Letter to the Editor
Migraine triggered by laughing as a form of presentation of a Chiari Type I malformation
Cefalea desencadenada por la risa como forma de presentación de una malformación de CHIARI tipo I
P.E. Jiménez Caballero
, M.L. Calle Escobar, J.C. Portilla Cuenca, I. Casado Naranjo
Corresponding author
Sección de Neurología, Hospital San Pedro de Alcántara, Cáceres, Spain
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Jiménez Caballero, M.L. Calle Escobar, J.C. Portilla Cuenca, I. Casado Naranjo" "autores" => array:4 [ 0 => array:4 [ "nombre" => "P.E." "apellidos" => "Jiménez Caballero" "email" => array:1 [ 0 => "pjimenez1010j@yahoo.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "M.L." "apellidos" => "Calle Escobar" ] 2 => array:2 [ "nombre" => "J.C." "apellidos" => "Portilla Cuenca" ] 3 => array:2 [ "nombre" => "I." "apellidos" => "Casado Naranjo" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Sección de Neurología, Hospital San Pedro de Alcántara, Cáceres, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Cefalea desencadenada por la risa como forma de presentación de una malformación de CHIARI tipo I" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 986 "Ancho" => 950 "Tamanyo" => 86058 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Sagittal, fat-suppressed cervical MR image revealing ectopia of the cerebellar tonsils 16<span class="elsevierStyleHsp" style=""></span>mm below the foramen magnum, angled medulla, and decreased subarachnoid space at the craniocervical junction.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Chiari malformation type I (CM1) is defined as the extrusion of the cerebellar tonsils through the foramen magnum and into the spinal canal. It can be confirmed by a radiograph showing descent of brain tissue 5<span class="elsevierStyleHsp" style=""></span>mm or more, lending a pointed appearance to the cerebellar tonsils and decreasing the subarachnoid space at the craniocervical junction.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The clinical manifestations of CM-I are associated with direct compression of the brainstem and cervical spinal cord, or with changes in cerebrospinal fluid.</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 38-year-old man with no relevant medical history described headaches occurring throughout the preceding year. Pain was dull and moderately intense (VAS score 6) and located in the occipital region radiating to the frontal region. Headache was triggered by laughing, but not by Valsalva manoeuvres or physical exercise. Episodes lasted 10 to 30<span class="elsevierStyleHsp" style=""></span>minutes and were not accompanied by focal neurological signs. In the preceding month, pain had grown more intense (VAS 8) and was triggered not only by laughing, but also by minimal exertion and Valsalva manoeuvres such as coughing or defecating. Lateral and rotational movements of the head also caused headache episodes. The general examination was normal; a neurological examination revealed left-beating horizontal nystagmus with no other relevant findings.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Brain and cervical MRI (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) showed that cerebellar tonsils had descended 16<span class="elsevierStyleHsp" style=""></span>mm below the foramen magnum, forming a point. The medulla had taken on an angled shape and the subarachnoid space at the craniocervical junction was reduced. Signs were consistent with a diagnosis of type I Chiari malformation.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The patient was initially treated with 600<span class="elsevierStyleHsp" style=""></span>mg ibuprofen every 8<span class="elsevierStyleHsp" style=""></span>hours but did not respond. Treatment was changed to 25<span class="elsevierStyleHsp" style=""></span>mg indometacin every 8<span class="elsevierStyleHsp" style=""></span>hours, still with no response. As the patient's headaches were incapacitating, he underwent decompressive occipital surgery associated with C1 laminectomy. The headaches, vertigo, and nystagmus all resolved and have not returned in 2 years of follow-up.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Our patient's pain met criteria for headaches caused by type 1 Chiari malformation according to the second edition of the International Headache Classification (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> There have been cases in which headaches triggered by laughing,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> one of which was prolonged, signalled the presence of CM1.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> In another published case of a patient with CM1 and IV-ventricle ependymoma without hydrocephalus, headaches triggered by laughing resolved once the tumour had been removed.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Although the phenomenon of headache caused by laughing is exceptional, and would rarely appear as the first manifestation of CM1, this did occur in our patient.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Laughter constitutes a Valsalva manoeuvre, and, like coughing, it raises intracranial pressure. Coughing and other activities involving Valsalva manoeuvres may cause primary cough headache. They may also trigger a headache in the context of CM1.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7</span></a> The difference between the headaches is that primary cough headache has an older age at onset (>60 years) and a shorter duration (seconds rather than minutes).<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> This trend can be seen in our patient; since he is a young adult with headaches lasting several minutes, symptoms are consistent with CM1. The pathophysiology of headache secondary to CM1 is uncertain. The postulated mechanism is a temporary increase in the pressure difference between the intracranial and intramedullary compartments. This would further force the cerebellar tonsils against the foramen magnum, causing pain due to traction on pain-sensitive structures.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> In some case series, the resolution rate for headaches after surgery reaches 88%.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Headache triggered by laughing may be primary, but it may also indicate diseases of the posterior fossa. Age at onset, pain duration, and the presence of neurological signs and symptoms may point to a structural cause.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Headache secondary to CM1 is often described as being similar to primary cough headache except that it may last longer (minutes instead of seconds). One theory holds that primary cough headache responds better than secondary headache to indometacin. However, distinguishing between primary and secondary headaches may be difficult. A brain MRI is not only useful, but absolutely necessary in cases of headache provoked by the Valsalva manoeuvre. Headache is the most frequent symptom of CM1, but patients may have localised vestibulo-ocular disorders (in 74% of cases); cranial nerve, brainstem, or cerebellar disorders (in 50%); and/or cervical spinal cord disorders indicating syringomyelia (in 66%). These symptoms are the most indicative of a secondary headache.</p><p id="par0040" class="elsevierStylePara elsevierViewall">In addition to being associated with better surgical results, early diagnosis and early treatment can prevent development of more critical cerebellar, brainstem, or cervical symptoms.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Jiménez Caballero PE, Calle Escobar ML, Portilla Cuenca JC, Casado Naranjo I. Cefalea desencadenada por la risa como forma de presentación de una malformación de CHIARI tipo I. Neurología. 2013;28:446–447.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 986 "Ancho" => 950 "Tamanyo" => 86058 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Sagittal, fat-suppressed cervical MR image revealing ectopia of the cerebellar tonsils 16<span class="elsevierStyleHsp" style=""></span>mm below the foramen magnum, angled medulla, and decreased subarachnoid space at the craniocervical junction.</p>" ] ] 1 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">A. Headache fulfilling at least 1 of the following conditions as well as condition D:</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">1. Triggered by cough and/or Valsalva manoeuvres</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">2. Prolonged occipital and/or suboccipital headache (lasting hours to days)</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">3. Associated with signs or symptoms of cerebellar, brainstem, or cervical spinal cord dysfunction</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">B. Herniation of cerebellar tonsils meeting one of the following criteria as shown by craniocervical MRI:</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">1. Caudal extrusion of the cerebellar tonsils measuring 5</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">mm or more</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">2. Caudal extrusion of the cerebellar tonsils measuring 3</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">mm or more, plus at least 1 of the following indicators of overcrowding of the subarachnoid space at the craniocervical junction:</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>(a) Posterior and lateral compression of cerebrospinal fluid spaces \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>(b) Reduced height of the supraocciput \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>(c) Increased tentorial angle \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleHsp" style=""></span>(d) Distortion of the medulla \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">C. Evidence of dysfunction among posterior fossa structures, based on at least 2 of the following criteria:</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">1. Otoneurological signs and/or symptoms (for example, dizziness, poor balance, perceived changes in ear pressure, hearing loss or hyperacusis, vertigo, vertical nystagmus, or oscillopsia)</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">2. Transient visual symptoms (scintillating photopsia, blurry vision, diplopia, or transient visual field defect)</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">3. Discovery of clinical symptoms originating in the spinal cord, brainstem, or nerves in the base of the skull; ataxia or dysmetria</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">D. Headache resolves within 3 months of successful treatment of the Chiari malformation</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab420279.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Diagnostic criteria for headaches caused by type I Chiari malformation.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Chiari I malformation redefined: clinical and radiographic finding for 364 patients" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "T.H. Milhorat" 1 => "M.W. Chou" 2 => "E.M. Trinidad" 3 => "R.W. Kula" 4 => "M. Mandell" 5 => "C. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 352 | 6 | 358 |
| 2024 September | 961 | 18 | 979 |
| 2024 August | 844 | 16 | 860 |
| 2024 July | 825 | 10 | 835 |
| 2024 June | 645 | 6 | 651 |
| 2024 May | 769 | 10 | 779 |
| 2024 April | 694 | 8 | 702 |
| 2024 March | 729 | 6 | 735 |
| 2024 February | 922 | 7 | 929 |
| 2024 January | 1291 | 6 | 1297 |
| 2023 December | 1038 | 11 | 1049 |
| 2023 November | 881 | 25 | 906 |
| 2023 October | 884 | 25 | 909 |
| 2023 September | 688 | 8 | 696 |
| 2023 August | 653 | 10 | 663 |
| 2023 July | 672 | 10 | 682 |
| 2023 June | 804 | 5 | 809 |
| 2023 May | 878 | 17 | 895 |
| 2023 April | 831 | 4 | 835 |
| 2023 March | 665 | 5 | 670 |
| 2023 February | 678 | 7 | 685 |
| 2023 January | 620 | 8 | 628 |
| 2022 December | 570 | 10 | 580 |
| 2022 November | 807 | 16 | 823 |
| 2022 October | 751 | 14 | 765 |
| 2022 September | 733 | 13 | 746 |
| 2022 August | 762 | 12 | 774 |
| 2022 July | 619 | 10 | 629 |
| 2022 June | 537 | 28 | 565 |
| 2022 May | 453 | 8 | 461 |
| 2022 April | 468 | 8 | 476 |
| 2022 March | 554 | 9 | 563 |
| 2022 February | 522 | 7 | 529 |
| 2022 January | 482 | 8 | 490 |
| 2021 December | 393 | 12 | 405 |
| 2021 November | 349 | 13 | 362 |
| 2021 October | 415 | 12 | 427 |
| 2021 September | 276 | 12 | 288 |
| 2021 August | 275 | 11 | 286 |
| 2021 July | 319 | 10 | 329 |
| 2021 June | 367 | 18 | 385 |
| 2021 May | 429 | 11 | 440 |
| 2021 April | 941 | 20 | 961 |
| 2021 March | 538 | 11 | 549 |
| 2021 February | 410 | 14 | 424 |
| 2021 January | 482 | 13 | 495 |
| 2020 December | 549 | 12 | 561 |
| 2020 November | 494 | 13 | 507 |
| 2020 October | 331 | 9 | 340 |
| 2020 September | 496 | 8 | 504 |
| 2020 August | 438 | 11 | 449 |
| 2020 July | 383 | 10 | 393 |
| 2020 June | 407 | 3 | 410 |
| 2020 May | 473 | 10 | 483 |
| 2020 April | 460 | 7 | 467 |
| 2020 March | 462 | 9 | 471 |
| 2020 February | 470 | 6 | 476 |
| 2020 January | 403 | 10 | 413 |
| 2019 December | 375 | 9 | 384 |
| 2019 November | 199 | 8 | 207 |
| 2019 October | 148 | 7 | 155 |
| 2019 September | 100 | 13 | 113 |
| 2019 August | 78 | 5 | 83 |
| 2019 July | 90 | 31 | 121 |
| 2019 June | 68 | 20 | 88 |
| 2019 May | 122 | 12 | 134 |
| 2019 April | 78 | 49 | 127 |
| 2019 March | 21 | 21 | 42 |
| 2019 February | 31 | 24 | 55 |
| 2019 January | 20 | 34 | 54 |
| 2018 December | 8 | 23 | 31 |
| 2018 November | 13 | 32 | 45 |
| 2018 October | 15 | 6 | 21 |
| 2018 September | 8 | 16 | 24 |
| 2018 August | 17 | 47 | 64 |
| 2018 July | 3 | 28 | 31 |
| 2018 June | 4 | 21 | 25 |
| 2018 May | 10 | 25 | 35 |
| 2018 April | 10 | 27 | 37 |
| 2018 March | 3 | 13 | 16 |
| 2018 February | 1 | 18 | 19 |
| 2018 January | 7 | 12 | 19 |
| 2017 December | 8 | 8 | 16 |
| 2017 November | 14 | 9 | 23 |
| 2017 October | 9 | 26 | 35 |
| 2017 September | 14 | 24 | 38 |
| 2017 August | 12 | 14 | 26 |
| 2017 July | 19 | 9 | 28 |
| 2017 June | 21 | 27 | 48 |
| 2017 May | 13 | 20 | 33 |
| 2017 April | 9 | 51 | 60 |
| 2017 March | 15 | 27 | 42 |
| 2017 February | 1 | 20 | 21 |
| 2017 January | 7 | 10 | 17 |
| 2016 December | 3 | 8 | 11 |
| 2016 November | 14 | 23 | 37 |
| 2016 October | 19 | 18 | 37 |
| 2016 September | 9 | 15 | 24 |
| 2016 August | 17 | 9 | 26 |
| 2016 July | 10 | 9 | 19 |
| 2016 June | 18 | 16 | 34 |
| 2016 May | 15 | 16 | 31 |
| 2016 April | 8 | 18 | 26 |
| 2016 March | 22 | 27 | 49 |
| 2016 February | 19 | 22 | 41 |
| 2016 January | 8 | 22 | 30 |
| 2015 December | 11 | 15 | 26 |
| 2015 November | 12 | 23 | 35 |
| 2015 October | 26 | 15 | 41 |
| 2015 September | 24 | 11 | 35 |
| 2015 August | 17 | 13 | 30 |
| 2015 July | 10 | 4 | 14 |
| 2015 June | 10 | 7 | 17 |
| 2015 May | 13 | 3 | 16 |
| 2015 April | 14 | 7 | 21 |
| 2015 March | 17 | 6 | 23 |
| 2015 February | 18 | 2 | 20 |
| 2015 January | 23 | 8 | 31 |
| 2014 December | 38 | 10 | 48 |
| 2014 November | 19 | 5 | 24 |
| 2014 October | 18 | 4 | 22 |
| 2014 September | 47 | 4 | 51 |
| 2014 August | 34 | 4 | 38 |
| 2014 July | 35 | 8 | 43 |
| 2014 June | 21 | 2 | 23 |
| 2014 May | 20 | 1 | 21 |
| 2014 April | 16 | 2 | 18 |
| 2014 March | 20 | 3 | 23 |
| 2014 February | 17 | 4 | 21 |
| 2014 January | 14 | 1 | 15 |
| 2013 December | 25 | 4 | 29 |
| 2013 November | 32 | 8 | 40 |
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