HEADACHE &

FACIAL PAIN
Anwar Wardy W
Dept. Neurology FKK UMJ

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

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 Facial Pain Syndrome
Trigeminal Neuralgia
Paroxysms of intense, stabbing pain in the
distribution of the mandibular and maxillary
divisions of the 5th cranial nerve
Pain is initiated by the stimulation of certain
areas of the face, lips or gums- the so-called
trigger zones
Other associated symptoms include more or
less continuous discomfort, itching and
sensitivity of the face
 Facial Pain Syndrome
Trigeminal Neuralgia
Usually a spatial and temporal summation of
impulses is necessary to trigger a paroxysm of
pain, followed by a refractory period of up to 2-3
minutes
Most cases are idiopathic
Anticonvulsant drugs such as phenytoin, valproic
acid, clonazepam, carbamazepine, alone or in
combination, suppresses or shorten the duration
of attacks
 Facial Pain Syndrome
Glossopharyngeal Neuralgia
Much less common than the trigeminal neuralgia
Pain is intense and paroxysmal; originates in the throat
and is provoked most commonly by swallowing
The only craniofacial neuralgia that maybe accompanied
by bradycardia and syncope
 Facial Pain Syndrome
Postherpetic Neuralgia
Neuralgia associated with a vesicular eruption due to
infection with the herpes zoster virus
Eruption will appear within 4-5 days after the onset of
pain
In the region of cranial nerves, 2 syndromes are
frequent: herpes zoster auricularis and ophthalmicus
 Facial Pain Syndrome
Postherpetic Neuralgia
Ramsay-Hunt syndrome: herpes of the external auditory
meatus and pinna and sometimes of the palate and
occipital region- with or without deafness, tinnitus,
vertigo combined with facial paralysis
 Facial Pain Syndrome
Occipital Neuralgia
Paroxysmal pain may occasionally occur in the
distribution of the greater and lesser occipital nerves
There may be tenderness where the nerves cross the
superior nuchal line
 Facial Pain Syndrome
Carotidynia
Special type of cervicofacial pain that could be elicited by
pressure on the common carotid arteries of patients with
atypical facial neuralgia, or the so-called lower half
headache of Sluder
 Facial Pain Syndrome
Coster Syndrome (TMJ Pain)
-A form of craniofacial pain consequent upon
dysfunction of the TMJ
- diagnosis is supported by findings of tenerness
over the joint , crepitus on opening the mouth,
limitation of jaw opening
- Mgt. Consists of careful adjustment of the sit by
a dental specialist and should be undertaken
only when the patient meets the diagnostic
critetria for this condition
 Facial Pain Syndrome
TMJ Pain Syndrome
pain localized to the muscles of mastication,
preauricular area or the TMJ
Innervation: auriculotemporal nerve
common initial symptom: otalgia
Deviation of the mandibular midline to one side is
usually due to a failure of the condyle to slide
forward on the side to which the chin is deviating
 PATHOPHYSIOLOGY
Pain
Referred pain
oPattern of referred pain

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CLINICAL ASSESSMENT
History
oHx of present illness
oPast medical hx
oFamily hx
oSocial hx
Physical examination

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

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 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.
Unknown aetiology, an arterial loop pushing
on the sensory root in the posterior fossa.
Females affected more than males
Analgesics, surgery, destruction of the
sensory neuron, division of nerve root.

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

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

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 Facial pain
Posttraumatic neuralgia
o Neuroma
o Parietal & occipital
o 90% recovery

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 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

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

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

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 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

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 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 .

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 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

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 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

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 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.

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 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

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 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

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 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

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

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 Wassalam,

Jakarta, 8 Maret 2013

Anwar Wardy w

fkk umj anwar wardy