Exertional Headaches Associated with Left Parotid Necrotizing Granulomatous Inflammation
Joudi Sharaf1, Lubna Salih1, Ashhar Ali2
1Henry Ford Hospital, 2Henry Ford Health
Objective:
To describe a case of exertional headaches associated with necrotizing granulomatous inflammation of the left parotid gland that resolved following surgical resection.
Background:
Primary exertional headaches are often benign, but secondary causes such as vascular, infectious, and inflammatory conditions must be ruled out, particularly in patients over 40 years old or those with focal, structural, or atypical features. This report presents an atypical case of exertional-triggered headaches associated with necrotizing granulomatous inflammation adjacent to the parotid gland.
Results:
A 41-year-old woman with a past medical history of left parotid salivary gland stones, ADHD, obesity, and anxiety developed new-onset headaches one year prior to presentation. The initial episode occurred abruptly after sexual climax, described as severe (8/10) left retro-orbital pain lasting 15–20 minutes. Later, she experienced exertion-induced left retro-orbital aching or burning pain rated 4–5/10, lasting 20–30 minutes. These headaches were associated with photophobia and phonophobia, but not with nausea or vomiting.
She underwent magnetic resonance imaging of the brain and magnetic resonance angiography of the head and neck, which were normal. Computed tomography scan of the neck showed a large enhancing solid and cystic mass and hyper-enhancing left cervical lymph nodes. ENT evaluation and partial parotidectomy revealed necrotizing granulomatous inflammation adjacent to the parotid salivary gland. There was no evidence of malignancy or infection. Autoimmune and infectious workups were largely unremarkable.
After partial parotidectomy, the patient experienced significant improvement, with near-complete resolution of exertional headaches. She later reported only occasional mild headaches, usually triggered by stress or prolonged bright light exposure.
Conclusions:
This case highlights a rare presentation of exertional-triggered headaches associated with inflammatory pathology in the parotid region. Local inflammatory processes or structural lesions can cause referred trigeminal or autonomic pain, leading to secondary headaches. Identifying structural or inflammatory causes is essential when evaluating new-onset exertional headaches, especially in middle-aged adults.
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