Hemicrania Continua

Herpes Zoster Ophthalmicus Initially Diagnosed As Cluster Headache, Complicated by Delayed Eruption

Herpes zoster ophthalmicus (HZO) manifests as a consequence of the reactivation of the Varicella-zoster virus (VZV) and primarily affects the ophthalmic division of the trigeminal nerve. Identification of the vesicular eruption is central to the diagnostic process; however, the delayed manifestation of this cutaneous phenomenon poses a challenge to timely and accurate diagnosis. This report elucidates the case of a 61-year-old Japanese male with painful trigeminal neuropathy attributed to VZV that was initially diagnosed as cluster headache, mainly due to the delayed cutaneous eruption. Contrary to the expected pattern of cluster headache presentations, there was no discernible fluctuation in headache severity. The transient improvement of symptoms following interventions tailored for cluster headache management, including pure oxygen inhalation and subcutaneous sumatriptan injection, inadvertently contributed to a delay in accurate diagnosis. The importance of distinguishing HZO from cluster headache is emphasized, particularly in cases involving elderly patients or those with persistent cephalo-ophthalmalgia without the characteristic fluctuation of symptoms. In cases where clinical suspicion of HZO is raised, cerebrospinal fluid analysis should be performed. This approach is consistent with the overall goal of facilitating a prompt and accurate diagnosis.

A retrospective observation on 105 patients with chronic cluster headache receiving indomethacin

BACKGROUND

Indomethacin (IMC) as a prophylactic treatment is considered to be ineffective in cluster headache (CH). However, small series suggested the interest of IMC in CH. Some authors support that an IMC test is useful in all trigeminal autonomic cephalalgias. We described clinical features of IMC responders in a retrospective cohort of chronic cluster headache (CCH).

METHODS

This single-center and retrospective study was conducted in a tertiary care specialist headache center in France. Patients were selected between January 2007 and December 2008. We included all patients fulfilling CCH criteria (ICHD-3-beta). Data were collected from medical records. We recorded all the prescriptions of IMC as a prophylactic treatment. Responders were defined by 50% reduction in attack frequency; complete response was defined by disappearance of the attacks. The non-responders must have received at least 100 mg daily during 7 days.

RESULTS

The study consisted of 324 CCH, 121 female (37%) and 203 males (63%) with an average age at onset of 33.93 (± 14.71) years. Of the patients, 105 were treated with IMC. Thirty patients (29%) were responders. Thirty-four patients (32%) were non-responders. Responding status was undefined for 41 patients (39%). Twelve patients (11%) had a complete response. Responders were composed by 18 women (60%) and 12 men (40%) and had on average 44.89 (± 12.88) years. The minimal effective dose was 86.11 mg daily (± 48.72).

DISCUSSION

This study shows the interest of IMC in CCH patients. We recommend an IMC test as a third-line treatment in CCH.

Hemicrania Continua and Pituitary Microadenoma - Post Hoc Ergo Propter Hoc?: A Case Report With a Side Note on Intra-Sellar Pressure and the Trigemino-Autonomic Reflex

We describe the case of a 38-year-old woman whose headache phenotype transformed from episodic migraine to hemicrania continua (HC) responsive to indomethacin, as expected per diagnostic criteria. Our patient also had a non-functioning pituitary micro-adenoma which is over-represented in the trigeminal autonomic cephalgias (TAC) such as HC, pituitary adenoma being the most common intra-cranial pathology. We explore our case further by outlining in detail the neural supply of the dura of the pituitary fossa, outline the dynamics of intra-sellar pressure (ISP), and posit potential mechanisms of generation of HC in patients with pituitary micro-adenoma. We stress and further explore the remarkable observation that indomethacin, which lowers intracranial pressure, exquisitely resolves the pain of HC. Furthermore, we hypothesize that despite normal ISP, the slight elevation of ISP and mass effect impairs portal venous circulation, which may lead to venous hypertension and/or parasympathetic hyperactivity, which explains the pain and autonomic features of HC.