Case Studies in Headache Archive: Treating Trigeminal Neuralgia

By Edmund Messina, MD, Medical Director of the Michigan Headache Clinic in East Lansing, Michigan

While headaches are typically thought to be located around the forehead or back of the head, there are types of headache that strike the face itself. Trigeminal neuralgia is a form of severe facial pain in which patients experience brief volleys of very painful electric shock sensations triggered by mild touch to the face or mouth. This touch can be from washing, shaving, eating, brushing the teeth or even talking. The trigger zones are particularly sensitive in the area between the nose and mouth or on the chin. Continue Reading

Case Studies in Headache Archives: Temporal Arteritis

By Robert Kunkel, MD, Consultant, Center for Headache and Pain Neurological Institute, Cleveland Clinic, Cleveland, OH


I first saw George on March 12, 2008. He was 75 years old and had had a headache since December 12, 2007, when he slipped on ice and fell. He said he didn’t hit his head, but he had left-sided neck and head discomfort afterward, which had persisted. He had high blood pressure, which was well controlled, but no other significant medical problems.

George described the head pain as “sharp” and constant in character. It was strictly on the left side and involved the left neck and upper shoulder area, the back of the head and spread forward above the left ear into the temple. It was not aggravated by neck motion, coughing or straining. He had a CT scan of the brain in January of 2008, which was negative, and a CT scan of his neck showed only mild degenerative arthritic changes. He was referred for physical therapy, which helped the neck pain but had no effect on his headache.

In February, his primary care physician diagnosed him with occipital neuritis and he was put on a dose of prednisone (a cortisone) that was tapered over the course of seven days. His head pain was completely gone for a few days but recurred when he reduced the dose. In addition to the head discomfort, George reported that he felt tired and had a lack of stamina. While taking the prednisone, he “felt like a new man.”

When I examined him, he had been off of prednisone for over two weeks. The exam was normal, including his blood pressure, except for mild tenderness with pressure over the left lower neck and at the base of the skull. His neck motion was slightly reduced.

On the presumption that this was a form of occipital neuralgia, we injected his occipital nerve with a mixture of an injectable cortisone preparation and a local anesthetic. Following this procedure, he was free of pain for five days.

Because this was a new headache for George, and because of his response to the prednisone, the diagnosis of temporal arteritis was also considered. On lab testing, he had an elevated sedimentation rate (sed rate), which reflects inflammation in the body. His sed rate was 70 while a normal level is between 0 and 20. Because of this elevated sed rate, we had a biopsy of the left temporal artery done one week after his first visit. His headache had returned by then and the biopsy showed active inflammation in the artery wall, which is typical of temporal arteritis. He was started on a daily dose of 60 mg. of prednisone along with extra calcium and vitamin D. Continue Reading

Sharing My Headache Story with NHF – Terri

My constant daily headaches began 36-years ago and they continue. The onset was sudden and I remember the day very well with extreme pain one evening. My head has constant pressure 24/7 from the occipital area to the top of my head. As the day goes on, eye pressure pain builds as the headache tends to worsen. I always feel like I have a vice on my head…squeezing my skull and neck muscles. Sometimes, the intense pain is felt before I even open my eyes in the morning, but typically the pain grows stronger as the day goes on. I AM NEVER WITHOUT PAIN! Continue Reading

Case Studies in Headache: Intercranial Hypertension

By Anne H. Calhoun, M.D.
Partner and co-founder of the Carolina Headache Institute, Chapel Hill, North Carolina


For the last year, Janice has had frequent headaches with nausea and vomiting. The headaches vary throughout the day, from mild to severe and from steady to throbbing. They are worse with lifting heavy objects or coughing. Janice often hears her pulse “whooshing” in her right ear and has begun noticing double vision and even some visual dimming for a few seconds after bending over. She is 37 years old and weighs 192 pounds.


This uncommon disorder, which affects about 1 in 100,000 individuals, is known by a variety of descriptive names. One is pseudotumor cerebri, Latin for “false brain tumor.” Another is benign intracranial hypertension, indicating that it isn’t life-threatening. Today, however, most would agree that a disorder with a capacity to cause blindness is hardly benign, so the preferred name is idiopathic intracranial hypertension, or IIH, which means that, for unknown reasons, there is increased pressure inside the skull.

Symptoms of IIH include headache, nausea, vomiting, visual problems and pulsating sounds within the head. Although IIH is not associated with increased mortality, it may cause progressive and permanent visual loss.

Women are up to eight times more likely to develop IIH than men, and obesity is the strongest predisposition for the disorder. Women who are more than 20% above their ideal weight are 19 times more likely to develop IIH. Interestingly, the same measure of obesity in men only conveys a five-fold higher risk.

“Idiopathic” means that the cause is unknown, so IIH can only be diagnosed in the absence of identified causes, such as a tumor. Diagnostic evaluation for IIH usually includes computed tomography (CT) or magnetic resonance imaging (MRI). If the problem is IIH, these tests will fail to show a mass or other cause of the symptoms. An MR venogram (radiograph of the veins) should exclude the possibility of any barriers to blood flow in the veins or cerebral venous sinus thrombosis (a rare form of stroke). A lumbar puncture characteristically demonstrates increased cerebrospinal fluid pressure and may provide pain relief with the removal of cerebrospinal fluid.

Factors that can produce the increased intracranial pressure associated with IIH include uncommon reactions to a number of medications including high-dose vitamin A derivatives (often used to treat acne), tetracycline antibiotics (such as minocycline), steroids or hormonal contraceptives. Non drug-related causes include obstructive sleep apnea, systemic lupus erythematosis, chronic kidney disease and hypothyroidism or excessive replacement of thyroid hormone.

When IIH is confirmed, close follow-up with repeated eye exams is needed to monitor any changes in vision. Weight loss may lead to improvement, while drugs such as acetazolamide may be used to reduce cerebrospinal fluid buildup and relieve pressure.

Surgery is normally offered only when medical therapy is unsuccessful, with two procedures most commonly employed: (1) shunts (placing a plastic tube to drain cerebrospinal fluid) and (2) optic nerve sheath decompression and fenestration (making an incision in the lining of the optic nerve behind the eye). The later procedure is primarily recommended for individuals who have limited headache symptoms, but significant threat to vision, or in those in whom a shunt was unsuccessful. In cases of severe obesity, gastric bypass surgery has also been associated with marked improvement in IIH symptoms. All of these procedures have attendant risks and complications, however, and all may eventually fail to control the symptoms.

For most patients, IIH will go into spontaneous remission or resolve with treatment. However, for some, it may continue chronically and in about half the cases that achieve remission, symptoms will recur.

With strong motivation, diet and exercise, Janice lost 13 pounds. This weight loss—along with aggressive medical therapy—led to a good clinical response. Her vision remains stable with no IIH-associated visual loss, but Janice understands the need for long-term follow-up to ensure that her symptoms do not return.