Headache for the ophthalmologist

Neruro-ophthalmic Causes of Headache

Raed Behbehani , MD FRCSC

Pain•Periocular pain due to diseases of the face, orbit, sinuses , and intracranial cavity.•Trigeminal innervation (V1-V3).

•Primary headache syndrome vs Secondary headache syndrome

Approach• Any headache can cause eye pain (vice versa).• Take good history ( loss of vision, diplopia, redness, photophobia, jaw claudication, systemic symptoms).• Examination : check vision at least grossly, look for redness, ptosis, corneal edema, check pupil reactions, palpate the eyes and orbits, check sensation v1-v3 and other cranial nerves.•FUNDOSCOPY !

Primary Headache Syndrome• Migraine (with / without aura)•Cluster Headache .•Tension Headache.•Chronic Daily Headache.•Medication overuse.

Secondary Headache Syndrome• Ocular disease.• Orbital disease.• Vascular disease.• Intracranial disease .

Ocular Disease

Dry eye syndrome• Inadequate tear production.• Primary / Secondary to rheumatological conditions.• Slit lamp examination : Flourescin stain/ Rose bengal• Artificial tears/ punctal occlusion is the treatment.

Inflammation

Uveitis• Anterior/Posterior Uveitis.•Pain and Photophobia.• Cells in the anterior chamber/ Ciliary injection/ Posterior synechiae.• Idiopathic/ associated with rheumatologic conditions/ infectious (post-operative).• Topical steroids for anterior / periocular and systemic for posterior• Intravitreal antibiotics for infectious post-operative.

High intra-ocular pressure

Acute Angle-Closure Glaucoma• Severe periocular pain +- headache.• Blurred vision , nausea , and vomiting.• Cilliary injection/ corneal edema/ fixed mid-dilated pupil.• Previous history of transient visual disturbances .• Laser iridotomy.

Vascular disease

Giant-Cell Arteritis• New onset of headache (temporal) , acute or transient loss of vision, jaw claudication, weight loss, fever, and myalgias.• Age over 60.• Anterior/posterior ischemic optic neuropathy• Retinal artery occlusion.• ESR, CRP, CBC.• Systemic steroids ( oral or IV).• Temporal artery biopsy.

Ocular ischemic syndrome.• Deep boring pain in the eye upon standing up or with sustained exposure to light (ocular claudication) .•Impaired retinal cicrulation due stenosis of the aoortic arch/carotids.• Fundus examination shows sign of ischemia (dilated retinal veins, hemorrhages, cotton wool spots, neovascularization).• ? Carotid endarterectomy.

Ocular Ischemic Syndrome

Accommodative Spasm• Incorrect glasses/ contact lenses.• Uncorrected presbyopia.

Orbital Disease• Optic neuritis.• Orbital inflammtory disease.• Orbital mass.• Orbital vascular malformation.

Orbital inflammation• Sudden onset. •Pain, proptosis, limited eye movement, chemosis.• Idiopathic or due to Wegener’s granulmatosis, Grave s’ disease, sarcoidosis)

Carotid-Cavenous Fistula

Intracranial

High-intracranial pressure• Can be primary (pseudo-tumor cerebri) or secondary (mass, hemorrhage)• Headache, pain in the neck and shoulders and upper back.•Worse with coughing/straining.•Pulsatile tinnitis.•Transient visual obscurations.• Diplopia. • Treatment of pseudotumor cerebri is Medical ( Diamox ) or Surgical (Optic nerve sheath fenstration, V-P or V-A shunt).

Sudden headache/ eye pain

Summary• Take good history ( try to distinguish primary from secondary headache syndrome).• Look for abnormal neuro-ophthalmic signs ( Ptosis, ophthalmoplegia, abnormal facial sensation, check visual acuity, and pupils, and look for papilledema).• Giant cell arteritis is vision-threatening.• Papilledema ican be life threatening.