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6.6:
Carotid or vertebral artery pain
There
may be pain associated with carotid or vertebral artery occlusion. This
is localized pain and rarely there is a tender artery (see carotidynia
below). Tender cervical carotid artery, ipsilateral to the more severely
affected hemicranium, is found between attacks in over 50 percent of
patients with frequent migrainous headaches (Raskin and Prusiner, 1977).
Of those with point tenderness, approximately 10 percent report that
their head pain is transiently produced after carotid examination.
Arterial
dissection
An
unusual headache combined with facial and neck pain and occasionally
associated with an ipsilateral Horner's syndrome may occur in patients
with spontaneous dissection of the cervical portion of the internal
carotid artery (West et al., 1976; Mohri et al., 1979; Fisher, 1981).
The headache typically involves the ipsilateral forehead above the
orbit, the orbit itself, or the regions of the face just lateral or
below the orbit. This pain is associated with neck pain that extends
from just above the clavicle to the area behind the ear (Fisher, 1981).
Recognition that these clinical symptoms represent a prodromal
manifestation of carotid dissection may allow the physician to prevent a
subsequent cerebrovascular accident by the use of anticoagulation.
Sometimes
a pain which initially may be thought to be temporal arteritis is that
caused by spontaneous dissection of the carotic and/or vertebral
arteries (Vinken and Bruyn, 1968) The vascular dissection may occur
spontaneously, especially in those with unsuspected fibromuscular
dysplasia. Carotid and/or vertebral artery dissection may follow head
and neck injury is in "whiplash", blows to the neck, and
following neck manipulation. The clues to making the diagnosis include
pain over the angle of the jaw and hemicranium, oculosympathetic
paresis, dysgeusia, and altered facial sensation, as in the following
case: A 46-year old mildly hypertensive woman developed "lightening
pains" that radiated to her face from the left side of her neck.
The following day the pain had become dull and was localized behind her
left eye. She noted slight drooping of her left eyelid, a strange
persistent metallic taste, and discomfort over the left side of her
forehead. Her unilateral neck and face pain then increase in intensity,
and the entire left side of her face became "numb and
disagreeable." Examination showed a left oculosympathetic paresis
and marked decrease in sensation to light touch and pinprick over all
three divisions of the left trigeminal nerve. Testing facial sensation
evoked an unpleasant sensation. The remainder of her examination was
normal as were CT and MRI. Cerebral angiography demonstrated a
dissection of the left internal carotid artery extending intracranially
to the cavernous sinus and a 2 cm dissection of the left vertebral
artery (Francis et al, 1987).
Carotid
dissection can mimic Raeder's paratrigeminal syndrome (see above), but
requires angiography for diagnosis.
Biousse
et al (1994) reviewed head pain in non-traumatic carotid artery
dissection in 65 patients. Seventy-four percent of patients complained
of a cephalic pain which was present at the onset in approximately 60
percent. It was on the same side of the dissection in 79 percent of the
cases and lasted from one hour to 30 days with a median of five days.
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