11.3.4 Trochlear headache

Identification: A 52-year-old female patient reports sudden orbital pain for the past 3 days. History of Present Illness: Pain: Location: Superomedial to the right orbit Characteristic: Acute, stabbing (1-2 seconds), recurrent (5-20 episodes/day) Triggers: Ocular movement downward and medially (especially when descending stairs) Associated symptoms: Vertical diplopia (worse when reading) Hyperesthesia in the region of the superior oblique tendon No visual deficit or other neurological symptoms Physical and Neurological Examination: Parks-Bielschowsky test (+): Increased diplopia with head tilt to the affected side Palpation: Pain on pressure at the insertion point of the superior oblique tendon Ocular movements: Limitation of depression in adduction (RE) Hypertropia of the affected eye in the primary position Complementary Exams: Magnetic Resonance Imaging (3 Tesla): Elongation and tortuosity of the right trochlear nerve Absence of vascular compression Local anesthetic test (supraorbital nerve block): Temporary pain relief (confirmatory)