The Causes of Headache Behind the Eye 2024
She told me, “You know, I don’t think it is a Migraine because it starts in the back of one eye, usually my right eye.”
I asked, “Is it always on the same side?”
She said, “Yes, it is, come to think about it. Almost all of my attacks are in my right eye, but occasionally it will switch to my left eye.”
I stayed silent and just nodded.
She continued. “Behind my eye it becomes a horrible, intense, red-hot pain that throbs and hurts when I move.”
I said, “You really should see a doctor about it.”
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This is an article by Britt Talley Daniel MD, member of the American Academy of Neurology, migraine textbook author, podcaster, YouTube video producer, and blogger.
Eye Pan and headaches is usually Migraine. Migraine comes from a word that means half of head. The Migraine process can direct pain to the trigeminal, fifth cranial nerve distribution which supplies pain fibers to behind the eye.
Most persons who start with pain behind one eye will also have other Migraine headache features such as intense, level 8, 9, 10 pain on a scale of 1 to 10. They may have throbbing from an expanding, inflamed blood vessel dilating with the pulse of a heartbeat and they may experience nausea and vomiting as Migraine turns the brain stem vomit center on. They may also have sensitivity to light and sound.
Related questions.
What are other possible causes of eye pain? Here is a list.
Allergies
Blepharitis (eyelid inflammation)
Chalazion (a type of cyst on your eyelid)
Cluster headache
Complication of eye surgery
Contact lens problem
Corneal abrasion (scratch): First aid
Corneal herpetic infections (herpes)
Dry eyes (decreased production of tears)
Ectropion (outwardly turned eyelid)
Entropion (inwardly turned eyelid)
Eyelid infection
Foreign object in the eye: First aid
Glaucoma (group of conditions that damage the optic nerve)
Injury, such as from a blunt trauma or burn
Iritis (inflammation of the colored part of the eye)
Keratitis (inflammation of the cornea)
Optic neuritis (inflammation of the optic nerve)
Pink eye (conjunctivitis)
Scleritis (inflammation of the white part of the eye)
Sty (a red, painful lump near the edge of your eyelid)
Uveitis (inflammation of the middle layer of the eye)
What about pain behind the eye with normal eye appearance and exam?
Pain behind the eye should involve the anatomical structures that are there which are mainly the ophthalmic artery, the optic nerve, and trigeminal nerve pain fibers. Neurologic exam consisting of checking vision, pupillary reactions, eye movement, and intraocular inspection with an ophthalmoscope should be performed. MRI imaging of the brain and eyeball can be included.
Why does Migraine headache pain come just on one side?
No body knows the answer to this question, but it is certainly true. Galen, 129 BC-216 BC, the doctor to one of the Roman Caesars described a headache syndrome he called “hemicrania.” This means half of head like the word hemisphere means half of a sphere. As time went on the “he” part was dropped and the name became micrania, then megrim, then migraine, the current name that is used.
One-sidedness is the most common accompanying feature of Migraine and 80% of Migraine patients have one-sided headaches.
No one knows
How can the symptoms of Migraine move from the C2 back of the neck area to the trigeminal fifth cranial nerve behind the eye position?
No one knows the answer to this question either, but Migraine is something that really likes to move around. Think of the 4 Migraine phases: prodrome, aura, attack, and postdrome, each reflecting different neurochemical and neurophysiologic metabolisms with different symptoms.
Syncope, known as fainting, is a simple clinical event-the patient may have a premonitory warning of dizziness, “feeling faint” whatever that is, light-headed, or visual black out, and then they fall unconscious for a few minutes and recover. Compared to syncope Migraine is exceedingly complex with many varying symptoms and neurologic processes activated as time passes.
An attack of Migraine has a procession of symptoms it goes through. The patient may develop an aura of visual images moving across their retina, or paresthesia which is tingling that develops in the fingers and then moves to the hand, and then the forearm, and the cheek and tongue on one side.
The Migraine without aura patient may start with mild headache that then advances to become severe while nausea and then vomiting are added to the mix. This is movement of symptoms.
Pain moving from the neck to the eye is something Migraine can easily do.
Pain in the back of the neck has a big differential diagnosis and could be many things.
That is true the differential diagnosis for neck pain could be: muscle strain from whiplash, traumatic neck flexion or extension injury, unusual sleeping position or neck posture like painting the ceiling, a herniated cervical disc, occipital neuralgia, stress and anxiety, or acute torticollis.
None of these conditions are described as leaving the neck and moving around to behind one eye and none of them later in the development of symptoms has nausea, vomiting, or sensitivity to light and sound. Neck pain does not usually have Migraine features unless it is the start of a Migraine.
Neck pain/head pain
If pain in the back of the neck on one side is a Migraine symptom, when should you treat it?
The pain should be treated with a triptan at the onset, preferably with one of the rapid acting triptans that works in 10 minutes like sc injectable mg sumatriptan or 5 mg zolmitriptan. If those are not available then consider timolol eye drop, 1 cc IM injection or nasal spray DHE, or one of the slower acting 30 minutes to onset use triptans such as rizatriptan, almotriptan, or eletriptan.
If the patient is a triptan non-responder of if he had cardiovascular risk factors that limit the use of triptans, the patient may try one of the new 2020 acute Migraine drugs-Nurtec, Reyvow, or Ubrevly.
My doctor wanted to work me up and do blood work and a head X-Ray.
If the patient has a typical Migraine history with transference of pain to one eye, and then the development of throbbing, severe pain, nausea and vomiting, and sensitivity to light and sound and triptan treatment, then results from work up with blood work are usually slim.
Head X-Ray without head trauma is usually no very helpful.
Neurologic exam should also be normal in this scenario, but regular MRI scan of the brain with and without contrast would, however, be appropriate.
What if the eye pain switched from one side to the other with different attacks? What does that mean?
Switching of pain from one side to the other is a strong feature of Migraine. This would be more convincing data supporting Migraine as the cause and decrease the likelihood of significant neurologic pathology.
Would not pain behind one eye give concern that the patient has an aneurysm?
Possibly, if it just stays on the same side with every attack, but not if the pain switched sides, like from right to left with different attacks. Persons with head pain like Migraine that switches from side to side should be reassured that they likely have no abnormal aneurysm or tumor in their head, but it is always reassuring to the patient and the doctor to do an MRI scan to check it out.
Aneurysms generally only have symptoms when they rupture and that is usually with a dramatic clinical presentation with a seizure, or development of a dropped eyelid, double vision, a blown, dilated pupil, or coma. Most persons who have headache symptoms before aneurysm rupture have had attacks of Migraine.
Summary
Headache pain in one eye that comes and goes and that is severe and associated with throbbing, sensitivity to light and noise and light and sound is usually Migraine.
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All the best.
Britt Talley Daniel MD
