Ask a Neurologist and Get an Answer ASAP
Hi, Welcome to Just Answer!
I am an American Board Certified Neurologist and I am familiar with the condition that you have described and glad to help you with your questions and concerns.
Please answer the following questions;
1) Have you had any investigations like CT or MRI of the brain done recently after you started noticing the swelling?
2) Could you describe the HA (headache) more, like the HA location, how long you have it, duration, severity, any associated symptoms like drooping of the eyelid, small size pupil, increased tearing or secretion from the nose on the same side as your HA?
All the Best!
No, i have not had CT or MRI since I started getting the swelling after my headaches.
The headaches are mostly on my suture line but at times they are other areas towards the front and over my left eye. They can last for days unless I take toradol and phenergan (which my family doctor prescribes) it was used in ER over the last several years and worked so he prescribes it for me. I get a pinching pain over my left eye and I did notice clear thin discharge once or twice from my nose, but i only noticed this twice. I have not noticed a small pupil, but I was not really looking to see it...I have been suffering with these headaches for 18 years but only in thre past six months have I started to get the lump and swelling afterwards.
Thanks for these details.
Just couple of more questions, do you have any migraine headache symptoms like light or sound bothering , nausea or vomiting along with headaches? And have you tried any medications for these headaches other than you mentioned here?
Yes, I am sensitive to light, sound and I do get nausiated. I have tried alot of migraine meds over the years but either did not help me or I got sideeffects. I know I have migraines, and I just treat them with the toradol and phenergan which does help...The lump and swelling is the only thing that is new and concerning to me.
The other thing that concerns me is the question of a fluid leak.
I did not mention that I have a PFO (small opening in my heart that never closed fully)
I am more susceptable to migraines with this...as i was told my the men I work with (cardiac nurse administrator) I work with heart surgeons and cardiologists, they were the ones who found my PFO after my tia and told me of the increase of migraines with PFO...just wanted to clarify this :)
Thanks for these additional details.
1) Yes I agree the lump/swelling is a new symptom and it needs full attention. You require an MRI of the brain with and without contrast and that will tell us is there any structural pathology in the scalp or skull bone area that might be producing the swelling. It is less likely coming from the brain, but a structural pathology in the scalp/skull bone area can produce similar swelling.
2) The chances of a CSF leak are very less likely. However the MRI with contrast will help us in that regard too.
3) If MRI comes normal then there is a possibility that you might be experiencing what we call as autonomic trigeminal cephalgia. These are headaches that are associated with swelling, eye symptoms and nasal secretions as you mentioned. Cluster headache is an example although you do not have classical features. But then there are variants of cluster headache that can present like this.
So if MRI comes normal that is what I will suspect in you.
4) The preferred treatment for this kind of headache includes (not all these treatments together, just try any one agent and see if it helps if no help then try another agent);
A) For acute attacks (agents for immediate relief):
a) Lidocaine 4% solution. Use nasal dropper and instill 1 ml into the affected nose, repeat another dos after 10 minutes if necessary, 2 total doses/day.
b) 100% O2, 10 liters/minute x 10 minutes by non re-breathing mask (keep tank at home)
c) Tab Caffergot: starting dose 2 tablets, then to repeat 1 tablet at one hourly interval x 2 more doses, maximum per day 4 tablets, maximum per week 10 tablets.
B) Preventive agents: (to use this if headaches are frequent, not otherwise).
a) Tab Verapamil: Starting dose at 40 mg twice daily
b) Tab Depakote ER: Starting dose 250 mg at bed time. If you use this periodically you should undergo liver function tests & CBC (cell count) as this drug can affect the liver and blood cells rarely.
C) If nausea and/or vomiting present:
Tab Stemetil 5 mg, 1 to 3 times per day
Tab Phenergan 25 mg: 1 to 3 times per day.
So if MRI comes normal I will consider your headache as above (in addition you do have some migraine type headache too) and the treatment plan is as discussed above.
5) Yes I agree the PFO may require additional intervention if possible since its presence can make management of migraine headache difficult.
These are my opinions & recommendations based on the details provided, and if you are seeking a more elaborative discussion or have additional concerns then please ask any number of questions until you clarify all your doubts.
Another thing the TIA/vertigo you had in the past is unrelated with your current symptoms like swelling. Just clarifying on that point too.
Thank you so much for all you time and advice. I am impresses with your quick response and medical advice. I will pursue these options and testing, but one final question...have you heard of other patients that get the forehead lump and tenderness?
On line blogs that I read before asking you questions on this site, showed atleast 15 people with similar lumps associated with their headaches...its so bizarre. It only appears after a headache...have you heard of any kind of headaches that produce this?
You are welcome and thanks for these additional details.
Yes the tenderness and swelling/lump after the headache occurs frequently in patients with autonomic trigeminal cephaligia group and that is what I am suspecting in you. Of course you do not have all the classical features (swelling and drooping of eye lids, pupil size changes, frequent tearing, nasal discharges etc, but this appears to be a variant of these kinds of headaches (more specifically cluster headache variant). Please check for pupil size too; small pupil on the side of the headache is a feature of these headaches like cluster headache.
Please ask any number of questions until you clarify all your doubts.
My lids do droop on occasion after headaches, I just did not mention that, sorry....thank you so much again, I could not sleep tonight because I was worried about the swelling and my headaches is starting back again as of the last 30 minutes, but know I feel much better. I will pursue the testing. Thank you and have a good evening (if its evening there!
Okay if drooping of eyelid occurs then that further increases the suspicion of the type of headache I was mentioning,
Any serious possibilities like CSF leak etc are very unlikely in your case. Anyway MRI is required and it is the standard protocol in these circumstances. Please pursue the treatments too and I genuinely hope they help you.
You are welcome and please ask any number of questions until you clarify all your doubts.
No, you have answered all my questions, and I am satisfied 100%!
Thank you, I just paid for your services you were excellent!
You are welcome and Thanks Very Much for the consultation, as well as for the feedback, payment & the bonus.
Please follow up any time if you require my services again. All the Best! Best Regards, Dr Sathya.
(Please disregard the "reply" button unless you have more questions; this message is sent to appreciate the consultation, feedback, payment & the bonus).
Just an addendum and clarification on some of the points discussed earlier;
While you do have certain features of autonomic trigeminal cephalgia like a cluster HA (headache), and some amount of forehead tenderness and swelling can also be seen with these conditions, however these conditions are not usually associated with a large swelling. So if your swelling is large then you definitely require an MRI with & without contrast as discussed earlier. MRI will rule out scalp, skull bone and brain pathologies to explain any of your symptoms including the swelling. MRI with contrast will also help with CSF leak too. However after the MRI if the CSF leak possibility is still unanswered then please undergo a cisternogram study (MRI or CT cisternogram) and it will be more definitive in ruling out CSF leak. But start with MRI because if that helps then no need to undergo a cisternogram that requires a lumbar puncture and injection of a dye into the cerebrospinal fluid.
I thought I will just clarify on these points so that you will not assume your condition is just only autonomic trigeminal cephalgia/variant of cluster HA, and nothing else. While CSF leak or other serious possibilities are very less likely but the above mentioned investigations are still necessary.
Please follow up any time if you require my services again.
All the Best! Best Regards, Dr Sathya.
(Please disregard the "reply" button unless you have more questions; this message is sent to clarify on the above points).