Primary trochlear headache: A new cephalgia generated and modulated on the trochlear region

Abstract

Some patients complain of periorbital pain, emanating from the trochlear area, in absence of trochleitis or other orbital or systemic disease. In these patients, adequate pain control may require local treatment rather than systemically administered medications. The goal of this study was to evaluate the role of the trochlear area in causing and modulating headache. Trochlear pain was defined as pain on this area, exacerbated upon examination and looking in supraduction. Pain was evaluated after trochlear injections of lidocaine, corticosteroids, and placebo. Secondary orbital pain was ruled out. Seventeen women and one man were evaluated (mean age: 44 years). All presented unilateral pain in the trochlear area (60% reported more extended headache), for more than 1 year in 70%. Neither ocular autonomic signs nor motility restrictions were observed. Imaging studies were normal in 100%. The temporal pattern was either chronic or remitting, with acute exacerbations. Pain increased at night in 55%. A total of 62% presented concurrent headaches. Locally injected corticosteroids relieved the pain within 48 hours in 95% and also improved concurrent headaches, by decreasing attack frequency and analgesics intake. Placebo was not helpful. Relapses were observed in 45% (average 8 months). The authors conclude that the trochlear region is the origin of a specific and unrecognized headache, which they have named “primary trochlear headache”. Local treatment at the level of the trochlear area seems to be helpful.—Valerie Biousse Some patients complain of periorbital pain, emanating from the trochlear area, in absence of trochleitis or other orbital or systemic disease. In these patients, adequate pain control may require local treatment rather than systemically administered medications. The goal of this study was to evaluate the role of the trochlear area in causing and modulating headache. Trochlear pain was defined as pain on this area, exacerbated upon examination and looking in supraduction. Pain was evaluated after trochlear injections of lidocaine, corticosteroids, and placebo. Secondary orbital pain was ruled out. Seventeen women and one man were evaluated (mean age: 44 years). All presented unilateral pain in the trochlear area (60% reported more extended headache), for more than 1 year in 70%. Neither ocular autonomic signs nor motility restrictions were observed. Imaging studies were normal in 100%. The temporal pattern was either chronic or remitting, with acute exacerbations. Pain increased at night in 55%. A total of 62% presented concurrent headaches. Locally injected corticosteroids relieved the pain within 48 hours in 95% and also improved concurrent headaches, by decreasing attack frequency and analgesics intake. Placebo was not helpful. Relapses were observed in 45% (average 8 months). The authors conclude that the trochlear region is the origin of a specific and unrecognized headache, which they have named “primary trochlear headache”. Local treatment at the level of the trochlear area seems to be helpful.—Valerie Biousse