A case of a GH–producing pituitary adenoma associated with a unilateral headache with autonomic signs

Abstract

IntroductionTen to fifteen percent of all diagnosed cerebral tumours are pituitary adenomas (60%-70% are secreting adenomas) that frequently occur during the 3rd or 4th decades of life. Half of them are diagnosed early by clinical hormonal symptoms even when the dimensions of the adenomas are small (5 mm) and the tumours are undetected on magnetic resonance imaging (MRI) scans. Among these, however, growth hormone (GH)-producing macroadenomas are uncommon, and often have blood hormonal levels so low that their diagnosis could be delayed [1,2]. In 10% of the adult population, MRI scans can detect silent pituitary adenomas [3].Thirty-three to seventy-two percent of pituitary adenomas, independently of their dimensions, induce headache [4,5]. Headache is the first symptom in about 11% of women and in about 15% of men [6]. Some studies have suggested that the incidence of headache was 57.1% in non-functioning adenomas [7] and 60% in GH-secreting adenomas [8]. Headache seems to be more frequent in prolactin (PRL)-secreting adenomas (57.1%) than in GHsecreting adenomas (12.5%) [9]. Headache, more frequently localised to the frontal region, is bilateral (89.5%) or monolateral (84.2%) and sometimes diffuse (42.1%).Pain is continuous or pressing-heavy, and rarely pulsating-intermittent (mostly in female patients) (57.9%) [9]. Headaches due to GH-secreting adenomas, with or without acromegaly, do not have significant sellar abnormalities or visual problems [5,8]. another MRI scan of the sellar region confirmed the presence of a pituitary macroadenoma on the left paramedian side. After an initial improvement of the symptomatology due to trans-sphenoidal ablation of a benign GH-producing macroadenoma, the headache worsened again. Pain was well correlated with the increased plasma levels of IGF-1. The patient died suddenly for myocardial infarct.

Clinical characteristics of pain in patients with pituitary adenomas

“…Nonetheless, neither systemic parameters such as medical therapy and hormonal hypersecretion (significant effect only on painDETECT score) had significant impact on pain, suggesting previous irreversible effects on the CNS leading to chronic pain. This contradicts previous findings, especially in patients with prolactinoma and acromegaly, showing positive correlation between headache and circulating PRL levels or GH excess respectively (35,36).…”

Headache and pituitary disease: a systematic review

“…Up to 60% of patients reported headaches but other studies found much lower rates (13%) . A causal link to GH was suggested as headaches improved dramatically in individual cases following successful surgery for acromegaly only to recur early with recurrent GH excess . Further support for a direct endocrine role of GH in the pathogenesis of headache derives from data on GH replacement in GH deficiency.…”

“…4,51-55 A causal link to GH was suggested as headaches improved dramatically in individual cases following successful surgery for acromegaly only to recur early with recurrent GH excess. 56 Further support for a direct endocrine role of GH in the pathogenesis of headache derives from data on GH replacement in GH deficiency. In a large cohort of more than 30 000 children treated with GH for GHD, headache was reported with an incidence of 793Á5 of 100 000 patient years on initiation of therapy.…”

Pituitary Hormones and Orofacial Pain

“…These patients reported a variety of types of headaches (Levy et al, 2005 ). Headaches improved dramatically in individual cases following successful surgery on removal of the tumor only to return with recurrent GH excess (Marzocchi et al, 2005 ). Additionally, somatostatin analogs rapidly eased headaches (Williams et al, 1987 ).…”