SUNCT headache
Overview
A syndrome involving a short-lived pain around one eye or on one side of the head as well as well as fluid being forced into the conjunctiva and mucous membranes of the eyelids.
Symptoms
* Red eye * Eye swelling * Conjunctival infection * Eye pain * Pain on one side of head * Headache * Runny nose * Sweaty forehead
Causes
- bacterial — Staphylococcus aureus, Streptococcus pneumoniae, Neisseria gonorrhoeae, Neisseria meningitidis - chlamydial — Chlamydia trachomatis (inclusion conjunctivitis) - viral — adenovirus types 3, 7, and 8; herpes simplex virus, type 1. Other causes include allergic reactions to pollen, grass, topical medications, air pollutants, smoke, or unknown seasonal allergens (vernal conjunctivitis); environmental (wind, dust, and smoke) and occupational irritants (acids and alkalies); and a hypersensitivity to contact lenses or solutions. Vernal conjunctivitis (so-called because symptoms tend to be worse in the spring) is a severe form of immunoglobulin E-mediated mast cell hypersensitivity reaction. This form of conjunctivitis is bilateral. It usually begins at age 3 to 5 years and persists for about 10 years. It’s sometimes associated with other signs of allergy commonly related to pollens, asthma, and allergic rhinitis. Epidemic keratoconjunctivitis is an acute, highly contagious viral conjunctivitis caused by adenovirus types 8 and 19. It’s commonly complicated by visual loss due to corneal subepithelial infiltrates. Health care providers must be careful to wash their hands and sterilize equipment to prevent the spread of this disease. In the Western hemisphere, conjunctivitis is probably the most common eye disorder.
Diagnosis
When you take the patient’s history, always ask if he has associated pain. If so, when did the pain begin, and where is it located? Is it constant or intermittent? Also, ask about itching, burning, photophobia, blurred vision, halo vision, excessive tearing, or a foreign body sensation in his eye. Does the patient have a history of eye disease or trauma? If he has suffered ocular trauma, avoid touching the affected eye. Test his visual acuity and intraocular pressure (IOP) only if his eyelids can be opened without applying pressure. Place a metal shield over the affected eye to protect it, if necessary. If the patient’s condition permits, examine the affected eye. First, determine the location and severity of conjunctival injection. Is it circumcorneal or localized? Peripheral or diffuse? Note any conjunctival or lid edema, ocular deviation, conjunctival follicles, ptosis, or exophthalmos. Also note the type and amount of any discharge. Test the patient’s visual acuity to establish a baseline. Note if the patient has had vision changes: Is his vision blurred or his visual acuity markedly decreased? Next, test pupillary reaction to light. Perform IOP measurements. To gauge increased IOP without a tonometer, gently place your index finger over the closed eyelid; if the globe feels rock-hard, IOP is elevated.
Prognosis
There is no cure for these headaches. The disorder is not fatal but can cause considerable discomfort.
Treatment
Treatment for conjunctivitis varies with the cause. Bacterial conjunctivitis requires topical application of the appropriate broad-spectrum antibiotic. Although viral conjunctivitis resists treatment, a sulfonamide or broad-spectrum antibiotic eyedrops may prevent a secondary infection. Patients may be contagious for several weeks after onset. The most important aspect of treatment is preventing transmission. Herpes simplex infection generally responds to treatment with trifluridine drops or vidarabine ointment or oral acyclovir, but the infection may persist for 2 to 3 weeks. Treatment for vernal (allergic) conjunctivitis includes administration of corticosteroid drops followed by cromolyn sodium, cold compresses to relieve itching and, occasionally, oral antihistamines. Instillation of a one-time dose of erythromycin or 1% silver nitrate solution (Credé’s procedure) into the eyes of neonates prevents gonococcal conjunctivitis.