 Okay let's go ahead and get started. So many of you know that I have a general ophthalmology practice in addition to my neuro-ophthalmology practice and I've tried to tailor this lecture to be more practical for people who are going to be comprehensive ophthalmologists and not targeted towards a neuro-ophthalmology audience. This is really about the kinds of headaches and eye pain stuff that I see come into my comprehensive ophthalmology clinic and that I think would be of practical value to someone who's going to be a comprehensive ophthalmologist. That seems like there was something else I wanted to say about it. Oh a lot of the stuff doesn't show up on OCAPs that I'm aware of and so this is really not about studying for the OCAPs. This is really about practically helping people in clinic. And some of this material was stolen from Dr. Diggree. Thank you very much. Okay so we're going to review some of the headache syndromes that can present with ocular and visual symptoms because that's the kind of stuff that comes into your clinic. My intention is not to make you headache experts but just enough information so that you can make the correct diagnosis and send the patient out with an appropriate workup or an appropriate referral. And then not to forget the treatment that's administered by ear. So just telling somebody that like okay this aura that you're having is a thing, it doesn't mean that you're having a seizure, it doesn't mean you're having a stroke, it doesn't mean you have a brain tumor and your eye is okay and this isn't going to damage your visual system like that. Often like it's really hard to know sometimes what patient's agenda, what their agenda is like somebody could come in with an aura and you could say oh your eye exam's normal everything's good see you later. You know you think you've done your job because they were worried something was wrong with their eye and you've told them that there's not but that leaves them still well then what the hell was it you know? So sometimes just telling the patient that there's a name for what they have, that other people have what they have, that they haven't damaged their eye, that they don't have something more serious can be incredibly therapeutic. So headache is incredibly common, even kids have headaches, even kids get migraines. There's probably 10 to 20 percent of us are genetically predisposed to getting headaches and headache is an incredibly common reason for any kind of visit to a doctor including to an eye doctor and headaches you know aren't just head pain they cause missed work, loss of income, missing social activities, missing church, missing school like they really have beyond just having pain like these things really affect people's lives. So why would somebody with a headache go to the eye doctor? Well number one it's very common so like just in your ordinary practice about 6 percent of men and 18 percent of women that's 1 out of 5 women coming through your office for whatever reason probably have migraine and then I hear this all the time people you know are getting headaches and maybe it's at work and they think that gee maybe glasses would help which you know I can count on one hand the number of times that's been true but people have this thing in their mind that well gee maybe if I just had glasses I'd feel better and then also primary and secondary headaches can cause eye pain and they can also cause visual symptoms like aura which I just mentioned and then photophobia is another reason why somebody with migraine might go to the eye doctor because their eyes are light sensitive and so they assume something's wrong with their eye and then also some of the primary and secondary headaches can have autonomic features that involve the eye can affect the eyelid it can cause changes in the size of the pupil it can cause some of them can cause injection of the eye during the headache syndrome and some of the headache syndrome can cause tearing so again people have a headache they have these associated eye symptoms they assume that something might be wrong with their eye so they go to the eye doctor so you'll see that it's not too surprising that people with headaches will go will have eye pain and that has to do with the innervation of the eye so the eye in the orbit are richly innervated by the trigeminal nerve and the trigeminal nerve is of course the nerve that's implicated in migraine pathogenesis so it you know just like some I explained to people sometimes like people that are having a heart attack will sometimes complain of left arm pain was there anything wrong with their arm no it's just the way we're wired and it just feels like we have our pain there's nothing wrong with our arm and the same can be true of migraine sometimes a trigeminal nerve gets irritated in migraine and you get higher eye paint does it mean there's higher eye socket pain does it mean there's something wrong with your eye or your orbit no it's just it's just the way we're wired and then also from a study that was done if you stimulate different points of the dura in the you know the lining of the brain you can get referred pain to all these different points along your head eye and face and so you can see that there are several points in the meninges where stimulation at that point causes pain right around the eye and so again this is just the way we're wired you know sometimes if the dura is is irritated as part of migraine pathogenesis because it's also innervated by the trigeminal nerve you can get referred pain around your eye in your orbit so primary headache disorders like migraine and tension type headache make up the vast majority of headache syndromes there are some other secondary headache syndromes in other words headaches are caused by something other than a primary headache syndrome like brain tumors subarachnoid hemorrhages you know intracranial pressure giant solar arthritis those make up a relatively small fraction of the headache syndromes so primary headache is even though these these ones down here the secondary headache disorders are the scarier ones they make up a smaller portion of the overall headache population okay so let's talk about this lady so does anybody have a guess to what her diagnosis is right it's just this is a very typical story in my clinic she's come in because she the pains concentrated over eyes so she's worried something's wrong with one of her eyes but her eye exam is normal it sounds like migraine so how can you make quickly make the diagnosis of migraine well these three questions that you can ask and if they answer positively to two out of three there's like a 90% chance that you're that you know you've picked up a migraine so you can say oh are your headaches or your eye pain so you have to be careful sometimes if you say are your headaches ever associated with light sensitivity she'll say well I don't have a headache I have pain in my eye so just the way you word things people get fussy so if your headaches ever been associated with light sensitivity and then sometimes I give them a example like when your eyes hurting is it you know does it make it worse to like be outside and do you just your headache or pain is it ever associated with nausea or an upset stomach and then have your has this pain or your headache ever caused you to have to change what you were doing that day like miss work or miss school or miss a social activity and so this is called the ID migraine questionnaire it's been shown to be very sensitive so if there's like only three things you can remember about migraine these are the three things to remember but it's you know nothing's a hundred percent and some of these patients still have migraine even if they answer positively to only one of these questions and so some other things that have kind of learned from dr. Diggory over the years is to ask about a family history so the problem is is often in my experience in my general ophthalmology clinic is that often migraine is misdiagnosed or undiagnosed and so a lot of people either aren't aware of their family history because they just don't know or because because people there are people in their family with migraine they just don't know it and so one of the questions I'll ask is when you were a kid you remember your mom being sick with a headache because females are more likely to have migraine in the family so I think it's sometimes more helpful to ask about female family members and then I hear about sinus headaches all the time and 99% of the time that means migraine and people think it's again they think it's their sinuses because the pain's here or here or here and that's where their sinuses are so they assume there's something wrong with their sinuses and then also asking about car sickness so kids who are car sicker often have migraine as adults and that can be an incredibly helpful question actually some of my migraine patients are still car sick it's very you know motion sickness is a common migraine personality trait I guess and then also some some kids who have who are going to go on to develop migraine as adults will often have episodic belly pain as a kid you know gassy crampy unexplained belly pain and some people think this is like a childhood manifestation of migraine maybe some effect on the enteric nervous system that's migraine like and then some of the other migraine characteristics that you can sometimes ask about if you think somebody has migraine and you're trying to you know pin down the diagnosis because right it's a clinical diagnosis right you can't get a x-ray or a blood test that says you have migraine so you have to do it based on really based on your history so we talked about nausea and vomiting we talked about light sensitivity some people also have sound sensitivity phonophobia and so when I ask about light sensitive or sound sensitivity I'll say you know when you're having this headache or this pain like and somebody was watching TV would you tell them to turn it down you know sometimes that's a sign of an associated symptom of migraine the fact the pain is unilateral and that it has sort of a throbbing quality also is kind of like more migrainee and then some sort of a aura that precedes the headache and you know far and away the most common form of aura is some sort of visual disturbance but some people will get an olfactory aura they'll smell like a like a bad smell or a chemical kind of smell before they get a headache that no one else can smell and rarely you know people can get confusion or even aphasia and other neurologic symptoms as part of their migraine symptomology like some my uncle actually has this and he was driving in a very in a part of town that he's very familiar with he grew up there and like all of a sudden he didn't know where he was going or what he was doing there and he you know he had to be worked up for stroke because these symptoms are very stroke-like but in the end it turned out to be you know migraine and then sometimes people will have like very specific aphasias that are very stroke-like or TIA like but it turns out to be migraine and these kids these are very tough people to take care of certainly way beyond what we want to discuss today but I just want you to be aware that people with migraine can have these funny almost stroke-like symptoms as part of their symptomology migraine you know visual migraine or is take on all kinds of crazy forms spots and dots people will talk about broken glass prisms colored lights you know most patients aren't going to use the words scintillating scatoma even though that's you know kind of what they they have so you have to use more like lay language when you're asking about any sort of a visual disturbance that precedes their headache or their pain psychiatric comorbidities very common with migraine and they kind of have like a vicious cycle they play on each other like the headaches make your anxiety worse because you're worried you have a brain tumor that makes your headaches worse and that makes your anxiety worse and you know a lot of times these people need treatment for both facets of their problem in order to get them under control there's not infrequently a history of neglect or abuse in childhood and some of these patients especially the women and then there are some of these triggers are really common with people with migraine and I pain that's migraness in nature not enough sleep skipping meals stress too much caffeine some people are set off by certain smells some people are very sensitive to perfumes and stuff some people are sensitive to certain kinds of light like maybe fluorescent lights and then medication overuse like so that a lot of these people are often overusing over-the- counter analgesics like Tylenol and approximate ibuprofen and that gets them into this vicious you know medication overuse headache rebound headache situation caffeine is sometimes used for migraine treatment like you go to the drugstore in Dubai etc. migraine it's Tylenol aspirin and caffeine but also like if people but caffeine can also trigger or worsen headaches it's it's kind of a fine balance with people so it's usually a change in their habits like if there are big caffeine drinkers and then all of a sudden they're not drinking caffeine it can make them pretty sick and if they're like caffeine users and all of a sudden they're not sleeping so they're drinking a lot of caffeine to stay awake that can also set people off I'm gonna just talk briefly about medication overuse headache because it is something I see commonly in these people that are coming in to see me for eye pain or pain around their eyes that they're overusing medications and that's in that even though the primary problem might have gone like now the thing has just been perpetuated by their overuse of medication and so people who are using ergot's opiates or triptans 10 or more days out of the month are very likely to be in rebound simple analgesics like acetaminophen hasperin nuproxen they're you know if they're using that 15 or more days per month they're very likely gotten into trouble with medication overuse and this can be really hard to treat you know these people need to be put on some sort of prophylactic medication and then withdrawn from the medication that they're overusing and again this is beyond the scope of today's lecture and you just want to recognize it in clinic you know like acid be well what are you taking for these headaches and how often are you taking it and then you can say well gee you know you might be having rebound headaches medication overuse headaches we really need to get you into a neurologist or a headache specialist to help you get better because this isn't going to get better until you stop overusing these medications so I'd say prophylactic prophylactic medications I would leave that to headache specialists and neurologists you know if that's something you want to learn about that's definitely something we can teach you about in neuro ophthalmology but I don't think it's part of the purview of a general ophthalmologist in terms of you know if you're recommending to somebody a board of medications over the counter-analgesis can be very helpful for some people some people's migraines are very well treated with naproxen etc. in migraine is available over the counter again that's aspirin acetaminophen and caffeine there's usually generic combinations that are available at the store that are pretty cheap alka salts or some people like because it kind of settles your stomach and because some of these people usually have a little tummy upset at the same time that can be good but then in terms of prescription drugs midrin which is known by many other trade names but it's this combination of acetaminophen dichlorofenazone and isomethipteen one of these is sort of like a sort of like a stimulant and the other one is sort of like a mild sedative they kind of balance each other out for some reason this combination seems to help some people it is schedule five it's a controlled substances a substance for reasons that I'm not aware of but it's not an addictive drug but it can be overused any of these medications can be overused and so if you're going to suggest these or prescribe these you just want to make sure that people are aware that they can't use them more than a certain amount per month without making things worse tryptans like imitrex and all the other triptan like drugs or guts are pretty rarely used I've never they kind of scare me they're kind of old drugs and they're definitely effective but they can be a little bit sketchy and people with heart disease and then you know people like it nausea with their headaches you really need to treat the nausea before you can treat the headache and so I really like metaclopramide it kind of helps their stomach move a little bit relieves their nausea and then they can take something for for their headache because some of these medications like you can imagine like if you have an upset stomach taking a couple ibuprofen is probably not going to help that very much and you really need to deal with the nausea before you can take some of these medications again without making yourself worse so don't forget about anti-imetics you know some people aren't into taking medications and so and even the people that are like sometimes lifestyle modification can be really helpful in reducing their headaches syndromes and sometimes these are these are things that people know they're not supposed to do they know they're not supposed to get stressed out they know they're supposed to get enough sleep they're not supposed to drink too much caffeine there's not supposed to be they know this stuff but sometimes some needs to tell it to them you know you really shouldn't do that because that's making you worse I know I know and then I'm a big believer in some non-traditional treatments for some people and you can laugh if you want like you know some of this stuff has some good like peer-reviewed literature behind it and some of it doesn't but sometimes these things can be really helpful for some people especially people who are sensitive to medications who don't like taking medications physical therapy the head and neck you know if especially if you send them to a therapist who has a specific interest in headache can be super helpful you know I I'm sure Dr. Diggory is wincing but sometimes chiropractors can adjust somebody's neck and and really relieve their headaches actually my former secretary not my current secretary my former secretary had a lot of migraines she was very medication sensitive and she ended up finding a chiropractor in sugarhouse who's really helped her a lot and has been able to not only help her manage her headaches but keep her off medication acupuncture and again you know like there's good acupuncturists out there and there's bad ones you just need to find a good one massage therapy can be super helpful it helps with stress management it helps relieve some of the muscle spasms and sternocleid amastoid and some of these spinal you know neck muscles up here which can be really important triggers for some people and then I'm just going to talk briefly about photophobia management because you know almost everybody with migraine will tell you that they're light-sensitive during a headache many of them will tell you that certain kinds of light will trigger a headache and then there's some people with migraine that are chronically light-sensitive and these people also will end up in your clinic because they think there's something wrong with their eyes and one of the funny things about the particular photophobia associated with migraine as well as bluff or spasm and traumatic brain injury is it's often non incandescent artificial light that bugs people you know they go outside and where you would think their light sensitivity would be worse you know on a bright sunny day but they throw in a pair of sunglasses and they're really pretty much okay but it's the indoor artificial light that sets these people off fluorescent lights these gas discharge lights these are the lights you see like in a big box store in the roof of like Lowe's or Home Depot or Costco they have kind of a funny if you've ever looked up at them they're gigantic and they're super bright they have kind of a funny color to them either an orangey kind of color or a bluish kind of color to them and they're super efficient right they don't use a lot of electricity they don't create a lot of heat but they create a lot of light and that's why the stores use them but for reasons that we don't quite understand completely people with migraine can find those lights very uncomfortable they have a hard time going into those stores and then computer screens you know which are like you know ubiquitous now can really set some people off and this is why I think it is so like there's no proof behind this but if you look at the solar emission of the sun it's kind of a nice Gaussian curve that sort of peaks you know has like a nice peak and a nice slope you know of a red orange yellow green blue indigo violet and if you look at the sensitivity of the human eye it sort of mirrors the sense the spectrum of the sun which I think makes sense because that's probably you know our eyes evolved over millions of years under the sun and I think it has evolved to be most sensitive to the wavelengths of light that are emitted by the sun if you look at the transmission spectrum of an incandescent light which is here says tungsten light because remember incandescent bulb has a tungsten filament in it it's also fairly Gaussian across the visible spectrum has kind of a nice smooth peak to it and that's because it's a burning filament just like the sun is a burning filament and so this spectrum emitted by that burning filament is kind of sunlight and I think that's why people with migraine prefer incandescent lights if you look at the spectrum of fluorescent lights they're very spiky because of the nature of the chemicals that are used in fluorescent lights they emit very strongly at certain wavelengths and then not at all at other wavelengths and with some of the modern engineering you know the more modern fluorescent lights have become better it in it being less spiky but that that characteristic is still there in any kind of a non incandescent artificial light and I think that bugs people with with migraine the reason we think it bugs these people is because of this class of cells in the vertebrate retina called intrinsically photosensitive retinal ganglion cells and I don't know if this information has met it and made it into the BCSC yet but about 1% of your retinal ganglion cells the cells that send their axons out to the lateral geniculate nucleus about 1% of them don't send their axons to the lateral geniculate nucleus they go to other important places in your brain so one of the places they go is to the suprachiasmatic nucleus which you might remember is where your body's 24-hour clock is located so it's these cells being activated by light that synchronize your suprachiasmatic nucleus and keep it on track with the local time change it's these cells that resynchronize your clock when you travel overseas these cells also send their axons to the pre-tectal nucleus over here in the brain stem where they then hook up with the eddinger Westfall nucleus which we'll remember is where the pupillary center is right so it's these cells being stimulated by light that stimulate the eddinger Westfall nucleus and constrict your pupil so these cells are important for pupillary constriction that's it's probably why some people who are blind like say from a photoreceptor degeneration still have a pupillary light response because these cells are still working and then these cells from work from done by Dr. Diggory in conjunction with Rami Burstein at Harvard has shown that these cells at least in rats send projections to the posterior thalamus that's what the PO here is and that's an important pain center in the thalamus and so it's thought that when we look at a light that's too bright like when we look at the Sun and it physically hurts I think it's these cells that are being stimulated and it's this part of your brain that's being stimulated that turns that light transforms it into a into a noxious signal and it's it's a probably a protective mechanism so it's a pretty fundamentally old part of our eye that keeps us from damaging our eye the funny thing about these intrinsically photosensitive greml ganglion cells is that you might have noticed from their name that they don't need although they do get input from rods and cones they don't require inputs from rods and cones in order to be activated they have a photo pigment in them called melanopsin which is isomerized by light just like rhodopsin and cone options and it's and that isomerization can stimulate these cells so in some of our patients who have photoreceptor degenerations these cells still respond to light they don't give you vision you can't see with them but they can still keep your super cosmetic nucleus synchronized they can still constrict your pupil and they can still cause pain melanopsin is most sensitive at a wavelength of about 480 nanometers so if you look at the sensitivity of the wavelength sense I've plotted so wavelength is plotted on the bottom here so here's red cones which are maximally sensitive you know like around 560 or so then you've got green cones which are slightly shorter wavelength then rhodopsin the photopigment that's in rods and then there's a big gap over to blue cones which are more sensitive like around 400 400 nanometers and then you see that opn4 that's just off of rhodopsin that's the melanopsin peak so the melanopsin melanopsin is most sensitive at a wavelength of about 480 nanometers it's about halfway between green and blue and I and I think that it's light that's emitted around 480 nanometers by some of these artificial light sources that bugs people with migraine because those cells which are hooking up to pain centers in your brain are maximally sensitive with that wavelength perfect if you look at this little diagram from a from a fluorescent bulb you can see there's a pretty strong peak right here at 480 so for some of our patients who are coming in who have this indoor light sensitivity a lot of them will wear sunglasses indoors because it's the only way that they can function and you really need to dissuade them from that because they're light they're dark adapting their retina and they're actually and so then when they do take the glasses off or they do go outside their light sensitivity is going to be worse and the example that I often use for people is I say you know what it's like when you go to a matinee movie and you're watching the movie and then you come out the exit doors into the bright sunlight how painful like that's what it's going to be like when you take these glasses off or when you go outside so I try to I say it's fine to wear them outside as dark as you want but indoors don't do that and instead I try to talk people into FL 41 because it seems to be more effective than other stuff that you can buy in the store and it's not expensive and it's easily applied to glasses or contact lenses has kind of a rose color compared to a pair of like ordinary gray sunglasses has kind of a pinkish rose reddish kind of color to it if you look at the transmission spectrum of a grip hair gray sunglasses versus a pair of FL 41 you'll notice that FL 41 has this pretty strong dip right around 580 nanometers right around the same wavelength or melanopsin is maximally sensitive so FL 41 was actually develop like 20 years before anybody knew about intrinsically photosensitive retina gangling cells or the or the spectrum of melanopsin it was developed empirically by trying different sorts of tints on people with light sensitivity till they found something that worked but I don't think it's a coincidence I think there's something intrinsically better about FL 41 because it's blocking those wavelengths of light that stimulate intrinsically photosensitive retina gangling cells and appear to make people with migraine less comfortable and again it's super cheap the Moran eye center sells it our contact lens shop can get contact lens tinted with it you're not going to kill anybody with FL 41 and you can it's really like the first time I started prescribing this to people people would come back and say oh my god you know this is you know I can go back to work and go back to school I can go to church and you're like really like it just it just sounded like I was I was really really surprised and continue to be surprised by how helpful it can be to certain people it's a very simple inexpensive thing so there's you know so of course diseases of the eye and the eye socket can also cause headache and eye pain and that's really part of your jobs and ophthalmologists as to as to rule those things out most of them luckily are pretty obvious to us with all of our special exam tools like if somebody has an inflammatory condition of the cornea conjunctivus claera iris we're gonna pick that up on our exam you know it's it's a lot more difficult for neurologists who are often treating these people to rule out these things because they don't have the tools we do and then also orbital inflammation like thyroid eye disease a fistula you know usually there are other signs and symptoms that are going to be present in that patient they're gonna tip you off to the fact that this is not some primary headache syndrome it really is an eye problem and we all and you know we all know how to take care of those things or how to work them up but then there are some patients that don't have any obvious inflammation in their eye they can also have a secondary eye pain syndrome like eye strain you know so that you know astonopia you know is the term that we use so of course if somebody is coming into your clinic and complaining of eye pain that's primarily when they're at work and when they're reading and they're working on the computer you want to make sure they don't have like latent hyperopia or convergence and sufficiency. A posterior scleritis can be very tricky best found by ultrasound will not be obvious on your examination it's fortunately not very common usually these patients have pain on eye movement that helps you you know raises your index of suspicion for some sort of a orbital cause rather than a primary headache syndrome. Early on an optic neuritis people can have eye pain but you know I've seen a bunch of patients over the years referred to me for optic neuritis who just have eye pain and no vision loss and that just doesn't happen people don't you know if to have optic neuritis you've got to have vision loss but for some reason that's especially pain on eye movement which can be caused by so many things will sometimes make people immediately jump to optic neuritis even when there's no vision loss but early on you could have pain you know preceding the vision loss by hours or maybe up to a day. Idiopathic orbital inflammatory syndrome we'll talk about a little bit more because this is another important cause of eye pain. Angle closure of course something that we wouldn't want to miss and then you know Zoster is something that I see you know fairly frequently in my general clinic and before the rash comes out it can be really hard to diagnose and people come in with you know horrible pain in the distance you know it's unilateral it's in the distribution of v1 usually if they're coming into the eye doctor and sometimes you don't exactly know what's going on until the rash breaks out and you're like okay now I know what it is. So just a quick talk about idiopathic orbital inflammatory syndrome also known as orbital pseudotumor so this condition is it is really it's kind of a garbage can term for any sort of a unexplained idiopathic inflammation that affects any of the contents of the orbit so it can affect the muscles it can affect the optic nerve sheath it can affect the lacrimal gland and you know if you if you suspect that especially in some of you has pain and high movement what I'll do in clinic is I'll take like a little cotton tip applicator and I'll gently touch I'll kind of rub over the superior rectus insertion through the closed eyelid over the lateral rectus insertion the medial rectus insertion inferior rectus insertion the trochlea and just ask them is it tender here is it tender here and compare it to the other side that's not symptomatic and sometimes that can tip you off to a case of myositis. Orbital ultrasound can be super helpful because Roger Harry can measure all the muscles and compare them side to side and tell you if one of them's inflamed and it's usually treatable with nonsteroidal analgesics and you know it's kind of beyond this is really an orbital lecture you know about the different things that can cause this syndrome and the appropriate workup but nonsteroidal analgesics are a very good treatment. Trochleitis is something that I don't see too commonly you can see that it's showed up here in this patient on the CT scan you know again by palpating over the trochlea you can make this diagnosis and it's caused by inflammation of the tendon the superior oblique tendon where it goes through the trochlea and it's more common in patients with some of these connective tissue diseases and then you know I don't think we have to talk a whole lot about glaucoma just remember that some drugs can cause this and that you know far-sightedness is a big risk factor this is a nice little statistic down here that 11 out of 2,000 patients with headache were misdiagnosed with migraine but actually had glaucoma so you want to you know you don't want to send somebody with glaucoma to the headache specialist it's a good reason to practice your gonioscopy skills alright so here are some other headache disorders that may manifest as eye pains we've already talked about the primary headache disorders which is primarily migraine and tension headache we're going to talk briefly about some of these headache syndromes that can have autonomic features like cluster and paroxysmal hemicrania and then we've also briefly touched on some of these other things we talked about we talked briefly about herpes zoster presenting as eye pain early on being difficult to diagnose before the rash comes up temporal arthritis is something that we talked about in another lecture of course important cause of a new head pain and an elderly patient you would want to miss carotid dissection can also present as eye pain again just because of the way that we're wired up and because the sympathetic that go to the lid and the pupil travel up on the carotid artery these patients can present with a horner syndrome and some of these patients with autonomic features to their headaches can also have a horner syndrome as part of their headache syndrome that makes it kind of confusing both increased and decreased intracranial pressure can present as eye pain we talked about idiopathic orbital inflammation we're going to talk briefly about trigeminal neuralgia because this is another headache syndrome that comes into my comprehensive ophthalmology clinic that's important to recognize and is in another thing that's you know recognized based solely on the history and then cervical spine disease can also present weirdly as eye pain or even blurred vision in some patients so let's talk about this guy so can anybody see what's wrong with so he needs a scan right anybody see what's wrong with him the brain is sagging through the frame and Magnum yeah so the frame and Magnum runs between the tip of the clivus bone down here and back here to the occipital bone you can see that the cerebellum is kind of sinking down through the frame and Magnum see his pituitaries very plump you know as opposed to somebody with the pseudotumor who usually has a flat pituitary he's got a big plump pituitary you can see how it looks like the whole cerebellum and brainstem are just kind of being shoved down into the bottom into the base of the skull so this is a imaging picture of intracranial hypotension which luckily is pretty rare the key thing are these positional headaches so like remember people with pseudotumor people with high intracranial pressure they feel worse when they lie down better when they stand up people with hypotension are generally the opposite they feel better when they lie down they feel awful when they try to stand up they can just like somebody with hyper tension they can have a six nerve palsy they might have cerebral spinal fluid leakage from their nose or ear and there's a bunch of risk factors for it that's I mean lumbar puncture is pretty obvious head trauma obvious water sports really weightlifting and golf it's been reported sometimes cough can cause a tear in the meninges seeing the chiropractor that dr. Katz sent you to cause this car wreck yoga and then there might be some genetic predispositions you know some of these connective tissue things so sometimes people with spasm of the of their neck muscles or irritation of the occipital nerve can manifest as eye pain even blurred vision especially in association with a whiplash injury and we're not a hundred percent sure why this is but a lot of times patients who all see who are coming in with eye pain and it doesn't really sound like one of these headache syndromes in their eye exams normal I kind of feel I'll ask them if I can feel their neck and you would not believe some of the neck muscles you can feel on people they are just like rocks I was like you know maybe you should get somebody to your neck and so it's not a completely clear why people with neck stuff get referred pain or referred symptoms into their eye but I think it's again like that example of somebody having a heart attack and having left arm pain it's because the nucleus of the trigeminal nerve dips way down into the upper part of the cervical cord and so I so it it's possible that irritation of that area is causing referred pain because the trigeminal nerve innervates the high in the high socket that irritation of the trigeminal nerve nucleus can sometimes manifest as visual symptoms or eye pain oh and so so when I see somebody like that like that's like a great patient to send for physical therapy right you know because sometimes just getting their neck work done and then you know if you want a chiropractor massage therapy acupuncture those things can all be effective the nice thing about physical therapy is it's usually paid for by insurance whereas the other modalities may or may not be okay so here's another example where somebody with metastatic disease to the the vertebrae comes into the eye doctor with eye pain it's probably the same mechanism irritation of the caudal part of the trigeminal nucleus so hopefully nobody misses this one in this audience right so go directly to IV steroids do not pass go I'm just just one slide about giant slarder items because this is in another lecture you know these are older people they generally have this kind of chronic low-grade boring continuous whole cranial head pain they can have tenderness over the temporal artery although not usually in my experience we want to ask about scalp tenderness you'd say is your scalp tender in the way of what so usually what we'll say is when you comb or brush your hair does that hurt they can have PMR symptoms you know achy joints and muscles weight loss anorexia anemia you know because people with giant slarderitis get the anemia of chronic disease jaw claudication is a super specific symptom for giant slarderitis like if somebody tells you they're having trouble chewing or swallowing that you know there's very few things that cause that now a lot of people have like temporal mandibular joint problems or tooth problems the way you can distinguish that is that those people as soon as they start chewing they're uncomfortable there because it irritates their TMJ it irritates their teeth but people with jaw claudication usually when they first start chewing and eating they're okay it's after they've been chewing for a few minutes that they get the claudication so that's a way that you can sometimes differentiate true claudication from some of these other more common mouth and jaw problems you want to get a complete blood count a C reactive protein not the high-sensitive sensitivity C reactive protein that's for heart you want just the plain old CRP and a sedrate and of course we all know that this can cause blindness and it's not something you want to miss let's back up and talk about trigeminal neuralgia because this is something that again will sometimes roll into your general ophthalmology clinic it's relatively common it's generally in the older class of people too the thing that is really you know pathic mnemonic about trigeminal neuralgia is it it's it's this unilateral pain that has a sudden severe stabbing electric jabbing shock like quality to it that's really very different from migranous pain or from pain caused by almost any of the other headache syndromes we've been discussing this morning it's this jab jab jab jab jabber you know that can be really severe enough that people like will stay home because they're afraid they're going to have an attack while they're out it can sometimes have a constant aching burning kind of quality to it but that's much less common you know it's really that it's that neuropathic kind of sense to it and it can be set off by shaving brushing their teeth being on the wind chewing food some fairly benign activities can you know because of the innervation of the face can set off these spells of this really severe pain and it's that characteristic that helps you differentiate it clinically from other things most in most cases it's thought to be due to a blood vessel pushing on the root exit zone of the trigeminal nerve it can also be associated with multiple sclerosis the nerve could be compressed by a tumor or an AVM if somebody could have had had had recent surgery that's damaged or irritated the nerve and their sinuses their mouth stroke facial trauma all these things anything that can injure or or touch or impact the trigeminal nerve can cause this syndrome it's generally you know these people need to be scanned Tegretol is a great treatment and arantan some of these people need surgery sometimes the trigeminal nerve has to be ablated or treated in some other way to get to stop firing because these people have since this horrible intractable pain and again this is sort of beyond the scope of what I would expect that comprehensive ophthalmologist to deal with but again just being aware of what the story sounds like so that you can say oh gee this sounds like trigeminal neuralgia we need to get you to a neurologist or I need to call your neurologist and talk to them about it and you know get you some treatment and get you worked up properly so we're going to talk briefly about the trigeminal autonomic sephalgias it's very rare that these patients come into my comprehensive ophthalmology clinic I just want you to be aware that this exists that you like heard of it so these include cluster the hemicranias and then these two very weird syndromes sunken sooner which you know you can read what they what they stand for but you can see that because of these autonomic symptoms especially the conjugal injection and tearing they might come into the eye doctor because they think that some eye problem might be part of their syndrome so cluster headache is also a unilateral pain it comes on very quickly and relatively short-lived it's very severe very sudden people are very agitated restless they walk around they can't sit still some people call this like a suicide pain because it's so severe and so debilitating so awful these patients can also have migranous symptoms like nausea light sensitivity sound sensitivity even aura and there can be autonomic features like a horner syndrome or tearing so 90% of patients with cholesterol report tearing the majority report congenital injection you can have nasal stuffiness or right or runny nose which is also an autonomic symptom they can have a droopy lid or eyelids swelling and or a horner's like appearance during an attack or even between attacks so here's a patient with a little bit of a droopy eyelid and a little bit of a small pupil on the left during a during a cluster headache there's a small segment of these patients who have a permanent horners even when they don't have an attack and there's a number of people that have a horner syndrome during an attack is kind of a big range there it's not clear if it's pre or post ganglionic and some of the other trigeminal autonomic sephalages can also be associated with a horner syndrome or a horner like syndrome but cluster is the classic one paroxysmal hemicrania is a syndrome of severe unilateral orbital or supra orbital or temporal pain it can also be short-lived but it happens multiple times a day unlike cluster hopefully doesn't mean you can see I'd be kind of hard to dissociate those two diagnoses because they have a lot of similar features but they usually have one of these autonomic symptoms on the same side and of course there's no secondary cause it's episodic or it can be episodic or chronic there's hemicrania continuum which is also unilateral and the pain is continuous as the name implies but it it fluctuates in severity but it never goes completely away like cluster or paroxysmal hemicrania the weird thing about this syndrome is that it's exquisitely responsive to endomethacin and that's actually part of the diagnostic criteria and that's kind of a cool thing like if somebody if somebody comes in with unilateral pain like this endomethacin can be therapeutic and diagnostic the sunk syndrome is this a short unilateral neuralgia form headache with conjugal injection and tearing again this is unilateral pain with autonomic symptoms but the weird thing is that these are very short lived you know under two minutes and it can happen you know multiple times throughout the day and then the pain is associated with one of these autonomic features sunk. Here's a picture of a guy on the left you know between attacks and then on the right during an attack you can see his eyelid is kind of swollen even his temporal artery kind of looks a little bit swollen in that picture and there's his eyelids and upper and lower eyelids are both endemic during an attack. There's a big differential diagnosis with with these trigeminal autonomic cephalgis because these other horrible things can cause similar features and so the bottom line is that all these patients need to be imaged to rule out a secondary cause. You know the big treatment for cluster is oxygen although there are other treatments preventative there's a number of preventative therapies we talked about hemocrania and endomethacin. Sunk is traditionally also treated with endomethacin but is notoriously difficult to treat and again I think treatment of these syndromes and even the evaluation these syndromes is beyond the scope of a comprehensive ophthalmologist but I think it's important to be aware that they exist to be aware that they have these autonomic features to be aware that that patient may come to you because of those autonomic features. Okay just a few minutes to do the quiz. Okay can I go on to number five? Okay the last one. Okay we're going to go over the answers. Migraine can present with eye pain that was kind of the whole point of the lecture so that's true. Tropleitis is inflammation of the superior oblique tendon in the trochlea not the muscle so that is false. As we talked about in the in the case example intracranial hypotension can present with double vision and of course pseudo tumor cerebrite intracranial hyper tension can cause a sixth nerve palsy so they can both present with diplopia and that's because remember the sixth nerve comes out of the pontomagillary junction goes up the clivus and over the top over through durella's canal into the cavernous sinus so if the brainstem moves up or down it's you know that's a teeny tiny nerve right it just innervates one little bitty muscle and so just any kind of pressure up or down on that teeny weenie nerve can can cause it to fail so that is true and then it's of course the trigeminal nerve that innervates the meninges as well as the eye and the eye socket these are both all of the above again that was kind of the point of the lecture I guess I didn't talk about Tulosa Hunt but hopefully remember that from another lecture and then all the autonomic sephalages are called that because of these autonomic symptoms like like a droopy lid yeah I noticed that as I put that up here I did this I did the quiz late at night so this should just say headache syndromes which are the following headache syndromes yeah I'll correct that okay so photophobia we talked about that briefly those are photo intrinsically photosensitive retinal ganglion cells these other ones don't exist and none of those other cells are intrinsically photosensitive and then it generally people with migraine like incandescent lights so the answer there is B whereas these other things tend to bug people with migraine and then of course the thing that needs to be ruled out here is a carotid dissection because you're worried because he's got ptosis and meiosis you're worried he's got a horny syndrome from a carotid dissection that's the thing that's going to cause a stroke and the thing like these other things can cause the same symptomology but the dissection is the thing that's going to cause a problem in the next 24 hours and needs to be ruled out okay thanks everyone