A Case-Based Guide To Eye Pain: Michael S. Lee Kathleen B. Digre

Michael S. Lee · Kathleen B.
Digre
A Case-Based
Guide to Eye Pain
Perspectives from
Ophthalmology and
Neurology
123
A Case-Based Guide to Eye Pain
Michael S. Lee • Kathleen B. Digre
A Case-Based Guide
to Eye Pain
Perspectives from Ophthalmology
and Neurology
Michael S. Lee Kathleen B. Digre
University of Minnesota University of Utah
Minneapolis, Minnesota Salt Lake City, Utah
USA USA
ISBN 978-3-319-65120-0 ISBN 978-3-319-65121-7 (eBook)

https://doi.org/10.1007/978-3-319-65121-7
Library of Congress Control Number: 2017959569
© The Author(s) 2018

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Foreword
“I have pain in (or around or behind) my eye.” This sentence is one that most physi-
cians, be they ophthalmologists, optometrists, neurologists, or primary care provid-
ers, dread to hear. In large part, this is because pain is such a subjective complaint.
Thus, the first assumption that most physicians make when they see a patient with
the complaint of “eye pain” is that they will not find the cause of the pain. This, in
turn, will make them believe that it is most likely that (1) there is nothing really
wrong with the patient, (2) the patient will be unhappy with them, and (3) the patient
will want some type of drug for the pain.
In reality, pain is a complex symptom with many etiologies. On the one hand, its
cause may be something straightforward, like a dry eye, and its treatment may be as
simple as ocular lubrication or punctal occlusion. On the other hand, patients with
eye pain may have a potentially vision-threatening condition such as intermittent
angle-closure glaucoma or even a life-threatening condition such as an intracranial
aneurysm or tumor. The ophthalmologist who finds no ocular cause for the patient’s
complaints is sure to be perplexed as will the neurologist who finds no neurologic
cause and who obtains neuroimaging that is unremarkable. The primary care pro-
vider may not even know to whom to refer the patient or what to do when the patient
returns from the general ophthalmologist and/or neurologist with no diagnosis.
Even neuro-ophthalmologists are not immune to the confusion that comes in deal-
ing with patients who have eye pain. A Case-Based Guide to Eye Pain—Perspectives
from Ophthalmology and Neurology, written by two neuro-ophthalmologists, Dr.
Mike S. Lee, an ophthalmologist, and Dr. Kathleen B. Digre, a neurologist, thus is
a welcome addition to everyone’s practice, particularly as it is, as the title indicates,
case based—like a conversation with a colleague.
The book begins with a chapter on key signs and symptoms, emphasizing their
importance in diagnosis. There follows a list of the various abbreviations used in the
book. The subsequent cases, all of which contain excellent figures and illustrations,
are then grouped into two main sections. The first section contains 18 cases demon-
strating ocular causes of pain, ten with relatively normal examination findings and
eight in which there are abnormal but often subtle findings. The second section
contains 25 cases demonstrating neurologic causes of eye pain, 15 in patients with
v
vi Foreword
little or no neurologic or eye findings and ten with abnormal findings. All 43 cases
begin with the history and examination, followed by commentary by both Dr. Lee
and Dr. Digre. Thus, the reader gets the views of both an ophthalmologist and a
neurologist. Each case ends with a summary, key points, and references for the
reader who wishes to pursue the topic further. The book ends with four appendices.
Appendix 1 lists the tables in the book. Appendix 2 lists the figures in the book.
Appendix 3 discusses how to obtain a proper history and perform an appropriate
examination in a patient with eye pain, and Appendix 4 discusses the pathophysiol-
ogy of eye pain.
Although eye pain is frustrating for patients and can be frustrating for the physi-
cians who care for such patients, the diagnosis and treatment of its cause can not
only improve a patient’s quality of life but also can prevent major ocular or neuro-
logic morbidity. This book fills a void in the ophthalmic, neurologic, and general
medical literature and should be on the shelf in every physician’s office.
Neil R. Miller, M.D., F.A.C.S.

Preface
Most of us have a “Do not schedule this with me” diagnosis list, and many of our
colleagues have told us that “eye pain” resides near the top of that list. Unfortunately,
there is not a good department for these patients, and there are a lot of them showing
up in our offices and clinics. In our neurology and ophthalmology residencies and
fellowships, we never received formal teaching or training in eye pain and, honestly,
had to learn a lot by trial and error (and by fire). So when a Springer editor
approached us in the fall of 2015 about writing a book about the subject, it intrigued
us.
She told us that no book on eye pain existed and that readers enjoy case-based
books. So, we set out to demystify the topic and create a practical approach to the
patient with eye pain. At first, we thought to target neurologists and ophthalmolo-
gists, but, as we inquired around, our colleagues in the emergency room and urgency
room and primary care asked if they could read some of the chapters as well.
There are 43 cases but more than 43 causes of eye pain. We use each case as a
springboard to generate a differential diagnosis and a thought process based on the
signs and symptoms. Some of the cases are not classic, but most of our patients
don’t always follow the book.
We have tried to give the International Classification of Headache Disorders
whenever possible. For a complete listing of these disorders please see: International
Headache Society Headache classification ICHD 3 beta. Cephalalgia 2013;
33(9):629–808.
We sincerely hope that you will enjoy this book and, after reading it, feel more
comfortable serving our patients with eye pain.
Minneapolis, MN Michael S. Lee

Salt Lake City, UT Kathleen B. Digre
vii
Acknowledgements
I would like to thank my loving wife, Mina, and my children, Sam, Nate, Isaac, and
Esthergrace, who mean the world to me. Your faith and your support make all the
difference and you are truly a gift and a blessing from above. Thanks to Yong and
Soo Lee and Hyung and Kilja Kim for your loving support and sacrifice. I would
also like to thank Nicholas Volpe, Simmons Lessell, Joe Rizzo, Mike Siatkowski,
and Andy Lee who have mentored me along in my career. Greg Kosmorsky has
taught me a lot about eye pain and about life in general. Finally, I would like to
thank my coauthor, Kathleen, who has made writing my first book an extremely
positive experience. It has been a pleasure working with you.
Michael S. Lee, MD
I would like to thank people who have really taught me about eye pain and head-
ache. My mentor, James Corbett, instilled in me an enthusiasm for the study of the
eye and headache. I have also learned a lot about eye pain and headache from my
wonderful colleagues Susan Baggaley, Judith Warner, Bradley Katz, and Alison
Crum at the Moran Eye Center, University of Utah. Finally, I would like to thank my
wonderful supportive husband, Michael Varner, and children Johanna and Gita
Varner for their encouragement. Thanks to you Mike for a wonderful, educational
experience writing this book—it has been fun.
Kathleen B. Digre, MD
We both would like to thank our patients who teach us about eye pain in all of its
varied forms and keep us wanting to learn more.
Supported in part by an Unrestricted Grant from Research to Prevent Blindness,

Inc., New York, NY, to the Department of Ophthalmology & Visual Sciences,
University of Utah.
ix
Signs and Symptoms
VA Eyelid Nasal Blurry Other
Case Diagnosis loss* Red White Ptosis edema Anisocoria Proptosis Tearing sxs Diplopia vision Photophobia comment
1 Dry eye syndrome (X) (X) (X)
2 Corneal erosions X X X X Upon
awakening
3 Post-LASIK pain X (X)
4 “Eye strain” X (X) (X)
5 Intermittent X X X X
angle-closure
glaucoma
6 Blepharospasm X (X) (X) X Excess
blinking
7 Chalazion (X) (X)
8 Trochleitis X (X)
9 Lacrimal gland X (X) (X) (X) (X)
tumor
10 Posterior scleritis (X) X (X) (X)
11 Idiopathic orbital (X) X (X) (X) (X) (X) X (X) (X)
inflammatory
syndrome
12 Uveitis (X) X (X) (X) (X) X
13 Conjunctivitis X (X) X X (X)
14 Thyroid eye (X) (X) (X) (X) X (X) (X) (X) (X)
disease
15 Orbital mass (X) (X) (X) (X) (X) X (X) (X) (X) (X)
16 Ocular ischemic (X) (X) (X) (X) (X) (X) TVL in
syndrome light
(continued)
xi
xii
17 Horner syndrome (X) (X) X X (X) (X) +/−

anhidrosis
18 Microvascular X (X) (X) X Ptosis and
cranial nerve palsy anisocoria
w/3np only
19 Migraine X X Aura may
cause TVL
20 Medication X
overuse headache
21 Photophobia (X) (X) X
22 Trigeminal X
neuralgia
23 Cervicogenic X (X)
headache
24 Ice pick headache X
25 Sinus disease X X
26 Tension type X (X)
headache
27 Supraorbital X (X)
neuralgia
28 Trigeminal X X X X X X unilat
autonomic
cephalalgia
29 Cough headache X
30 Traumatic X X
headache
31 Intracranial X (X) (X) Positional
hypotension pain
32 Giant cell arteritis (X) (X) (X) (X) (X) (X) (X) (X) >50 yo
Signs and Symptoms
33 Thunderclap X (X) (X)
headache
34 Meningitis (X) (X) (X) (X) (X) X
35 Optic neuritis X X X
36 Idiopathic (X) X (X) (X) (X)
intracranial
Signs and Symptoms
hypertension
37 Carotid cavernous (X) X (X) (X) (X) (X) (X) (X) (X)
fistula
38 Herpes zoster (X) (X) (X) (X) X (X) (X) (X) (X) Pain may
ophthalmicus antedate
vesicles
39 Periocular skin (X) X (X) (X) (X) (X) (X)
cancer
40 Tolosa Hunt (X) (X) (X) (X) (X) (X) (X) (X) (X) (X)
41 Pituitary tumor (X) X (X) (X) (X)
42 Aneurysm (X) X (X) (X) (X) (X) (X)
43 Ophthalmoplegic X X X X (X) <10 yo
migraine
X = Commonly occurs
(X) = Possibly occurs
xiii
Contents
Part I Ophthalmic Disorders Causing Eye Pain:

Relatively Normal Examination
1 Case 1�� 3
History of Present Illness �� 3
Discussion�� 4
For Further Study�� 7
2 Case 2�� 9
Discussion�� 10
3 Case 3�� 15
Discussion�� 16
4 Case 4�� 21
Discussion�� 22
5 Case 5�� 27
Discussion�� 28
6 Case 6�� 33
Discussion�� 34
xv
xvi Contents
7 Case 7�� 39

Discussion�� 40
8 Case 8�� 43
Discussion�� 45
9 Case 9�� 49
Discussion�� 50
10 Case 10�� 53
Discussion�� 54
Part II Ophthalmic Disorders Causing Eye Pain:

Abnormal Eye Exam
11 Case 11�� 61
Discussion�� 62
12 Case 12�� 69
Discussion�� 70
13 Case 13�� 75
Discussion�� 76
14 Case 14�� 81
Discussion�� 82
15 Case 15�� 87
Discussion�� 89
Contents xvii
16 Case 16�� 93

Discussion�� 94
17 Case 17�� 99
Discussion�� 101
18 Case 18�� 105
Part III Neurologic Disorders Causing Eye Pain:

19 Case 19�� 113
20 Case 20�� 119
21 Case 21�� 125
22 Case 22�� 131
23 Case 23�� 137
24 Case 24�� 143
xviii Contents
25 Case 25�� 149

26 Case 26�� 155
27 Case 27�� 161
28 Case 28�� 165
29 Case 29�� 173
30 Case 30�� 177
31 Case 31�� 183
32 Case 32�� 189
33 Case 33�� 195
Contents xix
Part IV Neurologic Disorders Causing Eye Pain:

Abnormal Eye or Neurologic Exam
34 Case 34 �� 203
35 Case 35�� 209
36 Case 36�� 215
37 Case 37�� 221
38 Case 38�� 227
39 Case 39�� 233
40 Case 40�� 239
41 Case 41�� 245
42 Case 42�� 251
xx Contents
43 Case 43�� 257

ppendix A: List of Tables�� 263

A
Appendix B: List of Figures�� 267
Appendix C: Obtaining a History and Doing an Exam for Eye Pain �� 269
Appendix D: Pathophysiology of Eye Pain�� 273
Index�� 279
Abbreviations
3NP Third nerve palsy

ABMD Anterior basement membrane dystrophy
ACE Angiotensin-converting enzyme
ANA Antinuclear antibody
APD Afferent pupillary defect
BB Ball bullet
BE Both eyes
C Cervical
c-ANCA Cytoplasmic antineutrophil cytoplasmic antibodies
C-C Carotid cavernous
CAS Clinical activity score
CBC Complete blood count
CI Convergence insufficiency
CISS Constructive interference in steady state
cm Centimeter(s)
CN Cranial nerve
CPAP Continuous positive airway pressure
CRP C-reactive protein
CSF Cerebrospinal fluid
CT Computed tomography
CTA Computed tomographic angiogram
CTV Computed tomographic venogram
DES Dry eye syndrome
EBV Epstein–Barr virus
ED Emergency department
EMG Electromyography
ENT Ear, nose, and throat
ESR Erythrocyte sedimentation rate
FTA-ABS Fluorescent treponemal antibody absorption
GCA Giant cell arteritis
GON Greater occipital nerve
xxi
xxii Abbreviations
GPA Granulomatosis with polyangiitis

Hg Mercury
HHV Human herpes virus
HIV Human immunodeficiency virus
HLA Human leukocyte antigen
HPI History of present illness
HSV Herpes simplex virus
ICHD International Classification of Headache Disorders
IgG Immunoglobulin G
IgM Immunoglobulin M
IIH Idiopathic intracranial hypertension
IOP Intraocular pressure
IV Intravenous
IVIG Intravenous gamma globulin
kg Kilogram
LASIK Laser in situ keratomileusis
LDS Latter Day Saints
LE Left eye
LP Light perception or lumbar puncture
LUL Left upper lid
mg Milligram (s)
MIDAS Migraine Inventory Disability Assessment Score
mL Milliliter(s)
mm Millimeter(s)
MOH Medication overuse headache
MR Magnetic resonance
MRA Magnetic resonance angiogram
MRI Magnetic resonance imaging
MRV Magnetic resonance venography
NMO Neuromyelitis optica
NOVEL Neuro-ophthalmology Virtual Educational Library
NSAIDS Nonsteroidal anti-inflammatory drugs
OD Right eye
OIS Ocular ischemic syndrome
OS Left eye
OU Both eyes
p-ANCA Perinuclear antineutrophil cytoplasmic antibodies
Pcomm Posterior communicating
PCR Polymerase chain reaction
PD Prism diopter
PEK Punctate epithelial keratopathy
PET Positron emission tomography
POTS Postural orthostatic tachycardia syndrome
prn As needed
PSP Progressive supranuclear palsy
Abbreviations xxiii
PST Pulse synchronous tinnitus

RAI Radioactive iodine
RAPD Relative afferent pupillary defect
RCVS Reversible cerebral vasoconstriction syndrome
RE Right eye
RF Rheumatoid factor
RNA Ribonucleic acid
RNFL Retinal nerve fiber layer
RPR Rapid plasma reagin
SOV Superior ophthalmic vein
SR Sustained release
SSA Sjögren syndrome-related antigen A
SSB Sjögren syndrome-related antigen B
SSRI Selective serotonin reuptake inhibitor
SUNA Short unilateral neuralgiform headache attacks
SUNCT Short unilateral neuralgiform headache attacks with conjunctival
injection and tearing
TAC Trigeminal autonomic cephalgia
TB Tuberculosis
TBUT Tear break up time
TED Thyroid eye disease
TMJ Temporomandibular joint
TRAB Thyroid receptor antibody
TSI Thyroid-stimulating immunoglobulin
TVL Transient vision loss
u Units
VDRL Venereal Disease Research Laboratory
VZV Varicella zoster virus
WHO World Health Organization
x/d Times per day
Part I
Ophthalmic Disorders Causing Eye Pain:
Case 1
History of Present Illness
A 63-year-old woman with a history of strabismus status-post childhood corrective

surgery describes pain in both eyes for the last 6 months. She describes an aching
pain that is absent when she first awakens then worsens as the day progresses. It is
symmetric, daily, and is getting worse occurring more frequently and earlier in the
day. She was given eye exercises and prisms without improvement. Nothing initiates
the pain, but reading seems to worsen it. Closing her eyes makes it better. Over-the-
counter NSAIDs are not beneficial. She endorses occasional redness and occasional
tearing. The pain has an aching quality, does not radiate, and measures three out of
ten at its worst. She denies blurred vision, ptosis, photophobia, and diplopia.
Past medical and ocular history Past surgical history

Osteoarthritis Total knee arthroplasty
Atrial fibrillation Family history
Depression Mother—Progressive supranuclear palsy
Hyperlipidemia Review of systems
Hypertension Easy bruising
Right-sided congestive heart failure
Rosacea
Medications Social history
Furosemide One glass of wine daily
Sertraline No smoking or drug use
Metoprolol Retired professor
Warfarin
Vitamin D
Spironolactone
Atorvastatin
© The Author(s) 2018 3

M.S. Lee, K.B. Digre, A Case-Based Guide to Eye Pain,
https://doi.org/10.1007/978-3-319-65121-7_1
4 1 Case 1
Examination
Acuity with correction
Right eye: 20/20 distance and near
Left eye: 20/25 distance, 20/20 near
Pupils
Equal, round, reactive, without an afferent pupillary defect
Intraocular pressure
Right eye: 17 mmHg
Left eye: 18 mmHg
External exam
Rosacea, mild ptosis of the left upper lid
Eye alignment and motility
Normal motility
Orthophoric in distance
3 PD exophoria at near
Convergence amplitudes 30 PD for distance, 40 PD near
Near point of convergence to nose
Slit lamp examination
Blepharitis
Mild nuclear sclerosis
Tear break up time 4 s BE
No foreign body seen
Visual field
Normal
Fundus examination
Normal
Neurologic examination
Normal
Discussion
Ophthalmic Perspective: Dr. Lee
The fact that the pain is intermittent, bilateral, and symmetric would argue away
from a fixed orbital process, where I would expect the pain to be constant and uni-
lateral. There are no other features of orbital inflammation such as persistent or
worsening redness, proptosis, or chemosis. Her pain is not present in the morning
and worsens as the day goes on suggesting this is not a more sinister process. While
the patient has a small eye misalignment (exodeviation), this would not constitute a
convergence insufficiency (CI). Typically, the deviation in CI (see Case 4) is 10
prism diopters greater at near than distance. Her exodeviation is too small to really
call it CI. The patient has very normal convergence amplitudes, well over what is
needed to overcome the small misalignment at near. Her near point of convergence
is also normal. Although her symptoms are worse with reading, which could sug-
gest CI, she has tried prisms and convergence exercises without benefit.
The mild pain and aching quality sound most consistent with dry eye syndrome
(DES). It is important to note that DES is the most common cause of eye pain! In
Discussion 5
my experience, most patients with dry eye-related pain describe generally mild,
aching, pressure, or pulling sensation. Some say it radiates behind the eye and oth-
ers say eye movement worsens it. It would be highly unusual for DES to cause
sharp, stabbing or pounding pain or for it to be severe. Many patients note that the
pain seems to wax and wane with the day. When patients wake up, their corneas
have been protected all night and then become painful with exposure to wind and
evaporation especially with reading. Interestingly, sometimes DES pain is unilat-
eral. Many patients will note other symptoms of DES such as burning, blurry vision,
tearing, redness, and foreign body sensation but not all will. Examination may show
punctate epithelial erosions, early tear break up time (TBUT), blepharitis, or abnor-
mal Schirmer’s tear testing (Fig. 1.1). In other cases, the slit lamp examination can
appear quite unremarkable. In many, a topical anesthetic will greatly improve the
pain. However, patients with chronic DES-related eye pain of several months dura-
tion may not enjoy improvement. This occurs because of upregulation of pain mod-
ulating proteins within the cornea. Looking at her medications, she is on two
diuretics, a beta blocker and a SSRI, which may worsen DES.
We know that she has rosacea, blepharitis, and an early TBUT. Rosacea can cause
inflammation of the eyelid margin and disruption of the meibomian glands, which
reduces tear quality. We could see if a topical anesthetic substantially improves the
pain. We could also measure her tear production. Given the strong history and physi-
cal, I would favor treating with artificial tears 4–6 × /day, washing the eyelids with
hot water, using warm compresses, fish oil or flaxseed oil (omega 3 oils) 2 × /day for
1 month then 1 × /day, humidifying her environment, and drinking a lot of water. At
bedtime, the patient can also use ocular ointment. If this does not benefit her, then I
would add topical corticosteroids 3–4 × /day tapering by one drop each week. If she
had improvement, but not resolution with the corticosteroids, then I would try topical
cyclosporine 2 × /d. I would also consider punctal plugs and doxycycline 100 mg
2 × /day. More extreme measures could include scleral contact lenses, which put a
layer of tears between the lens and the cornea, or even autologous serum eye drops.
Fig. 1.1 Schirmer tear testing. Some practitioners put anesthetic in and others do not. The strips
are placed in the lower fornix and left there for 5 min. After they are removed the degree of wetting
is measured using a ruler. Less than 5 mm is considered significantly reduced
6 1 Case 1
Neurologic Perspective: Dr. Digre
I agree with Dr. Lee, that this is dry eye. There are many conditions to at least con-
sider that could be co-morbid in this patient. I would want to be sure she does not
have underlying migraine. While she is 63 years old, her migraines may have
tapered off, but individuals with previous migraine could be more susceptible to the
pain of dry eyes. In addition, in my practice, dry eyes can worsen migraine patient’s
headaches. I would also be sure that she has no other neurological symptoms. Her
mother had progressive supranuclear palsy (PSP) and degenerative neurological
disorders can be associated with decreased blinking. While it is not known to be
inherited, movement disorders such as PSP and Parkinson disease are frequently
associated with both dry eyes and complaints about reading and mild convergence
insufficiency. Finally, I would also ask about dry mouth as a symptom of Sjögren’s
disease which often affects middle-aged women. I frequently do a Schirmer’s test.
While this is sometimes negative, even when I know the patient has dry eyes, it is
often helpful to know how dry the eyes are. As for other testing, if she had dry
mouth, I might draw Anti SS A (Anti Ro) and Anti SS B (Anti La) antibodies often
seen with Sjögren’s disease. Because these labs can be negative with Sjögren’s dis-
ease, I would consider lip biopsy, if I were very suspicious.
With the lack of any other neurological symptom or examination finding, I would
not recommend an MRI scan for this patient. Setting out a written treatment plan is
often helpful—outlining the steps to take in improving dry eyes. We frequently
recommend warm soaks if there is blepharitis, frequent preservative free tears, and
gels or ointments at night. Following up with the patient is also important since
further treatment may be helpful. The importance of treating this now and getting
DES under control is that, left untreated, this can lead to trigeminal nerve damage
and neuropathic pain, resulting in more severe pain, which is much more difficult to
treat, so primary prevention of further damage is important.
Non-ophthalmic/Non-neurologic Perspective
The history here will most likely lead you to the diagnosis. You may or may not have
a topical anesthetic in the office or emergency room. The pain, if it is going to
resolve, will do so within a minute. Staining the cornea with fluorescein may show
small, punctate dots of green (aka punctate epithelial erosions or keratopathy) con-
sistent with dry eye. You can use the blue filter on the slit lamp if you have one or,
on the direct ophthalmoscope, view the cornea using the +10 lens (green 10).
Generally speaking, the visual acuity should be normal or near normal (20/25).
Artificial tears are over the counter. There are two kinds, those with preservatives
and those without preservatives. Either one can be used, but some patients develop
sensitivity to the preservatives. When asking the patient to wash the eyelids with hot
water, this is directed at rubbing gently along the base of the eyelashes where the
For Further Study 7
meibomian glands sit. A warm wash cloth over the eyes is also effective. We often
ask patients to do this in the shower. We would not favor a non-ophthalmologist
giving out corticosteroid eye drops or a topical anesthetic to take home. There are
too many risks with an incorrect diagnosis. We would recommend a referral to an
ophthalmologist for a correct diagnosis.
Follow Up
The patient’s pain resolved with topical anesthetic in the office. She used artificial
tears and lid hygiene regularly. The pain persisted, and she tried topical corticoste-
roids. These did not help substantially. With continued use of the artificial tears and
eyelid hygiene and humidification of her environment, her pain resolved spontane-
ously over several months time. Final Diagnosis: Dry eye syndrome.
For Further Study
1. Jackson WB. Management of dysfunctional tear syndrome: a Canadian consensus. Can J

Ophthalmol. 2009;44(4):385–94.
2. Lemp MA. Advances in understanding and managing dry eye disease. Am J Ophthalmol.
2008;146(3):350–6.
3. Messmer EM. The pathophysiology, diagnosis, and treatment of dry eye disease. Dtsch Arztebl
Int. 2015;112(5):71–81.
Case 2
A 75-year-old woman complains of bilateral eye pain. She describes the pain as
burning, itching, and constant. Approximately every few weeks, when she awakes
she has severe right eye pain. She describes it as sharp with a foreign body sensa-
tion, and her vision seems blurred at that time. The pain seems to happen as soon
as she opens her eye and she is afraid to open her eyes in the morning. Both the blur
and the pain resolve slowly over a few hours. With these sharp pains, her eye
waters and it appears reddened. A hot towel and artificial tears make this feel bet-
ter. The left eye seems normal otherwise. She denies any history of trauma or
contact lens use.

Hypercholesterolemia Cataract surgery BE
Osteoarthritis Blepharoplasty BE
Atrial fibrillation Tonsillectomy
Anxiety Tubal ligation
Reflux Gallbladder removal
Hypertension Family history
None
Medications Review of systems
Pravastatin Longstanding joint pain, seasonal allergies, anxiety
Escitalopram Social history
Losartan Never smoked, no alcohol, homemaker
Estradiol
Omeprazole
Zolpidem
Warfarin

10 2 Case 2
Examination
Right eye: 20/20
Left eye: 20/20
Pupils
Equal, round, briskly reactive, no APD
Right eye: 19 mmHg
Left eye: 17 mmHg
External exam
3 mm ptosis right upper lid
2 mm ptosis left upper lid
Eye movements
Normal
Anterior basement membrane dystrophy (ABMD) BE
Punctate epithelial keratopathy (PEK) BE
Intraocular lenses BE
Visual field
Normal
Fundus examination
Mild drusen consistent with macular degeneration
Normal
Discussion
Previously, in Case 1 we discussed dry eye. The patient has signs PEK and symp-
toms (constant burning and itching) of dry eye syndrome. I believe this is the cause
of the constant dull pain that she describes. It almost sounds like she has corneal
abrasions but she likely is not scratching her right eye while she is asleep several
times.
However, dry eye syndrome (see Case 1) typically feels better in the morning and
it does not cause sharp, acute pain. We should examine the patient for lagophthal-
mos (eyes still partially open after closing gently), which can cause pain in the
morning, but the exposure keratopathy of lagophthalmos usually does not cause
severe, sharp pain. This scenario above would be most consistent with recurrent
corneal erosions. Most commonly, a patient notes a history of corneal abrasion with
a sharp object such as a paper cut or a fingernail. The abrasion elevates a layer of the
corneal epithelium, which does not cement itself back down well. When patients
sleep, the eyelid dries to and sticks to the corneal epithelium slightly. When the
patient opens their eye, the eyelid pulls that unstable epithelium off—hence the
severe eye pain. This classically improves over a few hours. Oftentimes, the patient
Discussion 11
will arrive at the eye doctor with no obvious corneal defects (subtle ones are often
present). In the case herein, the patient denied trauma. However, she has ABMD, a
condition of abnormal corneal epithelial basement membrane, which can lead to
poor adherence to the epithelium and corneal erosions. Dry eye syndrome also rep-
resents a risk factor for erosions.
The first line of therapy for preventing erosions is an over-the-counter lubricant
eye ointment placed in the eye(s) before going to sleep. This prevents the eyelid
from sticking to the epithelium. One could consider a bandage contact lens as a
protective barrier. If these do not help, then one could denude the faulty epithelium.
Other alternatives include lasering the epithelium and basement membrane (photo-
therapeutic keratectomy) or stromal micropuncture (using a 25-gauge needle to scar
the epithelium down).
The diagnosis of recurrent erosions or keratitis would be very hard for a neurolo-
gist to make, since it is really seen at the slit lamp and often with fluorescein strips.
Erosions could be considered especially with the history of stinging pain first
thing in the morning. The red eye should be a clue to send the patient to an oph-
thalmologist for a diagnosis. The other clue for me that this is a problem with the
cornea is the intermittent blurred vision—there is no loss of vision, but blurring
also in association with pain. As a first pass, one might start with ointment at night
and more tears throughout the day. Sometime I have prescribed moisture chamber
glasses. However, a referral to an ophthalmologist is probably the most important
step.
Some have advocated using proparacaine drops—but I think these should be
avoided unless the patient is under the care of an ophthalmologist. The other caveat
is that these individuals frequently have other corneal pathology.
You may not have access to or expertise with the slit lamp to identify a subtle epi-
thelial change or ABMD. Much of this diagnosis is based on the history—awaken-
ing with red, painful, tearing, blurry eye that resolves spontaneously over a few
hours. A history of corneal abrasion in the affected eye is gravy. This is not consis-
tent with angle closure glaucoma. If you do not see a corneal abrasion, there prob-
ably is not one. Pearl: Sometimes we see a provider “paint” the fluorescein strips on
the cornea and it can look like a corneal abrasion (Fig. 2.1a, b). The fluorescein
should be placed on the inside lower eyelid and the stain spreads when the patient
blinks (Fig. 2.1c).
12 2 Case 2
a b
Fig. 2.1 Instilling fluorescein. (a) The provider is erroneously placing fluorescein on the cornea.
(b) This leads to stain on the cornea than can look like a corneal abrasion. (c) Proper instillation of
fluorescein on the insider of the lower eyelid. When the patient blinks, this will spread fluorescein
over the cornea in the tear film
Follow Up
The patient used a lubricant eye ointment at bedtime and enjoyed significant
improvement in episodes of recurrent corneal erosions. On occasion, she would
forget to put the ointment in and would redevelop attacks. Final Diagnosis:
Recurrent corneal erosions.
For Further Study
1. Ahad MA, Anandan M, Tah V, Dhingra S, Leyland M. Randomized controlled study of ocular
lubrication versus bandage contact lens in the primary treatment of recurrent corneal erosion
syndrome. Cornea. 2013;32(10):1311–4.
2. Das S, Seitz B. Recurrent corneal erosion syndrome. Surv Ophthalmol. 2008;53(1):3–15.
For Further Study 13
3. Dedes W, Faes L, Schipper I, Bachmann LM, Thiel MA. Phototherapeutic keratectomy (PTK)

for treatment of recurrent corneal erosion: correlation between etiology and prognosis—pro-
spective longitudinal study. Graefes Arch Clin Exp Ophthalmol. 2015;253(10):1745–9.
4. Ewald M, Hammersmith KM. Review of diagnosis and management of recurrent erosion syn-
drome. Curr Opin Ophthalmol. 2009;20:287–91.
5. Heyworth P, Morlet N, Rayner S, Hykin P, Dart J. Natural history of recurrent erosion syn-
drome—a 4 year review of 117 patients. Br J Ophthalmol. 1998;82(1):26–8.
6. Hovanesian JA, Shah SS, Maloney RK. Symptoms of dry eye and recurrent erosion syndrome
after refractive surgery. J Cataract Refract Surg. 2001;27(4):577–84.
7. Moutray TN, Frazer DG, Jackson AJ. Recurrent erosion syndrome—the patient’s perspective.
Cont Lens Anterior Eye. 2011;34(3):139–43.
8. Swaminathan A, Otterness K, Milne K, Rezaie S. The safety of topical anesthetics in the treat-
ment of corneal abrasions: a review. J Emerg Med. 2015;49(5):810–5.
9. Torok PG, Mader TH. Corneal abrasions: diagnosis and management. Am Fam Physician.
1996;53(8):2521–9. 2532
10. Wang L, Tsang H, Coroneo M. Treatment of recurrent corneal erosion syndrome using
the combination of oral doxycycline and topical corticosteroid. Clin Exp Ophthalmol.
2008;36(1):8–12.
11. Watson SL, Lee MH, Barker NH. Interventions for recurrent corneal erosions. Cochrane
Database Syst Rev. 2012;9:CD001861.
12. Wilson SA, Last A. Management of corneal abrasions. Am Fam Physician. 2004;70(1):123–8.
Case 3
A 30-year-old woman underwent bilateral laser in situ keratomileusis (LASIK) sur-

gery 8 months ago. About a month following the surgery she developed pain in both
eyes. She describes it mostly as burning and “hurting.” It is made worse with wind
and computer use. She was given the following eyedrops: artificial tears, preservative-
free artificial tears, olopatadine, cyclosporine ophthalmic emulsion, a topical corti-
costeroid, and a topical nonsteroidal over the ensuing months without benefit. She
had punctual plugs placed in all four puncta and was given moisture goggles to
sleep at night. Despite these efforts, she rates her pain at seven out of ten by the end
of each day. She denies a history of migraine and endorses mild to moderate photo-
phobia. She wears sunglasses outside but not inside.

Fibromyalgia LASIK both eyes
Hypothyroidism
Medications Family history
Levothyroxine Macular degeneration—mother
Sertraline Review of systems
Clonazepam Negative
Vitamin D Social history
Lubricant eye gel Nonsmoker
Social drinker
Secretary

16 3 Case 3
Examination
Acuity without correction
Right eye: 20/20
Left eye: 20/20
Pupils
Equal, round, brisk, no afferent pupillary defect
Right eye: 16 mmHg
Left eye: 17 mmHg
External exam
Dermatochalasis of upper eyelids
No pain to palpation around the eyes
Mild lagophthalmos BE
Normal
A few punctate erosions both eyes (BE)
Unremarkable LASIK flap/scar BE
1+ conjunctivochalasis BE
1+ papillary reaction BE
Reddened and irritated skin along the upper and lower lids
Visual field
Normal
Fundus examination
Normal
Normal
Discussion
The burning history could certainly be consistent with dry eye syndrome. Certainly,
a high proportion of patients after LASIK complain about increased dry eye symp-
toms. I will say that seven out of ten pain is a little high for dry eye, but we have all
seen patients with pain exaggerate their pain score. She has been treated with plugs,
lubrication, moisture chamber, and anti-inflammatories without ANY benefit, which
would argue away from corneal surface concerns. I would see if a topical anesthetic
in the office helps with her pain, which would support an ocular surface issue. If it
were helpful, then one could consider autologous serum or a scleral contact lens. We
have already had a dry eye (see Case 1) case and so this cannot be the answer. 
The papillary reaction is mild and would be more indicative of an allergic issue
associated with itching instead of pain. Conjunctivochalasis is a common condition
where excess folds of the conjunctiva lie between the globe and the eyelid margin.
You can see the folds laying on the lower eyelid margin. Conjunctivochalasis can be
Discussion 17
asymptomatic or cause symptoms of dry eye or mild aching pain. Again, the seven
out of ten pain would be high for conjunctivochalasis. In the absence of a diagnosis,
I have seen ophthalmologists consider resection of the folds, but I am not convinced
this is the answer here.
While I had alluded to the dry eye symptoms following LASIK surgery, there is
a growing movement that these are neuropathic symptoms. When a LASIK flap is
cut and the corneal stroma is ablated, corneal nerves are damaged. Neuropathic pain
can be burning and patients may have allodynia, where light touch induces pain.
The eyelids rub the cornea with every blink and may be interpreted as a foreign
body sensation, but this could be allodynia. In many cases, the symptoms of dry eye
improve as the corneal nerves heal. However, as with nerve injury in other surgical
procedures, some patients experience persistent neuropathic pain. The corneal
nerves may not grow back properly leading to persistent pain. One way to identify
this is with confocal microscopy. Alternatively, one could begin treatment with gab-
apentin to see if there is any benefit.
When I see patients like this, I look to see if they have a family or self history of
migraine, fibromyalgia, or other chronic pain problem. I think some individuals
with these pain conditions are just extra pain sensitive. A recently reported paper by
Shtein et al. is really important—when we see patients with more symptoms than
findings, we need to think about central sensitization similar to what we see in
migraine. In their study, they took 48 patients with dry eyes, 23 patients with fibro-
myalgia, and 26 healthy controls. The dry eye patients were further divided between
concordant (dry eyes looked dry) and discordant (dry eye complaints but normal
examination). Of course Schirmer’s were actually lowest in dry eye patients, but
also in fibromyalgia patients. Ocular Surface Disease Index scores were equally
raised in dry eye and fibromyalgia patients. The discordant group also had decreased
visual quality of life scores that were very similar to the fibromyalgia patients and
the concordant dry eye patients were more like healthy controls!
So, my thinking is that she has a central pain disorder that makes her more likely
to have these complaints than a typical dry eye person. Fibromyalgia occurs in
2–8% of the population and occurs in women. Their functional MR brain imaging
shows similar structural changes seen in patients with chronic pain and migraine.
Treatment for these kinds of cases for me is difficult. First, I tend to maximize
tears and good lid hygiene. Gabapentin would be helpful for her fibromyalgia as
well as her eye symptoms. If she is light-sensitive, we recommend FL-41 tint since
it seems to block the wavelength that is least tolerable for light-sensitive people.
On occasion, I have had to recommend sympathetic blockade for these individuals
since the eye pain acts a little like sympathetically maintained pain (reflex sympa-
thetic dystrophy) or complex regional pain syndrome.
18 3 Case 3
The story is going to be in the history of LASIK or other corneal incision followed
by symptoms of pain a few to several weeks later. The pain often increases as time
progresses. I think you can think of this like a post-surgical neuroma, where the
nerve endings grow back in an anomalous fashion. Most ophthalmologists do not
have access to a confocal microscope, so I do not expect you would either. A trial of
gabapentin for 2–4 months may be reasonable. If the ophthalmologist and you agree
that this is apt to be neuropathic pain then a referral to a neurologist or a pain spe-
cialist may be reasonable. My guess is, these patients will not go to a non-
ophthalmologist since they had LASIK and then develop eye pain, so you may be
off the hook.
Follow Up
The patient underwent confocal microscopy and this showed a closed corneal nerve
loop instead of the normal branching pattern (Fig. 3.1). The patient was diagnosed
with post-LASIK neuropathic pain and was begun on gabapentin 300 mg pills three
times a day. The pain gradually improved over the course of several weeks.
As I review the current literature, there was a case report of a patient with neuro-
pathic eye pain and vitamin B12 deficiency who improved with supplementation.
Other patients have received typical treatments for neuropathic pain including pre-
gabalin and carbamazepine with success. One could consider a sympathetic block
in these cases. There have been a few refractory patients who have tried a spinal
cord stimulator or a pain pump in the area of C1. Final Diagnosis: Post-LASIK
eye pain.
Fig. 3.1 Confocal microscopy

demonstrates a subtle corneal
loop (arrowhead) indicating
abnormal regrowth following
LASIK resection (Courtesy
Stephen C. Kauffman, MD, PhD)
For Further Study
1. Hayek SM, Sweet JA, Miller JP, Sayegh RR. Successful management of corneal neuropathic
pain with intrathecal targeted drug delivery. Pain Med. 2016;17(7):1302.
2. Levitt AE, Galor A, Weiss JS, Felix ER, Martin ER, Patin DJ, Sarantopoulos KD, Levitt
RC. Chronic dry eye symptoms after LASIK: parallels and lessons to be learned from other
persistent post-operative pain disorders. Mol Pain. 2015;11:21.
3. Shetty R, Deshpande K, Ghosh A, Sethu S. Management of ocular neuropathic pain with vita-
min B12 supplements: a case report. Cornea. 2015;34:1324–5.
4. Shtein RM, Harper DE, Pallazola V, Harte SE, Hussain M, Sugar A, Williams DA, Clauw
DJ. Discordant dry eye disease (An American Ophthalmological Society Thesis). Trans Am
Ophthalmol Soc. 2016;114:T4.
Case 4
A 29-year-old man complains of left eye pain with prolonged near work for the past
several months. The pain begins after reading for several minutes and spreads to his
frontal region and the right eye unless he stops reading. If he does not read, he does
not really develop pain. He describes it as an ache that worsens to a 5/10 at its worst.
The clarity of his vision in each eye is unaffected. He denies double vision, ptosis,
oscillopsia, eye redness, and epiphora. He does not wear glasses, but has recently
purchased over-the-counter readers, which did not help.

Chronic sinusitis Sinus surgery
Social history Family history
1–2 beers daily, occasionally smokes marijuana but No history of migraine, no eye disease
not cigarettes, salesman Mother has glaucoma
None Negative
Examination
Acuity without correction
Right eye: 20/20 distance and near
Left eye: 20/20 distance and near
Cycloplegic refraction
Right eye: +0.25
Left eye: Plano
Pupils
Equal in size, briskly reactive, round

22 4 Case 4
Right eye: 20 mmHg
Left eye: 19 mmHg
External exam
No ptosis, no proptosis, normal appearance
Eye motility and alignment
Normal eye excursions, both eyes
Normal pursuits and saccades
Orthophoric in the distance in all gazes
12 prism diopter intermittent exotropia at near
Near point of convergence 20 cm (Fig. 4.1)
No blepharitis
No keratopathy or tear film dysfunction
Visual field
Normal
Fundus examination
Normal
Normal
Fig. 4.1 The patient is focusing on

the examiner’s finger as it is
brought closer to the nose. At this
point, 20 cm away, the patient’s
right eye is focused on the finger,
but the left eye has just deviated off
the finger. This patient has an
abnormal near point of convergence
consistent with CI
Discussion
This patient gives a story most consistent with “eyestrain,” where folks complain of
bilateral eye tiredness or aching that can radiate to the temples or the frontal region
with prolonged reading. Nowadays, you might hear it called “Computer Vision
Syndrome” as well. Sometimes this story could be consistent with dry eye syn-
drome (see Case 1), and this should be ruled out. Eyestrain is a wastebasket term
that includes uncorrected hyperopia, over-corrected myopia, poor accommodation,
or eye misalignment at near. Eye evaluation should include a good refraction at
Discussion 23
distance and near pushing plus. Patients younger than 45 may require a cycloplegic
refraction to determine any hidden hyperopia or overminus. Cover testing with a
near target may show a exo- or hyperdeviation. A Maddox Rod can help identify
cases of tiny hyperdeviations that may be difficult to observe.
The patient herein has a convergence insufficiency pattern—full eye movements,
exodeviation greater at near, and a distant near point of convergence. Typically, the
exodeviation measures at least 10 PD more at near than distance. Normally, the eyes
can converge on a target at <8 cm. Convergence insufficiency (CI) in this age group
most commonly results from head trauma or is idiopathic. He denies trauma, and
there is no need to pursue neuroimaging for isolated CI. Management usually
involves pencil pushups, where one looks at a target and brings it closer to the eyes
until it becomes double or blurred. The goal is to strengthen convergence by doing
these exercises hundreds of times a day. In our experience, most patients do not have
the discipline to do these. Other options include giving base in prisms for reading,
formal therapy with a trained orthoptist, computer-based convergence programs,
patching an eye for reading (not ideal) and surgery (rarely performed). Monovision
could be considered for presbyopic patients unable to tolerate the options above.
When I see someone with this history I do three things. First, I go over the migraine
history, because MANY patients with this disorder often are visually sensitive and
have migraine (see Case 19). Sometimes you have to ask, “you mean you have never
had a headache?” and then “did this headache ever make it hard for you to do your
work?” “were you ever light or sound sensitive with your headache?” I also ask
whether the reading problem is all types of reading material (like computer screens,
tablets, television, or books) in all forms of lighting—fluorescent lighting and com-
puter vs incandescent bulbs. Then on examination, I first look at acuity—and see if
this patient could be a latent hyperope (meaning they are far-sighted). I look really
carefully for dry eyes and sometimes perform a Schirmer’s test. We are a computer
using generation, and when we are on the computer, we blink less frequently, which
can set up dry eyes in someone you would not suspect. I agree that looking for con-
vergence insufficiency or divergence insufficiency is also important. Sometimes we
look at convergence and divergence amplitudes—how much reserve does a person
have. For example, we can use a prism bar and push it up and down base in or base
out to test these amplitudes. Third I treat. If they have modest dry eyes, I stress
lubrication at the computer screen. If they are also light-sensitive, FL-41 glasses can
be helpful (see Case 21). I do stress pencil push-ups and sometimes even pressure
points that were once developed by the Chinese for embroiderers for a living (see
Fig. 4.2). The exercises have been tested in children to prevent myopia and accom-
modation with minimal benefits, but for eye strain in some individuals they may be
more helpful.
24 4 Case 4
a b
c d
3
4
1
5
Fig. 4.2 Steps to Chinese exercises for eye strain. (1) Perform exercises in the morning and after-
noon. (2) Do not push on your eye balls (3) Press the pressure point until an ache feeling occurs and
repeat about eight times each time. (a) Push just under your eye brows (Zhan Zhu Point). (b)
Massage the bridge of your nose (Fu Jing Ming Point) (c) Press on your center of your cheek (Si Bai
Point). (d) Rub around your eye—first along your eye brow then a lower half circle below your eye
When a patient complains of pain or headache with prolonged reading, consider that
they may have eyestrain. In your office, you could consider having the patient stare
at a near target such as your nose at 1/3 of meter. Alternately, covering the eyes may
show a shift of the eyes as you go back and forth. If the eye shifts toward the nose,
then that is consistent with an exodeviation as seen in CI. If the eye shifts up or
down, then that is consistent with a hyperdeviation such as a fourth nerve palsy. You
can also have the patient look at a target and bring the target to the nose. As you
watch the eyes, they should converge on the target as it gets closer. If you see one of
the eyes deviate outward as you bring it closer, then that distance is the near point
of convergence. You could consider offering the patient convergence exercises, if
the eye movements are otherwise full. In the absence of an eye misalignment, the
patient will need to get a good refraction at distance and near with an ophthalmolo-
gist or optometrist.
Follow Up
The patient received a diagnosis of CI and was given pencil pushups. He reported
noncompliance with the exercises. He was given the options of visiting with an
orthoptist, using a computer convergence program, and base-in prisms. He was told
that prisms might make him dependent on the glasses and that he may see double at
near without the prisms. After consideration of all the factors, he elected to receive
a prescription for reading glasses with six base-in prism in each lens. He reported
significant improvement in his symptoms. Final Diagnosis: Convergence insuffi-
ciency causing “eyestrain”.
For Further Study
1. Akinci A, Güven A, Degerliyurt A, Kibar E, Mutlu M, Citirik M. The correlation. between
headache and refractive errors. J AAPOS. 2008;12(3):290–3.
2. Convergence Insufficiency Treatment Trial Study Group. Randomized clinical trial of treatments
for symptomatic convergence insufficiency in children. Arch Ophthalmol. 2008;126:1336–49.
3. Lin Z, Vasudevan B, Fang SJ, Jhanji V, Mao GY, Han W, Gao TY, Ciuffreda KJ, Liang YB. Eye
exercises of acupoints: their impact on myopia and visual symptoms in Chinese rural children.
BMC Complement Altern Med. 2016;16:349.
4. Serna A, Rogers DL, McGregor ML, Golden RP, Bremer DL, Rogers GL. Treatment of symp-
tomatic convergence insufficiency with a home-based computer orthoptic exercise program. J
AAPOS. 2011;15:140–3.
5. Schieman M, Gwizada J, Li T. Non-surgical interventions for convergence insufficiency.
Cochrane Database Syst Rev. 2011;3:CD006768.
6. Vincent AJP, Spierings ELH, Messinger HB. A controlled study of visual symptoms and eye
strain factors in chronic headache. Headache. 1989;29:523–7.
Case 5
A 56-year-old woman noted left, intermittent periorbital and orbital pain for
7 months. It occurs suddenly and can wake her from sleep. However, it occurs at all
times of the day approximately twice weekly, lasting 30–120 min. She denies a trig-
ger. She endorses a history of temporal mandibular joint issues and believes this is
related. Blurred vision coincides with the eye pain each time and she notes mild
nausea and photophobia, but denies osmophobia or phonophobia. The blurry vision
does not occur independent of the eye pain. She denies seeing sparkles or lights. She
has a history of severe diabetic retinopathy status post vitrectomy in the right eye
2 years ago. Her right upper lid has drooped since that surgery. She has had exten-
sive laser for neovascularization related to the diabetes to both eyes.

Diabetes mellitus Kidney transplant 1984
Addison disease Pancreas transplant 2002
Hyperlipidemia Heart bypass 2001
Hypertension
Agoraphobia with panic disorder
No history of migraine
Social history Family history
Unemployed, never smoked, former No eye disease
alcoholic Strong family history of diabetes, hypertension, and
hyperlipidemia
No family history of migraine

28 5 Case 5

Hydrocortisone Earaches from the wind
Prograf Shortness of breath
Cellcept Constipation
Actonel Joint pain
Aspirin Itchy skin
Atenolol Depressed mood
Diazepam Easy bruising
Percocet Numbness of hands and feet
Prozac Difficulty walking from leg weakness
Lipitor
Examination
Right eye: 20/200
Left eye: Hand movements; near vision 20/40
Pupils
Constricted, barely reactive, round, equal in size
Right eye: 16 mmHg
Left eye: 19 mmHg
External exam
Symmetric ptosis and dermatochalasis of both upper lids
Eye movement/alignment
Normal
Chronic blepharitis all four lids
Intraocular lens right eye, dense cataract left eye with
Phacodonesis
No evidence of rubeosis
Anterior chamber: Deep right eye, shallow left eye
Visual field
Constricted right eye, unable left eye
Fundus examination
Optic nerve pallor both eyes
Numerous and dense laser scars both eyes
Numbness both feet, 4/5 strength in legs, poor proprioception of toes bilaterally
Discussion
This patient sounds like she could have migraine (see Case 19)—she has episodic
eye pain associated with concomitant blurred vision, nausea, and photophobia.
The pain is side locked. However, she is older than the average bear to have first
onset migraine and does not have a history of migraine. The story is funny in that
Discussion 29
Table 5.1 Drugs causing angle closure glaucoma

Tricyclic antidepressants
Non-tricyclic antidepressants (e.g., escitalopram, fluoxetine, mirtazapine, venlafaxine, buproprion)
Anticholinergics
Acetazolamide
Topiramate
Promethazine
Ranitidine
Cabergoline
Cimetidine
HCTZ
she notes the blurred vision and eye pain begin at the same time and are of sudden
onset plus they can wake her from sleep. Auras usually take minutes to reach a
peak. Her acuity is better at near than at a distance—and this is induced myopia
that she never had before. When one looks at her physical examination, she has a
shallow anterior chamber in the left eye along with phacodonesis (excessive move-
ment of the lens).
The history and exam are certainly consistent with intermittent angle closure
glaucoma (ACG). She denies a trigger; however one should inquire about whether
sudden exposure to light, lying down, or taking medications (anticholinergics,
antidepressants, antihistamines, and adrenergics) seems to initiate these attacks.
She happens to be on fluoxetine (Prozac), which has been associated with ACG. See
Table 5.1. Risk factors for angle closure include female gender, smaller eyes
(hyperopia), older age, and Asian or Indian descent, topiramate use. She denies red
eye or tearing, but these can accompany ACG. Normally, we think of acute ACG
as a one-time event, where the patient presents to the ER with prolonged eye pres-
sure elevation that does not remit until the patient receives drops, lasers, or sur-
gery. In some cases, the angle can open and the pressure comes down spontaneously
and recurs intermittently as in this case. We have seen intermittent ACG misdiag-
nosed as migraine by neurologists because of the similarities in historical
features.
These patients should be instructed to avoid provocative medications and to have
a laser peripheral iridotomy to prevent further attacks. In some cases, if the lens is
very large, cataract extraction may be necessary.
This is a new headache in an older woman. Anyone presenting with a new headache
needs to be evaluated for a secondary cause, especially when she never really had
headaches before. The visual blur and pain would suggest to the neurologist that
there may be an ocular problem (e.g., corneal erosion (see Case 2)) and that the
patient should be seen by an ophthalmologist.
30 5 Case 5
The temporal mandibular joint (TMJ) dysfunction confounds the history as

well. TMJ is diagnosed when someone has demonstrated joint disease that is
demonstrated by imaging and/or clinical examination—for example, the individ-
ual cannot open the mouth more than 2–3 fingerbreadths. The pain is usually
associated with jaw movements, which is not part of the history here. TMJ dys-
function is greatly over-rated and while she may think this is the cause—look for
another cause. The nocturnal wakening could suggest hypnic headache especially
in an older person, but we are told this pain comes at all times of the day and
night.
For sure, this woman should have a good eye examination—and I would defi-
nitely want a slit lamp examination since her acuity is down 20/200, hand motions
PLUS she has diabetes. Too many red flags here for my liking. The ophthalmologist
finds a narrow angle on the left side. This could suggest angle closure.
Differentiating migraine and intermittent acute angle closure can be tricky. If
this woman had a previous migraine history, we might have thought she had
migraine as the cause of pain. The clues for me that this is not migraine is that it
occurs in the same eye and that the blur and the pain are simultaneous. Migraine
aura is not typically just a blur—it often as a progression over minutes and it
occurs in both eyes. Aura is often colored or has zig-zag lines and often the pain
will occur after the visual disturbance. The nausea with the pain can also con-
fuse the neurologist since we usually associate nausea with migraine. The only
other thing to worry about is ocular ischemia that could cause pain and visual
blurring. A fluorescein angiogram may be helpful looking at an arm to retina
time. Finally, always consider giant cell in any older individual with a new head-
ache (see Case 32).
The history will be essential in distinguishing ACG and migraine. There may be an
atypical feature that may guide you. Most patients with migraine experience the
blurred vision of an aura before the pain begins. The blur usually progresses over
minutes and subsides over minutes. Typically, the aura of migraine lasts less than an
hour. However, a new headache in an older person should always alert you that there
could be a secondary cause. Keep in mind that migraine is common and intermittent
ACG is uncommon.
You can also take a penlight and shine it from the side of the anterior chamber
parallel to the iris. If the chamber is deep, then the light will uniformly illuminate
the iris. If the chamber is narrow, it may cast a shadow on the nasal side of the iris
(Fig. 5.1).
Normal angle
Narrow angle
(Angle closure glaucoma)
Fig. 5.1 Shining a light from the side in a normal angle will produce no shadow. If the angle is
shallow, there may be a shadow. From Digre and Corbett, Practical Viewing of the Optic Disc.
Butterworth-Heineman, 2001 (with permission)
Follow Up
Compression goniscopy showed an occludable (appears closed, but can open the
angle with pressure) anterior chamber angle with areas of peripheral anterior syn-
echiae. She was diagnosed with intermittent angle closure glaucoma likely related
to the mobile lens in the left eye. The patient underwent laser peripheral iridotomy
(LPI) followed by uncomplicated cataract extraction. The episodic eye pain resolved
after the LPI. Final diagnosis: Intermittent angle closure glaucoma.
For Further Study
1. Lewis J, Fourman S. Subacute angle-closure glaucoma as a cause of headache in the presence

of a white eye. Headache. 1998;38:684e.
2. Murphy RM, Bakir B, O’Brien C, Wiggs JL, Pasquale LR. Drug-induced bilateral. Secondary
angle-closure glaucoma: a literature synthesis. J Glaucoma. 2016;25(2):e99–105.
3. Shindler KS, Sankar PS, Volpe NJ, Piltz-Seymour JR. Intermittent headaches as the presenting
sign of subacute angle-closure glaucoma. Neurology. 2005;65:757–8.
Case 6
A 59-year-old 6th-grade teacher presents with eye pain and difficulty keeping her
eyes open. She reports she was diagnosed with dry eyes in 2014 by an optometrist and
treated with cyclosporine ophthalmic solution (Restasis) for 8 months without relief.
During this time, she noticed that she had trouble keeping her eyes open at work as
though she was sleepy and she had frequent blinking that would worsen in bright
light. When driving she has been so bad that she has pulled off of the road to rest her
eyes. She noticed more and more trouble making eye contact. She has a dull ache in
both eyes that sometimes worsens at the end of the day; she has also noticed signifi-
cant light sensitivity. An ophthalmologist diagnosed blepharospasm 1 year before and
tried botulinum toxin A, which helped somewhat. She has noticed some adventitial
mouth movements for years. She wants to know if there is anything else to do.

Diagnosed with head tremors 12 years before Neck fusion, ankle surgery, gallbladder
treated with propranolol surgery, hysterectomy
Migraine with aura once each year; more recently
only an aura without headache
Anxiety for 30 years
Hyperlipidemia
Alprazolam Father with tremor
Artificial tears four times each day Amyotrophic lateral sclerosis in several
Cyclosporin eye drops twice daily family members
Propranolol Cancer in her mother
Social history Review of systems
Married with two children Mild weight gain
No alcohol or tobacco Breakouts of a rash on her face

34 6 Case 6
Examination
Right eye: 20/20
Left eye: 20/20
Pupils
Equal with no RAPD
Color vision (HRR)
9/9 bilaterally
Stereo vision
Perfect
External exam
Minimal rosacea changes of her skin
Eye alignment
Normal
Meibomian gland dysfunction in both eyes
Visual field
Normal to confrontation
Fundus examination
Normal
Mildly diminished movement of her forehead; frequent blinking, frequent lip movements.
After squeezing her eyes tightly, she had some difficulty opening them again. The rest of her
examination was normal
MR scan
Imaging done 2–3 years before showed a normal brain MR and aside from the fusion of the
neck, and normal neck MR
Discussion
This patient has the diagnosis of blepharospasm and apraxia of eye lid opening. She
also has co-morbid dry eye symptoms, photophobia (see Case 21), head tremor, and
some mouth movements (oral-facial dystonia or Meige syndrome).
Blepharospasm is a primary dystonia associated with frequent blinking, squeez-
ing, often heralded with symptoms of dry eye and photophobia. It is the most com-
mon form of dystonia and occurs typically more frequently in women and in the
fifth to sixth decade. As in our patient, many patients have other movement disor-
ders such as oral facial movements/dystonia or tremor. Many patients have a trick
(putting their finger to the eye, singing, reading) to keep the eyes open and not
spasming. Our patient did not know of any trick. Visit the Neuro-ophthalmology
Virtual Educational Library (NOVEL) where you can view many example videos.
For a typical case of blepharospasm with apraxia of eyelid opening see http://con-
tent.lib.utah.edu/cdm/singleitem/collection/EHSL-Moran-Neuro-opth/id/71/rec/5.
Discussion 35
The first symptoms are usually a scratchy, gritty feeling to the eye and frequently
dry eyes (see Case 1) are diagnosed. Photophobia is present in most of these patients.
Interestingly, many patients with dystonia and blepharospasm have increased fre-
quency of depression and anxiety like our patient. Some patients with blepharo-
spasm also have apraxia of eye lid opening—described often as the inability to keep
the eyes open even when doing such activities as driving. In addition, about one-
third of patients can have oral-facial dystonias as she does.
The diagnosis is made clinically with typical symptoms such as our patient and
findings of increased blinking, sometimes squeezing. The pain in the eyes in this
disorder is probably the dry eye symptoms but it is usually mild. A feeling of gritti-
ness is frequently described and treating the dry eye portion may help some, but the
movement disorder continues. In fact, some have speculated that the frequent blink-
ing may exacerbate the dry eye feeling. Rosacea has been reported in 15% of patients
with blepharospasm. Occasionally, the pain can be severe and has been associated
with corneal neuropathy. These cases may require more aggressive therapy.
The cause of blepharospasm is thought to be a lack of inhibition from malfunc-
tioning of the basal ganglia. Indeed lesions in the basal ganglia, thalamus, and
brainstem have been associated with symptomatic blepharospasm. However, most
blepharospasm has no obvious changes in the brain. Rarely, further testing is
required such as EMG or MR scan—EMG only if there is a doubt about the diagno-
sis and MR scan if there are other focal neurologic findings.
Treatment with botulinum toxin has been the mainstay in the last 30 years. There
are several varieties of botulinum toxin, but the two approved by the FDA currently
are onabotulinum toxin and incobotulinum toxin, but there are several others that
have been used in Europe and here including: Abobotulinum toxin, Rimabotulinum
toxin B. The drug has been highly successful in most patients. There have been few
side effects—worsening dry eyes, ptosis. Reinjection occurs variably from person
to person but 3–6 months is typical. We also address the dry eyes, by using frequent
preservative-free tears frequently and even ointment at night. The light sensitivity
can be treated with FL41 tint, which has been studied in blepharospasm and can
often reduce blinking and light sensitivity. Infrequently, surgical treatment is neces-
sary for blepharospasm.
Apraxia of eyelid opening is often more difficult to treat and frequently botuli-
num toxin is helpful. Other drugs have been tried including Aripiprazole which has
been reported helpful in Apraxia of eye lid opening associated with Parkinson dis-
ease. Sometimes lid crutches are helpful for the apraxia.
This is a diagnosis you could make in the grocery store. If you watch the videos, you
can see that patients with blepharospasm have uncontrolled spastic eyelid closure.
The muscles around the eyes (orbicularis oculi) are contracting. Meanwhile, in
36 6 Case 6
Fig. 6.1 Injection sites for

botulinum toxin A
injections. X typical
injection sites of 2.5–
5.0 units, O additional
injection sites for
refractory symptoms
apraxia of eyelid opening, the eyes appear passively closed. The patients note that
they feel too “weak” to open them.
Many patients do well with botulinum toxin A injections. One could give
2.5 units or 5 units at locations along eyebrows, along the eyelashes, and next to the
lateral canthus in the area of the “crow’s feet.” Generally, physicians do not give
more than 100 units at any given sitting, but some of my patients have received as
many as 150 units. Figure 6.1 shows the typical locations of injections (x) and some
accessory ones (o). Some patients find the botulinum injections painful because the
eyelid skin is so thin and sensitive. We will sometimes use a 32-gauge needle or
topical lidocaine to numb the skin. The lidocaine needs to sit about 30–45 min on
the skin. In other cases, patients have requested oral anxiolytics or oxycodone to
take before the injections.
Patients may also have significant degrees of dermatochalasis and ptosis. These
patients can undergo a limited orbicularis oculi myectomy, where muscle is removed
from around each eye. This is often not covered by insurance, but is billed as a func-
tional ptosis repair while orbicularis is also removed. Myectomy does not eliminate
the need for botulinum toxin but can reduce the frequency and the dose required.
Patients with apraxia may require a frontalis sling, where the eyebrows are surgi-
cally attached to the eyelids using cadaver fascia lata or silicone slings.
Primary care physicians can recognize blepharospasm and will likely need the help
of an ophthalmologist who is most likely to care for these patients. These patients
do not require an MRI unless other neurological features are present. Historically,
they were diagnosed with a nonorganic or anxiety issue and treated with oral anxio-
lytics. In some cases, patients note significant improvement with these agents, but
generally require botulinum toxin or surgery.
Follow Up
We treated our patient with continued onabotulinum toxin, FL41 tint for the light
sensitivity, and aggressive dry eye therapy (preservative free tears, ointment at
night, continued the cyclosporin drops). The apraxia of lid opening could be con-
trolled by singing—she had never recognized that she had a trick. While she was not
symptom-free, she became somewhat more functional. Final diagnosis: eye pain
from blepharospasm.
For Further Study
1. Blackburn MK, Lamb RD, Digre KB, Smith AG, Warner JE, McClane RW, Nandedkar SD,
Langeberg WJ, Holubkov R, Katz BJ. FL-41 tint improves blink frequency, light sensitivity,
and functional limitations in patients with benign essential blepharospasm. Ophthalmology.
2009;116(5):997–1001.
2. Borsook D, Rosenthal P. Chronic (neuropathic) corneal pain and blepharospasm: five case
reports. Pain. 2011;152(10):2427–31.
3. Hallett M, Albanese A, Dressler D, Segal KR, Simpson DM, Truong D, Jankovic J. Evidence-
based review and assessment of botulinum neurotoxin for the treatment of movement disorders.
Toxicon. 2013;67:94–114.
4. Hellman A, Torres-Russotto D. Botulinum toxin in the management of blepharospasm: current
evidence and recent developments. Ther Adv Neurol Disord. 2015;8(2):82–91.
5. Khan TT, Donaldson J, Hesse RJ. Facial dystonias and rosacea: is there an association? Orbit.
2014;33(4):276–9.
6. Peckham EL, Lopez G, Shamim EA, Richardson SP, Sanku S, Malkani R, Stacy M, Mahant P,
Crawley A, Singleton A, Hallett M. Clinical features of patients with blepharospasm: a report
of 240 patients. Eur J Neurol. 2011;18(3):382–6.
7. Rana AQ, Shah R. Combination of blepharospasm and apraxia of eyelid opening: a condition
resistant to treatment. Acta Neurol Belg. 2012;112(1):95–6.
8. Tokisato K, Fukunaga K, Tokunaga M, Watanabe S, Nakanishi R, Yamanaga H. Aripiprazole
can improve apraxia of eyelid opening in Parkinson’s disease. Intern Med. 2015;54(23):3061–4.
9. Valls-Sole J, Defazio G. Blepharospasm: update on epidemiology, clinical aspects, and patho-
physiology. Front Neurol. 2016;7:45.
Case 7
A 61-year-old man complained of new, gradual-onset, left-sided eye pain for 2 days.
It is annoying, aching pain that feels like a bruise. The left lower eyelid is tender.
The pain is rated as a 2/10. The eye and eyelid does not look red or swollen. There
is no effect on vision or double vision. The patient denies ptosis. He has a history of
physiologic anisocoria, discovered 15 years prior on routine examination. There is
no tearing, proptosis, nasal symptoms, or migraine symptoms. The pain seems like
it is perhaps worse with eye movement and it is gradually getting worse. He denies
trauma.

Hypertension Wisdom teeth removed as a teen
Hypercholesterolemia
History of soft contact lenses
Occasional migraine headaches
Seasonal allergies
History of traumatic iritis RE 10 years ago
Atorvastatin Father—High cholesterol, diabetes, hypertension
Metoprolol Mother—High cholesterol, glaucoma suspect
Multivitamin Brother—High cholesterol, diabetes
Nasal steroid spray
Krill oil
Married, never smoked, 1–2 drinks a day, Mild, chronic neck and shoulder pain
3–4 days a week Dermatographism
Difficulty sleeping
No fever, chills

40 7 Case 7
Examination
Right eye: 20/15
Left eye: 20/15
Pupils
Normal
Right eye: 14 mmHg
Left eye: 15 mmHg
External exam
Dermatochalasis
Normal
No injection, chemosis, uveitis
Visual field
Normal
Fundus examination
Normal
Normal
Discussion
This is not apt to represent a headache syndrome. This patient has mild localized
tenderness of the left eye and more focused on the left lower eyelid. However, the
external examination appears fairly unremarkable. It has only been a day or two,
and it is possible that this represents forme fruste preseptal cellulitis or stye. I would
palpate over the lacrimal gland (superotemporal eyelid) and the trochlea (superona-
sal eyelid). I would also look at the lacrimal gland to see if it is enlarged. We are told
that he does not have uveitis, but in some cases, iritis can present with mild tender-
ness. I would also consider a foreign body. The patient wears contact lenses and
occasionally contact lenses become “lost” under the upper eyelid. I would evert the
eyelids, and if no cause is found, then I would double evert the eyelid with a
Desmarres lid retractor. I would also sweep the upper fornix to make sure that no
foreign bodies have hidden there.
If we cannot find a cause, then I would recommend hot compresses and artificial
tears and observation…basically ordering the test of time. Time will tell whether
this represents something more sinister. I do not have anything to push me toward a
scan or blood work. I would not order a CBC or give antibiotics.
Discussion 41
Palpation around the eye is always a great idea in eye pain like this. A few things I do
would be to palpate the trochlea since trochleitis can cause pain and it is easy to pal-
pate. I would also gently palpate the lid of the left eye to see if I could find some focal
tenderness. Also, to rule out a vascular or migraine cause I frequently compress the
superficial temporal arteries or superior and inferior orbital arteries to see if this
improves the pain. If it does, my experience suggests that this is migrainous or vas-
cular. While this man has migraine, he is not complaining of any migraine features
like light and sound sensitivity or nausea. This does not sound like any trigeminal
autonomic cephalgias—it is a new pain for him. I would keep looking at the eye!
This sure sounds like a foreign body in the eye. And I agree with lid eversion.
I would also check for dry eyes since sometimes individuals complain about this
type of pain with dry eyes.
With such a normal looking eye and lack of other findings, I would recommend flip-
ping the eyelid. To flip the upper eyelid, you have the patient look down, then you
grab the eyelashes with your hand. The patient continues to look down, while you
push down on the eyelid crease and pull up on the eyelashes. A video of this can be
seen at this link: https://www.youtube.com/watch?v=XU-hZ4ryx48. To sweep the
upper fornix, you can put a numbing drop in the eye, have the patient look down,
and sweep a proparacaine covered cotton tip under the upper eyelid. If you are com-
fortable looking for uveitis, then I would use a slit lamp. If not, then consider send-
ing the patient for an eye exam. This is not an emergency!
Follow Up
The patient’s lower eyelid was everted and there was a localized area of redness
with a white spot in the center. This was sitting along the conjunctiva running on the
inside of the eyelid (Fig. 7.1). This is consistent with an early chalazion. The eyelid
was not swollen (yet) and there was no localized, erythematous external bump (yet).
After proparacaine was given, the patient had the chalazion “popped” using two
cotton tips. The pain resolved after a day or two.
The eyelid contains a firm, rubbery tissue called the tarsus. Meibomian glands in
the tarsus can become occluded and swell. Initially, the swelling appears on the
conjunctival surface of the eyelid and later become visible externally. They can be
painful acutely and painless, if they become chronic. Normally, these drain on their
42 7 Case 7
Fig. 7.1 The lower eyelid

is everted and shows a
focal area of redness and
elevation nasally along the
conjunctival side of the
eyelid consistent with an
acute stye (Courtesy Ali
Mokhtarzadeh, MD)
own, while some persist and may require an incision and drainage. Local injection
of corticosteroids is another option. If they are recurrent in the same location or not
located along the tarsus, then it may require biopsy to rule out other causes. Final
diagnosis: chalazion.
Digre’s last thought: Interestingly, chalazion contrary to a lot of people’s belief
can and do cause eye pain. We recently reviewed eye pain in two large eye centers
and it was definitely in the top 5 causes of eye pain going to ophthalmology. There
is not a lot of literature about pain in this disorder.
For Further Study
1. Bowen RC, Koeppel J, Christensen C, Snow KB Ma J, Katz BJ Krauss H, Landau K, Warner

JEA, Crum AV, Straumann D, Digre K. The most common causes of eye pain at two tertiary
ophthalmology and neurology clinics JNO in press.
2. Carlisle RT, Digiovanni J. Differential diagnosis of the swollen red eyelid. Am Fam Physician.
2015;92(2):106–12.
3. Waldman CW, Waldman SD, Waldman RA. A practical approach to ocular pain for the non-
ophthalmologist. Pain Manag. 2014;4(6):413–26.
Case 8
A 36-year-old, morbidly obese man noted pain behind his right eye and along his
right temple for 3 months. It is constant with intermittent worsening for several
hours at a time. The pain worsens with eye movement upward and with touching the
eye. He denies vision loss, tearing, redness, eyelid swelling, double vision, or intra-
cranial bruit. He has significant photophobia, but no phonophobia or osmophobia.
He denies nausea or vomiting. He notes a history of temporal mandibular joint
(TMJ) issues. He underwent an MRI and MRV brain, which showed a partially
empty sella. He has tried prednisone starting at 100 mg daily with taper over several
weeks, rizatriptan, and acetazolamide without benefit.

Diabetes mellitus Sinus surgery
Hypertension Colonoscopy
Gastric ulcer Appendectomy
Sleep apnea Cholecystectomy
Depression

44 8 Case 8

Simvastatin Diabetes
Losartan Hypertension
Trazodone Migraine
Prednisone 10 mg
Lamotrigine
Insulin
Fluoxetine
Clonazepam
Vitamin D
Rizatriptan
Cetiritzine
Multivitamin
Never smoked, casual drinker, works at a computer all day Dry mouth
Pain with chewing
Shortness of breath with exertion
Diffuse joint pain
Diffuse muscle aches
Low back pain
Diarrhea on and off for years
Reflux type pain for past few weeks
Examination
Right eye: 20/25-1
Left eye: 20/20
Pupils
Equal, round, briskly reactive, no afferent defect
Color vision
Normal
Right eye: 19 mmHg
Left eye: 21 mmHg
External exam
No edema, no redness, no ptosis
Severe tenderness to palpation deep to the right superomedial orbital rim
Normal, but pain with eye movement up and down when looking to the left
Normal, no injection, corneal staining
Visual field
Normal
Fundus examination
Normal, no diabetic retinopathy
Normal
Discussion 45
Discussion
“Pain with eye movements” often represents a knee-jerk reaction for optic neuritis.
Indeed, optic neuritis can also have tenderness to palpation of the globe. However, in
this case, the patient is not complaining of visual loss nor demonstrating evidence of
optic nerve dysfunction (color vision loss, afferent pupillary defect, visual field
defect, acuity loss). The pain from optic neuritis may last up to 2 weeks, so this
would be incredibly atypical. Other causes for pain with eye movements would
include myositis (inflammation of an extraocular muscle), trochleitis, or orbital
inflammation/infection. Of course, pain is such a squirrely symptom that patients
with migraine, dry eye, and occipital neuralgia may complain of pain with eye
movement as well—i.e. the symptom is not specific!
The patient is not demonstrating evidence of orbital inflammation such as propto-
sis, eyelid edema, conjunctival redness, or swelling. This could represent myositis or
trochleitis. The trochlea is a fibrous band in the superomedial orbit through which the
superior oblique tendon passes. Some patients may suffer inflammation of the trochlea
and develop acute on chronic pain, worsened by eye movement. The patient herein has
exquisite tenderness over the area of the trochlea, which strongly supports the diagno-
sis. Often, inflammation of the trochlea cannot be observed on neuroimaging or ultra-
sonography and is predominantly a clinical diagnosis. Myositis can affect the muscle
belly or tendinous insertions of any of the six extraocular muscles. This causes enlarge-
ment and enhancement of the affected muscle on CT, MRI, or orbital ultrasound.
Normally, I would not order an MRI since I feel strongly that this is trochleitis.
However, since we have it, I would take a look at the MRI for any missed eye muscle
inflammation or fat stranding in the orbit. If this appears normal or if I do not have an
MRI, then I would offer the patient an injection of corticosteroids to the trochlea. In
many cases, patients are worried about an injection to the periocular region so I might
offer a course of oral steroids or indomethacin. If the patient fails this, then they often
opt for the injection at that point. I inject 0.5–1.0 mL of triamcinolone 40 mg/mL using
a 25-gauge ½ in. needle. Triamcinolone is a suspension, so you cannot use a 30-gauge
needle because it will not pass through. There have been case reports of periocular
injections causing central retinal artery occlusions, so others use dexamethasone 4 mg/
mL. Dexamethasone is short acting and triamcinolone is long acting, which is why I
like to use it. Some of my colleagues mix the corticosteroids with 0.5 mL lidocaine 1
or 2% (without epinephrine) in the same syringe for a total of 1 mL. Lidocaine, if
injected into an eye muscle will cause severe myotoxicity. Fortunately, it is the tendon
that runs through the trochlea and there is a lower chance of a myotoxic event.
If you are going to give the injection, make sure the needle is directed superome-
dially and you draw back before injecting since the supraorbital vein lies temporal
to the trochlea. Generally, the injection does not hurt, it does not bleed, and does not
get infected. More than one injection may be required, but I like to wait at least
30 days between injections. It is my belief that everyone is entitled to get trochleitis
once in their life and do not require a workup. If it is recurrent, then one could con-
sider evaluation for rheumatoid arthritis, lupus, and sarcoidosis.
46 8 Case 8
Table 8.1 ICHD 3 Diagnostic criteria for trochleitis

A. Periorbital and/or frontal headache fulfilling criterion C
B. Clinical and/or imaging evidence of trochlear inflammation
C. Evidence of causation demonstrated by at least two of the following:
1. Unilateral ocular pain
2. Headache is exacerbated by movement of the eye, particularly downward in adduction
3. Headache is significantly improved by injection of local anesthetic or steroid agent into
the peritrochlear region
4. In the case of a unilateral trochleitis, headache is localized ipsilateral to it
D. Not better accounted for by another ICHD-3 diagnosis
Headache Classification Committee of the International Headache Society. The International
Classification of Headache Disorders: 3rd edition (beta version). Cephalalgia. 2013;33:629–808
Trochleitis is not rare, but it is not common either. The ICHD 3 beta suggests that
the diagnosis can be made by having the pain resolve after an injection of the troch-
lea (see Table 8.1 for ICHD 3 criteria). In fact, he really meets all of the criteria for
trochleitis. It is important to know that trochleitis can also worsen migraine. He
does not really sound like he has migraine headache (even though he has a family
history of migraine), and that is probably why the rizatriptan was not successful.
However, trochleitis can also contribute to migraine. In fact, the patients that I have
seen usually have underlying migraine. Having migraine does not keep an individ-
ual from having trochleitis and looking for causes that make headaches more chronic
can really be helpful—get rid of the trochleitis and the continuous irritation of the
trigeminal nerve, and the chronic migraine may improve. Many of the cases reported
by Smith et al. had concurrent migraine. The other condition that he has is
TMJ. However, in this case the pain would not be in the eye, but in the jaw. I think
the key here was palpation of the trochlea during the examination that helped to
make the diagnosis. It is also important to not over diagnose trochleitis. One study
showed that individuals with migraine had tenderness around the trochlea and this
is not trochleitis, but they propose that migraine causes sensitization of the superior
oblique muscle and this irritation may worsen migraine.
We think it is important to palpate around the eye in patients with eye pain espe-
cially in the area of the trochlea, the lacrimal gland, the supraorbital, and infraor-
bital nerve (Fig. 8.1). Usually, the eye should appear white and quiet as in this
case. There often is no swelling in the superonasal eyelid. The key to the diagnosis
will be palpation of the trochlear region and the history of pain with eye
Discussion 47
Supraorbital
Levator palpebrae
foramen and
superioris
nerve
Superior rectus
Trochlea
Lacrimal gland
Superior oblique
Lacrimal sac
Infraorbital
foramen and
nerve
Fig. 8.1 Anatomy of trochlea. The trochlea sits under the superonasal orbital rim. Note the loca-
tion of the supraorbital and infraorbital nerves, which can become inflamed in other disorders. The
lacrimal gland sits under the superotemporal orbital rim
movements. Not all ophthalmologists or pain specialists will deliver this trochlear
injection so you may want to ask around before sending the patient to someone.
Neurologists may not be familiar with the diagnosis and usually will not give peri-
ocular injections.
Follow Up
Review of his MRI showed that the trochlea was not imaged (not uncommon) on the
axial or coronal views. The patient elected for a trial of indomethacin without ben-
efit. An injection of 1 mL of triamcinolone 40 mg/mL on a 25-gauge ½ in. needle
was delivered to the area of the patient’s trochlea. There was no bleeding. The
patient noted gradual improvement in the pain over the course of 1 week. He
returned for a repeat injection 1 month later because of a recurrence of pain (not to
the same level as before). He remained pain-free at 6 months follow up. Final diag-
nosis: trochleitis or primary trochlear headache.
48 8 Case 8
For Further Study
1. Fernández-de-Las-Peñas C, Cuadrado ML, Gerwin RD, Pareja JA. Myofascial disorders in the

trochlear region in unilateral migraine: a possible initiating or perpetuating factor. Clin J Pain.
2006;22(6):548–53.
2. Pareja JA, Sanchez del Rio M. Primary trochlear headache and other trochlear painful disor-
ders. Curr Pain Headache Rep. 2006;10:316–20.
3. Smith JH, Garrity JA, Boes CJ. Clinical features and long-term prognosis of trochlear head-
aches. Eur J Neurol. 2014;21:577–85.
4. Yangüela J, Pareja JA, Lopez N, Sánchez Del Río M. Trochleitis and migraine headache.
Neurology. 2002;58(5):802–5. PubMed PMID: 11889246.
Case 9
A 22-year-old woman developed pressure pain in the right eye × 3 months. It was

tender to palpation and she felt like there was lump in the right upper eyelid. She
notes that she had mild double vision when looking to the right and that her vision
seems mildly blurred in that right eye. She tried hot compresses and a steroid-
antibiotic ointment on the right upper lid, but the pain and the lump did not improve.
Overall the pain has not changed substantially. She has a history of migraines, but
these have not changed recently. She denies any migraine accompaniments (light or
sound sensitivity or nausea) with this eye pain. She has a history of a blocked tear duct
in the right eye for which she underwent a probing and irrigation at 8 months of age.

Per HPI Per HPI
Sumatriptan prn headache Grandfather—Macular degeneration
Ondansetron prn headache
Birth control
Manages meetings and events Completely negative
Does not smoke or drink
Examination
Right eye: 20/150 improving with pinhole to 20/20
Left eye: 20/20
Pupils
Normal
Right eye: 17 mmHg
Left eye: 20 mmHg

50 9 Case 9
External exam
3 mm proptosis, right eye (Fig. 9.1a)
Firm lump in the superotemporal area right eye, inferior to the eyebrow and superior to the
tarsus
25% deficit of abduction and elevation, right eye
Right esotropia and hypotropia in right and upgaze
Orthophoric in primary gaze
Normal
Visual field
Normal
Fundus examination
Choroidal folds in the macula, right eye
Normal facial sensation
Otherwise unremarkable
Discussion
She has developed blurred vision likely from something pushing on the back of the
eye causing hyperopia. She also has double vision and is unable to move her eye up
and to the right, suggesting that she has a mass there. The photo shows mild edema
of the fat above the eyelid and below the orbital rim. There is mild ptosis of the right
upper eyelid. The eyes appear straight as she looks straight ahead (Fig. 9.1a). It
seems likely that she has a lacrimal gland mass.
a b
Fig. 9.1 (a) External images of the face show subtle enlargement of the brow fat above the eyelid.
The right upper eyelid shows mild ptosis. (b) Axial CT of the orbit shows a cystic mass in the area
of the lacrimal gland, lateral and posterior to the right globe (star). There is erosion of the lateral
orbital wall (red arrow)
Discussion 51
The most common would be a benign mixed tumor given the firmness of the
tumor. Adenoid cystic carcinoma is in the differential, but these are usually much
more painful because of neural invasion. The average age is 40 years, so our patient
is young to have that. The differential could also include lymphoid hyperplasia, lym-
phoma (not this firm), sarcoidosis (not this firm), infection (usually more obvious),
and other epithelial malignancies or metastases. See Fig. 8.1 for relationships of the
lacrimal gland and adjacent anatomy. We should really start with CT of the orbit to
look better at the bony orbital involvement and consider an excisional biopsy. MRI
does not give us a good view of the bone, but would be acceptable to show lacrimal
gland involvement. If there were more pain, redness, or a hot looking abnormality
then one might consider antibiotics for an orbital cellulitis or corticosteroids for lac-
rimal gland inflammation. This would not be consistent with a preseptal lesion,
because it is causing double vision. The double vision pushes us that there is some-
thing in the orbit.
First, her decreased vision is related to her choroidal folds in her macula; her vision
was correctable to 20/20 with pinhole and she has no RAPD. This is one more rea-
son why anyone with changes in the vision and eye pain needs a full, dilated eye
examination. Then she has diplopia—just looking at her, you can see something is
wrong because there is fullness over the lateral aspect of her orbit and that this dip-
lopia is not from a cranial nerve abnormality. Imaging is the first step in determining
the cause and CT of the orbit with bone windows would be what I would order.
Fortunately for her, the slight discomfort she is experiencing is not making her
migraines worse. Many of my patients with any kind of secondary pain will have
worsening of migraines. If the discomfort got worse, I would suggest an anti-
inflammatory medication (e.g., ibuprofen or naproxen).
This patient started with mild “eye” ache with some tenderness to touch of the right
upper eyelid area. Just hearing the story, the most common thing to consider would
be a stye. She tried hot compresses and eye ointment without benefit and now we are
3 months later. Early on styes can present with just some mild eyelid edema, but
these are usually very close to the eyelid margin. In this case, she has some mild
edema of the area inferior to the eyebrow, which would not be a stye since it does
not involve the tarsus. This is the area of the right lacrimal gland. If you pull up on
the eyelid and have the patient look down, you can get a better idea of whether the
lacrimal gland is enlarged. In many cases MRI is better than CT, but with lacrimal
gland disorders, it is better to get a CT orbit.
52 9 Case 9
Follow Up
The patient underwent an orbital CT (Fig. 9.1b). This showed a 2.5 × 2.0 × 2.6 cm

enhancing mass in the area of the lacrimal gland with adjacent orbital roof erosion.
She underwent an excisional biopsy of the lacrimal gland, which showed adenoid
cystic carcinoma, basaloid type.
Historically, the 5-year survival was 17–20% with chemotherapy, radiation, and
exenteration. With neoadjuvant intra-arterial doxorubicin and cisplatin, the survival
rate has improved to 57–100%. The patient underwent intra-arterial therapy fol-
lowed by orbital exenteration (removal of the eye and all of the orbital contents) and
radiation therapy. Two years later, she experienced a recurrence in her right mandi-
ble. This was resected and she remained in remission at 4 years follow up. Final
diagnosis: adenoid cystic carcinoma of the lacrimal gland.
Digre comment: Adenocystic in a 22-year-old is very rare. This case reminds us
that we must be ever vigilant and that all tumors of the orbit and lacrimal gland need
work up.
For Further Study
1. Tse DT, Kossler AL, Feuer WJ, Benedetto PW. Long-term outcomes of neoadjuvant intra-arterial
cytoreductive chemotherapy for lacrimal gland adenoid cystic carcinoma. Ophthalmology.
2013;120:1313–23.
2. von Holstein SL, Rasmussen PK, Heegaard S. Tumors of the lacrimal gland. Semin Diagn
Pathol. 2016;33:156–63.
Case 10
A uveitis specialist sent a 13-year-old boy for eye pain. He had normal develop-
ment. He started with eye pain at age 4 and was treated for allergies for 2 years. At
age 6, he was diagnosed with non-granulomatous uveitis and was evaluated for
systemic disease but none was found. He started having eye pain—usually one eye
at a time occurring 1–2 times each year from age 6 to 12. He was treated with
naproxen and prednisolone acetate drops for minor ocular inflammation. In between
his bouts of inflammation, he was pain-free. At age 12 he developed episcleritis in
the right eye and intermediate uveitis. Treatment with meloxicam and systemic
prednisone completely quieted his eyes down. He had an orbital ultrasound and MR
scan looking for orbital inflammation, but none was found. His work up included
normal CBC, CMP, ESR, lysozyme, ACE, ANA, quantiferon gold, HLA B27,
Serum IgG4, ANCA, and MPO. He had a negative RPR, FTA, toxoplasmosis, and
toxocara titer. He was seen by a rheumatologist who started methotrexate and began
tapering the steroids. When steroids were tapered to 5 mg, the eye pain recurred
without increased ocular inflammation. Repeat ultrasound showed minimal scleral
thickening. An orbital specialist evaluated him and no orbital disease was found. He
was referred to neuro-ophthalmology for further evaluation since he had eye pain
and no active uveitis or episcleritis.
The pain was a steady, constant ache in the left eye—he had no headache. He had
no light or sound sensitivity and it did not worsen with activity, but sometimes the
eye would tear. The pain lasts hours to days; and a cool rag over the eyes sometimes
worsens it. A burst of 60 mg of prednisone would quiet the pain, but when he tapered
below 15 mg, the pain would recur. Most of the time, it would occur in the left eye
but he had bouts of right eye pain. His vision he says is normal.

54 10 Case 10

Non-granulomatous uveitis Inguinal hernia repair

Calcium/Vitamin D Mother with migraine
Cellcept 500 mg
Prednisone 15 mg
7th grade Otherwise negative
Examination
Right eye: 20/20-2
Left eye: 20/20
Pupils
5 mm OD, 6 mm OS in darkness; 4 mm OD, 5 mm OS in light; No RAPD
Color vision (HRR)
8/10 OD and 9/10 OS
Stereo vision
Normal—9 circles by Titmus Test
Right eye: 17 mmHg
Left eye: 17 mmHg
External exam
Normal
Eye alignment
Normal
One deep scleral vessel mildly enlarged left eye, otherwise normal without cell or flare
Visual field
Fundus examination
Normal optic disc with 0.2 cup to disc ratio; normal macula and vessels
Normal neurological examination
Discussion
My first thought was—is this migraine coming on when the patient has a history of
inflammatory uveitis. His mother had migraine and he could not read in the car (often
seen in migraine). However, he had NO headache whatsoever, no migraine features of
light and sound sensitivity, no nausea, no worsening with activity. I also thought about
a form of cluster or autonomic cephalgia, but the pain could be on the right or left side,
lasted hours to days and completely went away after being on high dose steroids.
Discussion 55
We also wondered about scleritis or episcleritis, but his imaging (MR, ultra-
sound) were said to be normal. He had no active uveitis. His intraocular pressures
were normal. I tried him on indomethacin in case this was an unusual case of hemi-
cranias continua. There was only a partial response.
Recurrent uveitis would be the most common situation causing eye pain, but the slit
lamp examination was normal. However, I think inflammation of “something”
seems likely given the steroid responsive nature of his pain.
Episcleritis and anterior scleritis cause eye redness, but episcleritis is not very
painful while scleritis often becomes increasingly painful. If it is not clear, then a
drop of 10% neosynephrine will blanch the vessels in episcleritis but will not affect
deeper vessels in scleritis. Why is this important? As a general rule, episcleritis is
not associated with a systemic disease. Scleritis can be idiopathic or associated with
a systemic condition and also lead to visual loss.
In the absence of eye redness, then one could consider posterior scleritis or even
orbital inflammation. Often inflammation of the orbit will cause orbital signs such
as diplopia and ophthalmoplegia, proptosis, chemosis, and eyelid edema. Sometimes,
myositis will cause eye pain with eye movements with a white and quiet eye.
Scleritis is not a frequent cause of eye pain. This is a situation where having an ophthal-
mologist examine the patient can be very helpful. Think about scleritis or eye inflam-
mation in patients with autoimmune disease who have new onset of eye pain or red eye.
Follow Up
This is when I went back to the MR scan to review carefully. The MR scan showed
faint enhancement of the sclera and also the perioptic nerve sheath (Fig. 10.1). The
indomethacin helped a little, but did not stop the eye pain. We also repeated his ultra-
sound, and now he had classic findings of posterior scleritis. Posterior scleritis will
only be visible on imaging of the posterior globe—as in this case on the MR scan.
Table 10.1 gives the ICHD 3 beta criteria for scleritis and eye pain/headache.
Scleritis can often be misinterpreted as one of the autonomic cephalgias. But as in this
case, indomethacin was only partially helpful. Scleritis can occur in children as well.
In a large review of scleritis, Lavric et al. reported that scleritis was more com-
mon in women (71%), less likely to be bilateral (15.8%), and often associated with
autoimmune disorders such as rheumatoid arthritis, systemic lupus erythematous,
56 10 Case 10
Fig. 10.1 Axial,
postgadolinium T1 MRI of
the orbits shows mild
enhancement of the
posterior sclera in the left
eye (arrow). There is also
perineural enhancement at
the nerve/sclera junction
Table 10.1 ICHD 3 beta headache attributed to ocular inflammatory disorder

Diagnostic criteria:
A. Periorbital headache and eye pain fulfilling criterion C
B. Clinical, laboratory, and/or imaging evidence of ocular inflammatory diseases such as iritis,
uveitis, cyclitis, scleritis, choroiditis, conjunctivitis, or corneal inflammation
C. Evidence of causation demonstrated by at least two of the following:
1. Headache has developed in temporal relation to the onset of the ocular disorder
2. Either or both of the following:
(a) headache has significantly worsened in parallel with worsening of the ocular disorder
(b) headache has significantly improved or resolved in parallel with improvement in or
resolution of the ocular disorder
(a) headache significantly improves with topical application of local anesthetic agent
to the eye
(b) headache is aggravated by pressure applied to the eye
4. In the case of a unilateral eye disorder, headache is localized ipsilateral to it
According to the ICHD 3Beta—Description: Headache caused by ocular inflammatory conditions
such as iritis, uveitis, scleritis or conjunctivitis and associated with other symptoms and clinical
signs of the disorder
angiitis and or infection. Relapses occur in about 1/3. Pain in the eye is present in
over half; fewer (about 1/3) have blurred vision and light sensitivity is not common.
Sometimes one can see subtle disc swelling and even folds in the retina and serous
retinal detachment in posterior scleritis. Occasionally there can be longer lasting
pain (neuralgiform type) that challenges treatment.
In this case, he could not be tapered below 15 mg prednisone daily. If a patient
cannot get below 7.5 mg prednisone daily, then we would consider asking a rheu-
matologist to institute a steroid-sparing agent. The patient might also benefit from a
periocular steroid injection to reduce the systemic load. Final diagnosis: posterior
scleritis.
For Further Study
1. Alim-Marvasti A, Ho J, Weatherall M, Patel M, George S, Viegas S. Trigeminal autonomic

cephalgia caused by recurrent posterior scleritis. Pract Neurol. 2016;16(6):455–7. pii:
practneurol-2016-001433.
2. Lavric A, Gonzalez-Lopez JJ, Majumder PD, Bansal N, Biswas J, Pavesio C, Agrawal
R. Posterior scleritis: analysis of epidemiology, clinical factors, and risk of recurrence in a
cohort of 114 patients. Ocul Immunol Inflamm. 2016;24(1):6–15.
3. Shenoy R, Suryawanshi M, Isaac R, Philip SK. Posterior scleritis in pediatric age group: A case
report and review of literature. Oman J Ophthalmol. 2016;9(1):59–62.
Part II
Ophthalmic Disorders Causing Eye Pain:
Abnormal Eye Exam
Case 11
The patient is a 49-year-old, right-handed, special education teacher. She presented

initially with spells of kaleidoscopic prisms centrally in the right eye 2 days before
she was seen. At this point she had no pain, but a dull ache over the right eye. She
was treated with aspirin and the spells resolved. About 10 days later she presented
to the emergency room with severe right eye pain. The pain was worse with eye
movements and she denied any visual loss. She did have some mild swelling around
the eyelid and some tearing, but the pain was really severe.
Four years before she presented with diplopia and eye pain. Her examination at
that time showed an esotropia (eye crossing) and a mild hypertropia (vertical mis-
alignment). Imaging showed inflammation of the medial rectus muscle. She was
diagnosed with orbital myositis, treated with steroids and diplopia and pain resolved.
While she has had migraines in the past, the pain does not feel like migraine.

Wrist fracture History of uterine ablation for dysfunctional bleeding
Previous orbital myositis
Migraine in the past
Vitamin C Her mother died at age 60 from complications of
multiple sclerosis; heart disease in father
Currently single with 3 children Otherwise feels healthy
Non-smoker
No alcohol

62 11 Case 11
Examination in the Emergency Room

Right eye: 20/20 with correction
Left eye: 20/20
Pupils
6 mm in darkness and 3 mm in light
7 mm in darkness 4 mm in light
No RAPD
Right eye
20 mmHg
Left eye
21 mmHg
External exam
Normal—Hertel 14 OU at base of 92
Right eye: She had 1+ erythema and edema of upper and lower eyelid and mild resistance
to retropulsion
Eye alignment
She had −1 limitation of downgaze in the right eye but was full in other directions. While
she was orthophoric in primary gaze she had a small less than 4 diopters of right hypertropia
in downgaze
Mild chemosis of right eye only. LE was white and quiet. No cell or flare either eye
Visual field
Normal
Color vision
Ishihara 13/13 OU
Fundus examination
Normal
Normal
Discussion
This patient has visual disturbances and then presents with severe eye pain. Her
initial presentation of kaleidoscopic vision was not associated with any eye pain,
and it was thought that this could be a migrainous phenomenon so a baby aspirin
was started which often improves migrainous aura. At that time she also had a fluo-
rescein angiogram because of the unilateral nature of the visual change, and this
was normal.
When she presented to the ER 10 days later with severe pain with eye move-
ments, our first reaction is—this must be optic neuritis. However, she had absolutely
no other signs of an optic neuropathy (normal vision, no RAPD, normal fields, and
normal color vision).
There are only a few things that could cause eye pain with movement and normal
optic nerve function—inflammatory conditions like thyroid eye disease, sinus disease,
Discussion 63
cellulitis or infections, vasculitis like granulomatosis with polyangiitis (Wegener’s),

and sarcoid can all cause pain. Optic perineuritis (inflammation around the optic
nerve, without demyelination) can also present like this. Other findings to look for
include proptosis, chemosis (inflammation of the conjunctiva), scleral show, lid lag,
and swelling around the eye. See Table 11.1.
Thyroid orbitopathy is the most common orbital disorder but it is usually not that
painful. The next most likely thought would be idiopathic orbital inflammation, also
known as orbital pseudotumor, or orbital myositis. It really is the most common
cause of a painful orbital process. While it occurs at any age and sex (women slightly
more than men), it often occurs in middle age. When it occurs in children, it is often
bilateral, and has evidence of uveitis and even disc edema. The onset can be slowly
gradual to acute or subacute. Imaging has been very helpful in defining idiopathic
orbital inflammatory disease. Orbital ultrasound is very sensitive to subtle inflam-
matory disease, but one needs a competent orbital echographer. CT of the orbits
with contrast may show enhancing enlarged muscles or a mass in the orbit. MR scan
of the orbits with fat saturation and gadolinium enhancement also may be diagnos-
tic—muscle involvement usually does NOT spare the tendon (vs. thyroid ophthal-
mopathy which does). Further it has several distinct patterns: muscle only
involvement where single muscle or multiple muscles are enlarged and enhancing,
lacrimal gland enhancement, and sometimes the sclera will also enhance. The optic
nerve sheath can also be involved and this is often called peri-neuritis. Sometimes it
is very difficult to distinguish optic peri-neuritis from optic neuritis. However, optic
neuritis almost always causes visual loss, a relative afferent pupillary defect (RAPD)
and change in color vision, while optic peri-neuritis may have NO evidence of optic
nerve dysfunction. If the enhancement has intracranial extension and cranial nerves
are also involved, this is idiopathic cavernous sinus inflammation and called Tolosa
Hunt Syndrome. Occasionally idiopathic orbital disease can be fibrotic and this type
does not always respond to steroids.
Optic perineuritis can be a component of idiopathic orbital inflammation and is
very painful—especially with eye movements. While most of the time it is self-
limited with good recovery, secondary causes such as granulomatosis with polyan-
giitis and Behçet’s disease can cause severe visual loss.
While there are no official diagnostic criteria, some have suggested: acute orbital
pain including pain with eye movements, one or more muscles enlarged in the orbit
evident on CT or MR scan, in the face of absent thyroid disease, scleritis or uveitis,
normal visual acuity, and a prompt response to steroid therapy.
Aside from imaging, other labs to consider include: CBC, ESR, ANA, ANCA,
IgG4, syphilis serology, and lumbar puncture may be helpful to diagnose a second-
ary cause.
Occasionally a biopsy is needed to make the diagnosis of idiopathic inflamma-
tory disease—for example, when it is not clear if this is a lymphoproliferative (lym-
phoma), metastatic, or sarcoid orbital disease. The idiopathic form may occur after
respiratory or viral illness, may cluster with other immunological disorders (e.g.
Crohn’s disease).
Recently, IgG4 disease has been recognized to cause idiopathic inflammatory
conditions of the orbit and many other organs (e.g. pancreas, salivary glands,
Table 11.1 Causes of orbital inflammation/proptosis and eye pain
64
Cause Pain Symptoms Signs Imaging Laboratory Comments

Thyroid—most Usually mild Dry eyes, Proptosis, lid retraction, lid Enlargement of the T4, TSH, TRAB, Most common cause of orbital
common orbital or absent eyes lag; muscles usually muscle, but spares TSI inflammation; watch for optic
disorder unusually involved in order include tendon nerve compromise; may need
prominent inferior, medial, superior, orbital decompression or
eyes, diplopia lateral, obliques radiation; occasionally
steroids helpful
Orbital myositis Can be acute Usually Mild proptosis One muscle, can involve CBC, ESR, CRP Steroids are usually helpful
(idiopathic and very unilateral eye perio-optic nerve, and
inflammatory painful pain, diplopia, mass like in the entire
disease) Pain with and redness orbit; muscle tendon is
eye by muscle NOT spared; enlarged
movement insertion lacrimal glands
Tolosa Hunt Painful Diplopia Cranial nerve palsy—III, Usually shows Usually need to Look for malignancy, or
Syndrome IV, VI abnormality into the rule out lymphoproliferative disorder;
cavernous sinus malignancy steroids usually resolve true
Tolosa Hunt Syndrome
Sarcoid Variable but Diplopia Any pattern of muscle Enhancement of orbital ACE, CXR, Chest After diagnosis, treatment
can be involvement; can involve structures; lacrimal CT with steroids
painful optic nerve glands
Vasculitis (e.g. Painful Diplopia, Unilateral or bilateral See orbital enhancement ANCA, UA Steroid treatment
Granulomatosis Red eye muscle involvement; and often sinus disease cyclophosphamide, and
with polyangiitis episcleritis, scleritis, uveitis rituximab
(Wegener’s disease))
Infectious Painful Red eye, fever Proptosis, usually Can involve whole Increased WBC; Staph, Strep, mucor,
(cellulitis) unilateral, chemosis orbit; image sinuses culture and biopsyaspergillosis;
Treat with antibiotic,
antifungal, occasionally need
surgery
Metastatic disease Variable Diplopia En-ophthalmous, proptosis Mass in the orbit with Imaging; PET body Breast and lung most frequent
11 Case 11
to orbit pain bony erosion scan for primary

Discussion 65
thyroid, etc.). It is often treated with rituximab and steroid treatment can some-
times delay the diagnosis.
Treatment of idiopathic orbital inflammatory disease is usually corticosteroids in
doses of prednisone 1 mg/kg for 2–3 weeks with a slow taper. The pain often readily
responds and the diplopia improves later. If patients do not respond to this, consider
biopsy or another diagnosis or the fibrotic type. Steroid-sparing agents include aza-
thioprine, methotrexate, and infliximab. If the pain recurs or is insufficiently treated
with steroids consider other anti-inflammatory medications including naproxen,
indomethacin, or gabapentin. Recurrences can occur as well in less than half—but
do not be surprised if the inflammation recurs.
Ophthalmic Perspective: Dr. lee
The swollen eyelids could suggest a preseptal cellulitis, but the reduced eye move-
ments here indicate an orbital process. With the pain and redness, you should think
about orbital infection vs. orbital inflammation. Some clues to an orbital infection
would include fever, elevated white count, and sinus disease on neuroimaging. A
CT scan might show a subperiosteal abscess, which would definitely push you
toward infection. If this is seen, then the patient will need surgical removal of the
abscess. In some cases, you just cannot tell if this is infection vs. inflammation. The
safer thing to do is to treat with antibiotics first for 1–2 days. If there is no improve-
ment or worsening, then consider prednisone.
There is no clear evidence for how much steroids and how long to treat with
steroids for orbital inflammation, so I will give you my management plan, which
differs slightly from Dr. Digre. I treat with 60–80 mg prednisone orally for 1 week.
If the inflammation resolves and stays away, then I observe and do not do a systemic
workup. If it recurs, then I restart the prednisone and taper slowly over 6–8 weeks.
If it recurs again, then I pursue a biopsy because I am most worried about lym-
phoma. We generally think of lymphoma as painless, but it can be painful. If the
biopsy is negative, then I might offer the patient an even longer taper of steroids,
orbital radiation (2000 cGy over 10 days), or immunosuppression with a steroid-
sparing agent. If the patient is very intolerant of steroids, one could consider injec-
tion of 40 mg of triamcinolone in the peribulbar region. I also pursue a systemic
workup as described above for recurrent orbital inflammation.
Orbital inflammatory disease is not rare. The most common symptom is diplopia
and pain. The signs are usually proptosis, lid retraction, scleral show, and variable
extra-ocular movements. Always check visual acuity and look for an RAPD—if
there is loss of vision, and an RAPD, then refer the patient for further evaluation for
an optic neuritis. The most common orbital disease is thyroid ophthalmopathy
66 11 Case 11
which is usually not that painful. If you see signs of orbital disease and pain, be
thinking about other orbital inflammatory disease, of orbital myositis, or orbital
pseudotumor is the most common. See Table 11.1.
Follow Up
The history of a previous myositis 5 years before made the suspicion for orbital
inflammatory disease. Her evaluation showed an MR scan that showed enhance-
ment of the orbit and perioptic nerve (Fig. 11.1). Extensive laboratory studies
showed: Normal CBC, ESR, CRP, RPR, RF, ACE, anti-thrombin elevation, and
factor V Leiden and ANCA. Her protein C was mildly elevated. She was treated
with prednisone 60 mg which quickly stopped her pain. She was seen back in clinic
10 days later and her examination now was normal—no evidence of a phoria, or
chemosis or redness to the eyes. The prednisone was slowly tapered by 10 mg each
week. She remained recurrence free for the last 6 months. Final diagnosis: idio-
pathic orbital inflammatory syndrome.
a b
Fig. 11.1 (a) Coronal T1 with fat saturation showing the enhancement of the optic nerve sheath
(arrow) and surrounding orbital tissue. (b) Axial T1 with fat saturation showing enhancement of
the optic nerve sheath (arrow). Note there is mild evidence of proptosis compared to the opposite
orbit
For Further Study
1. Costa RM, Dumitrascu OM, Gordon LK. Orbital myositis: diagnosis and management. Curr
Allergy Asthma Rep. 2009;9(4):316–23.
2. Fraser CL, Skalicky SE, Gurbaxani A, McCluskey P. Ocular myositis. Curr Allergy Asthma
Rep. 2013;13(3):315–21.
3. Gordon LK. Orbital inflammatory disease: a diagnostic and therapeutic challenge. Eye (Lond).
2006;20(10):1196–206.
4. Hickman SJ. Optic perineuritis. Curr Neurol Neurosci Rep. 2016;16(2):16.
5. Lutt JR, Lim LL, Phal PM, Rosenbaum JT. Orbital inflammatory disease. Semin Arthritis
Rheum. 2008;37(4):207–22.
6. McNab AA, McKelvie P. IgG4-related ophthalmic disease. Part II: clinical aspects. Ophthal
Plast Reconstr Surg. 2015;31(3):167–78.
7. Wallace ZS, Khosroshahi A, Jakobiec FA, Deshpande V, Hatton MP, Ritter J, Ferry JA, Stone
JH. IgG4-related systemic disease as a cause of “idiopathic” orbital inflammation, including
orbital myositis, and trigeminal nerve involvement. Surv Ophthalmol. 2012;57(1):26–33.
Case 12
A 58-year-old woman began complaining of gradually worsening right eye pain for
6 years. She was diagnosed with dry eye syndrome. Artificial tears and warm com-
presses help to some degree. The pain is a deep ache in and behind the right eye
which can increase to 5/10 at times. The pain is intermittent lasting several weeks at
a time and then gradually resolving. She notes mild tearing, but no foreign body
sensation or itching. She has a history of classic, right-sided migraine headache for
the past 20 years. Brain MRI 5 years ago was normal. She has significant photopho-
bia with the eye pain but denies nausea, vomiting, or phonophobia.

Back pain Cataract removal right eye 2 years ago
Osteoarthritis in the knees and hips
Hypertension
Atenolol Father—Heart disease
Nasonex Brother—Glaucoma, brain tumor, heart
Alprazolam Disease
Sumatriptan Sister—Rheumatoid arthritis
Former smoker (pack a week × 10 years, quit last Overactive bladder
year) Shortness of breath
Does not drink Arthritis
Retired Salvation Army worker Panic attacks
Numbness in back and arms
Some incoordination

70 12 Case 12
Examination
Right eye: 20/25
Left eye: 20/20
Pupils
Slightly sluggish, equal, no afferent pupillary defect
Right eye: 14 mmHg
Left eye: 17 mmHg
External exam
Unremarkable
Normal
1+ conjunctival injection BE
Fine, diffuse endothelial keratic precipitates BE
2–3+ white blood cells BE
Old cells in anterior vitreous
No posterior synechiae
Visual field
Normal
Fundus examination
Mild cup to disc asymmetry (0.4 RE and 0.5 LE)
Otherwise normal
Normal
Discussion
Generally speaking dry eye does not cause 5/10 eye pain. Additionally, she has not
improved significantly with dry eye treatment. Her corneas do not show evidence of
dry eye as well. Although the patient has a history of right-sided migraine and
migraine can cause eye pain, generally migraine headaches do not last weeks at a
time. The main diagnosis here relies upon the slit lamp examination. The conjuncti-
val injection, keratic precipitates, and white blood cells in the anterior chamber are
most consistent with a bilateral anterior uveitis. One final nonspecific clue is that
patients with uveitis can be quite photophobic because the inflammation irritates the
iris. This tends to hurt when the iris constricts to light. I do not know why she only
complained of right eye pain when she had bilateral findings.
We like to divide uveitis into granulomatous vs. nongranulomatous inflamma-
tion. Granulomatous uveitis shows larger keratic precipitates called “mutton fat”
(Fig. 12.1). This distinction helps guide the work-up. For instance, the most fre-
quent differential diagnosis of granulomatous disease includes tuberculosis, sar-
Discussion 71
Fig. 12.1 Slit lamp

examination shows a
pharmacologically dilated
pupil. There are several
large, white lesions on the
back of the cornea
consistent with mutton-fat
keratic precipitates seen in
granulomatous uveitis
coidosis, syphilis, Lyme, toxoplasmosis, and granulomatosis with polyangiitis

(Wegener’s). The most common differential overlaps for nongranulomatous disease
and includes syphilis, sarcoidosis, ankylosing spondylitis, lupus, and rheumatoid,
and tubulointerstitial nephritis, and herpes simplex. Rarely, multiple sclerosis can
also cause granulomatous or nongranulomatous uveitis. Fifty percent of patients
have idiopathic uveitis, but if the above workup is negative and the patient has recur-
rent disease, then I will send the patient to a uveitis specialist.
A systemic workup is indicated for granulomatous uveitis, bilateral uveitis, and
recurrent uveitis. Patients with a first-time attack of nongranulomatous disease in one
eye may sometimes be treated without a workup. Treatment often includes topical cor-
ticosteroid eye drops. This is often begun empirically before testing for infectious dis-
orders comes back. I like to start with prednisolone acetate 1% every hour while awake
for a week followed by a taper to 6x/d for a week and reducing by 1 drop/day every
week for 6 weeks. If they have a recurrence on this regimen, then I restart the drops with
a slower taper over months. In some cases, recurrent and recalcitrant uveitis requires the
use of depot steroid injections, implantable steroid, and systemic immunosuppression
including oral prednisone, tumor necrosis alpha inhibitors, and methotrexate.
Really the only thing one would see on examination if a slit lamp exam was not
done was some conjunctival injection. So, without a slit lamp exam this could be
confused with a lot of other things like dry eyes or even migraine—which can go
on for weeks at a time in certain individuals (but usually they have a history of
migraines that are prolonged in duration). The sluggishly reactive pupils may be
72 12 Case 12
another clue that an ocular process is occurring. The other clue is complaint of
photophobia—Photophobia is a symptom that requires an explanation. We are
told that she has no phonophobia, nausea and this pain does not feel like her
migraine. So, something is wrong. The most common ocular causes of photopho-
bia are dry eyes and iritis; other causes of photophobia would be blepharospasm
(Case 6), which will have characteristic eyelid closure; and migraine should be
diagnosed by history.
Once uveitis is diagnosed by slit lamp, looking for underlying causes is
important as Dr. Lee has pointed out. While this patient does not seem to have a
severe headache accompanying her uveitis, there are some uveitides that go with
meningitis that can have headaches associated with them. See Table 12.1 for a
partial list.
Table 12.1 Uveitis and meningitis syndromes (adapted in part from: Allegri et al. J Ophthalmic
Vis Res. 2011;6:284)
Infectious
Virus (Herpes, cytomegalovirus, herpes zoster, West Nile virus, HIV virus
Bacterial: Bartonella Henslae (cat scratch disease), Whipples
Myocobacteria: Tuberculosis
Spirochete: Lyme disease, Syphilis, Leptospirosis
Protozoa: Toxoplasmosis, pneumocystis cariii
Autoimmune
Polyartereritis nodosa
Polyangiitis (Wegener’s granulomatosis)
Sjögren’s syndrome
Rheumatoid arthritis
Systemic Lupus erythematosus
Sarcoidosis
Vogt-Koyanagi Harada disease
Behçet’s disease
Acute multiocal placoid pigment epitheliopathy
Neoplasm
Lymphoma
Demyelinating disease
Multiple sclerosis
Acute disseminated myelitis
Uveitis really requires a good slit lamp exam to make the diagnosis. Sometimes, the
patient will have injection next to the colored part of the eye called limbal flush. The
rest of the conjunctiva appears relatively white. This can be suggestive of uveitis,
but is not a specific sign. Patients with mild eye redness without discharge and pho-
tophobia may have uveitis and may need a slit lamp exam.
Follow Up
This patient was diagnosed with uveitis. Her workup included a normal ANA, ACE,
RPR, HLA-B27, urinalysis, ESR, RF, and chest X-ray. She was started on predniso-
lone acetate 1% as described above and her uveitis was resolved at her 6 week
return. The pain resolved slowly over about a week or so after treatment was begun.
She was diagnosed with idiopathic anterior uveitis and did not suffer a recurrence.
Final diagnosis: anterior uveitis.
For Further Study
1. Agrawal RV, Murthy S, Sangwan V, Biswas J. Current approach in diagnosis and management
of anterior uveitis. Indian J Ophthalmol. 2010;58:11–9.
2. Allegri P, Rissotto R, Herbort CP, Murialdo UCNS. Diseases and uveitis. J Ophthalmic Vis
Res. 2011;6:284–308.
3. Janigian RH. Uveitis evaluation and treatment. Emedicine.medscape.com/article/1209123-
overview#a1. Accessed 6 Jan 2017.
Case 13
A 23-year-old woman developed a red and painful right eye. The pain was described
as burning, worse when she blinked, and better when she closed her eye and kept it
closed. She rated it as 4 out of 10. She endorsed tearing and eyelid crusting in the
morning. She denied ptosis, stuffy nose, or runny nose. The symptoms worsened
over the course of 3 days and then similar symptoms began in the left eye. She vis-
ited her primary care doctor and was prescribed an antibiotic drop four times daily.
The symptoms improved approximately 1 week after onset, but then worsened
again in both eyes. Every day, the pain, redness, and irritation seem worse. Her
primary care doctor ordered an MRI, which was normal. A methylprednisolone
dose pack did not improve her symptoms.

Normally wears soft contact lenses but cannot Tonsillectomy as a child
tolerate them since the redness began Myringotomy tubes as a child
Gentamicin eye drops Mother has optic disc drusen
Oral contraceptives Sister has migraines and wears glasses
Pre-school teacher Negative
Smokes socially
Drinks alcohol socially

76 13 Case 13
Examination
Right eye: 20/25
Left eye: 20/25
Pupils
Equal, briskly reactive, no APD
Right eye: Soft to palpation
Left eye: Soft to palpation
External exam
Bilateral eyelid redness and trace edema
Normal
2+ injection
Diffuse punctate epithelial keratopathy (PEK) BE
Mild chemosis BE
Follicles in inferior fornix BE (Fig. 13.1)
Visual field
Fundus examination
Normal
Normal
Fig. 13.1 External
photograph shows an
everted lower eyelid. Note
the multiple pinkish
“bumps” on the palpebral
conjunctiva consistent with
follicles
Discussion
Red eye, pain, and watery discharge sounds like conjunctivitis. There are mul-
tiple forms of conjunctivitis including allergic, viral, bacterial, mechanical, con-
tact lens related, toxic, and immune-related. Allergic conjunctivitis usually starts
in childhood, affects both eyes, and an adult is generally aware of these seasonal
issues. This patient wears contacts, so you have to worry about corneal infections.
Discussion 77
Ophthalmologists are usually very concerned about acanthomoeba (an extremely

painful corneal infection) often seen in a contact lens wearer with recent hot tub use.
Patients can also become contact lens intolerant, but this usually starts with both
eyes and is not so acute or angry as this.
The most common form of conjunctivitis is adenoviral. Her story of starting in
one eye and then spreading to the other is a classic one. The symptoms of morning
crusting are also extremely consistent. Typically, viral conjunctivitis resolves spon-
taneously after several days. Exam findings may include PEK and follicles as seen
in this patient. Normally, we ask these patients to use preservative free artificial
tears, cool compresses, and meticulously wash their hands to avoid spreading it. I
often advise patients use paper towels at home to avoid spreading it to the other eye
or another family member. The diagnosis is usually clinical and presumed viral
unless other findings such as severe pain, purulent discharge, excessive discharge,
or the symptoms last more than 4 weeks. If atypical, then cultures (blood and choco-
late agar) and gram stain should be performed.
The fact that she got better and then got worse might suggest that she has some-
thing other than viral conjunctivitis. However, the patient was placed on gentamy-
cin, which can cause a toxic reaction to the cornea and conjunctiva called
medicamentosa. This reaction can occur within days or weeks of eye drop use and
may relate to preservatives. Usually the symptoms continue to worsen for as long as
the patient uses the drops. Stopping the drops and adding preservative free artificial
tears often helps most patients. Severe cases may require use of NSAID drops or
steroid eye drops. These patients often do very well.
Red eye, eye pain and serous or purulent discharge usually signifies eye inflamma-
tion or infection. Traditional wisdom states that viral conjunctivitis presents with
itchy red eye, little pain and may have a cold, runny nose or congestion, whereas
bacterial conjunctivitis often presents with discharge (purulent), and may have che-
mosis, eyes glued shut in the morning and no other illness. The differential diagno-
sis of a red eye is important to review here. See Table 13.1. The most common are
dry eye, blepharitis, and conjunctivitis.
The important part for me as a neurologist is to look for warning signs of some-
thing really serious—either serious eye disease like uveitis, corneal abrasion, scleri-
tis, or neurological disease (dissection, fistula). What I look for is decreased vision
and red eye needs urgent evaluation. Significant photophobia rarely occurs with con-
junctivitis and if this is present I am more concerned. If the cornea appears hazy in
conjunction with a red eye, I immediately refer them to ophthalmology. Other symp-
toms include unequal pupils, or any muscle imbalance or complaint of diplopia.
I usually do not treat conjunctivitis with medications—but recommend tears and
cold/warm compresses—and see their ophthalmologist if it does not get better. I
also recommend the individual to stop wearing contact lenses if they are and avoid
heavy make up.
78 13 Case 13
Table 13.1 Differential diagnosis of a red eye

Ocular causes
Conjunctivitis
Allergic
Viral (usually adenovirus)
Bacterial
Blepharitis
Dry eye
Episcleritis and scleritis
Foreign body
Corneal abrasion
Iritis
Anterior uveitis
Keratitis
Subconjunctival hemorrhage
Medication use that irritates cornea
Neurological causes of the red eye
Carotid dissection and Horner’s syndrome
Carotid/dural cavernous fistula
Ophthalmic vein/cavernous sinus thrombosis
Herpes zoster ophthalmicus
Tolosa hunt
Meningitis
Trigeminal autonomic cephalgias
One of my best friends is a family doctor who developed likely viral conjunctivitis
and insisted upon getting antibiotic eye drops despite my protests. Daycares often
mandate that a child with “pink eye” receive antibiotic eye drops for 24 h before
returning. It is very challenging not to give patients antibiotic eye drops for what is
most likely viral conjunctivitis. However, keep in mind that they can develop a toxic
reaction to the eye drops and it may seem like they are getting worse. If it occurs,
you can tell the patient that s/he has medicamentosa, which has a good outcome
with removing the drop. This is not the same as an allergy and the drop does not
need to be placed on their allergy list.
Follow Up
The gentamicin eye drops were discontinued and the patient started preservative-
free artificial tears 4–6 times daily. The patient’s symptoms began to improve after
1 day and completely resolved after 4 days. Final diagnosis: conjunctivitis compli-
cated by medicamentosa.
For Further Study
1. Cornea/External Disease Preferred Practice Pattern Panel. Conjunctivitis. American Academy

of Ophthalmology. 2013. https://www.aao.org/preferred-practice-pattern/conjunctivitis-
ppp--2013. Accessed 1 Mar 2017.
2. Cronau H, Kankanala RR, Mauger T. Diagnosis and management of red eye in primary care.
Am Fam Physician. 2010;81(2):137–44.
3. Narayana S, McGee S. Bedside diagnosis of the ‘Red Eye’: a systematic review. Am J Med.
2015;128(11):1220–4.
4. Tarabishy AB, Jeng BH. Bacterial conjunctivitis: a review for internists. Cleve Clin J Med.
2008;75(7):507–12.
Case 14
A 32-year-old white woman noted 2 months of periocular swelling, tearing, and

redness of both eyes. She noted constant eye pressure behind both eyes worse with
far eccentric upgaze. Closing the eyes did not improve the pain. Nonsteroidals did
make the pain better but it did not resolve it. The pain had been the same without
worsening or improvement over the past 2 months. She denied any visual loss or
diplopia.

None None
None Father—Hyperlipidemia, prostate cancer, skin cancer
Mother—Hypothyroidism
One glass of wine daily Negative
Never used tobacco
Works as a cook at a military base
Examination
Right eye: 20/20-1
Left eye: 20/20
Pupils
Equal, brisk, no APD
Right eye: 14 mmHg
Left eye: 14 mmHg

82 14 Case 14
External exam
Mild eyelid retraction both upper eye lids
Margin reflex distance = 5.5 mm BE
Hertel exophthalmometry 21 mm BE
25% symmetric elevator deficit BE
Orthophoric in all gazes
1+ chemosis and trace injection BE
Visual field
Normal
Fundus examination
Normal
Normal
Discussion
Initially, one might assume that this is a dry eye case, which could be a contributing
factor. However, close inspection of the figure shows mild eyelid edema LE greater
than RE (Fig. 14.1) and some mild eyelid retraction BE. The combination of the
eyelid edema and eyelid retraction really point toward thyroid eye disease (TED).
The top limit of normal for Hertel exophthalmometry in a Caucasian woman is
20 mm, which would also make her suspicious for TED.
Now when I was in residency, I remember clearly being told that TED does not cause
pain and if you see pain in a patient with orbital signs and symptoms, then you should
think about something else. I held onto that mantra for a long time until I became a
faculty member and started keeping track of the clinical activity score (CAS, Table 14.1),
which is a standardized methodology for determining how active TED is. The first two
points include spontaneous retrobulbar pain and pain on vertical gaze. Therefore, I have
changed my tune that TED can definitely cause pain and is an indicator of activity.
I would have told this patient that the problem begins with an overactive immune
system that attacks the thyroid gland as well as the orbital tissues including the eye
muscles. Even if one removes the thyroid gland with surgery or radioactive iodine,
the immune system is still overactive and can attack the eyes. In the majority of cases,
the hyperthyroidism and orbital signs occur within 6 months of each other. There are
definitely a significant number of Graves’ patients who do not develop ophthalmopa-
thy. In some cases, there may be isolated TED, and the patient is euthyroid. Normally,
TED runs a course of getting worse, getting better, and then stabilizing but not return-
ing back to normal baseline eye appearance, known as Rundle’s curve. The time to
reach stability is usually 1–3 years and can be several years in some cases. Sometimes
it can be quite disfiguring and in others it may hardly be noticeable.
In mild cases, such as this, I would advise her to get thyroid function tests and a
thyroid stimulating immunoglobulin (TSI). I would advise her to avoid smoke and
secondhand smoke, which could worsen the course of the disease. I would ask her to
Discussion 83
Fig. 14.1 External photographs show bilateral upper eyelid retraction. Normally, the upper eyelids
cover the iris by about 1 mm. She also has very mild upper eyelid edema of the left upper eyelid
Table 14.1 Clinical activity score. One point for each and a score of 3+ = active TED
Spontaneous retrobulbar pain
Pain on attempted up- or downgaze
Redness of the eyelids
Swelling of the eyelids
Redness of the conjunctiva
Swelling of the conjunctiva
Inflammation of the caruncle or plica semilunaris
take selenium 100 micrograms twice daily and use artificial tears regularly. I would
see her back at 4–6 month intervals sooner if she develops vision loss in either eye.
In moderate to severe cases, I might initiate IV steroids 500 mg weekly × 6 weeks
followed by 250 mg weekly × 6 weeks. I might also give radiation therapy, 2000 cGy
in 10 fractions. I am not a fan of giving oral steroids on a daily basis because I think
that patients become very steroid-dependent. Recently, we have been trying pulsed
oral prednisone 600 mg weekly by mouth for 6 weeks followed by 300 mg weekly
for 6 weeks. For double vision, I either occlude one eye or blur one eye signifi-
cantly. Patients that want to try a Fresnel prism can, but they understand that this
may change with disease worsening. Hot off the presses in May 2017, a recent
study in the New England Journal of Medicine showed that teprotumumab, a human
monoclonal antibody inhibitor of IGF-IR, reduced proptosis and CAS in patients
with active, moderate-to-severe ophthalmopathy compared to placebo. This could
be a game changer and could conceivably reduce the time to stabilization of TED.
Once the patient stabilizes for at least 6 months and their CAS score is 2 or
below, then I recommend surgical intervention, which can include orbital decom-
pression, strabismus surgery, and eyelid repositioning (in this specific order). Some
patients require all of these procedures and some only one or two.
TED is the most common cause of diplopia and I always look for evidence of thyroid
eye disease if that is the chief complaint. Pain with thyroid eye disease is not rare and
sometimes it can throw us off the track. For example, orbital myositis or orbital
inflammatory disease can be in the differential diagnosis of thyroid eye disease. CT
84 14 Case 14
and MR of the orbit are helpful if the typical tendon sparing is present. If the tendon
is involved, it may be myositis. I also get orbital ultrasound when it is available,
because the ultrasonographer can tell the difference between myositis and TED.
Hashimoto’s thyroiditis can also be associated with eye pain and TED. A thyroid
receptor antibody can be helpful here. If patients have TED and migraine, migraines
can be worsened by the thyroid disease and also the pain can be more pronounced.
TED patients do require a good eye examination. I get a baseline visual field as
well as good measurements to follow the disease. Almost every thyroid patient gets
dry eyes because of the proptosis and I frequently prescribe artificial tears. We order
TSI and TRAB as well as thyroid tests.
Treatment of TED is so frustrating for patients because it is a waiting game for
the thyroid eye disease to settle down before doing anything. In the meantime, fol-
low the optic nerve function, and be sure the eyes stay lubricated. We try Fresnel
prisms for diplopia or we fog a lens. Recently vitamin D has been reported to help.
For pain, we often use a non-steroidal anti-inflammatory since the pain is gener-
ally mild to moderate.
Graves’ disease really requires a finding of either a high thyroid auto-antibody or an

abnormal radioactive iodine uptake test. I usually start with thyroid function testing
and a TSI along with the clinical exam to make the diagnosis. A CT or MRI of the
orbit might reveal a large extraocular muscle but usually only if the patient has
moderate disease and eye movement limitation. For whatever reason, there is a pref-
erential involvement of the muscles in the following order: inferior, medial, supe-
rior, and lateral. So, if you see a scan that shows isolated lateral rectus enlargement,
you would be suspicious that this may not be TED. Keep in mind that TED can
cause vision loss and even blindness if the eye muscles compress the optic nerve,
which requires urgent steroids and/or surgery. TED is best followed by either an
orbital specialist or a neuro-ophthalmologist or anyone with strong familiarity and
experience with the eye disease.
Follow Up
This patient had an elevated TSI and was diagnosed with Graves’ disease. She is
euthyroid on methimazole treatment. The literature supports that thyroidectomy
causes less TED activity than radioactive iodine (RAI). She and her endocrinologist
are debating the pros and cons of definitive treatment. If she opts for RAI, then I
would recommend prednisone treatment before, during, and after to try to mitigate
TED worsening. The patient is to follow up in 4–6 months sooner if she loses vision
in either eye. Final diagnosis: Thyroid eye disease.
For Further Study
1. Mourits MP, Koornneef L, Wiersinga WM, et al. Clinical criteria for the assessment of disease
activity in Graves’ ophthalmopathy. Br J Ophthalmol. 1989;73:639–44.
2. Bothun ED, Scheurer RA, Harrison AR, Lee MS. Update on thyroid eye disease and manage-
ment. Clin Ophthalmol. 2009;3:543–51.
3. Rao R, MacIntosh PW, Yoon MK, Lefebvre DR. Current trends in the management of thyroid
eye disease. Curr Opin Ophthalmol. 2015;26(6):484–90.
4. Smith TJ, Kahaly GJ, Ezra DG, et al. Teprotumumab for thyroid-associated ophthalmopathy. N
Engl J Med. 2017;376:1748–61.
Case 15
A 64-year-old Hispanic woman with a history of mixed connective tissue disease

and possible rheumatoid arthritis presented with severe eye pain and visual loss. She
had previous headaches as a young woman but had none until about 3 months ago,
when she began to have pain around her left eye and left side of her head. The pain
has steadily increased and is worsened with movement. She had light sensitivity in
that eye and preferred to have the left eye closed. She also has had some mild tearing
on the left side with the severe pain. About 1 month ago she noticed decreased
vision in her left eye. She thinks her visual loss is getting worse. She may have had
a cold the week before the onset of her symptoms.

Diabetes for many years—Type II Lung biopsy for hemoptysis showed pulmonary
Anemia vasculitis 5 years before; she had been on
Hypertension methotrexate and prednisone in the past—Now
Hypothyroidism none for long period of time
History of Bell’s palsy
Albuterol inhaler Negative
Benazepil
Glipizide
Metformin
Married, works as a cleaning lady; three Fatigue
children; does not speak English; never
smoked; no alcohol

88 15 Case 15
Examination
Right eye: 20/25
Left eye: 20/400
Pupils
2 mm OD and 2.5 mm OS in light
4 mm OD and 3.5 mm OS in darkness
1.2–1.5 log u RAPD in the left eye
Color vision (HRR)
9/9 OD 0/9 OS
Stereo vision
None
Right eye: 19 mmHg
Left eye: 19 mmHg
External exam
2 mm ptosis on the left
Exophthalmometry (Hertel)
18 OD and 21 OS at a base of 99 mm (Fig. 15.1)
Mild resistance to palpation on the left
35 diopters of exotropia with limitation of adduction, elevation
Mild blepharitis OU with Meibomian glad dysfunction OU. Mild conjunctival injection OU;
anterior chamber no cell; nuclear sclerosis OU and cortical cataract mild; no vitreal cell
Visual field
OD: Normal; central scotoma on the left with constriction and depression
Fundus examination
Normal OU with no edema or pallor; 0.2 c/d ratio; mild retinal artery attenuation
Normal except for a very mild postural tremor on outstretched arms; corneal sensation intact
Optical coherence tomography
Minimal decrease in RNFL OS
Fig. 15.1 External
photograph shows
proptosis of the left eye
Discussion 89
Discussion

Because of the loss of vision, pain and proptosis, imaging must be done to determine
where the problem is. The possibilities are orbital apex (with visual loss and partial
cranial nerve 3, 4, 6), less likely superior orbital fissure, which may not have visual
loss, and cavernous sinus, which would have multiple cranial nerve including V1 and
V2 involvement. The fact that her corneal reflex was intact and that she did not have
a sixth nerve palsy, I was thinking orbit not cavernous sinus. In these cases, careful
cranial nerve examination is also important—especially the fifth nerve (check the
corneal reflex) and fourth and sixth. She looked a little like a partial third nerve palsy,
but it certainly was not complete. All of her other eye findings—meibmonian gland
dysfunction and dry eye would not account for visual loss or this much pain.
Anytime there is pain and proptosis, it is important to think about an orbital lesion.
The most common cause of proptosis is thyroid disease, but there is too much pain for
that. In a diabetic, we worry the most about sinus disease especially an infection such
as orbital mucormycosis or other fungus like aspergillosis. Fungal infections, unless
treated promptly, could potentially kill the patient, so urgent evaluation is required.
Orbital cellulitis usually is associated with more flagrant edema around the eyelids,
which our patient did not have. Orbital tuberculosis could also be considered.
I would get an MR scan with orbital views and fat saturation and based on these
findings, decide what to do. Is the mass in the orbit alone or in the sinuses is the first
question. If in the sinuses, consider a referral to ENT for endoscopy and biopsy and
culture. If it is in the orbit, the characteristics of the mass may be helpful. Many
slow growing tumors do not usually cause pain but can cause visual loss and propto-
sis. The pain here suggests that this is either quickly growing or an invasive lesion—
such as a metastatic tumor (breast in women and lung in men are most frequent).
Lymphoma while normally painless is also a consideration.
Other things to consider would be inflammation. Sarcoid must be on the differ-
ential diagnosis since it can cause visual loss, but does not always cause pain. She
did have pulmonary vasculitis 5 years ago, so this could also be inflammation such
as granulomatosis with polyangitis (GPA, formerly known as Wegener’s granulo-
matosis). Giant cell arteritis can rarely present as proptosis and visual loss. Idiopathic
inflammatory disease is also a possibility.
An urgent MR scan was ordered. We also ordered laboratory studies: CBC,
Chem 27, Hemoglobin A1C, ESR, c-ANCA and p-ANCA, and C-reactive protein.
Notice in the history that proptosis was not something about which she complained.
I would say that most folks do not notice this when they have ptosis as well, since the
eyelids mask this appearance unless it is extreme. Even if her lid were in a normal
position, she may not make much of it. However, if the eyelid were retracted, patients
90 15 Case 15
often describe that as bulging. Many people are a bit asymmetric and studies of
Hertel exophthalmometry show that a 1 mm difference is acceptable; uncommonly,
normal individuals have up to 2 mm difference and anything more than that is likely
pathologic. The patient here has 3 mm of difference. One way to distinguish between
a restrictive process vs. a cranial neuropathy is the speed of the saccades. If you ask
the patient to adduct quickly, then a restrictive process will have a quick saccade but
limited excursion, and a cranial neuropathy will have a slowed saccade.
I would agree that neuroimaging is warranted. MRI may be the same or better
than a CT orbit, but CT would be an acceptable first step since they are so easy and
quick to get. CT will also help us identify bony destruction, which could suggest a
malignancy with a solid tumor. In this case, I would advocate for contrast especially
as infection is on the differential.
Other potential tests would include serum IgG4, Lyme, Ehrlichiosis, and a uri-
nalysis, but a lot of it depends on what the imaging shows.
For a primary care physician, the most important thing is to recognize proptosis.
First view the patient while seated from above or the worm’s eye view—does one
eye appear proptotic? Second is to recognize visual loss. Besides the patient’s com-
plaint—check visual acuity and look carefully for a relative afferent pupillary
defect. If present, this patient needs further evaluation with imaging and probably a
neuro-ophthalmology consult.
Follow Up
The MR scan showed a large mass engulfing the orbit involving the optic nerve
(Fig. 15.2). There was no evidence of naso-sinus disease. Because of the progres-
sive visual loss, a biopsy was obtained. She was also placed on prednisone after the
biopsy and she was supposed to return, but she went to visit relatives in Mexico. The
biopsy showed inflammation consistent with but not diagnostic of GPA. Quantiferon
Gold was negative, ESR and CRP were elevated. Her pANCA and cANCA were
positive—this is GPA of the lung and orbit. About 6 weeks later she returned, and
on prednisone her Visual acuity was 20/25 + 3 OD and 20/30 OS and her motility
completely normalized, she still had an RAPD OS but it had become smaller, and
she had no ptosis. Her visual field had also improved. She is followed by rheumatol-
ogy and monthly Rituximab and tapering steroids. A follow-up MR scan shows the
left mass in the orbit and also a mass developing on the right side as well. Final
diagnosis: orbital mass from GPA.
a b
Fig. 15.2 MR scan axial and coronal views. (a) Axial view: This is a T1 fat saturated view with
gadolinium enhancement. Notice the normally black fat is replaced by diffusely enhancing mass
bilaterally. On the left side the left optic nerve is displaced (arrow). (b) Coronal view, fat saturated
with gadolinium enhancement shows complete loss of the fat by an infiltrating mass on the left and
enhancement especially around on the lacrimal gland on the right (arrow)
For Further Study
1. Bitik B, Kılıç L, Küçükşahin O, Şahin K, Tufan A, Karadağ Ö, Pay S, Ateş A, Ucar M, Tutar
H, Karaaslan Y, Yilmaz S, Ertenli AI, Konuk O, Turgay M, Goker B. Retro-orbital granu-
loma associated with granulomatosis with polyangiitis: a series of nine cases. Rheumatol Int.
2015;35(6):1083–92.
2. Heier JS, Gardner TA, Hawes MJ, McGuire KA, Walton WT, Stock J. Proptosis as the
initial presentation of fungal sinusitis in immunocompetent patients. Ophthalmology.
1995;102(5):713–7.
3. Siddiqui S, Kinshuck AJ, Srinivasan VR. Orbital apex syndrome secondary to granulomatosis
with polyangiitis. BMJ Case Rep. 2013;2013 pii: bcr2013009519.
4. Singh M, Singh U, Zadeng Z. Orbital presentation of systemic vasculitis: a diagnostic and
management challenge. Nepal J Ophthalmol. 2015;7(1):65–8.
5. Shovlin JP. Orbital infections and inflammations. Curr Opin Ophthalmol. 1998;9(5):41–8.
Case 16
A 64-year-old man notes a pressure sensation for the past few months in his left eye
occurring about once per week mostly upon awakening lasting about an hour. He
does not take anything for the pain. There is mild pain to move the eye. It is becom-
ing more frequent. He has a history of a TIA 18 years ago where the entire right side
of his body went numb for a few minutes. The workup was negative at that time. He
has a history of cerebral palsy with right lower extremity weakness. He denies
vision loss or diplopia. He denies jaw claudication, weight loss, anorexia, fatigue, or
scalp tenderness. He describes a delay of about 5 min in dark adaptation in his left
eye when coming inside from bright sunlight.

High cholesterol Carpal tunnel surgery
Hypertension
Diabetes—diet controlled
Amblyopia LE
Glasses since 6 years old
Gemfibrozil Mother—glaucoma and cataract in her 70s
HCTZ
Multivitamin
Fish oil
Disabled Hands and feet always feel cold
Does not smoke or drink Hands tingle in the morning

94 16 Case 16
Examination
Right eye: 20/25
Left eye: 20/60
Pupils
Round, equal, briskly reactive, no RAPD
Right eye: 24 mmHg
Left eye: 19 mmHg
External exam
Dermatochalasis of the upper eyelids
Eye alignment
Normal
A few cells floating in the anterior chamber
No iris neovascularization
Visual field
Subtle superonasal step on automated perimetry BE
Fundus examination
0.55 CDR RE, inferotemporal notching
0.65 CDR LE, inferotemporal notching
Normal nerve and macula
Multiple hemorrhages in the midperiphery (Fig. 16.1)
3/5 Strength in RLE
a b
Fig. 16.1 Composite photographs of the fundus show a (a) normal fundus right eye and (b) hem-
orrhages in the midperiphery (arrows) left eye
Discussion
From a historical standpoint, the eye pain is not that specific. However, the delayed
light adaptation in the left eye only is intriguing. This symptom can manifest as day
Discussion 95
blindness too and occurs with severe carotid stenosis or a central retinal abnormal-
ity. When you add in the multiple mid-peripheral retinal hemorrhages and the cells
in the anterior chamber, then this is most consistent with ocular ischemic syndrome
(OIS). I would just caution the ophthalmologist that you might attribute the cells to
post-dilation effect, but it is only unilateral. Usually post-dilation cells are bilateral
and pigmented. Also, if you only look at the macula and nerve, then you might miss
the hemorrhages, then the diagnosis is not so easy. The patient also has a superona-
sal step and a notch, elevated intraocular pressure (IOP) and a family history of
glaucoma suggesting that he also has glaucoma, which has nothing to do with the
eye pain. Note that the IOP is lower in the LE, which can be seen in OIS presumably
due to ischemia of the ciliary body.
Some patients with OIS complain of more constant or boring pain. Other signs
include iris neovascularization, ipsilateral and unilateral cataract, and macular
edema. In some cases, patients with diabetes may have very asymmetric retinopathy
with worse disease on the contralateral side.
Given the rather classic findings of OIS, an imaging study of the carotids should
be performed. My preference is to obtain an MRA neck and brain so that we can see
the entire carotid and intracranial vascular system to the eye. I have seen intracranial
carotid stenosis causing OIS with a normal carotid ultrasound.
This guy is a “vasculopath” with hypertension, diabetes, and high cholesterol—at

least he does not smoke. He also had a transient ischemic attack 18 years ago and his
entire right side went numb. On neurological examination he clearly has lower extrem-
ity weakness on the right side. This is ominous for a problem in the left carotid artery.
The loss of vision with light is indeed curious—and should alert the astute clini-
cian that there is possible ischemia. Other symptoms of disrupted blood flow to the
retina are transient visual loss or progressive visual loss, which this patient did not
have. Ischemia can also be positional—more visual loss upright and less lying down
or brought about by exercise.
The pain associated with ocular ischemic syndrome may not be severe. Some
have reported the pain to get better lying down indicating better blood flow. If the
intraocular pressure is really high, the pain could be confused for acute glaucoma.
Other signs to look for include changes in the cornea, iris neovascularization and
of course cells in the vitreous. In the retina, narrowing of retinal arteries and dilated
veins can occur. Sometimes there are cotton-wool spots in addition to the mid-
peripheral hemorrhages. If we had not been told about the light—the retinal findings
could mimic diabetic retinopathy or central retinal vein occlusion.
The visual field is important to review and fluorescein angiography can be help-
ful if there is doubt about the diagnosis. The choroid will have delayed filling or
delay in the arteriovenous filling and can be a helpful sign.
The evaluation of these individuals is urgent imaging. Because he has right lower
extremity weakness, which we presume to be due to cerebral palsy, I would check
with previous exams to be sure this is not new. However, because he has a history of
96 16 Case 16
transient ischemic attack, I would recommend an MR with diffusion weighted

imaging (DWI) to be sure he has not had an acute stroke. Arterial imaging is also
really important, since if there is less than 100% occlusion, then treatment with
stenting, carotid endarectomy would be considered. MRA or CTA should be done
of the head AND neck since the stenosis can be in the internal carotid artery any-
where even intracranially. Rarely, digital substraction angiography is required to
fully visualize the carotid artery and the ophthalmic artery. Also of importance is to
check an ESR and CRP—giant cell arteritis has been known to cause OIS.
Treatment of OIS is based on getting the right diagnosis and knowing what lesion is
causing the ischemia. Maximizing medical control of hypertension, diabetes, and cho-
lesterol would also be helpful. Carotid artery endartectomy or carotid artery stenting
could be advised if there is not complete occlusion of the carotid artery in the neck. If the
stenosis is intracranial, stenting has been attempted with success. Rarely, external carotid
to internal carotid arterial bypass is recommended. For sure, I would also treat the raised
intraocular pressure. Sometimes the retinopathy also needs photocoagulation.
This is an eye pain you do not want to miss since the patient could have a stroke
or be at risk for death.
A patient with day blindness or poor dark adaptation can be assessed with the pho-
tostress test. In a darkened room with one eye covered, the patient looks into a bright
light for 10 s. The patient should be able to see two lines above their best acuity line
within 30 s (e.g., if the eye saw 20/20 then it should see 20/30 within 30 s). A posi-
tive test is not specific and could suggest OIS or a retinal condition. The cells in the
anterior chamber are usually very subtle and require an experienced examiner.
These should not be mistaken for uveitis causing pain (the clue here is history of day
blindness, midperipheral hemorrhages).
Follow Up
The patient underwent an MRA neck and brain, which showed 100% blockage
of the left carotid artery within the neck (Fig. 16.2). This was confirmed with arte-
riography. If there was severe, less than 100% stenosis of the extracranial carotid
artery, then endarterectomy or stenting could be considered. With 100% stenosis,
the patient was offered antiplatelets. He has been followed at regular intervals
for the development of iris or retinal neovascularization (if present, then would
receive panretinal photocoagulation). Finally, the patient was diagnosed with glau-
coma and referred to his primary ophthalmologist for management. Final diagnosis:
ocular ischemic syndrome secondary to complete carotid occlusion.
Fig. 16.2 Three-dimensional

rendering of the carotid
circulation. Note that the left
carotid artery is completely
missing indicating complete
occlusion (arrow)
For Further Study
1. Hazin R, Daoud YJ, Kahn F. Ocular ischemic syndrome: recent trends in medical management.
Curr Opin Ophthalmol. 2009;20:430–3.
2. Mendrinos E, Machinis TC, Pournaras CJ. Ocular ischemic syndrome. Surv Ophthalmol.
2010;55:2–34.
Case 17
A 62-year-old man developed a severe burning pain around the right eye and the
right side of his head. Initially, he thought it was due to sinus infection, which he
had in the past. Two years before, he had a bicycle accident and dislocated his shoul-
der but denied head trauma. The pain was continuous and not associated with light
or sound sensitivity or nausea or vomiting; occasionally the pain is bad enough that
he will lie down. As a youngster, age 12, he was shot with a b-b gun and still has a
copper BB behind his right eye and near the optic nerve.

Fatigue and muscle aching—Worked up for Knee surgery twice; tonsillectomy
polymyalgia rheumatica but this was negative
Previous sinus infection
Barrett’s esophagus
Hypothyroidism
Essential hypertension
Metoprolol 100 mg each day Diabetes in father and sister
Multiple vitamin Hypertension in brother and mother
Omeprazole 20 mg
Vitamin D 1000 I.U.
No smoking or alcohol; married Occasional fatigue
Social worker for LDS church

100 17 Case 17
Examination
Right eye: 20/25
Left eye: 20/20-2
Pupils
OD: 2 mm light and 4 mm darkness
OS: 3 mm light and 6 mm darkness
Dilation lag on the right (Fig. 17.1)
Color vision
9/9 BE Ishihara
Stereo vision
Reduced; 1/3 animals on Titmus test
Right eye: 23 mmHg
Left eye: 23 mmHg
External exam
No ptosis
Full excursions
Comitant 10 prism diopter exophoria (long standing)
Normal
Visual field
Normal
Fundus examination
Normal disks 0.3 cup to disk ratio in both eyes
The rest of the exam was normal
Fig. 17.1 External
photographs show very
mild ptosis on the right.
Note that the palpebral b
fissure is smaller on the
right. There is anisocoria at
(a) 5 s after turning off the
lights, which becomes less
obvious at (b) 15 s. This
difference is known as
dilation lag. (c) Thirty c
minutes after instillation of
5% cocaine eye drops, the
anisocoria becomes more
obvious. This is a positive
cocaine test, diagnostic of
a Horner syndrome
Discussion 101
Discussion
In every patient with eye pain, I look carefully at the pupils to see if there is a
Horner’s syndrome (small pupil, ptosis, upside down ptosis, and dilation lag) since
many headache syndromes are associated with a Horner’s or partial Horner’s syn-
drome. To look for a Horner’s syndrome I look for three things: First—assess the
size of the pupil in light and darkness. Typically, the Horner’s patient will have more
anisocoria in darkness than in light. Second, I look for a dilation lag—you can do
this in a dimly lighted room with a flashlight below the chin and turn the overhead
light on and off, looking to see if the smaller pupil is slow to dilate. Third, I look for
ptosis on the side of the smaller pupil—both superior lid ptosis but also upside down
ptosis (lower eyelid is higher). In this case the Horner’s syndrome was subtle since
he really did not have any appreciable ptosis.
This man fits the syndrome of paratrigeminal oculosympathetic syndrome
(sometimes called Raeder’s syndrome)—a painful Horner’s syndrome. It is typified
by pain in V1 or V2 and a Horner’s pupil. See Table 17.1 for the ICHD 3 beta defini-
tion of paratrigeminal oculosympathetic syndrome. This is a new headache in some-
one who does not have headaches.
Painful Horner’s syndrome can occur in an acute Cluster headache attack—and I
have seen this several times—a painful Horner’s in the ER and after all testing, it was
the first attack of cluster headache. Imaging is critical since carotid dissection or mid-
dle cranial fossa lesions (e.g., cavernous sinus disease) could also present this way.
Sometimes, the Horner’s is so subtle that I am not sure it is a Horner’s; then I perform
pharmacologic testing. Here photographs of the pupils before and after drop testing are
very helpful. I will apply cocaine (which blocks norepinephrine reuptake and therefore
dilates the normal pupil) 5% when available to each eye and wait 30–60 min to see if
both pupils dilate equally—if one pupil fails to dilate, it is a positive test. If there is more
than 0.8 mm of anisocoria after the testing, Horner’s pupil is diagnosed.
Table 17.1 ICHD 3 Beta: Paratrigeminal oculosympathetic syndrome (Raeder’s syndrome)

A. Constant, unilateral headache fulfilling criterion C
B. Imaging evidence of underlying disease of either the middle cranial fossa or of the
ipsilateral carotid artery
C. Evidence of causation demonstrated by both of the following:
1. Headache has developed in temporal relation to the onset of the underlying disorder
2. Headache has either or both of the following features:
(a) Localized to the distribution of the ophthalmic division of the trigeminal
nerve, with or without spread to the maxillary division
(b) Aggravated by eye movement
D. Ipsilateral Horner’s syndrome
E. Not better accounted for by another ICHD-3 diagnosis
102 17 Case 17
Sometimes cocaine is not available and the apraclonidine test is used. In this
pharmacologic test, we take advantage of adrenergic hypersensitivity since apra-
clonidine is a weak adrenergic agent. In this case, a drop is instilled in each eye.
After waiting for 30–40 min, you will see a reversal of anisocoria (that is the
Horner’s pupil will appear larger than the non-Horner’s pupil).
When available, I like to localize the Horner’s as a second- or third-order neuron
Horner’s pupil. It helps me order the appropriate imaging. In this test hydroxyam-
phetamine (which releases any norepinephrine from the iris terminal which causes
dilation in a normal pupil and in a first or second order Horner’s pupil) is instilled in
a separate session (usually 1–2 days apart from the previous testing). You wait
30–40 min and a third-order Horner’s will show NO dilation to hydroxyamphet-
amine. When the Horner’s syndrome is acute, you may want to skip this test, since
getting to imaging is critical to prevent stroke.
To determine if the Horner’s is acute—the history is helpful—sudden onset of
pain and changes in the eyelid or pupil. I usually look at old photographs—if a patient
has a driver’s license and has had a smaller pupil on that side for years, the emer-
gency of the pupil is lessened. If the Horner’s pupil is acute, I order imaging—usu-
ally MRI and MRA since I am most worried about a carotid dissection. In this man’s
case, he had a BB to the eye, so only a CT could be done, but a CTA was also ordered.
In the ophthalmologist’s office, a technician often evaluates patients and then dilates
the patient prior to seeing the physician. In cases of eye pain, it is critical that the
technician evaluates the pupil and eyelid, because if they dilate the patient, then you
will never find the Horner syndrome and may miss the carotid dissection. Since this
is an acute oculosympathetic disruption, some patients may have other autonomic
signs or symptoms such as ipsilateral conjunctival injection, tearing, lower intraocu-
lar pressure, nasal congestion, or an abnormally close near point of accommodation.
These other symptoms are transient and may only be there for hours to days. Patients
with autonomic symptoms can sometimes be mistaken for conjunctivitis or trigemi-
nal autonomic cephalgia. Keep in mind that 20–40% of folks can have physiologic
anisocoria. If your cocaine test is negative (both pupils dilate equally) then the
patient likely has headache plus physiologic anisocoria.
If the neuroimaging is normal and this is not part of an autonomic headache, the
Horner syndrome is generally idiopathic and permanent. Patients can undergo
eyelid surgery (Mullerectomy) for repair. Because the pupil and eyelid are
supersensitive to alpha 1 agonists, I have asked individuals to try over-the-counter
tetrahydrozoline (Visine) to reverse the lid and pupil findings for cosmesis.
As with all things medicine, differing opinions exist. Personally, I do not localize
a Horner syndrome with hydroxyamphetamine as described by Dr. Digre. I usually
Discussion 103
image the entire oculosympathetic axis. If the scan is normal then I do not pursue
further workup, since idiopathic Horner syndrome is not uncommon.
If you suspect a painful Horner’s syndrome and it is acute, it is a relative emergency

to prevent a stroke from occurring. Imaging will be critical to ensure that this is not
a carotid dissection. Most patients do not have the full triad and will not endorse the
anhidrosis. The radiologist needs to know that you are looking for a carotid dissec-
tion, or they may not protocol the scan properly.
Follow-Up
Normally, I would have ordered an MR on this patient, but because of the BB shot,
a CT scan was done. The CT showed the expected B-B pellet behind the right eye
and a double lumen sign consistent with a carotid artery dissection (Fig. 17.2). He
was placed on aspirin 81 mg and did well without further problems. Horner’s syn-
drome can be the presenting sign of carotid dissection along with headache. Final
diagnosis: Horner syndrome secondary to carotid artery dissection.
a b
Fig. 17.2 (a) CTA in this case showing a carotid dissection with a double lumen (arrow). (b) Axial
T1 MRI of another case shows classic hyperintense crescent typical of a carotid dissection (arrow)
104 17 Case 17
For Further Study
1. Davagnanam I, Fraser CL, Miszkiel K, Daniel CS, Plant GT. Adult Horner’s syndrome: a com-
bined clinical, pharmacological, and imaging algorithm. Eye (Lond). 2013;27(3):291–8.
2. Lemos J, Eggenberger E. Neuro-ophthalmological emergencies. Neurohospitalist.
2015;5(4):223–33.
3. Sheikh HU. Headache in intracranial and cervical artery dissections. Curr Pain Headache Rep.
2016;20(2):8.
Case 18
A 77-year-old woman developed a 6-day history of fever and right eye pain. The
fever was low grade, although she did not check her temperature with a thermome-
ter, and it lasted 4 days. The right eye pain is gradually worsening and is currently
8–9 out of 10. It is constant, sharp, and located in, behind and around the right eye.
There is no tenderness or pain with eye movement. She denies eye redness, ptosis,
or discharge. Three days ago, she developed horizontal binocular double vision. The
double vision is worse in the distance and is constant.

Diabetes Gallbladder surgery
Hypertension Hip replacement
Hypercholesterolemia Hysterectomy
Hypothyroidism
Insulin Hypertension
Amlodipine Diabetes
Lisinopril Hypercholesterolemia
Atorvastatin No migraine
Levothyroxine
Homemaker Reduced appetite × 4 days
Nonsmoker Malaise × several days
Nondrinker No jaw pain or fatigue
No myalgias
No arthralgias

106 18 Case 18
Examination
Right eye: 20/30
Left eye: 20/20
Pupils
Equal, briskly reactive, no APD
Right eye: 23 mmHg
Left eye: 28 mmHg
External exam
No ptosis, redness, normal temporal artery pulses
Esotropia worse in right gaze
Abduction deficit, right eye (Fig. 18.1)
Cataract RE
Visual field
Normal
Fundus examination
Cup to disc ratio 0.6 BE, no diabetic retinopathy
Normal facial sensation and strength
Normal hearing to finger rub
Color vision normal
Fig. 18.1 External photographs show a subtle esotropia in primary gaze. She has full motility
looking to the left, and she has a right abduction deficit in right gaze consistent with a right sixth
nerve palsy (Courtesy of Collin M. McClelland, MD)
Discussion
Clinically, this patient has a right, isolated sixth nerve palsy. When it comes to deter-
mining whether it is isolated, as one of my colleagues likes to say, “Can you count
to 7? They are numbered for a reason.” There is no optic neuropathy present (CN II).
She does not have a visual field defect, an APD, or color vision loss. There is no
ptosis, dilated pupil, or poor vertical movement to suggest a CN III or vertical mis-
alignment to suggest a CN IV palsy. Her facial sensation was normal (CN V) as was
her facial strength (CN VII). The oculosympathetics run with CN VI in the cavern-
ous sinus, so we also look for an ipsilateral Horner syndrome (ptosis and small
pupil), which she does not have. A cartoon of the anatomy is shown in Fig. 18.2.
Discussion 107
Interestingly, she may have had a fever, which could suggest an infectious or a
systemic collagen vascular disease. The fever was self-limited, which may argue for
a viral cause. She also has significant headache/eye pain. Giant cell arteritis (GCA,
Case 32) can cause double vision and a cranial nerve palsy, and it should be on the
differential. She has some malaise and anorexia but no jaw claudication. Her tem-
poral arteries are normal. I would favor drawing an ESR and CRP. If these are high,
then I would start her on prednisone and obtain a temporal artery biopsy. If these are
normal, then I would observe.
In my experience, patients with diabetes are more apt to have a PAINFUL micro-
vascular CN palsy than those without diabetes. Not all do, but some microvascular
CN palsies can be painless and it runs the gamut to excruciating. The excruciating
ones tend to be diabetic patients. By microvascular, I mean they have a presumptive
occlusion of a microvessel that causes the CN palsy. These typically resolve spon-
taneously over the course of 3–4 months.
There is a debate in neuro-ophthalmology about whether patients over 50 years
old with microvascular risk factors and an isolated CN palsy should get an MRI
or whether you should observe them for 3 months first. A lot of that debate began
in the 1970s and 1980s when it was difficult to get an MRI. Today, my opinion is
to scan right away. Neuroimaging is readily available and a lesion may be seen in
1–5% of patients. If the patient cannot afford it or has significant issues with get-
ting it, then I will wait 6 weeks. If the palsy is stable or worse at follow-up, then I
would get an MRI. If the palsy is improving and remains isolated, then I will
continue to wait. If it does not resolve by 3–4 months, then I will press upon them
to get a scan.
Lacrimal
gland
Supraorbital
Superior branch
ophthalmic Lacrimal
vein 2 branch
Carotid artery Nasociliary
branch
Cavernous sinus 3
4 5
Petrosal vein 5 6
7
8
Fig. 18.2 Diagram of cranial nerves 3, 4, and 6. Notice also how many other nerves are nearby,
including 5
108 18 Case 18
In this particular case, because she has such significant pain, I would scan her. I
am interested to know whether she has a cavernous sinus lesion or orbital inflamma-
tion and this could be Tolosa Hunt (Case 40) or idiopathic orbital inflammation
(Case 11). I would also treat the pain with non-steroidals or tramadol or in some
cases opioids. The pain tends to resolve after a few weeks.
The patient has a painful sixth nerve palsy and she is a vasculopath (hypertension,
diabetes, high cholesterol) so this is likely to be a diabetic or microvascular sixth
nerve palsy. However, the differential diagnosis of a painful sixth nerve palsy is
broader than this. As Dr. Lee points out an older person presenting with a painful
cranial nerve palsy needs an ESR and CRP to rule out giant cell arteritis. In this
condition, usually the pain is worse with eye movement and their might be propto-
sis. Be sure to look in the ears and test hearing with a painful sixth nerve palsy.
Gradenigo’s syndrome is an inflammation/infection of the petrous bone and clivus
which causes a sixth nerve palsy and pain and otitis media can be present. This can
be serious in an older individual. Other tumors of the petrous bone can be associated
with a painful sixth nerve palsy. Be sure to look for a sympathetic defect since a
sixth and a Horner’s can be indicative of a paratrigeminal defect in the posterior
cavernous sinus. Look carefully for subtle signs of a third, fourth, or fifth nerve
palsy indicating a cavernous sinus syndrome or lesion. Increased or decreased intra-
cranial pressure can present with a headache and sixth nerve palsy; unlike our
patient whose pain is really in the eye this is usually in the head. Be sure to do a
complete neurological examination since a slight hemiparesis contralateral to the
sixth nerve palsy could be a brainstem stroke or demyelination; while stroke is not
usually painful, it can be.
Consider the mimickers of a painful sixth nerve palsy such as: Orbital myositis
and thyroid eye disease (see Case 14); while these are not always extremely pain-
ful, they can be. Myasthenia, a mimicker of sixth nerve palsy, is almost never is
painful. Spasm of the near could look like a sixth nerve, but would not have as
much focal unilateral pain. We have also discussed painful third nerve palsies in
Cases 42 and 43.
This is why I usually get an MR scan in isolated cranial neuropathy whether it is
sixth, third, or fourth (unless there is trauma and a fourth nerve palsy). Sometimes
special imaging protocols are available to image these nerves—especially CISS
(constructive interference in steady-state imaging).
I usually treat the pain with acetaminophen or non-steroidal anti-inflammatory.

Sometimes the pain is bad enough to warrant an opioid, but in the elderly, I try to
avoid those.
I know you are thinking that this is more of a CN palsy/double vision case. But, her
main complaint was the pain and not the double vision. This does happen on occa-
sion. The first time I saw a very painful CN palsy, I thought the patient was exag-
gerating or drug seeking. However, I have seen it enough to know that there are
some patients who just have significant pain with microvascular cranial nerve
palsies.
Although her intraocular pressure was elevated (less than 21 is normal), this kind
of pain would be more consistent with a pressure of 40 or 50+. Patients with pres-
sures in the 30s usually do not have pain.
Follow-Up
Her ESR and CRP were both normal. Her MRI with contrast showed a normal orbit,
cavernous sinus, and course of the sixth nerve. She was diagnosed with a microvas-
cular CN palsy. She was placed on tramadol 50 mg every 6 h as needed. At 6 weeks
follow-up, her pain was gone and her double vision was substantially improved. At
3 months, her double vision had resolved. Her intraocular pressure was consistently
over 21 and she was sent for a glaucoma evaluation. Final diagnosis: Microvascular
sixth nerve palsy.
For Further Study
1. Murchison AP, Gilbert ME, Savino PJ. Neuroimaging and acute ocular motor mononeuropa-
thies: a prospective study. Arch Ophthalmol. 2011;129:301–5.
2. Tamhankar MA, Biousse V, Ying GS, et al. Isolated third, fourth, and sixth cranial nerve pal-
sies from presumed microvascular versus other causes: a prospective study. Ophthalmology.
2013;120:2264–9.
Part III
Neurologic Disorders Causing Eye Pain:
Case 19
This 28-year-old painter in the fine arts presented with a worsening headaches and
eye pain. She has a family history of headaches in her mother and cousin. She was
carsick as a child and had occasional night terrors. She began having headaches at
age 11, and some of those were preceded with visual aura. In high school she had
headaches about 2–3 times each month. In college she noticed headaches every
weekend and she would have a headache with light and sound sensitivity, and nau-
sea. The headache went from both sides of her neck and radiated to her eyes. She
started topiramate and her headaches markedly reduced to about once each month.
Three years later, she discovered she was pregnant and stopped the topiramate and
her headaches worsened. After delivery she restarted topiramate and onabotulinum
toxin and the headaches reduced to once monthly. She again stopped topiramate and
the onabotulinum toxin because of a planned pregnancy. After a miscarriage she
found herself pregnant again. She presents now with headaches radiating into her
eyes. The worst headache starts as a visual aura of zig-zag lines and a central sco-
toma in both eyes, followed by pain in her neck that radiates into both eyes. The
pain is throbbing, with light and sound sensitivity, nausea, and it worsens with activ-
ity. The pain lasts 1–3 days. In addition, she has less severe headaches 2–3 times
each week associated with pain in her eyes, a pressure feeling associated with light
and sound sensitivity but no nausea. Finally, she gets an aura without any head-
ache—these last about 20 min and occur 1–2 times each week. She is not sleeping
well, which she attributes to the pregnancy, and she drinks 44 ounces of diet cola
beverage. She has been on topiramate in the past, which she is not on during preg-
nancy. She has tried preventative medications including amitriptyline, magnesium,
fish oil, and onabotulinum toxin in the past. She has tried abortive medication
including sumatriptan, eletriptan, frovatriptan, ibuprofen, acetaminophen which
have not been helpful and isometheptene combination with acetaminophen and

114 19 Case 19
dichlorphenazone (Midrin) which has been effective. She had an MR scan 4 years
ago, and this was normal except for mild maxillary mucosal thickening.
Her Migraine Inventory Disability Score (MIDAS) is 54 indicating significant
disability from migraine. Her PHQ 9 (depression scale) was 22 indicating signifi-
cant depression and GAD 7 (anxiety scale) was 19 indicating significant anxiety.

Miscarriage 1 year ago D & C after the miscarriage
Hypothyroidism Family history
Depression and anxiety Headaches, depression, anxiety
Midrinprn Fatigue, dizziness, chronic light
Pre-natal multiple vitamins Sensitivity, constipation, back pain
Synthroid 0.1 mg
Sertraline 50 mg each day
Social history Allergies
Married, one child Aspirin causes throat swelling
Examination
Right eye: 20/20
Left eye: 20/20
Pupils: Large 6 mm OD, 6 mm OS in light; 8 mm OD, 8 mm OS in darkness; equal and no
RAPD
External exam
Normal
Eye alignment
Normal
Visual field
Normal fields to confrontation
Fundus examination
Normal
BP 122/76, HR 95, BMI 25
Normal except for mildly increased deep tendon reflexes; she had no change with superficial
temporal artery compression, but she did have some cervical and trapezius spasms
Discussion
This woman has three different kinds of headaches including: migraine with aura,
migraine without aura, and aura without headache (Acephalgic migraine). The eye
pain is associated with both her migraine with and without aura and interestingly
Discussion 115
pain starts in the neck and goes to the eyes—where the bulk of her migraines end—
behind her eyes. Furthermore she is pregnant.
Migraine is a very common disorder affecting almost 20% of women and 8–10% of
men. It is no wonder then, that it would be common in all of our clinics. The diagnosis
of migraine is often made with a family history of headaches (usually migraine), car
sickness, and night terrors as a child. The characteristics of light and sound sensitivity,
nausea and/or vomiting and worsening with activity are key characteristics of migraine
defined by the ICHD 3 beta (Table 19.1). She also has a fully reversible aura and cen-
tral scotoma that precedes some of her headaches followed by a typical migraine head-
ache (Table 19.2). She also gets an aura without a headache (often called acephalgic
migraine or migraine without pain) (Table 19.3). Since she is having slightly more than
15 migrainous days in a month, she meets the definition of chronic migraine
(Table 19.4). “The ID migraine study” found that headaches that meet 2/3 characteris-
tics from the following have a 96% specificity and 94% sensitivity: (1) moderate to
severe headache causing disability, associated with (2) light sensitivity, or (3) nausea.
She also has the common and important comorbidities that accompany migraine
including depression and anxiety. Her chronic light sensitivity which has also been
associated with chronic migraine as well as higher levels of depression and anxiety
could be making her migraines worse. She also is not sleeping well, which makes
migraines worse and she has cervical spasm, which can contribute to migraine as
well. The excessive amount of caffeine may be interfering with sleep, and the sweet-
ener, NutraSweet found in the cola she drinks has been associated with migraine.
Migraines are usually inherited headaches and, while the exact cause and mecha-
nism is not completely understood, are likely caused by changes in the trigemino-
vascular complex. The aura component may relate to spreading depression, and the
Table 19.1 ICHD 3 beta criteria for migraine without aura

A. At least five attacks 1 fulfilling criteria B–D
B. Headache attacks lasting 4–72 h (untreated or unsuccessfully treated) 2,3
C. Headache has at least two of the following four characteristics:
1. Unilateral location
2. Pulsating quality
3. Moderate or severe pain intensity
4. Aggravation by or causing avoidance of routine physical activity (e.g. walking or
climbing stairs)
D. During headache at least one of the following:
1. Nausea and/or vomiting
2. Photophobia and phonophobia
E. Not better accounted for by another ICHD-3 diagnosis
Description: Recurrent headache disorder manifesting in attacks lasting 4–72 h. Typical character-
istics of the headache are unilateral location, pulsating quality, moderate or severe intensity, aggra-
vation by routine physical activity and association with nausea and/or photophobia and phonophobia
116 19 Case 19
Table 19.2 ICHD-3 beta criteria for migraine with aura

A. At least two attacks fulfilling criteria B and C
B. One or more of the following fully reversible aura
Symptoms:
1. Visual
2. Sensory
3. Speech and/or language
4. Motor
5. Brainstem
6. Retinal
C. At least two of the following four characteristics:
1. At least one aura symptom spreads gradually over _5 min, and/or two or more
symptoms occur in succession
2. Each individual aura symptom lasts 5–60 min 1
3. At least one aura symptom is unilateral 2
4. The aura is accompanied, or followed within 60 min, by headache
D. Not better accounted for by another ICHD-3 diagnosis, and transient ischemic attack has
been excluded
Description: Recurrent attacks, lasting minutes, of unilateral fully reversible visual, sensory or
other central nervous system symptoms that usually develop gradually and are usually followed by
headache and associated migraine symptoms
Table 19.3 ICHD 3 beta criteria for typical aura without headache (migraine without aura,
acephalgic migraine, migraine without pain)
A. Fulfills criteria for migraine with typical aura (see Table 19.2)
B. No headache accompanies or follows the aura within 60 min
Description: Migraine with typical aura in which aura is neither accompanied nor followed by
headache of any sort
pain component may be caused by release of inflammatory molecules associated

with the dural vessels stimulating trigeminal afferents to the nucleus caudalis (a
spinal trigeminal nucleus) and modulated by the thalamus and sensed in the sensory
cortex. Because of the involvement of the spinal nucleus, sufferers may experience
neck pain as part of the migraine, like our patient. The pain can be unilateral or
bilateral, but characteristically occurs in the first division of the trigeminal nerve,
and not infrequently involves pain around, in, by the eyes. Neck pain can also be a
sign of migraine. This is due to the caudal nucleus extending into the upper cervical
spine (See Fig. 23.1 and Appendix 4).
Discussion 117
Table 19.4 Chronic migraine ICHD 3 beta criteria

A. Headache (tension-type-like and/or migraine-like) on >15 days per month for >3 months
and fulfilling criteria B and C
B. Occurring in a patient who has had at least five attacks fulfilling criteria B-D for migraine
without aura and/or criteria B and C for migraine with aura
C. On >8 days per month for >3 months, fulfilling any of the following:
1. Criteria C and D for migraine without aura
2. Criteria B and C for migraine with aura
3. Believed by the patient to be migraine at onset and relieved by a triptan or ergot
derivative
Description: Headache occurring on 15 or more days per month for more than 3 months, which has
the features of migraine headache on at least 8 days per month
Our patient does not need further imaging. Imaging in migraine has a very low
yield of any pathology and while MR and CT scans are not contraindicated in preg-
nancy, they are unnecessary in this case, since her migraines have not really changed
in character—only in frequency since stopping her preventatives AND her neuro-
logical examination is normal.
If she were not pregnant, we would consider putting her back on the topiramate
(100–200 mg) and back to the onabotulinum toxin (every 3 months) since these
were successful in the past. Other preventatives that could be considered include:
beta-blockers like propranolol, tricyclic antidepressants such as amitriptyline, nor-
triptyline, imipramine, desipramine and doxepin, calcium channel blockers such as
verapamil.
Since she is pregnant, we try to avoid anticonvulsant class drugs since topiramate
is a Class D drug (causing neural-tube defects). One could use low-dose aspirin
(81 mg) which is very helpful for preventing aura, and can be taken in pregnancy
especially after a woman has had previous miscarriage, but our woman has a signifi-
cant aspirin allergy. Other medications used successfully in pregnancy include tricy-
clic antidepressant, calcium channel blockers, and beta blockers (all Class C drugs).
In all patients with migraine, pregnant or not, there are some basic treatments that
should be counseled: First, limit caffeine to less than 1–2 cups of any caffeinated
beverage. Encourage sleep with sleep hygiene—eating at least 4 hours before bed
time, do no other activity in bed except sleep and sex, think only about sleep while in
bed (those who do, fall asleep faster), stay in bed for 6–8 h every night. Having some
“down time” before bedtime with relaxation techniques is also helpful. Frequent
exercise, eating regularly is also helpful. In this patient I would also recommend
FL-41 tinted lens for her chronic light sensitivity (see Case 21), which successfully
reduced migraines in studies. In this case, I would also recommend a Theracane or a
device where she could reduce her cervical spasm which can contribute to migraine.
For the acute treatment of migraine, we recommend to prevent nausea with med-
ications such as promethazine 25 mg (tablets and suppositories) or ondansetron
118 19 Case 19
2–4 mg, or metoclopramide 2.5–5 mg; treat the pain with an isometheptene combi-

nation drug or a triptan with or without a non-steroidal anti-inflammatory in the first
half of pregnancy (the non-steroidal would be contraindicated due to premature
closure of the ductusarteriosis in the last one-third of pregnancy).
This is a pretty classic migraine story. I do not really have anything to add. An oph-
thalmologist familiar with giving botulinum toxin A could consider learning the
indications and injection patterns. It is pretty straightforward and can be rewarding.
This woman has migraine with and without aura—treatment could proceed as out-
lined above.
Follow-Up
We discussed the above-mentioned non-medication treatments. We also increased

her sertraline to 100 mg to treat the depression and anxiety. We discussed stopping
caffeine and artificial sweeteners. We suggested a low dose of amitriptyline 25 mg
at night to aid in sleep. After pregnancy we suggested verapamil and retrying botu-
linum toxin, topiramate, or both. Final diagnosis: migraine with aura, migraine
without aura, aura without headache.
For Further Study
1. Becker WJ. Acute migraine treatment. Continuum (MinneapMinn). 2015;21(4 Headache):953–72.

2. Burstein R, Noseda R, Borsook D. Migraine: multiple processes, complex pathophysiology. J
Neurosci. 2015;35(17):6619–29.
3. Charles A, Hansen JM. Migraine aura: new ideas about cause, classification, and clinical sig-
nificance. Curr Opin Neurol. 2015;28(3):255–60.
4. Digre KB. Headaches during pregnancy. Clin Obstet Gynecol. 2013;56(2):317–29.
5. Lipton RB, Dodick D, Sadovsky R, Kolodner K, Endicott J, Hettiarachchi J, Harrison W,
Migraine Validation Study ID. A self-administered screener for migraine in primary care: the
ID Migraine validation study. Neurology. 2003;61(3):375–82.
6. Silberstein SD. Preventive migraine treatment. Continuum (Minneap Minn). 2015;21(4
Headache):973–89.
7. Sinclair AJ, Sturrock A, Davies B, Matharu M. Headache management: pharmacological
approaches. Pract Neurol. 2015;15(6):411–23.
Case 20
A 45-year-old sales clerk with a family history of migraine began having headaches
in high school. She treated her headaches early on with over-the-counter medica-
tions. After the birth of her two children, her headaches increased in frequency to
1–2 headaches each week. She then saw her primary care physician in her mid 30s
who diagnosed migraine and while she tried sumatriptan once, she did not like how
it made her feel, so the provider prescribed butalbital, acetaminophen, and caffeine,
which worked most of the time. However, over the last 5 years her headaches have
slowly increased in frequency and severity and over the last 1 year, the headaches
are daily with her needing to go to bed at least 1–2 days each week. She takes her
triptan at least 2–3 days in a week and the combination analgesic (acetaminophen,
butalbital, caffeine) 4 days each week.
The worst headache is focused around her right eye and forehead and can switch
to the left side rarely. The pain is throbbing, she has light and sound sensitivity as
well as nausea and vomiting for the most severe headaches. The pain is usually
worst in the morning and will respond to her acute medication. She denies any tear-
ing, conjunctival injection, rhinorrhea, or ptosis. She is now missing work and fears
her job will be terminated. She is also having trouble sleeping, and is somewhat
depressed. Her PHQ 9 depression scale is ten indicating moderate depression. Her
MIDAS score is 60 indicating severe disability from migraine.
What can we do to help her?
Hypothyroidism treated Cholecystectomy
Obesity Hysterectomy
Depression
Wears reading glasses

120 20 Case 20

Synthroid 0.1 mg each day Migraine in her mother, maternal grandmother
Sertraline 100 mg each day Depression in father
Prilosec prn
Zolpidem prn
Acetaminophen, butalbital, caffeine 1–4
every other day
Rizatriptan 2–3 days each week
Married with two children; no smoking; rare Poor sleep; knee pain
alcohol use Snores at night
Anxiety about her job
Examination
Right eye: 20/20
Left eye: 20/20
Pupils
Equal without RAPD
Right eye: 15 mmHg
Left eye: 15 mmHg
External exam
Normal
Eye alignment
Normal
Normal
Visual field
Normal
Fundus examination
Normal
Normal
Discussion
We first need to diagnose the problem with this woman. She has migraine (see Case
19), which has increased to near daily headaches—with more than 15 per month
signifying chronic migraine. As with many individuals, she started with episodic
migraine and then had gradual worsening. She has many risk factors for chronifica-
tion of her migraines including: her gender, migraine history, attack frequency, obe-
sity, snoring, depression, and frequency of use of medication. See Table 20.1 for
risk factors for chronification of migraine.
Discussion 121
Table 20.1 Risk factors that Non-modifiable factors:

lead to chronic migraine Sex (women more frequent)
Migraine history
Low education
Lower socio-economic status
Head injury
Modifiable factors:
Medication overuse*
Attack frequency
How well acute treatment works
Frequent nausea
Stressful life events
Snoring
Depression
*see Table 20.2
Overuse of medication can lead to medication overuse headache (MOH). While

migraine is very common chronic migraine occurs in about 3–4% of adults.
The combination of chronic migraine and MOH is very debilitating and occurs
about 1–2% of the population. Criteria for MOH are listed in Table 20.2. Other
names used for MOH include: rebound headache, drug-induced headache, and med-
ication misuse headache.
Medication overuse headache is most prevalent in women in their 40s. Patients
most frequently have a previous primary headache disorder like migraine or tension-
type headache. Risk factors for the development of MOH are primarily frequent use
of an acute rescue medication (ergotamine, triptan, opioid, and combination analge-
sic). Barbiturates (butalbital), which this woman is on, is notorious for causing
MOH. In fact, 70% of patients using barbiturates and 40% of those using opioids
develop chronic migraine. Other risk factors include depression and other psychiat-
ric contributions, and frequent migraine.
Treatment rests with withdrawal of the offending medication—sometimes
patients need to be detox’ed. Often the addition of a preventive is helpful. Sometimes
patients go through withdrawal especially from opiates and butalbital containing
compounds. The best evidence suggests stopping the offending agent and starting a
preventive such as topiramate or onabotulinum toxin. Coming off the offending
medication can be tricky too. Slow tapering off butalbital or switching short acting
butalbital to long acting phenobarbital and then tapering is what I would recom-
mend in this patient. Overuse of opiates would require slow taper to avoid with-
drawal symptoms. Sometimes the addition of clonidine to fight the opiate withdrawal
can be helpful. One can stop ergotamines and triptans abruptly without untoward
effects. Education about migraines and how to avoid them, and an acute and preven-
tive treatment plan are critical to stopping this headache.
With education and stopping the offending agent, 50–90% of patients revert to
episodic migraine. Teaching non-medication ways to handle pain including lifestyle
122 20 Case 20
Table 20.2 ICHD 3 beta: medication overuse headache criteria

A. Headache occurring on 15 days per month in a patient with a pre-existing headache
disorder
B. Regular overuse for >3 months of one or more drugs that can be taken for acute and/or
symptomatic treatment of headache*
C. Not better accounted for by another ICHD-3 diagnosis
*Regular intake risk varies by class
Ergotamine: More than 10 days per month for more than 3 months
Triptans: More than 10 days each month for more than 3 months
Simple analgesics (acetominophen, aspirin, non-steroidal anti-inflammatory): More than 15 days
per month for more than 3 months
Opioids: More than 10 days per month for more than 3 months
Combination analgesic: More than 10 days each month for more than 3 months
Multiple drug classes (any combination of ergotamine, triptans, simple analgesics, NSAID, and/or
opioids): More than 10 days per month for over 3 months
management and avoidance of trigger factors, mindfulness, and deep relaxation all
have been shown to be helpful in some individuals. Finding a migraine-specific
treatment like a triptan, sometimes the longer acting triptans like frovatriptan and
naratriptan can be helpful in treating patients. Limit acute triptan use to no more
than 2 days in a week. Start a preventive such as topiramate, amitriptyline, or ona-
botulinum toxin. Even in the best of hands, unfortunately, 20–40% of patients can
relapse after detox usually within the first 12 months.
Why these headaches occur is not completely understood, but some believe them
to have genetic underpinnings. The medications themselves may change the way a
person responds to pain medication as well. Clearly this is an area that needs further
study and understanding.
For the ophthalmologist, it is important to rule out eye disease that could cause pain.
Make sure there is no dry eye, uveitis, posterior scleritis, orbital inflammation, etc.
More than anything, it is critical to ask how many days per month they are taking
analgesics (see Table 20.2) and recognize that MOH exists. Referral to a neurologist
experienced in headache is important.
Primary care physicians play a vital role in discovering, diagnosing, and treating
MOH since most patients have contact with their primary care at least annually.
Also, most primary care providers will know all of the medications that a patient has
been prescribed. Just educating people that the medication they are taking is
CAUSING their headache is often enough to get individuals to taper off and avoid
medication overuse headache. Just knowing about medication overuse and its treat-
ment is one giant step for recovery.
Follow-Up
We educated the patient about chronic migraine and also about MOH. Because of
her obesity we started her on topiramate 25 mg at night with slow increase to 50 mg
twice daily. We also educated her on lifestyle and the importance of sleep and trig-
ger avoidance. We tapered her off butalbital by putting her on phenobarbital at night
40 mg and slowly tapered her off this medication over 1 month. We added in a
longer acting triptan frovatriptan 2.5 mg at onset and repeat in 2–4 h up to
7.5 mg/24 h—to be used no more than 2 days a week. In between we suggested
naproxen 500 mg 1 day each week. We also adjusted her antidepressant medication
to 150 mg each day to control anxiety and depression. She resumed episodic
migraine (so far!). Final diagnosis: chronic migraine with medication overuse
headache.
For Further Study
1. Chiang CC, Schwedt TJ, Wang SJ, Dodick DW. Treatment of medication-overuse headache: a
systematic review. Cephalalgia. 2016;36(4):371–86.
2. Diener HC, Holle D, Solbach K, Gaul C. Medication-overuse headache: risk factors, patho-
physiology and management. Nat Rev Neurol. 2016;12(10):575–83.
3. Kristoffersen ES, Lundqvist C. Medication-overuse headache: epidemiology, diagnosis and
treatment. Ther Adv Drug Saf. 2014;5(2):87–99.
4. Lipton RB. Risk factors for and management of medication-overuse headache. Continuum
(Minneap Minn). 2015;21(4 Headache):1118–31.
5. Westergaard ML, Munksgaard SB, Bendtsen L, Jensen RH. Medication-overuse headache: a
perspective review. Ther Adv Drug Saf. 2016;7(4):147–58.
Case 21
The patient is a 42-year-old registered nurse, who is referred for eye pain and photo-
phobia. She has a history of rheumatoid arthritis and mild hearing loss. At age 31 she
began experiencing bilateral eye pain and headaches associated with severe light
sensitivity. Despite having hearing loss, she said sound increased the pain in her fore-
head. She put blankets on the windows of her house and was only able to leave the
house at night. She would experience a squeezing sensation in her eyes that moved to
her forehead. She thought they were sinus headaches, and underwent sinus surgery
even though the otolaryngologist expressed doubt that the sinuses were causative.
She had no relief of the eye pain or improvement of her light sensitivity. Sometimes
the pain was so bad that she would cry and vomit. While she felt that her eyes could
be puffy, she denied any rhinorrhea, tearing, or redness of the eyes. She also had
several stressors at that time including a new diagnosis of rheumatoid arthritis and
marital discord. For several years she spent a lot of time in bed. She had to quit work-
ing and she wore sunglasses all day, inside and out. She had been treated intermit-
tently in the past with TobraDex eye drops, but these no longer give her relief.
She saw a neurologist who gave her topiramate that caused mental slowing and
another medication (that she did not know the name of) made her depressed. She
was diagnosed with depression and treated with duloxetine, which helped her mood,
but she discontinued this because she worried it caused sinus problems.
Her current symptoms are squeezing eye pain that radiates into her forehead with
extreme light sensitivity, mild sound sensitivity, and nausea with rare vomiting.
Sometimes she will have daily severe headache and photophobia. She is light sensi-
tive every day all of the time in both eyes. Her eyes feel dry and scratchy every night
and she also has dry mouth.

126 21 Case 21

Rheumatoid arthritis Sinus surgery
Depression Family history
Mother had “sinus headaches”
Hypertension, depression
Vitamin C and E and D and cod liver oil Joint pain
Oil of oregano Dry mouth
Polymyxin B ophthalmic solution prn
Tobramycin (tobrex) prn
Dexamethasone 0.1% solution prn
Valacyclovir prn
Social history
Married with three children
16 years of education; no smoking; no
alcohol
Examination
Right eye: 20/20
Left eye: 20/20
Pupils
Equal and there is no RAPD
Color vision (HRR)
6/6 OU
Stereo vision
Excellent stereopsis: 8/9 circles on the Titmus test
Right eye: 15 mm Hg
Left eye: 15 mm Hg
External exam
Normal
Eye alignment
Normal
She had Meibomian gland dysfunction in both eyes; normal anterior chamber and no cells were
seen. She did have 2+ punctate epithelial erosion and tear film debris
Visual field
Fundus examination
Normal optic disc, macula and retina
Normal, except that she has allodynia on the forehead when it is touched. She also has mild
hearing loss bilaterally.
Schirmer’s test
4 mm OD and 5 mm OS; topical proparacaine improved her eye pain
Discussion 127
Discussion
This patient presents with eye pain and photophobia, but she also has migraine
headaches (see Case 19) and dry eyes (see Case 1). Both dry eyes and migraine can
cause photophobia, and while she has been given eye drops in the past, she really
had not understood how all of these symptoms could make each other worse. Most
folks have a reason for photophobia and for some patients there may be more than
one reason—such as dry eyes and migraine. My approach to diagnosing photopho-
bia is this: first, a careful history is essential—I am looking for any central causes of
photophobia such as meningitis, pituitary tumor or other clue. If so, I proceed with
imaging (MRI) and possibly lumbar puncture. If not, I look for dry eyes. Dry eye
symptoms are extremely common and we have found that patients with chronic
migraine have more of these symptoms—even where there are no findings of ero-
sions or decreased tear film (such as in our case). Treatment of dry eye symptoms
may be helpful to reduce photophobia. I often will instill a drop of anesthetic to the
eye, when eye pain is associated with photophobia to see how much the cornea is
contributing to the symptoms. This helps with inflammation of the cornea, and cor-
neal neuropathy in many cases. Then I think about the retina—is there hemeralopia
(blindness from light) or night blindness, or trouble seeing the stars at night. A
dilated examination can pick up retinitis pigmentosa or other retinal dystrophy asso-
ciated with photophobia. I assess if there is excessive blinking to go along with
blepharospasm (see Case 6)—another very common cause of photophobia and
these individuals also may have dry eye symptoms. Finally, I am very careful to
look for a headache history—since many patients have underlying migraine head-
ache, which makes them more susceptible to photophobia. If I have not found a
reason for photophobia, I start over, because there is usually a reason. Coming up
with a diagnosis of the cause of photophobia is most important since treatment will
frequently be directed toward those cause(s). In this case, I think she has photopho-
bia due to migraine predisposition and dry eyes (Fig. 21.1).
I would recommend maximally treating the dry eyes. Sometimes with meibo-
mian gland dysfunction, warm packs can be helpful. Frequent preservative-free
tears can be helpful, and even ointment at night. While we discourage making the
house darkened and wearing sunglasses indoors, FL41 tint which blocks blue light
(which is the same wave length of the melanopsin pathway) and has been shown to
exacerbate photophobia, seems to be helpful in both blepharospasm and migraine.
When photophobia and eye pain are so severe, I have found gabapentin 100 mg
three times daily and working up to a dose tolerated and efficacious is also helpful.
Correcting the migraine component may also be important—treatment of migraine
is discussed in Case 19.
The cause of photophobia is not completely understood, but it is very clear that
one does not need vision. The melanopsin pathway of intrinsically photoactive gan-
glion cells synapse in the thalamus and connect with trigeminal afferents from the
128 21 Case 21
Is there evidence on history Evaluate with

or physical examination of neuroimaging, lumbar
Yes puncture and laboratory
central process?
studies
No
Treat dry eyes, anterior

SLE: dry eyes, iritis, uveitis,
segment disease: lid hygiene,
corneal staining,dendrites Yes
ointments, artificial tears, anti-
Schirmer test:
inflammatory drugs, anti-viral
No
Does the photophobia Look for corneal neuropathy,

resolve with topical Yes iritis, cyclitis, uveitis, dry
anesthetic or dilation? eyes
No
History of Hemeralopia, Retinal dystrophy: family

nyctalopia, decreased Yes history, electrophysiologic
visual acuity studies, genetic testing
No
Evidence of excessive Treat blepharospasm:

blinking, involuntary eye botulinum toxin, medications,
Yes
closure to light? surgical myectomy
No
Migraine history: HA, eye

Treat migraine: screen for
pain, phonophobia, nausea, Yes anxiety, depression
vomiting
No
Fig. 21.1 An approach to the patient with photophobia (adapted from Digre and Brennan)
Discussion 129
dura and presumably the eye causing the sensation of pain. Why some individuals
have lower thresholds is unknown, but it is clear that individuals with blepharo-
spasm and migraine have lower thresholds. One can understand why inflammation
from iritis, conjunctivitis, scleritis, and so forth in the eye could affect trigeminal
afferents directly and contribute to photophobia. We are beginning to understand
why some individuals retreat into the darkness of their homes, and become very
depressed too. Clinical studies have shown individuals with interictal photophobia
in migraine had more depression and anxiety. Furthermore, newly born fetal ani-
mals with only the melanopsin pathway active show signs of anxiety and have
increased expression of C-fos in the amygdala when exposed to light at an early
stage. These studies show that there may be an emotional component to photopho-
bia. It probably contributes to many providers diagnosing factitious disease among
individuals with sunglasses in their waiting room.
Wearing sunglasses indoors is not socially acceptable because folks cannot see
someone’s eyes. Additionally, the sunglasses dark adapt the individual and make
them more light sensitive (similar to when we non-photophobics walk outside of a
movie theater on a sunny day). Tinted lenses are much more acceptable and the
patient generally can see better indoors with them. Keep in mind that a patient can
order a light or a heavy FL-41 tint. Many will order a light tint for situations with
fluorescent lights and heavy tint for outdoors. There are also wraparound or cocoon
frames that block the light from getting in from the sides. Finally, I like to tell
patients to try smart lightbulbs. These LED lightbulbs connect to the internet and
are controlled by smartphones. You can change the color and set the brightness to
something that is more comfortable. There are also some optometrists and opticians
who can dispense tinted contact lenses. However, contacts are more difficult if dry
eye is a significant component of the photophobia.
Anything that irritates or inflames the cornea or uvea can cause photophobia,
which will generally be reflected in a red eye. However, sometimes the redness is
subtle or absent. Patients can have uveitis (see Case 12). This will generally cause
some blurring of the vision. Definitively evaluating for uveitis requires a slit lamp and
dilated fundus examination. I do not know who gave her Tobradex eyedrops, but
hopefully it was an eye doctor. The absence of redness or tearing argues against infec-
tion so I’m not certain why give her the antibiotic portion of the drops. As we all
know, steroids treats a lot of things including dryness and inflammation but it can lead
to cataract, high intraocular pressure, or worsen corneal infection. Anyone but an eye
doctor should probably avoid prescribing steroid eye drops for more than a week.
Finally, this woman has allodynia of her forehead. This suggest some type of
neuropathic pain. Hence, a trial of an anti-epileptic such as gabapentin may be
reasonable.
130 21 Case 21
The primary care physician will definitely need help from an ophthalmologist since
making the diagnosis of dry eyes can be challenging. Sometimes the eyes will not
even appear red or injected. The primary care physician will feel more comfortable
treating the migraine component. For all patients with photophobia, it is reasonable
to ask the patient to visit their optical shop and try to purchase FL-41 tinted lenses.
Follow Up
We did check SjÖgren’s antibodies, which were negative. We recommended FL-41

tinted lenses and this improved her symptoms markedly. This patient began using
tears during the day and ointment at night. She was instructed that migraine can be
worsened by her dry eyes and that some of her dry eye symptoms can accompany
chronic migraine. She improved—she is still light sensitive but is able to control
symptoms by controlling the dry eyes and treating her migraine and using the tinted
lenses. We started her on gabapentin 100 mg at bed time and increased her dose
weekly to a tolerated maximum dose of 300 mg three times daily. We suggested that
she work with her ophthalmologist on the dry eyes and that she may even need
punctual plugs. Final diagnosis: photophobia.
For Further Study
1. Digre KB, Brennan KC. Shedding light on photophobia. J Neuroophthalmol. 2012;32:68–81.

2. Katz BJ, Digre KB. Diagnosis, pathophysiology, and treatment of photophobia. Surv
Ophthalmol. 2016;61(4):466–77.
3. Llop SM, Frandsen JE, Digre KB, Katz BJ, Crum AV, Zhang C, Warner JE. Increased prev-
alence of depression and anxiety in patients with migraine and interictal photophobia. J
Headache Pain. 2016;17:34.
Case 22
A 72-year-old woman reports “electric shocks” behind her right eye for the last
2 years. The attacks last only for 1–3 s and can be precipitated by any tactile stimu-
lation such as wind or light touch to the right periorbital region. These attacks lasted
6 months and then completely resolved for 6 months. About 1 year ago, the pains
returned. She denied any unilateral tearing rhinorrhea, ptosis, or photophobia. She
denies jaw claudication, weight loss, anorexia, and malaise.

Depression Right eye lid surgery 25–30 years ago
Hypertension Cataract surgery LE 3 years ago
Hyperlipidemia Family history
Possible “mini stroke” after having left upper Non-contributory
extremity numbness when lying on it
Enalapril Sometimes trouble sleeping
Multiple vitamins (six different types) Social history
Widowed; drinks two glasses of wine each
day. No smoking
Examination
Right eye: 20/25 + 1
Left eye: 20/20-3
Near vision 20/20
Pupils
Equal and no RAPD
Right eye: 12 mmHg
Left eye: 12 mmHg

132 22 Case 22
External exam
Normal
Eye alignment
Normal
1+ nuclear sclerosis RE, PC-IOL LE, with inferior corneal scar LE
Visual field
Normal
Fundus examination
Normal
Normal; normal corneal reflex
Discussion
The key features in this case are: unilateral, stabbing, severe but brief (less than
1–2 min) pain, in the same spot and triggered by something innocuous like wind on
the face. Pain lasting seconds to less than 1–2 min in the eye has a broad differential.
These can be divided in primary headache disorders including trigeminal autonomic
cephalgias and also trigeminal neuralgia. See Table 22.1.
The primary headache disorders that are brief include ice pick pain (see Case
24)—this pain is very brief but does not necessarily need to be in a trigeminal dis-
tribution and frequently occurs holocranially. It is also not triggered. SUNCT and
SUNA both have autonomic features and this patient has none (Case 28).
Ocular conditions can also cause brief stabbing pain, but aside from her old cor-
neal scar on the opposite eye, she has no other ocular disease such as dry eye or
corneal dystrophy. She also is not light sensitive, which would usually accompany
a trigeminal mediated ocular pain like iritis or corneal disease.
We are left with the possibility that this is some type of neuralgia. The most com-
mon is trigeminal neuralgia, also known as tic douloureux. Other neuralgias like
nasociliary neuralgia (pain around the nose) and supraorbital neuralgia (above the
eye, see Case 27) are less common. Trigeminal neuralgia (Table 22.2) is not rare and
is more common as individuals age (with over three-quarters over age 50) and
slightly more common in women than men. The key features are that it is brief (usu-
ally less than 2–3 min), is limited to one side of the face (it is almost always unilat-
eral), and can be precipitated by what seems to be innocuous stimuli—like brushing
teeth, combing hair, or wind blowing on the face. The other characteristic is that it
has a refractory period—that once discharges have occurred, there is a time when
touching the same spot produces no pain. The distribution is most frequently in the
V2, followed by the V3 and the V1 distribution (so eye pain or periorbital pain can
occur). There are not usually any autonomic symptoms. The neurological examina-
tion is almost always normal—and the corneal reflex is present. When there is anes-
thesia or loss of corneal reflex accompanying the pain, an extensive evaluation for
other causes should ensue.
Discussion 133
Table 22.1 Causes of brief Primary headache disorders

(less than 2 min) unilateral Primary stabbing headache (also known as ice pick headache)
eye pain
SUNCT
SUNA
Paroxysmal hemicrania (indomethacin responsive)
Trigeminal neuralgia: Idiopathic or symptomatic
Nasociliary neuralgia
Supraorbital neuralgia
Occipital neuralgia
Secondary
Demyelination of trigeminal nerve or pathway (younger
individuals)
Aneurysms, masses, vascular loop (older individuals)
compressing the trigeminal nerve
Trauma
Post-herpetic neuralgia
Infiltrative disorders (neoplastic, sarcoid, Lyme disease)
Giant cell arteritis
Pituitary masses
Cavernous sinus masses
Ocular causes
Dry eyes
Table 22.2 ICHD3 beta Criteria for classic trigeminal neuralgia

A. At least three attacks of unilateral facial pain fulfilling criteria B and C
B. Occurring in one or more divisions of the trigeminal nerve, with no radiation beyond the
trigeminal distribution
C. Pain has at least three of the following four characteristics:
1. Recurring in paroxysmal attacks lasting from a fraction of a second to 2 min
2. Severe intensity
3. Electric shock-like, shooting, stabbing, or sharp in quality
4. Precipitated by innocuous stimuli to the affected side of the face
D. No clinically evident neurological deficit
E. Not better accounted for by another diagnosis
Trigeminal neuralgia can be (1) idiopathic; (2) classical, caused by a vessel com-
pressing the nerve root exit zone (look for vascular loops sitting on the 5th nerve exit
zone on older individuals); or (3) secondary, caused by another structural cause. The
most common causes of trigeminal neuralgia are demyelinating lesions associated
with multiple sclerosis in younger people; in fact, 7% of patients with MS can have
a trigeminal neuralgia. Sometimes, these can be bilateral. There can be more omi-
nous causes of trigeminal neuralgia such as tumors, aneurysms or infiltrating lesions.
Trigeminal neuralgia can also occur in conjunction with Cluster headache (some-
times called cluster tic) or with paroxysmal hemicranias (paroxysmal hemicranias
tic) which makes the diagnosis unclear.
134 22 Case 22
Evaluation for trigeminal neuralgia starts with appropriate imaging. MR with

gadolinium and dedicated protocols targeted at the trigeminal nerve work best to
find structural lesions, since routine MR may not show a lesion. Newer imaging
techniques such as CISS imaging are also very helpful.
Medical treatment of trigeminal neuralgia is usually anti-epileptic therapy.
Agents include carbamazepine 100–1200 mg in three divided doses (usually start-
ing at 200 mg) daily and oxcarbazepine (600–1800 mg in divided doses). Gabapentin
has been recommended at doses between 100 and 900 mg three times daily. Other
anti-epileptics include phenytoin (starting at 50 mg three times daily titrating to
300–400 mg at night) and lamotrigine (starting with 25 mg every other day and
slowly advancing to 200–400 mg). Lamotrigine added to low dose carbamazepine
was shown to be effective in the elderly. Other medications to consider include
baclofen and onabotulinum toxin which has been successful in some small series.
Surgical treatment for trigeminal neuralgia depends on the person’s ability to
undergo surgery and the cause. Microvascular decompression is for those who are
surgical candidates with success reported to be 70% pain free in 10 years after sur-
gery. For individuals who fail medical therapy and cannot tolerate surgery, there are
several peripheral denervation treatments with lidocaine or alcohol injection, and also
destructive procedures percutaneously including: destructive lesioning procedures
using radiofrequency rhizotomy, glycerol rhizotomy, and sterotactic radiosurgery.
One complication of these destructive procedures is anesthesia dolorosa—which can
cause severe pain while the area is also numb. This is very difficult to treat.
The history alone is so strong for trigeminal neuralgia – older woman with seconds
of unilateral severe pain with a trigger. The trigger is the strongest argument that
you have the right diagnosis. It is expected that the eye exam is completely normal
or should not explain the pain. Sometimes, a patient may note sudden sharp pain
lasting a moment occurring once a month or less frequently. They do not have a
trigger and this is likely ice pick headache (Case 24). MRI is recommended since up
to 10% can have a tumor instead of a vascular loop pressing on the nerve. If you are
not comfortable treating this, then you can refer the patient to primary care, facial
pain clinic, neurologist, or a neurosurgeon.
If a patient undergoes some type of destructive procedure or microvascular
decompression (placing a teflon sponge between the vessel and the nerve), they can
develop corneal anesthesia and subsequent keratopathy. In mild cases, I recommend
preservative free artificial tears every 1–3 h. In more severe cases, one can develop
corneal defects or ulcers, requiring antibiotic ointment 4–8×/day. These patients
may require a temporary or permanent tarsorraphy (sewing the lateral third of the
eyelids together), if the corneal sensation does not return.
Discussion 135
Trigeminal neuralgia is not rare, and this diagnosis is often made in the primary care
office. Characteristic imaging is helpful and anticonvulsant drugs are mainstay
treatments. Patients failing medical therapy are frequently sent to neurosurgeons for
further consideration of treatment.
Follow Up
An MR scan showed an anterior inferior cerebellar artery (AICA) vascular loop on

the right trigeminal nerve (See Fig. 22.1). The patient was tried first on carbamaze-
pine, but she never took it because when she read about the side effects, she decided
not take it. She was then placed on gabapentin 300 mg three times daily, but this
made her too sleepy. So she tried carbamazepine 200 mg twice daily, and this along
with gabapentin 900 mg at night controlled her pain. About 1 year later, she contin-
ued only the gabapentin and used carbamazepine for flare ups. She was last seen this
year (age 81) with another flare not completely controlled by medication. She will
be considering gamma knife for intractable trigeminal neuralgia. She was not
thought to be a good surgical candidate for decompression and she did not want a
glycerol injection. Final diagnosis: trigeminal neuralgia.
Fig. 22.1 MR scan

showing vascular
compression at the right
5th nerve root exit zone
(arrow)
136 22 Case 22
For Further Study
1. Bhatti MT, Patel R. Neuro-ophthalmic considerations in trigeminal neuralgia and its surgical
treatment. Curr Opin Ophthalmol. 2005;16(6):334–40.
2. Cheshire WP Jr. Cranial neuralgias. Continuum (Minneap Minn). 2015;21(4 Headache):1072–85.
3. Cruccu G, Finnerup NB, Jensen TS, Scholz J, Sindou M, Svensson P, Treede RD, Zakrzewska
JM, Nurmikko T. Trigeminal neuralgia: new classification and diagnostic grading for practice
and research. Neurology. 2016;87(2):220–8.
4. Montano N, Conforti G, Di Bonaventura R, Meglio M, Fernandez E, Papacci F. Advances in
diagnosis and treatment of trigeminal neuralgia. Ther Clin Risk Manag. 2015;11:289–99.
5. Oomens MA, Forouzanfar T. Pharmaceutical management of trigeminal neuralgia in the
elderly. Drugs Aging. 2015;32(9):717–26.
6. Prakash S, Rathore C. Side-locked headaches: an algorithm-based approach. J Headache Pain.
2016;17(1):95.
Case 23
A 34-year-old woman with a history of herpes simplex infection in her left eye
15 years ago presented with a 5-year history of severe, throbbing, intermittent, ret-
robulbar left eye pain lasting hours. There is a constant pain of 2.5/10 with intermit-
tent worsening to 7/10 occurring approximately 5 times per week and increasing in
intensity and frequency. There are no triggers and some improvement with ibupro-
fen and tramadol. The pain is occasionally associated with photophobia, but no
phonophobia or nausea. She denies redness, eyelid edema, skin rash, blurred vision,
and tearing. There is no pain with eye movement or palpation. She was placed on
antivirals orally and topically, but this did not help with the pain.

Degenerative cervical disease Cervical fusion 2006, 2008
Hypothyroidism Family history
Depression None
Famcyclovir Sinus pressure
Levothyroxine Eczema
Venlafaxine Easy bruising
Tramadol PRN Intermittent numbness and tingling of arms and
Ibuprofen PRN legs
Social history
1 pack per day smoker × 20 years
Cashier
Former alcoholic

138 23 Case 23
Examination
Right eye: 20/20
Left eye: 20/60
Pupils
Equal, briskly reactive, no afferent pupillary defect
Right eye: 22 mmHg
Left eye: 23 mmHg
External exam
Normal, no edema, no redness, no herpetic lesions
No tenderness to palpation
Eye motility/alignment
Normal
Meibomian gland dysfunction × 4 lids
Inactive, disciform scar centrally left eye
Trace punctate keratopathy both eyes
White and quiet conjunctiva
No iritis
Visual field
Normal
Fundus examination
Normal
Corneal sensation reduced left eye
Facial sensation is normal
Significant tenderness, left greater occipital nerve—Pressure here reproduces eye pain
No numbness or tenderness of the scalp
Discussion
The red herring here is the history of herpes simplex infection in the same eye as the
severe throbbing eye pain. It seems logical that would cause the pain, and in fact,
this patient was sent to a cornea specialist before coming to me. However, the exam
here does not comport with active infection or inflammation. The eye is white and
quiet without anterior chamber inflammation. The description of the pain compared
to the relatively unremarkable eye exam would argue that this is not an ocular cause.
I think the ophthalmologist could consider pressing on the supraorbital nerve, infra-
orbital nerve, trochlea (Fig. 8.1) and greater occipital nerve (GON). Alternatively,
the ophthalmologist could tell the patient that this is not an eye issue but a headache
one and send her to a neurologist. One could tell her that a lot of headaches are per-
ceived in the eye region because of the referred pain from the trigeminal nerve.
The GON sits medial and inferior to the occipital protuberance. Take care not
to press too hard, because you can hurt just about anyone with firm pressure. When
Discussion 139
Mesencephalic nucleus
of trigeminal nerve
Principal sensory nucleus
of trigeminal nerve Dorsal 2˚ ascending
tract of nerve V
Trigeminal nerve
(V) ganglion
Spinal tract of nerve V
V1 Semilunar
V2 ganglion(Gasserian
V3 ganglion)
Pain fibers
of nerve V
V1 C
C2
A B
V2 C1
A
C2
V3 C2 B
Spinal tract C3
C3
and spinal C
nucleus of V C4
C4 C3
Nucleus of C5
spinal tract
of nerve V
Fig. 23.1 Anatomical cartoon depicts the spinal portion of the trigeminal nerve that sits near the
C2 root. Inflammation of the GON likely leads to irritation of the trigeminal nerve causing the
perception of pain in the V1 distribution. The left side of the figure demonstrates the traditional
three divisional anatomic pattern of sensation (V1, V2, V3). The right side shows the somatotopic
and functional, “onion skin” arrangement of the spinal tract nucleus. The rostral part of the nucleus,
denoted by the letter A, corresponds in the perioral region. More caudally in the spinal tract nucleus
corresponds to the more lateral portions of the face (letters B and C)
the patient says it reproduces the eye pain, then that cinches the diagnosis in my
mind. If there is significant tenderness without radiation, I still consider the diag-
nosis but am less convinced. Why would this cause eye pain? The GON (C2)
ganglion sits in the upper spinal cord adjacent to the spinal nucleus of CN
V. Irritation and inflammation of the GON can cause irritation and firing of V1
(Fig. 23.1). We often suspect cervicogenic headache when the pain resolves with a
GON block.
Cervicogenic headache is somewhat of a lumping term—it usually refers to head-

aches associated with abnormalities of the neck. This patient really has many rea-
sons for eye pain. First, I am not sure if she also has underlying migraine (see Case
19). Sometimes when pain is accompanied by photophobia, I also ask about other
features of migraine including throbbing pain, worsening pain with activity. Recall
the definition of probable migraine can be made with moderate to severe pain,
140 23 Case 23
worsening with activity, and unilateral pain in the absence of nausea and or vomit-
ing and both photo and phonophobia. Interestingly, some cervicogenic headache
can have migraine features.
The second differential diagnosis is medication overuse headache (MOH) or
rebound headache (see Case 20). She is taking tramadol and ibuprofen. We are not
told how much, but when individuals take ibuprofen or other non-steroidal anti-
inflammatories more than 15 days each month, or combination analgesics more
than 10 days each month, the individual is in danger of MOH. The pain of migraine
is worsened by overusing medications. So carefully educating patients about over
using medications is important. MOH is not rare and is seen in 1–2% of the general
population and up to 50% in headache centers. To treat MOH, a withdrawal of the
pain medications should ensue and one should work on preventive strategies—med-
ications to prevent the pain and keep her from needing so many acute medications.
Even in this patient in whom we think there is cervicogenic headache, medication
overuse headache can occur.
The third differential diagnosis is post-herpetic neuralgia which we discuss in
Case 38. Post-herpetic neuralgia can occur after a bout of zoster or herpes simplex;
however, individuals who are prone to pain like having migraines often have these
symptoms more frequently and severely. Also, neuralgia is more continuous and
this is more episodic.
A final thought about another diagnosis is occipital neuralgia—which has more
shooting pains and usually does not last as long as this headache. But it too can be
helped with an occipital nerve block.
Cervicogenic headache is not rare and it is a somewhat of controversial topic
since it refers to a headache that comes from the spine. It is generally caused by
disorders of the cervical spine from bone, disc, or other soft tissue changes. The
ICHD 3 beta criteria are in Table 23.1. The diagnosis is fairly common occurring in
0.4–2.5% of the general population and in up to 20% of patients with chronic head-
ache. In this patient we know that she has imaging evidence of cervical disease,
which by the way is really common. 50% of women and men have some signs of
cervical degenerative disease by the age of 50. We know that palpation of the greater
occipital nerve created her pain but we do not know if range of motion was reduced
(frequently seen in cervicogenic headache) and we do not know if her pain would
resolve with a nerve block. If it responds to a nerve block, then she meets criteria for
cervicogenic headache.
There are also secondary causes of cervicogenic headache including C1-2 arthrop-
athy. It occurs in 5% of individuals in their sixth decade and 18% in the ninth decade.
Three-quarters are women and the location is usually unilateral and individuals report
crackling noises in the neck. CT scan of the neck can show condylar C1 arthritis or
an open mouth skull X-ray and demonstrate this arthritis; this form of arthritis
severely limits range of motion and is frequently seen in rheumatoid arthritis. The
pain will start occipitally and radiate to the eye. If very severe, surgery is sometimes
offered, but C1-2 arthropathy should be evaluated and treated by a neurosurgeon
trained in this condition. This patient is likely too young for C1-2 arthropathy. In
general, imaging is not required unless there are neurologic signs on examination.
Discussion 141
Table 23.1 ICHD 3 beta classification diagnostic classification of cervicogenic headache

A. Any headache fulfilling criterion C
B. Clinical, laboratory, and/or imaging evidence of a disorder in the cervical spine known to
cause headache
C. Evidence of at least two of the following:
1. Headache developed in temporal relation to the onset of the cervical disorder or
appearance of the lesion
2. Headache has significantly improved or resolved in parallel with improvement in or
resolution of the cervical disorder or lesion
3. Cervical range of motion is reduced and headache is made significant worse by
provocative maneuvers
4. Headache is abolished following diagnostic blockade of cervical structure or its nerve
supply
D. Not better accounted for by another ICHD 3 diagnosis
Treatment is divided into conservative therapy—which is mainly focused on

physical therapy which has been shown to be helpful in elderly patients. Trigger
point injections may also be helpful and muscle relaxants can be used. Surgical
treatments are considered when there is a cervical spine disorder that is causing
neurologic deficits—usually not for pain alone.
Cervicogenic headache is often a vicious cycle where the neck muscles tighten up
and compress the GON. The nerve becomes inflamed, which leads to tightening of
the neck muscles. If one can break the cycle, this can improve the pain. Most patients
with cervicogenic headache do not want a “shot in the back of the head” at the first
visit. We often prescribe a muscle relaxant such as metaxolone (Skelaxin) 800 mg 3
times daily along with NSAIDs for 3–5 days. Other medications that are useful
include: cyclobenzaprine (Flexeril) 10 mg at night and up to 3 times daily or tizani-
dine (Zanaflex) 4–8 mg at night. Other interventions include a soft cervical collar to
put the head in a neutral position and avoid neck guarding and stretching of the
GON. Soft collars however can sometimes worsen symptoms so this is not a long
range strategy as it can cause worsening range of motion. One could suggest neck
massage or neck physical therapy (PT), which involves massage, strengthening, and
stretching. Occasionally, a muscle massager device such as Theracane along with
warm towels can make cervicogenic headaches better. Many neurologists, pain spe-
cialists, radiologists, and spine surgeons would be willing to give a GON block. In
some cases, cervical facet injections by a radiologist or pain specialist may be nec-
essary. Rarely, a patient may undergo greater occipital neurectomy or radiofre-
quency ablation for pain relief. This is generally done by a pain specialist.
142 23 Case 23
If you were interested in doing an occipital nerve block yourself, you have to use
at least a 25-gauge needle because the triamcinolone has a particulate that can clog
smaller needles. A 1.5- to 2-in. needle is preferable since some patients have a lot of
adipose tissue. The needle is advanced to bone over the area of greatest pain. Be
sure to withdraw before injecting since the greater occipital artery is adjacent to the
nerve. Generally, if the patient enjoys improvement by half on the pain scale, the
chances are high that they will have a good response to the block. In some cases,
repeat injections may be necessary.
Follow-Up
The patient underwent a greater occipital nerve block using 1 mL triamcinolone

40 mg/mL and 1 mL 2% lidocaine without epinephrine mixed together into a 3 mL
syringe using a 22-gauge 2-in. needle. Five minutes later, the patient’s pain went from
4/10 to 0/10. The patient was pain-free at one-month follow-up and did not return
afterward. While an occipital nerve block is very helpful in making the diagnosis of
cervicogenic headache, this block also works to treat occipital neuralgia and even
migraine; so it is not a diagnostic test. Final diagnosis: cervicogenic headache.
For Further Study
1. Armbrust KR, Kosmorsky GS, Lee MS, Friedman DI. A pain in the eye. Surv Ophthalmol.
2014;59:474–7.
2. Bogduk N. The neck and headaches. Neurol Clin. 2014;32:471–87.
3. Bogduk N, Govind J. Cervicogenic headache: an assessment of the evidence onclinical diagno-
sis, invasive tests, and treatment. Lancet Neurol. 2009;8(10):959–68.
4. Munksgaard SB, Jensen RH. Medication overuse headache. Headache. 2014;54(7):1251–7.
5. Rana MV. Managing and treating headache of cervicogenic origin. Med Clin North Am.
2013;97(2):267–80.
6. Teraguchi M, Yoshimura N, Hashizume H, Muraki S, Yamada H, Minamide A, Oka H,
Ishimoto Y, Nagata K, Kagotani R, Takiguchi N, Akune T, Kawaguchi H, Nakamura K, Yoshida
M. Prevalence and distribution of intervertebral disc degeneration over the entire spine in a
population-based cohort: the Wakayama spine study. Osteoarthr Cartil. 2014;22(1):104–10.
Case 24
A 45-year-old woman has a personal and family history of migraine. Her migraines
started at age 12, and they have been fairly predictable around her menstrual period.
They occur about once each month and are controlled with sumatriptan taken at the
onset of the migraine. Sometimes she requires promethazine for nausea and a
migraine that does not otherwise respond.
She comes in for evaluation of a new pain that used to occur once each year, but
now these are occurring around her left eye—as a brief stabbing pain. Some days
she can have 1–6 of these. They can also occur anywhere around her head (and
posteriorly) as well, but she is most worried because she has had a few around her
eye. The attack lasts less than 1–2 s and has no associated tearing, redness of the eye
or rhinorrhea. Her eye lids never droops. They do not last long enough to take any-
thing. What should she do?

Myopia Tonsillectomy
Multiple vitamins Migraine in mother and sister
Sumatriptan prn
Promethazine prn
Married 2 children; no smoking or alcohol Negative

144 24 Case 24
Examination
Right eye: 20/20
Left eye: 20/20
Pupils
4 mm light BE and 6 mm darkness BE
Right eye: 12 mmHg
Left eye: 12 mmHg
External exam
Normal
Eye alignment
Normal
Normal
Visual field
Normal
Fundus examination
Normal
Normal
Discussion
Neurologic Perspective—Dr. Digre
This patient has a history of migraine and now has more frequent brief, short, sharp
stabbing pains mainly around her eye, but importantly they occur elsewhere in her
head as well. The causes of short stabbing pains (less than 10 s) are a pretty short
list—see Table 24.1. Of these, idiopathic stabbing headache (aka ice-pick headache or
pain, “jabs and jolts,” short-lived headache syndrome, “needle in the eye syndrome”)
is the most common and frequent. See Table 24.2 for diagnostic criteria. It occurs
more frequently in individuals with migraine than those without migraine. In addi-
tion, it is more frequent in women (just as migraine is more frequent in women). The
frequency can be daily, weekly, monthly, or yearly. Raskin et al. found the severity is
usually high in 90% and the quality to be most like ice pick or needle/nail like and
most frequently a single isolated jab, but could occur more frequently. Furthermore,
the location was, in order of frequency, most commonly temporal followed by orbital/
supraorbital then parietal. While the location is the same regularly in less than one-
third, it frequently changes locations and can even rarely occur bilaterally.
There are other causes of brief, lancinating pains that are other primary headache
disorders. Many of these will have historical features that will give you a clue—for
example, headaches only occurring at night (hypnic headache), cold stimulus head-
ache (ice cream headache), exertion, and sexual activity. Brief headaches with auto-
nomic features are discussed elsewhere (Case 28).
Discussion 145
Table 24.1 Causes of short eye pain (less than 10 s)

Cause Length Location Other features Treatment
Primary, without autonomic symptoms
Idiopathic Less than Anywhere in Often seen in Non-steroidal,
stabbing HA 5–10 s the head individuals with indomethacin
migraine
Hypnic Can last Orbital frontal Older individuals; Caffeine before
headache 5–15 min; “alarm clock bedtime; lithium,
sometimes up headache” melatonin;
to 3 h
Cold stimulus Lasting 30 s to Anywhere— Precipitated by Avoid cold
headache (ice less than but frontal, eating/drinking precipitants;
cream 5 min temporal most something cold indomethacin
headache) common
Coital 5 min–24 h Anywhere Acute at onset of Pretreat with
headache orgasm in men more propranolol,
frequently than indomethacin
women; must rule
out secondary cause
Exertional 5 min–24 h Anywhere Occurs at peak of Propranolol,
headache exertion indomethacin
Cough 1–30 s Anywhere, Occurs with upper Indomethacin and
headache often vertex; respiratory other
often bilateral infection; look for non-steroidals
structural lesions
since this can be
presentation of
secondary headache
Primary with autonomic symptoms (conjunctival injection, eyelid edema, lacrimation, nasal
congestion, ptosis, or rhinnorrhea)
SUNCT, 2–10 s Unilateral brief Seen most Treatment is
SUNA with or without frequently in men; difficult—
conjunctival must image to rule sometimes
injection; other out secondary lamotrigine
autonomic pathology
symptoms
present
Episodic 1–30 min Unilateral and Seen more Indomethacin
Hemicrania associated with frequently in responsive (150 mg
autonomic women; can be or less)
symptoms episodic or chronic
Hemicrania While the Unilateral with More frequent in Indomethacin
continua continuous autonomic women responsive
pain is side symptoms
locked, there
can be jabbing
pains on top of
these
(continued)
146 24 Case 24
Table 24.1 (continued)
Cause Length Location Other features Treatment
Cluster Usually lasts Always with More frequent in Verapamil, lithium,
headache 20 min to autonomic men topiramate and
1–2 h symptoms many others tried
(see cluster
chapter)
Secondary brief stabbing headaches
Chiari, posterior fossa lesions, pituitary lesions, herpes zoster, stroke, venous thrombosis,
multiple sclerosis (Chua et al.)
Trigeminal Can be Usually nose, Volleys of pain Anti-convulsants
neuralgia seconds eye, chin often precipitated by
touching a certain
area
Chiari Can be brief May be Be careful to not be Depending on
malformations accompanied fooled by severity, treat
by downbeat intracranial symptomatically
nystagmus, hypotension with amitriptyline
ataxia, sensory if severe, refer for
changes surgery
Posterior fossa Usually Episodic and Needs further Treat underlying
lesions ipsilateral may be imaging disorder
accompanied
by other
neurological
symptoms
(ataxia)
Giant cell Usually Usually seen in Check ESR and Biopsy temporal
arteritis underlying individuals CRP in older artery and treat
continuous over 65 individuals with prednisone
headache
Convexity Can be brief Ipsilateral to Often older Surgical removal of
meningioma and have a the individuals tumor
continuous meningioma
pain as well
Table 24.2 Idiopathic stabbing headache criteria by ICHD 3 beta

(A) Head pain occurring spontaneously as a single stab or series of stabs and fulfilling criteria
B–D
(B) Each stab lasts for up to a few seconds
(C) Stabs recur with irregular frequency, from one to many per day
(D) No cranial autonomic symptoms
(E) Not better accounted for by another ICHD-3 diagnosis
Discussion 147
Idiopathic stabbing headaches can also occur in children. There is no sex prefer-
ence, and almost any age has been reported. The children may not have migraine,
but they may have a family history of migraine as well as migraine-like condi-
tions—motion sickness, episodic vertigo, and abdominal pains. While indometha-
cin is used in adults and has been tried in children, acetaminophen was also reported
to be successful.
We should not forget that secondary headaches can present also with stabbing
pain; however, frequently these may have other neurologic findings, or may be asso-
ciated with a side-locked pain (the stabbing only occurs in one region). Trigeminal
neuralgia can also be confused with episodic stabbing headache.
In someone with typical migraine such as our patient, I think she has episodic
stabbing headache and simple reassurance can be enough. If the spells are too
frequent, I would try indomethacin 25 mg three times daily with meals or 75 mg
SR. Other Cox-2 inhibitors such as non-steroidals (celecoxib; naproxen), melato-
nin, calcium channel blockers, onabotulinum toxin, and gabapentin have been
tried.
Ophthalmic Perspective—Dr. Lee
This type of patient definitely will show up in the ophthalmology office. There
really is not an eye disease that causes this. Of course, bad corneal disease can give
stabbing pain but it is usually much more persistent and frequent. I usually do not
scan these individuals. I also ask them if they think it is worth it to take a medicine
every day (with side effects) for pain that lasts moments occurring once a month or
once a week or however often they have it. Almost all say no. In my experience, this
does not become significantly more frequent in the vast majority of people. I do not
typically schedule a follow-up unless it changes. I do not believe that the ophthal-
mologist needs to refer this patient.
Episodic stabbing headache is not rare and primary care providers will no doubt run
into it. The keys to the correct diagnosis are (1) the pain is brief, often not side
locked and roams around the head, (2) the patient usually has underlying migraine,
(3) there are NO autonomic symptoms with episodic stabbing headache, (4) reassur-
ance is frequently the only treatment needed but if it is disabling to the patient, then
consider a non-steroidal or indomethacin.
148 24 Case 24
Follow-up
We diagnosed idiopathic stabbing headache since her examination was completely

normal. We reassured her that there was no other cause. We offered her indometha-
cin treatment 25 mg three times daily, but she preferred to not take the medication.
She continued treating her monthly migraine headaches. Final diagnosis: idiopathic
stabbing headache.
For Further Study
1. Casucci G. Chronic short-lasting headaches: clinical features and differential diagnosis. Neurol
Sci. 2003;24(Suppl 2):S101–7.
2. Chua AL, Nahas S. Ice pick headache. Curr Pain Headache Rep. 2016;20(5):30.
3. Fusco C, Pisani F, Faienza C. Idiopathic stabbing headache: clinical characteristics of children
and adolescents. Brain Dev. 2003;25(4):237–40.
4. Newman LC. Effective management of ice pick pains, SUNCT, and episodic and chronic par-
oxysmal hemicrania. Curr Pain Headache Rep. 2001;5(3):292–9.
5. Raskin NH, Schwartz RK. Icepick-like pain. Neurology. 1980;30(2):203–5.
6. Sands GH, Newman L, Lipton R. Cough, exertional, and other miscellaneous headaches. Med
Clin North Am. 1991;75(3):733–47.
7. Selekler HM, Budak F. Idiopathic stabbing headache and experimental ice cream headache
(short-lived headaches). Eur Neurol. 2004;51(1):6–9.
8. Wang SJ, Fuh JL. The “other” headaches: primary cough, exertion, sex, and primary stabbing
headaches. Curr Pain Headache Rep. 2010;14(1):41–6.
Case 25
A healthy 55-year-old man went to see a neurologist for headaches around his
eyes. He has a family history of migraine in his paternal grandmother and aunt. He
was never car sick as a child. He has had occasional headaches around his eyes that
he has attributed to sinus headache since he was 20. They occurred infrequently but
especially after drinking red wine. Over the last 10 years he has had steadily wors-
ening sinus headaches unresponsive to acupuncture and sinus medications. He was
referred to the neurologist. The pain is behind his eyes, in his forehead and over
both cheeks. He has minimal light sensitivity and sound sensitivity but denies nau-
sea or vomiting. The only change that he noticed is that they are getting more fre-
quent—at least weekly and sometimes 2–3 days in a week. When the pain is severe,
he thinks he has more nasal stuffiness. He has taken ibuprofen with some success
although the efficacy seems to be waning. He wants to know if he should have
sinus surgery.

Prostate cancer diagnosed age 54 with normal Prostatectomy
PSA since
Myopic and wears contact lenses
Occasional flonase Migraine in a paternal grandmother and two
Ibuprofen paternal aunts
Married and successful in business Per HPI

150 25 Case 25
Examination
Right eye: 20/20
Left eye: 20/20
Pupils
Equal and no RAPD
Right eye: 14 mmHg
Left eye: 14 mmHg
External exam
Normal
Eye alignment
Normal
Normal
Visual field
Normal
Fundus examination
Normal
Normal
Discussion
I wish I had a dollar for everyone I see that thinks they have sinus headaches—I
would be very well off! Sinus headache, contrary to advertising and public belief, is
less common than you think. The ICHD 3 beta classifies sinus headache as either
acute rhinosinusitis or chronic recurring rhinosinusitis (see Table 25.1). These crite-
ria require evidence of either acute or chronic inflammation and infection either by
endoscopy or by imaging. Most individuals end up with normal imaging or minor
sinus thickening.
True sinus headaches do not keep recurring every week or month. They also have
an abnormal examination. The American Academy of Otolaryngology: Head and
Neck Surgery have developed criteria for rhinosinusitis (see Table 25.2).
Otolaryngologists point out that sinus headaches from chronic rhinosinusitis do not
typically have photo and phonophobia and nausea and vomiting such as what is seen
in migraine. The headache more clearly mimics tension-type headache including
changes in pressure, nasal congestion, rhinorrhea, and an abnormal ENT examination.
Other characteristics include morning worsening with improvement as the day goes
on. Furthermore, they point out that the imaging of the sinuses must depict inflamma-
tion (Fig. 25.1) in true sinus headache. However, imaging may show sinus thickening
in about 30% of scans in even normal non-headache individuals—so imaging alone is
insufficient to make the diagnosis. Individuals with more than two bouts of true sinus
headache in a year should be worked up for an immune deficiency.
Discussion 151
Table 25.1 ICHD 3beta: Acute and Chronic Rhinosinusitis

(A) Clinical, nasal endoscopic and/or imaging evidence of acute (or chronic or past infection)
rhinosinusitis
(B) Must have evidence demonstrated by at least two of the following
1. Headache developed in temporal relation to the onset of the rhinosinusitis
2. Either or both:
(a) Headache significantly worsened in parallel with worsening of the rhinosinusitis
(b) Headache has improved or resolved in parallel with improvement in or resolution of
the rhinosinusitis
3. Headache is exacerbated by pressure applied over the paranasal sinuses
4. In the case of unilateral rhinosinusitis, headache is localized ipsilateral
(C) Not better accounted for by another diagnosis
Table 25.2 American Major criteria

Academy of Otolaryngology; Purulence on examination of the nasal cavity
Head and Neck Surgery
Face pain/pressure
Nasal blockage or obstruction
Fever (acute sinusitis only)
Anosmia/hypo-osmia
Nasal discharge
Discolored post-nasal drainage
Minor criteria
Headache
Bad breath
Fatigue
Dental pain
Cough
Ear pain or pressure
Fever (non-acute)
Adapted from Houser and Levine, Current Pain and Headache
Reports 2008, 12:45–49
Acute frontal sinusitis often causes pain in the medial side of the orbit, maxillary
sinusitis causes pain in the cheek and teeth, whereas acute ethmoid sinusitis causes
pain at the bridge of the nose or behind the eyes, and sphenoid sinusitis causes pain
to the top of the head or whole head.
Otolaryngologists know that the most likely diagnosis is migraine when some-
one presents with “sinus headache.” In fact, studies have shown that among people
who think they have sinus headaches, 90% have migraine instead. Why would this
be? Well, first the sinuses are innervated by the same trigeminal system that is oper-
ant in migraine. Second, nasal congestion, tearing, and rhinorrhea are frequently
also seen with migraine.
There are many controversies about sinus headache—especially in discussing
mucosal “contact points,” septum deviation, enlarged turbinates, and nasal
152 25 Case 25
Fig. 25.1 Axial T1 MR

scan of chronic sinus
disease of the maxillary
and sphenoid sinus in a
patient with true sinus
headache (not the Patient
herein)
o bstruction. This confusion increases in children who often have viral-mediated

rhinitis and headaches. These diagnoses then lead to many unnecessary surgeries.
Make the correct diagnosis here—sinus headache is RARE-less than 4% of all
headaches. There are criteria to make the diagnosis. Treatment with nasal deconges-
tants most of the time are treating migraine. Think migraine first when someone
complains of sinus headache.
I very much agree with Dr. Digre. In fact, I do not send patients with eye pain to
otolaryngology, and our otolaryngologists are not interested in seeing headache pre-
sumed from sinus disease unless they have clear evidence of sinusitis on imaging.
However, to some hammers everything looks like a nail and patients may have
repeated sinus surgeries to help their “sinus headache.” Postoperatively, they feel
better but that is because their migraine resolved. When the migraine returns, the
patient undergoes another sinus surgery.
Sinus disease is such a common symptom coming to a primary care provider. When
can you diagnose true sinus headache? First, think migraine—since most individu-
als who think they have sinus headache will have migraine. If the person meets
criteria for sinusitis, treatment with antibiotics may be appropriate. If patients are
chronic, they deserve imaging and possible referral to an ENT.
Follow-up
He received a diagnosis of migraine and treated his headaches with sumatriptan

which worked far better than all of the previous nasal decongestants and ibuprofen.
Final diagnosis: Migraine masquerading as Sinus headache.
For Further Study
1. Cady RK, Dodick DW, Levine HL, Schreiber CP, Eross EJ, Setzen M, Blumenthal HJ, Lumry
WR, Berman GD, Durham PL. Sinus headache: a neurology, otolaryngology, allergy, and pri-
mary care consensus on diagnosis and treatment. Mayo Clin Proc. 2005;80(7):908–16.
2. Cashman EC, Smyth D. Primary headache syndromes and sinus headache: an approach to
diagnosis and management. Auris Nasus Larynx. 2012;39(3):257–60.
3. Eross E, Dodick D, Eross M. The sinus, allergy and migraine study (SAMS). Headache.
2007;47(2):213–24.
4. Gryglas A. Allergic rhinitis and chronic daily headaches: is there a link? Curr Neurol Neurosci
Rep. 2016;16(4):33.
5. Houser SM, Levine HL. Chronic daily headache: when to suspect sinus disease. Curr Pain
Headache Rep. 2008;12:45–9.
Case 26
This 63-year-old employed nuclear facility engineer presented with hissing in his ears,
multiple transient paresthesias, and a dull headache pressure over his head and eyes.
The pressure feeling feels like a band around his head. He has a history of migraine
with aura in the past occurring only once each year and migraine without aura 1–2
times each year. Paresthesias occur around his tongue and various parts of his face. He
also developed neck pain, vertigo, and dizziness, which was intermittent. He has asso-
ciated sound sensitivity, but no light sensitivity. The only time he feels at all nauseated
with his pressure headaches is when he has a bout of dizziness. Getting out for a walk
sometimes helps, but he develops back pain if he walks too much. He sleeps with
white noise only, and otherwise, he has insomnia. Extensive imaging was normal.

Diabetes for 5 years Knee surgery
Hypertension Elbow fracture surgery
Hyperlipidemia Vein stripping
Asthma Parotid gland tumor removal (benign)
Sleep apnea (cannot tolerate CPAP) Family history
History of multiple injuries due to motor Migraine, blood clots in mother; migraine in
cycle riding brother, sister and son
Seizures, father
Diazepam 5 mg prn dizziness Fatigue
Flonase prn Ear pressure, hearing loss left ear
Aspirin, acetaminophen caffeine prn (takes Back pain, joint pain, neck pain
about one time each week) Dizziness off and on insomnia
Ibuprofen prn
Social history
Married
Not working 7 years due to symptoms
No smoking; no alcohol

156 26 Case 26
Examination
Right eye: 20/20
Left eye: 20/20
Pupils
Equal and reactive to light
Color vision (HRR)
Not tested
Stereo vision
Not tested
Not tested
External exam
Normal
Eye alignment
Normal
Reported to be normal by his ophthalmologist
Visual field
Normal
Fundus examination
Normal
Change in sensation around left facial surgical scar. Normal corneal nerve reflex; normal
neurological examination except for hearing decrease on the left. Mild loss of vibratory
sensation in the feet but deep tendon reflexes normal
Migraine disability inventory score (MIDAS)
0 but he has had 90 days of headache in the last 3 months about grade 5
Discussion
This man has a dull daily headache around his eyes. He has no nausea except with
vertigo. He has sound sensitivity but no light sensitivity and activity may help his
headache. He meets criteria for chronic tension-type headache—occurring more
than 15 days each month and having only sound sensitivity. He also has intermittent
migraine, and in my experience, almost everyone that I see with tension-type head-
ache has underlying migraine or a history of migraine (as in this man). See the
ICHD3 beta criteria for tension-type headache (Table 26.1).
The key features of this kind of headache (rarely associated with eye pain alone)
include: bilateral, mild to moderate (never really severe), pain associated with no
vomiting and minimal if any nausea, only light or sound sensitivity (never both),
and it gets better with activity. While this is thought to be one of the most common
causes of headache occurring up to 80% of the population at anyone time, it is the
headache least likely to make it to a doctor’s office—it usually is not severe. In this
Discussion 157
Table 26.1 Chronic tension-type headache by ICHD 3 Beta criteria

(A) Headache occurring on greater 15 days per month on average for >3 months (180 days
per year), fulfilling criteria B–D
(B) Lasting hours to days, or unremitting
(C) At least two of the following four characteristics:
1. Bilateral location
2. Pressing or tightening (non-pulsating) quality
3. Mild or moderate intensity
4. Not aggravated by routine physical activity suchas walking or climbing stairs
(D) Both of the following:
1. No more than one of photophobia, phonophobiaor mild nausea
2. Neither moderate or severe nausea nor vomiting
(E) Not better explained by another ICHD3 beta diagnosis
Table 26.2 Migraine Inventory Disability Assessment Score (MIDAS)

How many days in the last 3 months was your productivity reduced because of headache?
How many days in the last 3 months was your productivity reduced by half because of
headache?
How many days in the last 3 months did you not do household work because of your headache?
How many days in the last 3 months was your productivity doing household work reduced
because of your headache?
How many days in the last 3 months did you miss family or social occasions because of
headache?
Total score
Scores: 0–5 little or no disability
6–10 mild disability
11–20 moderate disability
>21 severe disability
On how many days in the last 3 months did you have a headache
On a scale of 0–10 average how painful were these headaches?
From: Lipton RB, Stewart WF, Sawyer J, Edmeads JG. Clinical utility of an instrument assessing
migrainedisability: The migraine disability assessment (MIDAS) questionnaire. Headache.
2001;41:854–861
man’s case his MIDAS (Migraine Inventory Disability Assessment Score) score is
0—meaning the pain has very little impact on his daily life but really is present
every day (hence 90 days with headache grade 5) (Table 26.2).
He also has many other symptoms that in my mind are probably related to his
migraine tendency including dizziness. His diabetes is associated with early mild
peripheral neuropathy and often diabetics can have peculiar roving paresthesias
such as his. Since his examination is essentially normal and there are no red flags
about his headache, tension-type headache is his predominant headache.
158 26 Case 26
This dull ache around the eyes could be consistent with dry eye syndrome (Case 1),
and I would check whether he has punctate corneal changes. I would also ask this
patient if his pain is worse with prolonged reading, which might be suggestive of
“eyestrain” and its differential diagnosis (Case 4). Sometimes tension-type head-
ache can be improved with heat, cold, or massage, or taking a walk (activity).
Stretching exercises for the neck and jaw may be helpful. Assessing posture and
ergonomics can also lead to headache improvement.
Tension-type headache is a common complaint in a primary care’s office, although

it infrequently comes into the office because it is usually not severe. The greatest
diagnostic error that occurs in this population is that tension-type headache is
OVER diagnosed when the diagnosis is migraine. Be sure to ask—does the patient
have light AND sound sensitivity—automatically in the migraine camp. If there is
nausea and/or vomiting—the diagnosis is migraine. One of my favorite questions
in separating migraine from tension-type headache is what happens with activ-
ity—tension-type headache frequently resolves or improves whereas migraine
worsens. The reason that I think this is important is that there are many more
medication prescribed for migraine and migraine causes disability. The MIDAS
score is helpful in this regard—to check on how headaches interfere with some-
one’s life.
Follow-up
While I would not have imaged this man in the first place, he had been previously
imaged and I reviewed the imaging and it was (no surprise) normal. This man had
been on nortriptyline, which helped but caused him to have difficulty urinating;
gabapentin did not help; amitriptyline caused him to sleep for a long time.
Cyclobenzaprine had helped his back spasm. We tried him on tizanidine (4 mg) as
a mild muscle relaxant but he could not tolerate this. We retried cyclobenzaprine
since he tolerated this in the past for his back but he noticed no change in his head-
ache. Finally, we put him on desipramine because it has fewer cholinergic side
effects and is in the same family (tricyclic antidepressants) as amitriptyline which is
most frequently used in tension-type headache. Acutely, tension-type headache may
respond to aspirin, acetaminophen, ibuprofen, naproxen, diclofenac, and ketoprofen

(all Class I evidence). Preventively, amitriptyline 10 mg at night is the evidence-
based choice increasing as necessary to 40–60 mg at night. Other preventives
include mirtazapine, venlafaxine, and clomipramine. Final diagnosis: chronic
tension-type headache.
For Further Study
1. Freitag F. Managing and treating tension-type headache. Med Clin North Am.
2013;97(2):281–92.
2. Kaniecki RG. Tension-type headache. Continuum (Minneap Minn). 2012;18(4):823–34.
Case 27
A 49-year-old man noted intermittent episodes of severe bilateral eye pain for 1
year. The pain is throbbing and pounding, occurs daily, and lasts approximately
90 min. He denies photopsias, nausea, or vomiting but endorses photophobia. He
denies tearing eye redness, or nasal stuffiness. He denies any triggers or pain with
eye movement. His past ocular history includes a diagnosis of optic neuropathy LE
20 years ago. Over time, his visual acuity dropped 14 years ago to 20/50 LE and
5 years ago was 20/200 LE. Brain and orbit MRI 20 years ago was normal. He expe-
riences daily episodes of transient vision loss (TVL) LE for the past 20 years, last-
ing 2 min at a time. The TVL does not coincide with the eye pain.

Diabetes mellitus × 8 years None
Hypothyroidism
Dorzolamide-Timolol BE Father—hypertension, cataracts
Brimonidine BE
Travoprost BE
Unemployed Seasonal allergies
1–2 drinks a day Intermittent numbness in both hands lasting
No tobacco less than a minute

162 27 Case 27
Examination
Right eye: 20/20
Left eye: Hand motions
Pupils
Equal in size, round, sluggish LE with RAPD LE
Right eye: 12 mmHg
Left eye: 15 mmHg
External exam
Normal, no proptosis, no ptosis
Normal
Normal, deep anterior chamber
Open angles to gonioscopy
Visual field
Normal RE
Fundus examination
0.4 CDR RE with normal rim
0.7 CDR LE with 2+ pallor of rim
Discussion
The story is fairly unusual. This patient has had daily transient monocular blindness
in his LE since he was 29 years old lasting 2 min at a time and is otherwise healthy.
This equates to more than 7000 stereotypic episodes of TVL. I would say that this is
idiopathic vs. nonorganic and is unrelated to his eye pain. He also has an idiopathic
optic neuropathy, which is slowly progressive over 20 years. It is not consistent with
glaucoma given the pallor of the optic nerve and the vision being so poor with so
much nerve left. He has only had one MRI during this time and I would repeat it.
The pain began in the last year, and I would think they are unrelated. I cannot think
of a process other than tumor that would affect one optic nerve for 20 years, but the
pain would be unusual for a tumor. I do not think that bloodwork would be helpful
if the MRI is normal. If it shows enhancement, then I might consider sarcoid, syphi-
lis, lupus, Lyme, and NMO, but this presentation would be rarer than hen’s teeth.
As an ophthalmologist, I think we can palpate his lacrimal gland, infraorbital nerve,
trochlea, supraorbital nerve, and greater occipital nerve. These are often “hidden”
causes of eye pain (see Cases 8 and 23). If the MRI is negative, then I would ask about
analgesic overuse and be inclined to send the patient for a headache evaluation.
Discussion 163
Wow, this is a tough case even for a neuro-ophthalmologist and headache special-
ist! First the intermittent transient visual loss is very peculiar. We are not told what
the pattern of visual loss is or how he describes it but it lasts only 2 min and has
occurred for years with slow damage to the optic nerve. Are these repeated vascular
events? This could happen with vasospasm and be a migraine like phenomenon or
if he cannot describe it, it is unlikely to be carotid artery-related. At least it is not
associated with the pain! The pain that this man has is also peculiar. He has ele-
ments of migraine (throbbing and photophobia) but no nausea; we are not told if it
worsens with exertion. Also the pain is rather short—90 min which is short for
migraine. It has no other trigeminal autonomic cephalgias (Case 28) features either
(tearing, rhinorrhea, eye lid edema, etc.) so it is not likely to be hemicranias conti-
nua or paroxysmal hemicrania. It is too long for episodic stabbing headache (see
Case 24 for a list of short lasting headaches) and it is bilateral so that rules out typi-
cal trigeminal neuralgia—and the pain does not really sound neuralgiform since it
is not in a single nerve distribution like the trigeminal nerve. Trigeminal neuralgia
is more severe and rarely affects the forehead (more commonly the nasal area) and
is more brief and frequent. Supraorbital neuralgia is caused sometimes from com-
pression or irritation of the supra-orbital nerve(s) (see Fig. 8.1). There is a headache
syndrome called external compression headache which causes bilateral forehead
pain, but it is usually caused by wearing a hat or something around the head.
Swimmer’s headache is seen from swimmers using goggles across the forehead.
Diver’s headache also is in the forehead but he is not diving or even swimming
when he gets these pains. Nummular headache is also a consideration—this is a
focal, unilateral headache of unclear etiology that is the size and shape of a large
coin—his is bilateral across the whole forehead, but this is a consideration. This
kind of pain takes very careful examination of the patient and his imaging to be sure
we are not missing anything.
It certainly is possible that the TVL and slowly progressive optic neuropathy were
related to each other since they were in the same eye and began around the same
time. It is just very unusual for the two symptoms to run together. The TVL did not
change but the vision slowly worsened in the LE. Not sure we could make up a
reasonable, common etiology. Slowly progressive vision loss often mandates an
MRI. This is a patient that would probably end up best with a neuro-ophthalmologist.
The vision loss plus headache plus TVL might worry most ophthalmologists and
neurologists.
164 27 Case 27
Table 27.1 Supraorbital neuralgia (from ICHD 2, 2004—not listed in ICHD 3 beta)
Diagnostic criteria
(A) Paroxysmal or constant pain in the region of the supraorbital notch and medial aspect of the
forehead in the area supplied by the supraorbital nerve
(B) Tenderness over the nerve in the supraorbital notch
(C) Pain is abolished by local anesthetic blockade or ablation of the supraorbital nerve
Follow-up
Palpation over the supraorbital nerves reproduced the patient’s pain. He was on gabapen-
tin 300 mg daily, so his dose was increased to 300 mg Three times daily. He did not enjoy
benefit from this and felt fatigued with the higher dosage. MRI brain and orbit with
contrast was unremarkable. The optic nerve appeared normal on the scan. He was diag-
nosed with idiopathic optic neuropathy and unrelated supraorbital neuralgia. The patient
was given 1 mL of triamcinolone 40 mg/mL to both supraorbital nerves and enjoyed
complete resolution of his pain within a week. The transient vision loss persisted.
Supraorbital neuralgia is more of an inflammation of a branch of the trigeminal
nerve. In contrast, trigeminal neuralgia is typically due to compression of the tri-
geminal nerve with subsequent demyelination and faulty transmission. For refrac-
tory symptoms, other treatment modalities include gabapentin, capsaicin cream,
surgical decompression, or resection.
Dr. Digre’s comments: This is not completely typical of supraorbital neuralgia
since in large series the pain is usually shorter less than 15 min, unilateral, pressing,
stabbing, and burning. It is often a consequence of trauma, but non-traumatic cases
do occur. Migraine features like this man are less common with this headache type
and when reported were reported in individuals with a previous migraine history. I
cannot argue with the complete resolution of the pain with supraorbital nerve blocks
and that the pain was reproduced by tapping on that area. Interestingly, the supraor-
bital neuralgia which occurred in the ICHD 2 (2004) (see Table 27.1 for criteria for
the condition) does not appear in the ICDH 3 beta. He meets all of the criteria for
this condition. Treatment of supraorbital neuralgia has centered around nonsteroidal
anti-inflammatory, gabapentin such was tried in this man, pregabalin, and amitrip-
tyline. Nerve stimulators, acupuncture, and radiofrequency ablation as well as sur-
gical decompression have all been tried for this pain. This reinforces the need to
palpate the nerve areas in anyone with eye pain or headache! Final Diagnosis:
supraorbital neuralgi. Idiopathic optic atrophy and transient vision loss.
For Further Study
1. Evans RW, Pareja JA. Expert opinion. Supraorbital neuralgia. Headache. 2009;49(2):278–81.

2. Mulero P, Guerrero AL, Pedraza M, Herrero-Velázquez S, de la Cruz C, Ruiz M, Barón J,
Peñas ML. Non-traumatic supraorbital neuralgia: a clinical study of 13 cases. Cephalalgia.
2012;32(15):1150–3.
3. Pareja JA, Caminero AB. Supraorbital neuralgia. Curr Pain Headache Rep. 2006;10:302–5.
Case 28
A 29-year-old man presented with intermittent severe eye pain and redness. The
pain starts abruptly in the left eye and is a pressure, stabbing, severe, and throbbing
pain. He thinks his vision is blurred somewhat during the attack and he does not
know if his eyelid droops. He often presses on the eye when it is at its worst. He
endorses tearing in the left eye, and rhinorrhea. He has photophobia, nausea, and
has vomited once. The pain can last 30–50 min and afterward he has a lingering
ache for at least 30 min. He denies any facial numbness. The attacks started 3 weeks
ago, but recently he is getting these pains three times daily, and almost every night
he is awakened by the pain. He gets very restless with these attacks and has to pace
around the room. The pain is interfering with his work and life. He wonders if there
is something wrong with his eye that is causing this pain. He has tried ibuprofen
without success for the pain.
Past medical and ocular history Review of systems

History of a bicycle accident and “wrenched” Trouble with sleeping due to pain
back afterward 6 months ago
Normal eye examination before college
Medications Social history
Ibuprofen prn Works as a teacher
Single, engaged to be married
Smokes ½ pack of cigarettes/day
Drinks beer on weekend but recently quit due
to the eye pain
Past surgical history Family history
Tonsillectomy Sister and mother have migraine

166 28 Case 28
Examination
Right eye: 20/20
Left eye: 20/20
Pupils
4 mm right, 3 mm left in light
8 mm right, 6 mm left in darkness
Possible dilation lag on the left
No RAPD
Right eye: 16 mmHg
Left eye: 16 mmHg
External exam
2 mm ptosis left
Extraocular motility
Full
Eye alignment
Normal
Normal tear film
No meibomian gland dysfunction
Visual field
Normal
Fundus examination
Normal
Normal
Discussion
This young man has what sounds like cluster headache—a primary headache dis-
order. Cluster headache belongs to a classification of headache called the trigemi-
nal autonomic cephalgias (TAC). The symptoms of TACs include eye pain, with
lacrimation, rhinorrhea, ptosis, and possible Horner’s syndrome. The tearing, red-
ness, and nasal symptoms occur only during the headache phase, but the ptosis and
miosis can become permanent. The international classification of headache disor-
ders (ICHD 3 beta) has criteria for cluster (Table 28.1). He has some risk factors for
the development of cluster: his age (usually between 20–40), sex (male is three
times more likely than female), and drinking/smoking. His attack length is right for
cluster (15 min to 3 h) and the accompanying symptoms are consistent as well
(tearing, rhinorrhea, conjunctival injection). Some of the attacks awaken him from
sleep, and attacks cause him to pace or be restless—both typical cluster features.
Migraine patients, on the other hand, often want to remain still. He has nausea and
Discussion 167
Table 28.1 ICHD 3 beta criteria for cluster headache

(A) At least 5 headache attacks fulfilling criteria B–D
(B) Severe or very severe unilateral orbital, supraorbital, and/or temporal pain lasting
15–180 min (when untreated)
(C) Either or both of the following:
1. At least one of the following symptoms or signs, ipsilateral to the headache:
(a) Conjunctival injection and/or lacrimation
(b) Nasal congestion and/or rhinorrhea
(c) Eyelid edema
(d) Forehead and facial sweating
(e) Forehead and facial flushing
(f) Sensation of fullness in the ear
(g) Miosis and/or ptosis
2. A sense of restlessness or agitation
(D) Attacks have a frequency between 1 every other day and 8 per day for more than half of the
time when the disorder is active
photophobia (more typical migraine features), which occur frequently with cluster
attacks. In cluster, the photophobia is frequently unilateral. However, typical clus-
ter headache can simulate a more sinister diagnosis such as carotid artery dissec-
tion, tumors in the cavernous sinus, and pituitary tumors.
The first priority is to make the correct diagnosis. Cluster headache and other
TACs all require imaging when first making the diagnosis, since so many patholo-
gies can mimic cluster headache and the other TACs. Since the patient has a possi-
ble Horner syndrome, MR imaging and MR angiography (or CT angiography)
should be done to look for compressive lesions or carotid dissection along the ocu-
losympathetic pathway. If studies are negative, the patient can be diagnosed and
treated for cluster headache. Our patient’s imaging was completely normal.
Cluster occurs daily often at the exact same time each day as seen in our
patient. It is typically episodic—meaning there is a remission that can lasts weeks,
months, or years between the next group of attacks. It is frequently seasonal,
occurring in the spring and fall. Less frequently, cluster can also be chronic—
meaning there is no break from the cluster and these individuals can be severely
affected. Our patient is in the midst of his first attack, so his diagnosis would be
episodic cluster.
Treatment for cluster headache can be divided into two parts. First, preventive
therapy is frequently needed; these would be medications taken daily to prevent
attacks from occurring. Typical preventives include verapamil (240–480 mg), anti-
convulsants like topiramate (50–200 mg), or antidepressants such as lithium (300–
900 mg). A burst of steroids prednisone (20–60 mg) at the onset will frequently halt
attacks. Acute therapy would also include oxygen 5–10 L/min for 10–15 min.
168 28 Case 28
Table 28.2 ICHD 3 beta (A) At least 20 attacks fulfilling criteria B–E
Diagnostic Criteria for (B) Severe unilateral orbital, supraorbital, and/or temporal pain
paroxysmal hemicrania lasting 2–30 min
(C) At least one of the following symptoms or signs, ipsilateral to
the pain:
1. Conjunctival injection and/or lacrimation
2. Nasal congestion and/or rhinorrhea
3. Eyelid edema
4. Forehead and facial sweating
5. Forehead and facial flushing
6. Sensation of fullness in the ear
7. Miosis and/or ptosis
(D) Attacks have a frequency above 5 per day for more than half
of the time
(E) Attacks are prevented absolutely by therapeutic doses of
indomethacin
(F) Not better accounted for by another ICHD-3 diagnosis
Headache Classification Committee of the International Headache
Society. The International Classification of Headache Disorders: 3rd
edition (beta version). Cephalalgia. 2013;33:629–808
Sumatriptan injectable or nasal spray and zolmitriptan nasal spray have clear evi-
dence of benefit. Cluster attacks, in general, do not respond to typical analgesic
therapy. Finally, patients should be warned to quit smoking and drinking alcohol
during cluster attack periods.
There are many other types of trigeminal autonomic cephalgias—and the way to
recognize them is by the gender of the individual and the length of the attack. These
are ALL unilateral and can be severe. These ALL can sound like cluster and you can
be a hero or “shero” if you get this right. Paroxysmal hemicrania is a shorter version
of cluster, more common in women and usually not very long (usually less than
30 min). Individuals have to have at least one autonomic feature including facial
flushing and ear fullness. See Table 28.2. One of the keys to the diagnosis and treat-
ment is that it responds absolutely to indomethacin in doses of 75–150 mg. There
are two forms: episodic which occurs in bouts of 7 days up to a year with some
pain-free times in between and the worse version, chronic paroxysmal hemicrania,
occuring for over a year.
Another is short lasting unilateral neuralgiform headache attacks with conjuncti-
val injection and tearing (SUNCT) and the variety without conjunctival injection
and tearing (SUNA). See Table 28.3. This headache is really brief—lasting seconds
and also accompanied by an autonomic symptom. It is more frequently seen in men
and individuals have hundreds of these in a day—they are REALLY frequent.
SUNCT usually is accompanied by really prominent tearing and redness of the
conjunctivae in the ipsilateral eye. SUNA does not have the red eye. This headache
does not respond to the usual medications—some have reported success with
lamotrigine.
Discussion 169
Table 28.3 ICHD 3 beta Short Unilateral Neuralgiform headache attacks with Conjunctival
Injection and Tearing
(A) At least 20 attacks fulfilling criteria B–D
(B) Moderate or severe unilateral head pain, with orbital,supraorbital, temporal and/or other
trigeminal distribution, lasting for 1–600 s and occurring as single stabs, series of stabs or
in a saw tooth pattern
(C) At least one of the following cranial autonomicsymptoms or signs, ipsilateral to the pain:
1. Conjunctival injection and/or lacrimation
2. Nasal congestion and/or rhinorrhea
3. Eyelid edema
4. Forehead and facial sweating
5. Forehead and facial flushing
6. Sensation of fullness in the ear
7. Miosis and/or ptosis
(D) Attacks have a frequency of at least one a day for more than half of the time when the
disorder is active
Table 28.4 ICHD 3 beta (A) Unilateral headache fulfilling criteria B–D
Hemicrania Continuaa (B) Present for >3 months, with exacerbations of moderateor
greater intensity
(C) Either or both of the following:
1. At least one of the following symptoms or signs, ipsilateral
to the headache:
(a) Conjunctival injection and/or lacrimation
(b) Nasal congestion and/or rhinorrhea
(c) Eyelid edema
(d) Forehead and facial sweating
(e) Forehead and facial flushing
(f) Sensation of fullness in the ear
(g) Miosis and/or ptosis
2. A sense of restlessness or agitation, or aggravation of the
pain by movement
(D) Responds absolutely to therapeutic doses of indomethacin
Society. The International Classification of Headache Disorders:
3rd edition (beta version). Cephalalgia. 2013;33:629–808
Hemicrania continua is a continuous, side-locked headache most frequently seen in

women. The pain is unilateral with episodic stabbing worsening. It is also associated
with autonomic features. See Table 28.4. It characteristically responds absolutely to
indomethacin 75–150 mg a day. See Table 28.5 for comparisons between the TACs.
170 28 Case 28
Table 28.5 Differentiating the trigeminal autonomic cephalgias from migraine

Paroxysmal Hemicrania
Feature Cluster hemicrania SUNCT continua Migraine
Sex M:F 3:1 1:3 6–8:1 1:2 1:2–3
Attack Usually 2–30 min 6–250 s Days—with Hours to
duration less than exacerbations days
2 h over minutes
Number of 1–8 1–40 1/day to 30/h Usually Usually one
attacks continuous with attack at a
episodic stabbing time
Autonomic Frequent Frequent Conjunctival At least one None or
features injection and occasionally
tearing one
Nocturnal Frequent Occasional – Occasional Infrequent
awakening
Restless Definitely Yes Brief Yes NONE—
during wants to
headache rest/sleep
Indomethacin Rarely Absolute None Absolute Rarely
effect helpful helpful
The patient’s story could comport with intermittent angle closure glaucoma. These
patients have intermittent unilateral eye pain, nausea/vomiting, ipsilateral blurred
vision, and tearing. The episodes are extremely variable lasting minutes to hours.
Patients with intermittent angle closure tend to remain still. The blurring is typically
significant, where the patient would not be able to function. The ophthalmologist
may want to investigate for a narrow anterior chamber or compression gonioscopy
(Case 5).
There is also the concern that this represents the knee-jerk reaction to “PAINFUL
HORNER SYNDROME” that has been drilled into our heads-carotid dissection.
When your knee jerks and you get the MRI/MRA neck, you might miss the diagno-
sis of cluster, but you would not miss the dissection. Certainly, if you are in doubt,
pharmacologic testing could be considered and is covered in Case 17. I have also
noticed that many ophthalmologists have a tendency to over-diagnose cluster head-
ache, which is fairly rare. I think it is important to keep in mind that cluster cannot
go beyond 3 h and should happen daily for several days.
Cluster headaches are excruciating, unilateral, and side-locked. The patient is often
rocking back and forth if sitting or pacing around. As stated earlier, this should last
15–180 min, and if the duration falls outside of this window, you should not
Ptosis and eyelid edema
In between attacks During attack
Fig. 28.1 Patient with cluster headache demonstrates normal appearance between attacks (L) and
eyelid edema, ptosis, and enlargement of the temporal veins during an attack (R)
diagnose cluster headache. Most of the time the patient will come to see you between
episodes, and so a careful history is required focusing on the autonomic symptoms
red eye, tearing, nasal stuffiness, rhinorrhea, or eyelid edema or enlargement of
temporal vessels (Fig. 28.1) and the stereotypic timing.
If there is some question about Horner syndrome (ipsilateral ptosis and miosis),
a neuro-ophthalmology consult could be obtained. If cluster headaches are not
responding to conventional therapy, consider referral to a neurologist or headache
specialist.
Follow-up
This patient was very happy to hear a diagnosis and even happier to get on treat-
ment. We prescribed prednisone for 2 weeks at a higher dose (40 mg) then tapered
him slowly off the prednisone over 2 weeks, while initiating verapamil 80 mg three
times daily as a preventive regimen. We did have to increase the dose to 240 mg
twice daily to prevent break through clusters. We also gave him an oxygen concen-
trator and prescription for facial mask. We initiated Sumatriptan 4 mg injectable for
attacks that did not respond to oxygen. After 4 months he became headache-free,
and was able to successfully taper off verapamil. His Horner’s syndrome did not
resolve, which is typical of TAC. Final diagnosis: Trigeminal autonomic cephal-
gia—cluster headache.
For Further Study
1. Goadsby PJ. Trigeminal autonomic cephalalgias. Continuum (Minneap Minn).

2012;18(4):883–95.
2. MayA. Diagnosis and clinical features of trigemino-autonomic headaches. Headache. 2013;53(9):
1470–8.
172 28 Case 28
3. May A, Leone M, Afra J, Linde M, Sándor PS, Evers S, Goadsby PJ, EFNS Task Force. EFNS
guidelines on the treatment of cluster headache and other trigeminal-autonomic cephalalgias.
Eur J Neurol. 2006;13(10):1066–77.
4. Nesbitt AD, Goadsby PJ. Cluster headache. BMJ. 2012;344:e2407.
Case 29
Five months ago, a 66-year-old man with no previous headache history developed
pain behind both eyes while running. Since then, he has noted that the pain occurs
every time he coughs, sneezes, or picks up something heavy. It intermittently occurs
when he bends his head below his waist, strains on the toilet, or clears his throat. It
can occur if he gets up from his chair or goes up the stairs too quickly, but if he goes
slowly it does not happen. If he does not Valsalva, then it would not happen. He
describes it as a pressure pain, rating 5–6 out of 10, and lasting only seconds. He has
been getting chiropractic manipulation of his neck and he thinks this is helping. He
had a CT and an MRA brain done, which were read as normal. He denies other
visual symptoms and migraine accompaniments. He denies any change to his
appearance.

Hypothyroidism Inguinal hernia repair 15 years ago
Seasonal allergies
Irritable bowel syndrome
Atrial fibrillation
Levothryoxine Father—irritable bowel syndrome
Fish oil capsules Mother—stroke, heart disease, macular
Multivitamin degeneration
Flucatisone nasal spray 2 brothers—hypertension
Olapatadine
Aspirin
Former smoker none for 27 years Post nasal drip
2–3 drinks, 2–3 times per week Knee and hip pain
No drug use Mild scalp tenderness
Married No weight loss, jaw claudication, malaise

174 29 Case 29
Examination
Right eye: 20/20
Left eye: 20/20
Pupils
Equal, brisk, no afferent pupillary defect
Right eye: 18 mmHg
Left eye: 24 mmHg
External exam
No swelling, normal temporal arteries, no tenderness to palpation of trochlea, supraorbital or
infraorbital foramina
Eye alignment
Normal
Normal, no cells, deep anterior chamber
Visual field
Normal
Fundus examination
Epiretinal membrane RE, single microaneurysm LE
Normal
Discussion
At first glance, it seems like he is describing headaches brought on by movement, which

might make one think of migraine (Case 19), which is often made worse with move-
ment. However, he is older to have a first migraine, migraines do not last seconds, and
he denies other symptoms that accompany migraine. Low intracranial pressure can lead
to headaches when a patient is sitting or standing but resolve with lying down. Usually,
the headache persists while the patient is upright and that is not what he is describing.
Pain lasting seconds might be consistent with neuropathic pain. Classically, neuropathic
pain is described as electric shock like, but he describes an ache. He notes that chiro-
practic manipulation has made him better, so I would palpate over his greater occipital
nerve (Case 23). It may be a red herring. He notes mild scalp tenderness, but no other
symptoms of GCA (Case 32). I might consider a sed rate and CRP, if I felt that his story
were strong enough after talking to him. If the values were markedly elevated, then I
would pursue a temporal artery biopsy. If they were normal or mildly elevated, then I
would probably observe from that perspective. If they were markedly high, then I would
start prednisone and pursue a temporal artery biopsy. His eye pressure is elevated, but
not to the degree that this would cause pain. Also, angle closure glaucoma (Case 5)
would not be bilateral and simultaneous and would last for longer periods of time.
Boiling it down, he really sounds like it is more commonly associated with effort
or Valsalva. There is an entity known as cough headache. This can be a benign
phenomenon or relate to an Arnold Chiari malformation (Fig. 29.1), posterior fossa
lesions, or aneurysms. Typically, these lesions would give more significant headache
Discussion 175
Fig. 29.1 Sagittal T1 MRI

showing significant
tonsillar herniation. Note
the line signifying the
foramen magnum. The
tonsils (arrow) are well
below this level consistent
with an Arnold Chiari
malformation
symptoms—worse pain, longer durations. I would look to see if his imaging shows
any issues. If he has a lesion, then I would consider referral to neurosurgery.
This is a short headache brought on by cough or straining in an older individual with

presumably NO previous headache disorder. This is a headache to pay attention to.
Traction on the dura can cause these new headaches. The headaches are brief—too
short for many different headache types—maybe like ice pick headache or SUNCT
(this SUNCT while brief has conjunctival injection and tearing, Case 28). See Table
24.1 where we go through the differential diagnosis of short headaches.
One of the prominent features of this headache is that it is precipitated by cough-
ing or Valsalva maneuver. There is a primary headache disorder (meaning there is
no other cause to it) called Primary Cough Headache! It is sometimes also known as
Valsalva maneuver headache (see Table 29.1). While primary cough headache is a
rare headache disorder it can localize around the eyes. It is most often bilateral and
sometimes posteriorly and interestingly this headache hits people over 40 or 50.
However, there is caution with cough headache. Look for a secondary cause! The
one diagnosis you do not want to miss with cough headache is a Chiari malformation
since up to 40% of individuals presenting with cough headache can have this diag-
nosis. Other posterior fossa lesions like tumors should be ruled out. So this guy
deserves an MR not a CT scan to look at the cranial cervical junction. In addition, be
careful not to miss intracranial hypotension (Case 31) that can look a lot like a Chiari
1. Other causes of a cough headache include pinealoma, basilar impression, subdural
hematoma, brain tumor, midbrain cyst, and pituitary tumor. Treatment of these sec-
ondary or symptomatic cough headaches is dictated by the underlying pathology.
176 29 Case 29
Table 29.1 ICHD-3 beta Primary Cough Headache

(A) At least two headache episodes fulfilling criteria BD
(B) Brought on by and occurring only in association with coughing, straining, and/or other
Valsalva maneuver
(C) Sudden onset
(D) Lasting between 1 s and 2 h
Treatment of primary cough headache has been indomethacin—sometimes in

higher doses. Acetazolamide, amitriptyline, naproxen, and propranolol have been
reported to be helpful in some.
This is an uncommon cause of headache, but requires a careful history. The patient should
have an MRI and MRA to evaluate for Chiari malformations, posterior fossa lesions, or
aneurysm. We would recommend giving contrast, since one can also look for thickening
and enhancement of the dura mater seen in spontaneous intracranial hypotension.
Follow-up
I did not have his scans, and so I called radiology where he had it done and asked
them to look at the source images for an Arnold Chiari malformation or other pos-
terior fossa lesions. There were none present. Therefore, this clinical presentation
would be consistent with primary cough headache (formerly known as benign
cough headache). This entity often lasts seconds at a time, is more common in men,
and does not occur under the age of 40 years. His description is a little different in
that most patients describe sharp pain. It is associated with a normal MRI and mild
symptoms. It may benefit from the use of indomethacin or acetazolamide, but the
patient was not interested. This often spontaneously resolves over the course of
several years. The patient was given reassurance and will follow-up with his pri-
mary eye doctor regarding the epiretinal membrane, elevated eye pressure, and
single microaneurysm in the LE. Final diagnosis: Primary cough headache.
For Further Study
1. Boes CJ, Matharu MS, Goadsby PJ. Benign cough headache. Cephalalgia. 2002;22:772–779.21.
2. Chen PK, Fuh JL, Wang SJ. Cough headache: a study of 83 consecutive patients. Cephalalgia.
2009;29:1079–85.
3. Cordenier A, de Hertogh W, de Keyser J, Versijpt J. Headache associated with cough: a review.
J Headache Pain. 2013;14:42.
Case 30
A 52-year-old cardiology nurse has a history of a father with headaches and she
really had rare periodic headaches that were always easily treated with ibuprofen.
She was rear ended on the freeway by a truck going about 35–40 mph. No air bags
were deployed, she struck her head but did not lose consciousness, and did not go to
the hospital although emergency medical services were called. The next day she
went to instacare for a headache, neck pain, and eye pain. She was given ibuprofen
and sent home. She developed light sensitivity and missed work for a week. Her
primary care physician ordered an MR of the brain and cervical spine about 2 weeks
later and aside from some disc degeneration and one white spot on the brain, the
imaging was normal. She saw a neurosurgeon who treated her with 6 days of ste-
roids, but there was no effect on her eye pain. The headache became less frequent,
but the eye pain persisted. The pain is in both eyes left more than right and when the
headache occurs, the right eye pain intensifies. Her left eye pain severity fluctuates
as well. Currently, her worst headache occurs when the eye pain is severe—it feels
like a brick on the forehead and a band around the eyes. She has light and sound
sensitivity and when it is severe, she has nausea. These occur every 2 weeks and she
lies down. She has moderate headaches about 4 days each week lasting 2–8 h. The
eye pain is bilateral left more than right, sometimes she has watering in her both
eyes, and sometimes her eyes look red. Her neck is always sore. She feels her pro-
cessing speed is reduced and speech sometimes slurs.

178 30 Case 30

Basal cell cancer History of basal cell cancer removed by Moh’s
surgery
Vitamins C, D Glaucoma
Norethindrone Macular degeneration
Ibuprofen, hydrocodone PRN
Married, works as a nurse Per HPI
No smoking or alcohol use
Examination
Right eye: 20/20
Left eye: 20/20-1
Pupils
3 mm OU in light; 4 mm OU in darkness; no RAPD
Right eye: 14 mmHg
Left eye: 13 mmHg
External exam
Normal
Eye alignment
Normal
Mild meibomian gland dysfunction; trace nuclear sclerosis OU
Visual field
Normal
Fundus examination
Normal
Normal
Discussion
The phenotype of this patient’s worst headache is migraine (moderate to severe,

light and sound sensitivity with nausea and worsening with activity). While she had
periodic headaches before, after her whiplash and motor vehicle accident, she now
has developed migraine-like headaches, which are considered post-traumatic.
Headaches are very common after trauma to the head and neck. In fact, 90% of
persons with traumatic brain injury will have headache. There are two flavors of
post-traumatic headache—acute (occurring right after the injury) and persistent
(occurring for over 3 months after the injury). While most of the time headaches and
symptoms will resolve, many continue to have complaints after 3 months (about
Discussion 179
20%). These headaches and eye pain can occur after moderate to severe trauma or
mild trauma such as in this case. Furthermore, the headache can be attributed to
whiplash along with traumatic brain injury. Headaches may be seen as an isolated
symptom, but often there are other symptoms like difficulty concentrating, depres-
sion, dizziness, fatigue, depression and anxiety, insomnia, and irritability. In this
case, she had both a blow to the head without loss of consciousness and whiplash (a
sudden acceleration/deceleration) with movement of head either in flexion or
extension.
The risk factors for the development of post-traumatic headache include: female
gender, and history of previous traumatic brain injury. The phenotype of the head-
ache is often chronic tension type (Case 26) in the majority, and mixed tension-type
and migraine-like headaches—such as seen in our patient. The most common cause
of post-traumatic headache is motor vehicle accidents, but falls, sports and recre-
ational injuries and assaults are causative.
Post-concussive symptoms are not rare and fall into four types including sleep
disturbance, cognitive changes, emotional issues, and somatic complaints like
fatigue. She has developed, according to the ICHD 3beta, a persistent headache
after mild head trauma (see Table 30.1) and persistent headache attributed to whip-
lash (see Table 30.2).
In addition, she developed eye pain right after the injury. This pain may have a
couple of sources—first, as we have seen in cervicogenic headache (Case 29) eye
pain can occur probably related to the anatomy of the nucleus caudalis of the tri-
geminal system into the upper cervical cord.
She also has dry eyes which will compound the pain problems. Her Schirmer’s
were 1 mm in both eyes. Dry eyes may have been a pre-morbid condition but dry
eye symptoms can occur after trauma too. In addition, chronic pain disorders have
Table 30.1 ICHD 3 beta criteria for Persistent Headache attributed to mild head injury
Headache fulfilling the following:
1. Associated with NONE of the following
(a) Loss of consciousness for over 30 min
(b) Glasgow coma scale less than 13
(c) Post-traumatic amnesia lasting over 24 h
(d) Altered level of awareness for over 24 h
(e) Imaging evidence of traumatic head injury such as hemorrhage or contusion
2. Associated immediately following the head injury one or more of the following:
(a) Transient confusion, disorientation, or impaired consciousness
(b) Loss of memory for events immediately before or after the head injury
(c) Two or more of the following symptoms: nausea, vomiting, visual disturbance,
dizziness and or vertigo, impaired memory or concentration
3. Headache for over 3 months after the injury to the head
4. Not accounted for by another diagnosis
180 30 Case 30
Table 30.2 ICHD 3 beta A headache for over 3 months caused by whiplash
criteria for Persistent Criteria:
headache after Whiplash
(A) Any headache that fulfills criteria C and D
(B) Whiplash associated with neck pain and/or headache has
occurred
(C) Headache developed within 7 days after whiplash
(D) Headache persists for more than 3 months after whiplash
(E) No better accounted for by another diagnosis
Society. The International Classification of Headache Disorders:
3rd edition (beta version). Cephalalgia. 2013;33:629–808
also been associated with dry eye symptoms. Certainly, aggressively treating this
problem will help her eye pain.
Treatment of whiplash and post-traumatic-associated pains has focused on edu-
cation—explaining what happened, avoiding immobilization of the neck, encourag-
ing normal neck movements, and getting back to work. Physiotherapy in some cases
may be helpful, but was not found to be cost-effective. Further, evaluate for medica-
tion overuse—since many individuals receive narcotic medication at the time of the
accident that can further exacerbate headaches (Case 20). Treat the headache based
on the phenotype (e.g., migraine-specific medications can be helpful in migraine-
like pains like tricyclics, beta blockers, and anticonvulsants). Treat psychological
symptoms and also treat insomnia, depression, and anxiety. Risk factors for poor
outcome include: severe pain, headache at the time of injury, older age, lower edu-
cational level, no seatbelt use, low back pain, pre-injury neck pain, high pain cata-
strophizing, and female sex. There has long been a controversy about whether
post-traumatic headaches are non-organic or present because of compensation or
legal issues. In general, while there are certainly cases of malingering, most indi-
viduals want to get back to work like our patient.
Frankly, I was unaware of dry eye developing after head trauma, but I believe it
since I know one of the authors of that citation well. We discuss the treatment for
dry eye in Chap. 1. Two other common disturbances that occur following trauma are
convergence insufficiency (Case 4) and photophobia (Case 21). Some other findings
that might occur include nystagmus, binocular diplopia, or visual loss. Nystagmus
and visual loss are not related to eye pain. There is a nonorganic kind of fluttering
eye movements called voluntary flutter. Usually patients cannot maintain it for more
than 1 min and there is characteristic fluttering of the eyelids. Visual loss can also be
nonorganic. This should be evaluated with optical coherence tomography of the
nerve fiber layer (RNFL) and the macula at least 3 months after the injury. Commotio
will show thinning of the outer nuclear layer or disruption of the ellipsoid. Optic
neuropathy will show thinner RNFL and ganglion cell layer. Binocular diplopia
from a traumatic fourth nerve palsy can result in eyestrain and neck pain. The eye-
strain occurs by trying to fuse the two images together causes strain on the eyes. The
neck pain relates to patients with fourth nerve palsies typically tilt their head to one
side to improve the double vision. Convergence spasm is typically nonorganic and
manifests as an esotropia with miosis upon attempted abduction.
Post-traumatic headache and whiplash are common complaints in the primary care
office. It is clear that education, appropriate preventive medications for the pheno-
type of the headache is helpful. Be aware that the eye pain may be related to dry
eyes in addition to cervical spasm or trauma.
Follow-up
We educated her on her headache and dry eye diagnoses. We started her on tizani-
dine 4 mg at night or sleep and also headache prevention and treated her dry eyes
aggressively with preservative free artificial tears. We suggested she take isome-
theptene/acetaminophen combination (Midrin) for her migraine headaches. She
continued working and was doing well. Final diagnosis: post-traumatic eye pain.
For Further Study
1. D’Onofrio F, Russo A, Conte F, Casucci G, Tessitore A, Tedeschi G. Post-traumatic headaches:

an epidemiological overview. Neurol Sci. 2014;35(Suppl 1):203–6.
2. Galor A, Covington D, Levitt AE, McManus KT, Seiden B, Felix ER, Kalangara J, Feuer W,
Patin DJ, Martin ER, Sarantopoulos KD, Levitt RC. Neuropathic ocular pain due to dry eye is
associated with multiple comorbid chronic pain syndromes. J Pain. 2016;17(3):310–8.
3. Mishra A, Digre KB. Head Injury: Neuro-ophthalmic Disturbances in Head Injuries. In Head
Injury and Post-Concussive Syndrome. Rizzo, Tranel (ed). New York: Churchill-Livingston,
1996;201–26.
4. Obermann M, Naegel S, Bosche B, Holle D. An update on the management of post-traumatic
headache. Ther Adv Neurol Disord. 2015;8(6):311–5.
5. Sheftell FD, Tepper SJ, Lay CL, Bigal ME. Post-traumatic headache: emphasis on chronic
types following mild closed head injury. Neurol Sci. 2007;28(Suppl 2):S203–7.
6. Walton DM, Macdermid JC, Giorgianni AA, Mascarenhas JC, West SC, Zammit CA. Risk fac-
tors for persistent problems following acute whiplash injury: update of a systematic review and
meta-analysis. J Orthop Sports Phys Ther. 2013;43(2):31–43.
7. Walton DM, Pretty J, MacDermid JC, Teasell RW. Risk factors for persistent problems follow-
ing whiplash injury: results of a systematic review and meta-analysis. J Orthop Sports Phys
Ther. 2009;39(5):334–50.
8. Watanabe TK, Bell KR, Walker WC, Schomer K. Systematic review of interventions for post-
traumatic headache. PM R. 2012;4(2):129–40.
Case 31
A 32-year-old body builder and car salesman lifted weights every morning. He had
no previous headache or eye problems. One day while at work in his usual routine,
he developed a relatively acute, severe headache with pressure behind his eyes. He
noticed if he would lie down, it would abate, but within minutes of standing up, he
had a severe headache and the pressure feeling behind his eyes would begin. He also
complains of neck pain. He has minimal light sensitivity and mild sound sensitiv-
ity—and some muffling to his hearing, but no nausea. The pain does worsen with
activity—and he stopped lifting weights. He tried to sleep it off, but when it did not
resolve after 2 weeks, he began missing work and was referred for further evalua-
tion. Recently, he has noted fleeting diplopia—which is side by side, and only pres-
ent in the distance—and not all of the time.

History of MVA at age 18—no loss of None
consciousness
None Non-contributory
Married; used to smoke but quit years ago. Since the headache started he has been trying to
Drinks socially on occasion sleep more

184 31 Case 31
Examination
Right eye: 20/20
Left eye: 20/20
Pupils
Equal and no RAPD
Right eye: 14 mmHg
Left eye: 14 mmHg
External exam
Normal
Eye alignment
He has a mild comitant esophoria of 4–8 diopters on right and left lateral gaze
Normal
Visual field
Fundus examination
Normal
Normal
Discussion
This is a new onset of a daily headache in someone who has not had headaches
in the past—he requires further work up and questioning. While this could be
“new daily persistent headache”—a diagnosis of a headache starting one day and
never going away, the real clue in this case is the positional nature of his head-
ache. Anytime there are positional headaches, one has to consider a low cerebro-
spinal fluid volume or low intracranial pressure. The most common cause is after
a lumbar puncture, but these positional headaches can start spontaneously at any
time. Eye pain does occur with these headaches as well, but is often a dull ache—
and not the primary complaint. Other things can cause a positional headache too.
Individuals who have had a Chiari malformation surgery, a large dural sac, col-
loid cyst of the third ventricle, post-coital headache, cardiac cephalgia (eye pain
and headache with upright position and exertion, relieved by rest), and postural
orthostatic tachycardia syndrome (POTS) (usually seen in young women with
striking tachycardia after standing up for a while) can have positional headaches.
These headaches are commonly mis-diagnosed as tension-type headache. The
diplopia is not rare—probably coming from tugging on the sixth cranial nerve as
the brain stem slumps downward toward the foramen magnum.
While trauma is obviously a risk factor for developing these headaches, sports such
as golf and weight lifting, coughing from a upper respiratory infection, chiropractor
Discussion 185
Table 31.1 ICHD 3 beta: Intracranial hypotension

Description: Orthostatic headache caused by low cerebrospinal fluid (CSF) pressure of
spontaneous origin. It is usually accompanied by neck stiffness and subjective hearing
symptoms. It remits after normalization of CSF pressure
(A) Any headache fulfilling criterion C
(B) Low CSF pressure (<60 mm CSF) and/or evidence of CSF leakage on imaging
(C) Headache has developed in temporal relation to the low CSF pressure or CSF leakage, or
has led to its discovery
(D) Not better accounted for by another ICHD-3 diagnosis
manipulation, fishing and even yoga have been reported with its development. Even
minor trauma like sitting on a 4-wheeler can induce it in certain individuals. It is
thought that people with connective tissue problems like Marfan’s and Ehlers Danlos
syndromes are more susceptible.
The diagnosis is usually made by history and with imaging (Table 31.1). MRI shows
a sagging brain including cerebellar tonsillar herniation, optic nerve and chiasmal
downward displacement, and striking meningeal enhancement. The diffuse meningeal
enhancement seen on MRI, reported just over 10 years ago, has become one of the key
diagnostic imaging features. Since meningeal enhancement alone, however, can be a
sign of other conditions causing headache (meningitis, meningeal carcinomatosis, neu-
rosarcoidosis, subarachnoid hemorrhage), look for other findings. The other clear fea-
ture is the descent of the brain and brain stem, including: cerebellar tonsillar herniation,
reduced size of the pre-pontine cistern, inferior descent of the optic chiasm, and descent
of the iter (or the aqueduct opening). Ventricular size is on the smaller size in some and
reverts to normal after normalization of pressure. Enlargement of the pituitary gland
has also been shown. Engorgement of the venous plexus and spinal veins also occurs.
In this disorder, the spinal fluid pressure is not invariably low. Less than 50% of
individuals in many had pressures of less than 40 mm CSF—and many are nor-
mal—so reliance on pressure alone is inadequate. There can be lymphocytic pleo-
cytosis and increased CSF protein (up to a 1000 mg/dL in some cases). Once the
diagnosis has been made—treatment with a blind blood patch is often recommended
since many individuals will have complete resolutions of their symptoms.
However, if that fails, then looking for the leak is the next step and this is sometimes
tricky. The first imaging test can be high-resolution MRI, and rarely a leak can be
found. A CT myelogram is usually recommended, from the base of the skull through
the lumbar sacral regions. MR gadolinium myelogram has also been recommended.
Often medical treatment with IV fluids, corticosteroids, and IV caffeine has been
successful in treating the headache. Most frequently a directed blood patch is
required. The cause of the headache is more likely to be related to the volume and
not the pressure. Many complications of untreated intracranial hypovolemia or
hypotension occur including: subdural hematomas, stroke, central herniation syn-
drome with stupor and coma.
186 31 Case 31
I think it is important to note that the diplopia is not positional in intracranial hypo-
tension—meaning the double vision does not vary as quickly as the headache.
Additionally, not all patients have double vision or a sixth nerve palsy. So, if the
patient merely has eye pain or headache, then the diagnosis is really predicated on
the history of positional headache. Unless of course, you have an MRI and this
shows the dural thickening and enhancement, then the diagnosis may be suggested
by the radiologist.
Orbital varices can cause proptosis that varies with head position or Valsalva, but
these are not typically painful. Patients with autonomic dysfunction and pre-syncope
may develop transient bilateral visual loss with standing. Associated symptoms can
include lightheadedness, photopsias, and ataxia. Headache would be very unusual
in this circumstance. Patients with Arnold Chiari malformations could develop
headache with Valsalva or cough (Case 29), but this should be easily distinguishable
from the positional headache of low ICP.
When confronted with this diagnosis, it is best to send the patient for a blood
patch or to neurology to identify a leak using the imaging tools Dr. Digre men-
tioned. These patients most often have a leak from the area of a spinal root.
These positional headaches can occur in the primary care provider office and the
history is not always straight forward. I have had patients come to my clinic—and
when I walk in the room they are lying on the floor or on the examining table
because they are more comfortable. This is a great clue to this disorder. The new
headache is really a tip off too—and always asking about positional changes helps
to make this diagnosis. Sometimes if the pain has been present for a long time, ask
about what the pain was like at the very onset of the new daily persistent headache;
after a long period of time, the positional aspect of this pain can go away.
If the patient has diplopia—have them look at the end of the room at a target and
see if by cross covering their eyes you pick up an eso deviation (i.e., the eye moves
from in to out) and especially look for an eso in right and left gaze. Also check for
downbeating nystagmus because this can occur with this type of headache and eye
pain.
Follow-up
Imaging showed classic signs of intracranial hypovolemia with slumping of the

posterior fossa and tonsillar herniation, enlarged pituitary gland, axial images
showed compression of the midbrain, and smooth dural enhancement (see Fig. 31.1).
a b
Fig. 31.1 (a) Sagittal T1 MR scan showing tonsillar descent, dilated superior sagittal sinus and
enlarged pituitary; (b) coronal postgadolinium T1 shows marked thickening and enhancement of
the dura (arrow)
We did a blind blood patch with good relief of the headache and eye pain, but since
he still had intermittent pain, we repeated the blood patch with a larger volume and
the symptoms resolved. We recommended that he hold off on weight lifting for
about 3–6 months so that he did not have a recurrence. Final diagnosis: spontane-
ous intracranial hypotension.
For Further Study
1. Mokri B. Spontaneous intracranial hypotension. Continuum (Minneap Minn). 2015;21(4

Headache):1086–108.
2. Mokri B. Spontaneous low pressure, low CSF volume headaches: spontaneous CSF leaks.
Headache. 2013;53(7):1034–53.
3. Schievink WI, Deline CR. Headache secondary to intracranial hypotension. Curr Pain
Headache Rep. 2014;18(11):457.
Case 32
A 70-year-old white man began having sharp pains around the left eye a few days
after lumbar spine surgery 4 months ago. He notes that the eye and temple area are
tender to palpation. The pain is constantly a 3 of 10 but increases to 10/10 for hours
at a time. He denies nausea, vomiting, phonophobia, and photophobia. He denies a
personal or family history of migraine. He was diagnosed with migraine and was
treated with sumatriptan, diphenhydramine, ketorolac, and prochlorperazine. He
was then given prednisone 40 mg daily for 10 days and his headache resolved com-
pletely and then returned when the steroids were finished. He was then begun on
indomethacin 25 mg three times daily without benefit.

Hypertension Appendectomy as a child
Seasonal allergies Knee surgery 2012
Heart block Cataract surgery 2013
Pacemaker
Aspirin No pertinent history
Fish oil
Vitamin D
Loratadine
Lisinopril
Indomethacin
Retired social worker Postnasal drip
Former smoker Chronic cough
Occasional alcohol Pain with chewing
Easy bruising
Bilateral knee pain
Constipation
No weight loss, anorexia, malaise

190 32 Case 32
Examination
Right eye: 20/20
Left eye: 20/20
Pupils
Equal, brisk, no afferent pupillary defect
Right eye: 12 mmHg
Left eye: 13 mmHg
External exam
Tenderness of left temple
Dermatochalasis of both upper lids
No proptosis
Normal, notes left eye pain with movement
Normal except intraocular lenses
Visual field
Normal
Fundus examination
Normal
Normal
Discussion
Generally speaking, new headache/eye pain in a 70-year-old is unusual. New

migraine in a septuagenarian without migraine accompaniments would be a diagno-
sis of exclusion. Additionally, he did not respond to the migraine cocktail.
Interestingly, his eye pain resolved with steroid use, which suggests inflammation,
infection, or edema. The eyes are white and quiet, but he has pain with eye move-
ment. One consideration would be a myositis of the extraocular muscles.
Malignancies are not uncommon in this age group and steroids can improve pain/
headache from cerebral edema. Infections can invade from the paranasal sinuses
and also respond to steroids transiently. I think a CT orbit with and without contrast
would be reasonable (the patient has a pacemaker precluding an MRI) to evaluate
for eye muscle enlargement, paranasal sinus involvement, abscess, and mass.
His review of systems also shows pain with chewing. It is critical to find out more
information about this in patients older than 50 years because this could represent
giant cell arteritis (GCA). Patients with true jaw claudication experience pain similar
to what patients with leg claudication do. The pain begins after prolonged chewing,
worsens as the chewing progresses, and improves over the course of minutes after
the chewing has stopped. Pain with opening the jaw (temporomandibular joint dis-
ease), initially biting down (cracked tooth, tooth disease), or that stops immediately
when chewing desists (tooth disease) are not consistent with jaw claudication. If he
Discussion 191
Fig. 32.1 External
photograph shows an
enlarged temporal artery.
Palpation may show a
reduced pulse or
tenderness
endorses true jaw claudication, my suspicion goes up for GCA and he buys himself
a temporal artery biopsy. If he does not, then I would check ESR and CRP.
A high ESR is age divided by 2 in a man and age divided by 2 + 5 in a woman. Be
careful because 20% of patients with GCA may have no systemic symptoms or a
normal ESR. A high CRP is over the normal limits of the testing laboratory. Make
sure you pay attention to the units since some labs report in mg/L and others in mg/
dL, which is an order of 10 off. So a CRP of 4 could be really high or really normal!
I would palpate his temporal arteries to look for tenderness or pulselessness. Is it
enlarged or ropy (Fig. 32.1)? If the suspicion for GCA is high, then I would start oral
prednisone and get a temporal artery biopsy of at least 2 cm in length right away. He
has been on prednisone for 10 days recently. Generally, the results are not falsely
negative if the patient has been on prednisone less than 10–14 days.
First, this man has NEVER had migraine history—a new headache in anyone over 40
is a cause for great concern. Normally, we would get an MR scan on any new head-
ache like this, but of course the pacemaker makes this more difficult. CT imaging
would be a first step. Second, the review of systems lists jaw pain with chewing—one
of the most sensitive questions for giant cell arteritis. In fact in many series of posi-
tive temporal artery biopsies, jaw claudication is the most common symptom.
I would say ANYONE with a headache over the age of 65—that should be one of
your go-to questions. If we look at the ICHD 3 beta criteria (Table 32.1) for giant cell
arteritis—this guy has it: he has scalp tenderness AND jaw claudication. He also had
a response to his headache with steroids! So I am betting on a positive biopsy.
192 32 Case 32
Table 32.1 ICHD3 beta criteria for giant cell arteritis headache
(A) Giant cell arteritis (GCA) has been diagnosed
(B) Must have Evidence of causation demonstrated by at least two of the following:
1. Headache has developed in close temporal relation to other symptoms and/or clinical or
biological signs of onset of GCA, or has led to the diagnosis of GCA
(a) Headache has significantly worsened in parallel with worsening of GCA
(b) Headache has significantly improved or resolved within 3 days of high-dose steroid
treatment
3. Headache is associated with scalp tenderness and/or jaw claudication
I am with Dr. Lee—he needs a ESR and CRP and a temporal artery biopsy. There
is some intriguing work being done on using ultrasound or MR imaging, but this is not
good enough yet for diagnosis. In my practice, I see many individuals diagnosed with
GCA without a biopsy. I think this is one disorder that you have to get a right diagno-
sis—and sometimes you have to do both sides if you are suspicious. You do not want
to put older individuals on medications that can cause side effects like steroids without
a good solid diagnosis. Finally, headache is very common with GCA (about 75%) of
the time—and only a quarter are actually in the temple. Eye pain occurs around 10%
of the time—so keep this one in your differential of eye pain in older individuals!
A GCA review of systems includes asking about pain with chewing, weight loss,
anorexia, malaise, scalp tenderness, fevers, and shoulder or hip arthralgias. Jaw clau-
dication is by far the most specific symptom. Checking ESR and CRP in anyone over
65 with a new headache is reasonable. If they are elevated, then starting prednisone
and ordering a temporal artery biopsy is reasonable. In my experience, if the headache
does not improve on high-dose prednisone, then it is less likely to be GCA related.
Follow-up
The patient underwent an unremarkable CT brain and orbit. The ESR was 45 mm/h
and the CRP was 0.8 mg/dL (normal < 0.5 mg/dL). The patient was placed on pred-
nisone 40 mg daily and underwent a left temporal artery biopsy, which was positive.
The patient remained on prednisone and aspirin and was referred to rheumatology.
He was very interested in a steroid sparing agent and inquired about tocilizumab
(FDA-approved for GCA on 5/22/17). Final Diagnosis: Giant cell arteritis, tempo-
ral arteritis.
For Further Study
1. Frohman L, Wong AB, Matheous K, Leon-Alvarado LG, Danesh-Meyer HV. New develop-

ments in giant cell arteritis. Surv Ophthalmol. 2016;61:400–21.
2. Lee MS, Smith SD, Galor A, Hoffman GS. Antiplatelet and anticoagulant therapy in patients
with giant cell arteritis. Arthritis Rheum. 2006;54:3306–9.
3. Regent A, Redeker S, Deroux A, et al. Tocilizumab in giant cell arteritis: a multicenter retro-
spective study of 34 patients. J Rheumatol. 2016;43:1547–52.
4. Smith JH, Swanson JW. Giant cell arteritis. Headache. 2014;54(8):1273–89.
Case 33
A 39-year-old completely healthy woman presented to the emergency room. Four

days before she defecated and suffered an “explosion” of pain in her head and
behind her eyes. She had throbbing pain and nausea. She was first seen at an out-
side hospital and diagnosed with probable migraine. A head CT was negative and
she did not have a lumbar puncture. She was discharged and the pain gradually
decreased over the next 2 days and she was able to return to work. Then 4 days
later she again experienced another explosion in her head. She had mild photopho-
bia. She has a history of previous migraine. She does not recall any sympathomi-
metic use.

Moderate obesity None
Two pregnancies delivered by cesarean
section
Occasional codeine for headaches Cerebral aneurysm in a great aunt
Married with two children; no smoking, No prodromal illness
alcohol use

196 33 Case 33
Examination
Right eye: 20/20
Left eye: 20/20
Pupils
Equal and no RAPD
Right eye: 14 mmHg
Left eye: 14 mmHg
External exam
Unremarkable
Eye alignment
Normal
Normal
Visual field
Normal
Fundus examination
Normal
Normal
Blood pressure 116/75
Discussion
The sudden onset of the worst headache of one’s life is sometimes called a
“Thunderclap Headache”—and it usually makes every provider sit up and pay atten-
tion—since this is the typical headache of an ominous headache like a sub-arachnoid
hemorrhage. Indeed 70% of subarachoid hemorrhages from an aneurysm will pres-
ent this way. The key feature of these headaches are the pain develops in less than
1 min and it is very severe—usually resulting in going to an emergency room. There
is often photophobia and phonophobia as well as nausea and vomiting.
There are both primary and secondary thunderclap headaches. The definition of
a primary thunderclap headache by the ICHD 3 beta is that NO other cause is found
(see Table 33.1). This primary headache can be caused by cough (Case 29) or sexual
intercourse (sometimes called orgasmic headache). However, before making the
diagnosis, secondary causes must be evaluated. There are many serious causes of a
thunderclap headache besides sub-arachnoid hemorrhage. See Table 33.2 for a list
of primary and secondary causes of thunderclap headache. Looking for a secondary
cause for thunderclap is essential and headaches must be thoroughly evaluated with
imaging of the brain (usually a CT) and vessel imaging—CTA or MRA. In addition,
a lumbar puncture must be done to look for sub-arachnoid hemorrhage. Most of the
time, many of the causes will be seen on CT or MR scan.
In this case, the CT scan was initially normal, and the severe headache recurred
4 days later. This pattern of the recurrent thunderclap headache repetitively r ecurring
Discussion 197
Table 33.1 Diagnostic criteria for Primary thunderclap headache (by ICHD3 beta)
(A) Severe head pain fulfilling criteria B and C
(B) Abrupt onset, reaching maximum intensity in <1 min
(C) Lasting for more than 5 min
Table 33.2 Causes of thunderclap headache

Primary thunderclap headache:
Benign Exertional headache
Cough headache
Exertional headache
Orgasmic headache
Secondary thunderclap headache:
Vascular causes:
Subarachnoid hemorrhage from an aneurysm
other non-aneurysmal subarachnoid hemorrhage causes:
Vertebral dissection
Cavernous angioma
Vasculitis
Amyloid angiopathy
Reversible vasoconstriction syndrome
Cerebrovenous sinus thrombosis
Intracerebral hemorrhage
Arterial dissection
Posterior reversible encephalopathy syndrome (PRES)
Reversible cerebral vasoconstriction syndrome (RCVS)
Pregnancy (usually post-partum)—and pregnancy complications
Migraine
Medications associated with RCVS:
Illicit drugs (like cocaine, marijuana, lysergic acid diethylamide LSD, amphetamines, ecstasy)
Sympathomimetic drugs (epinephrine, pseudoephedrine, diet pills)
Triptans (e.g. Sumatriptan,
Ergotamines
Bromocriptine
Serotoninergic drugs (e.g. sertraline, fluoxetine)
Immunosuppressant (cyclophosphamide, Tacrolimus, interferon alpha)
Blood products: (intravenous immunoglobulin IVIG, blood transfusion)
Others: Nicotine patches, oral contraceptives, ginseng, licorice, indomethacin
Swimming and bathing
Altitude
Tumors
Pituitary apoplexy
Colloid cyst of the third ventricle
Intracranial hypotension
Acute sinusitis—barotrauma
198 33 Case 33
is typical of reversible cerebral vasoconstriction syndrome (RCVS). RCVS occurs

usually in middle aged women, although all ages and sex occurs. These headaches
may be triggered by simple every day activities such as bathing, swimming, or
coughing. Frequently, the CT scan is initially normal. Most of these cases are
misdiagnosed as migraine as in our case. Vessel imaging early on can be negative,
and looking for risk factors in the history for the diagnosis is a good idea. The vessel
imaging can look a lot like vasculitis, but a vasculitis workup is usually negative and
the CSF in RCVS is usually near normal. Even more vexing is that vessel imaging
can be initially normal and repeated vessel imaging should be performed, if there
are repeated bouts or one of the risk factors. Making the correct diagnosis is often
difficult. First, ruling out a sub-arachnoid hemorrhage with a CT scan and also LP
is often done. In RCVS sometimes there can be small hemorrhages, but there is no
aneurysm on angiography. Treatment of RCVS is directed usually to the use of cal-
cium channel blockers such as verapamil or nimodipine treatment. Steroids may
worsen the condition but have been used on occasion. Occasionally blood pressure
may be elevated and may require treatment. While the outcome is usually excellent,
complications can occur including hemorrhage, seizures, and stroke-like symptoms
if not stroke. We really do not understand the cause of these reversible constric-
tions—and some have suggested abnormal vascular receptor sensitivity.
These patients have the “worst headache of their life” and the pain is very sudden onset.
For the most part these patients will not present to the ophthalmologist and one of our
ilk may never see a patient with RCVS. However, I do have some thoughts for the dif-
ferential of the patient with sudden severe eye pain and headache. Besides an aneurysm,
pituitary apoplexy can cause abrupt and severe headache and also cause ophthalmic
findings. Usually this occurs in the setting of a previously present (but often not known
about) pituitary adenoma. A bleed into the tumor or an infarction in the tumor leads to
sudden expansion. The pituitary gland sits below the chiasm and between the two cav-
ernous sinuses. If the tumor expands superiorly, then the patient can develop vision loss
in one or both eyes. If it expands laterally, then it may cause a unilateral or bilateral
third, fourth, and/or sixth nerve palsy. Since the pain is sudden onset, the patient should
get a scan no matter what and imaging will typically show a bleed into a large sellar
mass. The biggest thing is to scan patients with sudden and horrible headache.
Thunderclap headache is a type of eye/head pain that all primary care physicians
should know about. While primary headache (benign, primary thunderclap headache)
is the most common, these headaches require an extensive evaluation of imaging,
lumbar puncture, and vessel imaging. Look out for RCVS since this one can be caused
by many medications often used in general internal medicine and primary care.
Discussion 199
Follow-up
The CT scan was normal; Lumbar puncture: protein 38, glucose 61, 0 WBC, 60
RBC, normal opening pressure. She had an MR scan which was normal. She was
admitted and a re-read of the CT showed a very small subarachnoid hemorrhage on
the left parietal region. She underwent an angiogram which showed diffuse segmen-
tal narrowing of her arteries in the MCA and PCA distribution (Fig. 33.1). There
was no evidence of an aneurysm. Initially, she was thought to have a vasculitis, but
all laboratory studies were negative. A trial of prednisone was initiated, and her
headache subsided once again. She was diagnosed with RCVS or benign reversible
angiopathy (see Table 33.3). She was placed on verapamil with improvement of her
headache. She continued verapamil and baby aspirin without recurrence of her
thunderclap headache. Final Diagnosis: thunderclap headache due to Reversible
Vasoconstriction Syndrome.
Fig. 33.1 Sagittal CTA

source image shows
arteriolar “beading”
(arrow) consistent with
RCVS. With thanks to
Jennifer Majersik and
Adam DeHavenon for this
case
Table 33.3 Diagnostic criteria for the diagnosis of reversible vasoconstriction syndrome (RCVS)
(A) Any new headache fulfilling criterion C
(B) Reversible cerebral vasoconstriction syndrome (RCVS) has been diagnosed
(C) Evidence of causation demonstrated by at least one of the following:
1. Headache, with or without focal deficits and/or seizures, has led to angiography (with
“strings and beads” appearance) and diagnosis of RCVS
2. Headache has either or both of the following characteristics:
(a) Recurrent during 1 month, and with thunderclap onset
(b) Triggered by sexual activity, exertion, Valsalva maneuvers, emotion, bathing and/or
showering
3. No new significant headache occurs >1 month after onset
(D) Not better accounted for by another ICHD-3 diagnosis, and aneurysmal subarachnoid
hemorrhage has been excluded by appropriate investigations
200 33 Case 33
For Further Study
1. Calic Z, Cappelen-Smith C, Zagami AS. Reversible cerebral vasoconstriction syndrome. Intern

Med J. 2015;45(6):599–608.
2. Cheng YC, Kuo KH, Lai TH. A common cause of sudden and thunderclap headaches: revers-
ible cerebral vasoconstriction syndrome. J Headache Pain. 2014;15(1):13.
3. Ducros A, Wolff V. The typical thunderclap headache of reversible cerebral vasoconstriction
syndrome and its various triggers. Headache. 2016;56(4):657–73.
4. Mehdi A, Hajj-Ali RA. Reversible cerebral vasoconstriction syndrome: a comprehensive
update. Curr Pain Headache Rep. 2014;18(9):443.
5. Schwedt TJ. Thunderclap headache. Continuum (Minneap Minn). 2015;21(Headache):1058–71.
Part IV
Neurologic Disorders Causing Eye Pain:
Abnormal Eye or Neurologic Exam
Case 34
A 19-year-old Pakistani student studying statistics at a local university was trans-

ferred for work up for unexplained fevers and headaches. He developed neck pain
radiating to both eyes and fever off and on for 2–3 weeks. He was seen in the emer-
gency room and a lumbar puncture showed 162 white cells with 81% lymphocytes.
A protein was 82 mg/dl (15–45 mg/dl) and glucose was 36 mg/dl (50–80 mg/dl). He
was treated with ceftriaxone and underwent a complete work up for bacterial men-
ingitis and viral meningitis (including EBV, enterovirus, HIV, VZV, Rocky Mountain
spotted fever, Brucella, West Nile virus, eastern and western equine encephalitis).
His chest X-ray and abdominal CT were negative. He had a seizure and when he
awakened, he complained that he could not see. He was transferred to our hospital
with headaches, severe eye pain, and photophobia.

None None
Normally none None known
Statistic student at a university Fevers and myalgias
Originally from Pakistan

204 34 Case 34
Examination
Right eye: Bare LP
Left eye: Bare LP No Optokinetic Drum response
Pupils
4 mm BE in light; 6 mm in darkness No discernable RAPD but very sluggishly reactive pupils
Right eye: 12 mmHg
Left eye: 12 mmHg
External exam
Very slight ptosis left eye
Bilateral esotropia by Krimsky; unable to look completely laterally
Normal
Visual field
None appreciated
Fundus examination
Very slight pallor diffusely in both eyes
Somewhat lethargic; neck stiffness; cranial nerves otherwise normal. Decreased leg strength and
unable to stand. Deep tendon reflexes present but reduced
VEP
Not-recordable
Discussion
This man had a new persistent headache that did not stop, and while one might think
of new daily persistent headache, the patient has decreased vision, bilateral sixth
nerve palsies in the face of headaches, light sensitivity, neck pain, fevers, and an
abnormal CSF. This kind of presentation smacks of infection in an otherwise healthy
guy. And it really sounds like a kind of meningitis. Headache caused by meningitis
while not common occurs in 1–2% of patients presenting to an emergency room for
headache. It should not be surprising that meningitis can cause eye pain and/or
headache since the meninges are also supplied by the first division of the trigeminal
nerve. The pain is usually bilateral and of course may involve the entire head; neck
pain can be present since there is meningeal inflammation around the nerve roots. In
bacterial meningitis, the headache can progress rapidly to the worst headache of a
person’s life, or in chronic meningitis or aseptic meningitis, the pain may be insidi-
ous and gradually develop. Photophobia, phonophobia, nausea, and vomiting may
accompany the headache, making differentiating the pain from migraine difficult.
The most important thing is to get a history—and hearing about a new headache,
fever, and neck stiffness tips you off to the diagnosis of meningitis.
Our patient’s initial evaluation was completely negative, and the outside hospital
rightly started antibacterial agents, but the CSF findings are really what we would
Discussion 205
consider an aseptic meningitis—since there are only a moderate number of white

cells and only somewhat low glucose. The differential diagnosis includes infections
such as herpes simplex virus type 2, herpesvirus type 6, varicella-zoster virus
(VZV), enterovirus, Epstein-Barr virus, arbovirus, mycoplasma pneumonia,
Borrelia burgdorferi (Lyme), Treponema pallidum (syphilis) cryptococcus neofo-
mans, tuberculosis, and coccidiomycosis. Viral meningitis occurs more frequently
in children or young adults and frequently in the spring or fall.
There are also non-infectious etiologies of aseptic meningitis including sarcoidsis,
leptomeningeal carcinomatosis, Behcet’s disease and even medications (trimethoprim
sulfamethoxazole, sulfasalazine, intravenous gamma globulin (IVIG), and some of
the monoclonal antibodies). There is even a recurrent form of aseptic meningitis not
precipitated by drugs called Mollaret’s meningitis—which can present with recurrent
chronic headache. Tuberculous meningitis is one of the most difficult to diagnose
since it often has an insidious onset. It is one of the most common causes of menin-
gitis worldwide. It is not associated with pulmonary tuberculosis in over half of the
cases. Because it causes intense inflammation and thick purulent exudate that has a
predilection to the base of the brain, cranial neuropathies are common. Complications
include hydrocephalus and brain ischemia from a vasculitis of the blood vessels.
Cranial nerve palsies can be present in meningitis with sixth nerve involvement being
most likely. Optic neuropathy can occur in tuberculosis due to an arachnoiditis of the
optic nerve and chiasm from inflammation of the basal meninges.
The work-up of the cerebrospinal fluid in aseptic meningitis includes: viral cul-
tures, PCR for enterovirus, HSV2, HHV6, VZV, EBV, HIV1 RNA, Virus-specific
IgM antibody, India ink and fungal culture, Cryptococcal antigen, Coccidiomycosis
immitis complement fixation, Histoplasma polysaccharide antigen, VDRL, FTA-
ABS, and anti-Borrelia Burgdorferi antibodies. For tuberculosis diagnosis ordering
a PCR for M tuberculosis is very specific, but can be lower in sensitivity. Other tests
include chest X-ray, or intradermal tuberculin skin test, Quantifreron gold testing,
and neuro-imaging.
Treatment of the meningitis really depends on the diagnosis since antivirals are
frequently given for some of the viral meningitides, and steroids for sarcoidosis and
Behcet’s. Tuberculous meningitis is usually treated with Isoniazid, pyrazinamide,
Rifampin, Streptomycin, and ethambutol. Steroid treatment of tuberculous meningi-
tis is begun if the patient has hydrocephalus, or other signs of vasculitis, and the
World Health Organization does recommend corticosteroids to reduce death and dis-
ability. The level of consciousness often determines the prognosis—meaning that if
treatment is started before the person becomes comatose, then the outcome is good.
This patient could have visited the ophthalmologist first with bilateral eye pain and
neck pain instead of the ER. The presence of fevers along with the neck pain may
have prompted neuroimaging or a referral to the ER. It depends on how well the
ophthalmologist takes a history or the patient complains of stiff neck. Let us sup-
pose that the patient had no visual complaints and the eye exam were normal.
206 34 Case 34
Studies show that getting neuroimaging with a normal eye exam and eye pain is low
yield. Since he did not go to the ophthalmologist before his visual loss, we do not
know if he had eye findings that may have tipped us off. The patient did not have
visual complaints or double vision prior to his seizure. He may have had subacute
acuity, color vision loss, or visual field loss that could have been picked up as an
optic neuropathy. The optic nerve pallor, if present, may have prompted neuroimag-
ing, which would have identified the leptomeningeal enhancement.
Besides ophthalmoplegia and optic atrophy, there were no other eye findings
present on this patient’s examination. However, there are some other things to con-
sider ophthalmologically speaking in meningitis. The most common infectious
causes of simultaneous ocular and meningeal infections include cat scratch, syphi-
lis, tuberculosis, and Lyme. Cat scratch may show a neuroretinitis and uveitis.
Syphilis, Lyme, and TB can cause just about any inflammatory lesion of the eye
including iritis, vitritis, retinal or choroidal lesions, and orbital inflammation (same
with sarcoid!). Fungal infections may present with an endophthalmitis picture or
varying degrees of chorioretinal whitening. Papilledema from increased intracranial
pressure may occur from Lyme, Cryptococcus, carcinomatous meningitis, viral
meningitides, or Brucellosis among others. In some cases, patients may present
with predominantly ocular findings but may have meningeal signs and symptoms
that lead to the diagnosis.
The triad of headache, fever, and stiff neck should ring a bell for meningitis in all
primary care providers and emergency room specialists. The usual work up is to get
the history to see if it can be determined what type of meningitis. When someone is
really acutely ill, suspect bacterial meningitis. Often starting antibacterials and then
getting imaging (usually CT) is the immediate work-up. Examination of the cere-
brospinal fluid is essential. Opening pressure is often elevated in meningitis. If there
is a major increased in white cells, particularly polymorphonuclear cells and a low
glucose—think bacterial meningitis. If there is elevated mononuclear cells and low
glucose think about mycobacterial, fungal, syphilis, and carcinomatous meningitis.
If there are atypical lymphocytes think about viral meningitis. Treatment of acute
bacterial meningitis includes Vancomycin 15 mg/kg IV every 6 h and Cefriaxone
2 g every 12 h or Cefotaximine 2 g IV every 8 h. If herpes virus encephalitis/men-
ingitis is suspected consider Acyclovir 10–15 mg every 8 h.
Follow-up
Imaging revealed multiple areas of leptomeningeal enhancement and signal abnor-

mality predominantly about the right temporal lobe, frontal lobe and occipital lobe,
without distinct nodularity (Fig. 34.1). These findings were concerning for an
Fig. 34.1 Axial T1

postgadolinium MRI
shows leptomeningeal
enhancement (red arrows)
and enhancement in the
interpeduncular cistern
(white arrow)
unusual leptomeningeal infection, neoplastic processes with CSF spread of tumor,

lymphoma versus sarcoidosis. Quantiferon Gold TB was positive. AFB culture was
positive. A PCR for mycobacterium tuberculosis was positive on CSF. He was
begun on rifampin 600 mg each day, ethambutol 1000 mg each day for 2 months,
and isoniazid 300 mg each day, pryridoxine 50 mg each day. During the hospitaliza-
tion, he was also treated with IV solumedrol and then switched to prednisone taper.
He was continued on Keppra for seizure protection. The IV antibiotics were discon-
tinued. He was followed for several years and his vision eventually improved to
6/200 OD, 20/500 OS, and 20/300 using both eyes. His pupils remained sluggishly
reactive and he had finger counting fields superiorly and hand motions inferiorly.
He had visual rehabilitation and was able to finish university. His headaches and eye
pain eventually resolved when the meningitis was controlled. Final diagnosis:
tuberculous meningitis.
For Further Study
1. Davis LE, Katzman JG. Chronic daily headache: when to suspect meningitis. Curr Pain
Headache Rep. 2008;12(1):50–5.
2. Garg RK. Tuberculous meningitis. Acta Neurol Scand. 2010;122(2):75–90.
3. Roos KL. Mycobacterium tuberculosis meningitis and other etiologies of the aseptic meningi-
tis syndrome. Semin Neurol. 2000;20(3):329–35.
4. Zunt JR, Baldwin KJ. Chronic and subacute meningitis. Continuum (Minneap Minn).
2012;18(6 infectious disease):1290–318.
Case 35
A 20-year-old male restaurant worker was referred for eye pain associated with
visual loss. Two weeks before he was seen he noted the he had some left eye pain
with eye movements or rubbing his eye. The eye feels sore, and he has stabbing
pains as well. About a week ago, he developed mild blurred vision. He has not
noticed any other weakness, numbness, or other symptoms. He does travel and was
recently in India.

None None
None Mother with depression
Maternal grandfather with cancer
Smokes rare; also rare alcohol Negative
Works in a restaurant
He is single and travels a lot
Examination
Right eye: 20/20
Left eye: 20/60
Pupils
Equal, but with a 1.9 log unit relative afferent pupillary defect on the left
Color vision (HRR plates)
9/9 OD and 4/9 OS
Right eye: 12 mmHg
Left eye: 12 mmHg
External exam
Normal

210 35 Case 35
Eye alignment
Normal
Normal
Visual field
Dense temporal defect OS (see original and follow-up visual fields, Fig. 35.1)
Fundus examination
Normal appearing optic nerves; normal retina
Normal
OCT
Mildly reduced nerve fiber layer inferiorly
Fig. 35.1 Visual field at onset (top) showed a dense temporal defect, which at 3 months (bottom)
improved greatly
Discussion 211
a b
Fig. 35.2 (a) Coronal postgadolinium T1 shows subtle enhancement of the left optic nerve.
(b) There was an enhancing ring-like lesion (arrow)
He underwent an MRI showing optic nerve brightness on STIR imaging and also
enhancement (Fig. 35.2a) and multiple white matter lesions signal on FLAIR imag-
ing as well as a enhancing ring-like lesion (Fig. 35.2b).
Discussion
Any young (20–45 years old) adult presenting with reduced vision and eye pain
(especially with eye movement) is suspicious for optic neuritis. Optic neuritis is
most frequently seen with multiple sclerosis. The hallmark signs are reduced vision,
the presence of a relative afferent pupillary defect (provided that the visual loss is
unilateral), and frequently a normal appearing fundus. The old adage: the patient
looks out and sees nothing from the eye, and the examiner sees nothing wrong,
holds in optic neuritis. The disc usually appears normal, but in about one-third of
cases there may be swelling. The reduction in color vision in the eye with the neu-
ritis is also classic for the diagnosis of optic neuritis. Mimics of optic neuritis exist
including neuromyelitis optica, sarcoid optic neuropathy, which may or may not be
painful; anterior ischemic optic neuropathy and Leber’s hereditary optic neuropathy
usually present with disc swelling and are generally not painful.
The eye pain with optic neuritis is mild to moderate. Severe pain, while it can
occur, is atypical, especially if it awakens the patient at night. Pain is most common
when the orbital optic nerve is involved as in this case. Some believe the eye pain to
be related to where the muscles insert in the posterior orbit.
The evaluation of optic neuritis includes imaging—MR scan with gadolinium. In
this case the optic nerve enhanced along the entire optic nerve. Sometimes there is
212 35 Case 35
no optic nerve enhancement. The brain imaging is also critical since finding even
one lesion on MR increases the likelihood of MS to 75% in 15 years. A lumbar
puncture may be helpful. Doing protein, glucose, cells, and oligoclonal bands can
be helpful if the presentation is unusual or if there is some concern about the MR
appearance such as in this case. We did not do a visually evoked potential since we
were sure he had an optic neuropathy.
The Optic Neuritis Treatment Trial taught us that an extensive blood battery is
not necessary, unless there are other factors that could be present. In this case our
patient had traveled frequently to other countries, most recently India, so we did do
a CSF examination. We would consider CBC, ESR, NMO IgG, Quantiferon Gold,
RPR, and toxoplasmosis IgG/IgM, and Chest CT. Our biggest concern was possible
Tuberculosis because of the travel to India or toxoplasmosis because of the ring-
enhancing lesion.
I would also be a bit concerned about Cryptococcus given the ring-enhancing lesion
and travel to India. This can be assessed on his spinal fluid. It is a rare cause of an
infectious optic neuropathy and is much more common in the southern US, South
America, and Africa. If it were to come back positive, then I would also assess him
for HIV. Patients with long segments of optic nerve enhancement are concerning for
neuromyelitis optica. I would ask him about intractable hiccups or vomiting (yes,
this is part of the diagnostic criteria for NMO!!). If his vision does not improve like
typical optic neuritis, then I would consider imaging his spinal cord for long (> 3
vertebral segments) lesions.
In follow-up, we expect his vision to improve with typical optic neuritis with or
without IV steroids. He may develop Uhthoff phenomenon – when he gets hot or
exercises, his vision may decline in the affected eye for 20–60 min. This does not
cause further damage to the eye and does not represent a recurrence. This can occur
with any optic nerve injury but is much more common with optic neuritis. Lastly, in
many cases, the optic neuritis may be idiopathic and unrelated to multiple sclerosis.
The risk of recurrence is approximately 33%.
Individuals presenting with eye pain and visual loss in primary care without any
finding except for an RAPD should lead the practitioner to consider optic neuritis. If
referral to an ophthalmologist, neurologist, or neuro-ophthalmologist cannot occur
in a timely fashion, then one may consider ordering an orbital MRI with gadolinium
and fat suppression. Patients with optic neuritis have an enhancing optic nerve in
over 90% of cases. If the MRI shows white matter lesions consistent with demyelin-
ating disease, then consider referral to neurology to treat for multiple sclerosis.
Follow-up
His workup was negative except for oligoclonal bands in his spinal fluid. After the
above studies, we diagnosed him with multiple sclerosis and treated him with intra-
venous steroids, 1 gram IV for 3 days with a short taper. The treatment of optic
neuritis with intravenous steroids has been accepted to hasten recovery of the optic
neuritis and perhaps delay for a while the onset of clinically symptomatic multiple
sclerosis. It does not improve the visual or visual field outcome. It does help the eye
pain in most cases. As is typical for most optic neuritis his vision cleared to 20/20
and his nerve showed pallor in about 6 weeks. He was referred to the neurology
service and was placed on glatiramer acetate (Copaxone). They are following his
imaging. Final diagnosis: optic neuritis.
For Further Study
1. Fazzone HE, Lefton DR, Kupersmith MJ. Optic neuritis: correlation of pain and magnetic
resonance imaging. Ophthalmology. 2003;110(8):1646–9.
2. Lepore FE. The origin of pain in optic neuritis. Determinants of pain in 101 eyes with optic
neuritis. Arch Neurol. 1991;48(7):748–9.
3. Mackay DD. Should patients with optic neuritis be treated with steroids? Curr Opin Ophthalmol.
2015;26(6):439–44.
4. Toosy AT, Mason DF, Miller DH. Optic neuritis. Lancet Neurol. 2014;13(1):83–99.
Case 36
A 28-year-old woman was referred for eye pain and headaches. She had been to the
emergency room in 3 different hospitals for headache and eye pain. Each time she
was treated with a migraine cocktail without success. She was referred now for a
dilated examination to look for papilledema. She had a family history of migraine,
and she herself had occasional migraines. However, this headache and eye pain
started rather abruptly and she thinks it is different than her migraines. She has some
pain with eye movement and a pressure feeling behind her eyes. The headache is
holocranial with pain into her neck and between her shoulder blades. She occasion-
ally has a whooshing noise in her head—especially at night when it is quiet.

Hypothyroidism Tonsillectomy at age 8
Obesity
Multiple vitamin Mother has migraine
Synthroid
She does not smoke or drink Trouble sleeping at night

216 36 Case 36
Examination
Right eye: 20/20
Left eye: 20/20
Pupils
Equal pupils, No Relative afferent pupillary defect
Right eye: 15 mmHg
Left eye: 15 mmHg
External exam
Normal
Eye alignment
Normal
Normal
Visual field
Normal to confrontation; Formal visual fields show enlarged blindspot and scattered defects
Fundus examination
Bilateral optic disc swelling
BMI is 45
Normal neurological
Discussion
This young woman has a change in her headache and has eye pain. What is more, she
has been to the emergency room three times for help and no one bothered to look at
her optic discs. I have seen this frequently, in fact, if I hear someone has been to the
emergency room several times with a headache or eye pain that does not go away, I
immediately consider increased intracranial pressure and idiopathic intracranial
hypertension (IIH). Neurologists often miss papilledema since they are not comfort-
able using an ophthalmoscope and they rarely dilate the patient. Another problem is
overdiagnosing IIH especially if someone has anomalous optic discs and headache.
Of course with papilledema, one first has to consider other causes of intracranial
hypertension and I would order an MRI and MRV or CTV. The MR can be helpful
since it may show signs of increased intracranial pressure as well. These include: an
empty sella, dilated optic nerve sheaths, flattening of the posterior globe, and often
dilated spaces around the foramen ovale as well as Meckel’s cave. It also will exclude
a mass lesion. The venogram is also critical since individuals with venous thrombo-
sis can present identically to the primary or idiopathic intracranial pressure; the
treatment of venous sinus thrombosis is different and therefore important to exclude.
After imaging, a lumbar puncture, measuring the opening pressure is important
as well as checking the fluid to be sure there is no evidence of meningitis. The open-
ing pressure is also important to measure correctly—usually in the lateral decubitus
Discussion 217
Table 36.1 IIH headache according to the ICHD3 beta

Headache caused by idiopathic intracranial hypertension (IIH), usually accompanied by other
symptoms and/or clinical signs of IIH. It remits after normalization of cerebrospinal fluid
pressure
(A) Any headache fulfilling criterion C
(B) Idiopathic intracranial hypertension (IIH) has been diagnosed, with CSF pressure >250 mm
CSF (measured by lumbar puncture performed in the lateral decubitus position, without
sedative medications, or by epidural or intraventricular monitoring)
(C) Evidence of causation demonstrated by at least two of the following:
1. Headache has developed in temporal relation to IIH, or led to its discovery
2. Headache is relieved by reducing intracranial hypertension
3. Headache is aggravated in temporal relation to increase in intracranial pressure
position with legs outstretched—being sure to have the patient relaxed and not hav-
ing a Valsalva maneuver.
Most neurologists do not have the capability of performing visual fields. It is
extremely important if someone has papilledema to get a formal visual field. Visual
acuity alone is not enough to follow these individuals. We get optic disc photos to
follow the papilledema and sometimes OCT is also helpful in order to see if the
swelling is decreasing.
To diagnose the headache associated with IIH see the ICHD 3beta (Table 36.1).
There are many interesting caveats about diagnosing IIH-related headache. First,
when papilledema is not present, can you still call it IIH if the pressure is only
mildly elevated? I see many patients with clear migraine and elevated pressures
being called IIH. I think IIH without papilledema is not common. I suggest that we
do not worship the opening pressure alone. Second, notice in the definition that the
headache leads to the discovery of the IIH—such as is in this case. Also, the finding
of the headache going away with the lumbar puncture is not 100% either. Many
individuals with migraine say that their headaches improve after lumbar puncture.
Treatment of IIH is usually weight loss—and this woman is obese. I recommend
five vegetables a day and walking 10,000 steps or swimming as exercise. For some,
a dietician is very helpful in setting up a weight loss program. We also use acetazol-
amide. The recently completed Idiopathic Intracranial Hypertension Treatment
Trial (IIHTT) showed that acetazolamide along with weight loss was more effica-
cious over weight loss alone.
Treating the eye pain and headache in IIH can really be a challenge, since just
lowering the pressure alone may not treat the headache and eye pain. The best treat-
ment for the headache is usually acetazolamide and a migraine preventative such as
topiramate, amitriptyline (although weight gain can occur with this), or other
migraine preventive. This woman also has a history of underlying migraine—indi-
viduals with IIH have a higher incidence of migraine (60%)—which is much higher
than in the general public (18% of women). The migraine headache can be treated
acutely with triptans or other migraine-specific medications.
218 36 Case 36
You can titrate the acetazolamide up to 4 g/day according to the IIHTT. If you are
not comfortable with that, then perhaps go up to 2.5 g/day (in divided doses). If that
does not help the eye or head pain, then I would send the patient to a neurologist to
help manage headache but the acuity, field, and nerves need to be monitored by an
ophthalmologist.
Generally, I do not advocate for a shunting procedure in patients with severe
headache alone. Although uncommon, there is risk to having a shunt, so I typically
reserve a shunt for those with moderate to severe visual loss. I have seen patients go
to a neurosurgeon for a shunt for the pulse synchronous tinnitus and headache
despite my protests.
In some cases, the patient complains of persistent headache despite the papill-
edema resolving. They insist that this is due to the intracranial pressure being high.
Sometimes, I will repeat the lumbar puncture to demonstrate to the patient that the
pressure is not high. In other cases, the patient is willing to visit a neurologist to
manage headache. I also have several patients who just want to stay on low-dose
acetazolamide. I do not have a problem with this, since we know that this was used
to treat glaucoma and has a reasonable safety profile over many years of treatment.
It also may help some people with migraine.
If a patient becomes pregnant, topiramate is contraindicated. Acetazolamide is
category C, but there have been a number of patients who have taken acetazolamide
while pregnant. We ask patients on acetazolamide to avoid pregnancy. If they
become pregnant, we may discuss stopping the medication for the first trimester or
staying on it. Finally, patients with a sulfa antibiotic allergy do not have cross reac-
tivity with sulfa diuretics, but anyone with an allergy to one medication may be
allergic to another.
Finding papilledema can be challenging for the primary care physician too. Dilating
the patient with 0.5% tropicamide is helpful in better seeing the optic disc. Recently
photographs with a non-mydriatic camera have helped primary care and emergency
room physicians see the optic discs better. There are also new phone apps and
devices that allow one to take a picture of the fundus.
If papilledema is seen—MR and MRV or CTV is important to order along with
a lumbar puncture. A primary care physician may be the best place to assist the
patient with weight loss strategies that are known to be helpful along with
acetazolamide.
Headache and eye pain with IIH is so common. Over 50% of patients with IIH
had previously diagnosed migraine headache. It is also the headache that causes a
reduced quality of life. So treating the migraine is really important in the treatment
of IIH.
a b
Fig. 36.1 (a) Axial T2 MRI shows evidence of increased intracranial pressure including flattened
posterior globe and dilated optic nerve sheaths (arrows). (b) Sagittal T1 MRI shows a partially
empty sella (arrow)
Follow-up
This woman had a normal MR and MRV except for an empty sella and other find-
ings of intracranial pressure (see Fig. 36.1). We started her on 500 mg acetazol-
amide twice daily and encouraged weight loss. Her most acute headache improved
after the lumbar puncture, and she now is followed with resolution of the papill-
edema, but her headaches persist. I have kept her on acetazolamide and topiramate.
That combination can cause lowered bicarbonate levels, tingling, taste changes, and
weight loss, but by and large it is well tolerated. If intolerable, then sodium bicar-
bonate 1300 mg twice daily can improve these side effects. Another consideration
is electrolyte replacement drinks. I follow electrolytes, which so far have been nor-
mal. Final diagnosis: idiopathic intracranial hypertension.
For Further Study
1. Fisayo A, Bruce BB, Newman NJ, Biousse V. Overdiagnosis of idiopathic intracranial hyper-
tension. Neurology. 2016;86:341–50.
2. NORDIC Idiopathic Intracranial Hypertension Study Group Writing Committee, Wall M,
McDermott MP, Kieburtz KD, Corbett JJ, Feldon SE, Friedman DI, Katz DM, Keltner JL,
Schron EB, Kupersmith MJ. Effect of acetazolamide on visual function in patients with idio-
pathic intracranial hypertension and mild visual loss: the idiopathic intracranial hypertension
treatment trial. JAMA. 2014;311(16):1641–51.
3. Friedman D, Quiros PA, Subramanian PS, Mejico LJ, Michael McDermott M, Wall and the
NORDIC IIHTT Study Group. Headache in Idiopathic intracranial hypertension: findings from
the Idiopathic intracranial hypertension treatment trial. Headache 2017;57:1195–205.
Case 37
A 51-year-old sheet metal worker developed photophobia and bilateral eye ache 2–3
months ago. The pain is constant, which she describes as 5 out of 10. The pain wors-
ens when she immerses herself in cold water. She states that the pain is localized to
the eyes and, overall, is not getting better or worse. Two weeks after the pain began,
her right eye became red. She denies tearing, discharge, or foreign body sensation.
She denies blurred vision, double vision, or ptosis. She does not wear contact lenses
and has been using Visine without improvement in the redness or pain. The redness
is worse upon awakening. She has heard a ringing in his left ear for the past month,
which is constant.

Steroid-responsive glaucoma (given for pink None
eye in the past)
Wears glasses
Artificial tears PRN Mother had brain cancer
Tetrahydrozoline (Visine) PRN Father had glaucoma but not severe
Works with sheet metal Per HPI
Social drinker
Has never smoked

222 37 Case 37
Examination
Right eye: 20/20
Left eye: 20/25
Pupils
Equal in size, Round shape, briskly reactive, no APD
Right eye: 23 mmHg
Left eye: 23 mmHg
External exam
No ptosis, 1 mm of proptosis RE, no eyelid edema
Motility and Eye alignment
Normal
RE: Normal cornea, large tortuous conjunctival vessels, no papillae or follicles. The vessels do
not blanch with neosynephrine (see Fig. 37.1a)
LE: normal
Visual field
Normal
Fundus examination
0.4 CDR RE/0.5 CDR LE
Normal
Otherwise unremarkable
Fig. 37.1 Color photos

show a red right eye. (a) a
Notice the corkscrew type
vessels typical of dural
cavernous fistulas. (b)
After treatment the redness
resolved
Discussion
Although her initial complaint was eye pain, I cannot ignore the red eye (I doubt this
is a red herring since it is ipsilateral to the pain). I will say that I have no idea why
her pain is worse when going under water. This story is not consistent with conjunc-
tivitis since there is no discharge or tearing. Additionally, the 2-month history is
Discussion 223
unusual for conjunctivitis (Case 13). Generally, the pain of scleritis gets worse over
time. She does not have any other stigmata of inflammation such as conjunctival
edema (chemosis), and she describes pain in both eyes but only her right eye is red.
Metal workers can get a metallic foreign body in their corneas, but her corneas were
clear. An intraocular foreign body typically causes a decline in vision and ipsilat-
eral, unilateral pain. It is not unusual to have 1 mm of relative proptosis in normal
individual but this may represent a real orbital finding.
I would like to know more about the ringing in her ear. Is it high-pitched or does
sound like rushing water that pulses with his heartbeat pulse synchronous tinnitus
(PST)? If you look closely at the redness, there are areas of relative “white” sclera
between the big red vessels, which are veins. Note also that these beefy veins start
at the limbus (junction of the cornea and conjunctiva). These are characteristic ves-
sels that we would see in a carotid cavernous (C-C) fistula.
C-C fistulas are abnormal connections between the carotid artery and the venous
flow in the cavernous sinus. There are two basic kinds of C-C fistula: high-flow and
low-flow. High-flow fistulas are usually traumatic and dramatic. The eye looks very
proptotic with dramatic eyelid edema, conjunctival edema, and proptosis. Basically, it
looks like the eye is popping out of the head, which is not the case here. Low-flow fis-
tulas typically present in elderly women and PST is common. If the venous flow is
toward the eye, then the patient gets arterialized conjunctival veins as seen here (if the
venous flow is more posterior, then the eye looks white and quiet). Some patients can
develop diplopia or facial pain from CN 3,4,5,6 involvement. Occasionally, patients
have a defect between cavernous sinuses and can develop bilateral findings despite a
unilateral fistula. The diagnosis is supported by a CT or MRI that shows enlargement
of the superior ophthalmic vein (SOV) but may require conventional catheter angiog-
raphy to confirm. I would start with a CT/CTV or an MRI/MRV to evaluate this patient.
I saw a case like this 2 days ago in my clinic, so I know these cases are not rare. First,
she is of the right sex and age. Individuals with the indirect fistulas are usually middle
or older aged women. The dull ache is really typical of these indirect dural fistulas. I do
not understand the worsening of pain with water either—unless cold water could cause
cold-induced headache. Sometimes having the patient bend over will make it worse.
Morning worsening is definitely a typical headache feature. See the ICHD 3 beta crite-
ria for dural arteriovenous fistula (Table 37.1). The cork-screw like vessels on the con-
junctivae either unilaterally or bilaterally are also really typical—and like this lady, they
do not blanch or go away with a topical sympathomimetic. The red did not come out
with Visine (which has a topical sympathomimetic). The elevated intraocular pressure
is also typical—and sometimes the pressure is high enough that it too requires therapy.
When fistulas are posteriorly draining into the petrosal sinuses, you do not see
the red eye, but can get facial numbness from trigeminal neuropathy, facial
weakness from a seventh nerve palsy, or diplopia from usually a third nerve palsy.
The posteriorly draining dural fistulas often cause a painful eye, but there will be no
224 37 Case 37
Table 37.1 ICHD 3 beta criteria for dural arteriovenous fistula

(B) A dural arteriovenous fistula (DAVF) has been diagnosed
1. Headache has developed in close temporal relation to other symptoms and/or clinical
signs of DAVF, or has led to the diagnosis of DAVF
(a) Headache has significantly worsened in parallel with other symptoms or clinical or
radiological signs of growth of the DAVF
(b) Headache has significantly improved after treatment of the DAVF
3. At least one of the following:
(a) Headache is accompanied by pulsatile tinnitus
(b) Headache is accompanied by ophthalmoplegia
(c) Headache is both progressive and worse in the morning and/or during coughing and/
or bending over
4. Headache is localized to the site of the DAVF
(D) Not better accounted for by another ICHD-3 diagnosis, and intracerebral hemorrhage and
cerebral venous thrombosis have been excluded by appropriate investigations
red eye. Risk factors to getting these fistula include: female sex, older individuals,
hypertension, and connective tissue disorders.
Besides getting MRI or CT with contrast, orbital color Doppler can be helpful
since it may detect the abnormal direction of flow. Occasionally angiography is
required to find the fistula since these fistulas can be made up of branches from the
internal or external carotid artery. We usually watch and admire if there are few
symptoms since 20–50% of these can close spontaneously. Air plane travel, using
the opposite hand to intermittently occlude the carotid artery on the side of the fis-
tula—in this case she would use her left hand to occlude her right artery—often will
assist in closure. She is not on anti-platelet therapy, but if she were, you could have
her stop it. If she chooses to observe, she should have her intraocular pressure fol-
lowed. Sometimes chemosis can progress and further treatment may be necessary.
These procedures include endovascular therapy (most common), direct surgery, and
radiotherapy. Rarely, these fistulas can recur.
Common things being common, history, and exam should help us rule out conjunc-
tivitis and foreign body (see above discussion). Intraocular inflammation is harder
to see unless you are facile with a slit lamp. Generally speaking, a 2–3 month his-
tory without worsening of pain or vision does not warrant an emergent consultation
no matter the cause. This particular kind of red eye is pattern recognition and if PST
is present, then the suspicion becomes very high. If you obtained a scan, then you
would direct the radiologist to look carefully at the SOV.
Fig. 37.2 Axial T1 MRI

shows a dilated and
tortuous right superior
ophthalmic vein (arrow)
Follow-up
The patient endorsed PST. MRI (Fig. 37.2) and MRV showed enlargement of the
right SOV and several atypical flow voids in the right cavernous sinus. Approximately
50% of low-flow fistulas can spontaneously resolve over a year, and observation is
reasonable in the absence of a defect or deficiency. Angiography may be required to
secure a diagnosis in some individuals and is also used to close fistulas. This patient
chose to undergo angiography and coiling. The redness and pain were gone at
6-week follow-up (Fig. 37.1b). Final diagnosis: Low-flow, Cavernous-carotid fis-
tula (dural cavernous fistula).
For Further Study
1. Miller NR. Dural carotid-cavernous fistulas: epidemiology, clinicalpresentation, and manage-

ment. Neurosurg Clin N Am. 2012;23(1):179–92.
2. Subramanian PS, Williams ZR. Arteriovenous malformations and carotid-cavernous fistulae.
Int Ophthalmol Clin. 2009;49(3):81–102.
Case 38
An 86-year-old man had a history of migraine with aura as a young man with infrequent
headache. He also had an episode of aura without headache every 2–3 months for the
last 20 years. However, about 2 weeks prior to being seen, he developed a severe, inca-
pacitating headache—over his left eye. The pain was boring, not throbbing, and he had
no light or sound sensitivity. While it is always there, sometimes the pain worsens 2–3
times in the day, and this can last 3–4 h. He is able to ignore it some of the time, espe-
cially if he is busy, but at night it keeps him from sleeping. He tried over the counter
ibuprofen and acetaminophen/aspirin/caffeine and he even tried some left over cafergot
(caffeine and ergotamine) combination with only modest success. His primary care phy-
sician ordered an MR scan which was normal and an ESR which was also normal. He
had left over hydrocodone from a previous surgery, and this provided temporary relief.

History of a right facial fracture after a fall 5 years ago Appendectomy years ago
Sinus infection 6 months prior to being seen Bilateral ptosis surgery
Asthma Cataract surgery
Basal cell cancer on face Skin biopsy and basal cell removal
Osteroporosis Family history
Arthritis No history of headache or migraine
Dry eyes Father had cancer
Aldendronate 70 Difficulty sleeping
Vitamin D Recent onset of fatigue
Diclofenac 75 Social history
Omeprazole 20 Married
Sumatriptan 100 prn Physician
Hydrocodone prn Non-smoker, non-drinker
Tobradex drops prn
Tears prn

228 38 Case 38
Examination
Right eye: 20/20
Left eye: 20/25
Pupils
2 mm BE in light, 4 mm BE in darkness, no RAPD
Right eye: 12 mmHg
Left eye: 12 mmHg
External exam
He had raised papules on his forehead over the left brow into the top of the hairline; he had mild
ptosis on the left and thickening of the eye lid on the left (Fig. 38.1)
Eye alignment
Normal
Chemosis of the sclera (mild)
Normal without cell or flare
Bilateral PCIOL
Visual field
Normal
Fundus examination
Normal
Normal; normal corneal reflex
Fig. 38.1 External color

photographs show small
vesicles in the left V1
frontal nerve distribution
and also the mild ptosis on
the left
Discussion 229
Discussion
The patient really has a new onset of headache over the left eye. While he has been
a migraine sufferer in the past, this does not sound like migraine—it has been daily
for 3 weeks and sometimes severe and he had no migrainous features (light and
sound sensitivity, nausea, or vomiting). A new headache in the elderly of course
should makes us think about temporal arteritis. His primary care checked a ESR and
CRP and these were normal. Imaging of the brain was appropriate in a new head-
ache in an older person, since he did have a history of sinus infection several months
before. The tip off that this was herpes zoster was the rash over the forehead in the
distribution of the first division of the trigeminal nerve. The boring pain is typical
and the pain is often precedes the rash—leading to an erroneous diagnoses.
Herpes Zoster affects about 30% of the population over a lifetime! This is NOT a
rare condition and when it occurs, 10–20% will have Zoster ophthalmicus. The virus
is a recurrence of viral particles that live in ganglia throughout the nervous system.
The typical headache associated with zoster involving the head includes: pain before
the eruption that is completely new for the individual, stabbing pain ipsilateral to the
eruption, and the pain interrupts sleep. See the criteria for the acute diagnosis
(Table 38.1). Frequently the pain is severe enough, that the individual has visited an
emergency room before the diagnosis. The pain is frequently misdiagnosed as
migraine, tension-type headache, dry eye, trigeminal neuralgia, and glaucoma.
Risk factors for developing herpes zoster ophthalmicus include age—with older
individuals being more susceptible, immune compromise, and pregnancy. An 85-year-
old has a 50% chance of having zoster twice in a life time. There is a prodrome before
Table 38.1 ICHD 3 beta criteria: Acute painful trigeminal neuropathy attributed to Herpes Zoster
(A) Unilateral head and/or facial pain lasting <3 months and fulfilling criterion C
(B) Either or both of the following:
1. Herpetic eruption has occurred in the territory of a trigeminal nerve branch or branches
2. Varicella zoster virus DNA has been detected in the CSF by polymerase chain reaction
(C) Evidence of causation demonstrated by both of the following:
1. Pain preceded the herpetic eruption by <7 days
2. Pain is located in the distribution of the same trigeminal nerve branch or branches
230 38 Case 38
Table 38.2 ICHD 3 beta: Post-herpetic trigeminal neuropathy

(A) Unilateral head and/or facial pain persisting or recurring for <3 months and fulfilling
criterion C
(B) History of acute Herpes zoster affecting a trigeminal nerve branch or branches
1. Pain developed in temporal relation to the acute Herpes zoster
2. Pain is located in the distribution of the same trigeminal nerve branch or branches
the rash appears in many. In some no rash ever appears. Herpes Zoster ophthalmicus
affects the trigeminal nerve (cranial nerve 5). There are three branches that can be
affected. In our patient, the first branch (frontal nerve) was affected. However, when
the nasociliary nerve is affected, sinuses, the skin over the nose, both eyelids, con-
junctiva, sclera can be affected. The tell-tale rash on the nose, Hutchinson’s sign,
alerts us to look carefully at the anterior segment and cornea for involvement.
The most frequent complication of herpes zoster ophthalmicus is post-herpetic
neuralgia—and this complication occurs in over 50% of older adults such as our
patient. Other neurologic complications are less rare, but can be serious including a
meningoencephalitis, cranial neuropathy, and even stroke. Systemic complications
include pneumonitis (which can be fatal) and hepatitis. Post-herpetic neuralgia is
also an unwelcome pain. The acute pain gradually gives way to a deep burning,
hypersensitivity, sometimes “crawling” pain with lancinating pains on top of that.
The amount of post-herpetic neuralgia can correlate with the severity of involve-
ment. The older the individual, often the worse the neuralgia can be. Suicide risk in
the elderly with chronic post-herpetic neuralgia is not rare. See the ICHD 3beta
criteria for post-herpetic neuralgia (Table 38.2).
Treatment of acute herpes Zoster ophthalmicus is with valacyclovir (1 g three
times daily) or famciclovir (500 mg three times daily) which are similarly effective
for 7 days if started within 3 days of the rash. Treatment with the antiviral agents
reduces zoster-related pain by half. Famciclovir is often used in individuals with
decreased renal clearance. Side effects are few, but can include more headache,
nausea, or gastrointestinal side effects.
Gabapentin (slowly escalating doses 300–1200 mg three times daily) given
acutely with the antiviral agents may reduce post-herpetic neuralgia. Other treat-
ments such as corticosteroids are not recommended due to side effects (develop-
ment of diabetes, hypertension, and glaucoma in the older individuals). Treatment
of post-herpetic neuralgia includes anticonvulsants like gabapentin (300–1200 mg
three times daily), or pregabalin (escalating doses to 300–600 mg each day); these
have been shown to be effective in randomized controlled trials. Lidocaine patches
and tricyclic antidepressants (e.g. amitriptyline or nortriptyline 25–100 mg at night)
have also been shown to be helpful. Opioid analgesics are often used for the acute
pain, but have many side effects especially in the elderly.
Discussion 231
Herpes zoster is most likely here because of the rash that respects the vertical mid-
line. Sometimes the pain precedes the rash and I agree that temporal arteritis is a
concern (Case 32) ESR and CRP are about 95–99% sensitive for GCA, so it drops
on the differential in this case. Another consideration is that sometimes skin cancers
can have a local reoccurrence and travel along the trigeminal nerve. This typically
causes pain and numbness. We are not told where the skin cancer was, but it would
be important to check facial sensation and inquire about the original location of the
basal cell carcinoma. The rash, however, would not be seen in skin cancer
recurrence.
I would also point out the importance of checking corneal sensation in HZO. A
numb cornea can lead to neurotrophic injury to the cornea along with corneal ulcer-
ation and scarring. Patients with a numb cornea should be followed by an ophthal-
mologist and instructed to seek care if their eye turns red. These patients may need
erythromycin ointment.
In some cases of HZO, the eyelid edema can be massive—so severe that the eye
is swollen shut. One may need to use retractors or a speculum for a good look at the
eye. Cool compresses and erythromycin ointment twice daily are reasonable for
conjunctival involvement. Corneal pseudodendrites can be managed with topical
ganciclovir three times daily. Topical prednisolone acetate four times daily is used
for stromal keratitis with a slow taper over months if no epithelial defect is present.
Treatment of uveitis with topical steroids and a cycloplegic agent are reasonable.
Some cases of uveitis may be associated with increased IOP and that may require
attention. Although HZO can cause a severe infection in the retina causing signifi-
cant vision loss, this typically is not associated with the skin rash. However, a dilated
eye examination is warranted to be sure the retina is not affected.
Herpes zoster is not a rare problem in primary care. Herpes zoster ophthalmicus is
also common. The main things to be concerned about are treating with antivirals as
above within 3 days of the rash. Watch the involvement of the eye—and if there is
chemosis, redness of the eye, or blurred vision, the patient should see an ophthal-
mologist. Treatment of post-herpetic neuralgia is very important.
Follow-up
We treated the patient with famciclovir 500 mg three times daily for 7 days. We also
started him on gabapentin 100 mg at night, increasing up to 300 mg three times
daily. At follow-up he was doing well. We typically keep patients on this for 2–3
232 38 Case 38
months until the sensations and pains have reduced. There are some whose post-
herpetic neuralgia require months-years of treatment. Final diagnosis: herpes zoster
ophthalmicus.
For Further Study
1. Kaufman SC. Anterior segment complications of Herpes Zoster ophthalmicus. Ophthalmology.

2008;115(2 Suppl):S24–32.
2. Lee HL, Yeo M, Choi GH, Lee JY, Kim JS, Shin DI, Lee SS, Lee SH. Clinical characteristics of
headache or facial pain prior to the development of acute herpes zoster of the head. Clin Neurol
Neurosurg. 2016;152:90–4.
3. Liesegang TJ. Herpes Zoster ophthalmicus: natural history, risk factors, clinical presentation,
and morbidity. Ophthalmology. 2008;115(2 Suppl):S3–S12.
4. Pavan-Langston D. Herpes zoster antivirals and pain management. Ophthalmology. 2008;115(2
Suppl):S13–20.
5. Tyring SK. Management of herpes zoster and postherpetic neuralgia. J Am Acad Dermatol.
2007;57(6 Suppl):S136–42.
Case 39
An 83-year-old man noted 3–4 months ago that he fell down, hit his head and after-
ward he could not open his right eye and could not move his right eye. An MRI at
that time was read as normal. This has not gotten better or worse as far as he can tell.
He has had headache behind his right eye for the past 2 months. The headache is
deep, boring, and constant. He rates it at a 6–7/10. Acetaminophen takes the edge
off. Nothing seems to make it worse or better. He denies ever having a headache in
his life before this. He denies a family history of migraine. He has lost 17# in the
past 6 months due to a poor appetite. He had a workup of a normal ESR and CRP
and a normal CT angiogram.

Mild dementia Cataract BE
Atrial fibrillation Retinal detachment LE 4 years ago
Squamous cell and basal carcinomas Multiple skin cancers removed
Hypertension Family history
Hyperlipidemia Unremarkable
Benign prostatic hypertrophy
Gastric reflux
Syncope
Glaucoma
Donepezil Hearing loss bilaterally
Finasteride Runny nose
HCTZ Poor memory
Ipratropium Social history
Latanoprost Retired from the military 25 years ago
Lisinopril Does not smoke
Metroprolol 1–2 drinks a day
Omeprazole
Simvastatin
Warfarin

234 39 Case 39
Examination
Right eye: 20/40
Left eye: 20/50
Pupils
RE unreactive to light or near, larger than left
APD LE
Right eye: 11 mmHg
Left eye: 14 mmHg
Color vision
All correct BE
External exam
Complete ptosis RE
Scar along right temple
Hertel: 20 mm BE
Eye alignmentand motility
Exotropic in primary gaze
Unable to elevate, adduct, or depress his right eye at all
No torsion with attempted downgaze
25% abduction deficit RE
LE normal
Intraocular lenses BE
Visual field
Altitudinal defect RE
Significant constriction LE
Fundus examination
Cupping LE ≫ RE
Corneal reflex absent
Discussion
This patient has multiple cranial neuropathies. The complete ptosis and complete
third nerve palsy are the biggest things here. However, he has a mild abduction defi-
cit in the RE. When a patient has a third nerve palsy, you can determine fourth nerve
function by having the patient look up and down. The eye should intort on down-
gaze if the fourth nerve is functioning properly. He has no torsion of the RE on
downgaze. The patient also has facial numbness in the right V1 distribution. So, to
summarize, he has right third, fourth, fifth, and sixth nerve dysfunction. These
nerves all hang out together in the cavernous sinus.
The patient’s ESR and CRP were negative arguing away from giant cell arteritis.
I would like to look carefully at his previous MRI. If this does not show an abnor-
mality, then I would likely repeat the scan with thin cuts through the right cavernous
sinus. He may have Tolosa Hunt Syndrome (Case 40), but usually that does not
Discussion 235
cause facial numbness. In this age group, I would be more concerned about a metas-
tasis. Also consider that patients with skin cancers on the face can develop perineu-
ral spread if the margins were not clean with resection. The cancer spreads along the
trigeminal nerve and causes numbness and/or pain. It can lead to an optic neuropa-
thy and/or CN III, IV, and VI dysfunction if it makes it to the orbital apex and cav-
ernous sinus. I would also look at V1 to see if it is enlarged or enhancing.
If there is an enhancing lesion in the cavernous sinus, one could consider steroid
treatment vs. biopsy. The danger of steroids is that you do not know what you are
treating and it may make it harder to identify lymphoma. A biopsy of the cavernous
sinus can be fairly invasive at this age. If there is a lesion of V1, then a more anterior
orbital biopsy can be considered.
Finally, as an aside, he has an APD in the LE. He has cupping of the optic nerves
LE ≫ RE consistent with asymmetric glaucoma. The color vision is normal, which
is what you would expect with glaucoma; whereas an optic neuropathy would typi-
cally show poor color vision. I do not think the APD is relevant to the other cranial
nerve palsies.
Here is another older person with a new headache and an abnormal examination—
this is worrisome. While we are told he has had a fall, his imaging is normal so we
know he probably does not have a subdural hematoma and since he is awake and
alert, he is not herniating—despite his pupil-involving third nerve palsy. He also has
numbness in the V1 distribution. One important point is pain plus numbness equals
something bad! For example the numb chin symptom is usually a sign of underlying
malignancy until proven otherwise.
We are told that he has had multiple skin cancers (both basal and squamous)
removed. This is an important historical point. Reviewing the previous MR would
be my first step—many times focusing the attention of the neuro-radiologist to the
area of interest is helpful. In this case, cranial nerves 3, 4, 5, and maybe 6 localizes
to the superior orbital fissure and cavernous sinus region. You may need to “run” the
nerves with the neuro-radiologist!
In general, perineural spread in skin cancer is through the fifth and seventh cranial
nerve since the skin has direct access to these nerves in the face and head. These
cancers can track along these nerves centrally via the orbit and superior orbital fis-
sure, foramen rotundum (V2) and foramen ovale (V3) where they gain access to other
cranial nerves such as in this case. Squamous cell is slightly more common in peri-
neural invasion than basal cell. Involvement of V or VII carries a worse prognosis.
While skin cancers can have perineural spread so can other tumors like adeno-
cystic carcinoma, lymphoma, and nasopharyngeal carcinomas. The differential
diagnosis in most cases other than cancer (for example metastasis) would be sarcoid
and infections (like mucormycosis). MR imaging with gadolinium is most impor-
tant. Treatment depends on the extent of infiltration and radiotherapy is usually
what is recommended.
236 39 Case 39
This patient was presumed to have a right, microvascular third nerve palsy. When it
did not improve in 3–4 months, he was sent for further evaluation. If someone had
checked facial sensation, then that would indicate that this is not an isolated third.
Additionally, his original MRI was described as normal, but maybe it is not. Not
everyone is comfortable looking at MRIs by themself, but a phone call to a radiolo-
gist asking him/her to take a closer look at the cranial nerves may have yielded a
diagnosis.
Follow-up
The MRI (Fig. 39.1) showed enlargement and enhancement of a right V1 branch of

the trigeminal nerve and also the right cavernous sinus. Biopsy of the branch showed
poorly differentiated adenocarcinoma from a primary lung or gastrointestinal can-
cer. Full body PET scan showed a hot spot in the colon. Colonoscopy with biopsy
was consistent with a colon adenocarcinoma but the immunohistochemical proper-
ties did not match! He was diagnosed with an orbital adenocarcinoma of unknown
etiology. He underwent cranial radiation and chemotherapy. There was no improve-
ment in his eye movements, but he continues to do well 4 years after diagnosis.
Final diagnosis: Metastatic adenocarcinoma to the cavernous sinus.
a b
Fig. 39.1 (a) Axial MRI shows widening of the right cavernous sinus compared to the left (arrow).
(b) Post-contrast Coronal T1 MRI shows enlargement and enhancement of the supraorbital nerve
(arrow). Note the displacement of the superior rectus inferiorly
For Further Study
1. Ableman TB, Newman SA. Perineural spread of head and neck cancer: ophthalmic consider-
ations. J Neurol Surg B Skull Base. 2016;77(2):131–9.
2. Moonis G, Cunnane MB, Emerick K, Curtin H. Patterns of perineural tumor spread in head and
neck cancer. Magn Reson Imaging Clin N Am. 2012;20(3):435–46.
3. Panizza B, Warren T. Perineural invasion of head and neck skin cancer: diagnostic and thera-
peutic implications. Curr Oncol Rep. 2013;15(2):128–33.
Case 40
A 36-year-old woman with no previous headache history developed a painful right

eye 5 weeks ago. The pain is a deep, boring ache (2/10) behind the right eye with
sharp, brief pains (5/10) intermittently. There was no tenderness or painful eye
movements. She denied photophobia, redness, discharge, vision loss, or double
vision. She went to an optometrist who diagnosed her with uveitis and gave her
steroid eye drops. One week later she developed diplopia and the records showed
she had a right abduction deficit and the uveitis was gone. No further testing was
performed. Two weeks after that, the optometrist recorded an exotropia. She states
that the diplopia is constant and does not fluctuate over the day. She thinks her
vision is blurry RE. She is not a native English speaker, and she is a poor historian.

Endometriosis Laparascopic salpingo-oophorectomy
Ovarian cyst
Loratadine Mother—some kind of eye degeneration, not
Ibuprofen blind
Artificial tears
A nun from Africa visiting for one year Seasonal allergies
No alcohol Trouble sleeping
No tobacco Poor appetite
Feels sadness and anxiety

240 40 Case 40
Examination
Right eye: 20/20
Left eye: 20/15
Color vision
Misses half a plate RE
Identifies all plates LE
Pupils
In bright light RE 4 mm, LE 3 mm
In dim light RE 5 mm, LE 4.5 mm
RE is sluggish, LE is brisk, no RAPD
Right eye: 20 mmHg
Left eye: 18 mmHg
External exam
1.5 mm ptosis RUL
2 mm relative proptosis RE
RE: 10% abduction, 10% elevation, 10% adduction, and 50% depression (saccades were
slowed)
LE: Normal
Normal
Visual field
Normal
Fundus examination
Normal
Normal including facial sensation
Discussion
I think it unlikely that she had uveitis. We will never know, but it seems unlikely
given the lack of photophobia, red eye, and the resolution in just 1 week. Additionally,
the pain did not resolve when the “uveitis” did. Instead, the pain was likely the ini-
tial symptom of the process picking off her right sixth nerve then her right third and
fourth nerves. She describes blurred vision RE. Her acuity is 20/20 RE and she
misses half a color plate with the RE but there is no APD. I do not think she has an
optic neuropathy at this point, but it could be the earliest manifestation of one. The
third, fourth, and sixth nerves run together in the cavernous sinus, the superior
orbital fissure, and the posterior orbit. See also Fig. 18.2 for a diagram of the cavern-
ous sinus, orbital fissure, and cranial nerves. The optic nerve meets them in the
posterior orbit. In either case, we need to evaluate the back of the orbit into the
cavernous sinus, and I would choose an MRI with gadolinium along with fat sup-
pressed imaging. The pain would make myasthenia unlikely. Although she has
Discussion 241
proptosis, this would be a very rapid course for thyroid eye disease (TED), which
also does not usually cause ptosis. Finally, the saccades were slowed suggesting a
neuropathic cause and not a restrictive process like TED (Case 14). There is an
entity discussed in Case 43 called ophthalmoplegic migraine but this almost always
occurs first under the age of 10. The pain and subacute progression here would sug-
gest an infectious, inflammatory, or neoplastic cause. We can wait for the MRI to
come back or order some basic inflammatory and infectious labs such as CBC, ESR,
ACE, ANA, Lyme, RPR (I know she is a nun, but I would still order), Serum IgG4,
Quantiferon gold (she is from Africa), C-ANCA.
This woman has painful ophthalmoplegia—pain around one eye associated with
partial cranial nerve 3, 4, and 6 dysfunction. She is young (less than 40) and has no
known malignancy or known infections. There is a huge differential of painful oph-
thalmoplegia (see Table 40.1). Imaging is the first step since many findings like
aneurysm, sinus disease, and tumors maybe seen. This person deserves evaluation
Table 40.1 Differential diagnosis of painful ophthalmoplegia (in part from Kline, Hoyt)
Trauma
Vascular
Carotid cavernous fistula or thrombosis (Case 37)
Aneurysm: intracavernous or internal carotid/posterior cerebral (Case 42)
Diabetic/ischemic third nerve palsy
Carotid dissection
Vasculitis: granulomatosis with polyangiitis (Wegener’s) (Case 15)
Giant cell arteritis (Case 32)
Neoplastic
Primary tumors: Pituitary, Meningioma, Neurofibroma, craniopharyngioma,
chordoma, and other(Case 41)
Metastases: nasopharyngeal, squamous cell, lymphoma, myeloma, carcinoma
(breast, prostate, lung), melanoma
Infections and Inflammation
Bacterial: sinus (Case 25)
Viral: Zoster (Case 38)
Fungal:Mucormycosis, aspergillosis
Spirochete: syphilis, Lyme
Mycobacterial: TB
IgG 4 disease
Orbital pseudotumor (Case 11)
Other
Sarcoid
Ophthalmoplegic Migraine (Case 43)
242 40 Case 40
Table 40.2 ICHD 3 beta Diagnostic criteria for Tolosa Hunt syndrome
(A) Unilateral headache fulfilling criterion C
(B) Both of the following:
1. Granulomatous inflammation of the cavernous sinus, superior orbital fissure or orbit,
demonstrated by MRI or biopsy
2. Paresis of one or more of the ipsilateral IIIrd, IVth, and/or VIth cranial nerves
1. Headache has preceded paresis of the IIIrd, IVth, and/or VIth nerves by _2 weeks, or
developed with it
2. Headache is localized around the ipsilateral brow and eye
as well not only the blood work that Dr. Lee ordered, but also consider a chest X-ray
and possibly cerebrospinal fluid evaluation looking for infections. She is from a
developing country and tuberculosis is very common. Sometimes, any lesion found
needs to be biopsied to rule out secondary causes of painful ophthalmoplegia.
Let us suppose that this work up is largely negative, we are left with the diagno-
sis of Tolosa Hunt disease. While Tolosa Hunt is usually a diagnosis of exclusion
of all of the things listed in Table 40.1, there are criteria to make the diagnosis (see
Table 40.2). This condition can present at any age from either gender. Usually pain
comes first (like in this case) followed by diplopia. The pain is often really severe—
and stabbing, burning, intense boring pain is the usual description. In addition, the
pain is around the eye, forehead, or temple. Any of the ocular motor nerves can be
involved in addition to the sympathetic and all three divisions of V and rarely the
facial nerve or optic nerve is involved. Imaging usually shows enhancement of the
cavernous sinus region and this often spreads beyond the sinus into the posterior
fossa.
Treatment is usually steroids and one of the real hallmarks of this disease is that
steroids really stop the pain. Sometimes as tapering occurs, the pain can recur
weeks, months, or years later. The dose for prednisone is variable—in children, it is
usually 1 mg/kg/day. In adults, it is usually 60 mg each day and then taper. Other
medications considered include methotrexate, infliximab, and rarely radiotherapy.
Hopefully you can diagnose multiple cranial neuropathies and localize them
based on the company they keep. I think a patient like this with diplopia, ptosis,
and pain will get an MRI from most physicians. However, I would just comment
that you should ask for fat-suppressed images and order contrast when you look
Discussion 243
at the orbit. Otherwise, the patient may be getting a second MRI! Given the com-
plexity of the situation, I do not think most primary care providers and neurolo-
gists would be comfortable with this patient and this patient should be seen by a
neuro-ophthalmologist.
Follow-up
Her MRI showed an enhancing lesion in the right cavernous sinus and right superior
orbital fissure (Fig. 40.1). This was not continguous with the paranasal sinuses. Her
lab workup was negative, and she was begun on prednisone 1 mg/kg/day for 7 days.
She enjoyed complete resolution of her pain and double vision, and repeat MRI was
not performed at that time. Two weeks later, she developed recurrent pain. MRI
showed no change to the lesion from the first MRI. Another course of prednisone
was begun reducing the daily dose by 10 mg every week for 8 weeks with resolution
of her pain. A third MRI showed a persistent enhancing lesion with partial interval
resolution of the lesion. A neurosurgical biopsy was planned; however the patient
Fig. 40.1 MR (T1, fat

desaturated with contrast)
Imaging shows
enhancement extending
from the right superior
orbital fissure, through the
cavernous sinus along the
posterior tentorium of the
petrous bone. This is a
typical appearance of
244 40 Case 40
was found to have an ovarian mass. She remained on 20 mg prednisone for the brain
lesion while her ovarian mass underwent biopsy. The mass proved to be benign, and
repeat MRI 2 months after the third MRI showed complete resolution of the lesion.
She was tapered off steroids and her symptoms did not return. Final Diagnosis:
Tolosa Hunt syndrome.
For Further Study
1. Gladstone JP. An approach to the patient with painful ophthalmoplegia, with a focus on Tolosa-
Hunt syndrome. Curr Pain Headache Rep. 2007;11(4):317–25.
3. Kline LB, Hoyt WF. The Tolosa-Hunt syndrome. J Neurol Neurosurg Psychiatry.
2001;71(5):577–82.
4. Pérez CA, Evangelista M. Evaluation and management of Tolosa-Hunt syndromein children: a
clinical update. Pediatr Neurol. 2016;62:18–26.
Case 41
A 60-year-old right-handed woman presented with bilateral eye pain. While she
used to get “stress headaches” off and on earlier in her life, these headaches were
dull, bi-frontal and temporal and behind her eyes. She noticed mild light sensitivity.
While ibuprofen dulls the headache and eye discomfort now, the headache/eye dis-
comfort continues daily. She thought she was having trouble with her glasses, and
saw her optometrist who found a normal exam. The blurring continued and she
noticed trouble with both horizontal and vertical diplopia with driving and reading.
She has had more fatigue. She saw her optometrist again and had a visual field
(Fig. 41.1) and she was referred for further evaluation.

Anemia (mild) Tonsilectomy
Osteoarthritis Cesarean section
Hypothyroidism
Wears glasses for reading
Dry eyes (mild)
Ibuprofen 200 mg every 4–6 h prn Daughter—migraine
Levothroxine Mother—arthritis, stroke, cancer, thyroid
Artificial tears Father—hypertension
Works as a chemist for a mining company Per HPI
Divorced with four children; no smoking but
occasional alcohol use

246 41 Case 41
Examination
Right eye: 20/70
Left eye: 20/40
Pupils
Equal with a 0.9 log unit RAPD in the right eye
Color vision (HRR)
1/6 OD and 3/6 OS
Stereo vision
No fly; 0/3 animals; 0/9 circles
Right eye: 12 mmHg
Left eye: 12 mmHg
External exam
Normal
Eye alignment
By Maddox rod she had one prism diopter Left hyper and two prism diopter of exophoria—
which was comitant in all directions
Normal except for mild bilateral nuclear sclerosis
Visual field
To confrontation: finger counting in all quadrants but red desaturations bitemporally. Formal
visual fields showed a bitemporal hemianopia (see Fig. 41.1)
Fundus examination
Cup to disc ratio 0.8 OD and 0.5 OS
Normal except for decreased vibration in the right big toe, and mild pronator drift in the right arm
30 30
Fig. 41.1 Visual fields show a bitemporal visual field defect

Discussion 247
Discussion
There were several clues in the history and examination that the eye pain to point to
the correct diagnosis. First, she had blurred vision that was not correctable with
refraction and she had reduced color vision testing and a bitemporal hemianopia to
confrontation with red colored balls. While she had mild nuclear sclerosis, this could
not account for the visual field defect, or the reduced color vision. Second, her com-
plaints of diplopia were associated with very mild abnormalities on Maddox Rod
testing and this could be the phenomenon of hemifield slide in which the visual fields
nasally can be affected by mild transient slips of a phoria or tropia which can cause
variable diplopia. Third, her eye discomfort and bitemporal headache was associated
with mild photophobia. Photophobia can be a presenting symptom of a pituitary
tumor, and a new headache in an older person should lead to further investigation. So
we are suspecting a lesion affecting the chiasm—perhaps a pituitary tumor.
The evaluation for a suspected pituitary tumor should be a dedicated MR of the
sella region with sagittal, coronal, and axial views. Blood studies are also helpful to
look for underlying endocrinologic findings: thyroid studies (T4 and Thyroid stimu-
lating hormone [TSH], prolactin, growth hormone, Luteinizing hormone, Follicular
stimulating hormone, testosterone). In our patient, her hormones were normal. So if
this is a tumor, this was a non-secretory pituitary tumor.
Treatment when vision is threatened is either surgical removal often through a
transphenoidal approach. If the tumor is not completely removed or if the vision is
not correctable, then directed radiation is considered. Often post-operatively, indi-
viduals require hormone replacement and are at risk for the development of diabetes
insipidus.
One of the dreaded complications of pituitary tumor is pituitary apoplexy or sud-
den bleed into a pituitary tumor. This is often heralded by a sudden onset of head-
ache/eye pain or visual loss or both.
The cause of the headache and eye pain is probably related to the tentorial inner-
vation (from branches off of V1) to the meninges and blood vessels around the sellar
region. While there are no guidelines for the treatment of headache and eye pain
related to pituitary tumors, non-steroidal anti-inflammatories such as naproxen
400–600 mg two to three times each day or meloxicam, diclofenac, or ibuprofen can
be helpful. Headache and eye pain can worsen post-operatively, not just because of
surgical changes, but fat packing that is generally used with the transsphenoidal
approach can transiently worsen compression on the tentorial nerves and increase
the pain and discomfort. This generally resolves within 1 month and one can uses
non-steroidal medication to treat as listed above.
248 41 Case 41
The prognosis is usually good for vision, especially if the optical coherence
tomography (OCT) is normal as was the case in this woman. The headache gener-
ally resolves after tumor removal.
In most cases, we focus on the patient’s chief complaint. The patient herein may
have significant eye pain and minimize the blurry vision or the double vision,
because this may be most concerning to her. Although this case seems straightfor-
ward, in an eye office, not all practitioners check color vision and pupils carefully.
So, maybe we miss the optic neuropathy. Personally, I believe that anyone with
uncorrectable visual acuity ought to undergo formal perimetry. It really tells you
whether the patient has true disease or maybe this is something benign like refrac-
tive error. It can also help localize vision loss as in this case.
The double vision here is a red herring. The comitant (same in all directions)
nature suggests that this is a pre-existing misalignment that is breaking down.
However, it might have led a physician to order an MRI and they would have found
a chiasmal lesion by “accident.”
A patient complaining of eye pain and blurred vision should have their visual acuity
checked in each eye separately. For confrontation visual fields, the patient covers
one eye and the examiner shows the patient two red objects in two different loca-
tions simultaneously and asks if they appear similar. The examiner can also hold up
different fingers in different quadrants and ask the patient to add them. If one finds
a reduced visual field in the temporal (toward the ear) hemifield in each eye, this
could suggest a chiasmal issue such as a pituitary tumor.
Follow-up
She had an MR scan which showed a large pituitary tumor compressing the right
optic nerve (Fig. 41.2). Our patient underwent tumor resection through a transphe-
noidal approach. Her vision gradually improved. Her headache worsened shortly
after surgery for a short while, but later improved. Final diagnosis: Eye pain sec-
ondary to a pituitary adenoma.
Fig. 41.2 Sagittal MRI

shows an enhancing sellar
mass extending into the
suprasellar space
For Further Study
1. Greenman Y, Stern N. Optimal management of non-functioning pituitary adenomas. Endocrine.

2015;50(1):51–5.
2. Kawasaki A, Purvin VA. Photophobia as the presenting visual symptom ofchiasmal compres-
sion. J Neuroophthalmol. 2002;22(1):3–8.
3. Lake MG, Krook LS, Cruz SV. Pituitary adenomas: an overview. Am Fam Physician.
2013;88(5):319–27.
Case 42
A 75-year-old retired administrative assistant with a history of cataracts and previ-

ous corneal erosion many years before was doing well until one day she noticed she
had a deep throbbing pain over her right eye and that her eye lid seemed droopy.
Within 2 weeks she was seeing double. She remembers a severe headache 2 weeks
before. She has a history of migraines all of her life, but recently she was getting
more headaches. She is worried, since things seem to be progressing—she was sent
for urgent evaluation by her ophthalmologist.

Hypertension None
Left bundle branch block
Hydrochlorothiazide 50 Father and mother heart disease and
Lopressor 50 hypertension
Potassium 20
Aspirin 625
Widowed with three children and now retired Dizziness

252 42 Case 42
Examination
Right eye: 20/50
Left eye: 20/40
Pupils
7.5 mm OD in darkness to 7.0 mm OD light
5.5 mm OS in darkness 4.5 mm OS light
Near 7 mm OD and 3 mm OS
NO RAPD by reverse technique
Right eye: 15 mmHg
Left eye: 15 mmHg
External exam
3 mm Ptosis OD
Eye alignment
Limited elevation and adduction-3 and depression-2. Good abduction (see Fig. 42.1); she has 25
diopters of right exotropia and eight diopters of hypotropia
Conjunctiva 1 + injection OU; 1 + nuclear sclerosis OD, and 1 + posterior subcapsular cataract OD
Visual field
Normal
Fundus examination
Normal
Aside from eye findings she was normal
Fig. 42.1 These were her cardinal positions of gaze. Note, that we had to raise her lid to get these
photos. The findings were typical for a pupil involving, third nerve palsy
Discussion 253
Discussion
When a person over 60 starts having new headaches, diplopia, and ptosis—you have
to pay attention! First, she had a previous headache 2 weeks ago, and you have to
find out what happened with that. Also careful query about other constitutional
symptoms (fatigue, pain with chewing her food)—looking for giant cell arteritis.
The ptosis and diplopia could be a symptom of ocular myasthenia, but there is
pain—and that is not myasthenia. The new pain with ptosis, a slightly larger pupil
on the right, and a pattern of a third nerve palsy is really disturbing.
In evaluation, the first step would be emergent imaging—MR scan and MRA to
rule out a mass lesion or aneurysm as well as ESR and CRP (since a painful third
could also be giant cell arteritis) (Case 32).
Aneurysms—especially posterior communicating (PComm) aneurysm com-
pressing the third nerve are one of the most feared causes of a new onset headache
and a third nerve palsy especially with pupil involvement such as is in this case.
Failure to diagnose correctly can lead to a deadly outcome. Sometimes the symp-
toms are vague and not easy to diagnose, and sometimes the symptoms are sudden
onset of a severe headache related to a sub-arachnoid hemorrhage. A sentinel head-
ache, like the headache she had 2 weeks before can be a warning of an aneurysm.
When thinking of thunderclap headache (Case 33), it is worth remembering that
aneurysm is one of the feared causes along with reversible vasoconstriction syn-
drome, arterial dissection, and venous thrombosis among others. The sentinel head-
ache can occur without evidence of a bleed. Headaches commonly occur with both
ruptured and non-ruptured aneurysm. The ICHD 3beta criteria for headache with
saccular aneurysm are in Table 42.1.
Table 42.1 Headache attributed to unruptured saccular aneurysm

(B) An unruptured saccular aneurysm has been diagnosed
1. Headache has developed in close temporal relation to other symptoms and/or clinical
signs of unruptured saccular aneurysm, or has led to its diagnosis
(a) Headache has significantly worsened in parallel with other symptoms or clinical or
radiological signs of growth of the saccular aneurysm
(b) Headache has resolved after treatment of the saccular aneurysm
(a) Headache has sudden or thunderclap onset
(b) Headache is associated with a painful IIIrd nerve palsy
(D) Not better accounted for by another ICHD-3 diagnosis, and intracranial hemorrhage and
reversible cerebral vasoconstriction syndrome have been excluded by appropriate
investigations
Classification of Headache Disorders: 3rd edition (beta version). Cephalalgia. 2013;33:629-808
254 42 Case 42
While aneurysms may lie dormant for years and never rupture, risk factors for
rupture of aneurysms include: female sex (check), age (check), hypertension (check)
aneurysm size (over 7 mm), and location. The most common symptom of an unrup-
tured aneurysm is headache, sometimes stroke like symptoms, and cranial neuropa-
thy. The most common symptom of a ruptured aneurysm is sudden onset of headache
with nausea and photophobia (symptoms of dural irritation), followed by change in
mental status and possibly abnormal neurological examination.
Third nerve palsy (TNP) is the most common cranial neuropathy seen with an
aneurysm followed by other cranial nerve palsies such as a fourth, sixth, fifth (first
and second division). The pain involved in this TNP comes from small first division
twigs innervating the third nerve—so eye pain occurs in association with the third
nerve compression from aneurysm in over a quarter of the cases.
Some of the causes of misdiagnosis include: diagnosing a primary headache
(thunderclap or migraine), diagnosing stroke (if there are neurological deficits),
diagnosing meningitis or infection if there is fever, or microvascular cranial neu-
ropathy (Case 18).
Evaluation should proceed with imaging: CT to look for acute blood and CTA for
an aneurysm or MR (acutely blood may not show up) and MRA. When an aneurysm
is detected, the size is very important, since as the size increases so does the risk of
hemorrhage. For example, aneurysms in the anterior circulation less than 6–7 mm are
considered incidental and often not treated since the risk of bleeding is so rare. Whereas
larger ones or ones found in the posterior circulation have a greater risk of bleeding.
Occasionally, digital subtraction angiography is needed to adequately define the
aneurysm before clipping. However, when an aneurysm is symptomatic like in our
case, it will require emergent treatment—with either clipping or coiling.
What happens to the pain and to the TNP after treatment? Guresir et al found that
clipping brought greater resolution to the TNP than coiling (complete improvement
55% compared to 32% and partial improvement 92% vs 74%). Others have found
90% improve no matter what the treatment. The pain generally resolves after treat-
ment, but I have seen post-clipping pain continue—usually behind the eye or on the
ipsilateral side of the head. Anti-inflammatories or anticonvulsants such as gabapen-
tin can be very helpful.
The rule of thumb is that a TNP is an aneurysm until proven otherwise. Sometimes,
as Dr. Digre points out, the TNP can be very subtle. In any patient with ptosis, I look
to see if there is anisocoria. If a bigger pupil is on the same side as ptosis, then I am
concerned about a TNP. If it is smaller on the same side of ptosis, then I am worried
about Horner syndrome (Case 17). If the patient with ptosis does not complain of
double vision, I have the patient look up to see if I observe limited elevation and I
ask the patient if they see double in upgaze. Generally, patients with diplopia only
in upgaze do not notice it, because we do not look up that often in daily life. In many
ophthalmic practices, a technician checks eye movements and pupils then dilates
Discussion 255
the patient, so it is critical to instruct your staff about this scenario. Lastly, I would
not be concerned if the patient has isolated ptosis (without anisocoria or ophthal-
moplegia) or has an isolated large pupil. However, if the eye movements are consis-
tent with a partial TNP then it is important to rule out aneurysm.
There was a super interesting and scary paper about underdiagnosis of PComm
aneurysms causing TNP. It turns out that patients underwent good CTA or MRA,
which showed the aneurysm but the aneurysms were missed. The reason…either a
neuroradiology-trained radiologist did not read the film or the request did not
include language about a TNP. So, if you are going to get a scan, make sure that you
include a history of TNP and evaluate for PComm aneurysm. If the scan is normal,
then call the radiologist to make sure they are neuroradiology trained and comfort-
able ruling an aneurysm out.
The lesson here is an older person with a new onset headache deserves immediate
attention especially if there are any findings of neurological involvement. Besides
listening to the history, examining the cranial nerves carefully and looking at the
pupil in this case was key. Often, an isolated dilated pupil is NOT an emergency, but
any hint of ptosis or diplopia should trigger an emergent CT and/or MR imaging.
Follow-up
She had an emergent CT which was negative, but an MR and MRA and digital sub-
traction angiogram (Fig. 42.2) showed a posterior communicating artery aneurysm
that was clipped by neurosurgery. She did very well and is currently alive in her 90s.
Fig. 42.2 Right internal

carotid angiogram shows
the PComm aneurysm
(arrow)
256 42 Case 42
She still has residual right hypertropia which appears to be stable. Her headaches
completely resolved. Final diagnosis: Posterior Communicating aneurysm causing
3NP.
For Further Study
1. Chaudhary N, Davagnanam I, Ansari SA, Pandey A, Thompson BG, Gemmete JJ. Imaging
of intracranial aneurysms causing isolated third cranial nerve palsy. J Neuroophthalmol.
2009;29(3):238–44.
2. Cianfoni A, Pravatà E, De Blasi R, Tschuor CS, Bonaldi G. Clinical presentation of cerebral
aneurysms. Eur J Radiol. 2013;82(10):1618–22.
3. Dimopoulos VG, Fountas KN, Feltes CH, Robinson JS, Grigorian AA. Literature review
regarding the methodology of assessing third nerve paresis associated with non-ruptured pos-
terior communicating artery aneurysms. Neurosurg Rev. 2005;28(4):256–60.
4. Elmalem VI, Hudgins PA, Bruce BB, Newman NJ, Biousse V. Underdiagnosis of posterior
communicating artery aneurysm in noninvasive brain vascular studies. J Neuroophthalmol.
2011;31:103–9.
5. Güresir E, Schuss P, Setzer M, Platz J, Seifert V, Vatter H. Posterior communicating artery
aneurysm-related oculomotor nerve palsy: influence of surgical and endovascular treatment
on recovery: single-center series and systematic review. Neurosurgery. 2011;68(6):1527–33.
discussion 1533–4
6. Lanzino G, Andreoli A, Tognetti F, Limoni P, Calbucci F, Bortolami R, Lucchi ML, Callegari
E, Testa C. Orbital pain and unruptured carotid-posterior communicating artery aneurysms: the
role of sensory fibers of the third cranial nerve. Acta Neurochir (Wien). 1993;120(1–2):7–11.
Case 43
A 6-year-old girl developed a severe unilateral, throbbing headache upon awaken-

ing 3 weeks ago. She experienced nausea, vomiting, photophobia and lay in bed.
The headache resolved after several hours, but she experienced persistent left eye
pain, which she described as sharp. One week later, her left upper eyelid drooped. It
was constant and unassociated with vision loss, ptosis, or worsening pain. One
week later, she developed diplopia and went to the emergency department (ED).
Brain MRI at that time was read as normal. The father notes that her left pupil has
been larger “as different as a dime and a quarter.”

Born at 39 weeks with normal pregnancy and None
delivery
Achieved normal milestones
No ocular or medical history
None Mother—sick headaches starting in college
Kindergartener, both parents at home, one No fever, chills, or night sweats
older sibling. No pets Some moderate malaise
Denies alcohol, tobacco, and street drugs No neck stiffness
No weight loss
Feels well

258 43 Case 43
Examination
Right eye: 20/20
Left eye: 20/20
Color vision
Normal BE
Pupils
Pharmacologically dilated by referring ophthalmologist
Notes reflect left pupil was larger
Right eye: Globe soft to palpation
Left eye: Globe soft to palpation
External exam
RE appears normal
2.5 mm ptosis LUL
No proptosis or enophthalmos
RE was normal
LE showed normal abduction and intorsion on downgaze
LE 50% adduction, 50% elevation, and 75% depression
Normal
Visual field
Normal
Fundus examination
Normal
Normal neurologic exam besides left CN 3
Discussion
Historically, the patient had what sounds to be her first migraine headache 3 weeks
ago and suffered persistent LE pain. While she is on the young side, migraine can
happen in that age group. Later, however, she develops a slowly progressive, pupil-
involving, left third nerve palsy (3NP). We really do not need to ask about myas-
thenic symptoms, because myasthenia does not cause pain nor affect the pupil. It
appears neurologically isolated with intact cranial nerves 2 (normal acuity and color
vision), 4 (intorsion with downgaze), 5 (normal facial sensation), 6 (normal abduc-
tion), and 7 (normal facial strength). Thyroid eye disease does not cause ptosis. It
usually does not occur in this age group or present this acutely. There are also no
obvious orbital signs suggesting thyroid eye disease.
We are always worried about aneurysm in a patient with a pupil-involving
3NP. This patient is young for aneurysm, but we do not want to miss it especially
since CTA and MRA are noninvasive and apt to find essentially all aneurysms big
enough to cause 3NP.
Discussion 259
There is a phenomenon known as ophthalmoplegic migraine (recently renamed

recurrent painful ophthalmoplegic neuropathy) that usually presents before age 10.
Often the child experiences a migrainous headache followed by a third nerve palsy
(it can be a sixth or a fourth nerve palsy too). Although the headache resolves within
hours, the nerve palsy resolves spontaneously over several weeks. Brain MRI almost
always shows enhancement of the third nerve at the root exit zone (This suggests
that this is not really migraine). So, I would like to look at the MRI from the ED. If
the MRI were not performed with gadolinium, then I would send her for an MRI/
MRA brain with gadolinium letting the radiologist know that she has a left 3NP and
please evaluate for posterior communicating artery aneurysm. If the original MRI
were done well and did not show enhancement, then I would talk to the radiologist
and the parents about CTA vs. MRA. Some institutions have better results with one
vs. the other but CTA has radiation (which we worry about giving in children).
This child has a family history of migraine and we do not know if she was a colicky
baby, but colic can portend migraine as the child gets older. She has a headache 3
weeks before that really sounds like migraine, and the mother obviously knew she
had a migraine and sent her to bed to sleep the migraine off. However, the pain per-
sisted and she had sequential ptosis and diplopia and now her examination looks
like a pupil involving third nerve palsy. We have to consider the differential diagno-
sis of a painful third nerve palsy in childhood (see Table 43.1).
Imaging apparently was negative—or at least no gross abnormality was identi-
fied. Recurrent ophthalmoplegic neuropathy is a likely diagnosis here. However,
according to the ICHD 3 beta criteria (see Table 43.2), the child should have at least
three attacks to be called recurrent ophthalmoplegic neuropathy (formerly known as
Table 43.1 Causes of third Congenital

nerve palsy in childhood Trauma
Tumor
Vascular (aneurysm)
Meningitis
Idiopathic (including ophthalmoplegic migraine)
Table 43.2 ICHD 3 beta diagnosis of Recurrent painful ophthalmoplegic neuropathy

(ophthalmoplegic migraine; ophthalmoplegic neuropathy)
(A) At least two attacks fulfilling criterion B
(B) Unilateral headache accompanied by ipsilateral paresis of one, two or all three ocular motor
nerves
(C) Orbital, parasellar, or posterior fossa lesion has been excluded by appropriate investigation
260 43 Case 43
Table 43.3 Causes of a Vascular causes

painful third nerve palsy Ischemia
Aneurysm
Pituitary apoplexy
Fistula (cavernous)
Inflammation
Giant cell arteritis
Infection
Meningitis
Tumor
Pituitary tumor
Pituitary apoplexy
Demyelination
Multiple sclerosis
Other
Ophthalmoplegic migraine or recurrent ophthalmoplegic
neuropathy
Herniation
ophthalmoplegic migraine). In general, this is seen more frequently in girls at

around age 4–10. However, it has been reported in individuals over 50. Pain is often
orbital or periorbital and the pain most frequently occurs before the onset of the
cranial neuropathy and the headache often goes away before the third nerve palsy
resolves. The pain may have some migraine symptoms like nausea, and vomiting,
photophobia but about 1/3 do not. The third nerve is most frequently involved—
rarely the sixth alone or combined with CN 3. The majority of individuals will have
typical migraine in between third nerve attacks. The pupil is most often partially or
completely involved. The spinal fluid is usually normal. The cause of the recurrent
neuropathy is unknown but some think it is a recurrent demyelinating event.
Treatment of the neuropathy is usually waiting, treat the pain with non-steroidal
anti-inflammatories, but some have suggested steroid therapy. Third nerve palsies
are always tricky especially when they are painful (Table 43.3).
If you are comfortable diagnosing a 3NP, then you could consider ordering an MRI/
MRA with contrast. It is critical that you talk to the radiologist about the diagnosis
of a 3NP and get a reading the same day because of the risk of aneurysm. It is also
MUCH better to use a radiologist with neuroradiology fellowship training.
Discussion 261
Follow-up
I reviewed the MRI personally. It was done with gadolinium and was not read by a
neuroradiologist. The scan showed avid enhancement in the area of the left third
nerve exit zone consistent with recurrent ophthalmoplegic neuropathy or ophthal-
moplegic migraine (Fig. 43.1). Because the migraine headache occurred 1–2 weeks
before the 3NP and the patient noted moderate malaise, a lumbar puncture was also
performed to evaluate cell count, protein, glucose, cytology, and Lyme. The spinal
fluid was normal. The patient’s 3NP resolved over the next 4 weeks. The patient’s
parents were warned that it is not unusual for this to recur over the patient’s lifetime.
Final diagnosis: Ophthalmoplegic migraine (Probable recurrent painful ophthal-
moplegic neuropathy).
Fig. 43.1 Axial T1

postgadolinium MRI
shows the typical bright
signal at the left third nerve
(arrow) exit zone between
the cerebral peduncles
262 43 Case 43
For Further Study
1. Elmalem V, Hudgins PA, Bruce BB, Newman NJ, Biousse V. Underdiagnosis of posterior
communicating artery aneurysm in noninvasive brain vascular studies. J Neuroophthalmol.
2011;31:103–9.
2. Forderreuther S, Ruscheweyh R. From ophthalmoplegic migraine to cranial neuropathy. Curr
Pain Headache Rep. 2015;19:21.
3. Gelfand AA, Gelfand JM, Prabakhar P, Goadsby PJ. Ophthalmoplegic “migraine” or recur-
rent ophthalmoplegic cranial neuropathy: new cases and a systematic review. J Child Neurol.
2012;27(6):759–66.
4. Schumacher-Feero LA, Yoo KW, Solari FM, Biglan AW. Third cranial nerve palsy in children.
Am J Ophthalmol. 1999;128(2):216–21.
Appendix A
List of Tables
Case Page Diagnosis Table

1 3 Dry eye syndrome None
2 9 Corneal erosions None
3 15 Post LASIK pain None
4 21 “Eye strain” None
5 27 Intermittent angle closure 5: Drugs causing angle closure glaucoma
glaucoma
6 33 Blepharospasm None
7 39 Chalazion None
8 43 Trochleitis 8: Diagnostic criteria for trochleitis
9 49 Lacrimal gland tumor None
10 53 Posterior scleritis 10: Diagnostic criteria for headaches attributable to
ocular inflammatory disorder
11 61 Idiopathic orbital 11: Causes of orbital inflammation/proptosis and
inflammatory syndrome eye pain
12 69 Uveitis 12: U veitis and meningitis syndromes
13 75 Conjunctivitis 13: D ifferential diagnosis of a red eye
14 81 Thyroid eye disease 14: Clinical activity score for thyroid eye disease
15 87 Orbital mass None
16 93 Ocular ischemic syndrome None
17 99 Horner syndrome 17: P aratrigeminal oculosympathetic syndrome
(Raeder’s syndrome)
18 105 Microvascular cranial None
nerve palsy
19 113 Migraine 19.1: Diagnostic criteria for migraine without aura
19.2: Diagnostic criteria for migraine with aura
19.3: Diagnostic criteria for typical aura without
headache
19.4: Diagnostic criteria for chronic migraine
(continued)

264 Appendix A

20 119 Medication overuse 20.1: Risk factors that lead to chronic migraine
headache 20.2: Diagnostic criteria for medication overuse
headache
21 125 Photophobia None
22 131 Trigeminal neuralgia 22.1: Causes of brief (less than 2 min) unilateral
eye pain
22.2: Diagnostic criteria for classic trigeminal
neuralgia
23 137 Cervicogenic headache 23: D
iagnostic classification of cervicogenic
headache
24 143 Ice pick headache 24.1: Causes of short eye pain (less than 10
seconds)
24.2: Diagnostic criteria for idiopathic stabbing
headache
25 149 Sinus disease 25.1: Diagnostic criteria for acute and chronic
rhinosinusitis
25.2: Diagnostic criteria for acute and chronic
rhinosinusitis
26 155 Tension-type headache 26.1: Diagnostic criteria for chronic tension-type
headache
26.2: Migraine Inventory Disability Assessment
Score (MIDAS)
27 161 Supraorbital neuralgia 27: Diagnostic criteria for supraorbital neuralgia
28 165 Trigeminal autonomic 28.1: Diagnostic criteria for cluster headache
cephalgia 28.2: Diagnostic criteria for paroxysmal hemicrania
28.3: Diagnostic criteria for SUNCT
28.4: Diagnostic criteria for hemicrania continua
28.5: Differentiating the trigeminal autonomic
cephalgias from migraine
29 173 Cough headache 29: Diagnostic criteria for primary cough headache
30 177 Traumatic headache 30.1: Diagnostic criteria for persistent headache
attributed to mild traumatic injury of the head
30.2: Diagnostic criteria for persistent headache
after whiplash
31 183 Intracranial hypotension 31: Diagnostic criteria for intracranial hypotension
headache
32 189 Giant cell arteritis 32: D iagnostic criteria for giant cell arteritis
headache
33 195 Thunderclap headache 33.1: Diagnostic criteria for primary thunderclap
headache
33.2: Causes of thunderclap headache
33.3: Diagnostic criteria for the diagnosis of
reversible vasoconstriction syndrome (RCVS)
34 203 Meningitis None
35 209 Optic neuritis None
36 215 Idiopathic intracranial 36: Diagnostic criteria for IIH headache
hypertension (IIH)
37 221 Carotid cavernous fistula 37: D
iagnostic criteria for dural arteriovenous
fistula
List of Tables 265

38 227 Herpes zoster 38.1: Diagnostic criteria for acute painful
ophthalmicus trigeminal neuropathy attributed to herpes
zoster
38.2: Diagnostic criteria for post-herpetic
trigeminal neuropathy
39 233 Periocular skin cancer None
40 239 Tolosa Hunt 40.1: Differential diagnosis of painful
ophthalmoplegia
41 245 Pituitary tumor 40.2: Diagnostic criteria for Tolosa Hunt syndrome
42 251 Aneurysm 42: D
iagnostic criteria for headache attributed to
unruptured saccular aneurysm
43 257 Ophthalmoplegic migraine 43.1: Causes of third nerve palsy in childhood
43.2: Diagnostic criteria for recurrent painful
ophthalmoplegic neuropathy
(ophthalmoplegic migraine)
43.3: Causes of a painful third nerve palsy
Appendix B
List of Figures
Case Page Diagnosis Figure
1 3 Dry eye syndrome 1: Schirmer tear testing
2 9 Corneal erosions 2: How to instill fluorescein
3 15 Post LASIK pain 3: Confocal microscopy of abnormal
corneal nerves
4 21 “Eye strain” 4: Measuring near point of convergence
5 27 Intermittent angle 5: Penlight assessment of shallow
closure glaucoma anterior chamber
6 33 Blepharospasm 6: Injection sites for botulinum toxin A for
blepharospasm
7 39 Chalazion 7: Everted eyelid showing chalazion
8 43 Trochleitis 8: Anatomy of trochlea, supraorbital and
infrarorbital nerve, and lacrimal gland
9 49 Lacrimal gland tumor 9A: External photo of lacrimal gland enlargement
9B: CT of lacrimal gland tumor
10 53 Posterior scleritis 10: MRI of posterior scleritis
11 61 Idiopathic orbital 11: MRI of orbital inflammation
inflammatory
syndrome
12 69 Uveitis 12: Slit lamp photo of mutton-fat keratic
precipitates
13 75 Conjunctivitis 13: Photograph of follicular conjunctivitis
14 81 Thyroid eye disease 14: External photograph of mild thyroid
eye disease
15 87 Orbital mass 15.1: External photograph of unilateral proptosis
15.2: MRI of orbital mass
16 93 Ocular ischemic 16.1: Fundus photograph of midperipheral
syndrome hemorrhages
16.2: Three-dimensional reconstruction of carotid
occlusion
(continued)
267
268 Appendix B
Case Page Diagnosis Figure

17 99 Horner syndrome 17.1: Horner syndrome—dilation lag and
cocaine test
17.2: CT and MRI of carotid dissection
18 105 Microvascular cranial 18.1: External photograph of sixth nerve palsy
nerve palsy 18.2: Anatomy of the cavernous sinus and
cranial nerves
19 113 Migraine None
20 119 Medication overuse None
headache
21 125 Photophobia 21: An approach to the patient with photophobia
22 131 Trigeminal neuralgia 22: MRI of vascular compression of CN V
23 137 Cervicogenic 23: Anatomical cartoon showing the functional
headache anatomy of cervicogenic headache and the
divisional and somatotopic arrangement of the
trigeminal sensory pathways
24 143 Ice pick headache None
25 149 Sinus disease 25: MRI of chronic sinusitis
26 155 Tension type headache None
27 161 Supraorbital neuralgia None
28 165 Trigeminal autonomic 28: Attack of cluster headache
cephalgia
29 173 Cough headache 29: MRI of Arnold Chiari malformation
30 177 Traumatic headache None
31 183 Intracranial 31: MRI of intracranial hypotension
hypotension
32 189 Giant cell arteritis 32: E
xternal photograph of an enlarged
temporal artery
33 195 Thunderclap headache 33: CTA showing arteriolar beading in RCVS
34 203 Meningitis None
35 209 Optic neuritis 35.1: Visual fields in optic neuritis
35.2: MRI of optic neuritis
36 215 Idiopathic intracranial 36: M
RI findings of increased intracranial
hypertension pressure
37 221 Carotid cavernous 37.1: Red eye appearance of CCF
fistula (CCF) 37.2: MRI findings in CCF
38 227 Herpes zoster 38: External photograph of HZO
ophthalmicus (HZO)
39 233 Periocular skin cancer 39: MRI of enlarged cavernous sinus and V1
40 239 Tolosa Hunt 40: MRI of Tolosa Hunt syndrome
41 245 Pituitary tumor 41.1: Visual fields showing bitemporal hemianopia
41.2: MRI of a pituitary adenoma
42 251 Aneurysm 42.1: External photograph of a third nerve palsy
42.2: Angiogram showing a posterior
communicating artery aneurysm
43 257 Ophthalmoplegic 43: MRI of enhancing third nerve
migraine
Figure D-1 273 Appendix D Pathophysiology of Eye Pain
Appendix C
Obtaining a History and Doing an Exam for Eye Pain
Taking an Eye Pain History
In many cases of eye pain and headache, no physical findings exist. This means that
the diagnosis depends almost completely on the history. Remembering to cover the
five elements of the history can prove extremely helpful. These include the family
history, life history, attack history, the medical and psychiatric history, and the
medication and drug history.
The family history helps us understand if there is a genetic predisposition to
headache or chronic pain. The strongest familial association occurs with migraine
and tension-type headaches and other pain disorders like fibromyalgia. Occasionally
cluster headache can run in families. Headaches/eye pain beginning at an older age
without a family history may raise concern for a secondary headache. A strong fam-
ily history of aneurysm may direct one to rule out aneurysm. Family history of
autoimmune disorders may suggest an inflammatory cause of pain as the first mani-
festation of a new autoimmune disorder in the patient.
The life history helps determine if this represents new or changed headache over
time. New chronic daily headache or a significant change in attack characteristics
should raise a red flag for a secondary headache especially in an older individual.
The heart of the history for eye pain is the attack history which focuses on the
quality, frequency, duration, modifying factors, and accompanying features. What
does the pain feel like? Is it sharp, scratching, shooting, stabbing, pounding, aching,
or throbbing? Is it constant or intermittent? If it is intermittent, then how often does
it occur? How many times a day, week, month, or year? How long does it last and
what was the time course? Is it seconds, minutes, hours, or days? An apoplectic pain
raises concern for a secondary cause (aneurysm or secondary thunderclap headache;
Cases 33 and 42). What makes it better or worse? Sometimes patients will tell you
that touching the face (trigeminal neuralgia; Case 22), moving the eye, sunlight, or
sitting upright (Spontaneous intracranial hypotension; Case 31) might worsen the
269
270 Appendix C
pain. It might improve with exercise (Tension-type headache; Case 26) or lying in a
dark room or pressing on the back of the neck (Cervical spasm; Case 23). As we all
know, pain is unique to each patient and one patient’s throbbing may be another
patient’s aching. However, if one can elicit a classic history for an eye pain or head-
ache disorder, a diagnosis may be determined. Accompanying features to inquire
about include migraine symptoms (nausea, vomiting, photophobia, phonophobia,
and osmophobia (migraine; Case 19)), autonomic symptoms (epiphora, conjuncti-
val injection, ptosis, miosis, sweating, and nasal stuffiness/rhinorrhea (Trigeminal
autonomic cephalgias; Case 28)), and giant cell arteritis symptoms, in the right age
group (jaw claudication, weight loss, anorexia, scalp tenderness, malaise, and
arthralgias; Case 32).
The medical and psychiatric history may identify a co-morbid condition that
could cause or worsen the eye pain and headache. Risk factors for chronic migraine
or tension-type headache (more than 15 days/month) include depression, anxiety,
stress, snoring, obesity, female gender, lower education level, and lower socioeco-
nomic status. Co-morbidities for migraine and even tension-type headaches include
depression, stress, fatigue, sleep apnea irritable bowel syndrome, fibromyalgia,
menstruation, Raynaud’s, depression, anxiety, and epilepsy. Whereas tension-type
headaches are increased in stress, fatigue, lack of sleep, depression, and anxiety.
Patients with hypercoagulable risk factors may develop cerebral venous thrombosis.
Graves ophthalmopathy can develop months to years after a diagnosis of Graves
disease (Case 14). Patients with collagen vascular disease, sarcoidosis, or autoim-
mune disorders may present with inflammation of the trochlea (Trochleitis; Case 8),
sclera (Posterior scleritis; Case 10), orbit (orbital inflammatory disease; Case 11),
uvea (Uveitis; Case 12), or the cavernous sinus (primary or secondary Tolosa Hunt
syndrome; Cases 39 and 40). Microvascular cranial nerve palsies (Case 18) are
more common in patients with diabetes, hypertension, and hypercholesterolemia.
Skin cancers removed from the face can recur and travel perineurally causing eye
pain and headache (Case 39).
The medication and drug history is critical. Medication overuse can easily
explain a headache and eye pain. This varies by the type of medication used (opiates
and barbituates vs. NSAIDs vs. triptans) and the number of days per week—and if
an acute rescue medication is taken more than 2–3 days in a week medication over-
use can develop. See Case 20 (Chronic migraine with medication overuse) for
details. A number of antihistamines, diuretics, anticholinergics, and antidepressants
cause dry eye leading to eye pain.
Eye Pain Examination
The history typically drives the examination. The basic evaluation includes visual
acuity, visual fields, assessment of the pupils and eye movements, evaluating the
eyelid position, slit lamp examination, fundus examination, and palpation. Visual
acuity and visual field are the vital signs of the eye similar to pulse and blood
Eye Pain Examination 271
pressure. The pupils may show anisocoria in Horner syndrome, trigeminal auto-
nomic cephalgia, or third nerve palsy. An afferent pupillary defect occurs in optic
nerve disorders such as optic neuritis. Ptosis may indicate involvement of the third
nerve or Horner syndrome, whereas eyelid retraction may mean thyroid eye disease
or an orbital mass. The slit lamp examination is critical to evaluate for dry eye syn-
drome (tear break up time, corneal staining, meibomian gland dysfunction), anterior
basement membrane dystrophy, or cells in the anterior chamber. The fundus exami-
nation helps determine the presence of papilledema or other optic nerve disorders.
We like to palpate the temporal arteries, the greater occipital nerve, the infraorbital
nerve, the supraorbital nerve, the lacrimal gland, and the trochlea. Improvement
with temporal artery pressure may be a clue to migraine or tenderness may suggest
temporal arteritis in the older patient. Improvement with an anesthetic drop indi-
cates an ocular surface disorder. It also allows us to check the intraocular pressure.
Finally, a brief neurological examination—look for drift of arms outstretched will
signify subtle weakness that may signal central event.
Appendix D
Pathophysiology of Eye Pain
That the eye would be a source of pain should not be surprising! The anatomy and
physiology play a huge role in why get eye pain.The trigeminal system is the sen-
sory supply to the eye, but it also is the sensory system to most of the head too AND
the trigeminal system supplies the blood vessels and parts of the dura (the cover-
ings of the brain). This system is complicated and is modulated by the thalamus and
the brain.
First, the anatomy is important. The trigeminal system consists of primary
afferents that sit on the cornea but also on blood vessels, muscles, and tissues of
the orbit and head and brain. The cornea has perhaps the densest set of afferent
nociceptors anywhere, and anything that affects these nerves on the cornea will cre-
ate pain. These nociceptors are mainly C fibers and A Delta fibers—small caliber
fibers and project to the Gasserian Ganglion and then on to the trigeminal sensory
nuclei of the brainstem. What is important to know is that the trigeminal nerve—
first division—also has both sympathetic and parasympathetic fibers that join it.
This is why there are so many other findings with certain types of eye pain—like
conjunctival injection, tearing, ptosis, anisocoria. The branches of the trigeminal
nerve include the lacrimal nerve which innervates the lacrimal gland, conjunctiva,
and upper eyelid sensation. The frontal nerve innervates the superior rectus muscle
and levator muscle, forehead, skin on the side of the nose and frontal sinus via the
supraorbital nerve and supratrochlear nerve. The nasociliary nerve holds the sen-
sory supply to the eye. This is really an important nerve since it gives off the short
ciliary nerves that supply the choroidal vessels and long ciliary nerves, which sur-
round the optic nerve and innervate the iris, ciliary body, and cornea. These long
ciliary nerves also have sympathetic fibers attached. These nerves supply the nasal
septum, turbinate, and skin to the tip of the nose. This is why in herpes zoster we
worry about the involvement of the tip of the nose as a sign that the eye itself is
involved in the outbreak.
273
274 Appendix D
The first division of the trigeminal nerve also innervates the dura of the anterior
intracranial fossa and tentorium and even the sagittal sinus. This is why intracranial
processes like meningitis can also present with eye pain and headache. These fibers
also innervate cerebral blood vessels which play an important role in our under-
standing of migraine. The importance of migraine is discussed below.
The second division of the trigeminal nerve is the maxillary nerve and it too sup-
plies areas around the eye—the lower eyelid, side of the nose, teeth, maxillary sinus,
and roof of the mouth.
The mandibular nerve or the third division of the trigeminal nerve is both sensory
and motor, but mainly provides sensation to the lower face.
The next step is for the three branches to coalesce in the Gasserian (also known
as the semi-lunar ganglion) and become the sensory root that enters the brainstem.
These fibers branch into both ascending and descending directions. The descending
fibers become the trigeminal spinal tract—and end in the nucleus of the trigeminal
spinal tract or the caudal nucleus. What is interesting about this nucleus is that the
nucleus is organized a little differently; it has projections to the mouth, the interme-
diate face, and the head. This results in a different pattern of sensation when this
nucleus is disrupted—instead of the three divisions we classically see in the face,
we get kind of an onion skinning appearance of the sensation with the most caudal
portion carrying fibers to the forehead and top of the head, the middle section to the
eye and the most rostral to the mouth and nose (See Fig. 23.1). The most caudal
nucleus (nucleus caudalis) extends to the cervical region—and this is why upper
cervical lesions can seem to project pain to around the eye and forehead. Fibers
from the upper cervical regions can project to this nucleus caudalis. Interestingly,
corneal afferents also project into this spinal nucleus—making it an important cen-
ter for all of us in neuro-ophthalmology since the nucleus caudalis of the spinal
nucleus is thought to play an integral role in migraine.
The trigeminal system has other sensory nuclei including the mesencephalic
nucleus which are primary sensory neurons that remain in the central nervous sys-
tem; these fibers end up going to the thalamus.
All of the trigeminal nuclei ascend after crossing through the medial lemniscus
to the thalamus via the ventral spinal thalamic tract and the lateral spinothalamic
tract. These fibers end in the posterior thalamic region. Interestingly, these fibers
also connect to the limbic system—hence these anatomical structures give an emo-
tional component to eye and head pain! From the thalamus, pain is relayed through
the corticothalamic projections into the primary somatic sensory cortex as well as
the anterior cingulate cortex, prefrontal cortex (the “pain matrix”). The eye is repre-
sented in the homunculus between the forelimb and forehead or nose.
Now, why do we want to know this anatomy anyway? Well, it turns out this
anatomy also applies to the primary headache disorders like migraine, cluster head-
ache, and the like! No wonder we get so confused sometimes that eye pain can be a
migraine and why migraine can be eye pain! Of great importance to us is the knowl-
edge the ophthalmic division (V1) also has connections to blood vessels around the
brain—thereby linking the vascular system and the trigeminal system. Some have
called this the trigeminal vascular unit.
Pathophysiology of Eye Pain 275
In fact, the most recent pathophysiology of migraine states that through the
migraine process—maybe starting in the hypothalamus—dural afferents (from our
first division of the trigeminal nerve) are stimulated and set up a microscopic dural
inflammation which in turn activates the thalamus and brain. This system has centers
participating in inhibition of signaling as well—otherwise, we would all have head
and eye pain! In migraine, however, once a migraine is started and this trigeminal
vascular pathway is ignited, it is hard to turn off and pain can occur in the surround-
ing areas—in a process called central sensitization. Pain is felt beyond the onset of
the headache. In addition, other migraine centers are activated to cause other visual
symptoms like photophobia, and visceral symptoms like nausea and vomiting.
There are also autonomic nuclei that play a role in eye pain in the brainstem—
including the superior salivatory nucleus which is located in the pons. This nucleus
contains the parasympathetic autonomic pathway which is vasodilatory and is also
connected to the sphenopalatine ganglion which also connects to the lacrimal gland
and participates in tearing, and other autonomic symptoms that are present in
migraine and trigeminal autonomic cephalgias like cluster headache. It can be stim-
ulated with any process causing pain in the eye. Many of our eye pain patients have
red eye and tearing no matter what the cause, and it is this system that is activated.
The sympathetic system can also be activated! It starts in the hypothalamus and
heads down the spinal cord to C8-T1 and drapes over the apex of the lung, ascends
the carotid artery into the orbit—entering after connecting with nerves including the
first division of the trigeminal system. When stimulated it can cause pupillary dila-
tion, when lesioned it causes miosis and ptosis.
The biochemistry of pain is also complicated but interesting! There are now
known vasoactive neuro-peptides associated with the trigeminal system as well as
the parasympathetic and sympathetic systems. The trigeminal sensory fibers impor-
tantly have calcitonin gene-related peptide as well as other neuropeptides like sub-
stance p, neurokinin A, and pituitary adenylate-cyclase activity. The parasympathetic
fibers associated with the trigeminal fibers contain a peptide called vasoactive intes-
tinal peptide, acetylcholine, and neuropeptide Y; whereas, sympathetic fibers con-
tain norepinephrine and neuropeptide Y. These peptides are important since they
play a role in the many varied symptoms and signs we see and importantly many
medications that are being investigated to treat migraine pain may be helpful in the
future for eye pain from migraine and other disorders.
So why do you think that you can get migraine and eye pain from such a diverse
anatomy and pathophysiology? First, there is a genetic susceptibility for migraine
and even for chronic pain disorders. The anatomy and physiology of the trigeminal
system affects the head causing migraine and the eye causing eye pain. In some
instances, there is no “pathological” cause of the pain (no signs) but just symptoms.
These symptoms are the result of activation of the trigeminal system, autonomic
systems, and biochemical peptides. These changes can cause spontaneous eye pain
from migraine or continuing eye pain after a corneal injury—the anatomy and phys-
iology is the same. Further, individuals more prone to activation of this system—
that is those with migraine, are more susceptible to having more eye pain. In our
cases, we are careful to discuss a family history of migraine or fibromyalgia in this
276 Appendix D
way. For example, not everyone with dry eye gets a lot of eye pain, but eye pain is
more actively reported in those with chronic pain conditions.
In our drawing (Fig. D-1), we have paralleled the anatomic pathways for
migraine—beginning with the dura and its blood vessels indicating one part of
the ophthalmic division of the trigeminal nerve and also the eye—the other major
structure innervated by the first division. These pathways are very similar and help
us to understand that eye pain and migraines can be very closely related by their
anatomy, autonomic connections, and biochemistry. Understanding these factors
help to demystify eye pain and give us better clarity on how to approach it and treat
eye pain.
Keywords
Eye pain
Migraine
Trigeminal vascular coupling
Central sensitization
Neuro-peptides
CGRP
Autonomic nervous system
Figure D-1
Corneal To paralimbic region and

nerve afferents somatosensory cortex
Third order
neuron
Thalamus Second order

neuron
First order Amygdala

neuron
Trigeminal
ganglion Trigeminal
nucleus Superior
caudalis salivatory nucleus
C1 Neuron
C2 crossing over
C3
Pterygopalatine
ganglion
Adapted in part from Goadsby et al N Engl J Med, 2002;346:257–267 and Rosenthal P, Baran I, Jacobs DS.
Corneal pain without stain. Is it real? Ocul Surf 2009;7:28–40
References 277
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Nat Rev Neurosci. 2011;12(10):570–84.
2. Burstein R, Noseda R, Borsook D. Migraine: multiple processes, complex pathophysiology.
J Neurosci. 2015;35(17):6619–29.
3. Goadsby PJ, Holland PR, Martins-Oliveira M, Hoffmann J, Schankin C, Akerman
S. Pathophysiology of migraine: a disorder of sensory processing. Physiol Rev.
2017;97(2):553–622.
4. Jacobs B, Dussor G. Neurovascular contributions to migraine: moving beyond vasodilation.
Neuroscience. 2016;338:130–44.
5. Rosenthal P, Borsook D. The corneal pain system. Part I: the missing piece of the dry eye
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Index
A follow up, 73
Abobotulinum toxin, 35 illness, history, 69
Acetazolamide, 176, 217–219 neurologic condition, 71–73
Aching, 5 non-ophthalmic/non-neurologic
Acute Cluster attack, 101 condition, 73
Acute frontal sinusitis, 151 ophthalmic condition, 70–71
Acute oculosympathetic disruption, 102 systemic workup, 71
Acute rhinosinusitis, 151 Apraclonidine test, 102
Adenoid cystic carcinoma, lacrimal gland Apraxia of eye lid opening, 34, 35
follow up, 52 Aripiprazole, 35
illness, history of, 49 Arnold Chiari malformation, 174, 176
neurologic conditions, 51 Artificial tears, 6, 69
non-ophthalmic/non-neurologic Aseptic meningitis, 205
conditions, 51 Aura without headache, 114, 116
ophthalmic conditions, 50, 51 Autonomic cephalgias, 144
Allergic conjunctivitis, 76
Allodynia, 17
Amitriptyline, 118, 217 B
Aneurysm, 199 Bacterial meningitis, 203, 206
examination, 252 Barbiturates, 121
follow-up, 255 Basal carcinomas, 235
illness, history, 251 Benign cough headache, 176
neurologic conditions, 253–254 Benign reversible angiopathy, 199
non-ophthalmic/non-neurologic Bilateral upper eyelid retraction, 83
conditions, 255 Bitemporal headache, 247
ophthalmic conditions, 254–255 Bitemporal visual field defect, 246
Aneurysms, 174 Blepharospasm, 127
Angiography, 225 cause of, 35
Angle closure glaucoma (ACG), 29, 30 diagnosis, 34
Anisocoria, 100, 101 follow up, 37
Anterior basement membrane dystrophy illness, history of, 33
(ABMD), 11 neurologic conditions, 34–35
Anterior inferior cerebellar artery (AICA), 135 non-ophthalmic/non-neurologic conditions, 36
Anterior scleritis, 55 ophthalmic conditions, 35–36
Anterior uveitis, 72 Botulinum toxin, 35

280 Index
Botulinum toxin A, 36 diagnosis, 167

Brief headaches, 144 examination, 166
Burning, 15–17 follow-up, 171
Butalbital, 121 ICHD 3 beta, 167
illness, history, 165
neurologic conditions, 166–170
C non-ophthalmic/non-neurologic
Caffeine, 117 conditions, 170–171
Calcitonin gene related peptide (CGRP), 275 ophthalmic conditions, 170
Carbamazepine, 134, 135 treatment for, 167
Carotid artery endartectomy, 96 Cocaine, 102
Carotid artery stenting, 96 Comitant diplopia, 183
Carotid cavernous (C-C) fistula, 223 Computer vision syndrome, 22
Carotid circulation, 97 Conjunctivitis
Carotid dissection, 103 examination, 75–76
Carotid stenosis, 95 follow up, 78
Cavernous sinus, 234–236, 240, 243 illness, hhistory, 75
Cervicogenic headache neurologic condition, 77
follow-up, 142 non-ophthalmic/non-neurologic
ICHD 3 beta classification, 141 condition, 78
illness, history, 137, 138 ophthalmic condition, 76–77
non-ophthalmic/non-neurologic See also Medicamentosa, conjunctivitis
conditions, 141–142 with
ophthalmic conditions, 138–141 Conjunctivochalasis, 16
Chalazion Convergence insufficiency (CI), 4, 21
follow up, 41–42 Convergence spasm, 181
illness, history, 39 Corneal abrasion, 11
neurologic conditions, 41 Corneal neuropathy, 35
non-ophthalmic/non-neurologic Corneal pseudodendrites, 231
conditions, 41 Corticosteroids, 65
ophthalmic conditions, 40 Cough headache, 145–146
Chiari malformation, 175, 184 Cox-2 inhibitors, 147
Chronic migraine, 115, 117 Cranial nerve palsies, 205
examination, 119–120 Cranial nerves, 107
follow-up, 123 Cryptococcus, 212
illness, hostory, 119 Cyclobenzaprine, 158
with MOH, 120–123 Cyclosporine, 33
non-ophthalmic/non-neurologic
conditions, 122–123 D
ophthalmic conditions, 122 Dark adaptation, 93
risk factors, 121 Day blindness, 94–95
Chronic rhinosinusitis, 151 Degenerative neurological disorders, 6
Chronic tension-type headache Demyelinating disease, 212
follow-up, 158 Dense temporal defect, 210
ICHD 3 Beta criteria, 157 Desipramine, 158
illness, history, 155 Dexamethasone, 45
MIDAS, 157 Dilated ophthalmic vein, 225
neurologic conditions, 156–157 Diplopia, 51, 83
non-ophthalmic/non-neurologic Diver’s headache, 163
conditions, 158 Dizziness, 155
ophthalmic conditions, 158 Double vision, 83, 105, 107, 109, 248
Chronification, 120 Dry eye syndrome (DES), 16, 69
Clinical activity score (CAS), 82, 83 anesthetic, 6
Cluster headache, 133 follow up, 7
Index 281
illness history, 3 ophthalmic conditions, 190–191

neurologic condition, 6 Goniscopy, 31
non-ophthalmic/non-neurologic Gradenigo’s syndrome, 108
condition, 6–7 Granulomatosis with polyangitis
ophthalmic condition, 4–5 (GPA), 89, 90
reading, 3 Granulomatous uveitis, 70
Dry eyes, 33, 35, 127, 179 Graves’ disease, 82, 84
Dural cavernous fistula. See Low flow Greater occipital nerve (GON), 138
cavernous-carotid fistula Growth hormone secreting tumor, 247
Dystonia, 34
H
E Hashimoto’s thyroiditis, 84
Endarterectomy, 96 Head and neck surgery, 151
Episcleritis, 53, 55 Headache, 30, 115, 119, 156
Esotropia, 61 Hemicrania continua, 169
Exertional headache, 145–146 Hemi-field slide, 247
Exotropia, 22 Hemorrhages, midperiphery in, 94
Eye discomfort, 247 Herpes zoster ophthalmicus
Eye redness, absence of, 55 complication, 230
Eyelid edema, 51 examination, 228
Eyelid surgery, 102 follow-up, 231–232
Eyestrain eye pain ICHD 3 beta, 229
follow up, 25 illness, history, 227
illness, history of, 21 neurologic conditions, 229–230
neurologic condition, 23–24 non-ophthalmic/non-neurologic
non-ophthalmic/non-neurologic condition, 24 conditions, 231
ophthalmic condition, 22–23 ophthalmic conditions, 231
risk factors, 229
treatment, 230
F Hertel exophthalmometry, 90
Facial numbness, 235 Horner’s syndrome, 254
Facial pain, 134 examination, 99–100
Famciclovir, 230, 231 follow-up, 103
Fat saturation, 66 illness, history, 99–100
Fibromyalgia, 17 neurologic conditions, 101–102
FL-41 tinted lenses, 129, 130 non-ophthalmic/non-neurologic
Fluoxetine, 29 conditions, 103
Fundus, 94 ophthalmic conditions, 102–103
Fungal infections, 89 Hydroxyamphetamine, 102
Hyperopia, 22
Hypnic headache, 144
G Hypotension, 185
Gabapentin, 17, 130, 134, 135, 230
Gadolinium, 91, 134
Ganciclovir, 231 I
Gentamicin eye drops, 78 Ice cream headache, 144
Giant cell arteritis (GCA), 107 Idiopathic intracranial hypertension (IIH)
examination, 190 diagnosis, 217
follow-up, 192 examination, 216
ICHD3 beta criteria, 192 ICHD3 beta, 217
illness, history, 189 illness, history, 215
neurologic conditions, 191–192 neurologic conditions, 216–217
non-ophthalmic/non-neurologic ophthalmic conditions, 218, 219
conditions, 192 treatment, 217
282 Index
Idiopathic orbital inflammatory syndrome, 89 Low flow cavernous-carotid fistula

follow up, 66–67 examination, 222
illness, history of, 61 follow-up, 225
neurologic conditions, 62–65 ICHD 3 beta, 224
non-ophthalmic/non-neurologic illness, history, 221
conditions, 65–66 neurologic conditions, 223–224
ophthalmic conditions, 65 non-ophthalmic/non-neurologic
treatment, 65 conditions, 224
Idiopathic stabbing headache ophthalmic conditions, 222–223
examination, 144 Low-dose aspirin, 117
follow-up, 148 Lumbar puncture, 199, 216
ICHD 3 beta, 146 Lymphoma, 65
non-ophthalmic/non-neurologic M
conditions, 147 Maddox Rod testing, 23, 247
ophthalmic conditions, 147 Conjunctivits with medicamentosa
IgG4 disease, 63 examination, 75–76
Indomethacin, 147, 148, 176 follow up, 78
Inflammation, 70, 89, 127 illness, history, 75
Intermittent angle closure glaucoma neurologic condition, 77
drugs, 29 non-ophthalmic/non-neurologic
follow up, 31 condition, 78
illness, history of, 27 ophthalmic condition, 76, 77
neurologic conditions, 29–30 Medication overuse headache (MOH), 121,
non-ophthalmic/non-neurologic 122, 140
conditions, 30–31 Meibomian glands, 41
ophthalmic conditions, 28–29 Meige syndrome, 34
Interpeduncular cistern, enhancement, 207 Meloxicam, 53
Intracranial hypotension headache, 185 Meningitis, 72
Intracranial hypovolemia, 185 examination, 204
Intraocular inflammation, 224 follow-up, 206–207
Intraocular pressure (IOP), 95 illness, history, 203
Intrinsically photoactive ganglion cells initial evaluation, 204
synapse, 127 neurologic conditions, 204–205
Iritis, 72 non-ophthalmic/non-neurologic
conditions, 206
ophthalmic conditions, 205–206
L treatment, 205
Lacrimal gland, adenoid cystic carcinoma Methylprednisolone, 75
follow up, 52 Microvascular cranial neuropathy
illness, history of, 49 examination, 105–106
neurologic conditions, 51 follow-up, 109
conditions, 51 neurologic conditions, 108–109
ophthalmic conditions, 50–51 non-ophthalmic/non-neurologic
Lagophthalmos, 10 conditions, 109
Lamotrigine, 134 ophthalmic conditions, 106–108
Laser in situ keratomileusis (LASIK), 15 Microvascular decompression, 134
Laser peripheral iridotomy (LPI), 29, 31 Mid-peripheral hemorrhages, 94, 95
Leptomeningeal enhancement, 206, 207 Migraine, 17, 127, 149
Lidocaine, 36, 230 aura, 30
Index 283
examination, 114 Ophthalmoplegia, 206

follow-up, 118 Ophthalmoplegic migraine. See Recurrent
illness, history, 113 painful ophthalmoplegic
neurologic conditions, 114–118 neuropathy
non-ophthalmic/non-neurologic Opioids, 121, 230
conditions, 118 Optic atrophy, 206
ophthalmic conditions, 118 Optic neuritis, 63
TAC from, 170 evaluation, 211
Migraine Inventory Disability Assessment eye pain with, 211
Score (MIDAS), 114, 157, 158 follow-up, 213
Migraine with aura, 114, 116 illness, history, 209–211
Migraine without aura, 114, 115 neurologic conditions, 211–212
Mild hypertropia, 61 non-ophthalmic/non-neurologic
Mollaret’s meningitis, 205 conditions, 212
Mullerectomy, 102 ophthalmic conditions, 212
Multiple cranial neuropathies, 242 Optic neuropathy, 205
Multiple sclerosis, 71, 211 Optic perineuritis, 63
Muscle contraction headache, 158 Oral-facial dystonia, 34
Mutton fat, 70 Orbital apex, 89
Myasthenia, 108 Orbital cellulitis, 89
Myectomy, 36 Orbital disease, 65
Myositis, 45 Orbital inflammation, 64
Orbital mass
examination, 87–88
N follow up, 90–91
Neck physical therapy, 141 illness, history, 87
Nerve block, 164 neurologic conditions, 89
Nerve fiber layer, 180 non-ophthalmic/non-neurologic
Neuralgia, 132 conditions, 90
Neuro-ophthalmology, 107 ophthalmic conditions, 89–90
Neuro-ophthalmology Virtual Educational Orbital myositis, 61, 63, 108
Library (NOVEL), 34 Orbital pseudotumor, 63
Nongranulomatous disease, 70, 71 Orbital ultrasound, 63
Nortriptyline, 158 Orbital varices, 186
NSAIDs, 3, 77, 122, 141 Oxcarbazepine, 134
Nummular headache, 163
Nystagmus, 180
P
Pain with eye movements, 44, 45, 55, 62, 63,
O 105, 137, 161, 190, 209, 215.
Occipital neuralgia, 140 See also Optic neuritis; Idiopathic
Ocular ischemic syndrome (OIS) intracranial hypertension (IIH)
examination, 93–94 Painful Horner syndrome, 170
follow up, 96 Painful ophthalmoplegia, 241
illness, history, 93 Painful third nerve palsy, 260
neurologic conditions, 95–96 Palpation, 41, 164, 191
non-ophthalmic/non-neurologic Palpebral fissure, 100
conditions, 96 Papilledema, 216, 218
ophthalmic conditions, 94–95 Paranasal sinuses, 243
treatment, 96 Paratrigeminal defect, 108
Oligoclonal bands, 212, 213 Paratrigeminal oculosympathetic
Onabotulinum toxin, 113 syndrome, 101
284 Index
Paresthesias, 155 ophthalmic conditions, 180–181

Paroxysmal hemicranias, 168 risk factors, 179
Perineural spread, 235 treatment, 180
Peri-neuritis, 63 Prednisone, 43
Phenytoin, 134 Pregnancy, 218
Photophobia, 35, 139, 247 Pressure, 5
cause of, 127 Primary cough headache
examination, 126 examination, 174
follow up, 130 follow-up, 176
illness, history, 125 ICHD-3 beta, 176
neurologic conditions, 127–129 illness, history, 173
non-ophthalmic/non-neurologic neurologic conditions, 175–176
conditions, 130 non-ophthalmic/non-neurologic
ophthalmic conditions, 129 conditions, 176
Photostress test, 96 ophthalmic conditions, 174–175
PHQ 9 depression scale, 119 treatment, 176
Pink eye, 78 Primary headache disorders, 132
Pituitary tumor Primary trochlear headache. See Trochleitis
examination, 246 Progressive supranuclear palsy (PSP), 6
follow-up, 248 Prolactinoma, 247
illness, history, 245 Promethazine, 143
neurologic conditions, 247, 248 Proptosis, 49, 64–66, 83
non-ophthalmic/non-neurologic cause of, 89
conditions, 248 non-ophthalmic/non-neurologic
ophthalmic conditions, 248 conditions, 90
Positional headache, 186 Pseudotumor cerebri. See Idiopathic
Positional headaches, 184, 186 intracranial hypertension (IIH)
Posterior communicating (PComm) Pseudotumor of orbit. See Idiopathic orbital
aneurysm, 253, 255 inflammatory syndrome
Posterior sclera, 56 Ptosis, 50, 100, 101
Posterior scleritis Pulling sensation, 5
follow up, 55–57 Pulse synchronous tinnitus (PST), 223
illness, history, 53 Pupil involvement, 253
neurologic coditions, 54–55
non-ophthalmic/non-neurologic
coditions, 55 R
ophthalmic coditions, 55 Radioactive iodine (RAI), 84
Post-herpetic neuralgia, 140, 230 Raeder’s syndrome, 101
Post-LASIK eye pain Rebound headache, 121, 140
follow up, 18 Recurrent corneal erosions
illness, history of, 15 follow up, 12
neurologic condition, 17–16 illness, history, 9
non-ophthalmic/non-neurologic neurologic conditions, 11
condition, 18 non-ophthalmic/non-neurologic
ophthalmic condition, 16–17 conditions, 11, 12
Post-traumatic headache ophthalmic conditions, 10–11
follow-up, 181 Recurrent painful ophthalmoplegic neuropathy
ICHD 3 beta, 179 examination, 258
illness, history, 177, 178 follow-up, 261
neurologic conditions, 178–180 ICHD 3 beta, 259
conditions, 181 neurologic conditions, 259–260
Index 285
non-ophthalmic/non-neurologic Subtle corneal loop, 18

conditions, 260 Subtle esotropia, 106
ophthalmic conditions, 258–259 Sulfa antibiotic allergy, 218
Recurrent uveitis, 55 Sumatriptan, 171
Red eye, 11, 76–78, 222 Supraorbital neuralgia
Relative afferent pupillary defect (RAPD), 63, 65 follow-up, 164
Reversible cerebral vasoconstriction ICHD 3 beta, 164
syndrome (RCVS), 198, 199 illness, history, 161
Rhinosinusitis, 150, 151 neurologic conditions, 163
Rimabotulinum toxin B, 35 non-ophthalmic/non-neurologic conditions,
Rosacea, 5, 35 163
Rundle’s curve, 82 ophthalmic conditions, 162
treatment of, 164
Suprasellar space, 249
S Swimmer’s headache, 163
Sarcoid, 89
Schirmer’s tear testing, 5, 23
Selenium, 83 T
Sellar mass, 249 Tarsus, meibomian glands, 41
Sentinel headache, 253 Temporal artery. See Giant cell arteritis (GCA)
Short eye pain, 145–146 Temporal mandibular joint (TMJ) dysfunction,
Short lasting unilateral neuralgiform headache 30, 43
attacks with conjunctival injection Tenderness, 40
and tearing (SUNCT), 168, 169 Tension-type headache, 158
Sinus headache Teprotumumab, 83
examination, 150 Tetrahydrozoline, 102
follow-up, 153 Theracane, 117, 141
illness, history, 149 Third nerve palsy (3NP), 234, 253–255, 258,
neurologic conditions, 150–152 259
non-ophthalmic/non-neurologic Thunderclap headache, 253
conditions, 153 causes of, 197
ophthalmic conditions, 152 examination, 196
Sixth nerve palsy, 108, 186 follow-up, 199
Sjogren’s disease, 6, 130 ICHD3 beta, 197
Skin cancers, 235 illness, history, 195
Slit lamp examination, 71 neurologic conditions, 196–198
Spontaneous intracranial hypotension non-ophthalmic/non-neurologic
diagnosis, 185 conditions, 198
follow-up, 186 ophthalmic conditions, 198
illness, history, 183 primary and secondary, 196
neurologic conditions, 184–185 recurrent, 196
non-ophthalmic/non-neurologic Thyroid eye disease (TED), 108, 241
conditions, 186 diagnosis, 83
ophthalmic conditions, 186 examination, 81–82
Squamous cell carcinomas, 235 follow up, 84
Steroid therapy, 63, 212 illness, history, 81
Steroid-sparing agents, 65 neurologic conditions, 83–84
Stiff neck, 205 non-ophthalmic/non-neurologic
Stress headaches, 245 conditions, 84
Stye, 42, 51 ophthalmic conditions, 82–83
Sub-arachnoid hemorrhage, 196 treatment, 84
Subperiosteal abscess, 65 Thyroid orbitopathy, 63
286 Index
Thyroid stimulating immunoglobulin (TSI), 82 Trochlea, 47

Tic douloureux, 132 Trochleitis, 41
Tinted lenses, 129, 130 follow up, 47
Tizanidine, 158 illness, history, 43
Tobradex eyedrops, 125, 129 neurologic conditions, 46
Tocilizumab, 192 non-ophthalmic/non-neurologic
Tolosa Hunt syndrome, 63 conditions, 46–47
diagnosis, 242 ophthalmic conditions, 45
examination, 234, 240 Tropicamide, 218
follow-up, 236, 243, 244 Tuberculous meningitis, 205
ICHD 3 beta, 242
illness, history, 233, 239
neurologic conditions, 235, 241, 242 U
non-ophthalmic/non-neurologic Uhthoff phenomenon, 212
conditions, 236, 242 Unilateral eye pain, 133
ophthalmic conditions, 234, 235, 240, 241 Unilateral photophobia, 166
treatment, 242 Unruptured saccular aneurysm, 253
Topiramate, 113, 117, 123, 125, 217–219 Uveitis, 96
Tortuous right
superior ophthalmic vein, 225
Toxic reaction, 77 V
Transient vision loss (TVL), 161, 164 Valacyclovir, 230
Traumatic fourth nerve palsy, 181 Valsalva maneuver, 173, 175, 217
Triamcinolone, 45, 47, 164 Varicella zoster virus, 229
Trigeminal autonomic cephalgias Vascular compression, 135
(TAC), 163, 166 Venogram, 216
diagnosis, 167 Verapamil, 167
from migraine, 170 Viral meningitis, 203
types of, 168 Visual field defect, 247
Trigeminal neuralgia, 139, 147, 163, 164 Visual loss, 87, 180
causes, 133 cause, 89
evaluation for, 134 non-ophthalmic/non-neurologic
examination, 131–132 conditions, 90
follow up, 135 Vitamin B12 deficiency, 18
ICHD3 beta criteria, 133 Vitamin D, 84
medical treatment, 134
neurologic conditions, 132–134 W
non-ophthalmic/non-neurologic Wegener’s granulomatosis, 89
conditions, 135 Whiplash, 179
ophthalmic conditions, 134 ICHD 3 beta, 180
surgical treatment for, 134 treatment, 180
Triptan, 122

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Michael S. Lee · Kathleen B.

ISBN 978-3-319-65120-0 ISBN 978-3-319-65121-7 (eBook)

Library of Congress Control Number: 2017959569

© The Author(s) 2018

Printed on acid-free paper

This Springer imprint is published by Springer Nature

 Neil R. Miller, M.D., F.A.C.S.

Minneapolis, MN Michael S. Lee

Supported in part by an Unrestricted Grant from Research to Prevent Blindness,

17 Horner syndrome (X) (X) X X (X) (X) +/−

Part I Ophthalmic Disorders Causing Eye Pain:

Part II Ophthalmic Disorders Causing Eye Pain:

Part III Neurologic Disorders Causing Eye Pain:

Part IV Neurologic Disorders Causing Eye Pain:

 ppendix A: List of Tables������������������������������������������������������������������������������ 263

3NP Third nerve palsy

GPA Granulomatosis with polyangiitis

PST Pulse synchronous tinnitus

History of Present Illness

A 63-year-old woman with a history of strabismus status-post childhood corrective

Past medical and ocular history Past surgical history

© The Author(s) 2018 3

Ophthalmic Perspective: Dr. Lee

Neurologic Perspective: Dr. Digre

For Further Study

1. Jackson WB. Management of dysfunctional tear syndrome: a Canadian consensus. Can J

History of Present Illness

Past medical and ocular history Past surgical history

© The Author(s) 2018 9

Ophthalmic Perspective: Dr. Lee

Neurologic Perspective: Dr. Digre

For Further Study

3. Dedes W, Faes L, Schipper I, Bachmann LM, Thiel MA. Phototherapeutic keratectomy (PTK)

History of Present Illness

A 30-year-old woman underwent bilateral laser in situ keratomileusis (LASIK) sur-

Past medical and ocular history Past surgical history

© The Author(s) 2018 15

Ophthalmic Perspective: Dr. Lee

Neurologic Perspective: Dr. Digre

Fig. 3.1 Confocal microscopy

For Further Study

History of Present Illness

Past medical and ocular history Past surgical history

© The Author(s) 2018 21

Fig. 4.1 The patient is focusing on

Ophthalmic Perspective: Dr. Lee

Neurologic Perspective: Dr. Digre

For Further Study

History of Present Illness

Past medical and ocular history Past surgical history

© The Author(s) 2018 27

Medications Review of systems

Ophthalmic Perspective: Dr. Lee

Table 5.1 Drugs causing angle closure glaucoma

Neurologic Perspective: Dr. Digre

The temporal mandibular joint (TMJ) dysfunction confounds the history as

For Further Study

Neil R. Miller, M.D., F.A.C.S.

Minneapolis, MN Michael S. Lee

Part I Ophthalmic Disorders Causing Eye Pain:

Part II Ophthalmic Disorders Causing Eye Pain:

Part III Neurologic Disorders Causing Eye Pain:

Part IV Neurologic Disorders Causing Eye Pain:

ppendix A: List of Tables�� 263

History of Present Illness

Ophthalmic Perspective: Dr. Lee

Neurologic Perspective: Dr. Digre

History of Present Illness

Ophthalmic Perspective: Dr. Lee

Neurologic Perspective: Dr. Digre

History of Present Illness

Ophthalmic Perspective: Dr. Lee

Neurologic Perspective: Dr. Digre

History of Present Illness

Ophthalmic Perspective: Dr. Lee

Neurologic Perspective: Dr. Digre

History of Present Illness

Ophthalmic Perspective: Dr. Lee

Neurologic Perspective: Dr. Digre

History of Present Illness

Neurologic Perspective: Dr. Digre

Ophthalmic Perspective: Dr. Lee

History of Present Illness

Ophthalmic Perspective: Dr. Lee

Neurologic Perspective: Dr. Digre

History of Present Illness

Ophthalmic Perspective: Dr. Lee

Neurologic Perspective: Dr. Digre

History of Present Illness

Ophthalmic Perspective: Dr. Lee

Neurologic Perspective: Dr. Digre

History of Present Illness

Neurologic Perspective: Dr. Digre

Ophthalmic Perspective: Dr. Lee

History of Present Illness

Neurologic Perspective: Dr. Digre

Ophthalmic Perspective: Dr. lee

History of Present Illness

Ophthalmic Perspective: Dr. Lee

Neurologic Perspective: Dr. Digre

History of Present Illness

Ophthalmic Perspective: Dr. Lee