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Título

Shocking, sharp and unilateral pain of onset in the eighth decade of life: a case-report of Paroxysmal Hemicrania-Tic Syndrome

RESUMO

Case report. A 72-year-old woman with a five-month history of headaches was admitted at our headache outpatient clinic. The pain was localized in the periorbital and left temporal regions. It was daily, sharp, intense, sometimes throbbing, and with diffuse ipsilateral irradiation. Episodes usually lasted about 30 minutes and occurred five times a day. The patient reported left hemiface heating during the attacks, however without conjunctival hyperemia, lacrimation, nasal congestion, or rhinorrhea. She sometimes referred shocking, short-lasting pain triggered by biting food and touching certain points of the face. Previous treatments with duloxetine, amitriptyline, lamotrigine, and carbamazepine, initiated by a neurologist in another clinic, provided no relief. Her previous medical history was remarkable for treatment of hypothyroidism and presence of temporomandibular joint dysfunction (TMJD). Physical examinations during pain-free periods were normal except for TMJD signs. Blood counts, liver, renal and thyroid function were normal, as well as Brain magnetic resonance imaging (MRI). Still using CBZ, the patient had pain in only the left side of the face. Therapy was changed to 75 mg a day mg of indomethacin and was increased to 100 mg a day, with headache frequency improvement and up to five pain-free consecutive days. After two months she was admitted due to recurrence of pain, with the same pattern, however associated with conjunctival hyperemia and eyelid edema. Reintroduction of CBZ 400 mg a day in combination with indomethacin resulted in complete improvement. Discussion. Paroxysmal Hemicrania-Tic (PH-TIC) syndrome is a rare association between chronic paroxysmal hemicrania (CPH) and trigeminal neuralgia (TN). The age of onset is usually between the fifth and seventh decades of life. Features such as pain of different durations, unilateral involvement of the face and partial response to indomethacin should alert to the overlap between PH and TN. Frequently, no abnormalities are found in laboratory tests or in brain MRI. CPH was improved with initiation of indomethacin and trigeminal neuralgia with reintroduction of CBZ. Final comments. PH-TIC is uncommon, however it should be hypothesized in patients with short-lasting headaches associated with facial pain that partially improve with carbamazepine or indomethacin. by case series, over single pharmacotherapy.

Palavras Chave

PAROXYSMAL HEMICRANIA;