Headache Medicine 2021, 12(2) p-ISSN 2178-7468, e-ISSN 2763-6178

144

ASAA

DOI: 10.48208/HeadacheMed.2021.26

Headache Medicine

Case Report

Paroxysmal hemicrania associated to carotid artery dissection: a

case report

Felipe Araújo Andrade de Oliveira , Pedro Augusto Sampaio Rocha-Filho

Universidade Federal de Pernambuco, Recife, Brazil

Abstract

There are numerous case reports relating trigeminal autonomic cephalalgias to structural injuries.

However there is no description of the association between paroxysmal hemicrania and carotid

artery dissection. We describe a previously healthy 63-year-old male presented with the onset

of severe, throbbing pain in the right frontal region, lasting between 10 and 30 minutes, with a

frequency of approximately two to three attacks per day, which began two days before seeking

medical care. Pain was associated with ipsilateral tearing, semiptosis and nasal congestion. A

cervical arterial magnetic resonance angiography demonstrated left carotid artery dissection in

the C1/C2 segment of the left internal carotid artery. The patient became asymptomatic after

indomethacin use. We conclude that The possibility of investigating carotid dissection should be

considered in patients with paroxysmal hemicrania.

Felipe Araújo Andrade de Oliveira

Abraham Lincoln St, 141, Recife,

Pernambuco, Brazil

felipe.oliveira1983@gmail.com

Edited by

Mario Fernando Prieto Peres

Marcelo Moraes Valença

Keywords:

Paroxysmal hemicranias

Carotid dissection

Secondary headaches

Trigeminal Autonomic Cephalalgias

Indomethacin

Pain

Received: July 8, 2021

Accepted: August 13, 2021

145

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Oliveira FAA, Rocha-Filho PAS

Paroxysmal hemicrania associated to carotid artery dissection: a case report

Introduction

aroxysmal hemicrania is a disorder characterized by se-

vere, unilateral headache, lasting between two to thirty

minutes, with an orbital, supraorbital and/or temporal local-

ization, associated with ipsilateral autonomic symptoms. A

marked response to indomethacin is essential for diagnosis.

Although trigeminal autonomic cephalalgias are classied as

primary headaches

, there are numerous case reports relating

such headaches to structural injuries.

2-4

To the best of our

knowledge, there is no description of the association between

paroxysmal hemicrania and carotid artery dissection. Herein,

we describe one case that may demonstrate this association.

Case report

A previously healthy 63-year-old white man presented with

the onset of severe, throbbing pain in the right frontal region,

lasting between 10 and 30 minutes, with a frequency of ap-

proximately two to three attacks per day, which began two

days before seeking medical care. Pain was associated with

ipsilateral tearing, semiptosis and nasal congestion. There

was no photophobia, phonophobia, nausea or vomiting

associated with pain. There was not any history of head or

neck trauma. Physical and neurological examination was

normal. The physical examination was not suggestive of other

disorders such as Marfan or Ehlers-Danlos syndrome.

Magnetic resonance imaging and intracranial magnetic

resonance angiography were normal. A cervical arterial

magnetic resonance angiography demonstrated left carotid

artery dissection in the C1/C2 segment (Figure 1 A and

B). This exam did not nd any specic cause for the carotid

dissection.

Figure 1. A and B) Cervical arterial resonance angiography demon-

strates dissection in the left carotid artery in the C1/C2 segment.

For the treatment of arterial dissection, acetylsalicylic acid

and atorvastatin were used. For the treatment of headache,

indomethacin (50 mg every 8 hours) was initiated orally,

with a signicant pain response in only 3 days. The patient

became asymptomatic. He took indomethacin for 15 days.

He has had no headaches for three years and has not had

any stroke. He still uses acetylsalicylic acid and atorvastatin.

He made follows-up magnetic resonance angiography every

six months. The last magnetic resonance angiography was

performed three years after the headache and the dissection

is stable.

The patient had given his written consent for the case report.

Comments

Our patient had no signs or symptoms on the same side as

the dissection. Between 26 to 36% of patients who have

carotid dissection have no head, face or neck pain

and

25.5% of these patients have no local signs or symptoms.

There are descriptions of headache compatible with parox-

ysmal hemicrania associated with intracranial secondary

lesions such as expansive lesions in the sella turcica, pituitary

apoplexy, intraparenchymal pontomesencephalic hemor-

rhage, type I Chiari malformation and giant cell arteritis.

2, 7-11

146

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Oliveira FAA, Rocha-Filho PAS

Paroxysmal hemicrania associated to carotid artery dissection: a case report

Our patient fullled the criteria for paroxysmal hemicranias,

except for the frequency of pain, which was less than ve

attacks per day, on most days. We cannot completely rule

out the possibility that the association between headache and

dissection was a coincidence. However, there was a temporal

relationship between the dissection and headache and, the

patient had no previous headache. This reinforces a cause

and effect relationship between dissection and headache.

There was also a temporal relationship between the use of

indomethacin and the patient’s improvement. We cannot

be certain whether this response was due to the use of the

medication or to the natural history of the disease.

We did not nd other reports about the association be-

tween paroxysmal hemicrania and carotid dissection. How-

ever, there were an association between carotid dissection

and cluster headache

and between carotid dissection and

hemicrania continua.

In all these reported cases of cluster

headache and hemicranina continua, the dissection was

ipsilateral to pain.

2, 12

Our patient presented with contralateral headache regard-

ing the side of the arterial dissection. The pathophysiology

of autonomic trigeminal headaches involves abnormalities

of the hypothalamic function, trigeminal-autonomic reex

disinhibition, cranial and trigeminovascular autonomic activa-

tion.

13, 14

In cluster headaches, studies with positron emission

tomography and functional magnetic resonance demonstrate

activation of the ipsilateral posterior hypothalamus during

the pain attack.

In the paroxysmal hemicrania, activation

occurs of the contralateral posterior hypothalamus and the

contralateral ventral midbrain to the pain during the attacks.

This may justify the fact that the dissection was contralateral

to our patient's headache since it would be ipsilateral to the

activated hypothalamus. Another case of paroxysmal hemi-

crania associated with intraparenchymal hemorrhage also

presented contralateral headache to the lesion, corroborating

this explanation.

Conclusion

In conclusion, in patients with paroxysmal hemicrania, the

possibility of investigating carotid dissection should be con-

sidered.

Key points

• Carotid dissection may present as paroxysmal hemi-

crania.

• Paroxysmal hemicrania can also be a secondary head-

ache.

• The headache presentation can be contralateral to the

lesion.

Conflict of interest: The authors declare that there is no conict

of interest.

Financial support: There was no nancial support.

Author´s contributions:

Felipe Araújo Andrade de Oliveira: Conceptualization, Data

curation, Writing original draft

Pedro Augusto Sampaio Rocha-Filho: Supervision, Writing

review and editing

Felipe Oliveira

https://orcid.org/0000-0002-9583-3165

Pedro Augusto Sampaio Rocha-Filho

https://orcid.org/0000-0001-5725-2637

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