Red forehead dot syndrome: a case report and review of literature

Migraine is a common neurological disorder with a broad spectrum of sensory and autonomic manifestations. Visible, recurrent, localized cutaneous changes temporally associated with migraine attacks are rare.

I report a 41-year-old Pakistani man with an approximately 21-year history of recurrent bilateral frontal and supra-orbital headaches associated with photophobia, phonophobia, and nausea. For many years, his attacks have been accompanied by recurrent, well-demarcated bilateral erythematous forehead changes in a distribution corresponding approximately to the ophthalmic (V1) trigeminal territory. Because of the long duration of symptoms, he could not reliably determine whether migraine-type headaches preceded the cutaneous manifestations or whether both had been associated from the beginning. Intermittent cranial autonomic features occurred during some attacks but were not consistently present and did not invariably coincide with the skin discoloration. Neurological examination, laboratory evaluation, and brain MRI were unremarkable. Following his usual acute analgesic treatment, both headache and skin changes improved within minutes to a few hours.

This case adds to the limited literature describing migraine-associated forehead erythema, previously termed "red forehead dot syndrome." The reproducible temporal relationship between headache and cutaneous changes supports an association with the migraine attack, although the underlying mechanism remains uncertain. Trigeminovascular activation, neurogenic inflammation, autonomic dysfunction, and vasoactive neuropeptides such as calcitonin gene-related peptide (CGRP) are biologically plausible mechanisms. Because this presentation is rare, appropriate evaluation for secondary neurological, vascular, inflammatory, and dermatological causes remains essential.