Diagnosis and Management of Trochleodynia, Trochleitis, and Trochlear Headache

Tran, Tu M.; McClelland, Collin M.; Lee, Michael S.

doi:10.3389/fneur.2019.00361

Cited by 27 publications

(25 citation statements)

References 56 publications

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“…Similar to our study, previous studies have also reported a variable (10-60%) prevalence of prior history of headaches in patients with CTRH. 6,7 In our CTRH group, binocular diplopia was reported by nearly 50% patients, local swelling was noted only with trochleitis and MRI orbit abnormalities only with ST. These findings are similar to the study conducted by Smith et al 7 Refractoriness to prophylaxis was found to be associated with acute-subacute onset, TTH-like headaches, local swelling, and presence of autoantibodies.…”

Section: Discussionmentioning

confidence: 63%

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Failure to identify underlying autoimmunity and primary headache disorder might be the reasons for refractoriness of trochlear headaches

Ojha¹,

Aglave

Basak³

et al. 2020

Cephalalgia Reports

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Introduction: A better understanding of etiology might improve poor outcomes of trochlear headaches (TRHs). Aims: To study clinical spectrum, etiology, and therapeutic response of TRH. Methods: Fifty-three TRH patients seen in a single center between 2015 and 2020 were included, excluding Trigeminal Autonomic Cephalalgia (TAC). Results: Mean age was 36.45 years (range 11–85 years), with 77.35% being females. Twenty-five patients had continuous trochlear headache (CTRH) and 28 episodic trochlear headache (ETRH). Tension-type headache (TTH) occurred in 9 ETRH patients and 24 of 25 CTRH patients, and migraine-like headaches occurred in 19 ETRH patients and 8 CTRH (trochlear migraine) patients. Prior history of headaches was noted in 22 of 28 ETRH and 11 of 25 CTRH patients. Twenty-eight responded to migraine/TTH prophylaxis, 25 being nonresponders (partial/no response). Fourteen of 25 nonresponders, 4 of 28 responders (4 of 4 secondary and 5 of 9 idiopathic trochleitis (IT), 3 of 9 primary TRH (PTRH), and 6 of 28 ETRH) had autoantibodies, that is, 11 antinuclear antibodies (ANAs) and 7 antithyroid antibodies. Ten of 14 (71.42%) antibody-positive nonresponders improved with immunosuppressants including steroids/hydroxychloroquine and only 11 required local injections. Finally, 38 patients had good response, 13 partial, and 2 no response. The etiology and refractoriness of IT can be attributed to underlying autoimmunity and a minor contribution by primary headaches, vice versa being the case for PTRH and ETRH. Refractory TRHs should be evaluated for underlying autoimmunity and primary headaches. Conclusion: Identification and treatment of underlying autoimmunity and primary headaches can help improve outcome of TRH.

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Section: Discussionmentioning

confidence: 63%

“…A likely explanation for this observation is that most of these studies included only severe cases requiring local injections. 2,6,7 Local injections were found necessary in less than half of our refractory patients.…”

Section: Discussionmentioning

confidence: 85%

Failure to identify underlying autoimmunity and primary headache disorder might be the reasons for refractoriness of trochlear headaches

Ojha¹,

Aglave

Basak³

et al. 2020

Cephalalgia Reports

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“…All of these headaches are linked to V1, but little is known about their molecular pathophysiology. This is also the case for trochleodynia which is a spectrum of disorders characterized by pain arising from the trochlear region [122] and idiopathic ophthalmodynia [123] which is linked to pain in the eyeball.…”

Section: Other Painful Conditionals Of the Trigeminal Nerve Branchesmentioning

confidence: 95%

The fifth cranial nerve in headaches

et al. 2020

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The fifth cranial nerve is the common denominator for many headaches and facial pain pathologies currently known. Projecting from the trigeminal ganglion, in a bipolar manner, it connects to the brainstem and supplies various parts of the head and face with sensory innervation. In this review, we describe the neuroanatomical structures and pathways implicated in the sensation of the trigeminal system. Furthermore, we present the current understanding of several primary headaches, painful neuropathies and their pharmacological treatments. We hope that this overview can elucidate the complex field of headache pathologies, and their link to the trigeminal nerve, to a broader field of young scientists.

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“…Some patients may report deep seated pain retro-orbitally with down radiation to the neck [32]. Localized trochlea pain/tenderness as pointed by a patient which is aggravated by stress physically or emotionally or contraction of superior oblique (SO) muscle and headache on the front side from the superior nasal orbit extending periorbitally to ipsilateral boundaries is useful to distinguish clinically trochleodynia from THS, therefore in the deficit of a CN palsy neuroimaging is not recommend for trochleodynia exclusion [33].…”

Section: Presenting History/symptomsmentioning

confidence: 99%

Tolosa Hunt Syndrome: Current Diagnostic Challenges and Treatment

Msigwa¹,

Li²,

Cheng³

2020

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Tolosa-Hunt syndrome (THS) is an uncommon diagnosis with an incidence of nearly 1 to 2 cases per million hallmarked by the presence of painful ophthalmoplegia (PO) due to a granulomatous inflammation (GI). Diagnostically, the major THS challenges encountered are owing to the exclusion of other GI presenting conditions necessitating multi-specialization consultations. This article presents uniquely advances in diagnosis and challenges encountered attempting to exclude THS mimics, details on physical examination and laboratory investigations have been incorporated. Tolosa Hunt MRI protocol (contrast-enhanced MRI), restricted diffusion and CISS MRI have lately proved to be precise investigations for THS diagnosis and follow up, on the contrary, number of false-negative/positive MRI diagnoses appears to be rising, hence proposed that MRI or biopsy shouldn't be mandatory criteria for diagnosis as opposed to IHS 2018 guidelines. Despite corticosteroids being the cornerstone therapy for THS, there are controversies concerning the better administration route, optimal dosage, and therapy longevity, through case reports, high dose IV mPSL of 500 mg BID for 3 days, followed with maintenance dose of prednisone 60 mg resulted in the earliest recovery, hereafter standardized guidelines are required. Alternatively, infliximab (300 mg infusion), azathioprine, methotrexate, and acupuncture can be used, farther studies are required to appraise the effectiveness and their safety. On the other side, microsurgery can be utilized for GI evacuation however associated risks of permanent CN VI palsy have been stated, nonetheless, GKRS can be employed when contraindication or corticosteroid intolerability exists though the hazard of late malignancy is a drawback.

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Diagnosis and Management of Trochleodynia, Trochleitis, and Trochlear Headache

Cited by 27 publications

References 56 publications

Failure to identify underlying autoimmunity and primary headache disorder might be the reasons for refractoriness of trochlear headaches

Failure to identify underlying autoimmunity and primary headache disorder might be the reasons for refractoriness of trochlear headaches

The fifth cranial nerve in headaches

Tolosa Hunt Syndrome: Current Diagnostic Challenges and Treatment

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