Your answer Was Incorrect
NEUROSAE 2018 ANNUAL MEETING EDITION (VOLUME 10, ISSUE 3)
QUESTION 62 OF 100
A 45-year-old man who presents with a headache and facial pain reports a 4-year history of headaches. The pain is localized to the right cheek, jaw, and retro-orbital area but does not radiate to the left side. He describes the pain as stabbing and exploding, with episodes of dull pain after the exploding pain subsides. The stabbing/exploding pain lasts about 10 minutes, but the dull pain can last up to 30 minutes. During the episodes of stabbing pain, his right eye tears, and he becomes sensitive to light, develops nausea, and closes his eyes. His wife states the right eye also becomes droopy. He usually experiences two episodes a day, almost exclusively in the morning. Results of a neurologic exam are unremarkable, and sensation in V1, V2, V3 is intact. Examination reveals mild to moderate tenderness over the right temporomandibular joint, temporal area, and greater and lesser occipital areas. MRI scans of the brain are shown. Which of the following is the most likely diagnosis?
A. Paroxysmal hemicrania
B. Trigeminal neuralgia
C. Tolosa-Hunt syndrome
D. Cluster headache **
E. Cerebellar tumor
** = Your answer
In patients with unilateral (i.e., side-locked) headache and facial pain associated with some autonomic characteristics, trigeminal autonomic cephalalgia syndrome is the principal differential diagnosis. Within this category, the patient meets the criteria for paroxysmal hemicrania. The most important feature that differentiates this category of headache disorders is the time each individual attack occurs, which in this case rules out a diagnosis of cluster headache.
Trigeminal neuralgia has a much shorter duration (seconds) and typically is characterized as a jabbing, electric shock-like pain. Pain in trigeminal neuralgia is triggered by specific actions, such as chewing, teeth brushing, and touching. Tolosa-Hunt syndrome is described as episodic orbital pain associated with paralysis of one or more of cranial nerves III, IV, and/or VI and usually resolves spontaneously but tends to relapse and remit.
The patient’s MRI scans show prominence of the extra-axial space in the posterior fossa, most likely representing a large cerebellar cistern or arachnoid cyst. This is a common incidental finding in MRI scans with no clinical significance.
* Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia. 2013 Jul;33(9):629-808.