Facial pain: cluster headache, giant cell arteritis and migraine

Question 1

Temporal arteritis (giant cell arteritis)

Answer 1

Unilateral or bilateral headache, mainly continuous or throbbing, usually in elderly, with temporal artery signs

An intense inflammatory response centred around the arterial internal elastic lamina

Question 2

What is temporal arteritis associated with

Answer 2

Polymyalgia rheumatica

Question 3

Signs and symptoms of temporal arteritis?

Answer 3

A) A new persisting headache

B) At least one of the following:

• Swollen tender scalp artery with elevated ESR or CRP
• Temporal artery biopsy demonstrating arteritis

C) Major improvement within 3 days of steroid therapy

Question 4

Presentation of temporal arteritis?

Answer 4

Elderly
New onset headache (70%)
Pain on mastication (40%)
Scalp tenderness
Generally unwell

Tenderness or decreased pulsation of temporal vessels
Elevated ESR >50mm/h
Biopsy
Doppler scanning

Question 5

What percentage of people with temporal arteritis have involvement of the opthalmic artery? What does this lead to?

Answer 5

50% have involvement of the opthalmic artery = may lead to blindness

Question 6

Management of temporal arteritis?

Answer 6

Steroids (prednisolone)

• Visual symptoms - initially 80g daily
• No visual symptoms - initially 60mg daily

Urgent referral to either GMP, rheumatology or opthalmology

Question 7

What makes up trigeminal autonomic cephalalgias (TAC)?

Answer 7

Cluster headaches
Paroxysmal hemicrania
SUNCT

Question 8

Define cluster headache

Answer 8

Unilateral pain principally in the ocular, frontal and temporal areas recurring in severe bouts with daily attacks for several months and usually with rhinorrhoea and lacrimination

Question 9

Presentation of cluster headaches?

Answer 9

Prevalence 1%
Males 5:1, aged 18-40yrs
Unilateral
Throbbing, burning, severe pain. May wake pt up from sleep
Severity comparable with trigeminal neuralgia
Associated factors: lacrimination, rhinorrhoea, conjunctival injection, horner’s syndrome

Question 10

Management of an acute attack with cluster headaches?

Answer 10

Oxygen 100% 10-12 litres/min
Sumatriptan (5HT1 agonist)
- Subcutaneous
- Intranasal

Question 11

Prevention management with cluster headaches?

Answer 11

Avoid precipitating factors

• Alcohol
• Caffeine

Verapamil
Lithium
Prednisolone
Methylsergide
Gabapentin
GON

Question 12

Migraine features?

Answer 12

Episodic headache usually accompanied by nausea, photophobia
Duration 4-72hrs
Pulsating
Aura (15% pts)
Triggers - hormonal, relaxation, perfume, stress

Question 13

Migraine treatment?

Answer 13

Simple analgesia

• Ibuprofen
• Paracetamol

5HT1 agonist - triptan
Antiemetic (metoclopramide)

Question 14

How to prevent migraines?

Answer 14

Over 2 per week
Interferes with daily functions
Medications do not control pain
- Amitriptyline
- Beta blocker
- Pizotifen

Pt education - triggers
Psychological
TENS/Acupuncture intraoral splints