A multidirectional epicrania fugax

Abstract

A multidirectional epicrania fugaxDear Editor, Epicrania fugax (EF) has been recently classified as a primary headache in the Appendix of the International Classification of Headache Disorders, 3rd edition, beta version (1). EF is characterized by a brief paroxysmal pain following a lineal or zigzag trajectory across the head surface. EF pain typically moves between two distant points through the territories of different nerves. In all the reported cases the pain was strictly unilateral with either forward or backward radiation, although some patients had shifting sides (2,3). Here we report a paroxysmal EF-type pain that changed directions in a striking way.A 52-year-old woman with migraine history since adolescence started having a new type of headache at age 48. This new pain was perceived as brief electric shocks that crossed her head in less than one second with a zigzag trajectory. The pain always moved between two distant points, but the direction was variable. On some occasions the pain stemmed from the right or left occipital area and then moved forward to reach the ipsilateral frontal area (Figure 1(a)). At times the pain shifted from the right or left occipital area to the opposite frontal area following a diagonal trajectory (Figure 1(b)). Finally, the pain could move from one temple-right or left-to the other in a coronal direction (Figure 1(c)). Regardless of the trajectory, the pain was extremely severe (10 out of 10) and always caught the patient off guard. There were no autonomic symptoms or other accompaniments. The attacks occurred with irregular frequency, from six episodes per month to one episode per day, with no identifiable triggers. Between attacks the patient remained asymptomatic. Magnetic resonance imaging (MRI) of the head and the cervical spine and routine blood tests including erythrocyte sedimentation rate did not show any abnormality. After this workup the patient felt reassured and no treatment was prescribed.In this patient all the painful paroxysms had identical features except for their topography. Those with forward radiation on one side of the head were clearly consistent with former descriptions of EF. However, in the remaining episodes the pain moved with a diagonal or transversal direction across both sides of the head. These episodes did not fit any other headache diagnosis and would most probably correspond to atypical variants of EF. In descriptive disorders, an atypical feature may sometimes be accepted if the rest of the features are typical. In fact, other unilateral headaches may switch sides or become bilateral within the same episode. That is the case for migraine, which commonly starts on one side and then spreads to the whole head. Even the trigeminal autonomic cephalalgias may rarely shift from one side to the other within a single attack or appear as a bilateral pain (4-6). It has been postulated

A recurrent headache circumscribed in a coronal line-shaped area around the head: a coronal linear headache

“…EF, a recently described novel headache syndrome, characterized by brief pain paroxysms starting in a particular area of the posterior scalp, and rapidly radiating forwards along a linear trajectory to reach the ipsilateral forehead, eye, or nose in a few seconds (Pareja et al 2008 , 2012a ; Guerrero et al 2010 ; Porta-Etessam et al 2010 ; Mulero et al, 2011 ; Cuadrado et al 2013 ; Jin and Wang 2013 ), has now been incorporated in the appendix of the third edition of the International Classification of Headache Disorders (ICHD-III beta) (IHS 2013 ; Belvis et al 2015 ). A typical pain trajectory of EF is different from that of the currently reported coronal line-shaped head pain, whereas, recent reports have shown that the pain trajectory of EF may distribute in different area (de la Cruz et al 2015 ), even in multiple directions (Cuadrado et al 2015 ). Furthermore, Pareja and Bandres reported an interictal persistent line-shaped head pain in EF (Pareja and Bandres 2015 ).…”

Pain Paroxysms With Coronal Radiation: Case Series and Proposal of a New Variant of Epicrania Fugax

“…10 To end with the proposed variants of EF, one striking case presented zigzag pain paroxysms in multiple directions: some of them followed a classical backward radiation on either side of the scalp, some followed a diagonal trajectory from one occipital area to the opposite frontal region, and finally some crossed the head from one temple to the other in a coronal radiation akin to the paroxysms described in our series. 11 We report 4 patients suffering lancinating and stereotyped pain paroxysms with a transverse radiation. Apart from this trajectory, the similarities to all cases with EF described up to now are evident, when considering pain characteristics (duration, intensity, character or motion of the pain following a lineal or zigzag trajectory), or the existence of a fixed stemming area, which can remain painful in between attacks.…”

“…A facial variant of EF has also been proposed after a description of 5 patients with a paroxysmal pain starting in the lower face and radiating upwards with linear trajectory . To end with the proposed variants of EF, one striking case presented zigzag pain paroxysms in multiple directions: some of them followed a classical backward radiation on either side of the scalp, some followed a diagonal trajectory from one occipital area to the opposite frontal region, and finally some crossed the head from one temple to the other in a coronal radiation akin to the paroxysms described in our series …”

Epicrania fugax combining forward and backward paroxysms in the same patient: the first four cases

“…The phenotype of EF has become even broader during the last few years. For instance, it has been reported that pain paroxysms may occur at shifting sides,1,7 along the mid-sagittal plane,9 with coronal radiation10 or even in a multidirectional fashion 11. A facial variant of EF4 has also been proposed.…”