Michael Eller; Peter J Goadsby


Expert Rev Neurother. 2013;13(3):263-273. 

In This Article

Trigeminal Autonomic Cephalalgias

The trigeminal autonomic cephalalgias (TACs) are a group of primary headaches consisting of cluster headache, paroxysmal hemicrania and short-lasting, unilateral neuralgiform headache with conjunctival injection, and tearing (SUNCT)/short-lasting neuralgiform headache with cranial autonomic features (SUNA).[5] Hemicrania continua can also be considered one of the TACs[40] and will join that group in the third edition of the classification. They are characterized by unilateral headaches with associated ipsilateral cranial autonomic signs, and can be individually distinguished by semiology and response to treatment such as indomethacin. These characteristic features, such as the attack frequency and duration, also allow the TACs to be differentiated from migraine, which is commonly associated with autonomic features.[41,42]

Just as the migraine phenotype can very rarely be caused by a discrete lesion in the midbrain[43] or pons,[44] the TAC phenotype can often manifest secondary to pituitary or cavernous sinus pathology.[45–47] The association of the TAC phenotype with a pituitary lesion is not uncommon, and is under-recognized (Figure 1).[45] Furthermore, a significant proportion of TAC patients demonstrate extrapituitary lesions.[47] Hence these patients have an absolute requirement of both a brain MRI as well as devoted views of the pituitary, accompanied by a full anterior pituitary endocrine work-up (Box 2): serum levels of prolactin, thyroid stimulating hormone, thyroxine (T4) ± triiodothyronine (T3), insulin-like growth factor 1, growth hormone, follicle-stimulating hormone and luteinizing hormone, as well as a 24-h urine cortisol assay.

Figure 1.

Two patients with a pituitary tumor. (A) An axial T2 MRI scan demonstrating a large pituitary macroadenoma in a young man presenting with acromegaly and headache; (B) A sagittal and (C) coronal T1 MRI brain scan demonstrating a macroadenoma in an otherwise well patient presenting with right-sided cluster headache.