Recurrent Activity-Induced Headache Associated with Posttraumatic Dural

Recurrent activity-induced headache associated with posttraumatic dural adhesion of the middle meningeal artery Lee Elisevich MS1, Justin Singer MD, Meggen Walsh DO Department of Clinical Neurosciences, Spectrum Health BACKGROUND IMAGING DISCUSSION v The dura mater and its vasculature are pain-producing An unusual headache presentation attributable to adhesion intracranial structures implicated in the pathogenesis of and traction of the middle meningeal artery against the inner headache1,2 calvarium provides some insight into the nature of headache v The middle meningeal artery (MMA) is a major vascular localized to this area. Surgical removal of the artery and constituent of the dura mater and is densely innervated by subsequent elimination of symptoms affirmed the cause was afferent fibers of the trigeminal nerve3 attributable to the adherence of the vascular structure and neighboring dura to the calvarium. Dural adhesion against the v Vasodilation and mechanical stimulation of the MMA in calvarium was ostensibly a consequence of the resolution of a awake patients have been associated with the production of posttraumatic epidural hemorrhage. The onset of the 1,4 pain consistent with symptoms of headache headache syndrome from the time of this patient’s v Mechanical perturbation of the MMA is a rarely considered Fig.1: Carotid angiograph of left middle meningeal artery, showing rollercoaster incident is thought to have resulted from the source of posttraumatic headache multifocal narrowing along posterior distribution (arrows) centrifugal force applied to a tethered MMA such as to induce sufficient traction upon local nociceptors to have perpetuated CASE REPORT the problem. The relationship between innervation of dural A 48-year-old Caucasian woman presented with a two-year arteries and headache disorders, especially migraine, has been studied extensively. Two recent studies have found that history of recurrent left frontal headache. These began MMA circumference increases ipsilaterally during the onset of following an experience on a rollercoaster in which she was one-sided migraine attacks2,4, with significantly less dilation2 subjected to strong centrifugal forces. Six years prior to this or no dilation4 of the contralateral MMA. This association experience, she had suffered a concussion with a loss of supports the notion that nociception along meningeal consciousness when she was struck on the left forehead in a vasculature plays a significant role in headache. The waterslide incident. Computed tomography showed no overt elimination of this patient’s headache syndrome by removal of cerebral contusion. She had no history of headache prior to a pathological MMA supports the notion of a meningeal origin this incident or the rollercoaster event. Her pain was Fig.2: H&E stained section of posterior left middle meningeal artery, for some forms of headache. characterized as a constant pressing sensation in the left showing calcification of the adventitia frontotemporal region and was punctuated by extreme ANATOMY CONCLUSIONS lancinating pain during relatively minor physical activities. v Head trauma can bring about a headache syndrome Descending stairs, coughing, and Valsalva maneuvers were attributable to the tethering of the MMA to the cranium stated examples of such episodes. Carotid angiography v Resection of the pathological vessel can provide relief revealed multifocal narrowing of the posterior division of the left v Presentation of posttraumatic headache with frontotemporal middle meningeal artery (MMA; Fig. 1). Submaximal balloon distribution and sharing features of migraine suggests the angioplasty of the left posterior MMA intensely reproduced her possibility of an MMA abnormality characteristic pain. Surgical exposure revealed the dura to be strongly adherent to the inner table of the cranium with a REFERENCES calcified pseudomembranous outer layer. A segment of the 1. Ray BS and Wolff HG. Experimental studies on headache: Pain-sensitive structures of the head and their significance in headache. Arch Surg 1940; 41: 813–856. MMA was removed from the level of the foramen spinosum 2. Khan S, Amin FM, Christensen CE, et al. Meningeal contribution to migraine pain: A magnetic along with adjacent pseudomembrane. Pathological study resonance angiography study. Brain J Neurol 2019; 142: 93–102. showed near circumferential calcification of the tunica 3. Steiger HJ and Meakin CJ. The meningeal representation in the trigeminal ganglion an experimental study in the cat. Headache 1984; 24: 305–309. adventitia of the posterior MMA segment (Fig. 2). The patient 4. Asghar MS, Hansen AE, Amin FM, et al. Evidence for a vascular factor in migraine. Ann Neurol 2011; has been free of her presenting headache for over one year. Fig.3: Graphic of left middle meningeal artery entering the cranium 69: 635–645. 5 and dividing into anterior and posterior segments 5. Creative Commons Attribution-Share Alike 4.0 International.

Load more