Headache for the ophthalmologist

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Headache for the ophthalmologist

  1. 1. Raed Behbehani , MD FRCSC
  2. 2. •Periocular pain due to diseases of the face, orbit, sinuses , and intracranial cavity. •Trigeminal innervation (V1-V3). •Primary headache syndrome vs Secondary headache syndrome
  3. 3. • Any headache can cause eye pain (vice versa). • Take good history ( loss of vision, diplopia, redness, photophobia, jaw claudication, systemic symptoms). • Examination : check vision at least grossly, look for redness, ptosis, corneal edema, check pupil reactions, palpate the eyes and orbits, check sensation v1-v3 and other cranial nerves. •FUNDOSCOPY !
  4. 4. • Migraine (with / without aura) •Cluster Headache . •Tension Headache. •Chronic Daily Headache. •Medication overuse.
  5. 5. • Ocular disease. • Orbital disease. • Vascular disease. • Intracranial disease .
  6. 6. • Inadequate tear production. • Primary / Secondary to rheumatological conditions. • Slit lamp examination : Flourescin stain/ Rose bengal • Artificial tears/ punctal occlusion is the treatment.
  7. 7. • Anterior/Posterior Uveitis. •Pain and Photophobia. • Cells in the anterior chamber/ Ciliary injection/ Posterior synechiae. • Idiopathic/ associated with rheumatologic conditions/ infectious (post-operative). • Topical steroids for anterior / periocular and systemic for posterior • Intravitreal antibiotics for infectious post-operative.
  8. 8. • Severe periocular pain +- headache. • Blurred vision , nausea , and vomiting. • Cilliary injection/ corneal edema/ fixed mid-dilated pupil. • Previous history of transient visual disturbances . • Laser iridotomy.
  9. 9. • New onset of headache (temporal) , acute or transient loss of vision, jaw claudication, weight loss, fever, and myalgias. • Age over 60. • Anterior/posterior ischemic optic neuropathy • Retinal artery occlusion. • ESR, CRP, CBC. • Systemic steroids ( oral or IV). • Temporal artery biopsy.
  10. 10. . • Deep boring pain in the eye upon standing up or with sustained exposure to light (ocular claudication) . •Impaired retinal cicrulation due stenosis of the aoortic arch/carotids. • Fundus examination shows sign of ischemia (dilated retinal veins, hemorrhages, cotton wool spots, neovascularization). • ? Carotid endarterectomy.
  11. 11. • Incorrect glasses/ contact lenses. • Uncorrected presbyopia.
  12. 12. • Optic neuritis. • Orbital inflammtory disease. • Orbital mass. • Orbital vascular malformation.
  13. 13. • Sudden onset. •Pain, proptosis, limited eye movement, chemosis. • Idiopathic or due to Wegener’s granulmatosis, Grave s’ disease, sarcoidosis)
  14. 14. • Can be primary (pseudo-tumor cerebri) or secondary (mass, hemorrhage) • Headache, pain in the neck and shoulders and upper back. •Worse with coughing/straining. •Pulsatile tinnitis. •Transient visual obscurations. • Diplopia. • Treatment of pseudotumor cerebri is Medical ( Diamox ) or Surgical (Optic nerve sheath fenstration, V-P or V-A shunt).
  15. 15. • Take good history ( try to distinguish primary from secondary headache syndrome). • Look for abnormal neuro-ophthalmic signs ( Ptosis, ophthalmoplegia, abnormal facial sensation, check visual acuity, and pupils, and look for papilledema). • Giant cell arteritis is vision-threatening. • Papilledema ican be life threatening.

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