1. Headache and Facial pain Dr. Abdulrahman Hagr MBBS FRCS(c) Assistant Professor King Saud University Otolaryngology Consultant Otologist, Neurotologist & Skull Base Surgeon King Abdulaziz Hospital

4. Headache and Facial pain Dr. Abdulrahman Hagr MBBS FRCS(c) Assistant Professor King Saud University Otolaryngology Consultant Otologist, Neurotologist & Skull Base Surgeon King Abdulaziz Hospital

5. Epidemiology 75% of adults have at least one headache/year 10% will seek physician evaluation 10% have emergent secondary cause

6. Headache Classification Primary v Secondary Paroxysmal v Chronic Episodic v Recurrent Mild to moderate v Moderate to severe

7. History

8. Headache history Onset Site Character Duration Frequency Diurnal pattern Associated symptoms Aggravating factors Relieving factors Treatment Ideas

9. Headache pattern Acute Intermittent Chronic

10. History Where does it hurt? –Unilateral/bilateral –Frontal/occipital/facial What is the character of the pain? –Pulsatile –Steady –Shocklike –Tightness

11. History What other symptoms do you experience? Nausea Vomiting LOC Flushing Lacrimation Drop attack Neck stiffness Photophobia Dizziness

12. Physical Exam

13. Vital signs –fever, hypertension, hypoxia Head/face –trauma, bruits, tenderness Eyes –conjunctiva, cornea, pupils, fundi:papilledema Ears –OM or hemotympanum Mouth –Teeth, TMJ

14. 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

15. 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

16. Diagnostic Studies

17. 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

18. Primary Headache Migraine Tension Cluster

19. 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

20. 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

21. International Headache Society Diagnostic criteria for migraine without aura A. At least 5 attacks fulfilling B–D. B. Headache attacks lasting 4 hours to 3 days (untreated). C. Headache has at least 2 of the following characteristics: (+ plus) 1. Unilateral location 2. Pulsating quality 3. Moderate or severe intensity (Limit daily activities) 4. Aggravation by stairs or similar routine physical activity D. During headache at least 1 of the following: 1. Nausea or vomiting 2. Photophobia and phonophobia Ruled out other disorderby appropriate investigations (0)

22. Migraine With Aura Aura 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

23. Migraine Triggers Sleep deprivation/excess Caffeine ingestion or caffeine withdrawal Fasting Sex hormones Most migraines have no trigger Strong familial pattern

24. 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

25. Cluster Headache Associated with Conjunctival injection Lacrimation Nasal congestion Rhinorrhea Miosis, Ptosis

26. 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

28. Red Flags for Headache Sudden Onset: –SAH –AVM –Mass lesion Worsening pattern: –Mass –SDH –Medication overuse

29. Red Flags for Headache Focal neuro signs: –Mass lesion –AVM –Collagen vascular disease –CVA Trigger with cough, exertion, valsalva: – SAH –Mass –Sinusitis

30. Red Flags for Headache Headache with fever, stiff neck or rash: –Meningitis –Encephalitis –Systemis infection –Collagen vascular disease –Arteritis

31. Headache Classification Critical Secondary Vascular –Hemorrhage –Stroke –Cavernous Sinus thrombosis –AVM –Temporal Arteritis –Carotid or Vertebral Artery Dissection CNS Infection Tumor

32. Headache Classification Critical Secondary (cont) Endocrine Metabolic Non-CNS Infections Opthalmic Drug Related Toxic

33. Secondary Headache  Temporal arteritis  Mass lesions  Tumor, abscess, arteriovenous malformation  Metabolic  Hypoglycemia, fever, hypothyroid, anemia  Glaucoma

34. Secondary Headache  Trigeminal Neuralgia  Post-concussion syndrome  Sinusitis without complication  Post-lumbar puncture  Diet  Medications  Fatigue, postexertion, postcoital

35. Tear in –Middle meningeal artery –Dural sinus rarely Direct trauma with –LOC  Lucid interval  Coma Lethargy, vomiting, ipsilateral dilated pupil (herniation) Epidural Hematoma

37. Subdural Hematoma Hematoma between dura mater and subarachnoid History of –Falls –Head trauma –Elderly –Anticoagulation

38. Subdural Hematoma Suspect –Bruise –Scalp laceration –Lethargy –Vomiting –Ipsilateral dilated pupil Treatment: –Support ABCs –Definitive treatment is neurosurgical evacuation

40. 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

43. Stroke 80% ischemic Hemorrhagic –HTN, elderly, prior CVA, bleeding diathesis, vascular malformation, cocaine use Embolus –A-fib, Valve replacement, recent MI, HTN, CAD, DM

44. Assessment 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

46. Temporal Arteritis 20 per 100,000 > 50 Y Women>men Risk for blindness if untreated Dx ESR, Biopsy for definitive diagnosis, Treatment with steroids

47. Temporal Arteritis Autoimmune 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

48. Carotid or Vertebral Dissection Characterized by –Headache –Vertigo –Unilateral Horner Syndrome Suspect if sudden neck rotation or extension  urgent imaging and neurosurgery

49. 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

50. Brudzinski’s and Kernig’s signs Both 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

51. Non-CNS Infection Viral syndromes Bacteremia Fever may often cause generalized headache

52. 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

53. 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

54. Non-CNS Infection Sinusitis Fever, malaise, Anosmia Toothache Purulent discharge Postnasal drip Sore throat, facial pain/pressure

55. Non-CNS Infection Sinusitis Treatment Antibiotics Nasal decongestants Antipyretics for fever and analgesia

56. Non-CNS Infections Dental Infections (Caries and/or periapical abscess) Toothache Jaw pain Earache Tooth tender to percussion

57. Non-CNS Infections Treatment involves –Covering exposed tooth –Analgesia –Abscess drainage

58. Ear Infections Otitis Media – middle ear infection Ear pain/fullness Decreased hearing Vertigo Fever Treatment with Antibiotics Antipyretics

59. Ear Infections Otitis Externa – External Ear infection –Itching –Decreased hearing –Fever –Tender external ear. Treated with –Antibiotic drops. –Caution if diabetic for malignant OE

60. Raised pressure headache Non-specific Aggravated by –Bending –Coughing –Sneezing –Waking Associated with N&V, visual blurring Papilloedema

61. Cases

62. Case #1 CHARACTERTHROBBING QUALITY UNILATERAL SEVERITYDISABLING ONSETMAXIMAL IN 1 HOUR DURATIONHOURS RELIEFNSAID INADEQUATE FREQUENCY2-4 PER WEEK

63. DIAGNOSIS #1 MIGRAINE

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

65. Thanks