decompression. There is continual effort to improve these techniques and predict the outcome for better patient selection.