Association between Chronic Paroxysmal Hemicrania and Primary Trochlear Headache: Pathophysiology and Treatment

Primary trochlear headache. A periorbital pain with a specific diagnosis and treatment

Primary trochlear headache is a little-known cause of periorbital headache described in adults. It can involve very disabling pain. In addition, it can be associated with other types of headaches, making them even more difficult to identify. To diagnose this pathology, it is necessary that the examination of the trochlea be incorporated into the usual clinical practice of the patient with headache, which will allow the establishment of an adequate treatment. The case is presented of an adolescent patient with a diagnosis of migraine, who was admitted with a disabling headache secondary to a primary trochlear headache.

Diagnosis and Management of Trochleodynia, Trochleitis, and Trochlear Headache

Migraine and tension-type headaches (TTHs) comprise a significant burden of neurological disease globally. Trochleodynia, also known as primary trochlear headache or trochleitis, may go unrecognized and contribute to worsening of these headache disorders. It may also present in isolation. We review the English literature on this under-recognized condition and describe what is known about the theorized pathophysiology, clinical presentation, and differential diagnosis. We also present a management algorithm for patients presenting with trochleodynia.

Unilateral recurrent periorbital pain: the role of the neuro-ophthalmologist

Unilateral recurrent periorbital pain is an aspecific symptom that may have originated from different orbital and ocular regions and structures that share the same innervation and can be provoked by different pathological disease. Since in some cases the patient is unable to associate with certainty the pain to a specific structure or region, a neuro-ophthalmological evaluation may be addressed to highlight signs useful to suspect the involvement of the eye, the optic nerve, the extra-ocular muscles, or intraorbital tissue or the cavernous sinus. This review describes the clinical patterns of periocular pain related to common ocular disease, orbital, or intracranial diseases.

Headaches attributed to visual disturbances

Ocular pain due to ophthalmological diseases is most commonly associated with redness and inflammation of the ocular surface and surrounding tissues. Pain in a quiet eye can be referred as headache and can be the first sign of a number of ocular or orbital conditions. Painful symptoms may be considered non-specific if signs of targeted diseases are not identified. Collection of appropriate history of pain around the eye and associated symptoms or signs should be considered to recognize when ophthalmological examination is needed. Some painful diseases such as intermittent angle closure glaucoma, uveitis or optic neuritis, can lead to severe and permanent visual loss and require a prompt diagnosis and treatment.

Peripheral nerve blocks: a therapeutic alternative for hemicrania continua

Objectives: A complete response to indomethacin is required for the diagnosis of hemicrania continua (HC). Nevertheless, patients may develop side effects leading to withdrawal of this drug. Several alternatives have been proposed with no consistent effectiveness. Both anaesthetic blocks of peripheral nerves and trochlear corticosteroid injections have been effective in some case reports.

Methods: Twenty-two patients with HC were assessed in a headache outpatient office. Physical examination included palpation of the supraorbital nerve (SON) and greater occipital nerve (GON) as well as of the trochlear area.

Results: In 14 patients, at least one tender point was detected. Due to indomethacin intolerance, at least one anaesthetic block of the GON or SON, or an injection of corticosteroids in the trochlear area, were performed in nine patients. Four of them were treated with a combination procedure. All these patients experienced total or partial improvement lasting from 2 to 10 months.

Conclusion: Anaesthetic blocks or corticosteroid injections may be effective in HC patients showing tenderness of the SON, GON or trochlear area.