Headache secondary to haemorrhagic stroke resembling paroxysmal hemicrania.

Dr. Rodrigo Bazan – Neurology Departament / Botucatu Medical School / UNESP 18610-180 Botucatu SP Brasil. E [email protected] The association between hemicrania and autonomic phenomena is the main aspect shared by a group of headaches called trigemino autonomic cephalalgias (TAC’s). Their pathophysiology is not entirely known. Trigeminal and intermediary nerves of Wrisburg are involved as well as structures and brainstem connections and posterior hypothalamus. Belonging to TAC’s, paroxysmal hemicrania (PH) was described by Sjaastad and Dale, 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. 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. CASE Male, 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