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Excruciating Headache but Nothing Obvious, Look at the Skin!
  1. Eelco F.M. Wijdicks*,
  2. Peter H. Win
  1. *Department of Neurology and
  2. Department of Ophthalmology, 200 First Street SW, Rochester, MN 55905, USA; E-mail: wijde{at}


Herpes zoster ophthalmicus is usually easily recognized by the periorbital vesicular rash restricted to the ophthalmic division of the trigeminal nerve. But sometimes the rash is not so obvious, despite severe symptoms

An 80-year-old woman presented with constitutional symptoms for 1 week. She had initially developed a nagging frontal ‘sinus’ headache which had gradually became excruciatingly severe and more localized behind the right eye. On examination on day 1, she looked debilitated, but her neurological examination was normal. The soft tissues around the right eye were oedematous and the skin was reddened (Fig. 1, day 1). The next day she developed erythematous papules and vesicles on the right V1 dermatome, including the nasociliary region (Fig. 1, day 2). On slit lamp examination, the right eye had trace conjunctival injection and tiny punctate epithelial keratopathy. The right ocular surface was protected with topical lubricant ointment. The skin abnormalities evolved quickly within

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