Headache and Facial painHeadache and Facial pain

Dr. Abdulrahman Hagr MBBS FRCS(c)Dr. Abdulrahman Hagr MBBS FRCS(c)Assistant Professor King Saud University Assistant Professor King Saud University

Otolaryngology ConsultantOtolaryngology ConsultantOtologist, Neurotologist & Skull Base Otologist, Neurotologist & Skull Base

SurgeonSurgeonKing Abdulaziz HospitalKing Abdulaziz Hospital

Headache and Facial painHeadache and Facial pain

Dr. Abdulrahman Hagr MBBS FRCS(c)Dr. Abdulrahman Hagr MBBS FRCS(c)Assistant Professor King Saud University Assistant Professor King Saud University

Otolaryngology ConsultantOtolaryngology ConsultantOtologist, Neurotologist & Skull Base Otologist, Neurotologist & Skull Base

SurgeonSurgeonKing Abdulaziz HospitalKing Abdulaziz Hospital

Epidemiology

• 75% of adults have at least one headache/year

• 10% will seek physician evaluation

• 10% have emergent secondary cause

Headache ClassificationHeadache Classification

• Primary v Secondary

• Paroxysmal v Chronic

• Episodic v Recurrent

• Mild to moderate v Moderate to severe

History

Headache history• Onset

• Site

• Character

• Duration

• Frequency

• Diurnal pattern

• Associated symptoms

• Aggravating factors

• Relieving factors

• Treatment

• Ideas

Headache pattern

• Acute

• Intermittent

• Chronic

History• Where does it hurt?

– Unilateral/bilateral– Frontal/occipital/facial

• What is the character of the pain?– Pulsatile– Steady– Shocklike– Tightness

HistoryWhat other symptoms do you experience?

• Nausea• Vomiting• LOC• Flushing• Lacrimation• Drop attack• Neck stiffness• Photophobia• Dizziness

Physical Exam

Physical Exam• Vital signs

– fever, hypertension, hypoxia• Head/face

– trauma, bruits, tenderness• Eyes

– conjunctiva, cornea, pupils, fundi:papilledema• Ears

– OM or hemotympanum• Mouth

– Teeth, TMJ

Physical Exam• Neck

– pain/stiffness/tenderness– Carotid and/or vertebral bruits

• Skin– rash

• Neurologic– Mental status– Pupils, EOM, Visual fields– Focal deficits– Horner's syndrome– Ataxia

Diagnostic Alarms

• Onset after age 50

• Sudden onset

• Increased frequency and severity

• New onset with risk factors for HIV or cancer

• Associated with systemic illness (fever, meningismus, rash)

• Altered consciousness or focal neurologic deficits

• Papilledema

• Significant trauma

Diagnostic Studies

Diagnostic Studies• Computerized tomography

– Hemorrhage, tumor, abscess, AVM

• Lumbar puncture

– Hemorrhage, infection, increased CSF pressure

• Limited indications for MRI, MRA, or Angiography

• Laboratory studies based on suspected etiologies

– ESR: Temporal arteritis

– Carboxy-hemoglobin: Carbon monoxide

Primary Headache

Migraine

TensionCluster

Tension Headache• 10+ episodes

• 30 min- 7 days

• 2 of the following• Bilateral

• Non-pulsating pressure

• Mild/moderate intensity

• Unrelated to activity

• Both of the following• No nausea or vomiting

• Either one of photophobia or phonophobia

Migraine Without Aura At least 5 attacks Duration

Headache attacks lasting 4 hours to 3 days (untreated). Pain characteristics (at least 2+)

Pulsating quality Limited Activity Unilateral location Stairs Aggravation

Associated symptoms (at least 1) Nausea, vomiting, or both Photophobia or phonophobia

H&P and Dx tests do not suggest underlying disease (0)

5, 4, 3, 2+, 1 & 0

Migraine With AuraAura characertistics (At least 3 )

1. One or more aura symptoms Fully reversible

Indicating focal cerebral cortical or brain-stem dysfunction

2. At least 1 aura symptom develops gradually over >4 minutes or 2 or more symptoms occur in succession

3. Headache begins within 60 minutes of aura onset

4. No single aura symptom lasts > 60 minutes

Migraine TriggersMigraine Triggers

• Sleep deprivation/excess

• Caffeine ingestion or caffeine withdrawal

• Fasting

• Sex hormones

• Most migraines have no trigger

• Strong familial pattern

Cluster Headache

• Rare, 0.4% population

• Lasting 15-180 minutes

• Severe

• Unilateral, orbital or temporal pain• 1 every other day to 8/day (Cluster )

• Secondary to trigeminal nerve dysfunction

Cluster Headache

Associated with

• Conjunctival injection

• Lacrimation

• Nasal congestion

• Rhinorrhea

• Miosis,

• Ptosis

Treatment of Primary Headache

Tension Oral Analgesics (NSAIDS, Acetaminophen)

Migraine NSAIDS Reglan or compazine (10 mg IV ) Serotonin agonists Sumitriptan Narcotics IV or IM

Cluster 100% oxygen Intranasal lidocaine ? NSAIDS Migraine specific therapies

Red Flags for Headache

• Sudden Onset: – SAH

– AVM

– Mass lesion

• Worsening pattern: – Mass

– SDH

– Medication overuse

Red Flags for Headache• Focal neuro signs:

– Mass lesion

– AVM

– Collagen vascular disease

– CVA

• Trigger with cough, exertion, valsalva:– SAH

– Mass

– Sinusitis

Red Flags for Headache

• Headache with fever, stiff neck or rash: – Meningitis

– Encephalitis

– Systemis infection

– Collagen vascular disease

– Arteritis

Headache ClassificationCritical Secondary

• Vascular– Hemorrhage– Stroke– Cavernous Sinus thrombosis– AVM– Temporal Arteritis– Carotid or Vertebral Artery

Dissection

• CNS Infection

• Tumor

Headache Classification

Critical Secondary (cont)

• Endocrine

• Metabolic

• Non-CNS Infections

• Opthalmic

• Drug Related

• Toxic

Secondary Headache Temporal arteritis

Mass lesions

Tumor, abscess, arteriovenous malformation

Metabolic

Hypoglycemia, fever, hypothyroid, anemia

Glaucoma

Secondary Headache

Trigeminal Neuralgia

Post-concussion syndrome

Sinusitis without complication

Post-lumbar puncture

Diet

Medications

Fatigue, postexertion, postcoital

• Tear in – Middle meningeal artery – Dural sinus rarely

• Direct trauma with – LOC Lucid interval Coma

• Lethargy, vomiting, ipsilateral dilated pupil (herniation)

Epidural Hematoma

Subdural Hematoma• Hematoma between dura mater and

subarachnoid

• History of – Falls

– Head trauma

– Elderly

– Anticoagulation

Subdural Hematoma• Suspect

– Bruise – Scalp laceration – Lethargy– Vomiting– Ipsilateral dilated pupil

• Treatment: – Support ABCs– Definitive treatment is neurosurgical evacuation

Subarachnoid Hemorrhage• 1/10,000 in U.S.• Young, median age 50 • 50% mortality at 6 months• 50% with initially normal exam, vitals, absence of

neck stiffness• Caused by anneurysm or AVM rupture• Diagnosis: CT detects 93% in 24hr• Treatment: support ABCs, definitive treatment is

coiling or clipping

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Stroke• 80% ischemic

• Hemorrhagic

– HTN, elderly, prior CVA, bleeding diathesis,

vascular malformation, cocaine use

• Embolus

– A-fib, Valve replacement, recent MI, HTN,

CAD, DM

AssessmentAssessment• Level of Consciousness• Vision (fields and eye movement)• Motor (strength, pronator drift)• Cerebellar function (gait, finger to nose,….)• Sensation• Language

– Dysarthria: inability to articulate– Aphasia: defect in language processing

• Cranial Nerve

Temporal ArteritisTemporal Arteritis• 20 per 100,000

• > 50 Y

• Women>men

• Risk for blindness if untreated

• Dx ESR, Biopsy for definitive diagnosis,

• Treatment with steroids

Temporal ArteritisTemporal ArteritisAutoimmune Vasculitis characterized by• Temporal headache• Visual disturbance (amaurosis fugax)• Claudication (masseter, temporalis tongue)• Scalp tenderness• Pulsating temporal artery (absent late stage)• Decreased visual acuity• Weakness• Weight loss

Carotid or Vertebral Dissection

• Characterized by– Headache

– Vertigo

– Unilateral Horner Syndrome

• Suspect if sudden neck rotation or extension urgent imaging and neurosurgery

CNS Infection• Meningitis: inflammation of arachnoid and pia

mater caused by bacteria, virus or fungi

• Headache, stiff neck, fever, chills, photophobia, confusion, phonophobia, nausea, vomiting, seizures (more common in children), rash, petechiae, Brudzinski or Kernig signs

• Protect yourself first– Fever + headache = mask

Brudzinski’s and Kernig’s signsBoth signs of meningeal irritation

•Kernig’s sign:•Resistance to extension of the leg while the hip is flexed

•Brudzinski’s sign:•Flexion of the hips and knees in response to neck flexion

Non-CNS Infection

• Viral syndromes• Bacteremia• Fever may often cause

generalized headache

Opthalmic Glaucoma• Acute angle closure: obstruction of aqueous humor outflow leading to

increased intraocular pressure and possible blindness

• Associated with – Sudden onset painful vision loss – Nausea, vomiting– Somnolence

• Exam with – Decreased vision– Conjunctival injection, hazy cornea, – Dilated unreactive pupil

Opthalmic• Iritis: inflamation of the Iris

– Risk if sarcoid, STDs, collagen vascular dz– Blurred vision, deep eye pain, photophobia, red eye– Exam with conjunctival injection, cell and flare

• Optic Neuritis

• Needs emergent opthomology referral

Non-CNS Infection

Sinusitis• Fever, malaise, • Anosmia• Toothache• Purulent discharge• Postnasal drip• Sore throat, facial pain/pressure

Non-CNS Infection

Sinusitis Treatment• Antibiotics• Nasal decongestants• Antipyretics for fever and analgesia

Non-CNS Infections

Dental Infections (Caries and/or periapical abscess)

• Toothache• Jaw pain• Earache• Tooth tender to percussion

Non-CNS Infections

Treatment involves – Covering exposed tooth– Analgesia– Abscess drainage

Ear Infections

Otitis Media– middle ear infection • Ear pain/fullness• Decreased hearing• Vertigo• Fever

Treatment with • Antibiotics• Antipyretics

Ear InfectionsOtitis Externa– External Ear infection

– Itching– Decreased hearing– Fever– Tender external ear.

Treated with – Antibiotic drops. – Caution if diabetic for malignant OE

Raised pressure headache• Non-specific• Aggravated by

– Bending– Coughing– Sneezing– Waking

• Associated with N&V, visual blurring• Papilloedema

CasesCases

Case #1Case #1CHARACTER THROBBING

QUALITY UNILATERAL

SEVERITY DISABLING

ONSET MAXIMAL IN 1 HOUR

DURATION HOURS

RELIEF NSAID INADEQUATE

FREQUENCY 2-4 PER WEEK

DIAGNOSIS #1DIAGNOSIS #1

MIGRAINEMIGRAINE

Cases• 2 y M • Fever• Stiff neck• L.O.C• +ve Kernig’s sign

Thanks