What are the causes and treatments of headache and eye pain?

Causes and Treatment of Headache and Eye Pain

Headache with eye pain has diverse etiologies ranging from benign ocular surface disorders to life-threatening vascular emergencies, requiring systematic evaluation to distinguish primary headache disorders from sight-threatening or neurologic conditions.

Primary Causes by Category

Ocular Surface and Refractive Disorders

• Dry eye syndrome causes burning, stinging pain with photophobia, often with symptoms exceeding visible signs on examination 1
• Refractive error produces frontal headaches worsening near end of day, particularly with high uncorrected refractive error and increased near work 2
• Convergence insufficiency presents with frontal pain, diplopia, and symptoms exacerbated by prolonged reading or screen time 2
• Low humidity environments (including air travel) cause ocular surface dryness with severe pain, headaches, and eye watering 1

Primary Headache Disorders with Ocular Features

• Migraine is characterized by moderate-to-severe throbbing pain lasting 4-72 hours, often unilateral, with nausea, photophobia, and phonophobia 1, 3
• Visual aura (scotomas, distortions) may precede migraine pain, though most migraines occur without aura 1
• Cluster headache causes severe unilateral supraorbital or temporal pain lasting 15-180 minutes with ipsilateral lacrimation, nasal congestion, ptosis, miosis, and eyelid edema 1
• Airplane headache (AHA) occurs in 1-2% of air travelers with severe unilateral fronto-orbital jabbing pain lasting <30 minutes during descent, believed secondary to sinus barotrauma affecting trigeminal nerve endings 1

Inflammatory Ocular Conditions

• Acute angle-closure glaucoma is an ocular emergency presenting with severe eye pain, headache, blurred vision, halos around lights, and a red eye with mid-dilated unreactive pupil (though dim lighting can trigger pupillary block even without obvious redness initially) 1
• Uveitis causes eye pain, blurred vision, photophobia, and headache, often bilateral and insidious in onset when associated with inflammatory bowel disease 1
• Scleritis produces severe, boring eye pain often described as worse than uveitis, with or without obvious redness 1
• Episcleritis presents with mild pain, hyperemia, itching and burning, generally less severe than scleritis 1

Neuropathic and Neurologic Causes

• Neuropathic ocular pain (NOP) results from dysfunction of trigeminal nerve pathways, causing burning, stinging, or aching pain with photophobia and wind sensitivity, often with symptoms far exceeding clinical signs 1
• NOP can develop post-surgically (refractive surgery, cataract extraction), post-infection (herpes), or idiopathically, and may coexist with migraine or fibromyalgia 1
• Optic neuritis in younger patients causes pain with eye movement and visual loss 4
• Temporal arteritis in older adults (>50 years) presents with headache, jaw claudication, and risk of permanent vision loss—requires urgent evaluation and treatment 4

Vascular and Life-Threatening Causes

• Posterior communicating artery aneurysm presents with severe headache, eye pain, and a dilated unreactive pupil—a neurosurgical emergency 4
• Internal carotid dissection or occlusion causes headache with transient visual loss and may produce Horner's syndrome 4
• Cavernous sinus lesions present with periocular pain, diplopia, and multiple cranial nerve palsies 4, 5

Diagnostic Approach

Red Flags Requiring Urgent Evaluation

• Thunderclap headache (sudden severe onset) 1, 3
• Headache awakening patient from sleep 1, 3
• Rapidly increasing headache frequency 1, 3
• Focal neurologic signs or symptoms 1, 3
• Persistent headache following head trauma 1, 3
• New headache in older patient (>50 years) suggesting temporal arteritis 1
• Dilated unreactive pupil with pain suggesting aneurysm 4
• Sudden vision loss requiring immediate ophthalmologic evaluation 4

Key Examination Elements

• Pupillary examination: Assess for anisocoria, reactivity, and relative afferent pupillary defect 4
• Ocular surface evaluation: Check for corneal clarity, conjunctival injection, tear film stability, and epithelial defects 1
• Intraocular pressure measurement: Essential to rule out acute angle-closure glaucoma 1
• Visual acuity and visual field testing: Document any deficits 4
• Extraocular motility: Assess for diplopia or cranial nerve palsies 4, 5
• Slit-lamp examination: Evaluate for anterior chamber inflammation, corneal pathology 1

Distinguishing Neuropathic from Nociceptive Pain

• Anesthetic challenge test: Instill topical anesthetic when pain is present; improvement suggests nociceptive or peripheral neuropathic component, while persistent pain suggests central or non-ocular cause 1
• Symptoms disproportionate to clinical signs suggest neuropathic component 1
• Burning quality, wind sensitivity, and persistent symptoms despite treatment of ocular surface disease indicate NOP 1

Treatment Algorithms

For Migraine-Pattern Headaches

• Mild-to-moderate migraine: Start with NSAIDs (aspirin, ibuprofen, naproxen sodium) 3
• Moderate-to-severe migraine or NSAID failure: Add triptan (sumatriptan, rizatriptan, naratriptan) to NSAID 3, 6
• Adjunctive therapy: Use antiemetics (metoclopramide, prochlorperazine) for nausea 3
• Preventive therapy: Consider for patients with >2 headaches per week, frequent acute medication use, or significant disability 1, 3

Critical triptan precautions: Contraindicated in coronary artery disease, uncontrolled hypertension, stroke/TIA history, Wolff-Parkinson-White syndrome, and within 24 hours of ergotamine use 6

For Airplane Headache

• Prophylaxis: Analgesics, NSAIDs, or triptans taken before flight 1
• Acute relief: Compression of pain region, Valsalva maneuver, earlobe extension, chewing, or yawning 1

For Ocular Surface Disorders

• Dry eye: Artificial tears, topical anti-inflammatory therapy (cyclosporine), tear conservation strategies 1
• Refractive error: Corrective lenses 2
• Convergence insufficiency: Prism glasses, orthoptic exercises, or in severe cases, surgery 2

For Inflammatory Conditions

• Episcleritis: Often self-resolves; topical or systemic NSAIDs or topical corticosteroids for symptomatic relief 1
• Scleritis and uveitis: Requires ophthalmologist management with topical/systemic corticosteroids, conventional immunosuppressants, or anti-TNF agents 1
• Acute angle-closure glaucoma: Immediate ophthalmologic emergency requiring IOP-lowering medications and laser peripheral iridotomy 1

For Neuropathic Ocular Pain

• Peripheral NOP: Topical nerve regenerative therapies (autologous serum tears) 1
• Central NOP or systemic comorbidities: Oral neuromodulators (pregabalin, gabapentin, duloxetine, amitriptyline, nortriptyline, low-dose naltrexone) requiring 3-4 months at therapeutic dose for effect 1
• Light sensitivity with headache: Transcutaneous electrical nerve stimulation or periorbital botulinum toxin A injections 1
• Cutaneous allodynia or post-surgical pain: Periocular nerve blocks with corticosteroid and long-acting sodium channel blocker 1
• Complementary therapies: Acupuncture, cognitive behavioral therapy, or hypnosis for concomitant anxiety and depression 1

Critical Pitfalls to Avoid

• Medication overuse headache: Frequent use (≥10 days/month) of ergotamine, triptans, opioids, or analgesics can cause rebound headaches requiring detoxification 1, 6
• Assuming "quiet eye" excludes serious pathology: Intermittent angle-closure glaucoma, low-grade inflammation, and early optic neuritis may lack obvious redness 4, 5
• Missing temporal arteritis: Any new headache in patient >50 years with jaw claudication or vision changes requires immediate ESR/CRP and consideration of empiric corticosteroids before biopsy 4
• Delaying evaluation of dilated pupil with pain: This combination requires urgent neuroimaging to exclude aneurysm 4
• Overlooking air travel contraindications: Avoid flying 2-6 weeks post-intraocular gas instillation (SF6 or C3F8) due to risk of rapid IOP rise 1