The trigeminal autonomic cephalgias are a group of primary headache disorders characterised by unilateral trigeminal distribution pain that occurs in association with prominent ipsilateral cranial autonomic features e.g.
- Ptosis; miosis; Nasal stuffiness; Nausea/vomiting; Tearing; eye lid oedema
NB IMPORTANT: Anyone with new onset, unilateral cranial autonomic features requires imaging with MRIb/MRIangio to exclude vascular/mass causes that could have severe consequences
Cluster Headache
- Men>Women
- 30-40 years old
- Circadian and seasonal
- Severe unilateral headache lasting 45-90 mins (20mins – 3hrs)
- Occurring 1-8 times/day
- Occur in ‘clusters’ that can last weeks/months
- Treat with
- Acutely: high flow oxygen (100%) and subcut sumatriptan (6mg)
- Short-term: Steroids (2 weeks- reducing dose)
- Long-term: Verapamil (prophylaxis)
Paroxysmal Hemicrania
- Women > Men
- 50-60 years old
- Severe unilateral headache with pronounced unilateral autonomic features
- Lasting 10-30mins (2-45mins)
- Occurring 1-40 times/day
- i.e. shorter duration but more frequent than cluster
- Treat with indomethacin (patients usually have an absolute response)
Hemicrania continua
- Essentially the same as P/H but features are persistent
- There is an equally good response to indomethacin
Short lasting Unilateral Neuralgiform headache with Conjunctival Tearing/injection- SUNCT
- Male > Female
- Short lived (15-20 sec), unilateral neuralgiform (i.e. nerve pain) headache
- With conjunctival tearing or injection (dominant autonomic feature)
- Treat with gabapentin
Trigeminal Neuralgia (technically not a TAC as there are rarely any autonomic features)
- Women>Men
- More common in the elderly
- Pain is triggered by touch and usually occurs in a particular facial distribution (V2 or V3)
- Pain is severe and stabbing; brief (1-90sec) but can occur 10-100 times/day
- Bouts of pain may last weeks/months before any sort of remission
- Treat with carbemazepine/gabapentin/phenytoin/baclofen
- Surgery may also be used to ablate/decompress the affected nerve
- MRI is only indicated if there are focal signs, atypical features, poor response to medication or prior to surgery
Persistent Idiopathic Facial Pain (Stabbing Headache)
- This is a diagnosis of exclusion and is usually treated with indomethacin (see above table)
Notes on Medicine/Surgery 