Flushing, Drooping, Tearing, and Stuffiness… Autonomic Symptoms in Headache

Key Points:

  1. Autonomic symptoms are common with different types of headaches including migraine and trigeminal autonomic cephalalgias.
  2. Look at yourself in the mirror when you have a headache and observe changes such as facial flushing, eyelid drooping, or tearing. Pay attention to sensations of ear fullness or nasal congestion. Notice if these are happening on one or both sides of your head. This information will be very useful in making the correct headache diagnosis.
  3. You may have a headache that is different from a migraine or sinus pain and that can be treated differently and completely as in the case of indomethacin-responsive headaches.

Facial flushing, eyelid drooping or swelling, eye redness, tearing, nasal stuffiness, sweating, and ear fullness are referred to as “autonomic symptoms.” These are transmitted by the autonomic nervous system which controls functions of glands (sweating, tearing), adrenaline release, and level of alertness, and many other involuntary functions. Autonomic symptoms are commonly associated with different types of headaches and can help make the correct diagnosis.

As many as 70% of adult migraineurs experience some autonomic symptoms. Pain sensing nerves of the brain covering, or the dura, are irritated in migraine. These nerves can activate the autonomic system, which produces autonomic symptoms. With migraine, in addition to throbbing head pain, light and noise sensitivity and nausea, autonomic symptoms typically occur on both sides of the head.

Nasal stuffiness, eyelid swelling, and tearing with headache are frequently misdiagnosed as “sinus headache.” Similar symptoms can occur in migraine and in sinus related pain because the same nerves that carry sensation from the brain covering also carry sensation from the face and sinuses, which can initiate autonomic symptoms. Nasal congestion does not necessarily mean that your headache is sinus related. Review “Sinus Headaches” for more information.

It is important to be aware of autonomic symptoms and to note when and where they are happening. Symptoms affecting only one side of the face, particularly the side where the head pain is most severe, suggest a different class of headache disorders. Hemicrania continua, paroxysmal hemicrania, cluster headache, and several other rare disorders are all associated with one-sided head pain, and autonomic symptoms and are categorized as “trigeminal autonomic cephalalgias.”

Hemicrania continua can be easily misdiagnosed as migraine. This is because the pain exacerbations of hemicrania continua can last many hours just as migraine, and can be associated with light and noise sensitivity. In both disorders, patients frequently experience autonomic symptoms. In hemicrania continua, it is part of the definition of the headache diagnosis and is present in up to 95% of patients. One of the differences between migraine and hemicrania continua is presence of autonomic signs just on one side of the head during pain exacerbations in hemicrania continua. Additionally, patients may notice that the photophobia and phonophobia are also more predominant on one side.

Next time you have a headache, look at yourself in the mirror and carefully observe your symptoms. Take notice of one-sided flushing or redness of the face, increased sweating, tearing or redness of one eye, drooping or swelling of one eyelid, small pupil on one side, nasal or ear fullness. If you are diagnosed with Migraine, but are not getting sufficient relief with prescribed migraine medications, make sure to mention to the doctor treating you for migraines that the symptoms you experience are on one side. You may need to be evaluated for trigeminal autonomic cephalalgias.

The correct diagnosis may make a huge difference for you because several of the trigeminal autonomic headaches are completely treatable. Hemicrania continua and paroxysmal hemicrania are most remarkable in that they both can resolve on daily indomethacin treatment. In fact, response to indomethacin is a part of the diagnosis. Indomethacin is a non-steroidal anti-inflammatory drug with a structure similar to melatonin. Melatonin has also been used to treat these disorders. Different treatments are also available for cluster headaches and other trigeminal autonomic cephalalgias.

Pay attention to your symptoms: you may have the key to the correct diagnosis and better treatment for your headache.

References:
1 Cittadini, Elizabeth; Goadsby, Peter J. “Hemicrania continua: a clinical study of 39 patients with diagnostic implications.”  Brain. 2010 July; 133:1973-86.
2 Eross, Eric, DO; Dodick, David, MD; Eross, Michael. “The Sinus, Allergy and Migraine Study (SAMS).”Headache. 2007 Feb; 47(2):213-24.
3 Gelfand, Amy A., MD; Reider, Amanda C., BA; Goadsby, Peter J., MD, PhD. “Cranial autonomic symptoms in pediatric Migraine are the rule and not the exception.” Neurology 2013;81;431-436