7-Headache and Facial Pain

7/30/2019 7-Headache and Facial Pain

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Headache and facial pain

Abeer Derawi

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Headache and facial pain

For you as dental students its very important to understand what is facial pain

rather than teeth, usually facial pain categorized in one of these classifications:

Secondary to pain of tooth origin Pain of Muscle and Joint Origin Pain of Nerve Origin Headache including Migraines (tension & cluster headache ) Others :Eyes, ears, sinus, parotid gland( otitis media, orbitalcellulitis,

sinusitis and mumps)

1) Pain of Muscle and Joint Origin:Usually we have pain of temporomandibular joint may occur in 10% of the US

population, most of them have it as a chronic period rather than an acute one.

TMJ anatomy

Look at the figure bellow you can see the synovial cavity which is very important,

here most of the pathophysiology would occur for the TMJ; we have the condyle of

the mandible that is resting in the temporal bone and it forms a synovial joint which

is a capsulated joint with a synovial fluid inside , so if we have any of thesecomponents inflamed we will have TMJ inflammation.


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So ,,,

Temporomandibular joint (TMJ ) is the site of articulation between the mandiblar

condyle and the skull, usually acts to open and close your mouth, specifically the

articular eminence of the temporal bone.

The articulation consists of parts of the mandible and temporal bones, which arecovered by dense, fibrous connective tissue and surrounded by several ligaments.

- We have several pairs of muscles attached to the mandible produce themovements (muscles of mastication): medial pterygoid ,lateral pterygoidtemporalis and the maseter.

- The nerve which supply it is the mandibular division of the trigeminal nerve V3.It's not only a motor, its also a major sensory of the face, it has pain-sensitive

elements within the TMJ inside the synovial capsule, so if this capsule becomeinflamed theV3 would actually has sensation , this is an implication for you

,because as you remember V3 has the inferior alveolar nerve which the one thatresponsible for innervation of the mandible and the lower teeth so sometimes

TMJ patients although they have a localized TMJ pain but also being supplied byV3 (inferior alveolar nerve branch) so it may radiate to the lower jaw !{ its an

important one of the differential diagnoses in the lower teeth that you shouldkeep in mind}

So its actually an inflammation within the joint accounts for TMJ pain, and the

dysfunction is caused by a disk-condyle incoordination.

It starts as inflammation that cause irritation at the TMJ , this TMJ pain wouldmake you not able to open your mouth properly and this will make the disk-condyle incoordination , this is the secondary effect of the problems of TMJ.

{keep in mind that it may radiate to the lower jaw !}

The etiology for TMJ usually include parafunctional behaviors, macrotraumas or

microtraumas, changes in the occlusion, and behavioral influences. Sometimespatients may have anteriorly located articulation of TMJ with the temporal bone,

sometimes even a trauma cause TMJ pain .

Its Known as a disk derangement disorder, articular disk displacement is the most

common temporomandibular arthropathy and is characterized by an abnormal


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relationship or misalignment of the articular disk relative to the condyle, so this is the

consequence of starting problem.

Its a cascade starts as inflammation in the TMJ secondary to trauma,secondary to misalignment that will lead to incoordination .

Sometimes TMJ problems may be associated with Myofascial pain which typically

occurs in patients that have stress in their life ,they will have some sorts of tender

points related to the muscles in their face.

So

- Its regional muscle pain or we call it myofascial pain.- these painful episodes usually when we palpate the muscle will have a pain

which makes it dull or achy in nature that associated with the presence of

trigger points in muscles, tendons, or fascia.- Most of the time its associated with trigger points in their body that we callit myalgia rheumatic.

- it may be associated with stress and oral habits (developmental factors) orpoor sleep, postural abnormalities, and depression.

- The major characteristics of myofascial pain include trigger points in musclesand local and referred pain.

- The trigger points may present clinically as active or latent. When active,digital palpation produces pain referral to a distant site.When latent, local

tenderness to palpation may be present, but no distant referral occurs.

This is actually related to the active inflammatory process, we dontcompletely understand why it happens , usually its associated to social

background these patient are depressed enough .

If you want to investigate paints with myofascial pain usually you have a disk

position and it is moving during the function so we do x-ray for the patient during the

active movement , we take it when the mouth is opened then we repeated with closed

mouth and we can see the inflammatory process that can occur in the TMJ .

evaluating how the condyle complex moves during these excursions is very useful

because sometimes its simple inflammatory that can be treated with non steroidal

but if its misdiagnosed and mistreated it may lead to the cascade that we discussed

(inflammatory process with the disk capsule derangement ) and so you might need

even MRI. (MRI remains the gold standard of diagnostic imaging for soft tissues and

the best method to assess disk position).


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Manegment :

The most important thing to diagnose the TMJ is the Patient Education and Self-

Care , if you have an inflammatory process at the TMJ so simply just ask the patient

not to move his TMJ that often so you rest the inflammatory process and the patient

become better , so : Ask the patient to avoid any thing that move the TMJ or using the muscles

of mastication for a while .

Patients should be instructed to avoid chewy foods, especially chewing gum. They can be taught to avoid clenching their jaws during the day, to apply

heat or ice, and to perform jaw-stretching exercises.

Pharmacological therapy:

the most common medications include nonsteroidal anti-inflammatory drugsand muscle relaxants. The use of tricyclic antidepressants for patient with Myofascial pain,

selective serotonin-norepinephrine reuptake inhibitors, and antiepileptic

drugs are also important in pain management , because most of the problems

are psychiatric.2) Neurological causes:

- trigeminal neuralgia- Glossopharyngeal neuralgia.

- Post-herpetic neuralgia.- Temporal arteritis.

Trigeminal neuralgia: (most important one )

TN is a neurologic condition that affects less than 1 percent of the population in the

United States but about 14 percent of those with nerve-related (neuropathic) pain,

more often in women, generally appearing in middle or late middle age.

The trigeminal nerve is the major nerve serving the face. It has three branches carry

sensations from the eyes, mouth, and jaw to the brain (ophthalmic , maxillary and the

mandibular).


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The pain of TN typically originates in the maxillary nerve, which runs along the

cheekbone and serves the nose, upper lip, and upper teeth, or the mandibular branch,

which controls sensation in the lower cheek, lower lip, and jaw( unlikely to be in the

ophthalmic ).

TN are classical and symptomatic,classical TN is the most common occurring

suddenly with no obvious trigger.

- Symptomatic TN is related to some underlying condition such as a tumor,aneurysm, multiple sclerosis, meningitis, or Lyme disease.(usually the mostdifficult to treat)

- Classical TN: the pain occurs when a vein or artery presses upon the trigeminalnerve where it enters the brain stem, the contact creates inflammation that

damages the nerve by stripping its myelin sheath interfering with the ability of a

nerve to conduct sensation normally( severe pain)

Symptoms :

- Very painful, sharp, electric-like spasms that usually last a few seconds orminutes but can become constant , usually its episodic pain

- Pain on one side of the face, often around the eye, cheek, and lower part of theface (although it can occur on both sides of the face)

- Pain triggered by touch or sounds and sometimes even cold weather-

Pain triggered by common, everyday activities, such as brushing teeth,chewing, drinking, eating, lightly touching the face, shaving the face (anything

that move your jaw stimulate the maxillary artery so the patient will have

electrical pain).

Treatment :

- Medical: AED including carbamazepine, pregabalin or Gabapentin.- Surgical: Peripheral nerve blocks involve the doctor attempting to block the

nerve with anesthetics such as lidocaine.


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Headache

We have primary headache which doesnt has any underlying mass / entiology in

the brain , it can be classified into : Migraine, tension, cluster and other primary

headache .

Definitely tension like headache is the most common which is a band like

headache secondary to muscular contraction ( front-occipitals muscle) and this can

has spasm related to stressors physical or emotional, so we call it tension like

headache that come in episodes usually occur at the late time of the day and released

by simple analgesia and rest .

Secondary headache is associated with underlying etiology, it might be secondary totrauma, vascular disease, intracranial pressure, substances abuse(cocaine),infections

and so many other etiology.

Migrain ) (:

Classically this patient will has pain in one side of the head and this can be

associated with other autonomic symptoms for example lacrimation.

Migraine is in essence an episodic disorder whose key marker is headache withcertain associated features :

- Unilateral, bilateral in 40%- Throbbing, worse with movement- Moderate to severe.- Associated with nausea/ vomiting/photo or photosensitivity (patient has the

attack of pain secondary to flashes of light or abnormal sounds).

- May occur with or without aura ,migraine aura is defined as a focalneurological disturbance manifesting as visual, sensory, or motor symptoms(may see stars dots or lines, feelparasthesia or has hemiparesis), its seen in

about 30% of patients.


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Why do we have autonomic manifestations secondary to the headache?

The intracranial contents above the tentorium cerebelli are innervated by the

trigeminal nerve which located in the Pons and one of the most important

autonomic nuclei located in the Pons as well ,So once the trigeminal nerve is being

stimulated it will release substances that will cause vasodilatation, and thisvasodilatation would aggravate the migraine headache , the sitmulation will go to

the nuclei of the nerve inside the Pons which is very adjacent to the autonomic

nuclei and so we will have what is called trigeminovascular system small fibers

enter the Pons down to the trigeminal nucleus which is associated to the autonomic

nuclei .

During the attack :

- The trigeminovascular system is activated- Trigeminal neuron supplying the dural vessels release many substances thatresult in vessel dilatation.

- Polysynaptic connections between the TNC and the superior salivatory nucleusexplain the ipsilateral autonomic symptoms(rhinorrhea, lacrimation and eye

redness).

Treatment :

Treatments for attacks can be divided into nonspecific and migraine-specific

treatments:

- Nonspecific treatments, (simple analgesia) such as aspirin, acetaminophen,nonsteroidal antiinflammatory drugs, opiates, and combination analgesics, are

used to treat a wide range of pain disorders.- Specific treatments, (related to the pathophysiology of the disease -

vasodilatation) including ergotamine, dihydroergotamine, and thetriptans.(vasoconstricting agents).

Preventive treatment: in order to decrease the frequency, duration, severity, and

tractability of acute attacks, we can use one of these options: AED, antidepressant,

beta blockers.


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Cluster headache

Cluster headache is a stereotypical episodic headache disorder , you cant

misdiagnose i.

- It is marked by frequent attacks of short-lasting, severe, unilateralhead painwith associated autonomic symptoms.

- Typical cluster headache location is retro-orbital, periorbital, andoccipitonuchal, (usually around the eye) associated with eye autonomic

symptoms as red eye and lacrimation .- Maximum pain is normally retro-orbital in greater than 70% of patients. Pain

quality is described as boring, stabbing, burning, or squeezing.- Cluster headache intensity is always severe, never mild.- The one-sided nature of cluster headaches is a trademark (retro-orbital or

periorbital).- Cluster sufferers will normally experience cluster headaches on the same sideof the head their entire life (unilateral ). Only in 15% of patients will the

headaches shift to the other side of the head at the next cluster period, and sideshifting during the same cluster cycle will only occur in 5% of patients.

- The duration of individual cluster headaches is between 15min up to 3 hours.- Attack frequency is between 1 and 3 attacks per day .- Cluster headache is marked by its associated autonomic symptoms, which

typically occur on the same side as the head pain, but can be bilateral.

- Lacrimation is the most common associated symptom, occurring in 73% ofpatients

- followed by conjunctival injection in 60% (red eye)- nasal congestion in 42%- rhinorrhea in 22%- partial Horners syndrome in 16% to 84%.

Triggers :

There are several distinct triggers associated with cluster headache including

hot weather, alcohol, nitroglycerin, histamine.

Treatment :

Oxygen inhalation is an excellent abortive therapy for cluster headache.

The treatment either abortive or preventive :


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- abortive treatment : most of the time we use 100% oxygen for 15 min and thisis the treatment of choice, we can give ergots, sumatriptan which arevasoconstrictions .

- preventive agents : Verapamile , Ca-channel blockers and Toperamate (antiepileptic).

Sunct syndrome :

The syndrome of short-lasting, unilateral neuralgiform headache attacks associated

with autonomic disturbances of conjunctival injection, tearing, rhinorrhea, or nasal

obstruction.

How can we differentiate this from cluster headache ?

definitely it is brief attack of moderate to severe head pain while cluster stats as

severe and the patient describe it as progressing symptoms so its not cluster ,

because cluster starts as severe then abates , in addition to this the typical age of onset

40-70 years but for cluster is younger.

So we have:

-

orbital or periorbital distribution.- Head pain can radiate to the temple, nose, cheek, ear, and palate.- The pain is normally side locked and remains unilateral throughout an entire

attack.

- stabbing, burning, pricking, or electric shocklike sensation. Pain duration is- extremely short, lasting between 5 and 240 seconds, with an average duration

of 10 to 60 seconds. ( this is the third and the most important way todifferentiate it from cluster )

- attack frequency ranges anywhere from1 to more than 80 episodes a day.Triggering maneuvers, including mastication, nose blowing, coughing, forehead

touching, eyelid squeezing, neck movements (rotation, extension, and flexion), and

ice-cream eating.


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Treatment :

By the time a patient with SUNCT would take an abortive medication the attack

theoretically would already be completed.

Preventive agents that have previously been tried include:

aspirin, paracetamol, indomethacin, naproxen, ergotamine, DHE, sumatriptan,prednisone, verapamil, valproate, lithium, propranolol, amitriptyline, and

carbamazepine.

Hemicrania Continua:

This is a female predominance syndrome, it is continuous daily head pain, which is

present 24 hours per day, 7 days per week, fluctuating it might be mild, moderate or

severe intensity.

Symptoms : include nausea, vomiting, photophobia, and phonophobia just like

migraine headache ( but migraine doesnt last for 7 days).

Treatment :usually we give Indomethacin to alleviate both the headache and aura.

Forgive me for any mistakeGood Luck

Abeer Derawi

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7-Headache and Facial Pain