María-Luz Cuadrado

Generalized neck-shoulder hyperalgesia in chronic tension-type headache and unilateral migraine assessed by pressure pain sensitivity topographical maps of the trapezius muscle

Spatial changes in pressure pain hypersensitivity are present throughout the cephalic region (temporalis muscle) in both chronic tension-type headache (CTTH) and unilateral migraine. The aim of this study was to assess pressure pain sensitivity topographical maps on the trapezius muscle in 20 patients with CTTH and 20 with unilateral migraine in comparison with 20 healthy controls in a blind design. For this purpose, a pressure algometer was used to assess pressure pain thresholds (PPT) over 11 points of the trapezius muscle: four points in the upper part of the muscle, two over the levator scapulae muscle, two in the middle part, and the remaining three points in the lower part of the muscle. Pressure pain sensitivity maps of both sides (dominant/non-dominant; symptomatic/non-symptomatic) were depicted for patients and controls. CTTH patients showed generalized lower PPT levels compared with both migraine patients (P = 0.03) and controls (P < 0.001). The migraine group had also lower PPT than healthy controls (P < 0.001). The most sensitive location for the assessment of PPT was the neck portion of the upper trapezius muscle in both patient groups and healthy controls (P < 0.001). PPT was negatively related to some clinical pain features in both CTTH and unilateral migraine patients (all P < 0.05). Side-to-side differences were found in strictly unilateral migraine, but not in those subjects with bilateral pain, i.e. CTTH. These data support the influence of muscle hyperalgesia in both CTTH and unilateral migraine patients and point towards a general pressure pain hyperalgesia of neck-shoulder muscles in headache patients, particularly in CTTH.

Epicrania fugax : an ultrabrief paroxysmal epicranial pain

Ten patients (one man and nine women, mean age 48.8 ± 20.1) presented with a stereotypical and undescribed type of head pain. They complained of strictly unilateral, shooting pain paroxysms starting in a focal area of the posterior parietal or temporal region and rapidly spreading forward to the ipsilateral eye (n = 7) or nose (n = 3) along a lineal or zigzag trajectory, the complete sequence lasting 1-10 s. Two patients had ipsilateral lacrimation, and one had rhinorrhoea at the end of the attacks. The attacks could be either spontaneous or triggered by touch on the stemming area (n = 2), which could otherwise remain tender or slightly painful between the paroxysms (n = 5). The frequency ranged from two attacks per month to countless attacks per day, and the temporal pattern was either remitting (n = 5) or chronic (n = 5). This clinical picture might be a variant of an established headache or represent a novel syndrome.

Duration of attacks of first division trigeminal neuralgia.

Objective measurements of duration of attacks have been performed in 8 (5 female and 3 male) patients suffering from primary first division (V-1) trigeminal neuralgia. The mean age of the patients was 67.5 ± 11.4 years, and the mean age at onset 64.0 ± 9.7 years. During the study the patients were off treatment. A total of 192 attacks were witnessed by the authors and exactly timed by a stop-watch. The duration of attacks ranged from 2 to 32 s, with a mean of 6.5 ± 6.1 s. The unweighted mean was 8.8 ± 5.7 s, with a range of 2.4-17.5 s. With the present data the duration of attacks of V-1 neuralgia has been exactly determined, and the clinical distinction of V-1 neuralgia from other shortlasting headaches, particularly from SUNCT, has been substantially clarified.

Pressure pain sensitivity of the scalp in patients with nummular headache: A cartographic study

Nummular headache (NH) is characterized by focal pain fixed within a small round or elliptical area of the head surface. Sensory dysfunction is apparently restricted to the symptomatic area, but a thorough analysis of cranial pain sensitivity has not been performed. Pressure pain sensitivity maps were constructed for 21 patients with NH and 21 matched healthy controls. In each subject pressure pain thresholds (PPT) were measured on 21 points distributed over the scalp. In each patient PPT were also measured in the symptomatic area and at a non-symptomatic symmetrical point. In both groups an anterior to posterior gradient was found on each side, with no significant differences of PPT measurements between sides or groups. In patients with NH, only the symptomatic area showed a local decrease of PPT (significant in comparison with the non-symptomatic symmetrical point, P < 0.001). These findings further support that NH is a non-generalized disorder with a peripheral source.

Bifocal nummular headache: the first three cases.

Nummular headache (NH) has been defined as a focal head pain that is exclusively felt in a small area of the head surface. Here we describe three patients who presented with focal head pain in two separate areas. This finding seems to be consistent with bifocal NH and further enlarges the clinical diversity of this headache disorder. The pathogenic mechanisms of NH may be active in multiple cranial areas in some particular patients.

Lacrimal neuralgia: So far, a missing cranial neuralgia

Background The lacrimal nerve supplies the lacrimal gland, the lateral upper eyelid, and a small cutaneous area adjacent to the external canthus. First division trigeminal neuralgia, supraorbital/supratrochlear neuralgia, and infraorbital neuralgia have been acknowledged as neuralgic causes of pain in the forehead and periorbit. However, the lacrimal nerve has never been identified as a source of facial pain. Here we report two cases of lacrimal neuralgia. Case reports A 66-year-old woman had continuous pain in the lateral aspect of her left superior eyelid and an adjacent area of the temple since age 64. A 33-year-old woman suffered from continuous pain in a small area next to the lateral canthus of her left eye since age 25. In both patients the superoexternal edge of the orbit was tender. In addition, sensory dysfunction could be demonstrated within the painful area. Anaesthetic blockades of the lacrimal nerve with lidocaine 2% resulted in complete but short-lasting relief. Pregabalin provided a complete response in the first patient. The second patient was refractory to various oral and topical drugs and different radiofrequency procedures, but she eventually obtained partial relief with pregabalin. Conclusions Lacrimal neuralgia should be considered among the neuralgic causes of orbital and periorbital pain.

A new lacrimal neuralgia, a new nerve blockade procedure.

Dear Sir, Lacrimal neuralgia has been recently described as a cause of orbital and periorbital pain (1). The two previously reported patients had continuous pain in the territory of the lacrimal nerve: one of them felt the pain in the lateral aspect of her left superior eyelid and an adjacent area of the temple, while the other localized her pain to a small area of her left temple. They also had local tenderness at the emergence of the lacrimal nerve and experienced short-lasting relief upon anaesthetic blockade of the nerve. The technique employed for the nerve blockades was the same as that used in oculofacial surgery, with the needle inserted deeply along the lateral wall of the orbit (2,3). Here we report a third case of lacrimal neuralgia and a more simple method for blocking the lacrimal nerve. This procedure not only confirmed the diagnosis, but also provided the patient with long-lasting pain relief. A 63-year-old woman, with former migraine with aura and no history of trauma or other relevant diseases, started suffering from constant pain in a small area of her left temple at age 60. The painful area was adjacent to the lateral angle of her left eye and had oval shape, with a horizontal diameter of 2 cm and a vertical diameter of 4 cm. The pain was always located at the same site, although it could occasionally expand over a wider area. It was described as severe in intensity – up to 9 out of 10 – and pressing in character. The temporal pattern was chronic and continuous since onset.

Are Cox-2 drugs the second line option in indomethacin responsive headaches?

Paroxysmal hemicrania and hemicrania continua are both indomethacin-responsive headaches. Although indomethacin use to be well tolerated, some patients developed gastrointestinal side effects. We report four cases of hemicrania continua and a patient suffering chronic paroxysmal hemicrania completely responsive to celecoxib. In our experience celecoxib is a good option treatment for patients suffering from hemicrania continua or chronic paroxysmal hemicranea that presents indomethacin adverse effects.

Infratrochlear nerve block for a new infratrochlear neuralgia.

Dear Sir, Painful cranial neuropathies are a group of entities causing pain in the distribution of one particular nerve (1,2). Some of them are well characterized while others have been identified only very recently. Apart from first-division trigeminal neuralgia, several neuropathies affecting the terminal branches of the trigeminal nerve may involve the orbital and periorbital area, including supraorbital/supratrochlear neuralgia (3), infraorbital neuralgia (4) and lacrimal neuralgia (5). Pareja et al. have recently described infratrochlear neuralgia in seven patients presenting with paroxysmal pain in the internal angle of the orbit (6). In each patient, the pain appeared in one of three different locations within the territory supplied by the infratrochlear nerve, namely, the medial half of the palpebra superior, the caruncula lacrimalis and the lateral aspect of the radix nasi. Although most of the patients (six out of seven) were treated with oral drugs, we advocate anaesthetic blockades as a safe and effective treatment for this condition. We aim to present a new case of infratrochlear neuralgia, as well as the result of the anaesthetic blockade of the infratrochlear nerve. A 46-year-old woman with prior history of migraine without aura came to our office complaining of a new type of pain. She had paroxysms of pressing pain in the internal angle of the right orbit and the medial half of the right palpebra superior. The episodes roughly lasted 2minutes and they ranged from mild (3 out of 10) to moderate (7 out 10) in intensity. She had been experiencing such a pain for 1 year with an average frequency of once per week. The patient could not identify any trigger. Between the paroxysms, she felt pain within the symptomatic area when gently touching it. Sensory examination demonstrated the presence of hyperesthesia and allodynia in the painful area. In addition, palpation of the medial edge of the right orbit just above the caruncula lacrimalis was extremely painful. This area matched the point where the infrathrochlear nerve emerges from the orbit. The pain evoked upon palpation did not increase with vertical eye movements. All ancillary tests, including routine blood tests, immunological screening and brain and orbital magnetic resonance imaging, were normal. Considering infratrochlear neuralgia as the most reasonable diagnosis, we performed an anaesthetic

Primary continuous unilateral headaches: A nosologic model for hemicrania continua

Background: Hemicrania continua was originally described as a strictly unilateral, continuous headache with an absolute response to indomethacin. Recognition of an increasing number of patients with the same clinical features except for a lack of response to indomethacin has generated controversy about whether the responsive/non-responsive phenotypes belong to the same disorder. Discussion: We suggest that the non-responsive phenotype should be differentiated from the original concept of hemicrania continua, because it probably indicates a separate type of headache of undetermined nature, i.e. hemicrania incerta. However, differentiating hemicrania incerta from hemicrania continua does not imply that the two headaches are unrelated. Both hemicranias may outline a continuum, giving rise to a broader diagnostic field. Conclusion: There seems to be a syndrome of ‘primary continuous unilateral headache’ with at least two distinctive categories: hemicrania continua and hemicrania incerta, which are differentiated by their respective response to indomethacin. This division means plurality but adds precision, and allows a clear-cut diagnosis of some controversial cases.