A Case of Prethoracic Pain Radiating Upward and Initiating Nervus Intermedius Neuralgia and Migraine Headache: Could Epicrania Fugax Pain Start in the Upper Body?

: Epicrania fugax (EF) was recently classified as a primary headache in the Appendix of the International Classification of Headache Disorders, third edition (ICHD-III). It is characterized by a paroxysmal pain rapidly radiating forward or backward along a linear or zigzag trajectory on the surface of the head. This article reports a 76-year-old woman who newly developed a paroxysmal EF-type pain distributed not only in the territories of the trigeminal and occipital nerves, but also in the territories of the cervical and thoracic nerves. This EF-type pain started in a point on the prethoracic area, radiated along the ipsilateral neck, face, auditory canal, and head surface in a linear trajectory, and finally initiated attacks of nervus intermedius neuralgia (NIN) and migraine without aura (MWA). Treatment with a low dose of carbamazepine was associated with decreased intensity of EF-type pain and fewer NIN and MWA attacks, while a higher dose of carbamazepine was associated with complete termination of EF-type pain and NIN and MWA attacks. This case report expands the clinical spectrum of EF and may also be helpful in understanding its pathophysiology.