2026-07-02 | Orbital Metastasis of Pancreatic Cancer Not Detected on MRI at the Time of Clinical Presentation.
The orbit is a rare site for metastasis from pancreatic cancer, and diagnosis can be challenging when early imaging findings are subtle. We report a case of orbital metastasis initially undetectable by magnetic resonance imaging (MRI) but subsequently managed with radiotherapy. A man in his 60s with metastatic pancreatic adenocarcinoma developed right-sided periorbital pain and hypoesthesia during chemotherapy. Initial brain and orbital MRI showed no evidence of metastasis, and symptoms were managed as suspected trigeminal neuralgia. Five months later, the patient developed diplopia; follow-up MRI revealed a soft tissue lesion at the right orbital apex with high signal intensity on fat-suppressed T1-weighted imaging, leading to a diagnosis of orbital metastasis. The patient underwent palliative radiotherapy, resulting in significant alleviation of pain and diplopia. Orbital metastasis from pancreatic cancer may present with morphological changes undetectable on initial MRI, highlighting the importance of a high index of clinical suspicion and serial imaging follow-up for unexplained neurological symptoms. Palliative radiotherapy is an effective modality for achieving symptomatic relief and improving quality of life in this rare manifestation. Clinicians should consider orbital metastasis when new-onset periorbital symptoms occur in patients with advanced pancreatic cancer.
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2026-07-01 | Botulinum Toxin Type A for Trigeminal and Postherpetic Neuralgia: An Umbrella Review of Systematic Reviews.
BACKGROUND AND OBJECTIVE: Trigeminal neuralgia (TN) and postherpetic neuralgia (PHN) are severe peripheral neuropathic pain conditions associated with substantial functional impairment. Although pharmacological treatments are available, many patients experience insufficient efficacy or poor tolerability. Botulinum toxin type A (BoNT-A) has emerged as a potential treatment, but uncertainties remain regarding its efficacy, safety, and clinical positioning. This umbrella review aimed to synthesise evidence from systematic reviews evaluating BoNT-A in TN and PHN. A systematic search was conducted in MEDLINE, Embase, Cochrane Library, Web of Science, and CINAHL from inception to November 2025. Systematic reviews with or without meta-analysis evaluating BoNT-A in adults with TN or PHN were included. Methodological quality was assessed using AMSTAR-2, and only moderate- or high-quality reviews were included. Primary outcomes were pain intensity reduction and responder rates (≥ 50% pain reduction). Secondary outcomes included quality of life and adverse events. Ten systematic reviews (2015-2024) met the inclusion criteria. Botulinum toxin type A was consistently associated with reductions in pain intensity and higher responder rates than placebo, particularly in TN. In PHN, evidence was more limited but supported short-term (1-3 months) improvements in pain intensity. Evidence on quality of life was scarce and inconclusive. Botulinum toxin type A was well tolerated, with mostly mild and transient adverse events. Botulinum toxin type A appears to provide short-term pain relief in selected patients with TN and PHN and is generally well tolerated. Current evidence supports its role as an adjunctive third-line option for focal peripheral neuropathic pain, although heterogeneity and limited long-term data warrant cautious interpretation.
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2026-06-29 | Emerging Pharmacological Strategies for Trigeminal Neuralgia.
Trigeminal neuralgia can be a debilitating pain condition that affects women more frequently than men and for which there are only limited therapeutic avenues. Trigeminal neuralgia can either be idiopathic (where there is no clearly identifiable cause), classical (which typically involves neurovascular compression of the trigeminal root entry zone) or secondary which results from nerve damage due to other causes. First-line treatments for trigeminal neuralgia include the sodium channel blockers carbamazepine and oxcarbazepine, whose mechanism of action is to stabilize the inactivated state of sodium channels, thereby reducing the electrical activities of trigeminal neurons. Second-line treatments include gabapentinoids, which act on Cavα2δ subunits of high voltage activated calcium channels to inhibit synaptic transmission in the trigeminal pain pathway. Both of these treatment avenues exhibit a number of adverse effects and many patients are refractory. Hence, new avenues for combatting trigeminal neuralgia are needed. In this review article, we discuss clinical evidence for efficacy and benefits of novel pharmacological treatment approaches for trigeminal neuralgia, including the inhibition of CGRP receptors, activation and desensitization of TRPV1 channels, the development of new generations of sodium channel blockers, and the use of botulinum toxin. We conclude that while there are potential benefits of these approaches, larger well-controlled cohort studies are needed to provide a definitive answer.
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