Headache & Facial Pain John F. Rothrock, M.D. Professor & Vice Chair, UAB Neurology

Headache Diagnosis: Primary vs Secondary When is “migraine” reallymigraine? When is “migraine” really migraine?

19 yo Female university coed reports 10 years of episodic, unilateral, pulsatile headache, often heralded by “sparkles & blind spots” in the right periphery of vision. Midrin no long helps.

“Secondary” Headache subarachnoid hemorrhage subarachnoid hemorrhage meningitis meningitis ICP too high or low ICP too high or low cerebral sinus thrombosis cerebral sinus thrombosis pituitary apoplexy pituitary apoplexy … and many more

Clues to Secondary Headache fever, seizure, behavioral change, etc fever, seizure, behavioral change, etc age >55 age >55 posterior location posterior location neurological deficit neurological deficit abrupt onset/severe intensity: “thunderclap” abrupt onset/severe intensity: “thunderclap”

“Primary” Headache tension-type tension-type migraine migraine cluster cluster all the rest all the rest

Recurrent Disabling Headache it’s usually migraine it’s usually migraine

What is Migraine? prevalence prevalence cost cost clinical definition clinical definition clinical phenotypes/ “chronification” clinical phenotypes/ “chronification”

What Causes Migraine? vascular theory vascular theory trigeminovascular theory trigeminovascular theory central theory central theory

Trigeminal Nucleus Caudalis Receives Afferent Messages and Acts as a Sensory Relay Center

Cortical Spreading Depression migraine generator? migraine generator?

Trigeminal Nucleus Caudalis Receives Afferent Messages and Acts as a Sensory Relay Center

Facial Pain typical” vs. “atypical” typical” vs. “atypical” “symptomatic” vs. “primary” “symptomatic” vs. “primary”

Trigeminal Neuralgia: Diagnosis Table 1 Trigeminal Neuralgia: IHS Diagnostic Criteria A. Paroxysmal attacks of facial or frontal pain which last a few seconds to less than two minutes B. Pain has at least 4 of the following characteristics: (1) distribution along one or more distributions of the trigeminal nerve. (2) sudden, intense, sharp, superficial, stabbing or burning in quality. C.No neurologic deficit D.Attacks are stereotyped in the individual patient. E. Exclusion of other causes of facial pain by history, physician examination and special investigations when necessary.

Trigeminal Neuralgia: Treatment pharmacologic pharmacologic “procedural” “procedural” anesthesia dolorosa anesthesia dolorosa

“Atypical” / Symptomatic Facial Pain carotid dissection carotid dissection giant cell (“temporal” arteritis) giant cell (“temporal” arteritis) acute V-Z & post-herpetic neuralgia acute V-Z & post-herpetic neuralgia Tolosa – Hunt syndrome Tolosa – Hunt syndrome