Headache and

Facial pain for

Dentist’54
Surat Tanprawate, MD, MSc(Lond.), FRCPT
Division of Neurology
Chaing Mai University

Tuesday, 31 May 2011

 Pain

René Descartes, French

Philosopher
31 March 1596 – 11 February 1650

Tuesday, 31 May 2011

 Headache and Pain Sensitive Structure
Meninges

Venous sinus

Artery:
-dural a.
-carotid a.
-basilar a.

Neural structure:
-glossopharyngeal n.
-trigeminal n.
-upper cervical n.
Tuesday, 31 May 2011
 International Classification of
Headache Disorder-2004

Part 1. The primary headaches

- Migraine, TTH, CH and other
TACs, and other primary headache
disorder
Part II. The secondary headaches International Classification of
-Headache attributed to .... Headache Disorder 2004

Part III. Cranial neuralgias,

central and primary facial pain and
other headaches http://ihs-classification.org

Tuesday, 31 May 2011

 Description and Criteria
http://ihs-classification.org

Description

Criteria

Tuesday, 31 May 2011

 Patient presents with
complaint of a headache Red flag signs

Critical first step: (+)

Hx taking, physical exam
Investigation

Red flag signs or alarming

signs

Meets criteria for primary

headache disorder?
(-) (+)

Migraine Tension-type
headache headache

Cluster
Other (rare) Secondary
Chronic daily headache headache
headache and
other TACs headache (CDH) disorder disorder
Tuesday, 31 May 2011
 Alarming signs and
symptoms

• “Alarming s/s suggest the possibility of

secondary headache
• The studies
• Headache sample (specific or non-
specific)
• Pool analyzed data => guideline

Tuesday, 31 May 2011

 Focal neurologic s/s
Abnormal neurological other than typical visual
examination or sensory aura

Papilledema
Normal neurological
Neck stiffness
examination

Temporal Concurrent Provoking

Age
profile event activity

Age> 50 Worsening headache Pregnancy, post Triggered by cough,

-Mass lesion, SDH, partum exertion or Valsava
MOH -Cerebral vein -SAH, mass lesion
thrombosis, carotid
dissection, pituitary
apoplexy
Sudden onset
Worse in the
-SAH, ICH, mass morning
lesion (posterior -IICP
fossa) Headache with
cancer, HIV, systemic
illness (fever,
arteritis, collagen Worse on awakening
vascular disease) -Low CSF pressure

Tuesday, 31 May 2011

 To Divide Primary
Headache
Common primary Chronic daily Other (unusual)
headache disorder headache primary headache
(CDH) disorder

Remember the Approach Identify the

criteria CDH triggers and
-Migraine associated
-Tension-type
factors
headache
-Cluster headache
and other TACs
Modified from Bigal M. E. et al. J Headache Pain. 2007; 8: 263-272

Tuesday, 31 May 2011

 Diagnostic criteria of common
primary headache disorder
Migraine without aura Infrequent ETTH

Migraine with typical aura needs 2 attacks ICHD-II Cephalalgia.2004

In children, the attack may last 1-72 hours
Tuesday, 31 May 2011
 Cluster headache
Cluster headache
and others TACs

“Short lasting, unilateral,

severe headache
accompanying with
autonomic symptoms”

ICHD-II Cephalalgia.2004
Tuesday, 31 May 2011
 Common primary
headache disorder

Migraine and Tension-type headache

Tuesday, 31 May 2011
 Early migraine
description
"He seemed to see something
shining before him like a light,
usually in part of the right eye; at
the end of a moment, a violent pain
supervened in the right temple,
then in all the head and neck....
vomiting, when it became
possible, was able to divert the
pain and render it more moderate."
Hippocrates (c.460-c.370 B.C.)

JMS Pearce. JNNP 1986;49:1097-1103

Tuesday, 31 May 2011
 Migraine with aura =
“Classic migraine”
"He seemed to see something
shining before him like a light,
usually in part of the right eye; at
the end of a moment, a violent pain
supervened in the right temple,
then in all the head and neck....
vomiting, when it became
possible, was able to divert the
pain and render it more moderate."

Tuesday, 31 May 2011

 ʻʻTeichopsiaʼʼ
(Greek for ʻʻtown
wall visionʼʼ)

ʻʻOn a distinct form of

transient hemiopsiaʼʼ by
Dr. Hubert Airy in 1870.

Tuesday, 31 May 2011

 The “Classic” Migraine =
Migraine with aura

Tuesday, 31 May 2011

 The different faces of migraine
Classic migraine

MA: Migraine
Headache
various aura types variant

-Change headache Clinical

- Typical aura
character in CM/ manifestation
-Atypical aura
TM

Tuesday, 31 May 2011

 Migraine Aura Typical aura:
-Visual
99% 31% -Sensory
-Speech

6%

18%

n=163
Michael B. R. et al. Brain 1996: 119, 355-361
Tuesday, 31 May 2011
 Typical aura
• Typical aura consisting of visual and/or
sensory and/or speech symptoms.
Gradual development, duration no
longer than one hour, a mix of
positive and negative features and complete
reversibility characterize the aura which is
associated with a headache that does not
fulfill criteria for Migraine without aura.

Tuesday, 31 May 2011

 Visual aura

Typical visual aura is simple

Tuesday, 31 May 2011

 Population-based study
Only migraine without aura
Only migraine with aura
Both types

14%

19%

67%

Migraine without aura is more common

(previously called common migraine)
Launer LJ et al. Neurology 1999;53:537-42

Tuesday, 31 May 2011

 Visual Aura
Zig-zag lines (fortification)

Zig-zag lines in migraine aura

Olomouc (c.1757) bastion fortress in Table of Fortification, from the 1728

today's Czech Republic
Tuesday, 31 May 2011
 Alice in Wonderland
Syndrome (AWS)

Somesthetic metamorphopsia.
Distortion of body and space
Did Lewis Carroll draw inspiration
from migraine auras?
Alice in Wonderland. By Lewis Carroll
Tuesday, 31 May 2011
 Hemiplegic
migraine Retinal
Basilar
migraine migraine

Persistent aura Typical aura

Migraine
without without
infarction Variant headache

Complication of migraine Childhood periodic syndromes

-Chronic migraine Migraine that are commonly precursors
-Status migrainosus triggered of migraine
-Persistent aura without seizure -Cyclic vomiting syndrome
infarction -Abdominal migraine
-Migrainous infarction -Benign paroxysmal vertigo of
childhood
Tuesday, 31 May 2011
 Tension-type headache

• Most common headache type

• Featureless headache, uncertain pathophysiology

(mental or muscular cause?)

• HRQoL of Headache

• ETTH > CTTH = EM > CM/TM

• When migraine become chronic, the headache’s

characters are similar to TTH

Tuesday, 31 May 2011

 TTH diagnostic criteria

Tuesday, 31 May 2011

 Uncommon primary
headache disorder

Cluster headache, and other TACs

Other primary headache disorder

Tuesday, 31 May 2011

 Patient presents with
complaint of a headache Red flag signs

Critical first step: (+)

Hx taking, physical exam
Investigation

Red flag signs or alarming

signs

Meets criteria for primary

headache disorder?
(-) (+)

Migraine Tension-type
headache headache

Cluster
Other (rare) Secondary
Chronic daily primary headache
headache and
other TACs headache (CDH) headache disorder
Tuesday, 31 May 2011
 Trigeminal Autonomic
Cephalalgia
“The most severe headache ever”

Tuesday, 31 May 2011

 TACs
“A group of primary headache disorders
characterized by strictly unilateral head
pain that occurs in association with
ipsilateral cranial autonomic
features”

- Cluster headache (CH)

- Paroxysmal hemicrania (PH)

- Short-lasting unilateral neuralgiform headache

attacks with conjunctival injection and tearing/
cranial autonomic features (SUNCT/SUNA)
Tuesday, 31 May 2011
 TACs subtypes

Cohen AS. Headache 2007

Tuesday, 31 May 2011
 Other headache disorder

Short duration Long duration

Triggered Not triggered

Physical Sleep
activity

-Primary cough Hypnic -Primary stabbing -Hemicrania continua

headache headache headache
-Primary exertional -New daily-persistent
headache
-Primary headache (NDPH)
-Primary headache thunderclap
associated with headache
sexual activity

http://ihs-classification.org
Tuesday, 31 May 2011
 Cranial Neuralgias and
Other causes of Facial
pain

Tuesday, 31 May 2011

 Structure based approach

• Musculoligamentous based
• Dentoalveolar based
• Neurological based
• Trigeminal Autonomic
Cephalalgias(TACs)
• Cranial neuralgias
Tuesday, 31 May 2011
 • Localisation
Clinical
• Time pattern clues
• Onset, circadian distribution,
Course and progression

• Duration
• Quality
• Intensity
• Precipitating and alleviating factor
• Associated symptoms and signs
Tuesday, 31 May 2011
 Clinical classification of
facial pain syndromes

1. Neuralgias
2. Facial pain syndrome with cranial nerve
signs and symptoms
3. Trigeminal autonomic cephalalgias(TACs)
4. Pure facial pain without neurological signs

Tuesday, 31 May 2011

 1. Neuralgias

• The presence of sudden, sharp, aching,

lancinating, burning, and stabbing pain lasting
from only a few seconds to less than 2 min
and recurring repeatedly within short
periods of time, which is often triggered by
sensory or mechanical stimuli

Tuesday, 31 May 2011

 ICHD-II, 2004

Tuesday, 31 May 2011

 Trigeminal Neuralgia

• 70% of patients are older than 60 years at

onset
• Clinical hallmark:
• brief electric shock-like pains

• abrupt in onset and termination

• limited to the distributions of the trigeminal

nerve

• commonly stimuli: mechanical

Tuesday, 31 May 2011

Tuesday, 31 May 2011
 Classical trigeminal neuralgia

Symptomatic trigeminal neuralgia

“TN caused by a demonstrable structural lesion”

Tuesday, 31 May 2011

 2. Facial pain syndrome with
cranial nerve signs and symptoms
• pain in the face accompanied by s/s caused by a
lesion of one or several cranial nerve
• pain around the eye+optic n. or ocular motor
system dysfunction

• pain with disturb facial sensation, facial palsy,

hyperacusis

• pain with disturbed balance

• pain with dysphagia, dysphonia, or dysarthria

Tuesday, 31 May 2011

 4. Facial pain without
neurological signs

• Disorder of the
temporomandibular joint
• Disorder of the oral structures or
salivary gland
• Rhinosinus-related headache

Tuesday, 31 May 2011

 Headache attributed to disorder
of teeth, jaws or related
structures
• Headache accompanied by pain in the teeth and/
or jaw(s) and fulfilling criteria C and D

• Evidence of disorder of teeth, jaws, or

related structures

• Headache and pain in teeth and/or jaw(s) develop

in close temporal relation to the disorder

• Headache and pain in teeth and/or jaw(s)

resolve within 3 months after successful
treatment of the disorder

Tuesday, 31 May 2011

 Headache attributed to
temporomandibular joint(TMJ) disorder
• Recurrent pain in one or more regions of the head and/or face fulfilling
criteria C and D

• X-ray, MRI and/or bone scintigraphy demonstrate TMJ disorder

• Evidence that pain can be attributed to the TMJ disorder, based on at least
one of the following:

• pain is precipitated by jaw movements and/or chewing of hard or tough

food

• reduced range of or irregular jaw opening

• noise from one or both TMJs during jaw movements

• tenderness of the joint capsule(s) of one or both TMJs

• Headache resolves within 3 months, and does not recur, after successful
treatment of the TMJ disorder

Tuesday, 31 May 2011

 International Classification of
Headache Disorder-2004

Part 1. The primary headaches

- Migraine, TTH, CH and other
TACs, and other primary headache
disorder
Part II. The secondary headaches International Classification of
-Headache attributed to .... Headache Disorder 2004

Part III. Cranial neuralgias,

central and primary facial pain and
other headaches http://ihs-classification.org

Tuesday, 31 May 2011

 Thank you for your attention
My deepest gratitude
to...

Dr Siwaporn Chankrachang
Department of Neurology, CMU,
Chiangmai, Thailand

Dr Manjit Matharu
Headache Group, Institute of Neurology,
Queen Square, London, UK

Tuesday, 31 May 2011