Epidermoid tumour of the posterior fossa causing multiple facial pain a case report

A 53-year-old woman presented with three types of pain. The pains had characteristics of neuralgia of the fifth cranial nerve, ninth cranial nerve, and cluster headache. On further investigation, a tumour in the posterior fossa was observed and histologically shown to be an epidermoid tumour.     

Conjunctival congestion in SUNCT syndrome

The purpose of this observational-retrospective study was to assess which type of conjunctival injection and related phenomena are present during SUNCT attacks. We studied the videorecords of 23 SUNCT attacks in three patients. Conjunctival injection was found to mostly involve vessels of the palpebral territory stemming from both superior and inferior palpebral vessels that supply the tarsal conjunctiva and most of the ocular (bulbar) conjunctiva. Episcleral injection was also observed. During attacks, the appearance of the conjunctiva suggested conjunctival edema or chemosis. Furthermore, the presence of edema below the capsule of Tenon was strongly suspected. During SUNCT attacks, there was a dramatic conjunctival congestion of the eye on the symptomatic side that tended to extend to the rest of the external tunica of the eye. Received: 24 January 2000 / Accepted in revised form: 19 May 2000     

Relief of cluster-tic syndrome by the combination of lithium and carbamazepine

This paper presents a further case of cluster-tic syndrome. Cluster headache and trigeminal neuralgia have coexisted in our patient for 18 years. Carbamazepine has selectively relieved the tic douloureux, while lithium has completely controlled the cluster headache. Our case shows again that the simultaneous occurrence of cluster headache and trigeminal neuralgia seems to be more than coincidental.     

"SUNCT" syndrome. A case of transformation from trigeminal neuralgia?

A patient with typical trigeminal neuralgia involving the first branch of the nerve developed short-lasting unilateral attacks in the same area which were associated with severe vasomotor phenomena consistent with the recently described SUNCT syndrome. This evolution suggests that SUNCT might correspond, at least in this case, to a "transformed" trigeminal neuralgia and emphasizes the close relationship between these unilateral facial pain syndromes.     

Chronic paroxysmal hemicrania-tic syndrome

We report the coexistence of both chronic paroxysmal hemicrania (CPH) and trigeminal neuralgia (tic douloureux) in a female patient. The clinical features combined to make a configuration of CPH-tic syndrome. The two components of the syndrome appeared synchronously in the same orbital region—first branch of the trigeminal nerve—with a latency of several years after the onset of isolated tic attacks of the second and third trigeminal divisions. The concurrence of both types of pain in the same symptomatic area may have some significance for pathogenic, clinical, and pharmacological aspects of such a syndrome. We discuss all these and postulate a provisional distinction between CPH-V_2,3 tic and CPH-V₁ tic.     

Cluster-Tic Syndrome and Basilar Artery Ectasia: A Case Report

SYNOPSISA 54-year-old patient presented with two types of pain. The first was similar to trigeminal neuralgia and the second was similar to cluster headache. Clinical diagnosis was cluster-tic syndrome. Neuro-imaging studies disclosed an ectatic basilar artery. The significance of this finding is difficult to ascertain.     

SUNCT Syndrome. Statuslike Pattern

Four SUNCT patients with a clinical "SUNCT status" witnessed by the investigators are reported. Such an extreme aggregation of typical attacks lasting for the better part of the day, 1 to 3 days in a row has not previously been observed. Appropriate supplementary examinations ruled out an intracranial lesion in all four patients. Indeed an observation period of more than 5 years speaks against a symptomatic etiology of SUNCT in these cases. Although rarely seen, clinical status may be a feature of the SUNCT syndrome.     

Trigeminal neuralgia with lacrimation or SUNCT syndrome?

An intimate relationship between trigeminal neuralgia (TN) and short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) syndrome, based on similar clinical signs and symptoms and on cases demonstrating possible "transformation" from one entity to the other, has been widely accepted. We evaluated the presence of lacrimation in 22 consecutive cases that had been diagnosed as TN. Ipsilateral lacrimation was reported by 6 such cases (5M, 1F). These cases responded to antineuralgic therapy with concomitant resolution of lacrimation and were clinically very similar to TN. The differential diagnosis and the possibility of lacrimation in TN are discussed.     

Cluster headache-like pain in multiple sclerosis

We describe a case with simultaneous occurrence of cluster headache-like pain and multiple sclerosis. Both neuroimaging and neurophysiology (trigeminal evoked potentials) revealed a demyelination plaque in the pons, at the trigeminal root entry zone, on the side of pain. Although that type of lesion is usually associated with trigeminal neuralgia pain, we hypothesize that in this case it may be linked with the concomitant cluster headache, possibly by activation of trigemino-vascular mechanisms.     

Percutaneous balloon compression for trigeminal neuralgias and autonomic cephalalgia

OBJECTIVE: This prospective study aimed to evaluate the results of percutaneous trigeminal ganglion balloon compression (BC) in patients with various types of trigeminal neuralgia (TN) and autonomic cephalalgia. METHODS: Twenty-five consecutive patients underwent BC and were followed up for 27-60 months. They were divided into 2 groups: group A (n=18) patients with idiopathic TN and group B (n=7) patients with secondary TN (n=5) and trigeminal autonomic cephalalgia (TAC) (n=2). RESULTS: Postoperatively, 15 patients in group A experienced pain relief, one required medication and 2 had no response; in group B, 6 were free of pain, including the 2 patients with TAC, and one required medication. Complications in both groups were either functionally trivial or infrequent. None of the patients developed keratitis or anesthesia dolorosa. Pain recurrence occurred early (<6 months) in one patient from group B, and late in 2 patients from group A. CONCLUSION: Balloon compression is a minimally invasive procedure that seems to be comparably successful for idiopathic and secondary TN, as well as TAC. However, further studies are deemed necessary to establish it as the first-line treatment in medically resistant trigeminal pain.     

The surgical management of chronic cluster headache

OBJECTIVE: Chronic cluster headache occurs in less than 10% of cluster headache sufferers, but remains an intractable medical problem. Surgical treatments have also been limited in their effectiveness. The authors describe their experience with attempted surgical amelioration of chronic cluster headache. DESIGN: Twenty-eight patients, including two with bilateral cluster headache, underwent 39 operations for microvascular decompression of the trigeminal nerve, alone or in combination with section and/or microvascular decompression of the nervus intermedius. Follow-up averaged 5.3 years. RESULTS: Initial postoperative success described as 50% relief or greater was achieved in 22 (73.3%) of 30 first-time procedures and greater than 90% relief in half (15 of 30) of these. Long-term follow-up saw this success rate (excellent or good) drop to 46.6%. Repeat procedures have little success, with 7 of 8 failing at long-term follow-up. Morbidity and neurological deficit from the operations was minimal. CONCLUSIONS: Chronic cluster headache remains a debilitating and poorly controlled syndrome. Although various surgical treatments have had limited success, microvascular decompression of the trigeminal nerve with section of the nervus intermedius compares very favorably to other destructive techniques without the accompanying neurologic deficits. It is, therefore, our recommendation as the first-line operative treatment of chronic cluster headache.     

Trigeminal Neuralgic-Type Pain and Vascular-Type Headache Due to Gustatory Stimulus

We present a case of facial pain associated with sweet stimulus. An immediate, electriclike, short, unilateral pain was evoked by strong sweet gustatory stimulation. This was followed 6 to 8 hours later by a bilateral severe headache associated with bilateral tearing, rhinorrhea, periorbital swelling, flushing, and photophobia that lasted up to 2 days. The immediate pain that was experimentally induced with 2.5 grams of sucrose placed on the tongue could be abolished with carbamazepine. However, carbamazepine did not prevent the headache complex that appeared 6 to 8 hours later. Conversely, a trial with indomethacin abolished the late-onset headache, but not the immediate neuralgic-type pain. The independent nature of these pains suggests different pathophysiological mechanisms which are discussed.     

Gamma Knife Treatment of Refractory Cluster Headache

Four men and two women were treated for refractory cluster headache by gamma knife radiosurgery of the trigeminal nerve root entry zone. The maximum dose of radiation was 70 Gy to the isocenter. Of five patients treated who had refractory chronic cluster headache and one with refractory episodic cluster headache, four had relief judged excellent. Of the two remaining patients with refractory chronic cluster headache, one had relief judged good and the other fair. Five of the six patients treated had relief within a few days to a week following gamma knife radiosurgery. Three with chronic cluster headache had remissions allowing cessation of all preventive and abortive medication. Although one patient experienced complete relief of chronic cluster headache, he continued to have migraine requiring medication. None of the patients treated developed significant postradiation side effects during a follow-up period of 8 to 14 months. The authors conclude that gamma knife radiosurgery of the trigeminal nerve affords great promise in the management of chronic and refractory cluster headache. The technique seemingly carries negligible short- and long- term risk.     

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.     

SUNCT Syndrome. Two Cases in Argentina

Two patients suffering from SUNCT syndrome are presented. Some features are remarkable. The first patient was a 69-year-old man whose first crisis was located in the right supraorbital region. After a 4-month spontaneous remission, the pain returned to the upper part of the cheek, radiating to the supraciliary region on the same side, with lacrimation and conjunctival injection. Rhinorrhea was absent The painful attacks were triggered by head movements. Clinical improvement occurred with carbamazepine treatment
The second patient was a 48-year-old woman whose painful attacks lasted from 30 to 45 seconds followed by a burning sensation lasting 2 hours. Autonomic signs such as conjunctival injection, lacrimation, and edema and ipsilateral ptosis of the upper lid were rather marked. There was never any rhinorrhea. Her attacks were triggered by head and eye movements. She responded to the administration of corticosteroids and carbamazepine.
According to these features, the two patients had SUNCT syndrome, and the positive carbamazepine response suggests a relationship with trigeminal neuralgia.     

Intracerebroventricular opiate infusion for refractory head and facial pain

AIM: To study the risks and benefits of intracerebroventricular(ICV) opiate pumps for the management of benign head and face pain.METHODS: SSix patients with refractory trigeminal neuralgia and/or cluster headaches were evaluated for implantation of an ICV opiate infusion pump using either ICV injections through an Ommaya reservoir or external ventricular drain. Four patients received morphine ICV pumps and two patient S received a hydromorphone pump. Of the Four patients with morphine ICV pumps, one patient had the medication changed to hydromorphone. Preoperative and post-operative visual analog scores(VAS) were obtained. Patients were evaluated post-operatively for a minimum of 3 mo and the pump dosage was adjusted at each outpatient clinic visit according to the patient's pain level.RESULTS: All 6 patients had an intracerebroventricular opiate injection trial period, using either an Ommaya reservoir or an external ventricular drain. There was an average VAS improvement of 75.8%. During the trial period, no complications were observed. Pump implantation was performed an average of 3.7 wk(range 1-7) after the trial injections. After implantation, an average of 20.7 ± 8.3 dose adjustments were made over 3-56 mo after surgery to achieve maximal pain relief. At the most recent follow-up(26.2 mo, range 3-56), VAS scores significantly improved from an average of 7.8 ± 0.5(range 6-10) to 2.8 ± 0.7(range 0-5) at the final dose(mean improvement 5.0 ± 1.0, P 0.001). All patients required a stepwise increase in opiate infusion rates to achieve maximal benefit. The most common complications were nausea and drowsiness, both of which resolved with pump adjustments. On average, infusion pumps were replaced every 4-5 years.CONCLUSION: These results suggest that ICV delivery of opiates may potentially be a viable treatment option for patients with intractable pain from trigeminal neuralgia or cluster headache.