Approach to the Patient with Head and Facial Pain Neurology

A headache which your history and physical exam suggests is due to the headache condition itself and not a separate cause. While they are likely triggered by genetic, developmental, and environmental factors, they are “idiopathic” in the sense that they do not arise from another underlying disease.

Symptoms bilateral band-like dull worse with activity age Treatment NSAIDS or Tylenol

Symptoms unilateral Pulsating moderate to severe lasts 4-72 hours worse with activity may have aura, nausea and/or vomiting, photophobia and photophobia often triggered by stress/foods/alcohol/sleep deprivation

Treatment Acute setting: sumatriptan, DHE Earlier treatment delivery is associated with better outcomes. Prophylaxis: beta-blockers, calcium channel blockers, amtriptyline, nortriptyline

Symptoms unilateral stabbing retro-orbital lasts 15 minutes to 3 hours ipsilateral lacrimation, ptosis, nasal congestion, rhinnorrhea

Patients are M>F, age Treatment 100% oxygen or low-dose prednisone

A secondary headache is a headache that is present because of another condition (such as a sinus headache from sinusitis). They are less common than primary headaches. Headache occurs in close temporal relation to the other disorder and/or there is other evidence of a causal relationship. Headache is greatly reduced or resolved within 3 months after successful treatment of the causative disorder.

Presentation often caused by head trauma associated with berry aneurysm rupture thunderclap "worst headache of my life" Diagnosis noncontrast head CT lumbar puncture (RBCs and xanthochromia)

Treatment neurosurgical evaluation calcium channel blocker (nimodipine) to prevent vasospasm blood pressure control (MAP <110 for unsecured aneurysm, <130 for coiled/clipped aneurysm)

Symptoms unilateral temporal associated with jaw claudication temporal artery tenderness to palpation Diagnosis ESR >50 temporal artery biopsy often associated with polymyagia rheumatica

Treatment steroids do not delay steroids for biopsy! can lead to blindness if not treated early

Symptoms unilateral facial pain episodic, severe, shooting Lasts seconds to minutes Often triggered by light touch, cold air, chewing hemifacial spasm: “tic douloureux” One, two, or three branches of the facial nerve may be affected; usually V2-3; (10% are bilateral)

Treatment carbamazepine second line treatments are also in the AED family: lamotrigine, oxcarbazepine, phenytoin, gabapentin

Meningitis Intracranial Neoplasm Pseudotumor cerebri

New onset of headache or new pattern of headache and age > 40 Focal signs or symptoms occurring with the headache, including auras Headaches worse with valsalva or worse in the laying down position (venous sinus thrombosis, intracranial hypertension) Headaches associated with severe vomiting

obese patient with intractable headaches or papilledema (pseudotumor) focal neurologic signs or symptoms or MRI findings needing cytological diagnosis (malignancy) subarachnoid hemorrhage older than 6 hours

A 65 y/o gentleman presents to his PCP with headache and transient “funny vision” in the R eye. Headache was in the right-sided, intermittent, pressure pain, started 2 weeks ago, progressively worse. He never had similar headache in the past. Also felt fatigue recently and had a low grade fever. Two days ago, he had an episode of right temporal vision loss for about 10 mins. Today, he had another similar episode for about 15 mins. What is your diagnosis?

55 yo man presents to the ER 36 hours after sudden onset severe headache. He initially rated the pain 10/10; now 8/10. He endorses neck pain, nausea/vomiting, and photophobia. His BP is 170/100, P 120. Exam is normal except for meningismus. A noncontrast head CT is normal. LP is performed. CSF has 3 WBC, 1200 RBCs/mm3 in tube 1 and 1220 RBCs/mm3 in tube 4. Protein is 85 mg/dL and glucose 32 mg/dL. What is your diagnosis?

A 48y/o F with h/o migraine presents with severe persistent headache for 1 week. The headache was similar to her previous migraine, but much more severe. Throbbing, left frontal temporal area, nausea, photophobia and phonophobia, worse with movement. No focal weakness, loss of consciousness, jerky movements, gait instability or other complaints. She tried Maxalt, but the pain only went away for two hours. She tried Topamax, Lyrica, Nortriptyline, Propranolol and Zonegran. None of these medications helped her headache very much. She used Tylenol, Ibuprofen and Vicodin almost every day. What is your diagnosis?