A set of related medical disorders that lack a proper classification system and diagnostic criteria is like a society without laws. The result is incoherence at best, chaos at worst. For this reason, the International Classification of Headache Disorders (ICHD) is arguably the single most important breakthrough in headache medicine over the last 50 years. The ICHD identifies and categorizes more than a hundred different kinds of headache in a logical, hierarchal system. Even more important, it has provided explicit diagnostic criteria for all of the headache disorders listed. The ICHD quickly became universally accepted, and criticism of the classification has been minor relative to that directed at other disease classification systems. Over the 20 years following publication of the first edition of the ICHD, headache research has rapidly accelerated despite sparse allocation of resources to that effort. In summary, the ICHD has attained widespread acceptance at the international level and has substantially facilitated both clinical research and clinical care in the field of headache medicine.

International Classification of Headache Disorders

Migraine and tension-type headaches (TTHs) comprise a significant burden of neurological disease globally. Trochleodynia, also known as primary trochlear headache or trochleitis, may go unrecognized and contribute to worsening of these headache disorders. It may also present in isolation. We review the English literature on this under-recognized condition and describe what is known about the theorized pathophysiology, clinical presentation, and differential diagnosis. We also present a management algorithm for patients presenting with trochleodynia.

/pdf/diagnosis-and-management-of-trochleodynia-trochleitis-and-hp8jgzytil.pdf

Diagnosis and management of trochleodynia, trochleitis, and trochlear headache

Purpose of Review: This article highlights painful conditions involving the eyes that are encountered in practice, emphasizing those that do not have obvious findings on the neurologic examination.Recent Findings: Peripheral and central sensitization are associated with chronic neuropathic o

The eye and headache

Objective The aim of this study was to describe clinical features unique to supratrochlear neuralgia. Background The supratrochlear nerve supplies the medial aspect of the forehead. Due to the intricate relationship between supraorbital and supratrochlear nerves, neuralgic pain in this region has been traditionally attributed to supraorbital neuralgia. No cases of supratrochlear neuralgia have been reported so far. Methods From 2009 through 2016, we prospectively recruited patients with pain confined to the territory of the supratrochlear nerve. Results Fifteen patients (13 women, 2 men; mean age 51.4 years, standard deviation 14.9) presented with pain in the lower paramedian forehead, extending to the eyebrow in two patients and to the internal angle of the orbit in another. Pain was unilateral in 11 patients (six on the right, five on the left), and bilateral in four. Six patients had continuous pain and nine described intermittent pain. Palpation of the supratrochlear nerve at the medial third of the supraorbital rim resulted in hypersensitivity in all cases. All but one patient exhibited sensory disturbances within the painful area. Fourteen patients underwent anesthetic blockades of the supratrochlear nerve, with immediate relief in all cases and long-term remission in three. Six of them had received unsuccessful anesthetic blocks of the supraorbital nerve. Five patients were treated successfully with oral drugs and one patient was treated with radiofrequency. Conclusions Supratrochlear neuralgia is an uncommon disorder causing pain in the medial region of the forehead. It may be differentiated from supraorbital neuralgia and other similar headaches and neuralgias based on the topography of the pain and the response to anesthetic blockade.

Supratrochlear Neuralgia: A Prospective Case Series of 15 Patients.

Ocular pain is a common complaint which forces the patient to seek immediate medical attention It is the primeval first response of the body to any severe condition of the eye such as trauma, infections and inflammation The pain can be due to conditions directly affecting the eye and ocular adnexa; or indirect which would manifest as referred pain from other organ structures such as the central nervous system Paradoxically, there are several minor and non-sight threatening conditions, which also leads to ocular pain and does not merit urgent hospital visits In this perspective, we intend to provide guidelines to the practising ophthalmologist for teleconsultation when a patient complains of pain with focus on how to differentiate the various diagnoses that can be managed over teleconsultation and those requiring emergency care in the clinic These guidelines can decrease unnecessary hospital visits, which is the need of the hour in the pandemic era and also beyond Patients who are under quarantine and those who are unable to travel would be benefitted, and at the same time, the burden of increased patient load in busy hospital systems can be reduced

Differential diagnosis of acute ocular pain: Teleophthalmology during COVID-19 pandemic - A perspective.

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.

Clinical features and long-term prognosis of trochlear headaches


 
 
 This is the first study investigating the relationship between NLR or PLR and outcomes of percutaneous cryoablation or RFA for small RCCs with long-term outcomes.
 
 
 
 All patients undergoing cryoablation or RFA for small RCCs (<7cm) from 2003–2016 at a regional centre for RCC were included. Optimal cut-offs for NLR/PLR were determined using the ROC curve and AUC using the Youden method. Outcomes were compared using Cox or logistic regression.
 
 
 
 203 patients (Cryoablation:103, RFA:100) were included. Median follow-up was 75 months and 98 months, respectively.
 Using the Youden method, high post-operative NLR values were associated with worsened local recurrence-free survival (LRFS) (NLR >5.38; HR: 5.13, p=0.037) and worsened Overall Survival (OS) (NLR >6.42; HR: 3.40, p<0.001) in all patients.
 High post-operative PLR values were associated with worsened OS in all patients (PLR >192; HR: 2.31, p=0.006) and RFA patients alone (n=100; PLR >260; HR: 8.27, p<0.001).
 Using continuous Cox regression model, greater changes in peri operative NLR were associated with worsened LRFS in cryoablation alone and all patients (Continous; HR: 1.09, p=0.028).
 Higher post-operative NLR was also associated with worsened LRFS in cryoablation patients alone (HR: 1.10, p=0.046).
 Post-operative NLR (HR:1.17, p=0.002), change in peri-operative NLR (HR:1.19, p=0.001), and change in peri-operative PLR (HR:1.20, p=0.009) were all associated with worsened CSS in all patients.
 Pre-operative PLR and NLR were not associated with complications and change in renal function.
 
 
 
 NLR and PLR are valuable prognostic factors for this group of patients and should be used to guide subsequent follow-up and monitoring of recurrence.


962 Prognostic Value of Neutrophil to Lymphocyte Ratio (NLR) and Platelet to Lymphocyte Ratio (PLR) for Small Renal Cell Carcinomas (RCC) After Image-Guided Cryoablation or Radio-Frequency Ablation (RFA)

BACKGROUND AND PURPOSE To date, no pathophysiological model has sufficiently accounted for all the findings encountered in patients with idiopathic intracranial hypertension (IIH). Intracranial elastance is an index of volume-buffering capacity known to play a role in certain disorders of cerebrospinal fluid (CSF) dynamics, which has not been previously investigated in relation to IIH patients. METHODS This was a single-center retrospective cohort study from 1 July 2011 to 1 July 2016. Values for opening pressure (PO ), closing pressure (PC ) and volume (V) of CSF removed were collected, as well as demographic and clinical covariates. Intracranial elastance (E) and pressure-volume index (PVI) were calculated according to established equations: E = (PO -PC )/V and PVI = V/log10 (PO /PC ), respectively. Those with an alternative central nervous system pathology, including meningitis, encephalitis and normal pressure hydrocephalus were excluded. Eligible patients were subdivided into two groups based on final diagnosis: a control group and an IIH group. RESULTS In our cohort (n = 49), a significant association of both E (P < 0.0001) and PVI (P = 0.005) with a diagnosis of IIH was observed. Median E was 0.45 [interquartile range (IQR) 0.29-0.63] in the control group and 1 (IQR 0.59-1.29) in the IIH group, and median PVI was 98.07 (IQR 59.92-135.86) in the control group and 64.1 (IQR 42.4-91.7) in the IIH group. Neither E nor PVI were significantly associated with age, gender or body mass index. PVI was independent of opening pressure. CONCLUSIONS As calculated by clinically accessible indices, our study provides evidence that intracranial elastance is increased in IIH, reflecting a novel insight into disease pathogenesis.

Intracranial elastance is increased in idiopathic intracranial hypertension.

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Clinical features and long-term prognosis of trochlear headaches

962 Prognostic Value of Neutrophil to Lymphocyte Ratio (NLR) and Platelet to Lymphocyte Ratio (PLR) for Small Renal Cell Carcinomas (RCC) After Image-Guided Cryoablation or Radio-Frequency Ablation (RFA)

Intracranial elastance is increased in idiopathic intracranial hypertension.