What are Trigeminal autonomic cephalgias (TACs)
A group of primary headache disorders characterised by unilateral trigeminal distribution pain that occurs in association with prominent ipsilateral cranial autonomic features.
What are the Ipsilateral cranial autonomic features present in trigeminal autonomic cephalgias (TACs)?
- Ptosis (drooping eyelid)
- Miosis (constricted pupil)
- Nasal Stuffiness
- Nausea/ vomiting
- Tearing
- Eye lid oedema
What are the 4 main types of Trigeminal autonomic cephalgias (TACs)?
- Cluster headaches
- Paroxsymal hemicrania
- Hemicrania continua
- SUNCT
Who usually gets cluster headaches ?
- Young (30s-40s)
- Men> women
What are the characteristic features of cluster headaches ?
- Rapid-onset of excruciating pain around one eye that may become watery and bloodshot with lid swelling
- Lacrimation (tearing)
- Facial flushing
- Rhinorrhoea
- Miosis +/- pitosis
- Pain is strictly unilateral and almost always affects the same side
How long do cluster headaches usually last and how often do they occur ?
- Lasts around 45- 90mins (20 mins-3 hours)
- Frequency: 1 to 8 day
- Often noctural Clusters last a few weeks to months followed by pain free periods of months or even years before the next cluster
What is the treatment of cluster headaches ?
- High flow oxygen 100% for 20 mins
- Sub cut sumatriptan 6mg
- Steroids- reducing course over 2 weeks
- Verapamil for prophylaxis
Who is usually affected by Paroxysmal hemicrania?
- Elderly (50s-60s)
- women> men
What are the features of a Paroxysmal hemicrania and how long do they last?
- Involves one-sided attacks (headaches) that have closely similar characteristics of pain and associated (autonomic) symptoms of cluster headache (CH) but symptoms tend to be much shorter
- Lasts between 10-30 minutes, but can be as short as two minutes or as long as 45 minutes
- They also tend to occur on average more frequently than CH (five per day or more - and sometimes up to 40 per day)
What is the treatment of a paroxysmal hemicrania ?
Absolute response to indomethicin
What is suggestive of hemicrania continua ?
In HC, the pain is present 24 hours per day, 7 days per week, continuously for at least 3 months. The continuous headaches are typically 6-7/10 intensity, but with frequent worsening, usually to severe pain, as often as daily or many times per week.
The same associated autonomic symptoms can be present
Like paroxymsal hemicrania it is treated with indomethacin
As with all the TCA’s features are unilateral
Whata are the features suggestive of SUNCT Syndrome?
Also manifests itself as a one-sided headache and is associated with the autonomici symptoms as described in cluster headache (CH)
- S= Short lived (15-120 secs), can occur up to 30 per hour
- U=unilateral
- N= neuralgiaform headache
- C= conjunctival injections
- T= Tearing
What is the treatment of SUNCT syndrome ?
Lamotrigine or Gabapentin
What investigations is required for all with new onset unilateral cranial autonomic features (Trigeminal autonomic cephalgias (TACs))
MRI brain and MR angiogram
Who is typically affected by trigeminal neuralgia ?
- Elderly (>60)
- women>men
What are the characteristic features of trigeminal neuralgia ?
- Intense, stabbing pain lasting seconds in the trigmenal nerve distribution
- It is unilateral typically affecting the mandibular or maxillary divisions (CN V2,3)
How long do symptoms of trigeminal neuralgia last and how often do they occur ?
- Duration: 1sec to 90 secs
- Frequency: 10 to 100 day
- Bouts pain may last from a few weeks to months before remission
What are the tiggers of trigmeninal neuralgia?
Triggered by touch e.g. shaving, eating, talking, dental prostheses
What are the treatment options for trigeminal neuralgia ?
- Pharmacological options - 1st line = Carbamazepine
- Gabapentin, phenytoin, baclofen are other options
- Surgical if pharmacology fails - abalation vs decompression
What investigations may be done when someone presents with trigemnial neuralgia ?
MRI brain if any signs on examination, atypical features, a poor response to medical treatment or if surgical treatment is being consider
