headache and facial pain - welcome to utmb health, the ... · headache and facial pain robert h....
TRANSCRIPT
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Headache and Facial Pain
Robert H. Stroud, M.D.
Faculty Advisor: Byron J. Bailey, M.D.
The University of Texas Medical Branch
Department of Otolaryngology
Grand Rounds Presentation
January 31, 2001
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Referred Pain
Brain tissue insensate
Anterior & middle fossae anterior to coronal suture
Posterior fossa occipital and upper neck
Sphenoid & sella vertex
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Sinus Innervation
Ophthalmic and maxillary branches of 5th cranial nerve
Greater superficial petrosal branch of 7th cranial nerve
Ostiomeatal complex > turbinates > septum > sinus mucosa
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Frontal Sinus
Ophthalmic branch of 5th cranial nerve
Pain referred to forehead and anterior cranial fossa
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Anterior Ethmoid
Ophthalmic division
Anterior ethmoid nerve off nasociliary
Anterior septum, turbinates, ostiomeatal complex
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Posterior Ethmoid and Sphenoid
Maxillary division
Posterior ethmoid nerve
Posterior septum, parts of superior and middle turbinates
Ophthalmic division
Greater superficial petrosal nerve
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Maxillary Sinus
Maxillary division of 5th cranial nerve
Posterior superior alveolar
Infraorbital
Anterior superior alveolar
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Referred Otalgia
Oral cavity
Mandibular division of 5th cranial nerve
Auriculotemporal nerve
Pharynx
Jacobson’s branch of 9th cranial nerve
Hypopharynx and supraglottic larynx
Arnold’s branch of 10th cranial nerve
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History
First occurrence
Timing
Quality
Treatments
Associated symptoms
Precipitating factors
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Past Medical History
Head injuries, infections, surgeries
Psychiatric diagnoses
Medications OTC analgesics
OCP
Herbal medications
Antihypertensives & vasodilators
Alcohol, tobacco, drugs
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Physical Examination
Complete head & neck exam
Cranial nerves
TMJ & muscles of mastication
Scalp vessels
Trigger points
Neurological exam
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Diagnostic Tests
EEG
CT and/or MRI
EMG
TMJ radiography
Cervical spine films
Labs
Psychometric testing
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Tension-Type Headache
Most common headache syndrome
Episodic < 15 days per month
Chronic > 15 days per month
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TTH - Characteristics
30 minutes to 7 days
Pressing or tightening
Mild to moderate pain
Variable location, often bilateral
Nausea and vomiting rare
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TTH - Treatment
Stress management
Biofeedback
Stress reduction
Posture correction
Medication rarely needed in ETTH
Benzodiazepines
amitriptyline
CTTH
Abortive
NSAIDs
ASA-caffeine-butalbital
Phenacetin
Preventative
Antidepressants
Muscle relaxants
NSAIDs
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Migraine
17% of females, 6% of males
Moderate to severe pain
Unilateral, pulsating
4 to 72 hours
Nausea, vomiting, photophobia or phonophobia
With or without aura
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Migraines - Causation
Sterile inflammation of intracranial vessels - trigeminovascular system
Serotonin (5-hydroxytryptamine) receptors
Triggering factors
Stress
Menses
OCP
Infection
Trauma
Vasodilators
Wine
Aged cheeses
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Migraine - Treatment
Abortive
5-hydroxytryptamine receptor agonists
Imitrex
Oral, SQ, nasal spray
Maxalt
Zomig
Amerge
Ergotamine
Butorphanol
Midrin
NSAIDs
Lidocaine
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Migraine - Treatment
Symptomatic
Prochlorperazine
Dihydroergotamine
Chlorpromazine
Haloperidol
Lorazepam
BOTOX?
Preventative
Antidepressants
Bellergal (ergotamine)
NSAIDs
-blockers
Calcium channel blockers
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Cluster
Intensely severe pain
Unilateral
Periorbital
15 to 180 minutes
Nausea and vomiting uncommon
No aura
Alcohol intolerance
Male predominance
Autonomic hyperactivity
Conjunctival injection
Lacrimation
Nasal congestion
Ptosis
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Cluster
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Cluster
Episodic
Two episodes per year to one every two or more years 7 days to a year
Chronic
Remission phases less than 14 days
Prolonged remission absent for > one year
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Cluster - Treatment
Preventative
Calcium channel blockers
Bellergal
Lithium
Methysergide
Steroids
Valproate
Antihistamines
Abortive
Oxygen
5-HT receptor agonists
Intranasal lidocaine
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Temporal Arteritis
Moderate to severe, unilateral pain
Patients over 65
Tortuous scalp vessels
ESR elevated
Biopsy for definitive diagnosis
Treat with steroids
Untreated complicated by vision loss
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Chronic Daily Headache
6 days a week for 6 months
Bilateral, frontal or occipital
Non-throbbing
Moderately severe
Due to overuse of analgesics
? Transformation of migraine or TTH
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CDH - Treatment
Patient understanding
Remove causative medication
Avoid substitution
Antidepressants
Adjuvant therapy
Treatment of withdrawal
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Trigeminal Neuralgia
Paroxysmal pain – seconds to < 2 min
Distributed along 5th cranial nerve
Asymptomatic between attacks
Trigger points
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Trigeminal Neuralgia - Treatment
Carbamazepine
Gabapentin
Baclofen
Phenytoin
Valproate
Chlorphenesin
Adjuvant
TCAs
NSAIDs
Surgery for refractory cases
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Glossopharyngeal Neuralgia
Similar to Trigeminal Neuralgia
Unilateral pain Pharynx
Soft palate
Base of tongue
Ear
Mastoid
Treatment as for Trigeminal Neuralgia
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Atypical Facial Pain
Diagnosis of exclusion
? Psychogenic facial pain
Location and description inconsistent
Women, 30 – 50 years old
Usually accompanies psychiatric diagnosis
Treat with antidepressants
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Post-Traumatic Neuralgia
Neuroma formation
Occipital and parietal scalp
Diagnosis based on history
Treatment
Trigeminal Neuralgia
Bupivicaine to trigger points
Occasionally amenable to surgery
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Post-Herpetic Neuralgia
Persistent neuritic pain for > 2 months after acute eruption
Treatment
Anticonvulsants
TCAs
Baclofen
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Temporomandibular Disorders
Symptoms
Temporal headache
Earache
Facial pain
Trismus
Joint noise
60% spontaneous
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Internal Derangements
Tenderness to palpation
Pain with movement
Audible click
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Degenerative Joint Disease
Pain with joint movement
Crepitus over joint
Flattened condyle
Osteophyte formation
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Myofascial Pain
Most common 60% - 70%
Muscle pain dominates
Tenderness to palpation of masticatory muscles
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TMD - Treatment
NSAIDs
Physical therapy
Biofeedback
Trigger point injection
Benzodiazepines
TCAs or SSRIs for chronic muscle pain
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Pseudotumor Cerebri
Intermittent headache
Variable intensity
Normal exam except papilledema
Normal imaging
CSF pressures > 200 cm H2O
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Pseudotumor Cerebri - Associated History
Mastoid or ear infection
Menstrual irregularity
Steroid exposure
Retro-orbital or vertex headache
Vision fluctuation
Unilateral or bilateral tinnitus
Constriction of visual fields
Weight gain
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Pseudotumor Cerebri – Treatment
Reduce CSF production
Furosemide
Acetazolamide
Weight loss
Low salt diet
CSF shunting
Incision of optic nerve sheath
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Intracranial Tumor
30% have headache
Dull or aching
Crescendo over time
Early morning
Increased with valsalva
Vomiting with nausea
Neuro exam may be normal
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Subdural Hematoma
History of trauma
Fluctuating level of consciousness
Pain lateralized
Tenderness to percussion over hematoma
Trauma may be remote in chronic SDH
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Subarachnoid Hemorrhage
Sudden onset, severe, generalized pain
Nausea and vomiting
Stiff neck progressing to back pain
LP if imaging negative
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Infectious
Meningitis
Acute meningitis
Fever
Stiff neck
Fungal
Tuberculous
Luetic
Epidural abscess
AIDS of CNS
Sarcoidosis
Diagnosis dependent on LP
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Hypertension
Usually with diastolic pressures > 115 mm Hg
Throbbing
Nausea
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Low ICP Headache
Usually from LP
Worse with sitting or standing
Vertex or occipital, pulling, steady
Usually resolve spontaneously
Blood patch for resistant cases
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Sinus Headache
Acute sinusitis accepted
Chronic sinusitis controversial
Constant, dull, aching
Worsened with jarring, stooping or leaning forward
Referred pain possible
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Contact Point Theory
Stammberger and Wolf 1988
Role of Substance P
Axonal reflex arc
Predisposing anatomy
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Agger Nasi Cells
Anterior and superior to insertion of middle turbinate
Narrow frontal recess
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Uncinate Variations
Anterior displacement
Pneumatization
Narrowing in middle meatus or contact with middle turbinate
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Middle Turbinate Variations
Paradoxically bent
Concha bullosa
Obstruction of middle meatus
Mucosal contact with lateral nasal wall
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Ethmoid Variations
Extensive pneumatization
Contact with middle turbinate
Obliteration of middle meatus
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Haller’s Cells
Anterior ethmoid cells on floor of orbit
Narrow maxillary sinus ostium
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Surgery for Sinus Headache
Clerico 1995 10 pts with prior
diagnosis of headache syndrome
Mucosal contact points
7 operated on with relief of HA
3 responded to medical therapy for sinonasal findings
Parsons and Batra 1998
91% of 34 pts had decreased intensity of HA post op
85% decreased frequency
All pts had indicators for surgery other than headache
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Surgery for Sinus Headache
Headache as SOLE indication for sinus headache still unproven
Headache should improve with decongestant and topical anesthesia if good results are to be expected post op
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Conclusion
Headache & facial pain are common complaints
History most important in making accurate diagnosis
Recognize psychological aspects of pain
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Case Study
29 year old WM presents with severe headache.