 All righty. Can you guys hear me okay? Okay. I'm not that loud either so just want to make sure you guys can hear me. So I'm Jonathan Galley or JJ as some of you know me as I am one of the PGY4 neurology residents. As you can tell I did change the title of my talk but I promise we will touch on the differential of a Horner's. So let's get started. I have no disclosures and so we'll start with a case that we recently saw in clinic probably two weeks ago or so. So a 58 year old woman comes into our clinic no prior medical history of headaches no real prior medical history in general and comes into clinic with this new onset headache that began about three months prior to coming in. She says she has a little bit of right temple pain kind of consistently but then about five times per day she'll get this pain that she describes as someone stabbing her in the head with a knife. Same area right temple but feels like someone just taking a knife driving it right through. The pain lasts anywhere from 10 to 15 minutes and fades away. When she gets the pain it's so bad she can't even do anything about it. It's not like a dull headache that she can go and rub her shoulders make it go away not even a migraine where she can go lay down and try and sleep it off. This is so bad she clutches her head and just tries to get through it. Interestingly she's also having photophobia just in the right eye just in the right side that's affected and she also gets severe lacrimation and tearing in both of her eyes only when this headache is happening. She also says I also noticed the other three months ago when the headache started my right eye has been drooping and it gets worse when I get this stabbing pain. So on her exam her right eye indeed is drooping and she also has a little bit of myosis in that eye. I'm gonna quickly move past this picture because we'll come through it next in a little bit. So with this stabbing pain that's including lacrimation she herself didn't have all the symptoms particularly of this phenomenon but the first thing on our mind was something that's called trigeminal autonomic cephalgia or TAC. This is a primary headache disorder that's characterized by unilateral headache specifically a stabbing like headache. So this isn't a throb this is a stab people will describe it like a spear is going through their head a knife or their eye and again it's it's typically unilateral. With this comes an associated lacrimation commonly it's on the affected side where the headache is. You'll also get conjunctival injection on that side and nasal discharge. In some cases you can actually have a horners on the associated side as well and these headaches, TACs in general are kind of an umbrella term for several subclasses that are characterized by the duration of how long the headaches lasting as well as the frequency of how often they're occurring in a day. So what are those subclasses? So they the kind of classic I think TAC that we all hear about in medical schools probably cluster headache right I think we all learn about cluster headache stabbing pain you know your nose runs you give them oxygen I think that's kind of a classic step question but that's just one one of the TACs and we'll talk about why it's important to characterize which one it is in just a second. So there is a predilection for sex so cluster headaches and then these other sunk headaches are more common in males whereas paroxysmal hemicrania is more common or sorry is equally common. The frequency and the duration though is really where this matters so a cluster headache only occurs really one to maybe eight times per day but they last a long time 30 at least 30 minutes to up to a couple hours of this pain again the autonomic symptoms. Paroxysmal hemicrania however starts to get more frequent so this is kind of 10 maybe up to 20 times per day but much shorter so really these headaches are lasting upwards of 30 minutes and lastly sunk headaches are very very very frequent but they only last up to a minute okay a minute to 10 minutes. Notably the cluster headache and paroxysmal hemicrania can have an associated corners and why this actually matters so why do we actually you know is this just semantics neurologist being nerds and trying to count symptoms or does it matter? So it turns out cluster headaches respond really well to sumatriptan intranasally as well as oxygen. Not so much into methicin however in patients with paroxysmal hemicrania they respond really really well to intramethicin but not so much to sumatriptan and oxygen in general. And lastly the sunk headaches those are less responsive not to quote a terrible joke that I told doctor degree last night but those patients are kind of sunk told you it was bad. All right so so we we're thinking right now our patient has a trigeminal autonomic ethalogen just based on symptoms alone okay but what about our horners? So I won't belabor this but a horn syndrome is it occurs when there's a loss of sympathetic input sympathetic autonomic input to the eye can be a first-order second-order or third-order cause and clinically these patients will have meiosis, ptosis, and sometimes anhydrosis on the affected side where the horners is. The confirmation of a horners can be done with cocaine eyedrops or apriclonidine eyedrops. We did apriclonidine in our patient and as you can see this was when she came in so she's got the horners over here and after the apriclonidine she had that hypersensitivity where she was more dilated on the affected side. So we were able to confirm she definitely has a horners. So now we have a patient with a painful horn syndrome. Why does that matter? So as you guys know a oftentimes horn syndrome can be idiopathic. However an acute onset horners or a painful horners should raise red flags to investigate a little bit more of why this is happening make sure there's no life-threatening or pathology or anything concerning going on. This additional evaluation can be guided by clinical symptoms, clinical signs, as well as you can use hydroxyamphetamine eyedrops to kind of help discern. I will not get too far into that because it's kind of beyond my what we're going to talk about today. So in our patient what what could be going on? So is this just a simple primary headache or is there something more concerning going on? And that's what we had to think about while we were in clinic with her. So interestingly, trigeminal autonomic phalages like I said are classically thought of as a primary headache disorder. However it's very important to realize when these patients come in that they have a high predilection for pituitary tumors. So not all of them are primary some of them are secondary to pituitary tumors. In one study they looked at patients with both pituitary tumors and headaches and 10% of those patients had tax. There are numerous reports out now that are associating tax as the original symptom that brings people in for the discovery of these pituitary tumors. So you can have a non-secreting tumor and just attack and that's how these patients are discovered. So the general rule of thumb is when you see trigeminal autonomic cephalgia you should scan them and look for a pituitary tumor. Again the general rule of thumb and primary headache disorder is I've ruled out everything it could be secondary to. So MRI brain for patients with trigeminal autonomic cephalgia. What else could this have been? So carotid artery dissection is something we also always think about for painful horners. This occurs from the inner lining of the carotid artery tears. You get blood rushing up into the side of the vessel. Pain occurs due to stretching of the trigeminal pain fibers that surround the artery and a hornar syndrome can occur in about 60% of these patients with up to 90% of patients that have horners due to carotid being painful. So painful carotid sorry painful horners should always make you at least think am I confident that this isn't a carotid artery dissection. Obviously if you dissect the carotid you can have associated stroke symptoms or even vision loss if it goes up the ophthalmic artery. To look for this vessel imaging with either MRA or CTA is the most efficient imaging modality. A CTA angiogram where they go in through the groin is the gold standard. Although here at the University of Utah an MRA with Dr. McNally is probably just as good. If they do have a dissection you can always call your neurology colleagues and we can start anticoagulation and take care of it. The other thing that we made sure to look at in our patient or to think about is does she have some kind of cavernous sinus pathology. So a horners from a cavernous sinus pathology will typically have ophthalmoplesia, some kind of trigeminal sensory loss, proptosis or chemosis of the affected eye if there's cavernous sinus pathology. The what can cause it is kind of a multitude of things. You can have fistula, carotid cavernous fistula, you can have a cavernous sinus thrombosis, tumors, infections, inflammation. All of that can cause cavernous sinus problems. Typically MRA, MRI within without contrast is a good place to start although think about doing vessel imaging as well if you're worried about a vascular issue. So what happened in our case? So our patient was indeed imaged and lo and behold she's got a pretty big pituitary macular adenoma sitting right here. So she is currently being considered for surgery by Dr. Caldwell. We started in Demethysine on her based on the timing of her headaches. Remember they were about 10 to 15 minutes and granted they were only happening about five times per day on average but given the length we treated it like paroxysmal hemicrania. We did visual fields on her. She was unfortunately having a headache at the time so they were very all over the place. So we're actually planning to see her in clinic tomorrow. Repeat those and see how she did on the in Demethysine. All right. So what was actually important in all of this talk? So trigeminal autonomic cephalgia is defined by a sharp excruciating headache or eye pain that's unilateral and involves lacrimation, conjunctival, injection and nasal discharge. We define them by frequency and duration of the attacks and again that's important because that helps drive our decision on treatment. All tax should be imaged with an MRI to look for a pituitary tumor with how frequent that we're finding these are these are occurring together. It's a very important thing to not miss. Again, when you think about primary headache always make sure you rule out secondary causes first. And lastly the acute onset of a painful Horner syndrome should be evaluated. This should involve both your history and clinical presentation of the patient to see what other symptoms are there to help drive what imaging modality you should get. And those resources and any questions.