Headache Headache & &

Facial PainFacial Pain

Headache & Facial Headache & Facial Pain:Pain:

Definition;

• Headache: Pain in the head: From the orbit back to the sub-occipital region.

• Facial pain: Pain elsewhere in the face.

Mechanism; Traction or distention of pain sensitive structures

Headache & Facial Headache & Facial Pain:Pain:

Pain sensitive structures

1. Dura of skull base

2. Cerebral arteries

3. Venous sinuses

4. Nerves

• Cranial nerves; 5, 9, 10

• Cervical nerves; C2,3

BackgroundBackground

Headache is the 4th most common symptom of Headache is the 4th most common symptom of outpatient visitsoutpatient visits

99% of women and 93% of men have had 99% of women and 93% of men have had headache during their lifetimeheadache during their lifetime

12.6 % prevalence (18% women, 6.5% men)12.6 % prevalence (18% women, 6.5% men) Prevalence is highest between age 25 – 55 Prevalence is highest between age 25 – 55

yearsyears

25% of women and 8% of men have had 25% of women and 8% of men have had migraine headachemigraine headache

Approximately 50% remain undiagnosedApproximately 50% remain undiagnosed

SinusSinus

TreatmentTreatment

TensionTension

MigraineMigraine

The Headache Dilemma…The Headache Dilemma…

Headaches: Headaches: PathophysiologyPathophysiology

Where does the pain Where does the pain arise from?arise from? ScalpScalp Dura materDura mater Blood vesselsBlood vessels Cervical & cranial nervesCervical & cranial nerves

Blood vesselsBlood vessels DilateDilate

Become congested Become congested PainPain

Headache ClassificationIHS Classification

Primary Headaches ( The headache is the disease )

Benign Headache disorders

Migraine (with or without aura) Tension-type headaches Cluster headaches Drug rebound headaches-Medication overuse headache Chronic daily headache

Secondary Headaches Headaches that are symptoms of organic disease

Characters of Primary Characters of Primary HeadacheHeadache

Benign, RecurrentBenign, Recurrent NOT associated with underlying NOT associated with underlying

pathologypathology The headache is the diseaseThe headache is the disease Recurrent attacksRecurrent attacks Symptoms free between the attacksSymptoms free between the attacks Clinical syndromesClinical syndromes Normal physical examinationNormal physical examination No organic causesNo organic causes Exception: drug-abuse headacheException: drug-abuse headache Diagnosis is based on exclusionDiagnosis is based on exclusion

Characters of Secondary Characters of Secondary HeadacheHeadache

Sudden, progressive CourseSudden, progressive Course Symptoms persistSymptoms persist Pain select to anatomical lesionsPain select to anatomical lesions Physical examination usually Physical examination usually

abnormalabnormal Associated with pathologyAssociated with pathology May require immediate actionMay require immediate action

Secondary HeadacheSecondary Headache

Aneurysms, Aneurysms, AVMs and SAHAVMs and SAH

Thunderclap Thunderclap HeadacheHeadache

MeningitisMeningitis StrokeStroke SOLSOL

Trigeminal Trigeminal NeuralgiaNeuralgia

Temporal ArteritisTemporal Arteritis HypertensionHypertension Benign Intracranial Benign Intracranial

HypertensionHypertension Lumbar Puncture Lumbar Puncture

HeadacheHeadache Sinus HeadacheSinus Headache

Secondary Headache Secondary Headache Warning Signs and SignalsWarning Signs and Signals

Sudden onset Sudden onset

Onset after age 50 yearsOnset after age 50 years

Systemic signs (fever, myalgias, weight loss) Systemic signs (fever, myalgias, weight loss)

Systemic disease (Malignancy, AIDS)Systemic disease (Malignancy, AIDS)

Change in headache patternChange in headache pattern Progressive headache with loss of headache-free periodsProgressive headache with loss of headache-free periods

Change in frequency or severityChange in frequency or severity

Neurologic symptoms or abnormal physical Neurologic symptoms or abnormal physical findingsfindings

Cognitive changesCognitive changes

AsymetryAsymetry

Clues for Secondary Clues for Secondary HeadacheHeadache

Focal neurological deficitsFocal neurological deficits Slowly progressive courseSlowly progressive course Sudden severe headacheSudden severe headache Appearance at old ageAppearance at old age Systemic manifestationSystemic manifestation

Secondary Headache Paracranial Secondary Headache Paracranial StructureStructure

Areas responsible for pain: Sinus, Eye, Areas responsible for pain: Sinus, Eye, Dental, Ear, Skull and base of skull, Dental, Ear, Skull and base of skull, Vascular, Soft tissue of head and neckVascular, Soft tissue of head and neck

Character of headacheCharacter of headache1. Small focal area of refered pain1. Small focal area of refered pain2. Localized tenderness2. Localized tenderness3. Local symptoms of the affected 3. Local symptoms of the affected

organorgan4. Persistent pain4. Persistent pain

Three Types of HA OnsetsThree Types of HA Onsets1)1) AcuteAcute

• Time: onset w/I – 2 Days ( 3 dys max )Time: onset w/I – 2 Days ( 3 dys max )• Intensity: severeIntensity: severe• ExamplesExamples

2)2) SubacuteSubacute• Time: onset wks-mnths, may be an acute Time: onset wks-mnths, may be an acute

presentationpresentation• Intensity: not as severeIntensity: not as severe• ExamplesExamples

3)3) Chronic/Recurrent Chronic/Recurrent Time: onset usually yearsTime: onset usually years Intensity: variedIntensity: varied ExamplesExamples

History of Presenting History of Presenting ComplaintComplaint

How recent in onset?How recent in onset? Abrupt onset?Abrupt onset? How frequent?How frequent? Episodic or constant?Episodic or constant? How long lasting?How long lasting? Intensity of pain?Intensity of pain? Quality of pain?Quality of pain? Site of pain?Site of pain? Radiation?Radiation? Eye pain?Eye pain? Aura?Aura? Photophobia?Photophobia?

Phonophobia?Phonophobia? Associated vomiting?Associated vomiting? Diurnal variation?Diurnal variation? Snoring?Snoring? Neck stiffness?Neck stiffness? Trigger factors?Trigger factors? Aggravating factors?Aggravating factors? Relieving factors?Relieving factors? Family history?Family history? What does the patient What does the patient

do during headache?do during headache? What medication What medication

used?used?

Physical ExaminationPhysical Examination Fever?Fever? Pulse/BPPulse/BP Neck stiffness?Neck stiffness? Purpuric rash?Purpuric rash? Pupils?Pupils? Neurologic examNeurologic exam GCS scoreGCS score Scalp tenderness?Scalp tenderness? Examine eardrumExamine eardrum

Thickened Thickened temporal arteries?temporal arteries?

Fundoscopy – Fundoscopy – papilloedema?papilloedema?

Sinus tenderness?Sinus tenderness? Cervical Cervical

tenderness/ROM?tenderness/ROM? Obese?Obese? Facial plethora?Facial plethora?

Localization & Localization & Characterization of HACharacterization of HA

Location:Location: Unilateral or Bilateral Unilateral or Bilateral CharacteristicsCharacteristics

Pulsating, Tightness, Dull & Steady, Pulsating, Tightness, Dull & Steady, Sharp/Lancinating, Ice PickSharp/Lancinating, Ice Pick

Associated SymptomsAssociated Symptoms Weight LossWeight Loss Fever/ChillsFever/Chills DyspneaDyspnea Visual DisturbancesVisual Disturbances Nausea/VomitingNausea/Vomiting PhotophobiaPhotophobia

Location of painLocation of pain Forehead : Primary > SecondaryForehead : Primary > Secondary Occipital area : Primary > SecondaryOccipital area : Primary > Secondary Face : Secondary > PrimaryFace : Secondary > Primary Neck : primary = SecondaryNeck : primary = Secondary Unilateral pain: Unilateral pain: - Large area- Large area intracranial structure intracranial structure

( Diffuse )( Diffuse )- Meningeal painMeningeal pain- Increased intracranial pressureIncreased intracranial pressure- Low intracranial pressureLow intracranial pressure- Toxic vascular headacheToxic vascular headache

In Summary…. To what extend should each patient be

evaluated? Absolute clinical indications Worst headache ever Onset associated with exertion Depressed cognition or neurologic deficit on

exam Nuchal signs Deterioration during observation Conservative approach acceptable in

patients Lack the above findings with normal VS

Improvement during observation

InvestigationsInvestigations FBCFBC ESRESR Capillary blood glucoseCapillary blood glucose Plasma Alkaline phosphatasePlasma Alkaline phosphatase Arterial blood gasArterial blood gas Skull radiographSkull radiograph Cervical spine radiographsCervical spine radiographs CT BrainCT Brain Lumbar punctureLumbar puncture CSF manometryCSF manometry MR angiogramMR angiogram Temporal artery biopsyTemporal artery biopsy Sinus radiographsSinus radiographs Sleep studiesSleep studies

Differential DiagnosisDifferential Diagnosis Tension headacheTension headache Cluster headacheCluster headache TraumaTrauma VascularVascular

MigraineMigraineSubarachnoid haemorrhageSubarachnoid haemorrhageArteriovenous Arteriovenous

malformationmalformationSubdural haematomaSubdural haematomaHypertensive Hypertensive

encephalopathyencephalopathyTemporal arteritisTemporal arteritis

Skull diseaseSkull diseaseSinusitisSinusitisSkull fractureSkull fractureMastoiditisMastoiditisPaget’s disease of bonePaget’s disease of bone

Acute mountain sicknessAcute mountain sickness

MedicationsMedicationsNitratesNitratesSildenafil Sildenafil OCPOCP

MetabolicMetabolicSepsisSepsisCOCO2 2 retentionretentionHypoxiaHypoxiaObstructive sleep Obstructive sleep

apnoeaapnoeaHypoglycaemiaHypoglycaemiaAlcohol withdrawalAlcohol withdrawal

Raised intracranial pressureRaised intracranial pressureCerebral tumourCerebral tumour

MeningitisMeningitis Otitis mediaOtitis media Acute angle-closure Acute angle-closure

glaucomaglaucoma HyperviscosityHyperviscosity

Tension-Type HeadacheTension-Type Headache Most common headache syndromeMost common headache syndrome Episodic Episodic << 15 days per month 15 days per month Chronic Chronic >> 15 days per month (2% of 15 days per month (2% of

population) population) Lifetime prevalence of 88% (F) and Lifetime prevalence of 88% (F) and

69% (M)69% (M) Highest prevalence in women, age 30-Highest prevalence in women, age 30-

39, with higher education39, with higher education

TTH - CharacteristicsTTH - Characteristics

30 minutes to 7 days30 minutes to 7 days Dull, persistent HA ( Pressing or Dull, persistent HA ( Pressing or

tightening )tightening ) Mild to moderate pain (Usually NOT Mild to moderate pain (Usually NOT

debilitating and intensity may debilitating and intensity may fluctuate throughout the day )fluctuate throughout the day )

Variable location, often bilateralVariable location, often bilateral Nausea and vomiting rareNausea and vomiting rare

TTH - CharacteristicsTTH - Characteristics Often occur during or after stressOften occur during or after stress Skeletal muscle overcontraction, Skeletal muscle overcontraction,

depression, and nausea may accompany depression, and nausea may accompany HAHA

No prodromeNo prodrome May be associated with depression, May be associated with depression,

repressed hostility, resentmentrepressed hostility, resentment Patients with recurrent TTHA may not Patients with recurrent TTHA may not

experience more stressful events than experience more stressful events than those without TTHA, but may have less those without TTHA, but may have less effective coping strategieseffective coping strategies

TTH - TreatmentTTH - Treatment

Stress Stress managementmanagement BiofeedbackBiofeedback Stress reductionStress reduction Posture correctionPosture correction

Medication rarely Medication rarely needed in ETTHneeded in ETTH BenzodiazepinesBenzodiazepines amitriptylineamitriptyline

CTTHCTTH AbortiveAbortive

NSAIDsNSAIDs ASA-caffeine-ASA-caffeine-

butalbitalbutalbital PhenacetinPhenacetin

PreventativePreventative AntidepressantsAntidepressants Muscle relaxantsMuscle relaxants NSAIDsNSAIDs

MigraineMigraine 17% of females, 6% of males ( F > M )17% of females, 6% of males ( F > M ) Moderate to severe painModerate to severe pain Unilateral, pulsatingUnilateral, pulsating 4 to 72 hours4 to 72 hours

Typically - Unilateral (may be bilateral), Typically - Unilateral (may be bilateral), pulsating (progresses from dull ache to pulsating (progresses from dull ache to pulsating pain)pulsating pain)

Moderate or severe intensity, aggravated by Moderate or severe intensity, aggravated by routine physical activity and associated w/ routine physical activity and associated w/ nausea, photo & phonophobia nausea, photo & phonophobia

Subclassified to Aura or No AuraSubclassified to Aura or No Aura

AuraAura Occurs with Migraine about 30% of casesOccurs with Migraine about 30% of cases Complex of focal neurologic symptoms Complex of focal neurologic symptoms

alterations in vision or sensationalterations in vision or sensation Usually begin 10 minutes to 1 hr prior to onset of head Usually begin 10 minutes to 1 hr prior to onset of head

pain pain Light headedness and photophopsia (unformed flashes Light headedness and photophopsia (unformed flashes

of light) of light) Scotoma- Isolated area within the visual field where Scotoma- Isolated area within the visual field where

vision is absent (30% of cases)vision is absent (30% of cases) Scintillating scotoma- looks like silvery kaliedoscope Scintillating scotoma- looks like silvery kaliedoscope

Migraines - CausationMigraines - Causation

Sterile Sterile inflammation of inflammation of intracranial intracranial vessels - vessels - trigeminovascular trigeminovascular systemsystem

Serotonin (5-Serotonin (5-hydroxytryptaminehydroxytryptamine) receptors) receptors

Triggering factorsTriggering factors StressStress MensesMenses OCPOCP InfectionInfection TraumaTrauma VasodilatorsVasodilators Aged cheesesAged cheeses

Migraine - TreatmentMigraine - Treatment

AbortiveAbortive 5-5-

hydroxytryptaminhydroxytryptamine receptor e receptor agonistsagonists

ImitrexImitrex Oral, SQ, nasal Oral, SQ, nasal

sprayspray MaxaltMaxalt ZomigZomig AmergeAmerge

ErgotaminErgotaminee

ButorphanButorphanolol

MidrinMidrin NSAIDsNSAIDs LidocaineLidocaine

Migraine - TreatmentMigraine - Treatment

SymptomaticSymptomatic ProchlorperazineProchlorperazine DihydroergotamineDihydroergotamine ChlorpromazineChlorpromazine HaloperidolHaloperidol LorazepamLorazepam

BOTOX?BOTOX?

PreventativePreventative AntidepressantsAntidepressants Bellergal Bellergal

(ergotamine)(ergotamine) NSAIDsNSAIDs -blockers-blockers Calcium channel Calcium channel

blockersblockers

Cluster HeadacheCluster Headache

Cluster Headaches (HA)Cluster Headaches (HA) M>F (5:1), usually 20-40 years old M>F (5:1), usually 20-40 years old Recurrent HA separated by periods of Recurrent HA separated by periods of

remission (months to yrs)remission (months to yrs) During the “cluster”time -HA occur During the “cluster”time -HA occur >>1/day1/day Unilateral, occurs behind eye, reaches MAX Unilateral, occurs behind eye, reaches MAX

intensity over few minutes, lasts for intensity over few minutes, lasts for <<3hrs 3hrs Unilateral lacrimation, rhinorrhea, and facial Unilateral lacrimation, rhinorrhea, and facial

flushing may accompany clusterflushing may accompany cluster HA is commonly precipitated by alcohol, HA is commonly precipitated by alcohol,

stress, missed meals and vasodilating drugs - stress, missed meals and vasodilating drugs - (Avoid during cluster period)(Avoid during cluster period)

No AuraNo Aura

Cluster HeadacheCluster Headache

Intensely severe Intensely severe painpain

UnilateralUnilateral PeriorbitalPeriorbital 15 to 180 minutes15 to 180 minutes Nausea and Nausea and

vomiting vomiting uncommonuncommon

No auraNo aura

Alcohol intoleranceAlcohol intolerance Male predominanceMale predominance Autonomic Autonomic

hyperactivityhyperactivity Conjunctival injectionConjunctival injection LacrimationLacrimation Nasal congestionNasal congestion PtosisPtosis

Cluster HeadacheCluster Headache

Episodic Episodic Two episodes per Two episodes per

year to one every year to one every two or more years two or more years 7 days to a year7 days to a year

ChronicChronic Remission phases Remission phases

less than 14 daysless than 14 days Prolonged Prolonged

remission absent remission absent for for >> one year one year

Cluster Headache - Cluster Headache - TreatmentTreatment

PreventativePreventative Calcium channel Calcium channel

blockersblockers BellergalBellergal LithiumLithium MethysergideMethysergide SteroidsSteroids ValproateValproate AntihistaminesAntihistamines

AbortiveAbortive OxygenOxygen 5-HT receptor 5-HT receptor

agonistsagonists Intranasal lidocaineIntranasal lidocaine

Chronic HeadachesChronic Headaches Analgesic/Caffeine Withdrawal Analgesic/Caffeine Withdrawal

HeadachesHeadaches Associated with intake of high doses Associated with intake of high doses

of caffeine and/or analgesics of caffeine and/or analgesics PathophysiologyPathophysiology

Serum level dropSerum level drop Clinical PresentationClinical Presentation

ConstantConstant AtypicalAtypical AfternoonAfternoon Hx keyHx key

Chronic Daily HeadacheChronic Daily Headache

6 days a week for 6 months6 days a week for 6 months Bilateral, frontal or occipitalBilateral, frontal or occipital Non-throbbingNon-throbbing Moderately severeModerately severe Due to overuse of analgesicsDue to overuse of analgesics ? Transformation of migraine or TTH? Transformation of migraine or TTH

CDH - TreatmentCDH - Treatment

Patient understandingPatient understanding Remove causative medicationRemove causative medication Avoid substitutionAvoid substitution AntidepressantsAntidepressants Adjuvant therapyAdjuvant therapy Treatment of withdrawalTreatment of withdrawal

Acute Headache (HA)Acute Headache (HA) May be symptomatic of May be symptomatic of

Subarachnoid hemorrhage (SAH), stroke, Subarachnoid hemorrhage (SAH), stroke, Meningitis, Intracranial mass lesion (e.g. Meningitis, Intracranial mass lesion (e.g. brain tumor, hematoma, abscess)brain tumor, hematoma, abscess)

SAH headache - “worst HA of my life”, SAH headache - “worst HA of my life”, may also see alteration in mental status may also see alteration in mental status and focal neurologic signsand focal neurologic signs

Meningitis HA - usually bilateral, Meningitis HA - usually bilateral, develops over hrs to days, may also see develops over hrs to days, may also see fever, photophobia, positive meningeal fever, photophobia, positive meningeal signs (Kernigs’s Brudzinski)signs (Kernigs’s Brudzinski)

Headaches of Acute OnsetHeadaches of Acute Onset Subarachnoid Hemorrhage (SAH)Subarachnoid Hemorrhage (SAH)

BackgroundBackground Aneurysms & AVM’sAneurysms & AVM’s

Clinical PresentationClinical Presentation Signs & SymptomsSigns & Symptoms

NEW, NEW, Sudden onset, LOC frequent, Vomiting & stiff Sudden onset, LOC frequent, Vomiting & stiff neckneck

Lab FindingsLab Findings CT & Lumbar PunctureCT & Lumbar Puncture

ComplicationsComplications Reoccurnance doubles mortality rateReoccurnance doubles mortality rate

PrognosisPrognosis 20% DOA20% DOA 25% die from initial bleed; 20% from reoccurance25% die from initial bleed; 20% from reoccurance SurvivalSurvival

Clinical Features of SAHClinical Features of SAH

Sudden Sudden “thunderclap” “thunderclap” headacheheadache

Can be associated Can be associated with exertional with exertional activitiesactivities

Nausea/vomitng-Nausea/vomitng-75%75%

Neck stiffness-25%Neck stiffness-25% Seizures-10%Seizures-10%

Meningismus-50%Meningismus-50% Subhyloid or Subhyloid or

retinal retinal hemorrhageshemorrhages

Oculomotor nerve Oculomotor nerve pulsy with dilated pulsy with dilated pupilpupil

Restlessness and Restlessness and altered level of altered level of consciousnessconsciousness

Headaches of Acute OnsetHeadaches of Acute Onset Infectious HeadachesInfectious Headaches

BackgroundBackground Meningitis and EncephalitisMeningitis and Encephalitis

Clinical PresentationClinical Presentation Classic: Classic: HA, Fever, Stiff Neck, & Altered Level HA, Fever, Stiff Neck, & Altered Level

of Consciousnessof Consciousness S/S can vary depending on ageS/S can vary depending on age

Neonate, Children & Adults, Adults, Older generationNeonate, Children & Adults, Adults, Older generation Headache PresentationHeadache Presentation

Diagnosis & Management:Diagnosis & Management: CSF analysisCSF analysis NeurologistNeurologist

Intracranial InfectionIntracranial Infection HA is common HA is common

complaint in complaint in meningitis, brain meningitis, brain abscess, encephalitis abscess, encephalitis or AIDSor AIDS

Diagnostic tools Diagnostic tools include CT of head include CT of head and LPand LP

MeningitiMeningitiss

Severe HA, Severe HA, nuchal rigidity, nuchal rigidity, meningismusmeningismus

EncephaliEncephalitistis

HA, confusion, HA, confusion, fever, change of fever, change of mental status, mental status, seizuresseizures

Brain Brain AbscessAbscess

HA, vomiting, HA, vomiting, focal focal neurological neurological signs, signs, depressed level depressed level of of consciousnessconsciousness

AIDSAIDS Toxoplasmosis, Toxoplasmosis, CMV, CMV, CryptococcusCryptococcus

Headaches of Acute OnsetHeadaches of Acute Onset Headaches Following Lumbar PunctureHeadaches Following Lumbar Puncture

BackgroundBackground Low Pressure HeadacheLow Pressure Headache MCMC is lumbar puncture is lumbar puncture

Headache PresentationHeadache Presentation Clinical Pearl: Clinical Pearl:

Worse with sitting or standingWorse with sitting or standing Vertex or occipital, pulling, steadyVertex or occipital, pulling, steady Usually resolve spontaneously Usually resolve spontaneously (Blood patch for (Blood patch for

resistant cases )resistant cases ) The more severe the HA, the more frequent it is assoc. w/ The more severe the HA, the more frequent it is assoc. w/

vertigo, nausea/vomiting, & tinnitusvertigo, nausea/vomiting, & tinnitus The longer the pt is upright, the longer it takes for the HA to The longer the pt is upright, the longer it takes for the HA to

subsidesubside

Headaches of Acute OnsetHeadaches of Acute Onset Coital HeadachesCoital Headaches

Three Types: Types I, II, IIIThree Types: Types I, II, III Clinical PresentationClinical Presentation

Type I: Type I: Occurs as sexual excitement incOccurs as sexual excitement inc Dull ache, Occipital or Diffuse, Sever @ orgasmDull ache, Occipital or Diffuse, Sever @ orgasm

Type II:Type II: AKA Vascular or Explosive AKA Vascular or Explosive Occurs @ orgasm Occurs @ orgasm Severe, throbbing, frontal or occipital, min-hrsSevere, throbbing, frontal or occipital, min-hrs Clinical PearlClinical Pearl

Type III:Type III: Occurs after coitus resembling a low pressure HAOccurs after coitus resembling a low pressure HA

Subacute Headache (HA)Subacute Headache (HA)

May be symptomatic ofMay be symptomatic of Increased intracranial pressure Increased intracranial pressure Intracranial mass lesion Intracranial mass lesion Temporal arteritisTemporal arteritis Sinusitis orSinusitis or Trigeminal neuralgiaTrigeminal neuralgia

Temporal Arteritis = Giant Cell Temporal Arteritis = Giant Cell ArteritisArteritis

Classic presentation is a 50 plus year old female Classic presentation is a 50 plus year old female with unilateral HA that is causing unilateral with unilateral HA that is causing unilateral visual disturbance. Intensity is moderate to visual disturbance. Intensity is moderate to severe and will be insidious in onset.severe and will be insidious in onset.

Moderate to severe, unilateral painModerate to severe, unilateral pain Patients over 65Patients over 65 Tortuous scalp vesselsTortuous scalp vessels ESR elevatedESR elevated Biopsy for definitive diagnosisBiopsy for definitive diagnosis Treat with steroidsTreat with steroids Untreated complicated by vision lossUntreated complicated by vision loss

Other findings:Other findings: Jaw claudicationJaw claudication Bruits over temporal arteryBruits over temporal artery BlindnessBlindness May be accompanied by polymyalgia rheumaticaMay be accompanied by polymyalgia rheumatica..

Trigeminal Neuralgia= Tic Trigeminal Neuralgia= Tic DouloureuxDouloureux

Paroxysmal pain – seconds to Paroxysmal pain – seconds to < 2 < 2 minmin

Distributed along 5Distributed along 5thth cranial nerve cranial nerve ( V2 & V3 )( V2 & V3 )

Asymptomatic between attacksAsymptomatic between attacks Trigger points ( Trigger points ( triggered by triggered by

talking, chewing, shaving)talking, chewing, shaving) Intense burningIntense burning Face may distort = ticFace may distort = tic

>>40, F>M, 40, F>M, Characterized by sudden intense Characterized by sudden intense

pain that recurs paroxysmally, pain that recurs paroxysmally, occurs along the second or third occurs along the second or third division of trigeminal nerve and division of trigeminal nerve and lasts only moments, lasts only moments,

Trigeminal Neuralgia - Trigeminal Neuralgia - TreatmentTreatment

CarbamazepineCarbamazepine GabapentinGabapentin BaclofenBaclofen PhenytoinPhenytoin ValproateValproate ChlorphenesinChlorphenesin

AdjuvantAdjuvant TCAsTCAs NSAIDsNSAIDs Surgery for Surgery for

refractory casesrefractory cases

Herpes zoster Facial painHerpes zoster Facial pain Herpetic eruption in territory of nerve in Herpetic eruption in territory of nerve in

distribution of nerve (10 – 15% the trigeminal distribution of nerve (10 – 15% the trigeminal ganglion and 80% the ophthalmic division)ganglion and 80% the ophthalmic division)

Geniculate ganglion causes eruption in the EAM.Geniculate ganglion causes eruption in the EAM. Upper cervical nerve roots affects soft palate.Upper cervical nerve roots affects soft palate. Pain precedes herpetic eruption by <7 daysPain precedes herpetic eruption by <7 days Pain resolves within 3 monthsPain resolves within 3 months Postherpetic NeuralgiaPostherpetic Neuralgia

Neuralgia of the trigeminal nerve following herpes Neuralgia of the trigeminal nerve following herpes infection. infection.

Most commonly affects V1 as well as V2 & V3Most commonly affects V1 as well as V2 & V3 This is the KEY difference between post-herpetic and This is the KEY difference between post-herpetic and

trigeminal neuralgia.trigeminal neuralgia.

Post-Herpetic NeuralgiaPost-Herpetic Neuralgia

Persistent neuritic pain for Persistent neuritic pain for > 2 > 2 months after acute eruptionmonths after acute eruption

TreatmentTreatment AnticonvulsantsAnticonvulsants TCAsTCAs BaclofenBaclofen

Glossopharyngeal Glossopharyngeal NeuralgiaNeuralgia

Severe (Unilateral pain )Severe (Unilateral pain ) Transient stabbing pain in the ear, Transient stabbing pain in the ear,

base of tongue, tonsillar fossa, or base of tongue, tonsillar fossa, or beneath the angle of the jaw. beneath the angle of the jaw. (auricular and pharyngeal branches of (auricular and pharyngeal branches of the vagus nerve and glossopharyngeal the vagus nerve and glossopharyngeal nerve)nerve)

Evoked by swallowing, talking, or Evoked by swallowing, talking, or coughingcoughing

Treatment as for Trigeminal NeuralgiaTreatment as for Trigeminal Neuralgia

Occipital NeuralgiaOccipital Neuralgia Paroxysmal jabbing pain in the Paroxysmal jabbing pain in the

distribution of the greater and lesser distribution of the greater and lesser occipital nerves or the third occipital occipital nerves or the third occipital nervenerve

Sometimes diminished sensationSometimes diminished sensation Pain is eased by local anaesthetic blockPain is eased by local anaesthetic block Must be distinguished from occipital Must be distinguished from occipital

referral of pain from the atlantoaxial or referral of pain from the atlantoaxial or upper zygoapophyseal joint or trigger upper zygoapophyseal joint or trigger points in suboccipital musclespoints in suboccipital muscles

Posttraumatic Posttraumatic Headache(PTHA)Headache(PTHA)

Estimated that 30-50% Estimated that 30-50% of 2 million closed head of 2 million closed head injuries per year injuries per year develop headache.develop headache.

Associated with Associated with dizziness, fatigue, dizziness, fatigue, insomnia, irritability, insomnia, irritability, memory loss, and memory loss, and difficulty with difficulty with concentration.concentration.

Acute PTHA develops Acute PTHA develops hours to days after hours to days after injury and may last up injury and may last up to 8 weeks.to 8 weeks.

Chronic PTHA may last Chronic PTHA may last from several months from several months to years.to years.

Patients have normal Patients have normal neurological neurological examination and examination and imagingimaging

Treatment for acute Treatment for acute PTHA is symptomatic PTHA is symptomatic while for chronic while for chronic PTHA, adjunct PTHA, adjunct therapies include beta-therapies include beta-blockers and blockers and antidepressants.antidepressants.

Atypical Facial PainAtypical Facial Pain

Diagnosis of exclusionDiagnosis of exclusion ? Psychogenic facial pain? Psychogenic facial pain Location and description Location and description

inconsistentinconsistent Women, 30 – 50 years oldWomen, 30 – 50 years old Usually accompanies psychiatric Usually accompanies psychiatric

diagnosisdiagnosis Treat with antidepressantsTreat with antidepressants

Temporomandibular DisordersTemporomandibular Disorders

SymptomsSymptoms Temporal headacheTemporal headache EaracheEarache Facial painFacial pain TrismusTrismus Joint noiseJoint noise

60% spontaneous60% spontaneous Tenderness to palpationTenderness to palpation Pain with movementPain with movement Audible clickAudible click

Degenerative Joint Degenerative Joint DiseaseDisease

Pain with joint movementPain with joint movement Crepitus over jointCrepitus over joint Flattened condyleFlattened condyle Osteophyte formationOsteophyte formation

Myofascial PainMyofascial Pain

Most common 60% - 70%Most common 60% - 70% Muscle pain dominatesMuscle pain dominates Tenderness to palpation of Tenderness to palpation of

masticatory musclesmasticatory muscles

TMD - TreatmentTMD - Treatment

NSAIDsNSAIDs Physical therapyPhysical therapy BiofeedbackBiofeedback Trigger point injectionTrigger point injection BenzodiazepinesBenzodiazepines TCAs or SSRIs for chronic muscle TCAs or SSRIs for chronic muscle

painpain

Pseudotumor CerebriPseudotumor Cerebri

Intermittent headacheIntermittent headache Variable intensityVariable intensity Normal exam except papilledemaNormal exam except papilledema Normal imagingNormal imaging CSF pressures CSF pressures > 200 cm H> 200 cm H22OO

Pseudotumor Cerebri - Pseudotumor Cerebri - Associated HistoryAssociated History

Mastoid or ear Mastoid or ear infectioninfection

Menstrual Menstrual irregularityirregularity

Steroid exposureSteroid exposure Retro-orbital or Retro-orbital or

vertex headachevertex headache

Vision fluctuationVision fluctuation Unilateral or Unilateral or

bilateral tinnitusbilateral tinnitus Constriction of Constriction of

visual fieldsvisual fields Weight gainWeight gain

Idiopathic Intracranial Idiopathic Intracranial Hypertension(IIP)Hypertension(IIP)

TreatmentTreatment

-Stop offending med-Stop offending med

-Lower CSF production -Lower CSF production with acetazolomide with acetazolomide andand furosemide. furosemide.

-Steroids-Steroids

-Repeat LPs-Repeat LPs

-Ventricular shunt if -Ventricular shunt if with impending with impending visual loss.visual loss.

Diagnostic Criteria for Diagnostic Criteria for IIPIIP

Increased intracranial Increased intracranial pressure(>200mmHg) pressure(>200mmHg) measured by lumbar measured by lumbar puncturepuncture

Signs Signs andand symptoms of symptoms of increased ICP, without increased ICP, without localizing signs localizing signs

No mass lesions or No mass lesions or hydrocephalus on imaginghydrocephalus on imaging

Normal or low CSF proteinNormal or low CSF protein

No clinical or neuroimaging No clinical or neuroimaging suspicion of venous sinus suspicion of venous sinus thrombosisthrombosis

Mass Lesion - Brain TumorMass Lesion - Brain Tumor Children - 75% InfratentorialChildren - 75% Infratentorial Adults - 75% SupratentorialAdults - 75% Supratentorial Metastatic tumor most common mid-lifeMetastatic tumor most common mid-life Symptoms due to increased intracerebral Symptoms due to increased intracerebral

pressure, tissue destruction, irritationpressure, tissue destruction, irritation Depends on growth rate and locationDepends on growth rate and location Headache ( 30 % ) - steady, non-throbbing, Headache ( 30 % ) - steady, non-throbbing,

dull, worse in AM. May be intermittent dull, worse in AM. May be intermittent initially.initially.

Headache worse with bending over, Valsalva Headache worse with bending over, Valsalva maneuversmaneuvers

Hx of IV drug abuse - abscessHx of IV drug abuse - abscess

Subdural HematomaSubdural Hematoma

History of traumaHistory of trauma Fluctuating level of consciousnessFluctuating level of consciousness Pain lateralizedPain lateralized Tenderness to percussion over Tenderness to percussion over

hematomahematoma Trauma may be remote in chronic Trauma may be remote in chronic

SDHSDH

HypertensionHypertension

Usually with diastolic pressures Usually with diastolic pressures > > 115 mm Hg115 mm Hg

ThrobbingThrobbing NauseaNausea

Sinus HeadacheSinus Headache

Acute sinusitis acceptedAcute sinusitis accepted Chronic sinusitis controversialChronic sinusitis controversial Constant, dull, achingConstant, dull, aching Worsened with stooping or leaning Worsened with stooping or leaning

forwardforward Referred pain possibleReferred pain possible

“ “ RED FLAG “ RED FLAG “ HeadachesHeadaches

Headache with altered mental statusHeadache with altered mental status Headache with focal neurological Headache with focal neurological

findingsfindings Headache with papillidemaHeadache with papillidema Headache with meningeal signsHeadache with meningeal signs The “worst headache of life”The “worst headache of life” Headache in the patient with AIDSHeadache in the patient with AIDS

ConclusionConclusion

Headache & facial pain are common Headache & facial pain are common complaintscomplaints

History most important in making History most important in making accurate diagnosisaccurate diagnosis

Recognize psychological aspects of Recognize psychological aspects of painpain