Q. My boyfriend has been having migraines for the past three years and finally went to the emergency room (ER). The ER physicians did a computed tomography (CT) scan and found a cyst on his brain. After many visits to all kinds of physicians, they told him it wasn’t the cyst that was causing the migraines—but it’s funny that he never had migraines until that cyst popped up. His headaches are so bad that his left eye becomes blood-red (not bloodshot, I mean real blood covering the white part) and then the skin under his eye turns black, yellow and green. Why is this happening and what can he do for his migraines? He has tried all kinds of medications and they haven’t helped. —Jennifer D.
A. It is important to know that the definitive brain imaging technique is magnetic resonance imaging (MRI), rather than the CT scan. There is a huge difference in the accuracy of these techniques, and important decisions should not be made because of a single CT scan. Because a CT scan was performed in response to the headaches, there is no way of knowing whether the cyst appeared at the same time as the headaches (unless there was prior testing). Many people are born with cystic changes in the brain, and the term “cyst” could mean many things. For example, an area of the brain that was damaged at birth is known as a porencephalic cyst, where there is an absence of brain matter and the space is filled with cerebrospinal fluid. Cystic structures in the brain are not uncommon and usually do not cause headache.
One type of cyst that might cause headache is known as an arachnoid cyst, but only if it is expanding and exerting pressure on the brain itself. Small arachnoid cysts are a common incidental finding and do not require treatment unless they change in size. They need to be monitored over time. Again, without knowing the details of the cyst, additional testing such as MRI and magnetic resonance angiogram (MRA) might be helpful. It is not entirely clear by your description, but one type of headache that produces extreme redness in the eye is known as Short-lasting Unilateral Neuralgiform headache attacks with Conjunctival injection and Tearing (SUNCT syndrome). These are very brief attacks and are accompanied by tearing and redness, but that would not explain changes in the skin below the orbit. At this point, a careful neurological evaluation with appropriate testing would be in order. Unusual headache patterns are best treated by headache specialists who are certified in headache medicine.
Edmund Messina, MD, Michigan Headache Clinic, East Lansing, Mich.
