Hemicrania Continua and Pituitary Microadenoma - Post Hoc Ergo Propter Hoc?: A Case Report With a Side Note on Intra-Sellar Pressure and the Trigemino-Autonomic Reflex

We describe the case of a 38-year-old woman whose headache phenotype transformed from episodic migraine to hemicrania continua (HC) responsive to indomethacin, as expected per diagnostic criteria. Our patient also had a non-functioning pituitary micro-adenoma which is over-represented in the trigeminal autonomic cephalgias (TAC) such as HC, pituitary adenoma being the most common intra-cranial pathology. We explore our case further by outlining in detail the neural supply of the dura of the pituitary fossa, outline the dynamics of intra-sellar pressure (ISP), and posit potential mechanisms of generation of HC in patients with pituitary micro-adenoma. We stress and further explore the remarkable observation that indomethacin, which lowers intracranial pressure, exquisitely resolves the pain of HC. Furthermore, we hypothesize that despite normal ISP, the slight elevation of ISP and mass effect impairs portal venous circulation, which may lead to venous hypertension and/or parasympathetic hyperactivity, which explains the pain and autonomic features of HC.