Headache & Facial pain

HEADACHE
AND FACIAL PAIN
A U D I A D I B A H | N I K N O R L I Y A N A | N U R U L H I D A Y U | A F F A N S Y A F I Q I | S
A T T I S H W A R A N

INTRODUCTION
 Headache is the most common reasons why a patient
seek for medical attention.
 Is the symptom of pain anywhere in the region of the
head or neck
 It classified into primary and secondary headache.

CLASSIFICATION
PRIMARY HEADACHE SECONDARY HEADACHE
 Or idiopathic
headaches
 The headache itself is
the disease
 Benign
 Recurrent
 No organic lesion in the
background
 Treat the headache
 Or symptomatic
headaches
 The headache is only a
symptom of an
underlying disease
 Treat the underlying
disease

PRIMARY HEADACHE
1. Tension-type
2. Cluster type
3. Migraine (with or without aura)
4. Sinus
5. Thunderclap headache - sudden onset (SAH)

TENSION HEADACHE
 Dull pain, tightness, or pressure around your forehead or the
back of your head and neck.
 Diffuse pain in tight head-band pattern
 Bilateral, non-pulsating
 Muscle aches and trouble focusing
 Mild photophobia or phonophobia
 10 attacks lasting 30 min–7 days
 Not aggravated by routine physical activity

CLUSTER HEADACHE
 The pain is sharp, burning or piercing sensation
 Unilateral pain behind eye
 Short, excruciating (15 min-3 hrs)
 Usually occur in the middle of the night
 Occur daily for 2-3mths then remit for months-years
 Red, watering eyes, blocked nose, sweaty face

SINUS HEADACHE
 Sinus headaches are headaches that may feel like an
infection in the sinuses (sinusitis).
 Pain, pressure and fullness in your cheeks, brow or
forehead
 Evidence of discharge from the nose
 Worsening pain if you bend forward or lie down
 Stuffy nose
 Fatigue

MIGRAINE HEADACHE
 A neurologic disorder characterised by idiopathic,
paroxysmal, recurrent attacks of headache lasting from
2-72 hours
 Migraine can occur with or without aura (flickering
lights, spots or zig-zag lines, fortification blind spots)
 Neurological, Gastrointestinal, Autonomic involvement
 Typical characteristics:
1. Unilateral (sometimes bilateral)
2. pulsating quality
3. Accompanied by nausea & vomiting or photophobia
& phonophobia
4. Aggravated by physical activity

MIGRAINE HEADACHE
Migraines often begin in
childhood, adolescence
or early adulthood.
Migraines may progress
through four stages,
though you may not
experience all stages.
 Prodrome
 Aura
 Headache
(‘attack’)
 Post-drome

MIGRAINE HEADACHE
Migraine triggers:
 Hormonal Changes in women – Fluctuation of
Estrogen
 Pregnancy or menopause
 Hormonal medication – oral contraceptives &
hormonal replacement therapy
 Foods / Food additives / Drinks
 Stress / Intense physical activities
 Changes in wake-sleep pattern
 Medication

COMPARISON
Source : NICE GUIDELINES 2012

MANAGEMENT
 Migraine
 Improved by lifestyle changes
 Medications are either to prevent or reduce symptoms once a
migraine starts.
 Beta-blockers, antidepressants, anticonvulsants and NSAIDs
 Tension-type headaches
 NSAIDs (ibuprofen, naproxen), acetaminophen or aspirin.
 For chronic tension type headaches, amitriptyline.
 Cluster headaches
 Subcutaneous, Sumatriptan and Triptan nasal sprays.
 High flow oxygen therapy also helps with relief.
 For people with extended periods of cluster headaches, preventive
therapy can be necessary.
 Verapamil is recommended as first line treatment

SECONDARY HEADACHE
Secondary to structures of the head and neck
• sinusitis, glaucoma, temporomandibular joint (TMJ) pain, tooth pain.
Secondary to chronic diseases
• Hypertension
• Anaemia
Secondary to psychiatric disorder
• somatisation, psychosis.
Infections
• Meningitis
• Encephalitis
Raised ICP
• Brain tumour
• Haemorrhagic stroke
• Head (SAH) and/or neck trauma
Secondary to a substance, or its withdrawal
• carbon monoxide, alcohol, medication-overuse headache

HOW TO APPROACH?
HISTORY
 Onset
 Progression
 Frequency
 Duration
 Location
 Character
 Severity
 Aura
 Eye/ear/nose symptoms
 Precipitating factors / Relieving factors
 Effective treatment
 Other medical problems

‘RED FLAG’ SYMPTOMS IN HEADACHE
SYMTPOMS POSSIBLE EXPLANATION
Sudden onset (maximal immediately or
within minutes)
1. Subarachnoid hemorrhage
2. Cerebral venous sinus thrombosis
3. Pituitary apoplexy
4. Meningitis
Focal neurological symptoms (other than
for typically migrainous) Intracranial mass lesion
Constitutional symptoms
 Weight loss
 General malaise
 Pyrexia
 Meningism
 Rash
Meningoencephalitis
Neoplasm
Raised intracranial pressure (worse on
wakening / lying down, associated
vomiting)
Intracranial mass lesion
New onset aged > 60 years Temporal arteritis

PHYSICAL EXAMINATION
GENERAL
 Vital signs
 Funduscopic examination (papilledema)
 CV assessment (assess risk of CVA)
 Palpation of the head and face (R/O sinusitis)
 Complete neurologic examination (focal neurologic signs)
 Evidence of meningeal irritation ( Neck flexion, Kernig sign,
Brudzinski sign)
RED FLAGS
 Headache beginning > 50 years of age (temporal arteritis, mass
lesion)
 Sudden onset of headache (SAH, haemorrhage into a mass lesion
or vascular malformation, mass lesion especially post. Fossa mass)

PHYSICAL EXAMINATION
RED FLAGS
 Headaches increasing in frequency and severity (mass lesion,
subdural hematoma, medication overuse)
 New onset headache in patient with risk factors for HIV infection or
cancer (Brain abscess, meningitis, metastasis)
 Headache with signs of systemic illness (e.g. fever, seizures, stiff
neck, rash indicating meningitis)
 Focal neurologic signs (mass lesion, vascular malformation, stroke,
collagen vascular disease evaluation)
 Papilledema (mass lesion, pseudotumor cerebri, meningitis)
 Headache subsequent head trauma (ICH, subdural hematoma,
epidural hematoma, post-traumatic headache)

INVESTIGATION
LABORATORY
 Random use of laboratory testing in the evaluation of acute
headache is not warranted.
 CBC when systemic or intracranial infection is suspected
 ESR when temporal arteritis is a possibility.
Neuroimaging
 Neuroimaging is not usually warranted in patients with primary
headaches.
 CT scanning is recommended to identify acute haemorrhage
 MRI studies are recommended to evaluate the posterior fossa.

INVESTIGATION
LUMBAR PUNCTURE
 CT scanning without contrast medium, followed by LP if
the scan is negative - is preferred to rule out SAH within
first 48 hours.
 LP is useful for assessing the CSF for blood, infection
and cellular abnormalities
 Headache are associated with low CSF pressure (e.g.
post-traumatic leakage of CSF) and elevated CSF
pressure (e.g. idiopathic intracranial HTN & CNS space
occupying lesion).

NEUROLOGIST REFERRAL
INDICATION
 Physician has inadequate level of comfort in diagnosing
or treating patient’s headache
 Patient request a referral
 Patient does not respond to treatment
 Patient’s condition or disability continuous or worsens
 Physician unable to classify patient’s headache
according to diagnostic criteria for primary or secondary
headache disorder
 Habituation or rebound headaches limit outpatient
management
 Patient has intractable or daily headaches

DEFINITION
Pain in the facial area may be due to neurological
or vascular causes, but equally well may be
dental in origin.
All the neurological and vascular causes of facial
pain (excluding headaches) are rare compared to
the dental and temporomandibular causes.

NEUROPATHIC AND VASCULAR PAIN
1. Trigeminal neuralgia
2. Post-herpetic neuralgia
3. Giant cell arteritis

TRIGEMINAL NEURALGIA
 A disorder of the trigeminal nerve that causes
episodes of sharp, stabbing pain in the cheek,
lips, gums, or chin on one side of the face.
 People with this pain often wince or twitch, which
is where trigeminal neuralgia gets its French
nickname ‘tic douloureux’, meaning "painful
twitch”.
 Commonly in middle aged or elderly people
 Female > Male

AETIOLOGY
Usually, the problem is contact between a
normal blood vessel — in this case, an artery or
a vein — and the trigeminal nerve at the base of
your brain. This contact puts pressure on the
nerve and causes it to malfunction.

AETIOLOGY
Can occur as a result of aging, or it can be
related to multiple sclerosis or a similar
disorder that damages the myelin sheath
protecting certain nerves. Less commonly,
trigeminal neuralgia can be caused by a tumor
compressing the trigeminal nerve.

TRIGGERS
1. Shaving
2. Touching your face
3. Eating
4. Drinking
5. Brushing teeth
6. Talking
7. Putting on makeup
8. Encountering a breeze
9. Smiling
10. Washing face

DIAGNOSIS
Trigeminal Neuralgia is mainly
diagnosed clinically
 History – Type, location and triggering factors
 Neurological examination
 MRI

TREATMENT
MEDICAL TREATMENT
1. Carbamazepine (Tegretol / Carbtal)
2. Phenytoin sodium (Dilantin)
3. Valproic acid
1. Microvascular decompression
SURGICAL TREATMENT

POST-HERPETIC NEURALGIA
If the pain is caused by shingles continues and
persists for more than 90 days (3 months) after the
bout of shingles is over – it is known as post-
herpetic neuralgia (PHN)
Post herpetic neuralgia is a painful condition that
affects the nerve fibres and skin.

POST-HERPETIC NEURALGIA
Age
Common is > 50 years
Site
Ophthalmic nerve is commonly affected
Complications
Parasthesia (loss of sensation)

PATHOPHYSIOLOGY
Shingles
Further nerve
damage by the virus
Changes in the
nervous system
Post-herpetic
neuralgia

SIGNS AND SYMPTOMS
SIGNS
 Pain is variable, from discomfort to very severe, and may be described as
burning, stabbing, or throbbing and constant.
 Area of previous herpes zoster may show evidence of cutaneous scarring
 Sensation may be altered over the areas involved, in the form of either
hypersensitivity or decreased sensation.
 In rare cases, the patient might also experience muscle weakness, tremor,
or paralysis if the nerves involved also control muscle movement.
SYMPTOMS

MANAGEMENT
PREVENTION
Varicella vaccine to prevent chickenpox – lessen the risk of the varicella
zoster virus lying dormant in the body and reactivating later as shingles.
TREATMENT
 Painkillers
 Anticonvulsants – calm nerve impulses and stabilizing abnormal electrical
activity in the nervous system caused by injured nerves
 Lidocaine skin patches – relieve itching, burning and pain from
inflamation
 Antidepressants – affects key brain chemical such as serotonon and
norepinephrine which influence how body interprets pain.

GIANT CELL ARTERITIS
Also called temporal arteritis – an inflammatory
disease of blood vessels and the cause is
unknown.

SYMPTOMS
1. Headache
2. Pain over the temples
3. Flu-like symtoms (fever, fatigue, loss of apetite)
4. Double vision or visual loss
5. Pain in jaw and tongue

INVESTIGATIONS
1. Erythrocyte sedimentation rate ESR – raised
2. CRP – elevated
3. Platelets – elevated

DIAGNOSIS
The gold standard for diagnosing temporal
arteritis is biopsy which involves removing a small
part of the vessel under local anesthesia and
examining it microscopically for giant cells
infiltration.
positive negative

TREATMENT
Corticosteroid (prednisolone) must be started as
soon as diagnosis is suspected to prevent
irreversible blindness secondary to ophthalmic
artery occlusion

OTHER CAUSES OF FACIAL PAIN
 Dental (tooth abscess) – one side, jaw, sensitive to touch
 Cluster headache – one side, stuffy nose, tearing around the eye,
30 minutes to 2 hours.
 Sinusitis – dull pain around the eyes and cheekbones worse
bending forward
 Migraine – aura, pain on one or both sides, nausea, throbbing or
pounding headache
 Post stroke pain – constant, moderate, or severe pain caused by
damage to the brain. This means that after a stroke, your brain does
not understand normal messages sent from the body in response to
touch, warmth, cold, and other stimuli. Instead, the brain may register
even slight sensations on your skin as painful.

APPROACH TO
FACIAL PAIN
DIAGNOSIS

HISTORY AND EXAMINIATION
 To make an accurate diagnosis, it is essential to
listen to the history and allow time for the patient
to complete their opening statement
 History needs to include details on:
1.Family history (any genetic predisposition)
2.Social history
3.Significant life events
4.Drug history
5.Past medical history

HISTORY
 Timing: onset, duration and periodicity
 Location and radiation
 Quality and severity
 Relieving and aggravating factors
Effect of prolonged chewing, eating, brushing teeth, touching the face,
etc
 Associated factors
Taste, salivary flow, clenching, nasal, eye or ear symptoms
 Other pain conditions
Headaches, migraines, etc.
 Impact of pain
e.g. sleep, mood, concentration, quality of life

PERIODICITY AND LOCATION
Chronic continuous pain
Bilateral Unilateral
 Temporomandibular disorders
 Persistent orofacial muscle pain
 Burning mouth syndrome
 Idiopathic orofacial pain
 Post hepatic neuralgia
 Post traumatic trigeminal pain
 Referred pain
 Post stroke pain
 Giant cell arteritis
 Chronic migraine
 Cancer pain
Neuropathic
Vascular
Musculoskeletal
Primary headache
Mixed / unknown

PERIODICITY AND LOCATION
Episodic pain
Bilateral Unilateral
 Tension type headache
 Medication overuse headache
 Classical trigeminal neuralgia
 Glossopharyngeal nauralgia
 Episodic migraine
Neuropathic
Vascular
Musculoskeletal
Primary headache
Mixed / unknown

EXAMINATION
 Extraoral examination is confined generally to the head and
neck region.
 Inspection
Any colour changes, swellings and skin lesions.
 Palpation
Any enlargement of salivary glands
Prominent temporal arteries with or without pulsation (Giant cell arteritis)
Any tenderness

EXAMINATION
Examination includes the muscles of mastication,
head and neck muscles for tenderness and trigger
points, muscle hypertrophy, and movement of the
temporomandibular joint including crepitus.
The cranial nerves need to be examined.
Intraoral examination (dental)

COMPARISON
Disorder Location / radiation Timing Quality / severity Aggravating factors
Post herpetic
neuralgia
Site of herpes zoster
extraoral and
intraoral
Continuous
Burning, tingling,
itchy, tender, can be
sharp at times
moderate to severe
Light touch, eating
Trigeminal neuralgia
Unilateral trigeminal
nerve most common
second and third
divisions extraoral
and intraoral
Paroxysmal attacks
of 2 s to minutes,
refractory period
between attacks,
10–30 attacks daily,
may remit for
weeks, months.
Other types can
have a longer pain
that can last for
hours
Sharp, shooting
electric shock like,
frightful, but in
some aching,
burning after pain,
moderate to very
severe
Light touch washing,
cold wind, eating,
brushing teeth,
many attacks are
evoked but some
can be spontaneous

COMPARISON
Disorder Location / radiation Timing Quality / severity Aggravating factors
Giant cell arteritis
Temporal region
jaw area may be
bilateral
Continuous often
sudden onset
Dull aching
throbbing but can
be very severe if
tongue
claudication is
occurring
Chewing
Post stroke pain
Ipsilateral to stroke
often whole side of
the face,
periorbital
Continuous begins
after a stroke
within a few
months but can be
delayed
Aching, burning
pricking, mild to
moderate
Touch

REFERENCE
 DAVIDSON’S PRINCIPLE & PRACTICAL
MEDICINE 22nd EDITION
 NICE GUIDELINES
 MAYO CLINIC
 MEDLINE PLUS

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