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What Would I Do Next? | Headache & Eye Pain

Mike Weinstock, MD and Michael Palacci, DO
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Important diagnostic considerations in patients with headache that may have an ocular component include glaucoma, temporal arteritis, orbital cellulitis, optic neuritis, iritis, corneal abrasion, and Herpes Zoster Opthalmicus (HZO).  The prodrome of HZO consists of pain/paresthesias of the scalp, photophobia, headache and malaise, and can last 1-7 days before the rash appears, making the diagnosis very difficult in this stage. Immunocompetent patients can be managed as outpatients.  Treatment includes antiviral medications +/- steroids. Steroids will decrease pain and duration of symptoms, but don't prevent post-herpetic neuralgia. Follow up with Ophthalmology has been the standard, however, a recent small Canadian study (see below) suggested that patients without a red eye or a supratrochlear rash (forehead just above the nasal bridge) have a very low incidence of keratitis and iritis, the dangerous complications of HZO, and therefore do not require Ophthalmologic follow up.

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Ian L., Dr -

I believe we ought treat the Hzoster in the prodrome stage .
The paper by Benbernou et al in the EuropeanJ Pain Nov 2011 1100-1106 followed 250 patients who developed Hzoster and measured the Severity and Duration of pain .
Mean pain duration was 4.7 days and pain 6/10.
Prodromal pain was associated with more severe acute pain when Hzoster rash emerged .
Makharita MY in Pain Physician Feb 2017 noted severe Prodromal pain was associated with severer post herpetic neuralgia .
In 2005 I was able to commence Valacyclovir 500mg orally TDS in a 78 year old lady on the second day of her severe cephalgia with scalp allodynia .
I treated for 14 days .
I took serum for Hzoster IGG and IGM a week
The IGG was positive on sample 1 and sample 2 a week later.
But IGM at first negative seroconverted to IGM after a week .
My patient got No rash and no Post Herpetic or any pain in her scalp .
Considering we energetically treat the prodromes of Hsimplex
it would be valuable to set up a process of care for likely Prodromal pain of Hzoster in the over 50 age group .

Mike W., MD -

Really good points as well as nice references - thx for that. Yes, treating early, even catching in the prodromal stage, is definitely the way to go. Suspicion of zoster and inc on the ddx is essential - thx for the well researched comments!
M

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Hacking Up A Lung Full episode audio for MD edition 176:04 min - 83 MB - M4AHippo Urgent Care RAP - April 2018 Written Summary 365 KB - PDF

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