Diagnosis and Management of Trochleodynia, Trochleitis, and Trochlear Headache

Abstract

Migraine and tension-type headaches (TTHs) comprise a significant burden of neurological disease globally. Trochleodynia, also known as primary trochlear headache or trochleitis, may go unrecognized and contribute to worsening of these headache disorders. It may also present in isolation. We review the English literature on this under-recognized condition and describe what is known about the theorized pathophysiology, clinical presentation, and differential diagnosis. We also present a management algorithm for patients presenting with trochleodynia.

Keywords: Brown syndrome; corticosteroid; diagnosis; headache; treatment; trochlear; trochleitis; trochleodynia.

Figure 1

Schematic of trochlear region anatomy (created using Human Anatomy Atlas 8, Visible Body, Boston, MA, USA). (A) Superior oblique tendon sheath covering the tendon hidden from view. (B) Trochlear region depicting periocular pain distribution (in yellow). The X marks the superomedial orbit with highest focal tenderness, typical front-parietal topography. Left panel (gray area): Bilateral frontal predominant pain suggests comorbid tension-type headache, which can also be triggered by trochleodynia. Right panel (gray area): Temporal location maybe indicative of comorbid migraine headache which can be triggered by trochleodynia; migraine headaches typically involve unilateral ocular and frontal regions as well.

Figure 2

Computed tomography and magnetic resonance imaging findings of trochlear inflammation [adapted from Smith et al. (6) with permission granted by John Wiley and Sons]. (a) Coronal CT showing soft tissue enhancement of left trochlea (broken arrow) from acute inflammation. (b) MRI of orbits with gadolinium enhancement showing uptake at the left trochlea (solid arrow).

Figure 3

Representative supraduction in adduction deficit in the right eye due to acquired Brown syndrome [reproduced from Giannaccare et al. (8) with permission granted by Springer Nature].

Figure 4

Algorithm for trochleodynia workup and management.

Figure 5

Trochleodynia patients receiving injections. (A) Distribution of total number of injections administered (pooled among 86 patients). (B) Distribution of remission period post-effective injection therapy (pooled follow-up data among 70 patients with reported follow-up).

Figure 6

Site for trochlear injection. Ideally, the index finger of the non-injecting hand pushes the globe down and out to make more room for the injection. The aimed site is right below the trochlea and not the trochlea itself. The needle is angled away from the globe.