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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 dilatationof pain sensitive structure.
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Facial Pain SyndromeTrigeminal Neuralgia
Paroxysms of intense, stabbing pain in thedistribution 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-calledtrigger zones
Other associated symptoms include more or lesscontinuous discomfort, itching and sensitivity ofthe face
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Facial Pain SyndromeTrigeminal Neuralgia
Usually a spatial and temporal summation ofimpulses is necessary to trigger a paroxysm of
pain, followed by a refractory period of up to 2-3minutes
Most cases are idiopathic
Anticonvulsant drugs such as phenytoin, valproic
acid, clonazepam, carbamazepine, alone or incombination, suppresses or shorten the durationof attacks
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Facial Pain SyndromeGlossopharyngeal Neuralgia
Much less common than the trigeminal neuralgia
Pain is intense and paroxysmal; originates in the throatand is provoked most commonly by swallowing
The only craniofacial neuralgia that maybe accompaniedby bradycardia and syncope
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Facial Pain SyndromePostherpetic Neuralgia
Neuralgia associated with a vesicular eruption due toinfection 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
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Facial Pain SyndromePostherpetic 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
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Facial Pain SyndromeOccipital Neuralgia
Paroxysmal pain may occasionally occur in the
distribution of the greater and lesser occipital nerves
There may be tenderness where the nerves cross thesuperior nuchal line
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Facial Pain SyndromeCarotidynia
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
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Facial Pain SyndromeCoster Syndrome (TMJ Pain)
-A form of craniofacial pain consequent upondysfunction of the TMJ
- diagnosis is supported by findings of tenernessover 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 undertakenonly when the patient meets the diagnosticcritetria for this condition
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Facial Pain SyndromeTMJ 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
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PATHOPHYSIOLOGY
Pain
Referred painoPattern of referred pain
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CLINICAL ASSESSMENT
HistoryoHx of present illness
oPast medical hxoFamily hx
oSocial hx
Physical examination
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CLINICAL ASSESSMENT Clinical features suggesting serious cause
o Crescendo
o Early morning
o Vomitingo Fever
o Seizures & other neurological symptomes
o Worst headache in my life
o Known malignancy
o Tenderness
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Facial painTypical Neuralgias1) Trigeminal neuralgia
Characterized by recurring paroxysmalsevere pain, brief duration (seconds) in theterritory of the trigeminal nerve, spontaneouslyor initiated by chewing, talking, touching theaffected side of the face.
Unknown aetiology, an arterial loop pushingon the sensory root in the posterior fossa.
Females affected more than males Analgesics, surgery, destruction of the sensoryneuron, division of nerve root.
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Facial painTypical Neuralgias2) Glossopharyngeal neuralgia
Unknown cause
Equal both sexes Severe, sudden episodes of pain in the
tonsil region one side only, ipsilateralear.
Pain - severe for 1-2 hours, recur daily Treated like trigeminal
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Facial painTypical Neuralgias3) 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
oNeuroma
oParietal & occipital
o90% 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 lacrimationor watering of the nose
Lasts for hours, days or weeks Psychological consultation, analgesics
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S i
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SymptomaticNeuralgias
Intracranial lesions1) Central lesions
Tumours of the brain stem, M.S., thromboticlesions, metastasis, occult naso-pharyngealca.
No precipitant, sensory loss.
2) Post herpetic neuralgia Herpes zoster may affect trigeminal nerve
ganglion
Vesicular rash covers one division commonlythe 1st with severe pain.
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HeadacheHeadache 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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Headache3) Migraine
Congenital predisposition Triggered by hunger, certain foods, sleep - toomuch 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 anyarea of the head, aching or throbbing oftenaccompanied 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 themuscles of the neck, head and face
Caused by emotional tension, secondaryto 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 ofbranches 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
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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 torheumatologist
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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 of60
Pain over the temples and frontal region, intense,throbbing, tenderness over the scalp, swelling andredness 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
anwar wardyfkk umj