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Treating periocular pain offers relief to some
migraine sufferers
By Sean Henahan
Madrid — Local treatment of inflammation of the superior oblique
muscle trochlea appears to offer significant relief to some migraine
sufferers, according to a Spanish study.
Julio Yangüela Rodilla MD and colleagues from the Headache
Program, Fundación Hospital Alcorcon, Madrid, Spain identified
five patients with trochleitis associated with chronic migraine
headaches.
The five female patients reported that the onset of pain around
the area of the eye socket caused their migraines to worsen for
periods ranging from several hours to several days. They described
the headache pain in terms ranging from “dull” to “excruciating”.
Dr Yangüela Rodilla treated the trochleitis with local injections
of 3.0 mg of dexamethasone and 3.0 mg methylprednisolone applied
directly to the inflamed trochlear area.
The treatment relieved the ocular pain and improved control of associated
migraine symptoms within 48-72 hours in all cases. All patients
experienced relief of both ocular pain an migraine after a course
of treatment, with one reporting complete relief. The other four
patients reported lasting relief after a second course of treatment.
After treatment all patients decreased basal pain, number of attacks
and medication intake to control chronic migraine.
The diagnosis of trochleitis was based on the presence of periorbital
pain appearing synchronously with and ipsilateral to the demonstrated
sore trochlea. Additional diagnostic criteria included palpation
of a swollen trochlea and obvious trochlea tenderness. In such cases,
there is an exacerbation of pain upon palpation of the trochlea
or when attempting supraduction of the symptomatic eye.
The differential diagnosis of idiopathic trochleitis includes thyroid
ophthalmopathy, carotid cavernous sinus fistula, arteriovenous malformation,
orbital myositis and infiltration of extraocular muscle by metastatic
tumor, sarcoidosis or lymphoma. The absence of other signs including
conjunctival injection, chemosis, proptosis and periorbital edema
can aid in the differential diagnosis.
Other causes of ocular pain such as cluster headache, SHUNT or optic
neuritis should also be excluded.
Although rare, trochleitis can also occur in rheumatoid arthritis,
systemic lupus erythematosus, psoriasis or enteropathic arthropathy.
Laboratory testing and imaging studies are required to confirm the
diagnosis.
The study indicates a new treatable trigger mechanism in chronic
migraine.
Authors suggest that trochlear area should be explored in all patients
referring periorbital pain or migraine associated with ocular pain.
Dr Yangüela Rodilla's study appeared in Neurology (2002;58:802–805),
the scientific journal of the American Academy of Neurology .
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