Download Clinical Features and Long-Term Prognosis of Trochlear Headaches

European Journal of Neurology 2013
doi:10.1111/ene.12312
Clinical features and long-term prognosis of trochlear headaches
J. H. Smitha, J. A. Garrityb and C. J. Boesc
a
Department of Neurology, University of Kentucky, Lexington, KY; bDepartment of Ophthalmology, Mayo Clinic, Rochester, MN; and
c
Department of Neurology, Mayo Clinic, Rochester, MN, USA
Keywords:
chronic daily headache,
migraine, neuroophthalmology, ocular
movements, secondary
headache disorders,
trochlea, trochleitis
Received 13 September 2013
Accepted 21 October 2013
Background and purpose: Trochlear headaches are a recently recognized cause of
headache, of which both primary and inflammatory subtypes are recognized. The
clinical features, long-term prognosis and optimal treatment strategy have not been
well defined.
Methods: A cohort of 25 patients with trochlear headache seen at the Mayo Clinic
between 10 July 2007 and 28 June 2012 were identified.
Results: The diagnosis of trochlear headache was not recognized by the referring
neurologist or ophthalmologist in any case. Patients most often presented with a new
daily from onset headache (n = 22, 88%). The most characteristic headache syndrome
was reported as continuous, achy, periorbital pain associated with photophobia and
aggravation by eye movement, especially reading. Individuals with a prior history of
migraine were likely to have associated nausea and experience trochlear migraine.
Amongst individuals with trochleitis, 5/12 (41.6%) had an identified secondary mechanism. Treatment responses were generally, but not invariably, favorable to dexamethasone/lidocaine injections near the trochlea. At a median follow-up of 34 months
(range 0–68), 10/25 (40%) of the cohort had experienced complete remission.
Conclusions: Trochlear headaches are poorly recognized, have characteristic clinical
features, and often require serial injections to optimize the treatment outcome. The
identification of trochleitis should prompt neuroimaging to look for a secondary
cause.
Introduction
The trochlea is a saddle-like cartilaginous structure
located in the superomedial orbit, which contains the
tendon of the superior oblique muscle. Histologically,
the trochlea is surrounded by a synovial membrane,
analogous to the structure of a joint [1]. The trochlea
is innervated by an ophthalmic nerve branch and is
capable of generating pain in the setting of trochleitis,
which is most often idiopathic, but may develop
secondary to autoimmune connective tissue disorders
[2]. Trochleitis is characterized by swelling and tenderness of the trochlea, and aggravation by vertical
ductions. Swelling may be observed clinically or documented on orbital imaging studies [2]. A non-inflammatory condition, termed primary trochlear headache
(PTRH), has also been described [3]. Treatment of all
trochlear headaches is presumed to require local
steroid injection in the vicinity of the trochlea, and is
Correspondence: J. H. Smith, Department of Neurology, University
of Kentucky, 740 S. Limestone, L445, Lexington, KY 40503, USA
(tel.: 859-323-5661; fax: 859-323-5943; e-mail: jonathan.smith@uky.
edu).
© 2013 The Author(s)
European Journal of Neurology © 2013 EFNS
generally thought to be associated with a positive
response.
Unfortunately, only a very limited number of cases
have been reported in the literature [3–5]. Therefore,
information regarding the clinical features, treatment
and prognosis is limited. To help clarify these issues,
our experience with trochlear headache in 25 previously unreported cases is reported.
Methods
Prior to the initiation of the study, Mayo Clinic Institutional Review Board approval was obtained. The
procedural records of one of the investigators (JAG)
was searched from 10 July 2007 to 28 June 2012 to
identify all adult (age ≥ 18) patients who had received
a trochlear injection. The electronic medical records
were manually abstracted to identify individuals where
a diagnosis of a trochlear headache could be definitively assigned and adequate clinical documentation
was available.
In our paper, the general term trochlear headache is
used to describe any headache referable to the troch-
1
2
J. H. Smith, J. A. Garrity and C. J. Boes
lear apparatus. Given the lack of validated criteria,
specific diagnoses of PTRH and trochlear migraine
were assigned based on previously suggested
definitions [3,5]. Trochlear migraine refers to a trochlear headache which then triggers a secondary
migraine attack [2,5]. The diagnostic criteria for headache secondary to trochleitis were used as suggested
by the newly published International Classification of
Headache Disorders, 3rd edition (online beta version)
[6]. A diagnosis of secondary trochleitis was assigned
if there was clinical, radiographic and/or histopathological evidence for orbital localization of an inflammatory or neoplastic process. The diagnosis of either
trochleitis or PTRH could be supported by aggravation and/or reproduction of pain by action of the
superior oblique muscle.
Patients were excluded if an alternative diagnosis
for the headache was established, such as a periorbital
cranial neuralgia, a trigeminal autonomic cephalalgia
or carotid-cavernous fistula.
Acuity of onset was summarized as acute if the
headache was daily from onset, subacute if daily
within 1 month of onset, and insidious if daily within
1 year of onset. Due to the retrospective nature of the
study, treatment efficacy was summarized as complete,
partial or ineffective based on the information available in the medical record. If the patient reported a
quantitative indicator of pain relief, this information
was specifically recorded.
Results
Over a 5-year period of chart review, 25 individuals
were identified with sufficient clinical characterization
for study inclusion (Table 1). Patients were generally
female (n = 20, 80%), with a median age at diagnosis
of 46 (range 18–77). Patients had a median time from
symptom onset to diagnosis of 6.7 months (range
2 weeks to 10 years). The diagnosis of a trochlear
headache had not been made in any patient prior to
referral, despite all patients having been seen previously by either a neurologist or ophthalmologist prior
to presentation. The most common mis-diagnoses
prior to presentation were chronic migraine (n = 13),
new daily persistent headache (n = 5), no diagnosis
(n = 4), hemicrania continua (n = 2) and atypical
facial pain (n = 1).
All patients with a prior headache diagnosis selfreported a new superimposed pain syndrome, which
was very apparent to all patients as distinct. Antecedent events were only occasionally noted by patients.
The most concrete association was in case 3, where a
new daily trochlear headache began immediately following orbital surgery for removal of an optic nerve
sheath meningioma. One individual developed the
headache 6 months following removal of an orbital
dermoid tumor (case 5), 1 month following orbital
decompression for Graves ophthalmopathy (case 6),
3 months post-partum (case 11) and 1 month following a Roux-en-Y gastric bypass (case 13). No enlargement of the superior oblique muscle had been
radiographically noted in case 6. There were no complications reported in review of any of the above mentioned procedures.
Trochlear headaches had an acute, daily from
onset, presentation in the majority of cases (n = 22,
88%), being subacute, daily within 1 month, in the
remainder. A final diagnosis of PTRH (n = 13, 52%)
was made slightly more often than trochleitis (n = 12,
48%). Bilateral involvement was seen in 8/13 (61.5%)
cases of PTRH and in 4/12 (33.3%) cases of trochleitis. In all bilateral cases this always occurred sequentially, and within 1 year of onset. Amongst patients
with trochleitis, five (41.6%) had an identified secondary mechanism. These included incomplete Behcet’s
(n = 1), idiopathic Tolosa Hunt (n = 1), granulomatosis polyangiitis (GPA) (n = 2) and orbital lymphoma
(n = 1). All five cases of secondary trochleitis underwent biopsy of an orbital mass located near the trochlea. In case 11, the trochlear headache had been the
presenting symptom of GPA. Secondary trochleitis
was most often bilateral, but was observed unilaterally
in one individual (case 11).
The location of the trochlear headache was most
often focused at the medial eyebrow, orbit or forehead
(n = 9, 36%), with radiation into the forehead, temple, periorbit or retro-orbitally. The pain was reported
as continuous (n = 25, 100%), and achy, dull or pressure-like (n = 19, 76%). The average intensity as rated
on a numerical rating scale was severe (7–10) in seven
(35%), moderate (4–6) in 10 (50%) and mild (0–3) in
three (15%) cases. The most common associated
symptoms were photophobia (n = 15, 68.1%) and binocular diplopia (n = 10, 45.4%). Four out of the five
patients who reported associated nausea also had comorbid migraine. The headache was characteristically
aggravated by eye movements (especially reading) by
18 (75%) patients.
Amongst individuals with a prior diagnosis of
migraine (n = 7), six were considered to have attacks
of trochlear migraine following the onset of the new
headache syndrome. These headaches were reported
to be ipsilateral to the trochlear pain.
Diagnostic evaluation consisted of either a magnetic
resonance imaging (MRI) of the head or a computed
tomography (CT) study of the orbits in all patients
except one (case 13). Three patients were found to
have an imaging abnormality directly involving the
© 2013 The Author(s)
European Journal of Neurology © 2013 EFNS
55/F
29/M
77/F
34/F
32/M
57/F
38/F
36/F
63/M
18/F
56/F
42/F
71/F
65/F
57/F
40/F
74/F
58/F
46/F
23/F
48/M
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
Age/gender
1
2
3
Case
no.
© 2013 The Author(s)
European Journal of Neurology © 2013 EFNS
Trochleitis, GPA/L
Trochleitis/L
PTRH, TM/Bil
PTRH/Bil
PTRH/Bil
Trochleitis/Bil
PTRH/R
Trochleitis/R
PTRH/Bil
Trochleitis, GPA/L
PTRH/R
Trochleitis, TM/L
Trochleitis,
incomplete
Behcet’s/Bil
Trochleitis/
Tolosa Hunt/Bil
Trochleitis/R
PTRH/Bil
PTRH, TM/Bil
PTRH/Bil
PTRH, TM/R
Trochleitis, TM/Bil
PTRH/R
Diagnosis/laterality
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acuity
of onset
Continuous
Continuous
Continuous
Continuous
Continuous
Continuous
Continuous
Continuous
Continuous
Continuous
Continuous
Continuous
Continuous
Continuous
Continuous
Continuous
Continuous
Continuous
Continuous
Continuous
Continuous
Continuous
or episodic
Table 1 Clinical features of patients with trochlear headache
Eyebrow
Orbit
Retroorbital
Retroorbital
Medial
forehead
Medial
eyebrow
Medial
forehead
Medial
eyebrow
Medial
eyebrow
Eyebrow
Medial
eyebrow
Periorbital
Periorbital
Periorbital
Orbit
‘Eye’
Orbit
Orbit, medial
Medial
eyebrow
Periorbital
Retroorbital
Location
Forehead,
bridge
of nose
Orbit
None
Forehead,
temple
None
Eyebrow
None
Retro-orbital
None
None
Forehead
None
None
Forehead
None
NR
Holocephalic
Temple
None
None
None
Radiation
Throb/7
Pressure/2
Pressure/4
Ache
Pressure/6
Pressure, sharp/4
Pressure/4
Pressure/4
Dull/3
Ache/2
Pressure/5
NR
Ache/8
Pressure/7
Ache/7
NR/7
Throb
Pressure/6
Pressure/6
Throb/6
Ache
Quality/
intensity
PHT, DIP
None
PHT
PHT, PHN
PHT
PHT, DIP
PHT
PHT, DIP
PHT
PHT, DIP
NR
NR
NR
NA, DIP
NA, DIP
DIP
NA, PHT, DIP
NR
NA, PHT
NA, PHT, DIP
NR
Associated
symptoms
EM
EM
EM
Touch
EM
EM
EM
EM
EM
EM
EM
NR
None
EM
EM
EM
None
EM
‘Reading’
EM
None
Aggravating
factors
None
None
None
None
Warmth
None
Warmth
None
Warmth
None
None
NR
None
Eye patch
None
NR
None
NR
None
None
None
Relieving
factors
GPA
ETTH
Depression
EMO, depression
History of gastric
bypass
GAD
History of
encephalitis in
childhood,
unknown cause
EMO
CMA
EMO
Left optic nerve
meningioma
EMO, IED
Right orbital
dermoid
Graves
ophthalmopathy
s/p decompression
1 month prior to
onset
CMO
Relevant
comorbidity
Prognosis of trochlear headaches
3
Bil, bilateral; CMA, chronic migraine with aura; CMO, chronic migraine without aura; DIP, diplopia; EM, eye movements; EMO, episodic migraine without aura; ETTH, episodic tension-type
headache; GAD, generalized anxiety disorder; GBM, glioblastoma multiforme; GPA, granulomatosis with polyangiitis; IED, intermittent explosive disorder; L, left; MALT, mucosa-associated
lymphoid tissue; NA, nausea; NR, not reported; PHN, phonophobia; PHT, photophobia; R, right TM, trochlear migraine; WBRT, whole brain radiotherapy.
Intensity refers to what the patient reported as average on a numerical rating scale from 0 to 10.
None
EM
Dull/7
None
Retroorbital
Continuous
Subacute
39/F
25
PTRH/Bil
Continuous
41/F
24
Trochleitis, orbital
MALT lymphoma/L
Subacute
Periorbital
Hemicranial/neck
Throbbing/7
PHT,
blurry
vision
None
None
None
EMO
GBM, s/p WBRT
(1 year before
onset) +Radiationinduced retinopathy
and optic neuropathies
History of
anticardiolipin
antibody
None
None
Eye
closure
EM
None
PHT, DIP
PHT
Pressure
Pressure/6
Eyebrow
Forehead
Periorbital
Medial
eyebrow
Continuous
Continuous
Subacute
Acute
35/F
48/M
22
23
Trochleitis, TM/L
PTRH/L
Continuous
or episodic
Age/gender
Case
no.
Diagnosis/laterality
Acuity
of onset
Location
Radiation
Quality/
intensity
Associated
symptoms
Aggravating
factors
Relieving
factors
Relevant
comorbidity
J. H. Smith, J. A. Garrity and C. J. Boes
Table 1 (Continued )
4
trochlear apparatus (Fig. 1). In the patient with Tolosa Hunt (case 8), no radiographic abnormalities
were visualized in the orbit. Two other patients were
noted to have radiographic enlargement of the lacrimal glands (cases 11 and 16). Clinical examination
was generally unremarkable except for trochleodynia
(all cases), clinically apparent trochlear edema (all
cases of trochleitis) and findings attributable to neuroophthalmic comorbidities (Table 1).
The treatment outcomes are summarized in Table 2.
Overall, at a median follow-up of 34 months (range 0–
68), 10 patients had reported complete remission, 10
continued to have either persistent or recurrent trochlear headache but with significantly improved pain levels and four had not experienced any substantial
improvements at all. Treatments with standard
migraine preventive medications were generally ineffective (Table 2). Complete remission was achieved with
immunotherapy (n = 2) or external beam radiation
(n = 1) in cases of secondary trochleitis. Trochlear injections were performed in a non-standardized way with a
single injection, generally containing 2–3 mg of dexamethasone, with or without triamcinolone, and lidocaine. When reported, responses occurred either
immediately (n = 4) or within 7 days (n = 5). Following
the injection, patients reported complete resolution of
trochlear pain (n = 10), partial improvement (n = 12)
or no effect (n = 8). When effective, the reported duration of effect was of the order of weeks to months (range
12 h to 12 months) (Table 2). The median number of
injections per patient was three (range 1–12). Amongst
the 17 individuals receiving repeat injections several
patterns of response were seen. Most commonly, an initially effective injection would continue to have either a
similar (n = 6) or increased (n = 4) benefit on subsequent injections. Of patients with an initially ineffective
first injection, subsequent injections were either ineffective (n = 5) or subsequently effective (n = 2). Overall,
the only adverse event noted was injection site bruising
in one case.
Discussion
In our specialty headache practice, trochlear headaches were very poorly recognized by referring neurology and ophthalmology physicians. The 25 patients in
our cohort presented with a fairly characteristic clinical syndrome of moderately severe, achy, periorbital
(especially medial) pain, variably associated with photophobia, and aggravation by eye movements
(especially reading). Individuals with a prior history
of migraine were likely to have associated nausea and
experience trochlear migraine as part of their clinical
course. It is notable that the daily from onset
© 2013 The Author(s)
European Journal of Neurology © 2013 EFNS
Prognosis of trochlear headaches
(a)
Figure 1 (a) Coronal computed tomography (CT) of the orbits showing calcification of the right trochlear tendon
(solid arrow) and thickening of the left
trochlea tendon (broken arrow) (case
21). (b) Magnetic resonance imaging
(MRI) of the orbits showing gadolinium
uptake at the left trochlear tendon
(arrow) (case 21). (c) Axial T2-weighted
fluid attenuated inversion recovery
(FLAIR) MRI of the head showing diffuse left orbital involvement by GPA
(arrow) (case 20). (d) Axial CT of the
head with contrast showing lymphomatous involvement of the left trochlear
tendon (arrow) (case 24).
(c)
presentation could be easily confused with new-daily
persistent headache, which is generally thought of as
extremely difficult to treat [7]. However, the prevalence of undiagnosed trochlear headache in patients
with presumed new-daily persistent headache has not
been studied.
In our cohort, patients were almost as likely to
receive a diagnosis of PTRH as trochleitis. However,
the distinction had important implications, as 5/12
(41.6%) patients with trochleitis (clinically apparent
trochlear edema) had an identified secondary mechanism. It is therefore concluded that all individuals
with trochleitis should undergo diagnostic imaging,
but CT versus MRI cannot be recommended based
on our limited experience. Dedicated orbital imaging
is likely to be important, on the basis that the trochlea
is often not visualized on routine head imaging.
Based on our retrospective data, dexamethasone/lidocaine injections of the trochlea appeared to be a generally efficacious strategy for many patients. As many
patients reported incremental success (and at times
remission) with serial injections, at least a second round
of injection is recommended for patients who are initially non-responders. This is especially important as
many of these patients do not seem to respond robustly
to typical migraine preventive treatments. In cases of
secondary trochleitis, treatments directed at the diseasespecific process were generally efficacious. The reasons
for treatment success in some patients but not others are
not known. An alternative diagnostic consideration
amongst refractory cases is idiopathic ophthalmodynia,
© 2013 The Author(s)
European Journal of Neurology © 2013 EFNS
5
(b)
(d)
which may represent a topographically restricted form
of persistent idiopathic facial pain [8].
The largest case series of trochleitis was provided
by Tychsen et al. in 1984, who reported on 13 patients
with a syndrome of subacute onset inflammatory trochleodynia [4]. Ages ranged from 27 to 69, and 9/13
were women. Three patients developed recurrences
over a mean 8 months of follow-up. Two previously
anophthalmic patients underwent excisional biopsy,
demonstrating perivascular lymphocytic infiltration
involving not only the tendon but also extending into
the superior oblique muscle itself. It was hypothesized
that the condition represented a localized form of
orbital pseudotumor. In our cohort, neuroimaging
abnormalities were confined to the trochlear tendon in
idiopathic cases and never involved the superior oblique muscle.
Limitations of our study included possible selection
bias, as consecutive cases were not included, and lack
of a standardized approach to evaluation and treatment. Strengths of our study include the relatively
large number of patients, long-term follow-up data of
treatment outcomes, and fairly complete clinical data
for the cohort.
In conclusion, the diagnosis of a trochlear headache
should be considered especially in patients presenting
with a new daily eye pain, aggravated by eye movements, especially reading. Our data provides a new
perspective on long-term treatment outcomes in this
poorly recognized, but important, headache syndrome.
a. Ibuprofen 600 mg,
as needed
a. Nortriptyline 75 mg
None
None
a. OxyContin 30 mg
twice daily
a. Amitriptyline 50 mg
b. Gabapentin 1800 mg
c. Intravenous
methylprednisolone
500 mg
d. Dilaudid, as needed
e. Methotrexate
f. Azathioprine
g. Infliximab
None
a. Nortriptyline 50
3
4
5
6
7
8
10
9
2
a. Indomethacin 50 mg TID
b. Botulinum toxin
A injections,
150 units 9 1
c. Melatonin 3 mg
a. Nortriptyline 25 mg
1
Case
no.
Prior treatments
other than
trochlear injection
a. Improved migraines,
but not trochleitis pain
NA
a. Ineffective
b. Ineffective
c. Ineffective
d. Ineffective
e. Ineffective
f. Ineffective
g. Complete
NA
a. Partial
NA
a. Ineffective
a. Partial
a. Ineffective
a. Partial
b. Partial
c. Ineffective
Efficacy of treatments
other than trochlear
injections
1
1
8
1
12
3
1
1
7
1
Total number
of trochlear
injections
Table 2 Treatment outcomes of patients with trochlear headache
3 mg dexamethasone, 0.125 ml
2% lidocaine with epinephrine
3 mg dexamethasone, 0.25 ml
2% lidocaine with epinephrine
3 mg dexamethasone,
40 mg triamcinolone
with 0.25 ml 2% lidocaine
4 mg dexamethasone
2 mg dexamethasone, 40 mg
triamcinolone with 0.25 ml
2% lidocaine
3 mg dexamethasone with
0.25 ml 2% lidocaine
with epinephrine
3 mg dexamethasone with
0.25 ml 2% lidocaine
with epinephrine
3 mg dexamethasone with
0.25 ml 2% lidocaine with
epinephrine
2 mg dexamethasone,
20 mg triamcinolone with
0.25 ml 2% lidocaine
2 mg dexamethasone,
20 mg triamcinolone with
0.25 ml 2% lidocaine
Injected material
(total volume 1 ml
for all cases)
Immediate
Immediate
Immediate
NR
2–4 days
NR
Immediate
Complete
Partial
Complete relief,
durability of
7 months, then
12 months, and then
ongoing relief
Complete relief
Injections 1–8, 10:
partial relief, average
durability of 22 days
Injections 9, 11–12:
ineffective
Partial relief,
durability
range 2–5 days
Partial relief
for only 12 h
50% reduction
in pain intensity
lasting 4 weeks
Complete relief
<1 week
NR
90% reduction
in pain intensity
Outcome of
injections
<1 week
Onset of
action of
injections
25
None
42
10
27
47
7
39
8
62
Time from
diagnosis to
last follow-up
(months)
Remission
Unknown
Remission
Remission
Improved, persistent
trochleitis
Remission
Chronic trochlear
headache
Remission
Improved, recurrent
trochleitis
Remission
Outcome at
last follow-up
6
J. H. Smith, J. A. Garrity and C. J. Boes
© 2013 The Author(s)
European Journal of Neurology © 2013 EFNS
© 2013 The Author(s)
European Journal of Neurology © 2013 EFNS
a. Prednisone
b. Azathioprine
None
a. Amitriptyline
b. Carbamazepine
None
None
None
a. Topiramate 100 mg
b. Amitriptyline 40 mg
c. Prednisone 40 mg
13
14
15
16
17
18
19
12
a. Propranolol 120 mg
b. Gabapentin 1800 mg
c. Prednisone 60 mg
d. Azathioprine
e. Rituximab
f. External beam
radiation (2000
cGy in 10 fractions)
a. Indomethacin
50 mg three
times daily
b. Acetazolamide 250 mg
twice daily
11
Case
no.
Prior treatments
other than
trochlear injection
Table 2 (Continued )
a. Ineffective
b. Ineffective
c. Partial
NA
NA
NA
a, b. Unable to
tolerate either
NA
a. Complete
b. Partial
a. Partial
b. Partial
a. Ineffective
b. Ineffective
c. Partial
d. Partial
e. Partial
f. Complete
Efficacy of treatments
other than trochlear
injections
2
1
2
4
3
5
3
18
5
Total number
of trochlear
injections
2 mg dexamethasone,
0.1 ml 2% lidocaine
with epinephrine
3 mg dexamethasone,
0.25 ml 2% lidocaine
with epinephrine
3 mg dexamethasone, and
0.25 ml 2% lidocaine with
epinephrine
2 mg dexamethasone,
20 mg triamcinolone
0.25 ml 2% lidocaine
2 mg dexamethasone, 20 mg
triamcinolone 0.25 ml 2%
lidocaine
3 mg dexamethasone,
0.125 ml 2% lidocaine
with epinephrine
3 mg dexamethasone, 0.25 ml
2% lidocaine with epinephrine
3 mg dexamethasone,
0.25 ml 2% lidocaine
with epinephrine
3 mg dexamethasone,
0.25 ml 2% lidocaine
with epinephrine
Injected material
(total volume 1 ml
for all cases)
10 days
Unknown
Unknown
Unknown
NA
Unknown
Unknown
Unknown
Unknown
Onset of
action of
injections
1, 2: complete
(right eye), partial
(left eye)
Complete
1–3: partial, durability
range of 8–12 months
4: ineffective
1, 2: partial, durability
of 2 months each
Ineffective
Complete, durability
of 3–4 months
1–3, 5–7, 9–1: partial,
durability range
2–6 weeks, except
last two injections
lasted 5, then 7 months
4, 8: ineffective
Complete, durability
9–12 months
1–2, 4–5: partial,
durability range
6 weeks to 2 months
3: Ineffective
Outcome of
injections
1
37
6
44
34
20
68
32
30
Time from
diagnosis to
last follow-up
(months)
Improved, low-grade
(2/10) trochlear
headache on left
side, remission
on right side
Remission
Improved, recurrent
trochlear headache
Persistent trochleitis
Chronic trochlear
headache
Improved, recurrent
trochleitis
Improved, recurrent
trochlear headache
Improved, recurrent
trochlear headache
Remission
Outcome at
last follow-up
Prognosis of trochlear headaches
7
a. Indomethacin 75 mg
three times daily
b. Amitriptyline 50 mg
c. Gabapentin 1800 mg
d. Propranolol 80 mg
e. Topiramate 50 mg
f. Botulinum Toxin
A injections, 150 units 9 2
g. Prednisone 80 mg
h. Methotrexate
i. External beam radiation
(25 CGy over 14 fractions)
None
22
None
25
NA, not applicable.
a. Nortriptyline 50 mg
b. Prednisone 60 mg
24
23
21
a. Oxycodone 15 mg
b. Methotrexate 0.5 ml
per week
c. Cyclophosphamide
d. Rituximab
e. Prednisone 60 mg
None
20
Case
no.
Prior treatments
other than
trochlear injection
Table 2 (Continued )
NA
a. Partial
b. Partial
NA
a–f, i. Ineffective
g. Partial
h. Near-complete
NA
a. Partial
b. Ineffective
c. Partial
d. Partial
e. Partial
Efficacy of treatments
other than trochlear
injections
7
1
4
6
3
2
Total number
of trochlear
injections
1–3: 2 mg dexamethasone, 20 mg
triamcinolone and 0.25 ml 2%
lidocaine with
epinephrine
4: 4 mg dexamethasone,
20 mg triamcinolone,
0.25 ml 2% lidocaine with
epinephrine
3 mg dexamethasone,
0.25 ml 2% lidocaine
with epinephrine
3 mg dexamethasone,
0.2 ml 2% lidocaine
with epinephrine
3 mg dexamethasone,
0.1 ml 2% lidocaine
with epinephrine
3 mg dexamethasone,
20 mg triamcinolone,
0.25 ml 2% lidocaine
1 mg dexamethasone,
0.1 ml 2% lidocaine
with epinephrine
Injected material
(total volume 1 ml
for all cases)
Ineffective
Partial, average
durability of 6 weeks
<7 days
Complete, durability
of 1–2: 3 months, 3:
6 months, 4: remission
<7 days
NA
Partial, durability
2–3 weeks
1, 2: ineffective
3: complete
1: ineffective
2: partial
Outcome of
injections
Unknown
Unknown
Unknown
Onset of
action of
injections
54
40
57
64
16
49
Time from
diagnosis to
last follow-up
(months)
Recurrent trochlear
headache
Chronic trochlear
headache
Remission
Improved, low-grade
(1-2/10) persistent
trochlear headache
Remission
Chronic trochlear
headache
Outcome at
last follow-up
8
J. H. Smith, J. A. Garrity and C. J. Boes
© 2013 The Author(s)
European Journal of Neurology © 2013 EFNS
Prognosis of trochlear headaches
Disclosure of conflicts of interest
The authors declare no financial or other conflicts of
interest.
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