ArticleLiterature Review

Headache attributed to hypothyroidism

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Abstract

Clinical and subclinical hypothyroidisms are common conditions in the population. Clinic-based studies suggest that hypothyroidism may be an exacerbating factor for some primary headaches. Furthermore, hypothyroidism may be a risk factor for incident new daily persistent headache. This article reviews the classification of the headaches attributed to hypothyroidism according to the second edition of the International Classification of Headache Disorders. We also review the prevalence, etiology, and principles of treatment of hypothyroidism. Because hypothyroidism is a treatable cause of secondary headaches, doctors should be aware of this relationship.

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... Headache and hypothyroidism are clinical conditions that cause a significant impact on the quality of life, and it is well established that both are more frequent among women (1)(2)(3). The association between headache and hypothyroidism has been known for more than 60 years (4)(5)(6)(7)(8)(9)(10)(11)(12)(13). ...
... Hypothyroid patients may develop headache with features similar to those observed in the relatively rare primary headache known as ''new daily persistent headache'' (NDPH), the definition of which is also, in our view, vague (''daily from its onset, which is clearly remembered. . .pain becoming continuous and unremitting within 24 hours,'' ICHD 3 beta) (8,11,12). Thus, without determining the duration of a continuous pain it is difficult or even impossible to establish a clear criterion. Furthermore, NDPH rarely improves with treatment, which makes some experts doubt the existence of a relationship with hypothyroidism. ...
... Other authors have mentioned the possibility of thyroxine antinociceptive effects through the elevation of platelet serotonin, prostacyclin metabolism or vasomotor activity following treatment with levothyroxine (7), which could also contribute to an excellent outcome, at least regarding migrainous features. The involvement of purinergic transmission has also been postulated (8,36). ...
Article
Objective: The objective of this article is to analyze the features of headache attributed to hypothyroidism (HAH), evaluate the differences between groups with and without HAH, between "overt" and "subclinical" hypothyroidism groups, and evaluate outcomes after levothyroxine treatment. Methods: Patients with hypothyroidism were selected in a cross-sectional study, followed prospectively for 12 months, and classified as subclinical or overt hypothyroidism. The patients were divided into two groups: with and without HAH. Results: HAH was reported by 73/213 (34%) patients, involving the following areas: fronto-orbital (49%), temporal (37%), and posterior part of the head (15%). The HAH features were as follows: pulsatile (63%), four to 72 hours' duration (78%), unilateral (47%), nausea/vomiting (60%), and moderate-severe intensity (72%). Hypothyroidism symptomatology was similar in both groups, except for a greater frequency of hoarseness in the group with HAH. Migraine history was more frequent in the patients with HAH (53% vs 38%, p < 0.05). The frequency of HAH was similar both in overt and subclinical hypothyroidism. After levothyroxine treatment 78% reported a decrease in HAH frequency. Subclinical and overt hypothyroid patients reported a similar alleviation of their headaches. Conclusion: Patients with HAH may present with unilateral, pulsatile, episodic pattern, and nausea/vomiting, which is at odds with the criteria for HAH established by ICHD 3 beta. Not all individuals responded to levothyroxine, and patients with the subclinical form of hypothyroidism benefit from this treatment.
... Hypothyroidism may exacerbate primary headaches in some of the patients and it can be a risk factor for the occurrence of new daily persistent headache. Based on the second edition of the International Classification of Headache Disorders, it is considered as a headache related to homeostasis (5). ...
... In a study carried out in Norway, in patients aged 20 years and more, high TSH values were associated with a low prevalence of headache, especially in women without a history of thyroid dysfunction, but in people who suffered from headache, especially in migraineurs, TSH was lower than those without headache (7). Tepper et al. reported that in USA, hypothyroidism was more prevalent in patients with new daily persistent headache than in migraineurs and chronic post traumatic headaches (5). ...
Article
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Hypothyroidism may be an exacerbating factor for primary headaches and migraine is one of the most common primary headaches in childhood. The purpose of this study was to evaluate the effect of treatment of subclinical hypothyroidism on children with migraine headache. In a quasi-experimental study, the severity and monthly frequency of headache of 25 migraineur children with subclinical hypothyroidism who were referred to the pediatric neurology clinic of Shahid Sadoughi University of Medical Sciences,Yazd, Iran between January 2010 and February 2011 and were treated with levothyroxine for two months were evaluated. Thirteen girls (52%) and 12 boys (48%) with the mean age of 10.2 ± 2.76 years were evaluated. In children with hypothyroidism, the monthly frequency of headache (mean ± SD: 17.64 ± 9.49 times vs. 1.2 ± 1.1 times) and the severity of headache (mean± SD: 6.24±1.8 scores vs. 1.33 ± 0.87 scores) were significantly decreased by treatment. Based on the results of this study, treatment of subclinical hypothyroidism was effective in reducing migraine headaches. Therefore, it is logical to check thyroid function tests in migraineur children.
... Usually, treatment of the sleep apnea syndrome ameliorates the headache. It has been estimated that about 30% of patients with hypothyroidism suffer from headache [3, 15], with a female preponderance. The headache is mostly bilateral, nonpulsatile , continuous, and not associated with nausea and vomiting. ...
... Symptoms that may alert toward hypothyroidism are fatigue, sluggishness, increased sensitivity to cold, constipation, pale and dry skin, a puffy face, hoarse voice, elevated blood cholesterol level, unexplained weight gain, muscle aches, tenderness and stiffness, pain, stiffness or swelling in the joints, muscle weakness, heavier than normal menstrual periods, brittle fingernails and hair, and depression. Generally, the headache resolves within a few months after effective treatment of hypothyroidism [16], which also may represent an exacerbating factor for some primary headaches, including TTH [15]. Myocardial ischemia may induce headache and cardiac cephalalgia, as reported in the ICHD-II [3,171819. ...
Article
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Tension-type headache (TTH) is the most common form of headache in the general population. Diagnosis of TTH is based merely on clinical features and on careful exclusion of all possible causes of headache. Most of the headaches that present in the context of medical disorders (e.g., hypothyroidism, sleep disorders, and hypertensive crisis) have clinical features overlapping with those of TTH; medical history and specific features of the systemic disorder are usually the clues to establish a correct diagnosis. Some medical disorders may worsen a preexisting TTH, and is also possible the comorbidity of TTH with psychiatric disorders and fibromyalgia.
... At times a nonspecific, continuous, nonpulsatile headache get exacerbated by underlying hypothyroidism which respond well to hormone replacement therapy. 3 Almost one third adult hypothyroid patients develop gradually progressive cerebellar ataxia mostly associated with auto immune or Hashimoto's thyroiditis. In a good number of patients this is a reversible clinical entity with restorting euthycoid state early in course of disease. ...
Article
p>Hypothyroidism the most common endocrine disorder of adults with its protean neurological, neuropsychiatrical and neuromuscular manifestation needs special attention in clinical practice as majority of these symptoms can be reversed on timely administration of levothyroxine and attainment of euthyroid state, Thyroid hormones have critical influence on integral growth, development and functioning of central nervous system. Apart from usual clinical symptoms (especially in females) of constipation, fatigue, weight gain, cold intolerance, bradycardia and menstrual irregularities, the persistent low thyroid hormones can present with wide range of neurological complications like mononeuropathy (corpal tunnel syndrome) and polyneuropathy, cerebellar ataxia, dementia, psychosis, coma, encephalopathy (Hashimoto's) as well as myopathies.</p
... Literature suggests that hypothyroidism exacerbates headache. [16] Our results indicate that patients with hypothyroidism had a significantly higher incidence of PDPH. We also found a significant effect of tea consumption habit on PDPH occurrence. ...
Article
Background and aims: Post dural puncture headache (PDPH) following caesarean delivery (CD) is a cause for concern for anaesthesiologists. We aimed to study the effect of reinsertion of the stylet after spinal anaesthesia procedure, prior to spinal needle removal, on the incidence of PDPH in women undergoing CD. We also evaluated the risk factors associated with PDPH. Methods: In this randomised, double-blind study in a tertiary care hospital, 870 American Society of Anesthesiologists (ASA) II/III women undergoing CD under spinal anaesthesia were randomly divided into-GroupA (n = 435): stylet reinsertion before spinal needle removal and Group B (n = 435): spinal needle removal without stylet reinsertion. All patients were questioned for occurrence of PDPH at various time-points. Statistical calculations were done using Statistical Package for the Social Sciences (SPSS) 17 version program for Windows. Results: Sixty-two (7.1%) patients developed PDPH; 27 (6.2%) patients with stylet reinsertion and 35 (8.0%) patients in those with no stylet reinsertion; P = 0.389. The onset of headache was significantly delayed in patients with stylet reinsertion (16.2 ± 6.7 and 13.2 ± 4.3 h, respectively); P = 0.041 and they had greater severity of PDPH compared with those with no stylet reinsertion; P = 0.002. Factors significantly associated with PDPH were hypothyroidism, tea habituation, number of skin punctures and needle redirections, first pass success rate, occurrence of paraesthesia and contact with bone, intraoperative hypotension and time to ambulation. Conclusions: Reinsertion of the stylet before spinal needle removal did not influence the incidence of PDPH. The onset of PDPH was delayed and the severity of headache was greater in women in whom reinsertion of the stylet was done.
... Clinic-based studies suggest that hypothyroidism (as documented by high blood levels of TSH, also known as thyroidstimulating hormone/thyrotropin) may be a comorbid disorder as well as a pain exacerbating factor for primary headache disorders such as migraine. Interestingly, headache attributed to hypothyroidism was recently classified by the International Headache Society in the headache categories [1,2]. The diagnostic criteria for headache attributed to hypothyroidism require pain resolution to have occurred within 2 months after effective treatment of hypothyroidism [3]. ...
Article
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PurposeThe purpose of the current study was to evaluate thyroid function in terms of serum thyroid-stimulating hormone (TSH, also known as thyrotropin), 3,5,3′-triiodo-l-thyronine (T3), and 3,5,3′,5′-tetraiodo-l-thyronine (T4, also known as thyroxine) levels in migraineurs in comparison with non-migraineurs using a systematic review of literature and a meta-analysis.Methods This is a systematic review of case-control studies on serum TSH, T3, and T4 concentrations of migraineurs in comparison with non-migraineurs. After extracting the data from the finally included studies, the weighted overall standardized mean difference (SMD) was calculated.ResultsThe weighted overall SMD for the impact of TSH, T3, and T4 blood levels for migraineurs in comparison with non-migraineurs was as follows: 0.804 (95% CI, 0.045–1.564), − 0.267 (95% CI, − 0.660–0.125), 0.093 (95% CI, − 0.077–0.263), respectively. It is noteworthy that only the p value for the significance of the overall SMD for serum TSH level was statistically significant (p = 0.038), as examined by the z-test.Conclusions The results of the current study point to an association between migraine pathogenesis and changing TSH levels in comparison with those of controls.
... Associations have been found with illnesses and disorders as hypertension, diabetes, hyperlipidaemia, asthma, obesity, hypothyroidism and depressive disorders. [19][20][21][22][23][24] Small differences were observed between male and female patients, principally in the diagnosis of mood disorders and hypothyroidism, which appeared to play a more significant role in women. These findings were in line with previous estimations in the general population. ...
Article
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Objectives To investigate the number and characteristics of the Spanish population affected by headache disorders and the direct medical cost that these patients represent for the healthcare system. Design A retrospective multicentre observational study. Setting Records from all patients admitted with headache in primary and secondary care centres in Spain between 2011 and 2016 that were registered in a Spanish claims database were included in the analysis. Direct medical costs were calculated using the standardised average expenses of medical procedures determined by the Spanish Ministry of Health. Results Data extraction claimed primary care records from 636 722 patients and secondary care records from 30 077 patients. Women represented 63% and 65% of all patients with headache in primary and secondary care respectively, with the exception of cluster headaches, a group with 60% of male patients. No large shifts were observed over time in patients’ profile; contrarily, the number of cases per 10 000 patients attended in primary care increased 2-folds between 2011 and 2016 for migraine and 1.85-folds for other headaches. Migraine was the cause for 28% of primary care consultations and 50% of secondary care admissions, and it was responsible for the largest portion of healthcare costs in 2016, a total amount of € 7 302 718. The estimated annual direct medical cost of headache disorders was € 10 716 086. Conclusions Migraine was responsible for half of the secondary care admissions linked to headache disorders. The raise detected in the number of cases registered in primary care is likely to impact the direct medical costs associated to these disorders causing an increase in the total burden they represent for the Spanish National Healthcare System.
... [15] However, hypothyroidism is itself known to cause headaches and must be ruled out while treating headache. [37] The influence of thyroxine on headache is not clear yet and requires further work. ...
Article
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Background - The prevalence of hypothyroidism in the developed world is about 4-5% and in India is 10.9%. The goal of treating hypothyroidism is to maintain thyrotropin (TSH) levels within the normal reference range. Studies have shown that even within the normal range of TSH, patients with low normal TSH (LNT) have better outcomes when compared to patients with high normal TSH (HNT). Aims and objectives - Our study aimed to find whether patients treated at a dose of levothyroxine resulting in an LNT had improved clinical outcomes and biochemical parameters, when compared to those on a levothyroxine dose resulting in an HNT. Materials and methods 180 patients with hypothyroidism on treatment, who had a TSH of 0.27-4.2mIU/L and had been on treatment with a stable dose of at least 50 micrograms of levothyroxine for at least 6 months were administered the Thyroid Symptom Questionnaire. TSH was assayed. Blood pressure and BMI were measured. Serum lipids were measured by spectrophotometry. Results We found that patients with LNT and HNT did not differ with respect to cognitive symptoms or feelings of coldness, lethargy and fatigue. However, patients with LNT had a better lipid profile (mean LDL 132.24 in HNT and 115.39 in LNT p= 0.08) and lower BMI (1.045kg/m 2 lower in LNT compared to HNT) compared to HNT. Conclusion These parameters might impact cardiovascular risk. This may be an argument in favour of titrating the dose of thyroxine to achieve a low normal TSH.
... Although a lumbar puncture can be a valuable diagnostic tool, one should be judicious about its use because it can make a patient with a headache signifi cantly worse rather than better. The most informative serum studies may include thyroid studies [26]. As many as 4% of adults with chronic headache have thyroid abnormalities, although this is less frequently observed in children. ...
Article
New daily persistent headache (NDPH) is frequently seen in young patients with chronic daily headache. NDPH begins with a sudden onset, often associated with an infection or other physical stress. This headache syndrome is difficult to treat and may persist for years. This review discusses the epidemiology, comorbid symptoms, evaluation, and treatment of this disorder.
... 44 Hypothyroidism has been associated with New Daily Persistent Headache and should also be considered for any refractory headache, especially when accompanied by symptoms of fatigue, depression, dry skin, slow speech, cold intolerance, weight gain, hair changes, constipation, decreased concentration, or irregular menses. 45 Although thyroid replacement hormone usually improves these headaches, it can also cause headaches via idiopathic intracranial hypertension. 46 Hyperthyroidism and Hashimoto's encephalopathy are rarer causes of headache. ...
... The results of the Nord-Trøndelag Health Study (Head-HUNT) of 2006 did show an inverse association between diabetes and headache; however, the reason for this inverse relationship is still unknown [25]. It is estimated that approximately 30% of patients with hypothyroidism suffer from headache, and hypothyroidism could be an exacerbating factor for some types of primary headaches including TTH [26,27]. In the present study, the prevalence of thyroid disease was 32.1% in the TTH group compared with headache-free subjects (17.9%). ...
Article
Migraine can be accompanied by some gastrointestinal (GI) disorders. In this study, we aimed to investigate the relationship between migraine and tension-type headache (TTH) and different lower and upper GI disorders as well as non-alcoholic fatty liver (NAFLD) and cholelithiasis. This cross-sectional study included 1574 overweight and obese participants who were referred to the Obesity Research Center of Sina Hospital, Tehran, Iran. The diagnosis of migraine and TTH was made by an expert neurologist based on the international classification of headache disorders-III β (ICHD III β). GI disorders, including irritable bowel syndrome (IBS), constipation, heartburn, dyspepsia, non-alcoholic fatty liver (NAFLD), and cholelithiasis, were diagnosed by a gastroenterology specialist. The overall mean age of participants was 37.44 ± 12.62. A total of 181 (11.5%) migraine sufferers (with and without aura) and 78 (5%) TTH subjects were diagnosed. After adjusting for potential confounders by multivariable regression models, migraine had significant association with IBS (OR = 5.16, 95% CI = 2.07–12.85, P = 0.000), constipation (OR = 3.96, 95% CI = 2.25–6.99, P = 0.000), dyspepsia (OR = 4.12, 95% CI = 2.63–6.45, P = 0.000), and heartburn (OR = 5.03, 95% CI 2.45–10.33, P = 0.000), while the association between migraine and NAFLD was marginally significant (OR = 2.03, 95% CI = 0.98–4.21, P = 0.055). Furthermore, the prevalence of NAFLD (OR = 2.93, 95% CI 1.29–6.65, P = 0.010) and dyspepsia (OR = 4.06, 95% CI = 2.24–7.34, P = 0.000) was significantly higher in TTH patients than the headache-free group. These findings show an association between GI disorders and primary headaches especially migraine and are, therefore, of value to the management of migraine and TTH. Further studies should investigate the etiology of the relationship between all subtypes of primary headaches and GI disorders.
... Klinikinėmis studijomis įrodyta, kad hipotiroidizmas gali paūminti pirminį galvos skausmą. Dar daugiau – hipotiroidizmas gali būti pirminio galvos skausmo rizikos veiksnys ir antrinio galvos skausmo priežastis [36]. Mūsų duomenimis, migrena sirgo keturios (6,5 proc.) ...
Article
Reikšminiai žodžiai: skydliaukės ligos, neurologinė patologija, neurologinės komplikacijos. Darbo tikslas. Išanalizuoti skydliaukės ligomis sergančių asmenų neurologinę patologiją. Tyrimo medžiaga ir metodai. Vilniaus miesto klinikinės ligoninės Vidaus ligų ir Nefrologijos skyriuose 2012 m. balandį – 2015 m. birželį tyrėme 62 skydliaukės ligomis sergančius ligonius (60 moterų ir 2 vyrus), kuriems buvo ar pasireiškė neurologinė patologija. Ligonių amžius – 39–88 metai (vidurkis – 66,8 ± 1,9 metų). Visiems ligoniams atliktas bendras ir biocheminis kraujo tyrimas, skydliaukės hormonų (TSH, FT4) kiekio nustatymas kraujo serume, skydliaukės echoskopija, vidaus organų echoskopija, esant indikacijoms – galvos (stuburo) KT, KT angiografija, magnetinio rezonanso tomografija (MRT). Statistinių duomenų vidurkių skirtumai vertinti Stjudento patikimumo kriterijumi t. Skirtumai laikyti statistiškai patikimi, esant p < 0,05. Rezultatai. Sergančiųjų skydliaukės ligomis neurologinė patologija Lietuvoje išanalizuota pirmą kartą. Galvos smegenų kraujotakos sutrikimai buvo 12 (19,4 proc.) ligonių, metastazės galvos smegenyse – 2 (3,2 proc.), meningioma – 1 (1,6 proc.), tiroidinė (Hašimoto) encefalopatija – 5 (8,1 proc.), hipotiroidinė demencija – 1 (1,6 proc.), lėtinė galvos smegenų išemija – 11 (17,7 proc.), Parkinsono liga – 1 (1,6 proc.), epilepsiniai priepuoliai – 2 (3,2 proc.), neramių kojų sindromas – 3 (4,8 proc.), hipotiroidinė miopatija – 1 (1,6 proc.), tiroidinė neuropatija – 4 (6,5 proc.), polineuropatija – 5 (8,1 proc.), migrena – 4 (6,5 proc.), somatoforminė autonominė disfunkcija – 10 (16,1 proc.). Nustatyta, kad galvos smegenų infarktas ir praeinantis smegenų išemijos priepuolis visais atvejais įvyko esant hipotireozei ir keturiems (6,5 proc.) iš penkių (8,1 proc.) ligonių, praeityje patyrusių galvos smegenų infarktą, buvo hipotireozė. Galvos smegenų infarkto atveju, palyginus su sergančiųjų lėtine galvos smegenų išemija grupe, nustatytas statistiškai reikšmingas TSH kiekio kraujyje padidėjimas – atitinkamai 6,47 ± 1,0 mIU/l ir 3,04 ± 1,3 mIU/l (p < 0,05). Pateikti klinikiniai atvejai. Apžvelgta naujausia mokslinė literatūra apie sergančiųjų skydliaukės ligomis neurologinę patologiją. Atliktų tyrimų duomenys palyginti su literatūros duomenimis. Išvados. Galvos smegenų kraujotakos sutrikimai yra dažniausios skydliaukės ligų neurologinės manifestacijos. Nustatytas galvos smegenų infarkto ir hipotiroidizmo ryšys. Tiroidinės encefalopatijos klinikinis spektras platus – nuo nežymios kognityvinės disfunkcijos iki demencijos. Epilepsiniai priepuoliai gali būti pirminė klinikinė Hašimoto encefalopatijos apraiška. Parkinsonizmas ir neramių kojų sindromas dažnesni sergant skydliaukės ligomis. Hipertireozė gilina parkinsoninį tremorą. Hipotireozė gali paūminti galvos skausmą. Neuropatija dažnesnė hipotiroidizmo atveju.
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Prevalence of headache lowers with age, and headaches of elderly adults tend to be different than those of the younger population. Secondary headaches, such as headaches associated with vascular disease, head trauma, and neoplasm, are more common. Also, certain headache types tend to be geriatric disorders, such as primary cough headache, hypnic headache, typical aura without headache, exploding head syndrome, and giant cell arteritis. This review provides an overview of some of the major and unusual geriatric headaches, both primary and secondary.
Chapter
This chapter on secondary headaches focuses exclusively on headaches which are due to non-vascular causes. The chapter begins with considerations on diagnosis of idiopathic intracranial hypertension (IIH, pseudotumor cerebri) and headaches of low CSF pressure or intracranial hypotension. Next, the author provides a discussion on headaches associated with intracranial neoplasm, disorders of infectious disease, disorders of homeostasis, and toxic headaches, along with clinical pearls for diagnosing these myriad secondary headaches. Tips on diagnosing cervicogenic headache and temporomandibular disorder are provided. Finally, the author summarizes clinical pearls on diagnosis of classic and secondary trigeminal neuralgia, along with clinical features of other, more rare facial neuralgias and persistent idiopathic facial pain. KeywordsSecondary headache–Idiopathic Intracranial Hypertension–Pseudotumor cerebri–Intracranial hypotension–Brain tumor headache–HIV headache–Headache attributed to infectious disease–Headaches associated with disorders of homeostasis–Cervicogenic headache–Trigeminal neuralgia–Facial neuralgia–Persistent idiopathic facial pain
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Background: Migraine is the most frequent acute recurrent primary headache in childhood. Hypothyroidism may be an exacerbating factor for some primary headaches. The purpose of this study was to determine the frequency of subclinical hypothyroidism in children with migraine headache. Methods: In a cross-sectional analytic study, the thyroid function tests of 5- to 15-year-old migraineurs who were referred to the Pediatric Neurology Clinic of Shahid Sadoughi University of Medical Sciences from January 2010 to February 2011 in Yazd, Iran, were measured based on the second edition of the International Classification of Headache Disorders. Results: Forty-eight girls (46.2%) and 56 boys (53.8%) with mean age of 10.46±2.72 years were evaluated. Twenty-five (24%) children had hypothyroidism. The monthly frequency of headache (mean±SD, 14.75±8.9 vs. 20.12±9.49, p=0.04) and the duration of headache (mean±SD, 1.96±1.08 vs. 3.75±2.71 h, p=0.03) were more statistically significant in migraineur children with hypothyroidism, but the mean age, mean of onset age of migraine, sex distribution, and severity of headache were not statistically different in both groups. Conclusion: Based on the results of this study, subclinical hypothyroidism was as an exacerbating factor for migraine headache. Therefore, it is logical to check the thyroid function tests in migraineur children.
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Headache is a common complaint in children, one that gives rise to considerable parental concern and fear of the presence of a space-occupying lesion. The evaluation and diagnosis of headache is very challenging for paediatricians, and neuroimaging by means of CT or MRI is often requested as part of the investigation. CT exposes children to radiation, while MRI is costly and sometimes requires sedation or general anaesthesia, especially in children younger than 6 years. This review of the literature on the value of neuroimaging in children with headache showed that the rate of pathological findings is generally low. Imaging findings that led to a change in patient management were in almost all cases reported in children with abnormal signs on neurological examination. Neuroimaging should be limited to children with a suspicious clinical history, abnormal neurological findings or other physical signs suggestive of intracranial pathology. Well-designed prospective studies are needed to better define the clinical findings that warrant neuroimaging in children with headache.
Chapter
This chapter is a guide to the diagnosis of secondary headaches that are nonvascular. By necessity, the sections are disparate, but important for diagnostic purposes. In the first part, consideration is given to the diagnosis of cerebrospinal fluid (CSF)-related abnormalities, such as idiopathic intracranial hypertension (IIH, pseudotumor cerebri) and CSF low-pressure headaches. The second part of the chapter deals with headaches secondary to tumors. The third part gives guidance on the diagnosis of headaches attributed to infection, such as human immunodeficiency virus (HIV). Headaches attributed to Chiari malformation type 1 constitute the fourth section. Headaches attributed to homeostasis disorders are covered in the fifth section. The next sections include headaches attributed to substances, cervicogenic headache, and temporomandibular disorders. The chapter ends with a section on the new International Classification of Headache Disorders, third edition (ICHD-3) classification system for diagnosing trigeminal neuralgia (TN) and painful trigeminal neuropathies, with a part on the other cranial neuralgias as well.
Chapter
This chapter reviews the impact that systemic disease can have upon the mechanisms that cause head pain. Headache can be caused by direct influence on pericranial and intracranial pain-sensitive structures or initiated by pain modulatory systems within the brain. Systemic disease can influence both of these paradigms to cause a wide variety of headache types. The review covers the following areas: endocrine dysfunction, metabolic disorders, autoimmune dysfunction, organ disease, cancer, infection, transplantation, critical medical illness, vitamins, drugs, and toxins. The analysis of these disciplines includes both review of both the current medical literature and the classification of various headache types as defined by the International Headache Society.
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This article discusses headaches secondary to disorders of homeostasis, which include headaches attributed to (1) hypoxia and/or hypercapnia (high-altitude, diving, or sleep apnea), (2) dialysis, (3) arterial hypertension (pheochromocytoma, hypertensive crisis without hypertensive encephalopathy, hypertensive encephalopathy, preeclampsia or eclampsia, or autonomic dysreflexia), (4) hypothyroidism, (5) fasting, (6) cardiac cephalalgia, and (7) other disorder of homeostasis. Clinical features and diagnosis as well as therapeutic strategies are discussed for each headache type.
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Many patients have low thyroid symptoms but normal thyroid laboratory results. Similarly, there are many patients that are on thyroid medication and whose thyroid hormone levels are normal, but who still do not feel well. The aim of this paper is to demonstrate how T3, botanicals and nutrition can optimize thyroid function, promote peripheral T4 to T3 conversion, and restore wellbeing to such patients.
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The diagnosis and management of headache disorders in the elderly are challenging. The evaluation of the elderly patient with new-onset or recurrent headache requires a grasp of the heterogeneous set of causes of secondary head pain disorders. Once such aetiologies are excluded, the correct primary headache disorder must be diagnosed. Although tension-type headache is the leading cause of new-onset headache in the elderly, other primary headache disorders such as migraine can manifest in later life, and one disorder, hypnic headache, occurs almost exclusively in the elderly. Primary chronic daily headache persists in elderly patients to a greater extent than the primary episodic headache disorders do. The treatment of elderly patients with primary headache disorders is multifaceted, including acute, prophylactic and at times transitional treatments. Knowledge of drug interactions is particularly important as polypharmacy is the rule. Concomitant illnesses may require adjustments in choice or dose of drugs. In addition, as many acute and preventive treatments are either contraindicated or poorly tolerated in the elderly, modifiable risk factors for headache progression and perpetuation must be addressed. In spite of these treatment complexities, there are numerous opportunities to bring relief to older patients with primary headache disorders from the currently available therapies. New treatment options for elderly patients with headache will soon be available, including acute, prophylactic and interventional techniques.
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Hypothyroidism is a clinical entity very commonly encountered in clinical practices. Untreated hypothyroidism can lead to hypertension, dyslipidemia, infertility, cognitive impairment, neurological and neuromuscular involvements. Neurological complications include reversible cerebellar ataxia, dementia, peripheral neuropathy, psychosis, coma, encephalopathy (Hashimoto's encephalopathy), neuromuscular disorders. The disease identification in the initial stage remains difficult as it presents with a large number of clinical features. Neonatal screening protocols in all patients of hypothyroidism can help in the timely detection as well as treatment. Most of the neurological manifestations can be reversed on timely administration of levothyroxine which works well even in reversing of the symptoms as it reverses the metabolic abnormalities. It is important to evaluate every patient with hypothyroidism or with the suspicion of the disease for any neurological abnormalities.
Chapter
Although the majority of chronic headaches are primary in nature, secondary underpinnings must be first considered to limit morbidity and mortality. Some may develop abruptly, while others will progress gradually over several weeks to months. Perhaps the most common chronic secondary headache in clinical practice is that following injury to the head or neck. Intracranial vascular malformations may cause headaches, and chronic headache may result from prior stroke, venous occlusion, arterial dissection, or intracranial hemorrhage. Giant cell arteritis should be considered in all subjects over age 50 with chronic headaches. Disorders of cerebrospinal fluid pressure such as intracranial hypertension or hypotension often present with chronic head pain. Brain tumors may aggravate an underlying primary headache condition or provoke a new headache profile. A key complaint from those with symptomatic Chiari malformations is headache. Systemic conditions such as hypothyroidism and local disease of the eye, ear, or paranasal sinuses may also cause headaches often in association with other physical examination abnormalities. Imaging of the head and/or neck, typically with MRI, is the most valuable diagnostic tool in the evaluation of secondary causes of chronic headache. Vascular imaging, lumbar puncture, and serum studies (thyroid function tests, ESR, CRP) may be valuable in select circumstances. Management is dictated by the underlying pathology.
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This article discusses headaches secondary to disorders of homeostasis, which include headaches attributed to (1) hypoxia and/or hypercapnia (high-altitude, diving, or sleep apnea), (2) dialysis, (3) arterial hypertension (pheochromocytoma, hypertensive crisis without hypertensive encephalopathy, hypertensive encephalopathy, preeclampsia or eclampsia, or autonomic dysreflexia), (4) hypothyroidism, (5) fasting, (6) cardiac cephalalgia, and (7) other disorder of homeostasis. Clinical features and diagnosis as well as therapeutic strategies are discussed for each headache type.
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To describe the prevalence, sociodemographic profile, and the burden of migraine in the United States in 1999 and to compare results with the original American Migraine Study, a 1989 population-based study employing identical methods. A validated, self-administered questionnaire was mailed to a sample of 20 000 households in the United States. Each household member with severe headache was asked to respond to questions about symptoms, frequency, and severity of headaches and about headache-related disability. Diagnostic criteria for migraine were based on those of the International Headache Society. This report is restricted to individuals 12 years and older. Of the 43 527 age-eligible individuals, 29 727 responded to the questionnaire for a 68.3% response rate. The prevalence of migraine was 18.2% among females and 6.5% among males. Approximately 23% of households contained at least one member suffering from migraine. Migraine prevalence was higher in whites than in blacks and was inversely related to household income. Prevalence increased from aged 12 years to about aged 40 years and declined thereafter in both sexes. Fifty-three percent of respondents reported that their severe headaches caused substantial impairment in activities or required bed rest. Approximately 31% missed at least 1 day of work or school in the previous 3 months because of migraine; 51% reported that work or school productivity was reduced by at least 50%. Two methodologically identical national surveys in the United States conducted 10 years apart show that the prevalence and distribution of migraine have remained stable over the last decade. Migraine-associated disability remains substantial and pervasive. The number of migraineurs has increased from 23.6 million in 1989 to 27.9 million in 1999 commensurate with the growth of the population. Migraine is an important target for public health interventions because it is highly prevalent and disabling.
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NHANES III measured serum TSH, total serum T(4), antithyroperoxidase (TPOAb), and antithyroglobulin (TgAb) antibodies from a sample of 17,353 people aged > or =12 yr representing the geographic and ethnic distribution of the U.S. population. These data provide a reference for other studies of these analytes in the U.S. For the 16,533 people who did not report thyroid disease, goiter, or taking thyroid medications (disease-free population), we determined mean concentrations of TSH, T(4), TgAb, and TPOAb. A reference population of 13,344 people was selected from the disease-free population by excluding, in addition, those who were pregnant, taking androgens or estrogens, who had thyroid antibodies, or biochemical hypothyroidism or hyperthyroidism. The influence of demographics on TSH, T(4), and antibodies was examined. Hypothyroidism was found in 4.6% of the U.S. population (0.3% clinical and 4.3% subclinical) and hyperthyroidism in 1.3% (0.5% clinical and 0.7% subclinical). (Subclinical hypothyroidism is used in this paper to mean mild hypothyroidism, the term now preferred by the American Thyroid Association for the laboratory findings described.) For the disease-free population, mean serum TSH was 1.50 (95% confidence interval, 1.46-1.54) mIU/liter, was higher in females than males, and higher in white non-Hispanics (whites) [1.57 (1.52-1.62) mIU/liter] than black non-Hispanics (blacks) [1.18 (1.14-1.21) mIU/liter] (P < 0.001) or Mexican Americans [1.43 (1.40-1.46) mIU/liter] (P < 0.001). TgAb were positive in 10.4 +/- 0.5% and TPOAb, in 11.3 +/- 0.4%; positive antibodies were more prevalent in women than men, increased with age, and TPOAb were less prevalent in blacks (4.5 +/- 0.3%) than in whites (12.3 +/- 0.5%) (P < 0.001). TPOAb were significantly associated with hypo or hyperthyroidism, but TgAb were not. Using the reference population, geometric mean TSH was 1.40 +/- 0.02 mIU/liter and increased with age, and was significantly lower in blacks (1.18 +/- 0.02 mIU/liter) than whites (1.45 +/- 0.02 mIU/liter) (P < 0.001) and Mexican Americans (1.37 +/- 0.02 mIU/liter) (P < 0.001). Arithmetic mean total T(4) was 112.3 +/- 0.7 nmol/liter in the disease-free population and was consistently higher among Mexican Americans in all populations. In the reference population, mean total T(4) in Mexican Americans was (116.3 +/- 0.7 nmol/liter), significantly higher than whites (110.0 +/- 0.8 nmol/liter) or blacks (109.4 +/- 0.8 nmol/liter) (P < 0.0001). The difference persisted in all age groups. In summary, TSH and the prevalence of antithyroid antibodies are greater in females, increase with age, and are greater in whites and Mexican Americans than in blacks. TgAb alone in the absence of TPOAb is not significantly associated with thyroid disease. The lower prevalence of thyroid antibodies and lower TSH concentrations in blacks need more research to relate these findings to clinical status. A large proportion of the U.S. population unknowingly have laboratory evidence of thyroid disease, which supports the usefulness of screening for early detection.
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The etiology and prognosis of chronic daily headache (CDH) are not well understood. The aim of this study is to describe factors that predict CDH onset or remission in an adult population. Potential cases (180+ headaches per year, n=1134) and controls (two to 104 headaches per year, n=798) were interviewed two times over an average 11 months of follow-up. Factors associated with CDH prevalence at baseline were evaluated. The incidence of CDH and risk factors for onset were assessed in controls whose headache frequency increased to 180+ per year at follow-up. Prognostic factors were assessed in CDH cases whose headache frequency fell at follow-up. CDH was more common in women, in whites, and those of less education. CDH cases were more likely to be previously married (divorced, widowed, separated), obese, and report a physician diagnosis of diabetes or arthritis. At follow-up, 3% of the controls reported 180 or more headaches per year. Obesity and baseline headache frequency were significantly associated with new onset CDH. In CDH cases, the projected 1-year remission rate to less than one headache per week was 14% and to less than 180 headaches per year was 57%. A better prognosis was associated with higher education, non-white race, being married, and with diagnosed diabetes. Individuals with less than a high-school education, whites, and those who were previously married had a higher risk of CDH at baseline and reduced likelihood of remission at follow-up. New onset CDH was associated with baseline headache frequency and obesity.
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Patients with serum thyroid-stimulating hormone (TSH) levels outside the reference range and levels of free thyroxine (FT4) and triiodothyronine (T3) within the reference range are common in clinical practice. The necessity for further evaluation, possible treatment, and the urgency of treatment have not been clearly established. To define subclinical thyroid disease, review its epidemiology, recommend an appropriate evaluation, explore the risks and benefits of treatment and consequences of nontreatment, and determine whether population-based screening is warranted. MEDLINE, EMBASE, Biosis, the Agency for Healthcare Research and Quality, National Guideline Clearing House, the Cochrane Database of Systematic Reviews and Controlled Trials Register, and several National Health Services (UK) databases were searched for articles on subclinical thyroid disease published between 1995 and 2002. Articles published before 1995 were recommended by expert consultants. A total of 195 English-language or translated papers were reviewed. Editorials, individual case studies, studies enrolling fewer than 10 patients, and nonsystematic reviews were excluded. Information related to authorship, year of publication, number of subjects, study design, and results were extracted and formed the basis for an evidence report, consisting of tables and summaries of each subject area. The strength of the evidence that untreated subclinical thyroid disease is associated with clinical symptoms and adverse clinical outcomes was assessed and recommendations for clinical practice developed. Data relating the progression of subclinical to overt hypothyroidism were rated as good, but data relating treatment to prevention of progression were inadequate to determine a treatment benefit. Data relating a serum TSH level higher than 10 mIU/L to elevations in serum cholesterol were rated as fair but data relating to benefits of treatment were rated as insufficient. All other associations of symptoms and benefit of treatment were rated as insufficient or absent. Data relating a serum TSH concentration lower than 0.1 mIU/L to the presence of atrial fibrillation and progression to overt hyperthyroidism were rated as good, but no data supported treatment to prevent these outcomes. Data relating restoration of the TSH level to within the reference range with improvements in bone mineral density were rated as fair. Data addressing all other associations of subclinical hyperthyroid disease and adverse clinical outcomes or treatment benefits were rated as insufficient or absent. Subclinical hypothyroid disease in pregnancy is a special case and aggressive case finding and treatment in pregnant women can be justified. Data supporting associations of subclinical thyroid disease with symptoms or adverse clinical outcomes or benefits of treatment are few. The consequences of subclinical thyroid disease (serum TSH 0.1-0.45 mIU/L or 4.5-10.0 mIU/L) are minimal and we recommend against routine treatment of patients with TSH levels in these ranges. There is insufficient evidence to support population-based screening. Aggressive case finding is appropriate in pregnant women, women older than 60 years, and others at high risk for thyroid dysfunction.
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Subclinical thyroid dysfunction is a risk factor for developing symptomatic thyroid disease. Advocates of screening argue that early treatment can prevent serious morbidity in individuals who are found to have laboratory evidence of subclinical thyroid dysfunction. This article focuses on whether it is useful to order a thyroid function test for patients who have no history of thyroid disease and have few or no signs or symptoms of thyroid dysfunction. A MEDLINE search, supplemented by searches of EMBASE and the Cochrane Library, reference lists, and a local database of thyroid-related articles. Controlled treatment studies that used thyroid-stimulating hormone (TSH) levels as an inclusion criterion and reported quality of life, symptoms, or lipid level outcomes were selected. Observational studies of the prevalence, progression, and consequences of subclinical thyroid dysfunction were also reviewed. The quality of each trial was assessed by using preset criteria, and information about setting, patients, interventions, and outcomes was abstracted. The prevalence of unsuspected thyroid disease is lowest in men and highest in older women. Evidence regarding the efficacy of treatment in patients found by screening to have subclinical thyroid dysfunction is inconclusive. No trials of treatment of subclinical hyperthyroidism have been done. Several small, randomized trials of treatment of subclinical hypothyroidism have been done, but the results are inconclusive except in patients who have a history of treatment of Graves disease, a subgroup that is not a target of screening in the general population. Data on the adverse effects of broader use of L-thyroxine are sparse. It is uncertain whether treatment will improve quality of life in otherwise healthy patients who have abnormal TSH levels and normal free thyroxine levels.
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Purinergic system exerts a significant influence on the modulation of pain pathways at the spinal site. Adenosine has antinociceptive properties in experimental and clinical situations, while ATP exerts pronociceptive actions in different pain models. In this study we investigated the hydrolysis of ATP to adenosine in synaptosomes from spinal cord in parallel with the nociceptive response of rats at different ages after hypothyroidism induction. Hypothyroidism elicited a significant increase in AMP hydrolysis to adenosine in synaptosomes from spinal cord of rats subjected to neonatal hypothyroidism and in 420-day-old rats submitted to thyroidectomy. Accordingly, these rats presented an analgesic response as a consequence of hypothyroidism. In contrast, the ATP hydrolysis was decreased in the spinal cord of 60-day-old hypothyroid rats in parallel with a significant increase in nociceptive response. These results indicate the involvement of adenine nucleotides in the control of the hypothyroidism-induced nociceptive response during development.
Article
Background.—Chronic daily headache (CDH) is one of the more frequently encountered headache syndromes at major tertiary care centers. The analysis of factors related to the transformation from episodic to chronic migraine (CM) and to the de novo development of new daily persistent headache (NDPH) remain poorly understood.Objectives.—To identify somatic factors and lifestyle factors associated with the development of CM and NDPH.Methods.—We used a randomized case-control design to study the following groups: 1) CM with analgesic overuse (ARH), n = 399; 2) CM without analgesic overuse, n = 158; and 3) NDPH, n = 69. These groups were compared with two control groups: 1) episodic migraine, n = 100; and 2) chronic posttraumatic headache (CPTH); n = 65. Associated medical conditions were assessed. We investigated the case groups for any association with somatic or behavioral factors. Data were analyzed by the two-sided Fischer's exact test, with the odds ratio being calculated considering a 95% confidence interval using the approximation of Woolf.Results.—When the active groups were compared with the episodic migraine group, the following associations were found: 1) ARH: hypertension and daily consumption of caffeine; 2) CM: allergies, asthma, hypothyroidism, hypertension, and daily consumption of caffeine; and 3) NDPH: allergies, asthma, hypothyroidism, and consumption of alcohol more than three times per week. The following associations were found when comparing the active groups with CPTH: 1) ARH: asthma and hypertension; 2) CM: allergies, asthma, hypothyroidism, hypertension, and daily consumption of caffeine; and 3) NDPH: allergies, asthma, hypothyroidism, and consumption of alcohol more than three times per week.Conclusions.—Several strong correlations were obtained between patients with specific types of CDH and certain somatic conditions or behaviors; some have not been previously described. Transformation of previously episodic headache or development of a NDPH thus may be related to certain medical conditions and behaviors beyond the frequently incriminated precipitant analgesic overuse. As similar results were obtained when CPTH was used as a control, the correlation is more complex than simple comorbidity.
Article
Objective.—A population-based survey was conducted in 1999 to describe the patterns of migraine diagnosis and medication use in a representative sample of the US population and to compare results with a methodologically identical study conducted 10 years earlier. Methods.—A survey mailed to a panel of 20 000 US households identified 3577 individuals with severe headache meeting a case definition for migraine based on the International Headache Society (IHS) criteria. Those with severe headache answered questions regarding physician diagnosis and use of medications for headache as well as headache-related disability. Results.—A physician diagnosis of migraine was reported by 48% of survey participants who met IHS criteria for migraine in 1999, compared with 38% in 1989. A total of 41% of IHS-defined migraineurs used prescription drugs for headaches in 1999, compared with 37% in 1989. The proportion of IHS-defined migraineurs using only over-the-counter medications to treat their headaches was 57% in 1999, compared with 59% in 1989. In 1999, 37% of diagnosed and 21% of undiagnosed migraineurs reported 1 to 2 days of activity restriction per episode (P<.001); 38% of diagnosed and 24% of undiagnosed migraineurs missed at least 1 day of work or school in the previous 3 months (P<.001); 57% of diagnosed and 45% of undiagnosed migraineurs experienced at least a 50% reduction in work/school productivity (P<.001). Conclusions.— Diagnosis of migraine has increased over the past decade. Nonetheless, approximately half of migraineurs remain undiagnosed, and the increased rates of diagnosis of migraine have been accompanied by only a modest increase in the proportion using prescription medicines. Migraine continues to cause significant disability whether or not there has been a physician diagnosis. Given the availability of effective treatments, public health initiatives to improve patterns of care are warranted.
Article
To compare the effect of three treatments for thyrotoxicosis on subsequent body weight, a retrospective survey of 65 patients was performed. The effect of thyroxine replacement on body weight in 25 patients with primary hypothyroidism was also examined. In one year after starting therapy 21 patients treated with carbimazole gained a mean of 5.4kg (95% confidence interval 3.6 to 7.2kg); 20 patients after thyroidectomy gained a mean of 6.3kg (95% c.i. 3.4 to 9.2kg); and 24 patients given radioiodine gained a mean of 7.4kg (95% c.i. 5.2 to 9.6kg), p<0.001 in all three groups. The weight gain in the three groups was not significantly different. 54–67% of the weight gain occurred in the first three months. The patients treated for hypothyroidism had lost an insignificant amount of weight 12 months after starting therapy — Mean change was −0.6kg (95% c.i. −2.2 to +1.1kg) p>0.1. This data suggests that all patients treated for thyrotoxicosis will gain body weight irrespective of the treatment used, but patients treated for primary hypothyroidism will not lose an appreciable amount of weight. Therefore dietary advice should be given, where appropriate, at the onset of any treatment of thyroid dysfunction.
Article
The original Whickham Survey documented the prevalence of thyroid disorders in a randomly selected sample of 2779 adults which matched the population of Great Britain in age, sex and social class. The aim of the twenty-year follow-up survey was to determine the incidence and natural history of thyroid disease in this cohort. Subjects were traced at follow-up via the Electoral Register, General Practice registers, Gateshead Family Health Services Authority register and Office of Population Censuses and Surveys. Eight hundred and twenty-five subjects (30% of the sample) had died and, in addition to death certificates, two-thirds had information from either hospital/General Practitioner notes or post-mortem reports to document morbidity prior to death. Of the 1877 known survivors, 96% participated in the follow-up study and 91% were tested for clinical, biochemical and immunological evidence of thyroid dysfunction. Outcomes in terms of morbidity and mortality were determined for over 97% of the original sample. The mean incidence (with 95% confidence intervals) of spontaneous hypothyroidism in women was 3.5/1000 survivors/year (2.8-4.5) rising to 4.1/1000 survivors/year (3.3-5.0) for all causes of hypothyroidism and in men was 0.6/1000 survivors/year (0.3-1.2). The mean incidence of hyperthyroidism in women was 0.8/1000 survivors/year (0.5-1.4) and was negligible in men. Similar incidence rates were calculated for the deceased subjects. An estimate of the probability of the development of hypothyroidism and hyperthyroidism at a particular time, i.e. the hazard rate, showed an increase with age in hypothyroidism but no age relation in hyperthyroidism. The frequency of goitre decreased with age with 10% of women and 2% of men having a goitre at follow-up, as compared to 23% and 5% in the same subjects respectively at the first survey. The presence of a goitre at either survey was not associated with any clinical or biochemical evidence of thyroid dysfunction. In women, an association was found between the development of a goitre and thyroid-antibody status at follow-up, but not initially. The risk of having developed hypothyroidism at follow-up was examined with respect to risk factors identified at first survey. The odds ratios (with 95% confidence intervals) of developing hypothyroidism with (a) raised serum TSH alone were 8 (3-20) for women and 44 (19-104) for men; (b) positive anti-thyroid antibodies alone were 8 (5-15) for women and 25 (10-63) for men; (c) both raised serum TSH and positive anti-thyroid antibodies were 38 (22-65) for women and 173 (81-370) for men. A logit model indicated that increasing values of serum TSH above 2mU/l at first survey increased the probability of developing hypothyroidism which was further increased in the presence of anti-thyroid antibodies. Neither a positive family history of any form of thyroid disease nor parity of women at first survey was associated with increased risk of developing hypothyroidism. Fasting cholesterol and triglyceride levels at first survey when corrected for age showed no association with the development of hypothyroidism in women. This historical cohort study has provided incidence data for thyroid disease over a twenty-year period for a representative cross-sectional sample of the population, and has allowed the determination of the importance of prognostic risk factors for thyroid disease identified twenty years earlier.
Article
To review information on the benefits of screening with a sensitive thyroid-stimulating hormone (TSH) test for thyroid dysfunction in asymptomatic patients seeking primary care for other reasons. This paper focuses on whether screening should be aimed at detection of subclinical thyroid dysfunction and whether persons with mildly abnormal TSH levels can benefit. A MEDLINE search for studies of screening for thyroid dysfunction and of treatment for complications of subclinical thyroid dysfunction. Studies of screening with thyroid function tests in the general adult population or in patients seen in the general office setting were selected (n=33). All controlled studies of treatment in patients with subclinical hypothyroidism or subclinical hyperthyroidism were also included (n=23). The prevalence of overt and subclinical thyroid dysfunction, the evidence for the efficacy of treatment, and the incidence of complications in defined age and sex groups were extracted from each study. Screening can detect symptomatic but unsuspected overt thyroid dysfunction. The yield is highest for women older than 50 years of age: In this group, 1 in 71 women screened could benefit from relief of symptoms. Evidence of the efficacy of treatment for subclinical thyroid dysfunction is inconclusive. Even though treatment for subclinical thyroid dysfunction is controversial, office-based screening to detect overt thyroid dysfunction may be indicated in women older than 50 years of age. Large randomized trials are needed to determine the likelihood that treatment will improve quality of life in otherwise healthy patients who have mildly elevated TSH levels.
Article
To evaluate the frequency of headache in patients with hypothyroidism. A prospective study of a cohort of patients with hypothyroidism. Outpatients or inpatients in a headache clinic and endocrinological clinic. 102 adults, ages 35 to 78 (83F, 19M) experiencing clinical and biological hypothyroidism. Thirty-one patients with hypothyroidism of 102 (30%) presented with headache 1 to 2 months after the first symptoms of hypothyroidism. The headache was slight, nonpulsatile, continuous, bilateral, and salicylate responsive and disappeared with thyroid hormone therapy. The authors believe there is a prevalence of nonspecific headache in hypothyroidism and that it has a particular response to thyroid hormone therapy. Hypothyroidism is another cephalalgia with an endocrinological cause after menstrual cephalalgia. We suspect a metabolic or vascular pathophysiological process.
Article
To evaluate the association between hypothyroidism, and the health status of older Hispanic and non-Hispanic white (NHW) men and women. To accomplish this, we determined the prevalences of the treated and untreated conditions and examined the associations between an elevated serum thyroid stimulating hormone (TSH) and cognitive and affective (mood) functions and the prevalences of symptoms and comorbidity, specifically coronary heart disease (CHD), diabetes, hypertension, and hyperlipidemia. A cross-sectional study of equal numbers of Hispanic and NHW men and women selected randomly from the Health Care Financing Administration (Medicare) rolls and recruited for a home interview followed by a 4-hour interview/examination in a senior health clinic. 883 volunteers, mean age 74.1 years, participated in interviews/examinations Serum TSH was determined in 825 participants responding to questions about thyroid replacement therapy. Serum free thyroxine (free T4) concentrations were determined in 139 participants with elevated TSH concentrations (>4.6 microU/mL). Symptoms, cognitive tests, a screen for depression, comorbidities (e.g., CHD), and risk factors (e.g., lipid abnormalities, diabetes, and hypertension) were compared in participants with high versus normal TSH values. Subclinical hypothyroidism is more common in women than in men and in non-Hispanic white women compared with Hispanic women. No differences were observed between participants with TSH elevations from 4.7 to 10 microU/mL and those with normal TSH concentrations, and only a few differences were observed in those with TSH concentrations above 10. Subclinical hypothyroidism is a common condition in community-living older people, especially women. However, it appeared to have no effect on any of the measures of health status utilized until serum TSH concentrations exceeded 10 microU/mL, and even then the effects were rarely significant.
Article
Overt hypothyroidism has been found to be associated with cardiovascular disease. Whether subclinical hypothyroidism and thyroid autoimmunity are also risk factors for cardiovascular disease is controversial. To investigate whether subclinical hypothyroidism and thyroid autoimmunity are associated with aortic atherosclerosis and myocardial infarction in postmenopausal women. Population-based cross-sectional study. A district of Rotterdam, The Netherlands. Random sample of 1149 women (mean age +/- SD, 69.0 +/- 7.5 years) participating in the Rotterdam Study. Data on thyroid status, aortic atherosclerosis, and history of myocardial infarction were obtained at baseline. Subclinical hypothyroidism was defined as an elevated thyroid-stimulating hormone level (>4.0 mU/L) and a normal serum free thyroxine level (11 to 25 pmol/L [0.9 to 1.9 ng/dL]). In tests for antibodies to thyroid peroxidase, a serum level greater than 10 IU/mL was considered a positive result. Subclinical hypothyroidism was present in 10.8% of participants and was associated with a greater age-adjusted prevalence of aortic atherosclerosis (odds ratio, 1.7 [95% CI, 1.1 to 2.6]) and myocardial infarction (odds ratio, 2.3 [CI, 1.3 to 4.0]). Additional adjustment for body mass index, total and high-density lipoprotein cholesterol level, blood pressure, and smoking status, as well as exclusion of women who took beta-blockers, did not affect these estimates. Associations were slightly stronger in women who had subclinical hypothyroidism and antibodies to thyroid peroxidase (odds ratio for aortic atherosclerosis, 1.9 [CI, 1.1 to 3.6]; odds ratio for myocardial infarction, 3.1 [CI, 1.5 to 6.3]). No association was found between thyroid autoimmunity itself and cardiovascular disease. The population attributable risk percentage for subclinical hypothyroidism associated with myocardial infarction was within the range of that for known major risk factors for cardiovascular disease. Subclinical hypothyroidism is a strong indicator of risk for atherosclerosis and myocardial infarction in elderly women.
Article
The prevalence of abnormal thyroid function in the United States and the significance of thyroid dysfunction remain controversial. Systemic effects of abnormal thyroid function have not been fully delineated, particularly in cases of mild thyroid failure. Also, the relationship between traditional hypothyroid symptoms and biochemical thyroid function is unclear. To determine the prevalence of abnormal thyroid function and the relationship between (1) abnormal thyroid function and lipid levels and (2) abnormal thyroid function and symptoms using modern and sensitive thyroid tests. Cross-sectional study. Participants in a statewide health fair in Colorado, 1995 (N = 25 862). Serum thyrotropin (thyroid-stimulating hormone [TSH]) and total thyroxine (T4) concentrations, serum lipid levels, and responses to a hypothyroid symptoms questionnaire. The prevalence of elevated TSH levels (normal range, 0.3-5.1 mIU/L) in this population was 9.5%, and the prevalence of decreased TSH levels was 2.2%. Forty percent of patients taking thyroid medications had abnormal TSH levels. Lipid levels increased in a graded fashion as thyroid function declined. Also, the mean total cholesterol and low-density lipoprotein cholesterol levels of subjects with TSH values between 5.1 and 10 mIU/L were significantly greater than the corresponding mean lipid levels in euthyroid subjects. Symptoms were reported more often in hypothyroid vs euthyroid individuals, but individual symptom sensitivities were low. The prevalence of abnormal biochemical thyroid function reported here is substantial and confirms previous reports in smaller populations. Among patients taking thyroid medication, only 60% were within the normal range of TSH. Modest elevations of TSH corresponded to changes in lipid levels that may affect cardiovascular health. Individual symptoms were not very sensitive, but patients who report multiple thyroid symptoms warrant serum thyroid testing. These results confirm that thyroid dysfunction is common, may often go undetected, and may be associated with adverse health outcomes that can be avoided by serum TSH measurement.
Article
A 51-year-old woman with daily attacks of migraine with visual aura is described. The aura always occurred on the right and the headache always on the left side of the head, suggesting a structural lesion in the left occipital lobe. The lesion appeared to be an arteriovenous malformation of which almost full obliteration resulted in a decrease in frequency of the aura and in intensity of the headache. Subsequent treatment of borderline hypothyroidism with levothyroxine brought about a dramatic improvement in frequency of both the aura and the headache. The case is discussed in the light of our present understanding of the pathogenesis of the migraine attack.
Article
Chronic daily headache (CDH) is one of the more frequently encountered headache syndromes at major tertiary care centers. The analysis of factors related to the transformation from episodic to chronic migraine (CM) and to the de novo development of new daily persistent headache (NDPH) remain poorly understood. To identify somatic factors and lifestyle factors associated with the development of CM and NDPH. We used a randomized case-control design to study the following groups: 1) CM with analgesic overuse (ARH), n = 399; 2) CM without analgesic overuse, n = 158; and 3) NDPH, n = 69. These groups were compared with two control groups: 1) episodic migraine, n = 100; and 2) chronic posttraumatic headache (CPTH); n = 65. Associated medical conditions were assessed. We investigated the case groups for any association with somatic or behavioral factors. Data were analyzed by the two-sided Fischer's exact test, with the odds ratio being calculated considering a 95% confidence interval using the approximation of Woolf. When the active groups were compared with the episodic migraine group, the following associations were found: 1) ARH: hypertension and daily consumption of caffeine; 2) CM: allergies, asthma, hypothyroidism, hypertension, and daily consumption of caffeine; and 3) NDPH: allergies, asthma, hypothyroidism, and consumption of alcohol more than three times per week. The following associations were found when comparing the active groups with CPTH: 1) ARH: asthma and hypertension; 2) CM: allergies, asthma, hypothyroidism, hypertension, and daily consumption of caffeine; and 3) NDPH: allergies, asthma, hypothyroidism, and consumption of alcohol more than three times per week. Several strong correlations were obtained between patients with specific types of CDH and certain somatic conditions or behaviors; some have not been previously described. Transformation of previously episodic headache or development of a NDPH thus may be related to certain medical conditions and behaviors beyond the frequently incriminated precipitant analgesic overuse. As similar results were obtained when CPTH was used as a control, the correlation is more complex than simple comorbidity.
Article
GR79236 is a highly potent and selective adenosine A1 receptor agonist that has analgesic and anti-inflammatory actions in humans and animals. In animal models it inhibits trigeminal nerve firing and calcitonin gene-related peptide release which play a pivotal role in migraine pathophysiology. Thus GR79236 may have therapeutic potential in migraine. Although there are no validated human models of migraine, the trigeminal nociceptive pathways may be studied with a novel electrode to elicit nociception-specific blink reflex responses. Twelve healthy female volunteers were randomized in a double-blind, placebo-controlled, cross-over trial to investigate the effect of GR79236 on trigeminal nociceptive pathways, as measured by the blink reflex. A secondary objective was to compare the use of two types of electrode, the standard (SE) and nociception-specific electrodes (NE), to investigate human trigeminal pharmacology. Blink reflexes were elicited with SE and NE before and 30 min after GR79236 (10 microg/kg i.v.) or placebo. The median area under the curve of repeated sweeps of the R2 component of the blink reflex was analysed using analysis of covariance with baseline as covariate. Using NE, GR79236 produced a non-significant reduction of the ipsilateral R2 compared with placebo (P = 0.097) and a significant reduction contralaterally (P = 0.008). No significant changes were observed using SE. There were no significant adverse events. The results suggest that NE is more sensitive than SE to detect pharmacological effects in the trigeminal nociceptive system. Furthermore, the adenosine A1 receptor agonist GR79236 inhibits trigeminal nociception in humans. These results support a possible therapeutic role for GR79236 in primary headache disorders.
Article
We assessed the psychological profile of a large sample of patients with chronic daily headache (CDH) seen in tertiary care. We used a case-control design to study 791 patients who fell into the following categories: ARH group, chronic migraine with analgesic overuse (analgesic rebound headache, ARH), n=399; CM group, chronic migraine (CM) without analgesic overuse, n=158; and new daily persistent headache (NDPH) group, n=69. These groups were compared to two control groups: 1, migraine, n=100; 2, chronic posttraumatic headache (CPTH), n=65. We assessed personality and psychopathology with the Minnesota multiphasic personality inventory (MMPI)-2. The number of patients with Tscores > or =65 and < or =40 were analyzed by the two-sided Fischer's exact test. The ARH and CM groups had a higher number of subjects with T-scores > or =65, when compared to the migraine group, on the following scales: 1 (hypochondrias), 2 (depression), 8 (schizophrenia) and 0 (social introversion). No differences were observed between the NDPH and migraine groups. Considering CPTH as the control group, the pattern we found was quite the opposite of that described above: NDPH group presented a higher number of subjects with T-scores > or =65 on the following scales: 1, 2, 7 (psychasthenia) and 8. ARH and CM groups had significantly higher T-scores for scale 7 alone. NDPH showed T-scores < or =40 in scale 9 when compared to both control groups. We conclude that: (1) psychopathological factors are common in CDH patients, and appear to be a consequence of the chronification process; (2) low scores on scale 9 (hypomania) may relate to the development of NDPH; (3) psychopathological profiles differ among the subgroups of CDH and the MMPI-2 is reliable in identifying such patterns; and (4) psychological assessment is an essential step in the evaluation and treatment of patients with CDH.
Article
Standard therapy for patients with primary hypothyroidism is replacement with synthetic thyroxine, which undergoes peripheral conversion to triiodothyronine, the active form of thyroid hormone. Within the lay population and in some medical communities, there is a perception that adding synthetic triiodothyronine, or liothyronine, to levothyroxine improves the symptoms of hypothyroidism despite insufficient evidence to support this practice. To evaluate the benefits of treating primary hypothyroidism with levothyroxine plus liothyronine combination therapy vs levothyroxine monotherapy. Randomized, double-blind, placebo-controlled trial conducted from May 2000 to February 2002 at a military treatment facility that serves active duty and retired military personnel and their family members. The trial included a total of 46 patients aged 24 to 65 years with at least a 6-month history of treatment with levothyroxine for primary hypothyroidism. Patients received either their usual dose of levothyroxine (n = 23) or combination therapy (n = 23), in which their usual levothyroxine dose was reduced by 50 micro g/d and substituted with liothyronine, 7.5 micro g, taken twice daily for 4 months. Scores on a hypothyroid-specific health-related quality-of-life (HRQL) questionnaire, body weight, serum lipid levels, and 13 neuropsychological tests measured before and after treatment. Serum thyrotropin levels remained similar and within the normal range in both treatment groups from baseline to 4 months. Body weight and serum lipid levels did not change. The HRQL questionnaire scores improved significantly in both the control group (23%; P<.001) and the combination therapy group (12%; P =.02), but these changes were statistically similar (P =.54). In 12 of 13 neuropsychological tests, outcomes between groups were not significantly different; the 1 remaining test (Grooved Peg Board) showed better performance in the control group. Compared with levothyroxine alone, treatment of primary hypothyroidism with combination levothyroxine plus liothyronine demonstrated no beneficial changes in body weight, serum lipid levels, hypothyroid symptoms as measured by a HRQL questionnaire, and standard measures of cognitive performance.
Article
To assess the influence of the body mass index (BMI) on the prevalence and severity of chronic daily headache (CDH) and its most frequent subtypes, transformed migraine (TM) and chronic tension-type headache (CTTH). The authors gathered information on headache, medical features, height, and weight using a computer-assisted telephone interview. Participants were divided into five categories, based on BMI: underweight (<18.5), normal weight (18.5 to 24.9), overweight (25 to 29.9), obese (30 to 34.9), and morbidly obese (>35). The prevalence and severity of CDH, TM, and CTTH were assessed. Multivariate analyses modeling these diagnoses as a function of BMI were conducted. Among 30,215 participants, the prevalence of CDH was 4.1%; 1.3% had TM and 2.8% CTTH. In contrast with the normal weight group (3.9%), the prevalence of CDH was higher in obese (5.0% [odds ratio (OR) = 1.3, 95% CI = 1.1-1.6]) and morbidly obese (6.8% [OR = 1.8, 95% CI = 1.4 to 2.2]). BMI had a strong influence on the prevalence of TM, which ranged from 0.9% of the normal weighted to 1.2% of the overweight (OR = 1.4 [1.1 to 1.8]), 1.6% of the obese (OR = 1.7 [1.2 to 2.43]), and 2.5% of the morbidly obese (OR = 2.2 [1.5 to 3.2]). The effects of the BMI on the prevalence of CTTH were just significant in the morbidly obese group. Adjusted analyses showed that obesity was associated with CDH and TM but not CTTH. Chronic daily headache and obesity are associated. Obesity is a stronger risk factor for transformed migraine than for chronic tension-type headache.
Bigal ME, Lipton RB: Obesity is a risk factor for trans-formed migraine but not for chronic tension-type headache
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Headache Attributed to Hypothyroidism Tepper et al. 309 20. Bigal ME, Lipton RB: Obesity is a risk factor for trans-formed migraine but not for chronic tension-type headache. Neurology 2006, 67:252–257.
Hypothyroidism. In Harrison's Principles of Internal Medicine, edn 13
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Jameson JL, Weetman AP: Hypothyroidism. In Harrison's Principles of Internal Medicine, edn 13. New York: McGraw-Hill; 2005:2108–2109.
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