Post on 23-Dec-2015
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 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