Headache&FacialPainDiagnosisandmanagement

• TheInterna*onalClassifica*onofHeadacheDisorders3rd,edi*onbetaversion2013->280typesofheadachearedescribed• Interna*onalHeadacheSociety(hDp://www.ihs-headache.org/)• „Cephalalgia”(hDp://cep.sagepub.com/content/33/9/629.full).

HEADACHE:• 1/PRIMARY• 2/SECONDARY• 3/NEURALGIA

TENSION–TYPEHEADACHE•  Tension-typeheadachepainiso\endescribedasaconstantpressure,asiftheheadwerebeingsqueezedinavise.Thepainisfrequentlypresentonbothsidesoftheheadatthesame*me.Tension-typeheadachepainistypicallymildtomoderate,butmaybesevere.•  Episodicorchronic•  Tensionheadachesaffectabout1.4billionpeople(20.8%ofthepopula*on)andaremorecommoninwomenthanmen(23%to18%respec*vely)

Variousprecipitatingfactorsmaycausetension-typeheadache:•  Stress:usuallyoccursinthea\ernoona\erlongstressful

workhoursora\eranexam•  Sleepdepriva*on•  Uncomfortablestressfulposi*onand/orbadposture•  Irregularmeal*me(hunger)•  Eyestrain•  Tension-typeheadachesmaybecausedbymuscletensionaroundtheheadandneck.Oneofthetheoriessaysthatthemaincausefortension-typeheadachesisteethclenchingwhichcausesachroniccontrac5onofthetemporalismuscle.

Headachediagnosis:1/Historytalking:localisa*onofthepain,character,howlong?,howo\en?,precipita*ngfactors;aura,characterofaura,nusea,vomi*ng,ifdependsonbodyposi*on,physicalac*vity,weather,menstrua*on,sleep,historyofheadacheinfamily,concomitantdisease,concomitanttreatment2/Physicalexamina*on,Neurologicalexamina*on3/Laboratory(morphology,Fe,Borreliaburgdorferi)4/Neuroimaging:MRofthehead,angioMR,angioCT5/ECG6/Ophthalmologistconsulta*on7/Laryngologistconsulta*on-sinusi*scanbeacauseofchronicheadache8/Stomatologistconsultac*on9/Psychologist10/Inprac*ceitisrecommendedtoprovidepa5ent’sdiary

Treatment:• preven*on• ibuprofen,paracetamol/acetaminophen,aspirin• relaxa*ontechniques

MIGRAINE:•  Typically,theheadachesaffectsonehalfofthehead

(butinchildreno\enbilateral),arepulsa*nginnature,andlastsfromtwoto72hours,canbemoderateorsevere•  Associatedsymptomsmayincludenausea,vomi*ng,andsensi*vitytolight,soundorsmell•  Thepainisgenerallymadeworsebyphysicalac*vity.•  Uptoone-thirdofpeoplehaveanAURA:typicallyashortperiodofvisualdisturbancewhichsignalsthattheheadachewillsoonoccur

MIGRAINE:•  AURA-mechanismof“cor*calspreadingdepression”•  Auraappearsgraduallyoveranumberofminutesandgenerallylastlessthan60minutes.•  Symptomscanbevisual,sensoryormotorinnatureandmanypeopleexperiencemorethanone.•  Visualeffectsoccurmostfrequently:scin*lla*ngscotoma(anareaofpar*alaltera*oninthefieldofvisionwhichflickersandmayinterferewithaperson'sabilitytoreadordrive)•  Thesetypicallystartnearthecentreofvisionandthenspreadouttothesideswithzigzagginglineswhichhavebeendescribedaslookinglikefor*fica*onsorwallsofacastle.Usuallythelinesareinblackandwhitebutsomepeoplealsoseecolouredlines.Somepeopleloosepartoftheirfieldofvisionknownashemianopsiawhileothersexperienceblurring.

,,AliceinWonderlandSyndrom”

•  Sensoryaura:O\enafeelingofpins-and-needlesbeginsononesideinthehandandarmandspreadstothenose–mouthareaonthesameside•  Othersymptomsoftheauraphasecanincludespeechorlanguagedisturbances,worldspinning,andlesscommonlymotorproblems.• Motorsymptomsindicatethatthisisahemiplegicmigraine,andweaknesshemiplegia,hemiparesiso\enlastslongerthanonehourunlikeotherauras–5min-24hours-familialhemiplegicmigraine–type1(FHM1-genCACNA1A),type2(FHM2-genATP1A2),type3(FHM3-genSCN1A)

• Migrainesarebelievedtobeduetoamixtureofenvironmentalandgene*cfactors.Abouttwo-thirdsofcasesruninfamilies.Changinghormonelevelsmayalsoplayarole,asmigrainesaffectslightlymoreboysthangirlsbeforepubertyandtwotothree*mesmorewomenthanmen.• Mechanismsarenotfullyknown–probablyinvolvethenervesandbloodvesselsofthebrain• Migraineisbelievedtobeaneurovasculardisorderwithevidencesuppor*ngitsmechanismsstar*ngwithinthebrainandthenspreadingtothebloodvessels.Onetheoryisrelatedtoincreasedexcitabilityofthecerebralcortexandabnormalcontrolofpainneuronsinthetrigeminalnucleusofthebrainstem.HighlevelsoftheneurotransmiDerserotonin,alsoknownas5-hydroxytryptamine,arebelievedtobeinvolved.

Thediagnosisofmigrainewithoutaura,accordingtotheInterna5onalHeadacheSociety,canbemadeaccordingtothefollowingcriteria:•  FiveormoreaDacks—formigrainewithaura,twoaDacksaresufficientfordiagnosis.

•  Fourhourstothreedaysindura*on•  Twoormoreofthefollowing:•  Unilateral(affec*nghalfthehead);•  Pulsa*ng;•  Moderateorseverepainintensity;•  Aggrava*onbyorcausingavoidanceofrou*nephysicalac*vity

•  Oneormoreofthefollowing:•  Nauseaand/orvomi*ng;•  Sensi*vitytobothlight(photophobia)andsound(phonophobia)

Migrainesaredividedintosevensubclasses(someofwhichincludefurthersubdivisions):§ Migrainewithoutaura,or"commonmigraine",involvesmigraineheadachesthatarenotaccompaniedbyanaura.

§ Migrainewithaura,or"classicmigraine",usuallyinvolvesmigraineheadachesaccompaniedbyanaura

§ Childhoodperiodicsyndromesthatarecommonlyprecursorsofmigraineincludecyclicalvomi*ng(occasionalintenseperiodsofvomi*ng),abdominalmigraine(abdominalpain,usuallyaccompaniedbynausea),andbenignparoxysmalver*goofchildhood(occasionalaDacksofver*go).

•  Re*nalmigraineinvolvesmigraineheadachesaccompaniedbyvisualdisturbancesoreventemporaryblindnessinoneeye.•  Complica*onsofmigrainedescribemigraineheadachesand/oraurasthatareunusuallylongorunusuallyfrequent,orassociatedwithaseizureorbrainlesion.•  Probablemigrainedescribescondi*onsthathavesomecharacteris*csofmigraines,butwherethereisnotenoughevidencetodiagnoseitasamigrainewithcertainty(inthepresenceofconcurrentmedica*onoveruse).•  Chronicmigraineisacomplica*onofmigraines,andisaheadachethatfulfillsdiagnos*ccriteriaformigraineheadacheandoccursforagreater*meinterval.Specifically,greaterorequalto15days/monthforlongerthan3months.

MIGRAINE-MANAGEMENT1.ManagementoftheaDack:•  -Analgesic:Paracetamol,Ibuprofen,Aspirin,Naproxen,•  -Triptans•  -Metoclopramid•  -Ergotamine•  Statusmigrainosus(whenmigrainelas*nglongerthan72hours)-Metoclopramid,Diazepam,Mannitol,steroids

2.Preven*vetreatment:•  Propranolol,Flunaryzyna,amitryptylina,an*epilep*cdrugs(VPA,topiramat,gabapentyna)•  Nonpharmacologicalmethods-useofstressreduc*ontechniquessuchascogni*vebehaviouraltherapyandrelaxa*ontechniques•  elimina*onoftriggers,dietary

SECONDARYHEADACHE•  Traumacapi*s,vasculardiseases,hypertension,infec*on,epilepsy,increasedintracranialpressure(tumourcerebri,idiopathicintracranialhypertension=pseudotumourcerebri),laryngologicaldisease(sinusi*s,o**s),ophatmologicdisease(visionloss,glaucoma)• Headacheinstomatology:odontogenicpain,non-odontogenicpain,temporomandibularjointdysfunc*onsyndrome• Headacheintumourcerebri:Duetoincreaseofintracranialpressure,bilateral,o\eninthemorningwithvomi*ng-neuroimagingcito!!!

• Bruns’syndrome:Characterizedbysuddenandsevereheadache,accompaniedbyvomi*ngandver*go,triggeredbyabruptmovementofthehead.Principalcausesarecystsandcys*cerosisofthefourthventricle,andtumoursofthemidlineofthecerebellumandthirdventricle

Trigeminalneuralgia=ticdouloureux•  episodesofintensefacialpainalongthetrigeminalnerve

divisions.Thetrigeminalnerveisapairedcranialnervethathasthreemajorbranches:theophthalmicnerve(V1),themaxillarynerve(V2),andthemandibularnerve(V3).

TrigeminalneuralgiamostcommonlyinvolvesV2orV3.•  EachindividualaDackusuallylastsfromafewsecondstoseveralminutesorhours,butthesecanrepeatforhourswithveryshortintervalsbetweeneachaDack.Inotherinstancesonly4-10aDacksareexperienceddaily.Theepisodesofintensepainmayoccurparoxysmally.

Trigeminalneuralgia•  Todescribethepainsensa*on,pa*entso\endescribeatriggerareaonthefacesosensi*vethattouchingorevenaircurrentscantriggeranepisode;however,inmanypa*entsthepainisgeneratedspontaneouslywithoutanyapparents*mula*on.Itaffectslifestyleasitcanbetriggeredbycommonac*vi*essuchasea*ng,talking,shavingandbrushingteeth.Wind,chewingandtalkingcanaggravatethecondi*oninmanypa*ents.•  TheaDacksaresaidbythoseaffectedtofeellikestabbingelectricshock,burning,sharp,pressing,crushing,explodingorshoo*ngpainthatbecomesintractable.

Trigeminalneuralgia

•  Severaltheoriesexisttoexplainthepossiblecausesofneuralgia.•  leadingresearchindicatesthatitisanenlargedorlengthenedbloodvessel–mostcommonlythesuperiorcerebellarartery–compressingorthrobbingagainstthemicrovasculatureofthetrigeminalnervenearitsconnec*onwiththepons.Suchacompressioncaninjurethenerve'sprotec*vemyelinsheathandcauseerra*candhyperac*vefunc*oningofthenerve.ThiscanleadtopainaDacksattheslightests*mula*onofanyareaservedbythenerveaswellashinderthenerve'sabilitytoshutoffthepainsignalsa\erthes*mula*onends.

•  Thistypeofinjurymayrarelybecausedbyananeurysm;byanAVM(arteriovenousmalforma*on);byatumourinthecerebellopon*neangle.

•  Othercauses:mul*plesclerosis,Herpessimplex(V1)

Trigeminalneuralgia

• Diagnosis:MR,angioMR• MANAGEMENT:•  carbamazepin,gabapen*n,okskarbazepine,pregabalin,valproicacid,lamotrigine,phenytoin,clonazepam•  Surgical–non-destruc*vemethod-microvasculardecompressionordestruc*vemethods

Glossopharyngealneuralgia(GN)•  Affectstheglossopharyngealnerveandcauses

sharp,stabbingpulsesofpaininthebackofthethroatandtongue,thetonsils,andthemiddleear.•  Paincanlastforafewsecondstoafewminutes,andmayreturnmul*ple*mesinadayoronceeveryfewweeks.• ManyindividualswithGNrelatetheaDacksofpaintospecifictriggerfactorssuchasswallowing,drinkingcoldliquids,sneezing,coughing,talking,clearingthethroat,andtouchingthegumsorinsidethemouth.•  GNcanbecausedbycompressionoftheglossopharyngealnerve,butinsomecases,nocauseisevident.Itcanbeassociatedwithmul*plesclerosis.GNprimarilyaffectstheelderly.

STROKE

DEFINITIONOFSTROKE•  Stroke,alsoknownascerebrovascularaccident(CVA)or"brainaDack",is

asyndromecausedbyadisrup*onintheflowofbloodtopartofthebrainduetoeitherocclusionofabloodvessel(ischemicstroke)orruptureofabloodvessel(hemorrhagicstroke).Theinterrup*oninbloodflowdeprivesthebrainofnutrientsandoxygen,resul*ngininjurytocellsintheaffectedvascularterritoryofthebrain.Ischemicstrokesaremorecommonthanhemorrhagicstrokes.

•  Whenbraincellsdie,func*onofthebodypartstheycontrolisimpairedorlost,causingparalysis,speechandsensoryproblems,memoryandreasoningdeficits,coma,andpossiblydeath

TYPESOFSTROKE

•  Ischemicstroke

(IS) 75-85%•  Intracerebralhemorrhage

(ICH) 10-20%•  Subarachnoidalhemorrhage(SAH)

ok.5%

BRAINISCHEMIA

•  TransientischemicaDack,TIA(<24hours)•  Reversibleischemicneurologicaldeficit,RIND(<21days)

•  Minorstroke(non-disabling)•  Majorstroke(disabling)

FACTORSASSOCIATEDWITHANINCREASEDRISKOFSTROKE

•  Age(increasedwithage)•  Gender(males>females)•  Race(Blacks>AsiansandHispanics>Whites)•  Geographicregion(EasternEurope>WesternEurope;Asia>EuropeorNorthAmerica)

•  Familyhistory(strokeorheartdisease<age60)

POTENTIALLYMODIFABLERISKFACTORSFORSTROKE

•  Hypertension•  Diabetesmellitus•  Hyperlipidemia•  Smoking•  Atrialfibrilla*on•  Hyperhomocysteinemia•  Physicalac*vity

OTHERPOTENTIALRISKFACTORS

•  Migraine•  Oralcontracep*ves•  Obesity•  Pregnancy•  Alcoholabuse•  Drugabuse•  Sleepdisorders(sleepapnea)

TYPESOFIS

•  ATHEROSCLEROTIC(Plaquesleadtostenosis,occlusion,distalembolisa*on(artery-to-arteryembolism)andstealphenomena

•  CARDIOEMBOLIC

•  LACUNAR

•  OTHERS

•  UNDETERMINED

CARDIACCAUSESOFIS•  Atrialfibrilla*on•  RecentMI•  Ventricularaneurysm(postMI)•  Akine*csegment(postMI)•  Dilatedcardiomyopathy•  Muralorintraven*cularthrombus•  Valvularabnormali*es(mitralinsufficiency,mitralandaortalstenosis).

Alsocongenital•  Infec*veendocardi*s•  Atrialseptalaneurysm/defect•  Patentforamenovale(PFO)•  Myxoma•  Mechanicalorbioprosthe*cvalve•  CABG,PTCA,othercardiacsurgery

OTHERCAUSESOFIS

•  Vasculopathies– Noninflamatory(dissec5on,vasospasm,others)–  Inflamatory(PAN,SLE,vasculi5s,others)–  Infec5ous(syphilis,HerpesZoster,AIDS,others)

OTHERCAUSESOFIS•  Hematologicandcoagula5ondisorders–  Polycythemia,thrombocytosis,trombocytopenia–  An5thrombinIIIdeficiency–  ProteinCorSdeficiency–  DeficiencyoffactorsV,VII,XII,XIII–  An5phospholipid/an5cardiolipinan5bodies– Malignancy–  Pregnancy–  Oralcontracep5ves

SYMPTOMSOFSTROKE

•  Symptomsdependonlocaliza5onandsizeoflesion

•  Lessone5ology/causeofstroke•  Focalsymptoms•  Globalsymptoms

SYMPTOMSOFSTROKE

Timecourseandevolu5on:•  Suddenorrapidonsetofsymptoms–  inthemorning,inday5me– onsleep,exercise

•  Reachmaximalintensitywithin24hours•  Gradualorstepwiseworseningcanoccur

SYMPTOMSOFSTROKE

Focalneurologicalsymptoms:•  Cogni5veimpairments(aphasia,neglect,apraxia)

•  Weaknessorincoordina5onoflimbs•  Facialweakness•  Numbnessoflimbsand/orface•  Cranialnervepalsies

SYMPTOMSOFSTROKE

Globalsymptomsandsigns:•  Headache•  Nauseaandvomi5ng•  Alteredmentalstatus–  syncope–  seizure–  coma

•  Hypertensionandabnormalvitalsigns•  Nuchalrigidity

SYMPTOMSOFTIA/STROKE

•  Caro5dcircula5on–  Ipsilateralmonocularblindness– Contralateralweakness,numbness(hand,arm,face,leg)

– Aphasia

Lechemisphere(ie,dominant)

•  Righthemiparesis,variableinvolvementoffaceandupperandlowerextremity

•  Right-sidedsensoryloss,inasimilarpaeerntothemotordeficit;usuallyinvolvesallmodali5es,decreasedstereognosis,graphesthesia

•  Righthomonymoushemianopia•  Aphasia,fluentandnonfluent•  Alexia•  Agraphia•  Acalculia•  Apraxia

Righthemisphere(ie,nondominant)

•  Lechemiparesis(samepaeernasonright)•  Lec-sidedsensoryloss(similarpaeernasthemotor

deficit)•  Lechomonymoushemianopia(samepaeernasonright)

•  Neglectofthelecsideofenvironment•  Anosognosia•  Asomatognosia•  Lossofprosodyofspeech•  Flataffect

Posteriorcircula5on

PCAocclusion•  Themostcommonfindingisoccipitallobeinfarc5onleadingto

contralateralhemianopiawithmacularsparing

•  ClinicalsymptomsassociatedwithocclusionofthePCAvarydependingontheloca5onoftheocclusionandmayincludethethalamicsyndrome,thalamicperforatesyndrome,Webersyndrome,cor5calblindness,colorblindness,failuretoseeto-and-fromovements,verbaldyslexia,andhallucina5ons.

Basilararteryoclusion

•  Abnormallevelofconsciousness

•  Quadriparesis,whichusuallyisasymmetric

•  Pupillaryabnormali5es

•  Oculomotorsigns

Subarachnoidhaemorrhage(SAH)

• Bleedingintothesubarachnoidspace—theareabetweenthearachnoidmembraneandthepiamatersurroundingthebrain.•  Thismayoccurspontaneously,usuallyfromarupturedcerebralaneurysm,ormayresultfromheadinjury

Cerebralaneurysm—aweaknessinthewallofoneofthearteriesinthebrainthatbecomesenlarged.TheytendtobelocatedinthecircleofWillisanditsbranches.

Subarachnoidhaemorrhage(SAH)

•  Signsandsymptoms:asevereheadachewitharapidonset("thunderclapheadache"),aheadachedescribedas"likebeingkickedinthehead",orthe"worstever",developingoversecondstominutes.Thisheadacheo\enpulsatestowardstheocciput(thebackofthehead),meningism,vomi*ng,confusionoraloweredlevelofconsciousness,andsome*messeizures•  Diagnosis:CTofthehead,MR,lumbarpuncture-mandatoryinpeoplewithsuspectedSAHifimagingisnega*ve(redbloodcells,xanthochromiaatleast>12hoursa\ertheheadache),ECG,angiography

Subarachnoidhaemorrhage(SAH)Management:•  involvesgeneralmeasurestostabilizethepa*entwhilealsousingspecificinves*ga*onsandtreatments.• preven*onofrebleedingbyoblitera*ngthebleedingsource(neurosurgery),preven*onofaphenomenonknownasvasospasm(nimodipine-calciumchannelblocker),•  andpreven*onandtreatmentofcomplica*ons(seizures-an*epilep*cdrugs,electrolytedisturbanceslikehyponatremia,hydrocephalus)

CEREBRALHAEMORRHAGE:

•  spontaneousintracerebralhemorrhage(inptwithhypertension)•  headtrauma•  ruptureofananeurysmorarteriovenousmalforma*on(AVM)•  bleedingwithinatumor•  amyloidangiopathy•  RiskfactorsforICHinclude:•  hypertension(highbloodpressure)•  Diabetesmellitus•  CigareDesmoking•  Excessivealcoholconsump*on•  Severemigraine

Moyamoyasyndrome:•  isadisease(congenitaloracquired)inwhichcertainarteriesinthebrainareconstricted.Acollatercircula*ondevelopsaroundtheblockedvesselstocompensatefortheblockage,butthecollateralvesselsaresmall,weak,andpronetohemorrhage,aneurysmandthrombosis.Onconven*onalX-rayangiography,thesecollateralvesselshavetheappearanceofa"puffofsmoke"(describedas"もやもや(moyamoya)"inJapanese).•  Moyamoyadiseasetendstoaffectadultsinthethirdtofourthdecadeoflife.Inchildrenittendstocausestrokesorseizures.Inadultsittendstocausestrokesorbleeding.Theclinicalfeaturesarestrokes,recurrenttransientischemicaDacks(TIAs),sensorimotorparalysis(numbnessandparalysisoftheextremi*es),convulsionsand/ormigraine-likeheadache.•  Treatment:aspirin,surgical

ThankYou