Headache & Facial Pain

1. Headache & Facial Pain

2. 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 • Pain sensitive structures • Dura of skull base • Cerebral arteries • Venous sinuses • Nerves • Cranial nerves; 5, 9, 10 • Cervical nerves; C2,3 Headache & Facial Pain:

3. Background • Headache is the 4th most common symptom of outpatient visits • 99% of women and 93% of men have had headache during their lifetime • 12.6 % prevalence (18% women, 6.5% men) • Prevalence is highest between age 25 – 55 years • 25% of women and 8% of men have had migraine headache • Approximately 50% remain undiagnosed

4. Headaches: Pathophysiology • Where does the pain arise from? • Scalp • Dura mater • Blood vessels • Cervical & cranial nerves • Blood vessels • Dilate • Become congested  Pain

5. Headache Classification • IHS 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

6. Characters of Primary Headache • Benign, Recurrent • NOT associated with underlying pathology • The headache is the disease • Recurrent attacks • Symptoms free between the attacks • Clinical syndromes • Normal physical examination • No organic causes • Exception: drug-abuse headache • Diagnosis is based on exclusion

7. Characters of Secondary Headache • Sudden, progressive Course • Symptoms persist • Pain select to anatomical lesions • Physical examination usually abnormal • Associated with pathology • May require immediate action

8. Secondary Headache • SAH • Meningitis • Stroke • SOL • Trigeminal Neuralgia • Temporal Arteritis • Hypertension • Benign Intracranial Hypertension • Lumbar Puncture Headache • Sinus Headache

9. Secondary Headache Warning Signs and Signals • Sudden onset • Onset after age 50 years • Systemic signs (fever, myalgias, weight loss) • Systemic disease (Malignancy, AIDS) • Change in headache pattern • Progressive headache with loss of headache-free periods • Change in frequency or severity • Neurologic symptoms or abnormal physical findings • Cognitive changes • Asymmetry

10. Secondary Headache Paracranial Structure Areas responsible for pain: Sinus, Eye, Dental, Ear, Skull and base of skull, Vascular, Soft tissue of head and neck • Character of headache 1. Small focal area of referred pain 2. Localized tenderness 3. Local symptoms of the affected organ 4. Persistent pain

11. How recent in onset? Abrupt onset? How frequent? Episodic or constant? How long lasting? Intensity of pain? Quality of pain? Site of pain? Radiation? Eye pain? Aura? Photophobia? Phonophobia? Associated vomiting? Diurnal variation? Snoring? Neck stiffness? Trigger factors? Aggravating factors? Relieving factors? Family history? What does the patient do during headache? What medication used? History of Presenting Complaint

12. Fever? Pulse/BP Neck stiffness? Purpuric rash? Pupils? Neurologic exam GCS score Scalp tenderness? Examine ear drum Thickened temporal arteries? Fundoscopy – papilloedema? Sinus tenderness? Cervical tenderness Obese? Facial plethora? Physical Examination

13. Localization & Characterization of HA • Location: Unilateral or Bilateral • Characteristics • Pulsating, Tightness, Dull & Steady, Sharp/Lancinating, Ice Pick • Associated Symptoms • Weight Loss • Fever/Chills • Dyspnea • Visual Disturbances • Nausea/Vomiting • Photophobia

14. Location of pain • Forehead : Primary > Secondary • Occipital area : Primary > Secondary • Face : Secondary > Primary • Neck : primary = Secondary • Unilateral pain: - Large area intracranial structure ( Diffuse ) • Meningeal pain • Increased intracranial pressure • Low intracranial pressure • Toxic vascular headache

15. 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

16. Investigations • FBC • ESR • Blood glucose • Plasma Alkaline phosphatase • Arterial blood gas • Skull radiograph • Cervical spine radiographs • CT Brain • Lumbar puncture • CSF manometry • MR angiogram • Temporal artery biopsy • Sinus radiographs • Sleep studies

17. Tension headache Cluster headache Trauma Vascular Migraine Subarachnoid haemorrhage Subdural haematoma Hypertensive encephalopathy Temporal arteritis Skull disease Sinusitis Skull fracture Mastoiditis Paget’s disease of bone Acute mountain sickness Medications Nitrates Sildenafil OCP Metabolic Sepsis CO2 retention Hypoxia Obstructive sleep apnoea Hypoglycaemia Alcohol withdrawal Raised intracranial pressure Cerebral tumour Meningitis Otitis media Acute angle-closure glaucoma Hyperviscosity Differential Diagnosis

18. Tension-Type Headache • Most common headache syndrome • Episodic < 15 days per month • Chronic > 15 days per month (2% of population) • Lifetime prevalence of 88% (F) and 69% (M) • Highest prevalence in women, age 30-39, with higher education

19. TTH - Characteristics • Often occur during or after stress • Skeletal muscle overcontraction, depression, and nausea may accompany HA • No prodrome • 30 minutes to 7 days • Dull, persistent HA ( Pressing or tightening ) • Mild to moderate pain (Usually NOT debilitating and intensity may fluctuate throughout the day ) • Variable location, often bilateral • Nausea and vomiting rare

20. Stress management Biofeedback Stress reduction Posture correction Medication rarely needed Benzodiazepines amitriptyline CTTH Abortive NSAIDs ASA-caffeine Paracetamol Preventative Antidepressants Muscle relaxants NSAIDs TTH - Treatment

21. Migraine • 17% of females, 6% of males ( F > M ) • Moderate to severe pain • 4 to 72 hours • Typically - Unilateral (may be bilateral), pulsating (progresses from dull ache to pulsating pain) • Moderate or severe intensity, aggravated by routine physical activity and associated w/ nausea, photo & phonophobia • Sub classified to Aura or No Aura

22. Sterile inflammation of intracranial vessels - trigeminovascular system Serotonin (5-hydroxytryptamine) receptors Triggering factors Stress Menses OCP Infection Trauma Vasodilators Aged cheeses Migraines - Causation

23. Aura • Occurs with Migraine in about 30% of cases • Complex of focal neurologic symptoms • alterations in vision or sensation • Usually begin 10 minutes to 1 hr prior to onset of head pain • Light headedness and photophopsia (unformed flashes of light) • Scotoma- Isolated area within the visual field where vision is absent (30% of cases) • Scintillating scotoma

24. Abortive 5-hydroxytryptamine receptor agonists Imitrex (Oral, SQ, nasal spray ) Maxalt Zomig Amerge Symptomatic Ergotamine Chlorpromazine Haloperidol Lorazepam NSAIDs Lidocaine Migraine - Treatment • Preventative • Antidepressants • Bellergal (ergotamine) • NSAIDs • -blockers • Calcium channel blockers

25. Cluster Headache

26. Cluster Headaches (HA) • M>F (5:1), usually 20-40 years old • Recurrent HA separated by periods of remission (months to years) • During the “cluster”time -HA occur >1/day • Unilateral, occurs behind eye, reaches maximal intensity over few minutes, lasts for <3hrs • Unilateral lacrimation, rhinorrhea, and facial flushing may accompany cluster • HA is commonly precipitated by alcohol, stress, missed meals and vasodilating drugs - (Avoid during cluster period) • No Aura

27. 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 Cluster Headache

28. Preventative Calcium channel blockers Lithium Methysergide Steroids Valproate Antihistamines Abortive Oxygen 5-HT receptor agonists Intranasal lidocaine Cluster Headache - Treatment

29. Chronic Headaches • Analgesic/Caffeine Withdrawal Headaches • Associated with intake of high doses of caffeine and/or analgesics • Pathophysiology • Serum level drop • Clinical Presentation • Constant • Atypical • After noon • History is the key

30. Acute Headache (HA) • May be symptomatic of • Subarachnoid hemorrhage (SAH), stroke, Meningitis, Intracranial mass lesion (e.g. brain tumor, hematoma, abscess) • SAH headache - “worst HA of my life”, may also see alteration in mental status and focal neurologic signs • Meningitis HA - usually bilateral, develops over hrs to days, may also see fever, photophobia, positive meningeal signs (Kernigs’s Brudzinski)

31. Headaches of Acute Onset • Subarachnoid Hemorrhage (SAH) • Background • Aneurysms & AVM’s • Clinical Presentation • Signs & Symptoms • NEW, Sudden onset, LOC frequent, Vomiting & stiff neck • Lab Findings • CT & Lumbar Puncture • Complications • Reoccurnance doubles mortality rate • Prognosis • 20% DOA • 25% die from initial bleed; 20% from reoccurance • Survival

32. Headaches of Acute Onset • Infectious Headaches • Background • Meningitis and Encephalitis • Clinical Presentation • Classic: HA, Fever, Stiff Neck, & Altered Level of Consciousness • S/S can vary depending on age • Neonate, Children & Adults, Adults, Older generation • Headache Presentation • Diagnosis & Management: • CSF analysis • Neurologist

33. Headaches of Acute Onset • Headaches Following Lumbar Puncture • Background • Low Pressure Headache • MC is lumbar puncture • Headache Presentation • Clinical Pearl: • Worse with sitting or standing • Vertex or occipital, pulling, steady • Usually resolve spontaneously (Blood patch for resistant cases ) • The more severe the HA, the more frequent it is assoc. w/ vertigo, nausea/vomiting, & tinnitus • The longer the pt is upright, the longer it takes for the HA to subside

34. Subacute Headache (HA) • May be symptomatic of • Increased intracranial pressure • Intracranial mass lesion • Temporal arteritis • Sinusitis • Trigeminal neuralgia

35. Temporal Arteritis = Giant Cell Arteritis • Classic presentation is a 50 plus year old female with unilateral HA that is causing unilateral visual disturbance. Intensity is moderate to severe and will be insidious in onset. • 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 • Other findings: • Jaw claudication • Bruits over temporal artery • Blindness • May be accompanied by polymyalgia rheumatica.

36. Trigeminal Neuralgia= Tic Douloureux • Paroxysmal pain – seconds to < 2 min • Distributed along 5th cranial nerve ( V2 & V3 ) • Asymptomatic between attacks • Trigger points ( triggered by talking, chewing, shaving) • Intense burning • Face may distort = tic • >40, F>M, • Characterized by sudden intense pain that recurs paroxysmally, occurs along the second or third division of trigeminal nerve and lasts only moments,

37. Carbamazepine Gabapentin Baclofen Phenytoin Valproate Chlorphenesin Adjuvant TCAs NSAIDs Surgery for refractory cases Trigeminal Neuralgia - Treatment

38. Herpes zoster Facial pain • Herpetic eruption in territory of nerve in distribution of nerve (10 – 15% the trigeminal ganglion and 80% the ophthalmic division) • Geniculate ganglion causes eruption in the EAM. • Upper cervical nerve roots affects soft palate. • Pain precedes herpetic eruption by <7 days • Pain resolves within 3 months • Postherpetic Neuralgia • Neuralgia of the trigeminal nerve following herpes infection. • Most commonly affects V1 as well as V2 & V3 • This is the KEY difference between post-herpetic and trigeminal neuralgia.

39. Post-Herpetic Neuralgia • Persistent neuritic pain for > 2 months after acute eruption • Treatment • Anticonvulsants • TCAs • Baclofen

40. Glossopharyngeal Neuralgia • Severe (Unilateral pain ) • Transient stabbing pain in the ear, base of tongue, tonsillar fossa, or beneath the angle of the jaw. (auricular and pharyngeal branches of the vagus nerve and glossopharyngeal nerve) • Evoked by swallowing, talking, or coughing • Treatment as for Trigeminal Neuralgia

41. Occipital Neuralgia • Paroxysmal jabbing pain in the distribution of the greater and lesser occipital nerves or the third occipital nerve • Sometimes diminished sensation • Pain is eased by local anaesthetic block • Must be distinguished from occipital referral of pain from the atlantoaxial or upper zygoapophyseal joint or trigger points in suboccipital muscles

42. Estimated that 30-50% of 2 million closed head injuries per year develop headache. Associated with dizziness, fatigue, insomnia, irritability, memory loss, and difficulty with concentration. Acute PTHA develops hours to days after injury and may last up to 8 weeks. Chronic PTHA may last from several months to years. Patients have normal neurological examination and imaging Treatment for acute PTHA is symptomatic while for chronic PTHA, adjunct therapies include beta-blockers and antidepressants. Posttraumatic Headache(PTHA)

43. 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

44. Temporomandibular Disorders • Symptoms • Temporal headache • Earache • Facial pain • Trismus • Joint noise • 60% spontaneous • Tenderness to palpation • Pain with movement • Audible click

45. Myofascial Pain • Most common 60% - 70% • Muscle pain dominates • Tenderness to palpation of masticatory muscles

46. TMD - Treatment • NSAIDs • Physical therapy • Biofeedback • Trigger point injection • Benzodiazepines • TCAs or SSRIs for chronic muscle pain

47. Pseudotumor Cerebri • Intermittent headache • Variable intensity • Normal exam except papilledema • Normal imaging • CSF pressures > 200 cm H2O

48. 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 Pseudotumor Cerebri - Associated History

49. Idiopathic Intracranial Hypertension(IIP) • Treatment -Stop offending med -Lower CSF production with acetazolomide and furosemide. -Steroids -Repeat LPs -Ventricular shunt if with impending visual loss.

50. Mass Lesion - Brain Tumor • Children - 75% Infratentorial • Adults - 75% Supratentorial • Metastatic tumor most common mid-life • Symptoms due to increased intracerebral pressure, tissue destruction, irritation • Depends on growth rate and location • Headache ( 30 % ) - steady, non-throbbing, dull, worse in AM. May be intermittent initially. • Headache worse with bending over, Valsalva maneuvers • Hx of IV drug abuse - abscess