Unexplained eye pain, orbital pain or headache


Headache or facial pain can both be due to disease in the:

  • eye

  • orbit

  • fifth nerve

  • meninges

  • skull base

  • paranasal sinuses

  • internal carotid artery

  • neck

Headache and facial pain are common symptoms with multiple causes. The 2004 International Classification of Headache Disorders recognizes 45 primary and 120 secondary headache types and subtypes and 29 causes of cranial neuralgias and central causes of facial pain. Some patients will present to ophthalmologists either because they have pain in or around the eye or because they have other ophthalmic symptoms or signs.

When presented with a patient whose principal symptom is headache or facial pain, the ophthalmologist has the responsibility to:

  • recognize and treat ophthalmic causes of headache and facial pain

  • recognize ophthalmic symptoms and signs of an intracranial or systemic cause of headache or facial pain

  • recognize common “benign” headache patterns with ophthalmic features

  • know when to refer other patients for further investigation

Examination checklist

Unexplained eye pain or headache

Have you asked about, and looked for, all the following key features?


  • the pain or headache

    • where is it?

    • when did it start?

    • speed of onset?

    • development over time?

    • triggers?

    • getting better or worse or staying the same?

  • other neurologic symptoms?

    • symptoms of raised intracranial pressure, e.g. nausea, vomiting, pulsatile tinnitus?

    • symptoms of migraine, e.g. visual disturbance preceding headache, nausea, photophobia?

    • numbness, weakness, loss of balance?

    • deafness, tinnitus or vertigo? (possible cerebellopontine angle [CPA] tumor)

    • neck or arm pain: possible internal carotid artery (ICA) dissection

  • other ophthalmic symptoms: diplopia, blurred vision, redness or swelling?

  • previous medical and surgical history: cancer?

  • if patient over 50: symptoms of giant cell arteritis (GCA)?

  • system review questions


  • visual acuity

  • refraction: undercorrected hypermetropia, overcorrected myopia or presbyopia?

  • visual field defect to confrontation?

  • limitation of eye movements: sixth nerve palsy plus persistent orbital or hemifacial pain: high risk of skull base or cavernous sinus tumor

  • pupils

    • is there anisocoria?

    • small pupil with ipsilateral pain: possible Horner syndrome due to tumor or ICA dissection

    • large pupil with ipsilateral pain: possible partial third nerve palsy due to aneurysm or tumor

  • eyelids and adjacent skin

    • ptosis: possible Horner syndrome or partial third nerve palsy

    • rashes: herpes zoster ophthalmicus

  • corneal and facial sensation to light touch: if reduced: increased risk of compressive tumor

  • orbicularis and facial muscle power: seventh nerve palsy plus persistent orbital or hemifacial pain: high risk of CPA tumor

  • slit-lamp

    • conjunctiva, sclera: chemosis, injection?

    • anterior chamber: depth, cells, flare?

    • intraocular pressure (IOP)?

    • gonioscopy

    • vitreous: cells?

    • disc: swelling, hemorrhages, pallor?

  • if patient over 50: palpate temporal arteries

  • perimetry if: field defect to confrontation, decreased vision, relative afferent pupillary defect (RAPD), diplopia or motility defect

  • full neurologic examination if: persistent headache or pain of unknown cause

Ophthalmic causes of headache or facial pain

Most ophthalmic causes of headache or facial pain are easily diagnosed by their characteristic features; for example, the sharp “surface” pain of a corneal abrasion or the aching pain and photophobia of acute iritis. The following may be missed if not specifically considered.

Headache due to angle-closure glaucoma

  • typically severe pain in or around the affected eye

  • usually associated with loss of vision, haloes around lights and a red eye

  • occasionally, patients experience recurrent episodes that resolve spontaneously with milder or no associated symptoms. Therefore, it is essential that all patients with atypical eye or facial pain are gonioscoped

Headache due to herpes zoster ophthalmicus

  • burning or aching, frequently severe pain in the distribution of the ophthalmic division of the trigeminal nerve

  • often associated with hyperesthesia and/or numbness in the same area

  • pain may precede the emergence of the vesicular rash by up to one week

  • if this diagnosis is suspected, the patient should be monitored closely and appropriate antiviral treatment started at the first signs of a rash or ocular inflammation. If no rash appears within 1 week, alternative diagnoses should be considered

Headache due to refractive error

  • recurrent mild frontal and/or ocular headache

  • normally absent on awakening

  • precipitated or aggravated by prolonged visual tasks (e.g. reading for patients with presbyopia)

  • headaches are often attributed to refractive error; genuine cases are rare but rapidly respond to the use of appropriate glasses

Headache due to heterophoria or heterotropia

  • recurrent non-pulsatile mild to moderate frontal headache

  • caused by significant heterophoria (close to or at limit of fusion range) or intermittent heterotropia

  • patients often also complain of intermittent blurred vision or diplopia and difficulty adjusting focus

  • usually absent upon awakening but worsens throughout the day

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Jun 25, 2019 | Posted by in OPHTHALMOLOGY | Comments Off on Unexplained eye pain, orbital pain or headache

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