Head, neck and facial pain

1. Head, neck and facial pain A pain in the head, face or a pain in the neck?

2. AIMS • TO DISCUSS HEAD, FACE AND NECK PAIN AND THE POSSIBLE CAUSES

3. OBJECTIVES • To consider the innervation of the head and neck region • To understand some of the physiological relationships • To know some of the conditions giving rise to pain

4. INNERVATION OF THE HEAD AND NECK REGION • Trigeminal nerve • Branches from C2, C3, C4 and C5 • Afferent impulses from the Trigeminal and cervical region converge in the 2nd cervical segment of spinal cord

5. RELEVANT NEUROLOGY • Trigeminal nerve and ganglion • Cervical nerves, mainly C2 • Sphenopalatine ganglion • Cutaneous nerve supply

10. Head, face and neck pain • Pain in the face: -Trigeminal or neck • Pain in the head:-supplied by C2 and C3 • Pain in the neck:- supplied by C2-C5 • Pain in or around the ears:-supplied by C2

11. HISTORY • Very important • Ensure it is very detailed • Enquire about the function of all parts of the head and neck • Ensure you understand the time sequence of events and symptoms • Ask about sympathetic symptomatology

12. Site Sort Severity Onset Duration Radiation Associated factors Precipitating factors Relieving factors Red flags (night pain, loss of sensation, symptoms elsewhere) HISTORY

13. EXAMINATION • Full Cranial Nerve examination • Full neurological examination of the neck and arms • Check for trigger points in neck, around occiput, Sternocleidomastoid, Masseters, Pterygoids, Temporalis, behind the ear. Check common acupuncture points

14. CLASSIFICATION OF FACIAL PAIN • Local disease • Neurological disorders • Psychogenic conditions • Referred pain

15. PAIN IN JUST THE FACE • Trigeminal Neuralgia • TMJ pain • Trigeminal autonomic syndromes • Atypical facial pain • Very occasionally a C2 problem • Glossopharyngeal neuralgia • VII/VIII complex (N intermedius)

16. TRIGEMINAL NEURALGIA • Symptom rather than specific disease. • Can be due to a specific lesion which is causing destruction, irritation or demyelination.

17. CAUSES OF TRIGEMINAL NEURALGIA • Idiopathic • Vascular compression. • Tumour. • Aneurysm. • M.S. • Demyelinating peripheral neuropathies.

18. FEATURES • Episodic, recurrent unilateral facial pain. • Lasts a few seconds, occurring many times a day. • V2 > V3 > V1. • Triggers are trivial events. • 2.7:100 000 men and 5.0: 100 000 women. • 50 - 60 years. • Neurology normal.

19. MEDICAL TREATMENT • Gabapentin 1.2g – 1.8g daily • Carbamazepine up to 1000 - 1200mg/day. • Phenytoin. • Baclofen. • Clonazepam. • Valproic Acid.

20. SURGICAL TREATMENT • R.F Trigeminal Ganglion. • Injection of Gylcerol into cistern of Meckel’s Cave. • Microvascular decompression of Trigeminal Nerve. • Peripheral Neurectomy of a branch of Trigeminal Nerve.

21. TMJ PAIN • Pain in the joint and masticatory muscles • Dull ache/ear ache • Radiates to temporal, masseteric, occipital and mastoid areas • Associated with other stress induced syndromes • Females > males

22. The problem • Emotional stress • Muscle hyperactivity • Bruxism • Joint overloading

23. Examination • Tender mandibular condyles and maxillary tuberosities • Tender Temporalis, Masseter and Pterygoid muscles

24. Treatment • Simple analgesia • TCA • Local Anaesthetic injections • Botulium Toxin • Acupuncture

25. MYOFASCIAL PAIN • Associated with tender muscles of the face, head and neck • Can be primary or secondary

26. HISTORY AND EXAMINATION • History is vague and difficult to decipher • Examination reveals multiple trigger points within the facial and neck musculature • Travell shows these trigger points well

27. Treatment • Acupuncture • Physiotherapy • TENS • Local anaesthetic and steroid injections

28. PAIN IN JUST THE NECK • Cervical facets • Cervical discs • Cervical ligaments • Cervical muscles • Sternocleidomastoid and Strap muscles • Has there been any neck trauma?

29. CERVICAL PAIN • Originates from C2 and C3 • May have neck pain • Often have facial pain/head pain • Distribution is C2/C3 • Can involve the Trigeminal region

30. History • Pain on neck movement • Feeling of pressure on their head • Feel as if they cannot support their head

31. Examination • Limited neck movement, usually extension, lateral flexion • Tender cervical muscles • Tender cervical facets

32. Treatment • Physiotherapy • TENS • Acupuncture • Local anaesthetic blocks

33. PAIN IN /AROUND EARS • Parotid gland • Submandibular • Masseter/Pterygoids • Within the ear • From previous surgery (a type of CRPS) • Cervicogenic

34. ATYPICAL FACIAL PAIN • Diagnosis of exclusion • Other pathology has been ruled out

35. Treatment • Reassurance • CBT • ACP/Tens • Baclofen • Gabapentin • Amitriptyline

36. HEADACHES • Migraine +/- aura • Tension type • Trigeminal autonomic cephalagias • Medication overuse • Cervicogenic

37. SERIOUS CAUSES OF HEADACHE • Intracranial tumours • Meningitis • Subarachnoid Haemorrage • Giant cell arteritis • Primary closed angel glaucoma • Idiopathic intracranial hypertension • Carbon Monoxide poisoning

38. SUMMARY • Anatomy • Physiological links • Common syndromes

39. THANK YOU

41. Useful references • NICE guidelines on Neuropathic pain • UHL guidelines on neuropathic pain (intranet LMSG web site and inpatient web site) • BASH guidelines. www.bash.org.uk

42. ANATOMY • Head and face supplied by Trigeminal nerve and the first 3 cervical nerves • Afferent impulses from the Trigeminal and cervical region converge in the 2nd cervical segment of spinal cord

44. PAIN SYNDROMES • TRIGEMINAL NEURALGIA • TMJ PAIN • ATYPICAL FACIAL PAIN • MYOFASCIAL PAIN • CERVICAL PAIN