Primary trochlear headache. A periorbital pain with a specific diagnosis and treatment

The Pediatric Trochlear Migraine: Diagnostic and Therapeutic Implications

“…After our first publication [ 9 ], other descriptions of PTM or probable PTM [ 10 , 11 ] have been added to the literature supporting the non-rarity of this clinical presentation in children. However, it should be specified that Sanchez Ruiz et al, defined their case as Primary Headache Trochlea [ 10 ] although the child described was an adolescent patient with a history of migraine, who showed episodic painful unilateral infratrochlear attacks associated with moderate photophobia as well as abdominalgia and incoercible vomiting, satisfying the criteria for migraine despite the atypical localization. Unfortunately, the authors did not describe other aspects regarding this potential case of “pure” TM and did not report the effects of local therapy on previous migraine attacks.…”

“…From the description of these cases [ 9 , 10 , 11 ] together with our case series, it is possible to define the main characteristics of this potential type of migraine: the initial infra-trochlear localization of pain in many attacks; the episodic frequency of the attacks; the duration of the attack must be >2 h; the pain is throbbing as in a typical migraine; frequent alternation of sides; the presence of associated autonomic signs such as nausea, vomiting (typical of a migraine attack); the reduction of pain at infra-trochlear compression, similar to the reduction of pain at temporal compression typical in children with migraine; the possible presence of local autonomic signs; irradiation of the episodes in the temporal-frontal area unilaterally, and possible painfulness in movements; the presence of typical migraine attacks in addition to those of PTM. : “In addition, the good response to 5 HT1 agonists (see Sumatriptan), specific drugs in the therapy of migraine further supports the diagnosis of migraine”.…”

“…In Table 1 , we summarize the main clinical features of our four patients [ 10 ] and the Sanchez-ruiz et al’s case report compared to the Yanguela et al [ 2 ] cases defined as Trochlear Migraine.…”

“…Therefore, its sensory innervation can send nociceptive afferents to the trigeminal nerve and can thus constitute an activation point for migraine, with pain originating from the periorbital area that can radiate to the ipsilateral frontal site [ 13 , 14 ]. The reported cases, in fact, presented exemplary examples, where attacks with a more typical site (fronto-temporal) alternated with attacks at infra-trochlear site, due to the probable presence of trigger points in this site [ 9 , 10 , 12 ]. It is possible, in those cases with attacks strictly localized in the unilateral superior-inner angle of the orbit and no other main localizations, that there would be a peripheral locus of the genesis of migraine pain [ 13 , 14 ] which is especially alternating and exclude a secondary peripheral cause.…”

“…According to our interpretation, this was due to a form of migraine with atypical localization and typical characteristics of migraine, the “Pure Trochlear Migraine”, which has been differentiated from Primary Trochlear Headache and Secondary Trochleitis [ 9 ]. Furthermore, to our opinion, other pediatric cases of that resemble possible “Pure trochlear migraine”, following the clinical description of PTH [ 10 ], have been also reported or included in mixed clinical series of adolescents and adults [ 11 ].…”