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Headache and Facial Pain
Robert H. Stroud, M.D.
Byron J. Bailey, M.D.
January 31, 2001
Referred Pain
 Brain tissue insensate
 Anterior & middle fossae → anterior to
coronal suture
 Posterior fossa → occipit...
Sinus Innervation
 Ophthalmic and maxillary branches of
5th
cranial nerve
 Greater superficial petrosal branch of 7th
cr...
Frontal Sinus
 Ophthalmic branch
of 5th
cranial nerve
 Pain referred to
forehead and
anterior cranial
fossa
Anterior Ethmoid
 Ophthalmic division
 Anterior ethmoid
nerve off nasociliary
 Anterior septum,
turbinates,
ostiomeatal...
Posterior Ethmoid and
Sphenoid
 Maxillary division
 Posterior ethmoid
nerve
 Posterior septum,
parts of superior and
mi...
Maxillary Sinus
 Maxillary division of
5th
cranial nerve
 Posterior superior
alveolar
 Infraorbital
 Anterior superior...
Referred Otalgia
 Oral cavity
 Mandibular division of 5th
cranial nerve
 Auriculotemporal nerve
 Pharynx
 Jacobson’s ...
History
 First occurrence
 Timing
 Quality
 Treatments
 Associated symptoms
 Precipitating factors
Past Medical History
 Head injuries, infections, surgeries
 Psychiatric diagnoses
 Medications
 OTC analgesics
 OCP
...
Physical Examination
 Complete head & neck exam
 Cranial nerves
 TMJ & muscles of mastication
 Scalp vessels
 Trigger...
Diagnostic Tests
 EEG
 CT and/or MRI
 EMG
 TMJ radiography
 Cervical spine films
 Labs
 Psychometric testing
Tension-Type Headache
 Most common headache syndrome
 Episodic < 15 days per month
 Chronic > 15 days per month
TTH - Characteristics
 30 minutes to 7 days
 Pressing or tightening
 Mild to moderate pain
 Variable location, often b...
TTH - Treatment
 Stress management
 Biofeedback
 Stress reduction
 Posture correction
 Medication rarely
needed in ET...
Migraine
 17% of females, 6% of males
 Moderate to severe pain
 Unilateral, pulsating
 4 to 72 hours
 Nausea, vomitin...
Migraines - Causation
 Sterile inflammation
of intracranial
vessels -
trigeminovascular
system
 Serotonin (5-
hydroxytry...
Migraine - Treatment
 Abortive
 5-hydroxytryptamine
receptor agonists

Imitrex
 Oral, SQ, nasal
spray

Maxalt

Zomig...
Migraine - Treatment
 Symptomatic
 Prochlorperazine
 Dihydroergotamine
 Chlorpromazine
 Haloperidol
 Lorazepam
 BOT...
Cluster
 Intensely severe
pain
 Unilateral
 Periorbital
 15 to 180 minutes
 Nausea and
vomiting uncommon
 No aura
 ...
Cluster
Cluster
 Episodic
 Two episodes per
year to one every
two or more years 7
days to a year
 Chronic
 Remission phases
le...
Cluster - Treatment
 Preventative
 Calcium channel
blockers
 Bellergal
 Lithium
 Methysergide
 Steroids
 Valproate
...
Temporal Arteritis
 Moderate to severe, unilateral pain
 Patients over 65
 Tortuous scalp vessels
 ESR elevated
 Biop...
Chronic Daily Headache
 6 days a week for 6 months
 Bilateral, frontal or occipital
 Non-throbbing
 Moderately severe
...
CDH - Treatment
 Patient understanding
 Remove causative medication
 Avoid substitution
 Antidepressants
 Adjuvant th...
Trigeminal Neuralgia
 Paroxysmal pain –
seconds to < 2 min
 Distributed along 5th
cranial nerve
 Asymptomatic
between a...
Trigeminal Neuralgia -
Treatment
 Carbamazepine
 Gabapentin
 Baclofen
 Phenytoin
 Valproate
 Chlorphenesin
 Adjuvan...
Glossopharyngeal Neuralgia
 Similar to Trigeminal Neuralgia
 Unilateral pain
 Pharynx
 Soft palate
 Base of tongue
 ...
Atypical Facial Pain
 Diagnosis of exclusion
 ? Psychogenic facial pain
 Location and description inconsistent
 Women,...
Post-Traumatic Neuralgia
 Neuroma formation
 Occipital and
parietal scalp
 Diagnosis based on
history
 Treatment
 Tri...
Post-Herpetic Neuralgia
 Persistent neuritic pain for > 2 months
after acute eruption
 Treatment
 Anticonvulsants
 TCA...
Temporomandibular Disorders
 Symptoms
 Temporal headache
 Earache
 Facial pain
 Trismus
 Joint noise
 60% spontaneo...
Internal Derangements
 Tenderness to
palpation
 Pain with movement
 Audible click
Degenerative Joint Disease
 Pain with joint movement
 Crepitus over joint
 Flattened condyle
 Osteophyte formation
Myofascial Pain
 Most common 60% - 70%
 Muscle pain dominates
 Tenderness to palpation of masticatory
muscles
TMD - Treatment
 NSAIDs
 Physical therapy
 Biofeedback
 Trigger point injection
 Benzodiazepines
 TCAs or SSRIs for ...
Pseudotumor Cerebri
 Intermittent headache
 Variable intensity
 Normal exam except papilledema
 Normal imaging
 CSF p...
Pseudotumor Cerebri -
Associated History
 Mastoid or ear
infection
 Menstrual
irregularity
 Steroid exposure
 Retro-or...
Pseudotumor Cerebri –
Treatment
 Reduce CSF production
 Furosemide
 Acetazolamide
 Weight loss
 Low salt diet
 CSF s...
Intracranial Tumor
 30% have headache
 Dull or aching
 Crescendo over time
 Early morning
 Increased with valsalva
 ...
Subdural Hematoma
 History of trauma
 Fluctuating level of consciousness
 Pain lateralized
 Tenderness to percussion o...
Subarachnoid Hemorrhage
 Sudden onset, severe, generalized pain
 Nausea and vomiting
 Stiff neck progressing to back pa...
Infectious
 Meningitis
 Acute meningitis

Fever

Stiff neck
 Fungal
 Tuberculous
 Luetic
 Epidural abscess
 AIDS ...
Hypertension
 Usually with diastolic pressures > 115
mm Hg
 Throbbing
 Nausea
Low ICP Headache
 Usually from LP
 Worse with sitting or standing
 Vertex or occipital, pulling, steady
 Usually resol...
Sinus Headache
 Acute sinusitis accepted
 Chronic sinusitis controversial
 Constant, dull, aching
 Worsened with jarri...
Contact Point Theory
 Stammberger and
Wolf 1988
 Role of Substance P
 Axonal reflex arc
 Predisposing
anatomy
Agger Nasi Cells
 Anterior and
superior to insertion
of middle turbinate
 Narrow frontal
recess
Uncinate Variations
 Anterior
displacement
 Pneumatization
 Narrowing in middle
meatus or contact
with middle turbinate
Middle Turbinate Variations
 Paradoxically bent
 Concha bullosa
 Obstruction of
middle meatus
 Mucosal contact
with la...
Ethmoid Variations
 Extensive
pneumatization
 Contact with middle
turbinate
 Obliteration of
middle meatus
Haller’s Cells
 Anterior ethmoid
cells on floor of orbit
 Narrow maxillary
sinus ostium
Surgery for Sinus Headache
 Clerico 1995
 10 pts with prior
diagnosis of
headache syndrome
 Mucosal contact
points
 7 ...
Surgery for Sinus Headache
 Headache as SOLE indication for sinus
headache still unproven
 Headache should improve with
...
Conclusion
 Headache & facial pain are common
complaints
 History most important in making
accurate diagnosis
 Recogniz...
Case Study
29 year old WM presents with
severe headache.
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Headache and Facial Pain Robert H. Stroud, M.D.

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Headache and Facial Pain Robert H. Stroud, M.D.

  1. 1. Headache and Facial Pain Robert H. Stroud, M.D. Byron J. Bailey, M.D. January 31, 2001
  2. 2. Referred Pain  Brain tissue insensate  Anterior & middle fossae → anterior to coronal suture  Posterior fossa → occipital and upper neck  Sphenoid & sella → vertex
  3. 3. Sinus Innervation  Ophthalmic and maxillary branches of 5th cranial nerve  Greater superficial petrosal branch of 7th cranial nerve  Ostiomeatal complex > turbinates > septum > sinus mucosa
  4. 4. Frontal Sinus  Ophthalmic branch of 5th cranial nerve  Pain referred to forehead and anterior cranial fossa
  5. 5. Anterior Ethmoid  Ophthalmic division  Anterior ethmoid nerve off nasociliary  Anterior septum, turbinates, ostiomeatal complex
  6. 6. Posterior Ethmoid and Sphenoid  Maxillary division  Posterior ethmoid nerve  Posterior septum, parts of superior and middle turbinates  Ophthalmic division  Greater superficial petrosal nerve
  7. 7. Maxillary Sinus  Maxillary division of 5th cranial nerve  Posterior superior alveolar  Infraorbital  Anterior superior alveolar
  8. 8. Referred Otalgia  Oral cavity  Mandibular division of 5th cranial nerve  Auriculotemporal nerve  Pharynx  Jacobson’s branch of 9th cranial nerve  Hypopharynx and supraglottic larynx  Arnold’s branch of 10th cranial nerve
  9. 9. History  First occurrence  Timing  Quality  Treatments  Associated symptoms  Precipitating factors
  10. 10. Past Medical History  Head injuries, infections, surgeries  Psychiatric diagnoses  Medications  OTC analgesics  OCP  Herbal medications  Antihypertensives & vasodilators  Alcohol, tobacco, drugs
  11. 11. Physical Examination  Complete head & neck exam  Cranial nerves  TMJ & muscles of mastication  Scalp vessels  Trigger points  Neurological exam
  12. 12. Diagnostic Tests  EEG  CT and/or MRI  EMG  TMJ radiography  Cervical spine films  Labs  Psychometric testing
  13. 13. Tension-Type Headache  Most common headache syndrome  Episodic < 15 days per month  Chronic > 15 days per month
  14. 14. TTH - Characteristics  30 minutes to 7 days  Pressing or tightening  Mild to moderate pain  Variable location, often bilateral  Nausea and vomiting rare
  15. 15. TTH - Treatment  Stress management  Biofeedback  Stress reduction  Posture correction  Medication rarely needed in ETTH  Benzodiazepines  amitriptyline  CTTH  Abortive  NSAIDs  ASA-caffeine- butalbital  Phenacetin  Preventative  Antidepressants  Muscle relaxants  NSAIDs
  16. 16. Migraine  17% of females, 6% of males  Moderate to severe pain  Unilateral, pulsating  4 to 72 hours  Nausea, vomiting, photophobia or phonophobia  With or without aura
  17. 17. Migraines - Causation  Sterile inflammation of intracranial vessels - trigeminovascular system  Serotonin (5- hydroxytryptamine) receptors  Triggering factors  Stress  Menses  OCP  Infection  Trauma  Vasodilators  Wine  Aged cheeses
  18. 18. Migraine - Treatment  Abortive  5-hydroxytryptamine receptor agonists  Imitrex  Oral, SQ, nasal spray  Maxalt  Zomig  Amerge  Ergotamine  Butorphanol  Midrin  NSAIDs  Lidocaine
  19. 19. Migraine - Treatment  Symptomatic  Prochlorperazine  Dihydroergotamine  Chlorpromazine  Haloperidol  Lorazepam  BOTOX?  Preventative  Antidepressants  Bellergal (ergotamine)  NSAIDs  β-blockers  Calcium channel blockers
  20. 20. Cluster  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
  21. 21. Cluster
  22. 22. Cluster  Episodic  Two episodes per year to one every two or more years 7 days to a year  Chronic  Remission phases less than 14 days  Prolonged remission absent for > one year
  23. 23. Cluster - Treatment  Preventative  Calcium channel blockers  Bellergal  Lithium  Methysergide  Steroids  Valproate  Antihistamines  Abortive  Oxygen  5-HT receptor agonists  Intranasal lidocaine
  24. 24. Temporal Arteritis  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
  25. 25. Chronic Daily Headache  6 days a week for 6 months  Bilateral, frontal or occipital  Non-throbbing  Moderately severe  Due to overuse of analgesics  ? Transformation of migraine or TTH
  26. 26. CDH - Treatment  Patient understanding  Remove causative medication  Avoid substitution  Antidepressants  Adjuvant therapy  Treatment of withdrawal
  27. 27. Trigeminal Neuralgia  Paroxysmal pain – seconds to < 2 min  Distributed along 5th cranial nerve  Asymptomatic between attacks  Trigger points
  28. 28. Trigeminal Neuralgia - Treatment  Carbamazepine  Gabapentin  Baclofen  Phenytoin  Valproate  Chlorphenesin  Adjuvant  TCAs  NSAIDs  Surgery for refractory cases
  29. 29. Glossopharyngeal Neuralgia  Similar to Trigeminal Neuralgia  Unilateral pain  Pharynx  Soft palate  Base of tongue  Ear  Mastoid  Treatment as for Trigeminal Neuralgia
  30. 30. 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
  31. 31. Post-Traumatic Neuralgia  Neuroma formation  Occipital and parietal scalp  Diagnosis based on history  Treatment  Trigeminal Neuralgia  Bupivicaine to trigger points  Occasionally amenable to surgery
  32. 32. Post-Herpetic Neuralgia  Persistent neuritic pain for > 2 months after acute eruption  Treatment  Anticonvulsants  TCAs  Baclofen
  33. 33. Temporomandibular Disorders  Symptoms  Temporal headache  Earache  Facial pain  Trismus  Joint noise  60% spontaneous
  34. 34. Internal Derangements  Tenderness to palpation  Pain with movement  Audible click
  35. 35. Degenerative Joint Disease  Pain with joint movement  Crepitus over joint  Flattened condyle  Osteophyte formation
  36. 36. Myofascial Pain  Most common 60% - 70%  Muscle pain dominates  Tenderness to palpation of masticatory muscles
  37. 37. TMD - Treatment  NSAIDs  Physical therapy  Biofeedback  Trigger point injection  Benzodiazepines  TCAs or SSRIs for chronic muscle pain
  38. 38. Pseudotumor Cerebri  Intermittent headache  Variable intensity  Normal exam except papilledema  Normal imaging  CSF pressures > 200 cm H2O
  39. 39. Pseudotumor Cerebri - Associated History  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
  40. 40. Pseudotumor Cerebri – Treatment  Reduce CSF production  Furosemide  Acetazolamide  Weight loss  Low salt diet  CSF shunting  Incision of optic nerve sheath
  41. 41. Intracranial Tumor  30% have headache  Dull or aching  Crescendo over time  Early morning  Increased with valsalva  Vomiting with nausea  Neuro exam may be normal
  42. 42. Subdural Hematoma  History of trauma  Fluctuating level of consciousness  Pain lateralized  Tenderness to percussion over hematoma  Trauma may be remote in chronic SDH
  43. 43. Subarachnoid Hemorrhage  Sudden onset, severe, generalized pain  Nausea and vomiting  Stiff neck progressing to back pain  LP if imaging negative
  44. 44. Infectious  Meningitis  Acute meningitis  Fever  Stiff neck  Fungal  Tuberculous  Luetic  Epidural abscess  AIDS of CNS  Sarcoidosis  Diagnosis dependent on LP
  45. 45. Hypertension  Usually with diastolic pressures > 115 mm Hg  Throbbing  Nausea
  46. 46. Low ICP Headache  Usually from LP  Worse with sitting or standing  Vertex or occipital, pulling, steady  Usually resolve spontaneously  Blood patch for resistant cases
  47. 47. Sinus Headache  Acute sinusitis accepted  Chronic sinusitis controversial  Constant, dull, aching  Worsened with jarring, stooping or leaning forward  Referred pain possible
  48. 48. Contact Point Theory  Stammberger and Wolf 1988  Role of Substance P  Axonal reflex arc  Predisposing anatomy
  49. 49. Agger Nasi Cells  Anterior and superior to insertion of middle turbinate  Narrow frontal recess
  50. 50. Uncinate Variations  Anterior displacement  Pneumatization  Narrowing in middle meatus or contact with middle turbinate
  51. 51. Middle Turbinate Variations  Paradoxically bent  Concha bullosa  Obstruction of middle meatus  Mucosal contact with lateral nasal wall
  52. 52. Ethmoid Variations  Extensive pneumatization  Contact with middle turbinate  Obliteration of middle meatus
  53. 53. Haller’s Cells  Anterior ethmoid cells on floor of orbit  Narrow maxillary sinus ostium
  54. 54. Surgery for Sinus Headache  Clerico 1995  10 pts with prior diagnosis of headache syndrome  Mucosal contact points  7 operated on with relief of HA  3 responded to medical therapy for sinonasal findings  Parsons and Batra 1998  91% of 34 pts had decreased intensity of HA post op  85% decreased frequency  All pts had indicators for surgery other than headache
  55. 55. Surgery for Sinus Headache  Headache as SOLE indication for sinus headache still unproven  Headache should improve with decongestant and topical anesthesia if good results are to be expected post op
  56. 56. Conclusion  Headache & facial pain are common complaints  History most important in making accurate diagnosis  Recognize psychological aspects of pain
  57. 57. Case Study 29 year old WM presents with severe headache.

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