2. Pain
Pain is defined as an unpleasant sensory and emotional
experience associated with actual or potential tissue damage, or
described in terms of such damage.
4. Sinogenic Pain
Patients may complain of pressure, fullness or
throbbing in the distribution of the paranasal sinuses
or at the vertex of the head
Symptoms may be bilateral or unilateral, particularly if
individual sinuses are affected by pathology
Examples include pathology such as pyomucocele of
the maxillary antrum, or fibrous dysplasia or osteoma
of the ethmoid sinus causing secondary obstruction of
drainage pathways, or mucocele of the sphenoid sinus
Symptoms may be
Acute
Recurrent acute (moderated by repeated short courses
of antibiotics)
chronic.
5. Sinogenic pain
Associated symptoms:
Nasal congestion and/or hyposmia
Endoscopic signs of polyposis and obstruction of outflow drainage pathways and
mucosal disease
Imaging done for failed maximal medical therapy, complications of rhinosinusitis, or
suspicion of malignancy
80% of patients with endoscopic evidence of purulent secretions have no headache
or facial pain
Treatment:
Initially medical imaging done for failed maximal medical therapy, complications
of rhinosinusitis, or suspicion of malignancy
Surgery should be targeted after correlation between symptoms, signs and
radiological findings.
6. Non sinogenic pain
Primary Headaches
Migraine
Tension type headache
Cluster Headaches and other
trigeminal Autonomic Cephalgias
Cluster headache
Paroxysmal hemicrania
SUNCT/SUN
Hemicrania continua
8. Non sinogenic Pain
Other causes of non sinogenic pain
Mid-facial segment pain
Analgesia-dependency headache or medication-overuse headache
Myofascial pain
Cervical spine degenerative disease and cervicogenic headache
Temporal arteritis
Pain caused by tumour
Persistent Idiopathic Facial Pain (Atypical Facial Pain)
9. Migraine
Migraine is characterized by recurrent,
often unilat-eral, moderate to severe
headaches, which may be asso-ciated
with a number of symptoms attributable to
the autonomic nervous system
pulsatile or throbbing, and may be severe
enough to force the sufferer to bed in a
darkened and quiet room as the pain is
generally aggravated b
Types of migraine:
Classcial
Common
10.
11. Migraine (contd)
Classical Migraine
Accounts upto 25% cases
Associated autonomic symptoms: Nausea, vomiting, photophobia, and
phonophobia.
Up to one-third of classical migraine prodromal aura:
A transient visual (scintillating scotoma, which is an area of partial alteration in
the field of vision that flickers with zigzagging lines resembling fortifications or
walls of a castle)
Sensory (olfaction or taste)
Language
motor disturbance (pins-and-needles or numbness),
Simple Migraine
Headache and nausea but without the aura associated with classical
migraine
12. Pathophysiology of migraine
Runs in family, more common in women; sufferers may describe triggers
encountered up to 24 hours prior to the onset of an attack.
Triggers include stress, hunger, fatigue, hormonal changes, foodstuffs containing
tyramine (aged cheeses, smoked fish, cured meats, some types of beer),
monosodium glutamate, indoor air quality and lighting.
Previously believed to be a neurovascular disorder, now believed to be a disorder of
the brain itself.
Cortical spreading depression is a wave of intense depolarization that starts in the
occipital lobe, propagates through the brain followed by a period of suppressed
activity
Activation of the trigemino-vascular system causes the release of neuropeptides
(e.g. calcitonin gene-related peptide, substance P) from peripheral trigeminal nerve
endings
Pulsating quality of migraine is thought to be caused by a process of peripheral
sensitization
13. Migraine
Treatment:
Aspects of migraine management
• Trigger avoidance
• Acute symptomatic control
• Pharmacological prevention.
Non-steroidal anti-inflammatory drugs (NSAIDs) or the combination of
acetaminophen, acetylsalicylic acid and caffeine recommended for initial treatment in
acute attacks
Ibuprofen provides effective relief of symptoms in about half of people
Diclofenac has also been found to be effective
Both prescribed either with or without metoclopramide
14. Migraine
Treatment :
Triptans (e.g. sumatriptan, naratriptan, rizatriptan, zolmatriptan) help individuals with
moderate to severe symptoms or those with milder symptoms not responding to simple
analgesics; effective in up to 75%
Ergotamine and dihydroergotamine, remain as effective as ; are less expensive, and are
associated with side effects that are typically benign
Preventative measures in migraine include medications, nutritional supplements and
lifestyle alterations
Medical prevention
Anti-epileptic drugs (e.g. topiramate, sodium valproate)
Beta-blockers (e.g. propanolol, metoprolol)
Beta-adrenergic receptor antagonists (e.g. timolol)
Antidepressants (e.g. amitriptyline, venlafaxine)
15. Migraine
Treatment new modalities
Botulinum toxin type A
Administered intra-muscularly to between 31 and 39 sites around the head and back of
the neck in chronic migraines (15 or more headache days per month of which at least 8
days are with migraines) but not those with episodic ones (0 to 14 headache days per
month)
16. Tension Type Headache
Feeling is of tightness, pressure or
constriction (vice-like)
Confined to a small area at the
glabella or extend across the whole
forehead and into the
temporoparietal scalp, with a
tightness or tenderness in the
occiput and trapezius
Aggregate of symptoms suggests
an underlying association with
stress and tension, but depression
and anxiety may also contribute
17. Tension type headache
Pathophysiology:
Pericranial myofascial mechanisms in episodic type
sensitization of central nociceptive pathways and inadequate endogenous anti-
nociceptive circuitry in chronic tension-type headache.
Management
Relaxation training
Stress management
Counselling
Therapeutic: Amitriptyline 10mg once daily at night increased by 10mg
every 6 weeks until the pain is controlled; enhances quality of sleep cause a
‘hangover’ effect the following morning. Continued for at least 6 weeks. If
effective contined for 6 month at least
18. Cluster headache
Men are more often affected than women, primarily between the
ages of 20 and 50 years
Duration: 15 minutes to 3 hours
Excruciating unilateral headaches of extreme intensity affecting the
frontal and temporal regions, extending over the cheek and even into
the teeth
19. Cluster Headache
Presented with lacrimation,
rhinorrhoea and nasal obstruction
(misdiagnosis of sinusitis)
Pain is typically lancinating or
boring/ drilling in quality, and is
located behind the eye or in the
temple
Descriptions range from a red-hot
poker inserted into the eye or a
spike penetrated from the top of the
head, behind one eye, and radiating
down the neck
21. Paroxysmal Hemicrania
Severe debilitating unilateral headache affecting usually the periorbital and
frontotemporal region
Average age of onset of 30 to 40 years
Attacks are usually short-lasting, ranging from 2 to 45 minutes, and frequent,
more than 5 times a day
Trigeminal autonomic symptoms may include nasal congestion, rhinorrhoea
and lacrimation
Management:
1st line Drug: Indomethacin respond within 24 hr
2nd line Drug: calcium-channel blockers, naproxen, carbamezapine, and
sumatriptan.
22. SUNCT/SUNA
Short-lasting unilateral neuralgiform headache attacks with conjunctival
injection and tearing (SUNCT)
Short-lasting unilateral neuralgiform attacks with cranial autonomic features
(SUNA)
Shortest attack duration and the highest attack frequency
Severe, brief, unilateral attacks that usually occur in the distribution of the
trigeminal nerve
SUNA differs from SUNCT in that autonomic symptoms are less prominent
Treatment :
Drug of choice of SUNCT: Lamotrigene
Drug of choice of SUNA: Gabapentin
23. Hemicrania Continua
Unilateral headache causing moderately severe pain, without side-shift
More common in women and first episode in adulthood
Daily and continuous, without pain-free periods, and lasts for more than 3
months
Exacerbations that can include cranial autonomic symptoms
Conjunctival injection, lacrimation, nasal congestion, rhinorrhoea, ptosis, or miosis
Treatment:
Drug of choice: Indomethacin
Other measures:
Gabapentin,
Topiramate
Radiofrequency ablation of the supraorbital nerve
Nerve blocks or botulinum toxin.
24. Trigeminal Neuralgia
Inflammation of the trigeminal nerve, causing intense facial pain, paroxysmal, sharp
pain and followed by lacrimation, facial spasm
Also known as tic douloureax
Character of pain: Stabbing or lancinating, burning, pressing, crushing,
exploding or shooting
Patients may describe a trigger area on the face so sensitive that touching or
even air currents may trigger an episode.
Affect one side of the face at a time, lasting from several seconds to a few
minutes and may repeat up to hundreds of times throughout the day .
Occur in cycles with remissions lasting months or even years
25. Trigeminal Neuralgia
International Headache Society has established criteria for making the diagnosis and includes
the following
Paroxysmal attacks of pain lasting from a fraction of a second to 2 minutes, affecting 1 or more
divisions of the trigeminal nerve
Pain has at least one of the following characteristics:
(1) intense, sharp, superficial or stabbing; or (2) precipitated from trigger areas or by trigger
factors
Triggers:
Brushing your teeth
Talking
Putting on makeup
Encountering a breeze
Smiling
Washing your face
26. Trigeminal neuralgia
Cause:
Vascular (arterial and venous) compression of the trigeminal nerve root
Superior cerebellar artery, the anterior and posterior inferior cerebellar arteries, and the
superior petrosal vein including several of its tributaries
Compression can injure the protective myelin sheath of the nerve and cause erratic and
hyperactive nerve functioning.
Investigations:
Magnetic resonance imaging should be performed to exclude multiple sclerosis or
posterior fossa pathology
27. Trigeminal neuralgia
Management:
Anticonvulsant carbamazepine: Drug of choice
Gabapentin, lamotrigine and topiramate: Second-line agents
Percutaneous radiofrequency thermo or chemical rhizotomy of the
Gasserian ganglion
Stereotactic radiotherapy
Microvascular decompression
28. EAGLE SYNDROME
Headache or facial pain attributed to
inflammation of the stylohyoid ligament
Typically present with unilateral
headaches, neck pain, oropharyngeal
pain, or facial pain.
The diagnostic criteria require
radiographic evidence of a calcified or
elongated stylohyoid ligament and at least
two of the following symptoms:
1. Pain is provoked or exacerbated by digital
palpation of the stylohyoid ligament
2. Pain is provoked or exacerbated by head
turning
3. Pain is significantly improved by injection
of a local anesthetic agent into the
stylohyoid ligament or by styloidectomy
4. Pain is ipsilateral to the inflamed stylohyoid
29. Eagle Syndrome
Treatmet
Nonsteroidal anti inflammatory medications
Anticonvulsants
Antidepressants
Local injection of steroids or local anesthetics
Surgical management typically consists of a transoral or transcervical approach with
excision of the calcified stylohyoid ligament
30. Post Herpetic Neuralgia
Pain following a herpes zoster
infection, recurring or continuing at
the site of shingles after the onset
of the rash
50% of elderly patients with
shingles may develop post-herpetic
neuralgia , most recover during the
first year
Management:
Antiviral agents curtail the pain
of acute shingles; also reduce
the risk of subsequent post-
herpetic neuralgia
Carbamazepine
Gabapentin with or without a
tricyclic antidepressant.
31. Post surgical/traumatic Neuralgia
External portion of the nose is highly
innervated by branches of the
ophthalmic and maxillary divisions of
the trigeminal nerve
Nasociliary nerve, external nasal
nerve, infratrochlear nerve, anterior
ethmoidal nerve, and infraorbital
nerve.
These nerves can be easily
traumatized with any impact to the
nose, either following trauma or after
surgery
32. Post surgical/traumatic Neuralgia
Pathophysiology:
Unclear Central, due to neuroplasticity within the trigeminal nucleus producing
spontaneous firing of neurons and reverberating circuits
Peripheral phenomenon, due to direct neural damage with fibrosis or neuroma
formation, or neural entrapment
Management:
Removal of prosthetic pressure (e.g. from spectacles)
Treat neuropathic pain (amitriptyline, gabapentin, or pregabalin),
infiltration with local anaesthetic and corticosteroid
Nerve decompression and ultimately, nerve section may offer some
symptom relief.
33. Sludders Neuralgia
Implicates mucosal contact points within the nose as a cause of headache or
facial pain
Mucosal contact points within the nasal cavity can cause referred pain
Septal spur, concha bullosa, a paradoxically curved middle turbinate, a superior
turbinate touching the septum, or a large ethmoid bulla.
35. Painful Teeth
True dental pain can often be elicited
by percussing the offending tooth
Pain originating from pulp disease
may be poorly localized causing
misdiagnosis
Rarely crosses the midline but
radiation to the opposite jaw (e.g.
maxilla to mandible) and surrounding
structures may further confuse the
picture.
Dentino-enamel defects will produce
a sharp, well-localized pain often
caused by a lost or cracked filling
Once the periodontium is involved the
pain becomes localized to the
affected tooth, which throbs and is
tender to percussion
36. Temporomadibular joint Disorder
Muscular hyper- or parafunction may produce acute or chronic pain in the pre- or
periauricular areas, deep otalgia, and tenderness in the temporoparietal and cervical
regions of the scalp.
Causes include malocclusion, mal-alignment following dental restorative procedures,
stress and anger, excessive chewing (e.g. gum), and degenerative joint disease
Clinical findings may include scalloping of the buccal mucosa in cases of bruxism,
tenderness in the muscles of mastication or in the temporomandibular joint itself, and
smoothed contours of the pre-molar and molar dentition
Treatment:
Joint rest
Non-steroidal anti-inflammatory analgesia
correction of aetiological factors, and an occlusal splint (e.g. biteguard) worn at night or,
sometimes, longer duration can relieve inflammation in a tender joint
Physiotherapy
temporomandibular joint injection with corticosteroid and local anaesthetic or
botulinum toxin
Low-dose amitriptyline may be useful in some resistant cases.
37. Phantom Tooth
Unrelenting pain in the teeth, gingival, palatal or alveolar tissues
Pain complaints are due to a neuropathic alteration of the trigeminal nerve
Treatment:
Gabapentin
Tricyclics
topical anaesthetics
Opioids.
38. Analgesia- Dependency Headache
Also called medication-overuse headache
Cycle of taking an excessive amount of analgesics in spite of little effect
Dull, diffuse and band- like headaches, usually starting in the early morning
Drugs Include: Acitaminofen,caffeine, non-steroidal anti-inflammatory medications,
codeine, ergot alkaloids, and pyrazalone derivative
Underlying mechanisms behind analgesia- dependency headache remain unknown.
On stopping analgesics, headaches disappear or decrease by more than 50% in two-
thirds of patients
39. Myofasial Pain
Characterized by chronic pain caused by multiple trigger points in the neck, jaw or
ear, and is five times more common in post-menopausal women
Aetiological factors include malocclusion and poor delto pectoral posture, but stress
and tiredness have a tendency to amplify the symptoms .
Clinical feature of Myofasial trigger points
Focal point tenderness
reproduction of pain on trigger point palpation
hardening of the muscle upon trigger point palpation
pseudo-weakness of the involved muscle
referred pain
limited range of motion following approximately 5 seconds of
sustained trigger point pressure
40. Myofasial Pain
Management:
Applying local heat
Ultrasound therapy and often massage to relieve trigger point tenderness
Low-dose amitriptyline may be useful in some resistant cases.
41. Cervical Spine Degenerative disease and
Cervicogenic Headache
Referred pain in the head and by muscular association, to the face
Primary sensory afferents from the cervical roots C1 to C3 converge with afferents
from the occiput and trigeminal afferents on the same second-order neuron in the
upper cervical spine
Pain may originate from different muscles and ligaments of the neck, from
intervertebral discs and particularly, from the atlanto-occipital, atlanto-axial, and
C2/C3 zygapophyseal joints
Treatment:
acupuncture or massage
cervical epidural corticosteroid injection, local botulinum toxin injection
radiofrequency ablative therapy
surgery
42. Pain caused by Tumor
80% of patients with head and neck cancers experience facial pain related to
their tumor or treatment
A thorough examination of the head, neck and upper aerodigestive tract along
with appropriate radiological imaging is mandatory to exclude the possibility of
underlying tumor
Constant or progressive dull or gnawing pain, particularly if associated with
other suspicious symptoms or neurological signs
Neoplasia of the paranasal sinuses, benign or malignant, often present with
advanced disease.
Unilateral nasal obstruction, bloody or discolored nasal discharge, a proptosed or
displaced globe, facial paraesthesia or swelling, and a loose tooth or ill-fitting denture
43. Temporal Arterities
Inflammatory vasculitis of the temporal artery
Women over 55 years are most commonly affected
Presenting with headache, fever, jaw or tongue claudication, and visual
disturbance
Patient may get blind due to disease progression and involvement of the
ophthalmic artery
Temporal area may be tender, with prominence of the temporal arteries
aised erythrocyte sedimentation rate and a minimum 1cm length biopsy of the
temporal artery, which shows giant cells infiltrating the tissue, intimal
hyperplasia and fragmentation of the internal elastic lamina
44. Temporal Arterities
Diagnosis:
Raised erythrocyte sedimentation rate
1cm length biopsy of the temporal artery shows giant cells infiltrating the
tissue, intimal hyperplasia and fragmentation of the internal elastic lamina
Negative biopsy result does not definitely rule out the diagnosis
Treatment:
High-dose corticosteroids (prednisolone 1mg/kg/day) (started even before
biopsy confirmation)
45. Persistent idiopathic facial pain
Also called Atypical facial Pain
Diagnosis of exclusion only
Idiopathic ophthalmodynia; Idiopathic rhinalgia
Persistent facial pain that does not have the classical characteristics of cranial
neuralgias and for which there is no obvious cause
Diagnosis is possible if the facial pain is localized, present daily, and throughout
all or most of the day
pain does not usually stay within the anatomical boundaries of the trigeminal
nerve distribution
Significant psychological disturbance or a history of depression may exist with
the suggestion that they are unable to function normally as a result of their pain.
Pessimistic view of treatment, almost giving the impression patient do not wish to
be rid of the pain that plays such a central role in their lives.
46. Persistent idiopathic facial pain
Treatment:
Reassurance
Analgesics
Antidepressant levels of amitriptyline (75 to 100mg) at night
Second-line drugs: Gabapentin and carbamazepine
Psychiatrist or Psychological consultation
47. History Taking In Facial pain
Where is the pain and does it radiate anywhere?
Is the pain continuous or intermittent?
What is the character of the pain?
What precipitates or is associated with the pain?
What relieves the pain?
What effect does the pain have on daily life?
48. References
Scott and Brown’s 8th edition
Scott and Brown’s 6th edition
Cummings otorhinolaryngology 7th edition
