Headache and the Eye

Ula Jurkunas, MD; John W. Gittinger, JR, MD

Disclosures

Compr Ophthalmol Update. 2004;5(4) 

In This Article

Facial Pain With Dermatologic Implications

A history of facial skin cancer excision along with pain and numbness or hyperesthesia in the distribution of the cranial nerve V should prompt consideration of neurotrophic spread of carcinoma along trigeminal or facial nerves, including squamous cell, basal cell, and nasopharyngeal cancers, as well as sinus and salivary gland tumors.[35,36,37,38] Such recurrences may manifest years after the original surgery. Neuroimaging may be normal.[35] These tumors may travel along the nerve into the cavernous sinus and Meckel's cave.[38]

In herpes zoster ophthalmicus (HZO), trigeminal der matomal involvement produces pain that may precede the vesicular eruption by several days. The patient may experience flushing, hypesthesias, and pain secondary to acute neuroganglionitis upon the reactivation of the latent herpes zoster virus (HZV).[39] Many patients are elderly, immunocompromised, or have neoplasia or blood dyscrasias. Spread of virus through trigeminal nerve sensory branches involves frontal and nasociliary nerve branches. In these cases, the pain may be exacerbated by corneal involvement, iridocyclitis, scleritis, or anterior segment ischemia from 360° perilimbal vasculitis. Marked elevation in intraocular pressure in 10% of patients is produced by trabeculitis and endotheliitis.[39,40,41]

Orbital and cavernous sinus involvement secondary to HZV occlusive vasculitis may result in numerous posterior pole manifestations as well as cranial nerve palsies, most often cranial nerve III. A severe headache not related to dermatomal distribution, along with focal neurologic findings, indicates an intracranial vasculitis that is life-threatening and may present even several months after acute HZO infection.[39,41,42,43] A young patient with HZO or bilaterality should raise the question of HIV infection.[44,45] Postherpetic neuralgia, persistent chronic pain after acute infection, is more prevalent with advancing age and occurs in 50% of patients in the sixth and seventh decades of life.[46,47] Treatment of HZO is outlined in Table 4 .

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