1. HEADACHE & FACIAL PAIN Ahmed Alarfaj,MD

2. INTRODUCTION Major reason for seeking medical care. Major reason for seeking medical care. 90% is vascular headache. 90% is vascular headache. 10% is mixture of inflammation,traction or dilatation of pain sensitive structure. 10% is mixture of inflammation,traction or dilatation of pain sensitive structure.

3. PATHOPHYSIOLOGY Pain Pain Referred pain Referred pain –Pattern of referred pain

4. CLINICAL ASSESSMENT History History –Hx of present illness –Past medical hx –Family hx –Social hx Physical examination Physical examination

5. CLINICAL ASSESSMENT Clinical features suggesting serious cause Clinical features suggesting serious cause –Crescendo –Early morning –Vomiting –Fever –Seizures & other neurological symptomes –Worst headache in my life –Known malignancy –Tenderness

6. Facial pain Typical Neuralgias 1) Trigeminal neuralgia Characterized by recurring paroxysmal severe pain, brief duration (seconds) in the territory of the trigeminal nerve, spontaneously or initiated by chewing, talking, touching the affected side of the face.Characterized by recurring paroxysmal severe pain, brief duration (seconds) in the territory of the trigeminal nerve, spontaneously or initiated by chewing, talking, touching the affected side of the face. Unknown aetiology, an arterial loop pushing on the sensory root in the posterior fossa.Unknown aetiology, an arterial loop pushing on the sensory root in the posterior fossa. Females affected more than malesFemales affected more than males Analgesics, surgery, destruction of the sensory neuron, division of nerve root.Analgesics, surgery, destruction of the sensory neuron, division of nerve root.

7. Facial pain Typical Neuralgias 2) Glossopharyngeal neuralgia Unknown causeUnknown cause Equal both sexesEqual both sexes Severe, sudden episodes of pain in the tonsil region one side only, ipsilateral ear.Severe, sudden episodes of pain in the tonsil region one side only, ipsilateral ear. Pain - severe for 1-2 hours, recur dailyPain - severe for 1-2 hours, recur daily Treated like trigeminalTreated like trigeminal

8. Facial pain Typical Neuralgias 3) Sluder’s neuralgia and Vidian neuralgia Intractable pain in the nose, eye, cheek and lower jaw.Intractable pain in the nose, eye, cheek and lower jaw. Could be due to lesion of the sphenopalatine ganglion, or vidian nerve.Could be due to lesion of the sphenopalatine ganglion, or vidian nerve. Analgesics, vidian neurectomyAnalgesics, vidian neurectomy

9. Facial pain Posttraumatic neuralgia Posttraumatic neuralgia –Neuroma –Parietal & occipital –90% recovery

10. Facial Pain Atypical facial pain Atypical facial pain  Pain felt over the cheek, nose, upper lip or lower jaw  Usually bilaterally symmetrical  Aching, shooting, burning, accompanied by reddening of the skin and lacrimation or watering of the nose  Lasts for hours, days or weeks  Psychological consultation, analgesics

11. Symptomatic Neuralgias Intracranial lesions 1) Central lesions Tumours of the brain stem, M.S., thrombotic lesions, metastasis, occult naso-pharyngeal ca.Tumours of the brain stem, M.S., thrombotic lesions, metastasis, occult naso-pharyngeal ca. No precipitant, sensory loss.No precipitant, sensory loss. 2) Post herpetic neuralgia Herpes zoster may affect trigeminal nerve ganglionHerpes zoster may affect trigeminal nerve ganglion Vesicular rash covers one division commonly the 1 st with severe pain.Vesicular rash covers one division commonly the 1 st with severe pain.

12. Symptomatic Neuralgias Extracranial lesions 1) Sinus disease Infective and neoplastic lesions of the paranasal sinus.Infective and neoplastic lesions of the paranasal sinus. Facial pain & dental pain, loss teeth.Facial pain & dental pain, loss teeth. Clinical suspicion.Clinical suspicion. TreatmentTreatment 2) Dental neuralgia Dental carriesDental carries Dental extractionDental extraction 3) Temporomandibular joint pain

13. Headache Headache is one of the commonest symptoms in medical practice. Aetiology: 1) Raised intracranial pressure  Due to tumours, abscesses, subdural haematoma, brain haemorrhage. 2) Inflammation of the brain and meninges  e.g. meningitis, cerebritis, others

14. Headache 3) Migraine  Congenital predisposition  Triggered by hunger, certain foods, sleep - too much or too little, hormonal variations, stress.  Pathology-vascular dilatation  Females affected more than males  ? Proceeded by aura usually visual, paraesthesiae of hands, weakness  Headache is unilateral or bilateral, affects any area of the head, aching or throbbing often accompanied by nausea and vomiting  Diagnosis - by history alone  Treatment - prevention by avoiding precipitating factors, appropriate medication.

15. Headache 4) Tension headache  More common in adult females  Positive family history (40%)  Maybe associated with migraine  Produced by persistent contraction of the muscles of the neck, head and face  Caused by emotional tension, secondary to other headaches, posture habit  Treated by analgesics, muscle relaxants, physiotherapy

16. Headache 5) Cluster headache  90% are men  Age 20 - 30  Attacks occur in groups, no aura  Caused by vascular dilatation of branches of external carotid  Triggered by histamines, alcohol  Treated by analgesics, anti-histamine, steroids

17. Pains from head and neck muscles Pain from temporalis muscles  Can arise from grinding teeth at night (bruxism), impacted wisdom teeth, temporomandibular joint dysfunction, anxiety when the patient clenches the jaws too tightly Treatment: Refer to interested dental surgeon.

18. Pains from head and neck muscles Pain from upper neck muscles  Can radiate over the head Treatment by physio-therapist or rheumatologist Pain from frontalis muscles  Usually due to bad posture at work or while driving Treatment: physio-therapy

19. Pains from head and neck muscles Cervical spondylosis  Pain mediates upwards from the neck to the occiput or vertex to the front of the head, down to the shoulders  Due to cervical discs prolapse  Diagnosis - x-ray Treatment: Physio-therapy, referral to rheumatologist

20. Pains from head and neck muscles Temporal arteritis  Due to acute inflammation of the artery, the cause unknown, affects men and women over the age of 60  Pain over the temples and frontal region, intense, throbbing, tenderness over the scalp, swelling and redness of the overlying skin with general malaise, partial or complete loss of vision.  ESR Elevated Treatment: Cortisone, analgesics

21. Pains from head and neck muscles Psychologic headache  Usually accompanied by depression, anxiety  No organic lesion