Álvaro Gutiérrez-Viedma

Greater occipital nerve block for the acute treatment of prolonged or persistent migraine aura

Background Presently, there is no evidence to guide the acute treatment of migraine aura. We aimed to describe the effect of greater occipital nerve (GON) anaesthetic block as a symptomatic treatment for long-lasting (prolonged or persistent) migraine aura. Methods Patients who presented with migraine aura lasting > 2 hours were consecutively recruited during one year at the Headache Unit and the Emergency Department of a tertiary hospital. All patients underwent a bilateral GON block with bupivacaine 0.5%. Patients were followed up for 24 hours. Results A total of 22 auras were treated in 18 patients. Auras consisted of visual (n = 13), visual and sensory (n = 4) or sensory symptoms alone (n = 5). Eleven episodes met diagnostic criteria for persistent aura (>1 week) without infarction. The response was complete without early recurrence in 11 cases (50%), complete with recurrence in < 24 hours in two cases (9.1%), and partial with ≥ 50% improvement in six cases (27.3%). Complete responses without recurrence were more common in cases with prolonged auras lasting < 1 week than in those with persistent auras (72.7% vs. 27.3%; p = 0.033). Conclusions GON block could be an effective symptomatic treatment for prolonged or persistent migraine aura. Randomised controlled trials are still required to confirm these results.

Lacrimal Nerve Blocks for Three New Cases of Lacrimal Neuralgia

Our aim was to report three new cases of lacrimal neuralgia and their response to superficial nerve blocks.

Infratrochlear neuralgia: A prospective series of seven patients treated with infratrochlear nerve blocks

Background Infratrochlear neuralgia is a recently described painful cranial neuropathy that causes pain in the internal angle of the orbit and the medial upper eyelid, the upper bridge of the nose and/or the lacrimal caruncle. We aim to present seven new cases of infratrochlear neuralgia treated with anaesthetic nerve blocks. Methods Over an 18-month period, we prospectively identified seven cases of infratrochlear neuralgia among the patients attending the Headache Unit in a tertiary hospital. Anaesthetic blocks were performed by injecting 0.5 cc of bupivacaine 0.5% at the emergence of the nerve above the internal canthus. Results All patients were women, and the mean age was 49.1 years (standard deviation, 17.9). The pain appeared at the internal angle of the orbit and/or the medial upper eyelid in six cases, and the whole territory of the infratrochlear nerve in one case. Six patients had continuous pain and one had episodes lasting 8–24 hours. All patients showed sensory disturbances within the painful area and tenderness upon palpation of the infratrochlear nerve. Nerve blocks resulted in complete and long-lasting relief in four patients and short-lasting relief in the other three patients. Conclusions Infratrochlear neuralgia should be considered among the neuralgic causes of orbital and periorbital pain. Anaesthetic blocks may assist clinicians in the diagnosis and may also be an effective therapy.

Pain Paroxysms With Coronal Radiation: Case Series and Proposal of a New Variant of Epicrania Fugax.

We aim to report 4 patients with brief pain paroxysms whose clinical features remind of typical epicrania fugax (EF), except for the direction along a transverse trajectory.

Case report: Epicranial pain after radiotherapy for skull base meningioma – the first symptomatic epicrania fugax?

Background To date, no symptomatic forms of epicrania fugax (EF) have been reported. Here, we describe the first EF-type pain to be probably caused by an underlying disorder. Case report A 77-year-old woman started suffering from left V1–V2 trigeminal neuralgia at 72 years of age. Neurologic examination was normal. Magnetic resonance imaging (MRI) showed a left middle sphenoid wing meningioma compressing the left trigeminal nerve medially. After trying several neuromodulators, she received stereotactic radiotherapy. One month later, the episodes of facial pain were significantly diminished, but she started feeling brief electric paroxysms across her left hemicranium that were clinically identical to those of backwards EF. Serial MRI showed persistence of the meningioma without changes. Conclusion Although the pathogenesis of EF remains uncertain, this case is consistent with a symptomatic origin in the trigeminal root/pathway. The onset of the EF-like pain could have been caused by the compressive effect of the tumour or, most likely, by the radiation.

Supratrochlear Neuralgia: A Prospective Case Series of 15 Patients

The aim of this study was to describe clinical features unique to supratrochlear neuralgia.

Facial epicrania fugax: A prospective series of eight new cases.

Introduction Epicrania fugax (EF) is a primary headache whose main feature is the dynamic character of the pain. EF pain typically moves across different dermatomes in a linear or zigzag trajectory. Recently, a facial variant of EF has been described, with the pain starting in the lower face and radiating upwards. Aim We report eight patients with an EF-type of pain of facial location and either upward or downward radiation. Methods For each patient, we recorded relevant demographic and clinical data. Magnetic resonance imaging (MRI) with fast imaging employing steady state acquisition (FIESTA) was obtained in all cases for the assessment of neurovascular compression of the trigeminal nerve. Results There were seven women and one man, and the mean age was 76.1 years (standard deviation, 11.3). Six patients had a paroxysmal pain starting at the lower face and moving upwards, while two patients had downward radiation. The pain always followed a fixed linear trajectory across different dermatomes. All cases had triggers, and pain intensity was consistently severe. Half of the patients had accompanying autonomic features. Neurovascular compression with imprinting over the trigeminal root on the symptomatic side was identified in three patients. All cases responded to antiepileptic drugs, and three had spontaneous remissions. Conclusions This series reinforces the facial variant of EF and extends the phenotype with cases of downward radiation. It also contributes to enriching the differential diagnosis of facial pain. Neurovascular compression of the trigeminal nerve may be found in some cases, although a possible pathogenic link needs further research.

Living With Cluster Headache: A Qualitative Study of Patients' Perspectives.

Our aim was to explore the views and experiences of a group of Spanish men suffering from cluster headache (CH).

OnabotulinumtoxinA injections for atypical odontalgia: an open-label study on nine patients

Background Atypical odontalgia (AO) manifests as continuous pain in the region of one or several teeth, in the absence of signs of dental pathology. Currently, there is insufficient evidence to establish treatment guidelines for AO. The aim of this study was to describe the effectiveness and safety of treatment with OnabotulinumtoxinA (OnabotA) on a series of patients with AO. Methods Nine patients with AO (four males and five females, aged between 31 and 77 years) received injections of OnabotA in the region of pain. The dosage used in each procedure ranged between 10 and 30 U, spread between 4 and 12 injection sites along the gums (n=9), the lips (n=3), and the hard palate (n=1). The median follow-up time was 27 months (interquartile range, IQR 20–40) and the median number of injection sessions per patient was seven (IQR 4.5–9). The assessment variables included the change in the maximal intensity of pain on a 0–10 numerical rating scale (NRS), the response latency, and the duration of the effect. Results All patients experienced a significant improvement, with ≥50% of reduction in the intensity of the maximal pain. The median of reduction of maximal pain after treatment was six points on the NRS (IQR 5–8.5). The response latency was 2–15 days and the duration of the effect was 2–6 months. No significant adverse reactions were registered. Conclusion OnabotA may be a safe and effective option for the treatment of AO.

Zygomaticofacial Neuralgia: A New Cause of Facial Pain

Injury of the terminal branches of the trigeminal nerve may cause pain in the area innervated by the affected branch. The diagnosis of terminal branch neuralgias is based on pain location and is further confirmed by pain relief after local anesthetic blockade. Some of these neuralgias are well characterized while others have been described only very recently. We aim to present a patient with a distinct pain condition that apparently corresponds to zygomaticofacial neuralgia. To our knowledge, this is the first reported case in the literature. A 54-year-old woman was assessed in our Headache Clinic for facial pain. At age 51, she suffered from Graves’ ophthalmopathy, and was initially treated with high doses of systemic corticosteroids (intravenous methylprednisolone 500 mg weekly during 6 weeks followed by oral prednisone taper during 3 months) combined with fractionated external-beam radiotherapy to both orbits (20 Gy in 2-Gy fractions within 2 weeks). The ophthalmopathy showed complete response to treatment, with no relapses during follow-up. Three years later, the patient presented with a 1-year history of facial pain, consisting of episodes of pain and tenderness in a circumscribed area on her right cheek. She was able to outline the painful area with well-defined boundaries. The episodes occurred 1-3 times per day and lasted 2-24 hours. Pain intensity varied from moderate to severe (4 to 9 on a 10-point numeric rating scale, NRS) and pain quality was described as pressing, sometimes throbbing. She did not notice any exacerbating or relieving factors. There were no other accompanying symptoms. From the Department of Neurology, Hospital Cl ınico San Carlos, Instituto de Investigaci on Sanitaria del Hospital Cl ınico San Carlos (IdISSC), Madrid, Spain (V. G omezMayordomo, A. Guti errez-Viedma, J. Porta-Etessam, and M.-L. Cuadrado); Department of Medicine, School of Medicine, Universidad Complutense de Madrid (UCM), Madrid, Spain (V. G omez-Mayordomo, A. Guti errez-Viedma, J. Porta-Etessam, and M.-L. Cuadrado); Department of Radiation Oncology, Hospital Universitario HM Sanchinarro, Madrid, Spain (C. Rubio-Rodr ıguez); Department of Clinical Medical Sciences, School of Medicine, Universidad San Pablo CEU, Madrid, Spain (C. Rubio-Rodr ıguez).