HEADACHE & FACIAL PAIN

Classification of Headaches  Pulsating or throbbing

 Associated with nausea, vomiting, photo
1. Iry headache disorders – Headache which and phonophobia
is the illness itself  Made worse by simple physical
 Tension type headache activities
 Migraine  Patient prefers to lie down in a quiet,
 Cluster headache darkened room
2. IIry headache – Patient has underlying
illness leading to headache. Aura of migraine

 Duration – approximately 20 mins

 Followed by migraine headache within
Tension type headache <60 mins
 Commonest aura- visual
 Main cause for chronic daily headache
o Photopsia(coloured/flickering
 Dull/ pressure/ head fullness
dots)
 Like a tight cap or band like o Fortification spectra(zig-zag
 Non throbbing lines)
 Bilateral o Scotoma(visual field deficits)
 Intensity is mild to moderate
 No aggravation by normal physical Management of migraine
activities. But heavy physical activities
will aggravate.  Abortive(acute) therapy
 Duration- 30 min-7 days  Preventive(prophylactic) therapy
 No nausea, vomiting, photo or
phonophobia Management of acute migraine

Management of tension type headache  Simple analgesia with anti-emetic –

NSAID + prokinetic(domperidone)
 Reassurance  Triptans(5HT 1B/1D agonist)-
 Tri-cyclic anti-depressants (TCAD) sumatriptan, rizatriptan, naratriptan
–low dose amitriptyline o work best when taken early
 Stress management o contraindicated in CAD, CVD,
 Regular aerobic exercise and uncontrolled hypertension
o very expensive
Migraine
Migraine prophylaxis
Classification
If 2 or more attacks per month or
1. Migraine with aura (classical)- 20% substantially interferes with daily routine-
2. Migraine without aura (common)- 80% After 6-12 months of effective prophylaxis
gradual withdrawal should be considered
 Females > males - 3:1
 Onset- adolescent- early adult life  β blocker(propranolol)
 TCAD(amitriptyline)
 Family history is common  CCB(flunarazine)
 Typically episodic  5HT2 antagonist(pizotifen)
 Each episode lasts for hours to 3 days  AED(topiramate, valproate)
 Unilateral in most  Angiotensin Receptor blocker-
 Typically fronto-temporal candesarton
 Moderate to severe intensity pain

Tver 2019
Cluster headache
 Occurs in clusters- daily for 1-2 months Medically sinister headaches
at a time
 Same time every day, usually at night  Neurological
 M>F o Increased ICP(SOL, BIH)
 Age 20s or 30s o Intra cranial infections
 Unilateral, usually begins around the (meningitis, encephalitis,
eye abscess)
 Excruciating pain, maximal within o SAH
minutes  Non- neurological
 30 mins-3 hrs(usually 45-60 mins) o Giant cell arteritis
 Lacrimation & redness in the ipsilateral o Glaucoma
eye o Acute hypertension
 Nasal congestion on same side
 Horner’s syndrome Features that suggestive of a medically sinister
cause for headache

 Sudden onset(few seconds)

Management of cluster headache  Progressively worsening daily
headaches
 Abortive therapy  Awakened by headaches
 Preventive therapy  Associated with fever
 New headache in a person over the age
Abortive therapy
of 50 yrs
o 100% O2  Papilloedema
o Sumatriptan- subcut. or IM  Focal neurological symptoms and signs
o Short course of steroid  Meningism

Preventive therapy

o Verapamil Giant cell arteritis

o Lithium
 Systemic vasculitis affecting
o AED- Topiramate, valproate
 Delay in treatment leads to irreversible
Neuro-imaging in Iry headache visual loss
 Steroid therapy prevents visual loss
 Recent change(significant) in pattern,  F:M= 2:1
frequency, severity of headache  ESR is >50
 Progressive worsening of headache  Focal headache, scalp tenderness, jaw
despite treatment claudication
 Focal neurological signs  Constitutional symptoms
 Onset of headache within exertion  Temporal arteries are typically tender,
 Onset of headache after 40 yrs swollen and non-pulsatile
 Reassurance  Temporal artery biopsy :- GCA
1. Decide which patient to neuroimage  High dose of steroid must be started
2. Manage or refer appropriately immediately if Dx is strongly suspected

IIry headache disorders

Tver 2019
  Neurological MRI Indicated for
o Increased ICP
o Intra cranial infections  Sensory loss(corneal reflex)
o SAH  <40 yrs
o Cervicogenic headache  Bilateral
 Non neurological  Poor response to conservative
o Giant cell arteritis management
o Sinusitis Treatment:-
o Refractory errors
o Glaucoma  Medical
 Systemic disorders o CBZ(drug of choice) or other
o Drugs: nitrates AED
 Surgical
o Microvascular decompression
o Ablative procedures of
Facial pain trigeminal nerve
o Injection of alcohol around the
Causes
ganglion- temporal
 Trigemianal neuralgia
 Post-herpetic neuralgia
 Dental pain
 Sinusitis(acute)
 Temporo-mandibular joint dysfunction

Trigeminal neuralgia

 After 50 yrs
 Duration- seconds
 May be repetitive
 Usually V2 or V3 and
unilateral(maxillary / mandibular)
 Trigger zones and trigger
factors(washing, ointment touching,
wind blowing)
 Typically does not disturb the sleep
 No clinically evident neurological
deficit

Cause: compression by an aberrant loop of

an artery or vein

MRI scan:- do only if atypical features are

present

Tver 2019