Chronic Paroxysmal Hemicrania in a Patient with a Macroprolactinoma

Abstract

We report a patient with headaches meeting the criteria of chronic paroxysmal hemicrania, as defined by the International Headache Society classification. Headaches were fully responsive to indomethacin during the first 3 months of treatment but recurred when daily doses were lowered. Investigations revealed a macroprolactinoma. Headaches stopped after cabergoline treatment. This report further suggests that patients with paroxysmal hemicrania should be investigated for pituitary abnormalities.

The Association of Pituitary Tumors and Headache

“…The most common headache syndrome observed in association with pituitary tumors is chronic migraine, often occurring in patients with previous migraine [4,[17][18][19]. There is an increased prevalence of trigeminal autonomic cephalgias (TACs) in patients with pituitary tumors compared with the general population [20•], which includes cluster headache [4,7,11,12], SUNCT (short-lasting, unilateral, neuralgiform headache attacks with conjunctival injection and tearing) [4,6,8,9], paroxysmal hemicrania [21], and hemicrania continua [6]. There are also descriptions of "trigeminal neuralgia" occurring with pituitary tumors [14][15][16]22], although some of these historical cases would probably now be classified as TACs.…”

Headache and brain tumors

“…Dopamine agonists are used for the medical management of prolactinomas, but in the series reported by Levy et al [28,29]. This effect is not consistent, as others have reported chronic paroxysmal hemicrania (CPH) and cluster-like headache associated with prolactinomas responding well to dopamine agonists [30][31][32].…”

“…Only one of nine cases of HC and no cases (out of seven) of SUNCT were associated with tumors. Other cases of CPH have been reported in a patient with multiple cranial metastases, including one in the right cavernous sinus and in another patient with a macroprolactinoma [32,36]. SUNCT syndrome has been associated with lesions in a number of locations.…”

Chronic headache and pituitary tumors

“…There are numerous case reports of pituitary tumors presenting with the entire range of headache disorders (Table 1), including migraine [16][17][18], cluster headache [4,[19][20][21], SUNCT [5,22,23], hemicrania continua [5], paroxysmal hemicrania [6], and "trigeminal neuralgia" [8][9][10]24]. On close inspection of the literature, some of the cases labeled as trigeminal neuralgia appear to have had cranial autonomic features [24], suggesting the presence of a trigeminal autonomic cephalalgia.…”

“…Growth hormone-secreting pituitary tumors are particularly associated with headache that may be successfully aborted with somatostatin analogues [3]. Prolactinomas have been reported in association with cluster headache [4], SUNCT (shortlasting, unilateral, neuralgiform headache attacks with conjunctival injection and tearing) [5], paroxysmal hemicrania [6], and hemicrania continua [5], and the administration of dopamine agonist therapy can lead to either a dramatic improvement or exacerbation of symptoms [5]. These observations have led to the hypothesis that headache may have a biochemical basis in certain pituitary tumors.…”