Update on the diagnosis and management of Trigemino-Autonomic Headaches

Abstract

Severe shortlasting headaches are rare but very disabling conditions with a major impact on the patients' quality of life. Following the IHS criteria, these headaches broadly divide themselves into those associated with autonomic symptoms, so called trigeminal autonomic cephalgias (TACs), and those with few autonomic symptoms. The trigeminal-autonomic cephalgias include cluster headache, paroxysmal hemicranias, and a syndrome called SUNCT (short lasting unilateral neuralgic cephalgias with conjunctival injection and tearing). In all of these syndromes, hemispheric head pain and cranial autonomic symptoms are prominent. The paroxysmal hemicranias have, unlike cluster headaches, a very robust response to indomethacin, leading to a notion of indomethacin-sensitive headaches. Although TACs are, in comparison with migraine, quite rare, it is nevertheless very important to consider the clinical factor that they are easy to diagnose and the treatment is very effective in most patients.

Emotional modulation of autonomic responses to painful trigeminal stimulation

“…Indeed, autonomic responses can be used in conjunction with self-reported pain and nociceptive blink reflexes to provide a comprehensive assessment of responding to trigeminal nociceptive input. Evidence is currently equivocal whether autonomic system function contributes to headpain disorders (Feuerstein et al, 1982;Kroner-Herwig et al, 1993;Leistad et al, 2007;May, 2006;Obermann et al, 2007;Rubin et al, 1985). Nonetheless, assessing supraspinal modulation of autonomic reactivity to trigeminal stimulation in persons with head and craniofacial disorders could provide insight into their pathophysiology.…”

“…Consistent with prior findings, results indicated pain and nociceptive blinks were facilitated during unpleasant pictures and inhibited during pleasant pictures, with the valence linear tend explaining 51% of the variance in pain and 25% of the variance in nociceptive blinks (Williams and Rhudy, in press). The autonomic nervous system and its supraspinal controls have been implicated in the initiation and maintenance of headaches (via abnormalities in the hypothalamic generator), and autonomic symptoms are common among some types of headaches (e.g., cluster headache, migraine) (May, 2006;Obermann et al, 2007). Therefore, it seems natural to extend the ECON paradigm to study modulation of autonomic responses to painful stimulation of the trigeminal nerve.…”

Orofacial pain management: current perspectives

“…These headaches require neurological evaluation and management; therefore, it is of fundamental importance to make an appropriate differential diagnosis to avoid unnecessary dental treatments or being misdiagnosed as other types of orofacial pains of non neurovascular etiology. Detailed reviews of trigeminal autonomic cephalalgias and their treatment can be found elsewhere 166–168…”

Italian guidelines for primary headaches: 2012 revised version

“…The objectives of a correct and effective symptomatic treatment are (1) to treat the attack when it starts; (2) to obtain pain relief as soon as possible (possibly within 15 min from the administration of the drug); (3) to limit to a minimum the adverse events [247]. …”