Paul G. Mathew, MD, DNPAS, FAAN, FAHS

"The analogy that I give to many patients is that it’s like when you have an electrical problem inside of a house. You can take all the pictures you want outside and inside of the house, but it’s not going to show you the short circuit that’s causing the electrical problems.”

Cranial neuralgias, common in the setting of posttraumatic headache, can generate neuropathic symptoms such as lancinating pain and sensory dysesthesias. These neuralgias are identified based on a clinical history of focal neuropathic pain and physical examination findings including tenderness with palpation and percussion, at times eliciting radiating pain or paresthesia in the corresponding sensory nerve distribution.

Paul G. Mathew, MD, DNBPAS, FAAN, FAHS, recently conducted a case study that included 2 patients who met the criteria for posttraumatic headache, but upon further examination, suggested the presence of a focal painful cranial neuralgia. One patient was diagnosed with auriculotemporal neuralgia responded well to an auriculotemporal nerve block, while the second patient was diagnosed with supratrochlear neuralgia and was effectively treated with a supratrochlear nerve block.

Mathew, assistant professor of neurology, Harvard Medical School, has particular interest in uncovering more about those with refractory cases of posttraumatic headache and associated neuralgias. He sat down with 

to provide context on areas within the space that need additional research, including expanding on the use of surgeries and identifying which patients should be eligible for them.

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The assistant professor of neurology at Harvard Medical School discussed related areas of research regarding cranial neuralgias and the optimal time to proceed with surgery. 

Expanding Cranial Neuralgia Research, Affiliated Surgeries: Paul G. Mathew, MD, DNBPAS, FAAN, FAHS

"Because of the society we’re living in, when we’re typing, texting, eating, driving, we’re in this anterior position that puts a lot of tension on those muscles and generates a lot of bad chronic posture. Even something as simple as that, over the years, can lead to the development of occipital neuralgia.” 

In clinical practice, posttraumatic headache can manifest as a new type of headache with unique features from any previously experienced headache or a worsening in frequency and/or intensity of a pre-existing headache disorder. As in the case with primary headache disorders, the diagnosis of comorbid focal painful cranial neuralgias can often be missed in patients who present with posttraumatic headache. These neuralgias can manifest as brief, sharp, lancinating pain in a particular nerve distribution, and palpation where the nerve exits the skull may produce the pain. 

A recently conducted case study involving 2 patients with posttraumatic headache later diagnosed with auriculotemporal neuralgia and supratrochlear neuralgia, respectively, helped uncover more about the condition which some, including lead investigator Paul G. Mathew, MD, DNBPAS, FAAN, FAHS, consider “overlooked” within the headache space. Treatment options for painful cranial neuralgias are different than those traditionally employed for posttraumatic headache without cranial neuralgias, which can include peripheral nerve blockade, neuropathic medications, and in some refractory cases, peripheral nerve decompression surgery. 

Mathew, an assistant professor of neurology at Harvard Medical School, also concluded in his research that an increased awareness for these neuralgias may lead to more specific and effective treatments and subsequent overall improvement in patient outcomes. He sat down with NeurologyLive to discuss the difficulties in treating patients with cranial neuralgias and why thorough examination and questioning is key to guiding patients towards making the correct treatment decisions. 

The assistant professor of neurology at Harvard Medical School discussed why there isn’t just a “one size fits all” approach to treating cranial neuralgias.

Personalized Treatment of Cranial Neuralgias: Paul G. Mathew, MD, DNBPAS, FAAN, FAHS

"We also must listen carefully to the timeline of their attacks. When patients have this abrupt turn of their head and their headaches get worse, it’s worthwhile to ask those questions.”

Occipital neuralgia is a condition in which the occipital nerves, which run through the scalp, are injured or inflamed. This causes headaches that feel like severe piercing, throbbing or shock-like pain in the upper neck, back of the head, or behind the ears. Occipital neuralgia, like many other cranial neuralgias, can be difficult to diagnose because of its similarities to migraines and other headache disorders.

While there is no concrete test that will reveal a positive or negative diagnosis, a physical examination and neurological examination can be done to look for abnormalities. A recently conducted case study involved 2 patients who presented with headaches that met criteria for posttraumatic headache that ended up diagnosed with a focal painful cranial neuralgia explored this examination process. Authors Paul G. Mathew, MD, DNBPAS, FAAS, FAHS, and Wade Cooper, DO, concluded that the presence of cranial neuralgias is often overlooked within the migraine community, and can be overshadowed by other related posttraumatic headaches.

Mathew, an assistant professor of neurology at Harvard Medical School, stressed that a thorough examination is key to understanding where the pain is occurring and how to properly treat it. In an interview with 

Mathew claimed that the awareness of these neuralgias is not adequate among neurologists, noting that making the proper diagnosis is only possible if there is continual conversation between patient and clinician.

Mathew PG, Cooper W. The Diagnosis and Management of Posttraumatic Headache with Associated Painful Cranial Neuralgias: a Review and Case Series. 

Published online June 23, 2021. doi: 10.1007/s11916-021-00969-w

The assistant professor of neurology at Harvard Medical School provided thoughts on the need to increase awareness on cranial neuralgias and the importance of the diagnostic process for this condition. 

Raising Cranial Neuralgias Awareness via Improved Diagnostics: Paul G. Mathew, MD, DNBPAS, FAAN, FAHS

"Migraine is like a sensitive car alarm. Patients developing occipital neuralgia and some of these other painful cranial neuralgias is like a small child coming and kicking the wheels of this car, setting the alarm system off more frequently."

Authors Paul G. Mathew, MD, DNBPAS, FAAN, FAHS, and Wade Cooper, DO, recently published a retrospective report of 2 cases of posttraumatic headache with associated painful cranial neuralgias to further build upon previous literature about the conditions. One patient was diagnosed with auriculotemporal neuralgia, which was exquisitely responsive to an auriculotemporal nerve block, while the second patient was diagnosed with supratrochlear neuralgia, which was effectively treated with a supratrochlear nerve block.

The duo concluded that while painful cranial neuralgias frequently occur within the clinical spectrum of posttraumatic headache, they are often undiagnosed. These cranial neuralgias have features including lancinating pain in the distribution of the affected nerve, pain with palpation of the nerve’s superficial elements, and/or the presence of Tinel’s signs. In addition to the uniqueness in presentation, they are treated quite differently than the tactics traditionally employed for posttraumatic headache without cranial neuralgias.

Mathew, assistant professor of neurology, Harvard Medical School, sat down with 

to detail the importance of conducting research on this subtype of headache and why communication with a patient is key to understanding where the pain is located and how to go about treating it.

The assistant professor of neurology at Harvard Medical School discussed the motivation behind uncovering more about painful cranial neuralgias and their association with posttraumatic headache. 

Paul G. Mathew, MD, DNPAS, FAAN, FAHS

Articles

Expanding Cranial Neuralgia Research, Affiliated Surgeries: Paul G. Mathew, MD, DNBPAS, FAAN, FAHS

Personalized Treatment of Cranial Neuralgias: Paul G. Mathew, MD, DNBPAS, FAAN, FAHS

Raising Cranial Neuralgias Awareness via Improved Diagnostics: Paul G. Mathew, MD, DNBPAS, FAAN, FAHS

Researching Posttraumatic Headache With Cranial Neuralgias: Paul G. Mathew, MD, DNBPAS, FAAN, FAHS