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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