12 - Head, Ocular or Facial Pain

Question 1

Head Pain

Answer 1

1. In addition to eye exam — check BP, check pulse, neurological examination for meningeal signs (neck stiffness), CN functions
2. Any visual phenomena should prompt careful visual field testing
3. SNOOP to identify red flags of headache

Question 2

Head Pain

Answer 2

1. GCA should be suspected in all patients > 50.
2. Elevated ICP — 2/2 IIH or intracranial mass can cause global, constant headache worse in AM. Bending or momving head worsens pain as does Valsalva maneuver from coughing or straining. Vomiting may occur without nausea. CN 6 palsy or papilledema may be present, pulsatile tinnitus and transient visual loss are common associated symptoms
3. Sudden severe headache accompanied by neck stiffness, change in mentation or focal neurologic signs suggests intracranial hemorrhage. Neuroimaging urgently required
4. Meningitis — may not be associated with focal neurological deficits. neck stiffness on flexion, back pain, pain on eye movement and photophobia may suggest meningeal inflammation

Question 3

Migraine

Answer 3

1. Repetitive bouts of headache
2. Linked to hormonal changes, pregnancy, puberty, hunger, stress, foods, sleep deprivation
3. Unilaterality and pulsating nature associated with phonophobia, photophobia, nausea, vomiting, aggravation of pain with routine physical activity
4. Evaluation
   
   1. Occasionally mass lesion or large vascular malformation heralded by typical migraine symptoms but in such cases often residual visual field defects — thus important to perform visual field testing in evaluation of patients with presumed migrainous visual aura.
   2. Referral to neurologist prudent
   3. Additional evaluation in patients with headaches alwasy on same side, headache preceding aura, neurological deficit, visual field defect, persisting aura resolves, more than 1 aura

Question 4

Migraine without aura

Answer 4

1. 65% of all migraine
2. Global, asymmetric bilateral, unilateral, hours to days
3. Hard to distinguish from tension headache

Question 5

Migraine with aura

Answer 5

1. 30% all migraines
2. Because visual aura originates from occipital lobes, visual aura bilateral although patient may report them as monocular in eye that has symptoms in temporal visual field
3. Aura builds over minutes with positive visual phenomena that has movement — scintillating scotoma with fortification spectrum. Scotoma bounded by zigzag, shimmering, colorful silvery image that moves temporally into periphery adn then breaks up. Loss of vision may occur and presence of both positive and negative phenomena hallmark of migraine aura. Lasts 5-60 minutes usually followed by contralteral throbbing headache. Aura completely resolves and associated with nausea, photophobia, phonophobia.
4. Pathophysiology — primary dysfunction of sensory neurons of CN V

Question 6

Aura without headache

Answer 6

1. AKA acephalgic migraine
2. Must be differentiated from TIA
3. Mainly occours in adults with hx of migaine with aura
4. Scintillating scotoma and less commonly transient homonymous hemianopia without positive visual phenomena OR peripheral visual field constriction that progresses to tunnel vision or complete vision loss
5. Last 5-60 minutes

Question 7

Tension headache

Answer 7

1. Chronic
2. Often precipitated by stress
3. Provoked by foods, estrogen, scents, exercise, smoke, sleep, depression

Question 8

Headache treatment

Answer 8

1. Migraine
   
   1. Acute — Triptans, NSAIDs, medications with caffeine
      
      1. Triptans should be used cautiously as to avoid vasoconstriction-induced artifact. May cause MI and not used in patients with CAD
      2. Analgesic medications should be used with caution as can cause analgesic rebound headache thus medication hx important
      3. Topirimate (GABA agonist) may cause acute myopic shift, ciliochoroidal effusion, acute bilateral angle-closure glaucoma
   2. Prophylactic — NSAID, SSRIs, Ca-channel blockers, TCAs

Question 9

Trigeminal autonomic cephalgias

Answer 9

1. Short-lasting unilateral head pain + ipsilateral cranial autonomic findings
2. Cluster headache — 15-180 minutes of excruciating bouts of pain and localized behind one eye in distribution of CN V₁. Associated ipsilateral tearing, conjunctival injection, rhinorrhea, transient postganglionic Horner syndrome. Pain may wake the patient from sleep and cause restlessness. Headaches occur in episodes over days to weeks typically same time of day then remit for months or years
3. Paroxysmal hemicrania — 2-30 minutes of severe pain that occur several times daily. Indomethacin cures attack
4. Short-lasting unilateral neuralgiform headache attacks with conjunctival injection (SUNCT) — 20x per day lasting 5-240 seconds associated with conjunctival injection and tearing
5. Hemicraina continua — continuous unilateral headache that waxes and wanes and responsive to indomethacin

Question 10

Idiopathic stabbing headache

Answer 10

1. Episodic momentary stabbing pains that responds to indomethacin

Question 11

MELAS

Answer 11

1. Headache may be seen in patients with mitochondrial myopathy and encephalopathy, lactic acidosis, and stroke-like episodes

Question 12

CADASIL

Answer 12

1. Headache may be presenting sign in patients with cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy

Question 13

Trochleitis

Answer 13

1. May cause headache
2. May be associated limitation of eye movement
3. May be associated with underlying systemic autoimmune disease
4. High doses of NSAIDs used

Question 14

Facial pain

Answer 14

1. Patients may refer localized facial pain to the eye
2. Common sources include dental and sinus disease
3. Causes
   
   1. Occiptal neuralgia from lesser occipital nerves
   2. TMJ
   3. ICA dissection
   4. HZO — pain may arise in affected region priro to vesicular eruption appears. Gabapentin, TCA or topical lidocaine 5% patches may be used for some patients for relief
   5. Neoplastic process — Facial numbness with or without pain suggests pathologic involvement of CNV₁ such as neoplastic process affecting nerve in area of cavernous sinus and Meckel cave.​

Question 15

Trigeminal Neuralgia

Answer 15

1. AKA tic douloureux
2. 80-90% due to vascular compression of CN V 2/2 superior cerebellar artery contact
3. Secondary trigeminal neuralgia may be due to demyelinating or infiltrative process or posterior fossa mass
4. Almost always V₂ or V₃
5. Chewing, tooth brushing or cold wind may precipitate paroxysmal burning or electric shock-like jabs lasting seconds to minutes
6. Patient need neuroimaging with MRI