Secondary Trigeminal Autonomic Cephalgia Associated with Multiple Sclerosis

Pain in multiple sclerosis: a systematic review of neuroimaging studies

Introduction

While pain in multiple sclerosis (MS) is common, in many cases the precise mechanisms are unclear. Neuroimaging studies could have a valuable role in investigating the aetiology of pain syndromes. The aim of this review was to synthesise and appraise the current literature on neuroimaging studies of pain syndromes in MS.

Methods

We systematically searched PubMed and Scopus from their inception dates to the 2nd of April 2013. Studies were selected by predefined inclusion and exclusion criteria. Methodological quality was appraised. Descriptive statistical analysis was conducted.

Results

We identified 38 studies of variable methodology and quality. All studies but one used conventional structural magnetic resonance imaging, and the majority reported a positive association between location of demyelinating lesions and specific neuropathic pain syndromes. Most investigated headache and facial pain, with more common pain syndromes such as limb pain being relatively understudied. We identified a number of methodological concerns, which along with variable study design and reporting limit our ability to synthesise data. Higher quality studies were however less likely to report positive associations of lesion distribution to pain syndromes.

Conclusions

Further high quality hypothesis-driven neuroimaging studies of pain syndromes in MS are required to clarify pain mechanisms, particularly for the commonest pain syndromes.

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We reviewed neuroimaging studies of pain syndromes in multiple sclerosis (MS).

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All studies investigated neuropathic pain or headache, mainly using structural MRI.

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Most reported associations between location of demyelinating lesions and pain.

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Culprit lesions were most commonly reported in the brainstem.

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High quality hypothesis-driven neuroimaging studies of pain in MS are still needed.

Multiple sclerosis: an update for oral health care providers

Multiple sclerosis (MS) is a chronic, inflammatory, demyelinating disease of the central nervous system. The disease mostly affects young adults and is increasing in prevalence and incidence. Multiple sclerosis is characterized by periods of activity and remission which, after numerous relapses, cause permanent neurologic deficits. Diagnosis of MS is based on patient history and clinical examination supplemented by the findings of radiologic and laboratory tests. Numerous motor and sensory disturbances occur in MS and may present in the orofacial region. This medical management update highlights issues that are important to the oral health care provider, including orofacial manifestations of MS and dental considerations for patients with MS.

Symptomatic trigeminal autonomic cephalalgia associated with allodynia in a patient with multiple sclerosis

A patient with symptomatic trigeminal autonomic cephalalgia (TAC) provides a chance to understand the pathophysiology and anatomic correlates of TAC. A 28-year-old woman experienced intermittent sharp and excruciating pain over her right temporal, ear and neck regions for 3 days. The headaches lasted 10-20 minutes each, occurred 1-2 times a day, and were accompanied by prominent ipsilateral lacrimation and conjunctival injection. The patient had hiccups, 4-limb numbness and impaired visual acuity in both eyes. She had also had 3 episodes of left-side optic neuritis in the past half year. Neurologic examination showed brushing allodynia over the right face and scalp during the headache attacks. The visual acuity of her right eye was 6/60 and that of the left eye was 1/60. Brain magnetic resonance imaging showed non-enhancing lesions on the right lateral tegmentum of the lower pons where the spinal trigeminal nucleus is located and the floor of the 4th ventricle. The patient was diagnosed as having multiple sclerosis with symptomatic TAC. Her headaches, autonomic signs and allodynia subsided 3 days after pulse therapy and gabapentin treatment were given. We suggest that the spinal trigeminal nucleus lesion was responsible for the symptomatology of TAC and cutaneous allodynia in our patient.

Symptomatic cluster-like headache triggered by forehead lipoma: a case report and review of the literature

We describe the case of a patient with symptomatic strictly unilateral paroxysmal headache mimicking cluster headache related to an ipsilateral forehead lipoma. Interestingly, immediately after the surgical excision of the lipoma pain attacks disappeared with no recurrence during a follow-up period of 18 months. Like other descriptions of cluster-like headaches secondary to extracranial lesions, this case report focuses on the hypothetical role of a peripheral trigger factor for trigeminal autonomic cephalgias (TACs). To our knowledge, this is the first well-described cluster-like headache case secondary to an extracerebral lipoma. This case offered the opportunity to discuss the possible pathophysiological mechanisms underlying probable TACs and the relationship with peripheral extracerebral activation of the trigeminal-autonomic reflex.

Visual disturbances and migraine

There is a close relationship between headache and the visual system. Visual symptoms are prominent features of clinical syndromes such as migraine, cluster headache, and the trigeminal autonomic cephalgias. There are also strong links between headache and the visual system on the basis of genetics, molecular biology, neurophysiology, and neuroimaging. Studies of these links are leading to the development of novel therapies for a variety of headache syndromes. This review is designed to summarize the most recent literature on headache and the visual system. A particular emphasis is placed on publications of interest to clinicians.