Carotidynia: a cause of neck and face pain

T.J. MURRAY,* MD, FRCP[C]

Carotidynia is a form of vascular neck ogic features, as well as management,relieve the pain.
and face pain in which the vascular are presented.
change occurs in the carotid artery in She was treated with pizotyline
the neck. The disorder is not uncommon, hydrogen malate (Sandomigran@),
Case report four tablets per day (for a total dose
and most patients have a prior history
of migraine. They present with pain A 53-year-old woman was seen of 2 mg of pizotyline), and the pain
in the neck and face, and are often in neurologic consultation complain- decreased greatly within a week; at
thought to have a disorder such as ing of pain in the right side of her 10 days she reported feeling better
chronic sinusitis or tngeminal neuralgia.face and jaw and in her right ear. She than she had in over a year. The pain
Diagnosis can be made from the type
and location of the pain and the had experienced recurring bouts of continued as a mild ache for 2
finding of a tender and swollen carotid pain for 1 year. The episodes prima- months and then disappeared.
artery on the same side. rily involved mild to moderate aching
soreness, but at times there was deep, Characteristics of 11 cases
Carotidynia responds to the prophylactic
medications used for migraine, often agonizing, throbbing pain centred in
disappearing in weeks or months. In All 11 patients I have seen had
some patients the syndrome may her neck below the angle of the jaw undergone many investigations and
become recurrent or chronic, with a and radiating over the temporal re- been subjected to various procedures.
variable response to medication. gion. The usual presenting diagnosis was
Examination showed marked ten- sinusitis, trigeminal neuralgia or
La carotidynie est une forme de douleur derness over the right common and
vasculaire affectant le cou et le visage dental abscess. Carotidynia had not
dans laquelle l'atteinte vasculaire se external carotid arteries and some been considered.
produit dans l'artere carotide au tenderness over the face and scalp In the 11 cases (Table I) the clin-
niveau du cou. Cette affection n'est on the same side. There was slight ical picture was similar to that de-
pas rare et Ia plupart des patients swelling and redness over the right scribed in 1960 by Lovshin.1 The pa-
possedent des antecedents migraineux. malar area.
Ils accusent de Ia douleur au cou et tients' ages ranged from 16 to 55
au visage, et l'on confond frequemment The patient had been treated for years, and 7 of the 11 were women.
avec des malaises tels que Ia sinusite sinusitis by sinus drainage. Her eyes All presented with chronic or recur-
chronique ou Ia n6vralgie du trijumeau. had been examined and she had ob- rent pain in the neck or face or both.
Le diagnostic peut 6tre 6tabli a partir tained new glasses. She had had Many had most of their pain in the
du type et de Ia localisation de Ia repeated sinus and skull roentgeno- face, and only two complained of
douleur, et de Ia decouverte du mAine
cAte d'une artere carotide enfl6e et graphy. Medications including anti- neck pain alone. In all patients, in-
sensible. histamines, antibiotics, tranquillizers, cluding those with no complaints re-
La carotidynie r6agit aux m6dicaments analgesics and narcotics had had no ferable to the neck, the carotid artery
utilises dans Ia prophylaxie de Ia lasting effect on the pain. The week was tender, and pressure over the
migraine, et disparait souvent en she was seen in consultation she was common carotid artery increased or
quelques semaines ou quelques mois. also seen by a dentist to determine reproduced the pain (Fay's test).
Chez certains patients le syndrome
peut devenir recidivant ou chronique, whether any dental procedure might Seven of the patients had a prior
et reagir de fa9on variable a Ia
medication.
Carotidynia is a vascular syndrome
causing pain in the neck and face.
It is probably a variant of migraine.
I have seen 11 cases since 1970. The
patients presented with neck and
face pain, and in most instances had
been referred for the management of
trigeminal neuralgia. Because caroti-
dynia is not widely recognized, a ty-
pical case history and a brief review
of the condition's clinical and etiol-

*Professor of medicine, Daihousie

University, and chief of medicine, Camp
Hill Hospital, Halifax
Reprint requests to: Dr. T.J. Murray,
Camp Hill Hospital, Rm. 367, Robie
Street, Halifax, NS B3H 3G2

CMA JOURNAL/FEBRUARY 17, 1979/VOL. 120 441

 Brief prescribing information or concomitant history of migraine. wane over many months without dis-
CHLOROMYCETIN® OPHTHALMIC In two cases carotidynia and classical appearing. After a symptom-free in-
PREPARATIONS migraine occasionally occurred at the terval of weeks or months another
Indications: The treatment of superficial ocular in- same time, always on the same side. episode may occur. Some patients ex-
fections involving the con.unctiva and/or cornea All the patients benefitted from perience only one episode.
caused by chloramphenicol-susceptible organisms. therapy, although the problem has
Bacteriological studies should be performed to Etiologic considerations
determine the causative organisms and their sen- recurred in one patient each time the
sitivity to chloramphenicol. dose of medication has been reduced, Fay4 reported three cases of
Precautions: The prolonged use of antibiotics may and three patients have had mild re- atypical facial neuralgia to the Phila-
occasionally result in overgrowth of nonsusceptible curring symptoms requiring medica- delphia Neurological Society in 1927.
organisms, including fungi. If new infections ap- tion for longer than a year. The re- This was probably the first report of
pear during medication, the drug should be discon- maining seven patients are free of carotidynia. Since Fay thought the
tinued and appropriate measures should be taken. pain. In at least one case the problem problem was neurogenic, he per-
It should be borne in mind that a patient may disappeared spontaneously and the formed surgical procedures on his pa-
become sensitized to chloramphenicol when it is response could not be ascribed to any tients. However, in a report several
applied topically. Signs of local irritation, with sub-
jective symptoms of itching or burning, angio- specific form of therapy. years later he concluded that the
neurotic edema, urticaria, vesicular and maculo- problem was vascular pain.5 In 1948
papular dermatitis have been reported in patients Clinical features Wolff commented that face and head
sensitive to chloramphenicol and are causes for Carotidynia may occur at any age; pain syndromes were due to vascular
discontinuing the medication. Similar sensitivity it has been reported in persons from changes, and the next year Hilger7
reactions to other materials in the topical prepara- age 10 to 75 years.1 A history of mi- suggested that the basis of carotidy-
tions may also occur. Prolonged or frequent inter- graine is common, as is a family his- nia was an autonomic defect causing
mittent use of topical Chloramphenicol should be
avoided because of the possibility of hypersensitivi- tory of migraine. The factors that carotid artery vasodilation. Lovshin'
ty reactions. may precipitate an attack of carotidy- in 1960 described 100 patients and
Contraindications: Preparations containing corti- nia once the syndrome has developed clearly outlined the clinical picture
costeroids are contraindicated in viral diseases of are those that precipitate an attack of carotidynia. He pointed out that
the cornea and conjunctiva; tuberculosis of the of migraine :2 stress, the "letdown" many of the patients had vascular
eye; fungal diseases of the eye; acute purulent un- following stress, certain dietary fac- symptoms and the same personality
treated infections of the eye, which like other tors, bright lights, loud sounds, fast- traits as migraine patients. He also
diseases caused by micro-organisms, may be ing and menstruation. noted that many had their neck pain
masked or enhanced by the presence of the
steroid. When the pain begins it is usually on weekends, and he stated: "Week-
Adverse Reactions: Extended ophthalmic use of noted in the upper neck and face. end headache is just as diagnostic of
corticosteroid drugs may cause increased in- The carotid artery may be the focal vascular neck pain as a week-end
traocular pressure in certain individuals and in point of tenderness and pain. As the headache is of vascular headache."
those diseases causing thinning of the cornea, per- episode worsens, the pain may spread Roseman"8 suggested that a rela-
foration has been known to occur. over the neck and up over the side tion between carotidynia and mi-
Dosage: Apply 2 drops of the solution or a small of the face and scalp, but some pa- graine was possible. It has been noted
amount of the ointment, to the affected eye every tients have pain only in the neck or that an increase in carotidynia symp-
3 hours or more frequently if necessary. Continue only in the face. The pain is also felt toms occurs in cold weather, and a
administration day and night for the first 48 hours, by some patients in the ear and eye. viral origin for the condition has
at which time the frequency can be decreased. There are usually no associated find-
Treatment should be continued for at least 48 been suggested.9"0 Although there is
hours after the eye appears normal. ings except for tenderness over the one unusual case with the pathologic
Supplied: Chloromycetin Ophthalmic Ointment 1%; carotid artery. An occasional pa- changes of temporal arteritis,1' such
Chloromycetin Polymyxin Ophthalmic Ointment, tient, such as the one I have de- changes have not been present in
each gram contains 10 mg Chloromycetin and scribed in detail, has redness or others who have undergone biopsy.
5,000 units Polymixin B las the sulphatel; swelling over the distribution of the Some authorss.A.ls.ls have suggested,
Chloromycetin Hydrocortisone Ophthalmic, 5 ml external carotid artery. The carotid however, that nonspecific arteritis
vial with dropper, each ml contains 2.5 mg artery may be enlarged and tender, could be present.
Chloromycetin; 5 mg Hydrocortisone Acetate; and pressure over the common ca-
OphthocortOphthalmic Ointment; each gram con- Carotidynia is now regarded as a
tains 10 mg Chloromycetin; 5 mg Hydrocortisone rotid artery will reproduce pain in variant of migraine occurring in the
Acetate and 5,000 units Polymixin B las the sul- the neck and face.3 The surrounding carotid artery.'2"4'7 The pain and
phatel in a special petrolatum ointment basel; muscles in the neck may be tender, swelling in the neck and face are due
Chloromycetin Ophthalmic Solution 0.5%, Chloro- and there may be some swelling of to vasodilation and inflammation of
mycetin Ophthalmic 25 mg vials with and without other tissue in the region of the caro- the carotid artery, which probably
Diluent for preparing 0.16%-0.5% concentrations. tid artery. occur through mechanisms similar to
FULL PRESCRIBING INFORMATION An episode of carotidynia may those that more commonly occur in
AVAILABLE ON REQUEST.
last for hours or weeks, but the usual the peripheral branches of the ex-
PARKE-DAVIS duration is 7 to 10 days. In some ternal and internal carotid arteries
Parke, Davis &t Company, Ltd. cases the symptoms may wax and
Scarborough, Ontario MiK 5C5 during typical attacks of migraine.

442 GMA JOURNAL/FEBRUARY 17, 1979/VOL. 120

 Naprosyn It is presumed that the biochemical
and hormonal changes initiating mi-
graine are also responsible for caro-
a day. Propranolol, methysergide
and ergot preparations can also be
used, and I tend to use them in that
tidynia; the main difference is the order if pizotyline therapy is not
BRIEF PRESCRIBING INFORMATION
Tharapautlc Clmlflcatlon
size of the vessel involved. This rela- successful. The long-term complica-
Oral antI-Inflammatory, analgaslc and antilpyretlc agent.
IndIcatIons
tion is further supported by the find- tions of methysergide must be kept
The treatment of osteoarthritis, rheumatoid arthritis and ankytosing
(rheumatoid) spondytitis.
ing of Raskin and Prusiner15 that in mind; this drug can be used for 6
Contralndlcatlons
Naprosyn should not be given to patients with active peptic utcer or about half of the patients with fre- months at a time, with breaks of 1
active inftammatory disease ot the gastrointestinal tract. tt is atao
contraindicated tor those who have shown a sensitivity to it and tor quent attacks of migraine have ten- month, in long-term management.
patients in whom aspirin or other non-steroidal anti-inttammatory
drugs induce the syndrome ot asthma. rhinitia or urticaria.
derness over one or both carotid ar- Carotidynia also responds to corti-
Warnlnga
The safety of Naprosyn in pregnant, lactating or pediatric patients teries. costeroid therapy, but I have not
has not been estabtished and, therefore, its use is not recommend-
ed under these conditions.
yet had to use it.
PrecautIons Treatment Because treatment is often very
Naprosyn shoutd be given under close supervision to patients
prone to gastrointestinal tract irritation and to those with diverticulo-
sis ore history of peptic utcer. Naprosyn may displace other The treatment of carotidynia is the helpful in relieving carotidynia, and
albumin-bound drugs from their binding sites and may tead to drug
interactions. For esampte, patients receiving bishydroxycoumarin, same as that for migraine,14"5 and because the patients are often sub-
wartarin, hydantoin, sutfonamide or sutfonylures should be watched
ctosely for signs of overdosage or toxicity when Naprosyn is added the best results occur when the pro- jected to many needless investiga-
to the regimen. Mild perpheral edema has been observed in stew
cases. Consequently, patients with compromieed cardiac function phylactic drugs for migraine are used. tions, it is worth keeping this syn-
should be kept under observation when taking Naprosyn. The pre-
scriber should be alert to the fact that anti-inflammatory, analgesic In the 11 patients I have seen, me- drome in mind when seeing a patient
and antipyretic effects of Naprosyn may mask the usual signs ot in-
Iaction. Naprosyn is excreted primarily in the urine and should be thysergide, ergot preparations, pizo- complaining of neck or face pain.
adminietered with adequate precauiton to patients with diminiehed
renal function. Naprosyn may produce increased urinaryvalues in tyline and propranolol each gave
the sassy for 17-ketogenic steroids due to interaction behesen na-
proxen or its metaboittes and m-dinitrobenzentl used in this sassy. good results in some patients but not References
It is, therefore, suggested that Naprosyn therapy be temporarily
discontinued 48 hours before adrenal function tests are performed. all. Pizotyline is preferred because it 1. LOVSHIN LL: Vascular neck pain -
Advsraa ReactIons a common syndrome seldom recog-
Gastrointest,nei Tract: Infrequent bleeding with or without ulcera- gives good results in most cases and nized. Cleve Clin Q 27: 5, 1960
lion. tn some cases, the relstionshp to Naprosyn was difficult to as-
sess. Other adverse effects, in decreasing order of prevalence, does not have the long-term compli- 2. MURRAY TJ: Migraine. NS Med Bull
were: heartburn, constipation, abdoma,al paln, nausea, diarrhea, 56: 15, 1977
dyspepsia and diverticulitis. Only slew complaints were severe cations of methysergide, the next
enough to warrant discontinuation of therapy. 3. ROSEMAN DM: Carotidynia. A distinct
Skin: Rashes have been relatively uncommon and generally clear- best drug. Propranolol seems very syndrome. Arch Otolaryngol 85: 81,
ed on withdrawal of the drug. Other reactions encountered, in de-
creasing order of frequency, were: pruritis, sweating and purpura. useful in some patients and is partic- 1967
Angioneurotic edema has been seen rarely.
Central Nervous System: Headache, dizziness, droweiness, de- ularly well tolerated. I have used all 4. FAY T: Atypical neuralgia. Arch
pression and fatigue have been seen occasionally. Only slew pa-
tients had to discontinue treatment because of the severity of some
of these complaints (headache, dizziness).
these medications in the same dosages 5. Neurol Psychiatr 18: 309, 1927
Idem: Atypical facial neuralgia, a
Hematologic Reactions: Although a definite causal relationstap has
not been established, rare cases of thrombocytopenia or leuco-
as for migraine,14 and have continued syndrome of vascular pain. Ann Otol
penis have been reported.
Cardiovascular Reactions: Dyspnea, mild perpheral edema, ec-
their use for 3 months on a prophy- Rhinol Laryngol 41: 1030, 1932
chymoses and palpitations have been encountered infrequently. lactic basis but in an uncontrolled si- 6. WOLFF HG: Headache and Other
Hapatic: One case of jaundice which reappeared on chalienge with Head Pain, Oxford U Pr, New York,
Naprceyn has been reported, but a detinite relationship to the drug
has not been estabished.
tuation. If the symptoms disappear, 1948, p 642
Special Senses: A few eye abnormalties, including comeel chang-
as, lens opacties, macular degeneration and blurred vlaion have
therapy is slowly stopped, to be re- 7. HILGER JA: Carotid pain. Laryngo-
been reported, but the relationship to Naprosyn has not been estab-
lished. Occasional instances of mild to moderately severe tinnitus
instituted if the symptoms recur. In scope 59: 829, 1949
have been seen.
Mouth and Throat Reactions: A few cases of severe sore throat
the event of recurrence the drug is 8. ROSEMAN DM: Carotidynia, in Hand-
book of Clinical Neurology, vol 5:
have been observed, but the relatlonship to the drug has not been
estabtished.
given again, in the same initial do- Headaches and Cranial Neuralgias,
Laboratory Tests: It should be kept in mmd when bleeding times are
determined that Naprosyn decreases platatet aggregation and pro-
sage. In most patients symptoms VINKEN PG, BRUYN GW (eds), Else-
longs bleeding time. Other laboratory tests during Naprosyn therapy have not recurred after initial control. vier-North-Holland, Amsterdam, 1968,
have shown sporadic abnormalbes, but no definite trend was seen
that wnuld indicate potential toxicity.
Doaage and AdmInIstratIon
Because the syndrome is self-limiting 9. pp 375-78
SAUNDERS WH: Carotid arteritis: new
The usual daily dosage of Neprosyn for oateoarthritis, rheumatoid
arthritis and ankylosing spondytitia is 500 mg in divided doses. This
in some instances, some of the ap- treatment for an often-overlooked
may be increased to 750 mg or decreased, depending on there-
aponse of the patient. Administration more frequently than twice parently good responses to therapy condition. Laryngoscope 72: 481, 1962
dady is not necessary.
Dosage Forma may be simply the natural history of 10. JAMA Carotidynia, a distinct syndrome (E).
199: 121, 1967
Naprosyn5 is avadable as oval, biconvex tablets, engraved N on
one side and SYNTEX on the other. Each pale green tablet the syndrome. Management of caro- 11. PEARSE HE, HINSHAW JR: Bilateral
contains 125 mg naproxen. Bottles of 100 and 500 tabtets. Each
yelbw tablet contains 250mg naproxen. Bottles 0150 and tidynia may leave the patient with arteritis simulating carotid body tu-
250 tablets.
Product Monograph avadable on request. occasional migraine despite the fact mors. Surg Gynecol Obstet 103: 263,
1956
that the syndromes respond to the 12. FORD FR: The carotid pain syndrome.
same therapy. Report of two cases which suggest
References:
1. Haslock. D. I.. et xl. A comparative trial 01 naproxen (Naprosyn)
The suggested approach to man- that, in some instances, migraine is
and high dose indomethacin in rheumatoid arthritis - prelimi- aging carotidynia is to start with responsible. Bull Johns Hopkins Hosp
nary results. Proceedings of a Symposium. London. ed. G. A. 114: 266, 1964
Christie. M.B.. Che.. B.Sc.. 35-37. 1973.
2. Ruedy. J.. A comparison of the analgesic efficacy ol neproxen pizotyline, one tablet twice a day, 13. BROWN RL: Carotid arteritis from
(Naprosyn) and acetylsalicylic acid-codeine in patients with pain
after dental surgery. Scand. J. Rheumatology. Suppl. 2:60-63.
1973.
then to increase the daily dose, over aphthous ulcers. Angiology 14: 522,
3. Hill. H. F. H.. et al, Naprosyn in open study in patients intolerant
of other non-steroidal anti-inflammatory agents. Proceedings of I week, to a maintenance level of 1963
a Symposium. London, ed. 0. A. Christie. MB.. Ch.B.. B.Sc..
one tablet four times a day. As many 14. MURRAY TJ: Migraine: an overview.
47-49. 1973. Can Pharm J 110: 6, 1977
As early as indicated as 12 tablets per day can be given if 15. RASKIN NH, PRUSINER S: Carotidynia.
As long as required necessary to control the symptoms. Neurology 27: 43, 1977
When symptoms are controlled, the 16. LovsHIN LL: Carotidynia. Headache
17: 192, 1977
dosage is reduced to a maintenance 17. DAVIS JVSA: Carotid pain: report of
SYT.JT..(SYntex
Montreal,Ltd.Ousbec H4P 2B5 EEEJ [mi] level of one tablet three or four times six cases. Br Med J 2:1528, 1961

CMA JOURNAL/FEBRUARY 17, 1979/VOL. 120 443