O014. The diagnostic mistake: when the patient reports pain affecting eyes and benzodiazepines abuse without any glaucoma or any apparent organic cause

Background

It is not so infrequent that a patient reports severe pain with a clear focus in/around the eye that looks like an atypical facial pain/persistent idiopathic facial pain. All the patients fulfilled DMS-IV criteria for depression or bipolar disorder-I and sleep and benzodiazepines overuse were reported as the only escape and cure treatment. This may or may not appear as a psychological flight reaction characterized by vegetative signs [1], or a medication-overuse headache. The diagnosis could be wrong even though the IHS/IASP and psychological criteria were respected. What could be the problem? We did not take into account that demodex is present even in man. Demodex -type A and type B-, the most serious non-neoplastic dermatological disease [2, 3], is not so widely known in human pathology [4]. This ascaris provokes discomfort and pain, the severity of which depends on the extent and seriousness of the disease [2–4], as well as on the pain proneness evidenced in third hyperalgesia test we proved several years ago [5]. Thus, pain proneness and pain redundancy might be present in both migraine sufferers and in their relatives.

Aim

To evidence possible causes of therapeutic mistakes in persistent facial pain, chiefly affecting the eye area.

Materials and methods

Observation started 26 years ago. Recruited patients (53 males; mean age 33.9 years ± 7.5 SD) suffering from atypical facial pain chiefly affecting the area of the eyes, were previously treated with all the substances commonly used in such a pain, namely tricyclics, negative modulators of excitatory aminoacids, selective serotonin reuptake inhibitors and norepinephrine reuptake inhibitors given as 3-month treatments and narcotics given as hospital short-lasting (5 days) regimen. Neither indomethacin 50 mg nor sumatriptan 6 mg, parenterally administered, induced relief.

Results

None of the patients, except one, achieved pain relief, i.e. decrease vs baseline 17% on VAS 0-10. Only narcotics induced a benefit, which vanished when treatment was discontinued. Magnifiers observation focusing cilia showed that all non-responder patients were affected by demodex as evidenced with the use of a magnifying glass. The specific treatment for curing demodex completely relieved non-responders’ pain. Later (i.e., 3-25 years; mean 19.3 years+10.9 SD), episodic migraine without aura appeared in 25 patients.

Conclusions

a) When a disease is rare it does not mean it can be neglected; b) an inherited abnormality of the central nervous system, namely inheritable hyperalgesia pattern seemingly provokes a redundancy of painful expression that may lead to diagnostic mistakes.

Written informed consent to publish was obtained from the patient(s).