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acute headache attacks were reported in 30% of 43 patients with resistant chronic migraine treated with zolmitriptan [ 17 ]. the headaches were described as dull, severe and non-throbbing. the headaches lasted between 1 and 36 h, and only one patient experienced nausea [ 17 ]. attack frequency was reduced from 13.4/month to 5.7/month [ 17 ]. attacks were always associated with a triptan. in a case series of nine patients with resistant chronic migraine, triptans were used before the onset of the headache and within 24 h of its onset. all attacks were reported as a severe headache and all patients were treated with a triptan [ 18 ]. in this case series, patients were in a usual day-to-day life. the case series was not blinded and was not a placebo-controlled trial [ 18 ].
on the basis of the current understanding, ah is a separate headache; and, we feel that the international headache society (ihs) should consider ah as a separate entity in the classification of headache disorders. this paper is the first systematic review that focuses on ah-attacks and the first one that connects ah to the concept of autonomic dysregulation. the importance of this paper is that it provides new insight into the significance of ah as a headache disorder and to understand the underlying pathophysiological mechanisms that contribute to ah-attacks. this would allow for future studies, as well as for the development of new drugs and therapeutic strategies. these steps are essential for the understanding and treatment of ah, which would benefit millions of travelers, who suffer from this condition.
the onset of migraine attacks is not always sudden. a study by thomsen et al. [ 56 ] showed that most migraine attacks have a gradual onset with an initial mild tension headache followed by a pulsating headache and finally a migraine attack. the same is true for ah. an initial headache that is followed by a pulsating headache is very typical for ah [ 25 ]. this also explains the fact that many ah-patients also have migraine and vice versa. the time from onset of the initial headache to the pulsating headache was around two to three hours. the fact that this patient experienced a sudden ah-attack is most likely due to use of triptans. it is possible that the use of triptans caused vasoconstriction leading to development of ah. it is also possible that the use of triptans caused vasodilation of the cerebral arteries, which then led to development of ah. in this case, this would be the first known case of ah that is induced by vasodilation in the cerebral arteries. it is interesting that triptans can have both vasoconstrictive and vasodilatory effects on the cerebral arteries [ 57 ]. the correct diagnosis of ah is based on the recognition of the symptoms and the exclusion of other conditions. the diagnosis of ah should be suspected when patients experience attacks of ah while on a vacation, if the attacks are not related to syncope, or if the attacks are related to migraine. attacks of ah should be differentiated from migrainous aura. for the diagnosis of migraine, a detailed history, a clinical examination, neuroimaging and the exclusion of other diseases must be carried out [ 6, 7 ]. ah should be suspected in children with complex partial seizures, tics or tourette syndrome. in older adolescents and adults, the presence of migraine may be raised because the two conditions are frequently comorbid. the diagnosis of migraine should be considered when a patient has a history of migraine with or without aura and has auras similar to those of ah [ 8 ]. ah is a diagnostic challenge, especially in patients with complex partial seizures, tics, tourette syndrome, or migraine because of the similarities between these conditions. ah should be considered in patients with paroxysmal dyskinesias, hyperkinetic movement disorders, migraine aura or migraine with aura, or migraine with complex aura or migraine with hemiplegia [ 9 ]. in children and young adolescents, the diagnosis of migraine should be considered when patients have migraine with or without aura and have attacks that start in childhood and include one or more of the following: abdominal pain, nausea, vomiting, photophobia, phonophobia or osmophobia [ 10 ]. the correct diagnosis of ah is a challenge because of the similarity of the symptoms of ah and migraine, and the patients may experience both types of attack while they are on vacation. the diagnosis of ah is usually made after exclusion of other conditions, and especially when patients present attacks of ah while on a vacation. patients may have ah on at least one occasion or may experience attacks during a vacation. we have not found any study that has tried to classify ah patients into separate groups based on whether they have ah on only one or several occasions while on vacation or whether they have ah while on vacation. further studies are needed to determine whether they have ah or not. ah is a diagnosis of exclusion. attacks of ah are generally classified into two categories: those that are not related to syncope, and those that are. attacks of ah that occur while on vacation are usually classified as those that are not related to syncope. 5ec8ef588b
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