Hemicrania continua-like headache secondary to nasopharyngeal carcinoma: A case report

Case report

A 31-year-old man presented with a four-month history of continuous left temporal pain with frequent exacerbations. The exacerbations were associated with ipsilateral conjunctival injection and a sense of restlessness. The pain entirely resolved with indomethacin (50 mg three times per day). The presentation fulfilled criteria A to D of hemicrania continua of the International Classification of Headache Disorders (1). This patient had a 20-year history of migraine, with attacks once or twice each month, and a family history of migraine. Subtle abnormalities were found on the initial brain magnetic resonance imaging scan with gadolinium enhancement (Figure 1). However, a neoplasm was excluded due to non-specific findings by fibre optic nasopharyngoscopy. At follow-up one month later, the patient had developed a left cranial nerve VI palsy. Thus a second brain magnetic resonance imaging scan with gadolinium was obtained, which revealed a neoplasm in the nasopharynx. A biopsy sample showed this to be an undifferentiated non-keratinizing carcinoma (T4N2M0) (Figure 2). After chemoradiotherapy, the hemicrania continua-like headaches gradually ceased in parallel with a reduction in tumour volume.

Figure 1.

Initial brain magnetic resonance imaging scan with gadolinium. Coronal scan with gadolinium shows (a) a left inferior turbinate hypertrophy (black arrow) and (b) an abnormal signal on the left side of the nasopharynx (black arrow).

Figure 2.

Neuroimaging and histopathology findings of patients at the one-month follow-up. (a) Coronal and (b) axial FLAIR images show a neoplasm (arrows) on the left side of the nasopharynx. (c) The tumour morphology shows atypical cells with vascular proliferation with haematoxylin and eosin staining (×200). (d) Immunohistochemistry showed widespread staining for CK200 (×200). The Ki67 index was c. 10%. The cells were also positive in patches for CD68. Negative stains included EMA, S-100, CgA and CD31.

Numerous cases of secondary hemicrania continua have been reported, but nasopharyngeal carcinomas are rare (2). A nasopharyngeal carcinoma should be considered as a trigger of a mimic of hemicrania continua. This case report also emphasizes that a short history of trigeminal autonomic cephalalgia-like headaches and an abnormal neurological examination on follow-up, even with an absolute response to indomethacin, should always prompt an evaluation for secondary causes.

Clinical relevance

Nasopharyngeal carcinoma should be considered as an entity that can trigger a hemicrania continua mimic.

A short history of trigeminal autonomic cephalalgia-like headaches and abnormal neurological examinations on follow-up, even with an absolute response to indomethacin, should always prompt the evaluation for secondary causes.