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We read with great interest the excellent review of trigeminal autonomic cephalgias (TAC) due to structural lesions reported by Favier et al.1 A main concern in the management of patients with TAC is when to perform neuroimaging studies because secondary causes may appear in 3% to 5% of cases.2 If a patient presents with typical TAC at a normal examination and the response to treatment is favorable, further diagnostic studies are probably not warranted. However, the clinician should be alert to atypical signs and symptoms, which should lead to appropriate testing.3
Favier et al recommend neuroimaging in all patients with typical TAC. This may be a questionable approach and perhaps not cost-effective in typical cases that show a good response to therapy. The 4 cases added by these authors were atypical with increasing headache and new neurological signs and symptoms, and further diagnostic testing was clearly indicated.
Another question raised, given the relatively high proportion of pituitary tumors (specifically prolactinomas) in patients with TAC and structural lesions, is whether it is practical to obtain serum prolactin levels or perform pituitary-hormone panel screening in patients with these headaches types.
The authors omit a report4 of TAC provoked by physical maneuvers and secondary to a cervical syringomyelia. After surgical therapy, the cluster headache disappeared. It was suggested that a mechanical irritation of the caudal portion of the spinal trigeminal tract-nucleus precipitated the clusterlike attacks, which is in line with the implication of this structure in the pathogenesis of cluster headache.3 Neuroimaging of the brain may not be sufficient in the complete workup of TAC.
Unfortunately, the authors did not review the non-English literature, which reports cases of atypical TAC.5 Perhaps including more cases would lead to firm clinical predictors that may guide clinicians in performing diagnostic tests in selected patients.
Correspondence: Dr Seijo-Martinez, Neurology Service, Hospital do Salnes, Ande Rubians, Villagarcia de Arosa 36619, Spain (mseijom@meditex.es).
Financial Disclosure: None reported.
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal
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The Rational Clinical Examination Among Patients With Headaches, Who Should Have Neuroimaging?
The Rational Clinical Examination Assessing the Likelihood of a Significant Neuroimaging Intracranial Abnormality
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