Abstract
The first patient suffering from ‘airplane headache’ was described in 2004 (1). Recently, Mainardi et al. proposed provisional diagnostic criteria (2). Airplane headache is defined as a primary headache with at least two attacks of pain during airplane travel lasting <20 min, with at least two of the following characteristics: (i) severe intensity, (ii) jabbing or stabbing quality (pulsatility may occur), (iii) strictly unilateral and (iv) periorbital location (forehead involvement may occur); no accompanying symptoms should be present (although nasal congestion, stuffy feeling of face or tearing may occur omolaterally). We describe an unusual case of airplane headache preceded by sensory aura symptoms.
Case report
A 20-year-old woman came to our observation in October 2008. Her family history proved negative for headaches. Her past medical history was unremarkable and nothing particular was referred that could be related to migraine or sinusitis. She had had her first attack 1 year before and the attacks had recurred three times since then. All attacks showed the same characteristics. After the plane took off, while it was gaining altitude, a very severe pulsating pain suddenly started in the right retro-orbital and frontal regions. She described this as the most severe pain she had ever experienced (10/10 on a verbal numeric scale). The pain was not associated with phono- or photophobia, nausea or vomiting. During the attack the patient preferred to stay still, holding her right eye with one hand. No neuroautonomical features such as tearing, rhinorrhoea or ocular manifestations were referred. The headache remained severe for 10 min, then spontaneously diminished and resolved in about 20 min. Every attack was preceded by a typical sensory aura. She described paraesthesias starting from the left thumb and gradually spreading to the whole hand and to the perioral region with a cheiro-oral distribution. These symptoms lasted 5–10 min and the headache started immediately after they had disappeared. The patient, who had travelled by plane four times (from Pisa to Catania and from Catania to Pisa), suffered from this headache during all flights; she did not take any drugs because the episodes were very short. Apart from the episodes described above, she had never had headaches of any sort. She performed routine blood examination, which proved normal. Ear, nose and throat evaluation showed no evidence of sinus pathology. Neurological examination and EEG evaluation were normal. Computed tomography of the sinuses and brain magnetic resonance imaging with gadolinium did not reveal any abnormalities, both excluding structural lesions and sinus pathology; magnetic resonance angiography of the intracerebral vessels was also performed and proved normal.
Discussion
Since the first case suffering from ‘airplane headache’ was published in 2004 (1), 14 more cases have been reported (2–7); all these patients share a very similar clinical picture, as observed by Mainardi et al. (2). The case we reported, although fulfilling the diagnostic criteria for an airplane headache, was unusual because it presented an aura. To our knowledge, this is the first case of an airplane headache presenting an aura with cheiro-oral distributed sensory disturbances.
The aetiology and pathophysiology of airplane headache have not yet been completely clarified, but it seems that a change in environmental pressure during take-off and landing of the plane might lead to a barotrauma. This could produce changes in ethmoidal sinuses, stimulation of the anterior ethmoid artery nociceptors and subsequent activation of the trigeminovascular system (3). This hypothesis probably explains the close temporal relationship between the rapid change of cabin pressure in the airplane and the onset of headache, but the relationship to aura is less clear.
Auras can be considered as an independent phenomenon that can accompany any form of primary headache disorder. Auras are not an exclusive migraine-dependent phenomenon, as suggested by several cases of aura occurring with other headaches, such as cluster headache, hemicrania continua, and chronic paroxysmal hemicrania (8); moreover, the onset of aura symptoms without headache or followed by tension-type headache is frequent in clinical practice. The pathophysiology of aura seems to be intrinsic to the cerebral cortex; one possible scenario begins with brain-initiated events that evolve into cortical spreading depression (CSD); this can subsequently activate the trigeminal nerve to cause pain (9). Although electrophysiological studies have shown how the migraineur's brain becomes increasing sensitive to the precipitants of headache attacks and although known triggers have been reported in 64.9% of patients suffering from migraine with aura (10), the way CSD can be triggered in the human cortex during the attack is not yet clear (9).
In our case, we hypothesize that external stimuli due to changes in pressure variations during the airplane travel might be responsible for CSD activation, which could produce the aura features and subsequently activate the trigeminovascular reflex responsible for the pain. Our case report suggests that airplane headache may be associated with aura, and that aura symptoms could be triggered by changes in pressure variation.