1. Intervention & Outcome Conclusions/Relevance
New onset of cluster-like headache after cataract surgery and intraocular lens implant: A Case Report Grigor M. Harutunian, M.D., Soma Sahai-Srivastava, M.D. University of Southern California, Los Angeles, California, USA
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Abstract
Intervention & Outcome
Conclusions/Relevance
Objective: To describe a rare case of new onset cluster like headache after cataract surgery.
Background: There have been several case reports of cluster headaches that began subsequent to eye trauma, infections, orbital tumors or orbital myositis, but only rarely after cataract surgery.
Method: Case report
Results: Failed a treatment trial of amitriptyline and verapamil but responded to a trial of topiramate plus sumatriptan.
Conclusion: In the rare circumstance in which a cluster headache develops after cataract surgery, the involvement of the ophthalmic branch of the trigeminal nerve by a foreign body such as a lens could be responsible for some of the symptoms associated with the cluster headaches.
Case Presentation
History : A 61-year-old hispanic woman presented to neurology clinic with episodes of strictly left-sided sharp, stabbing pain lasting on average about 60 mins associated with conjunctival injection and lacrimation, within two weeks of uneventful cataract surgery. The attacks would occur initially occur twice a day, in the early afternoon and evening. During the attacks the patient was very distressed and restless.
Exam :Neurological and ophthalmological exam was unremarkable.
Lab: Routine lab testing was all normal. Neuroimaging: MRI of brain with and without contrast showed incidental finding of a small subarachnoid cyst in the middle cranial fossa. MR angiogram of the head and neck showed some irregularity of the right middle cerebral artery, likely due to atherosclerotic disease and again an incidental finding.
Course and treatment
She obtained good pain relief with oral Sumatriptan for acute abortive treatment.
Preventative T/t: she failed amitriptyline and verapamil but responded to Topiramate 100mg QHS
At 3 month follow up, she reported a significant decrease in headache severity, and duration.
We hypothesize that, the involvement of the ophthalmic branch of the trigeminal nerve by a foreign body such as a lens could have triggered cluster headaches.
The ophthalmic nerve supplies branches to the cornea, ciliary body, iris, lacrimal gland, conjunctiva, part of the mucous membrane of the nasal cavity, and to the skin of the eyelids, eyebrow, forehead, and nose.
Activation of the V1 branch of Trigeminal N. can provoke pain in the periorbital region and activation of adjacent parasympathetic fibers leading to lacrimation, nasal congestion, conjunctival injection, and sympathetic dysfunction from compression of the superior cervical ganglion adjacent to the carotid wall resulted in miosis and ptosis.
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Background
The International Headache Society describes cluster headache as attacks of severe strictly unilateral pain orbitally, supraorbitally, and/or temporally, lasting minutes, occurring from once every other day to 8 times/day associated with one or more of: 1.conjunctival injection
2. Lacrimation
3. Nasal congestion
4. Rhinorrhea
5.Forehead and facial sweating
6. Miosis
7. Ptosis
8. eyelid edema.
References
1. The International Headache Society Classification of Headaches (ICHD-II). Classification and diagnostic criteria for headache disorders under section 3.1 of part I: Cluster headache and other trigeminal autonomic cephalalgias
2. Maggioni, F; Dainese, F; Mainardi, F; Lisotto, C; Zanchin, G. Cluster-like headache after surgical crystalline removal and intraocular lens implant: a case report (2005). J Headache Pain (2005) 6:88-90.
3. Michael S. Lee, MD; Simmons Lessell, MD (2002) Orbital Myositis Posing as Cluster Headache: an observation. Archives Neurology/Volume 59, April
4. Pianigiani, R; Grosso, S; Galluzzi, P; Cerase, A; Buonocore, G; Morgese, G; Balestri, P. Orbital Myositis Presenting As Cluster Headache (2005). Pediatric Research: August 2005 volume 58 Issue 2 pgs
 5. JS Harley; F Ahmed. Cluster-like Headache Heralding Inflammatory Orbital Pseudotumor (2008). Cephalalgia April 2008 vol. 28 no. 4 pgs