Objective:

N/A

Background:

Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) manifest as daily severe unilateral pain in trigeminal distribution lasting 1-600 seconds. Lyme neuroborreliosis (LNB), from central nervous system invasion of Borrelia burgdorferi, has a variable clinical course and can present with headache, cranial nerve palsy, and lancinating pain. Although rare, LNB has been associated with trigeminal nerve impairment. LNB typically has a subacute onset with progression over weeks.

Design/Methods:

N/A

Results:

A 73-year-old female with hypertension and no prior history of headaches presented to the emergency department with episodic cervical pain radiating to the vertex, accompanied by a sharp right-sided headache involving the right face and temple. Symptom duration was < 5 seconds; however, occurring ~100 times daily. Associated features included right-sided conjunctival erythema, ptosis and lacrimation. Initial neurologic exam was pertinent for mild anisocoria with right miosis and ptosis. SUNCT was suspected and the patient started gabapentin, which alleviated symptoms. She was admitted to the hospital 2 months later for generalized weakness and imbalance. Brain and cervical spine MRIs were unrevealing. Neurologic exam revealed left facial droop, bilateral shoulder abduction weakness, hyperreflexia within left upper extremity and diminished vibratory sense in lower extremities. CSF revealed pleocytosis. Due to recent tick exposure, Lyme serologies were tested and resulted positive for IgM and IgG bands. She was started on IV Ceftriaxone; however, transitioned to IV Penicillin for 4 weeks due to drug rash. One month following discharge, her symptoms remarkably improved and she remained headache-free.

Conclusions:

The patient’s initial presentation was concerning for a primary headache disorder; however, progression to diffuse CNS symptoms shifted our perspective. We highlight the importance of maintaining a broad differential when evaluating patients for new-onset headaches. This is also a unique presentation of neuroborreliosis as a headache phenotype similar to one of the trigeminal autonomic cephalalgias.