Chronic paroxysmal hemicrania presenting as otalgia with a sensation of external acoustic meatus obstruction: Two cases and a pathophysiologic hypothesis

Objective.-To describe two cases of chronic paroxysmal hemicrania manifeste d by otalgia with a sensation of external acoustic meatus obstruction and t o suggest that the trigeminal-autonomic reflex is a mechanism for the sensa tion of ear blockage. Background.-Maximum pain in chronic paroxysmal hemicrania is most often in the ocular, temporal, maxillary, and frontal regions. It is less often loca ted in the nuchal, occipital, and retro-orbital areas. Review of the litera ture on chronic paroxysmal hemicrania found mo reports of pain primarily lo calized to the ear and associated with a sensation of external acoustic mea tus obstruction. Methods.-The history, physical examination, imaging studies, and successful treatment plan in two patients with otalgia and ear fullness and a subsequ ent diagnosis of chromic paroxysmal hemicrania are summarized. Results.-The first patient was a 42-year-old woman with a 10-year history o f unilateral, severe, paroxysmal otalgia occurring five times a day with a duration of 2 to 60 minutes. During an attack, the ear became erythematous and the external acoustic meatus felt obstructed. There were no other assoc iated autonomic signs. The second patient was a 49-year-old woman with a 3- year history of unilateral, severe, paroxysmal otalgia occurring 4 to 15 ti mes a day with a duration of 3 to 10 minutes. During an attack, her ear fel t obstructed, and she noted ipsilateral eyelid edema and ptosis. Both patie nts quickly became pain-free after taking indomethacin and required its con tinued use to prevent headache recurrence. Conclusions.-Chronic paroxysmal hemicrania may be manifested by otalgia wit h a sensation of external ear obstruction, When the otalgia is paroxysmal, unilateral, severe, frequent, and associated with autonomic signs, one shou ld consider the diagnosis of chronic paroxysmal hemicrania, especially beca use of the prompt response to indomethacin. The most important feature to c onsider when making the diagnosis of chronic paroxysmal hemicrania is the f requent periodicity of discrete, brief attacks of unilateral cephalgia sepa rated by pain-free intervals. It is hypothesized that the sensation of ear obstruction in these patients is due to swelling of the external acoustic m eatus mediated through increased blood flow by the trigeminal-autonomic ref lex.