Download - HA Facial Pain 2001 Ppt
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Headache and Facial Pain
Robert H. Stroud, M.D.Byron J. Bailey, M.D.
January 31, 2001
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Referred Pain Brain tissue insensate Anterior & middle fossae
anterior to coronal suture Posterior fossa occipital and
upper neck Sphenoid & sella vertex
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Sinus Innervation Ophthalmic and maxillary
branches of 5th cranial nerve Greater superficial petrosal branch
of 7th cranial nerve Ostiomeatal complex > turbinates
> septum > sinus mucosa
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Frontal Sinus Ophthalmic
branch of 5th cranial nerve
Pain referred to forehead and anterior cranial fossa
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Anterior Ethmoid Ophthalmic
division Anterior ethmoid
nerve off nasociliary
Anterior septum, turbinates, ostiomeatal complex
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Posterior Ethmoid and Sphenoid Maxillary division
Posterior ethmoid nerve
Posterior septum, parts of superior and middle turbinates
Ophthalmic division Greater superficial
petrosal nerve
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Maxillary Sinus Maxillary division
of 5th cranial nerve Posterior superior
alveolar Infraorbital Anterior superior
alveolar
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Referred Otalgia Oral cavity
Mandibular division of 5th cranial nerve Auriculotemporal nerve
Pharynx Jacobson’s branch of 9th cranial nerve
Hypopharynx and supraglottic larynx Arnold’s branch of 10th cranial nerve
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History First occurrence Timing Quality Treatments Associated symptoms Precipitating factors
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Past Medical History Head injuries, infections, surgeries Psychiatric diagnoses Medications
OTC analgesics OCP Herbal medications Antihypertensives & vasodilators
Alcohol, tobacco, drugs
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Physical Examination Complete head & neck exam
Cranial nerves TMJ & muscles of mastication Scalp vessels Trigger points
Neurological exam
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Diagnostic Tests EEG CT and/or MRI EMG TMJ radiography Cervical spine films Labs Psychometric testing
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Tension-Type Headache Most common headache syndrome Episodic < 15 days per month Chronic > 15 days per month
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TTH - Characteristics 30 minutes to 7 days Pressing or tightening Mild to moderate pain Variable location, often bilateral Nausea and vomiting rare
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TTH - Treatment Stress
management Biofeedback Stress reduction Posture correction
Medication rarely needed in ETTH Benzodiazepines amitriptyline
CTTH Abortive
NSAIDs ASA-caffeine-
butalbital Phenacetin
Preventative Antidepressants Muscle relaxants NSAIDs
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Migraine 17% of females, 6% of males Moderate to severe pain Unilateral, pulsating 4 to 72 hours Nausea, vomiting, photophobia or
phonophobia With or without aura
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Migraines - Causation Sterile
inflammation of intracranial vessels - trigeminovascular system
Serotonin (5-hydroxytryptamine) receptors
Triggering factors Stress Menses OCP Infection Trauma Vasodilators Wine Aged cheeses
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Migraine - Treatment Abortive
5-hydroxytryptamine receptor agonists
Imitrex Oral, SQ, nasal
spray Maxalt Zomig Amerge
Ergotamine Butorphanol Midrin NSAIDs Lidocaine
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Migraine - Treatment Symptomatic
Prochlorperazine Dihydroergotamin
e Chlorpromazine Haloperidol Lorazepam
BOTOX?
Preventative Antidepressants Bellergal
(ergotamine) NSAIDs -blockers Calcium channel
blockers
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Cluster Intensely severe
pain Unilateral Periorbital 15 to 180 minutes Nausea and
vomiting uncommon
No aura
Alcohol intolerance Male predominance Autonomic
hyperactivity Conjunctival
injection Lacrimation Nasal congestion Ptosis
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Cluster
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Cluster Episodic
Two episodes per year to one every two or more years 7 days to a year
Chronic Remission phases
less than 14 days Prolonged
remission absent for > one year
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Cluster - Treatment Preventative
Calcium channel blockers
Bellergal Lithium Methysergide Steroids Valproate Antihistamines
Abortive Oxygen 5-HT receptor
agonists Intranasal
lidocaine
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Temporal Arteritis Moderate to severe, unilateral pain Patients over 65 Tortuous scalp vessels ESR elevated Biopsy for definitive diagnosis Treat with steroids Untreated complicated by vision loss
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Chronic Daily Headache 6 days a week for 6 months Bilateral, frontal or occipital Non-throbbing Moderately severe Due to overuse of analgesics ? Transformation of migraine or
TTH
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CDH - Treatment Patient understanding Remove causative medication Avoid substitution Antidepressants Adjuvant therapy Treatment of withdrawal
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Trigeminal Neuralgia Paroxysmal pain –
seconds to < 2 min
Distributed along 5th cranial nerve
Asymptomatic between attacks
Trigger points
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Trigeminal Neuralgia - Treatment Carbamazepine Gabapentin Baclofen Phenytoin Valproate Chlorphenesin
Adjuvant TCAs NSAIDs Surgery for
refractory cases
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Glossopharyngeal Neuralgia Similar to Trigeminal Neuralgia Unilateral pain
Pharynx Soft palate Base of tongue Ear Mastoid
Treatment as for Trigeminal Neuralgia
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Atypical Facial Pain Diagnosis of exclusion ? Psychogenic facial pain Location and description inconsistent Women, 30 – 50 years old Usually accompanies psychiatric
diagnosis Treat with antidepressants
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Post-Traumatic Neuralgia Neuroma
formation Occipital and
parietal scalp Diagnosis based
on history
Treatment Trigeminal
Neuralgia Bupivicaine to
trigger points Occasionally
amenable to surgery
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Post-Herpetic Neuralgia Persistent neuritic pain for > 2
months after acute eruption Treatment
Anticonvulsants TCAs Baclofen
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Temporomandibular Disorders Symptoms
Temporal headache Earache Facial pain Trismus Joint noise
60% spontaneous
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Internal Derangements Tenderness to
palpation Pain with
movement Audible click
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Degenerative Joint Disease Pain with joint movement Crepitus over joint Flattened condyle Osteophyte formation
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Myofascial Pain Most common 60% - 70% Muscle pain dominates Tenderness to palpation of
masticatory muscles
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TMD - Treatment NSAIDs Physical therapy Biofeedback Trigger point injection Benzodiazepines TCAs or SSRIs for chronic muscle
pain
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Pseudotumor Cerebri Intermittent headache Variable intensity Normal exam except papilledema Normal imaging CSF pressures > 200 cm H2O
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Pseudotumor Cerebri - Associated History Mastoid or ear
infection Menstrual
irregularity Steroid exposure Retro-orbital or
vertex headache
Vision fluctuation Unilateral or
bilateral tinnitus Constriction of
visual fields Weight gain
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Pseudotumor Cerebri – Treatment Reduce CSF production
Furosemide Acetazolamide
Weight loss Low salt diet CSF shunting Incision of optic nerve sheath
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Intracranial Tumor 30% have headache Dull or aching Crescendo over time Early morning Increased with valsalva Vomiting with nausea Neuro exam may be normal
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Subdural Hematoma History of trauma Fluctuating level of consciousness Pain lateralized Tenderness to percussion over
hematoma Trauma may be remote in chronic
SDH
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Subarachnoid Hemorrhage Sudden onset, severe, generalized
pain Nausea and vomiting Stiff neck progressing to back pain LP if imaging negative
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Infectious Meningitis
Acute meningitis Fever Stiff neck
Fungal Tuberculous Luetic
Epidural abscess AIDS of CNS Sarcoidosis Diagnosis
dependent on LP
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Hypertension Usually with diastolic pressures >
115 mm Hg Throbbing Nausea
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Low ICP Headache Usually from LP Worse with sitting or standing Vertex or occipital, pulling, steady Usually resolve spontaneously Blood patch for resistant cases
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Sinus Headache Acute sinusitis accepted Chronic sinusitis controversial Constant, dull, aching Worsened with jarring, stooping or
leaning forward Referred pain possible
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Contact Point Theory Stammberger and
Wolf 1988 Role of Substance
P Axonal reflex arc Predisposing
anatomy
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Agger Nasi Cells Anterior and
superior to insertion of middle turbinate
Narrow frontal recess
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Uncinate Variations Anterior
displacement Pneumatization Narrowing in
middle meatus or contact with middle turbinate
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Middle Turbinate Variations
Paradoxically bent
Concha bullosa Obstruction of
middle meatus Mucosal contact
with lateral nasal wall
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Ethmoid Variations Extensive
pneumatization Contact with
middle turbinate Obliteration of
middle meatus
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Haller’s Cells Anterior ethmoid
cells on floor of orbit
Narrow maxillary sinus ostium
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Surgery for Sinus Headache Clerico 1995
10 pts with prior diagnosis of headache syndrome
Mucosal contact points
7 operated on with relief of HA
3 responded to medical therapy for sinonasal findings
Parsons and Batra 1998 91% of 34 pts had
decreased intensity of HA post op
85% decreased frequency
All pts had indicators for surgery other than headache
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Surgery for Sinus Headache Headache as SOLE indication for
sinus headache still unproven Headache should improve with
decongestant and topical anesthesia if good results are to be expected post op
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Conclusion Headache & facial pain are
common complaints History most important in making
accurate diagnosis Recognize psychological aspects of
pain
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Case Study
29 year old WM presents with severe headache.