WEEK 3: Headache and Facial Pain Syndromes Flashcards
What are the pain sensitive structures in the head?
- Trigeminal
- Facial
- Glossopharyngeal
- Vagus
- Upper three cervical roots
(10, 9 , 7, 5, C1 to C3)
The brain is pain sensitive. T or F?
F. the brain is not pain sensitive
Sensory supply of the anterior and middle fossa?
V1 V2 V3
sensory supply of the posterior fossa?
C1 C2 C3
what are intracranial pain sensitive areas?
- Venous sinuses and afferent veins
- Arteries of the dura mater and pia-arachnoid
- Arteries of the base of the brain and their major branches
- Parts of the dura mater near the large vessels
What are the extracranial pain sensitive structures?
- Sinuses
- Eyes/orbits
- Ears
- Teeth
- TMJ
- Blood vessels
- 5,6,7,9,10 cranial nerves carry pains from these structures
Intracranial pain sensitive areas?
- Arteries of circle of Willis and proximal Dural arteries
- Dural Venous sinuses, veins
- Meninges
- Dura
Characterized by recurring paroxysmal severe pain, brief duration (seconds) in the territory of the trigeminal nerve, spontaneously or initiated by chewing, talking touching the affected side of the face.
Trigeminal neuralgia
Causes of trigeminal neuralgia?
gender predisposition?
Unknown etiology, an arterial loop pushing on the sensory root in the posterior fossa
Females affected more than males
management of trigeminal neuralgia?
Analgesics, surgery, destruction of the sensory neuron, division of nerve root.
IHS Diagnostic Criteria for Trigeminal Neuralgia
A. Paroxysmal attacks of facial or frontal pain which last a few seconds to less than 2 mins
B. Pain has at least 4 of the following charactereistics:
1. distributions along one or more distributions of the CN V
2. Sudden internse sharp superficial stabbing or burning in quality
C. No neurological deficit
D. Attacks are stereotyped in the individual patient
E. exclusion of other causes of facial pain by history, physician examination and special inestigations when necessary.
Severe, sudden episodes of pain in the tonsil region one side only, ipsilateral ear
o Pain - severe for 1-2 hours, recur daily
Glossopharyngeal Neuralgia
CN 9 neuralgia: cause and genetic predisposition
o Unknown cause
o Equal both sexes
What can be some causes of irritation in the CN 9?
blood vessels pressing on CN 9
Growth at the base of the skull pressing on CN 9
Tumors or infections of the throat and mouth pressing on CN 9
o Intractable pain in the nose, eye, cheek and lower jaw
o Could be due to lesion of the sphenopalatine ganglion, or vidian nerve
Sluder’s neuralgia, Vidian Neuralgia
managed by : Analgesics, vidian neurectomy
characterized by unilateral paroxysms of intense pain in the region of the eyes, the maxilla, the ear and mastoid, base of the nose and beneath the zygoma.
these paroxysms of pain have a rapid onset, persist for about 15 mins to several hours, and then disappear as rapidly as then began. there is no triugger zone
Sphenopalatine neuralgia
aslo refereed to as alarm clock headache
Sphenopalatine Neuralgia aka Vidian nerve neuralgia, periodic migrainous neuralgia, sluder’s headache
Sphenopalatine Neuralgia aka
Vidian nerve neuralgia, periodic migrainous neuralgia, sluder’s headache
What type of neuralgia? o Neuroma
o Parietal & occipital
o 90% recovery
Post traumatic neuralgia
Pain felt over the cheek, nose, upper lip or lower jaw
• Usually bilaterally symmetrical
• Aching, shooting, burning, accompanied by reddening of the skin and lacrimation or watering of the nose
• Lasts for hours, days or weeks
• Psychological consultation, analgesics
Atypical neuralgaia / symptomatic facial pain
Atypical neuralgaia / symptomatic facial pain may be associated wiht?
o Carotid dissection
o Giant cell (“temporal” arteritis)
This is common in the elderly people
This is an inflammation in the temporal artery
If you palpate this in the temporal area, it will feel hard and bouncing
o Acute V-Z & post herpetic neuralgia
o Tolosa-Hunt syndrome
Extracranial lesions that may cause atypical neuralgia or symptomatic facial pain?
sinus disease
Dental neuralgia
TMJ joint pain
If there are point tenderness in the sinuses, it is?
Sinusitis
Due to acute inflammation of the artery, the cause unknown,
affects men and women over the age of 60.
- Pain over the temples and frontal region, intense, throbbing,
tenderness over the scalp, swelling and redness of the
overlying skin with general malaise, partial or complete loss
of vision.
ESR Elevated
temporal arteritis
Tx for symptomatic facial pain?
Cortisone, analgesics
Headache that is not secondary to focal or structural brain lesion
Primary headache
what are the primary headaches? (3)
Migraine
Tension type headache
Trigeminal autonomic cephalalgias
common disabling primary headache disorder.
• Many epidemiological studies have documented its high
prevalence and socio-economic and personal impacts. In the
Global Burden of Diseases Study 2010, it was ranked as the
third most prevalent disorder in the world.
• In GBD 2015, it was ranked third-highest cause of disability
worldwide in both males and females under the age of 50
years.
Migraine
theories in the causes of migraine?
- Vascular theory
- Trigeminovascular theory
- Central theory
migraine that has visual manifestations?
retinal migraine
migraine without aura AKA?
hemicrania simplex
Recurrent headache disorder manifesting in attacks lasting 4-71 hours.
- Typical characteristics of the headache are:
- Unilateral location, pulsating quality.
- Moderate or severe intensity, aggravation by routine physical activity.
- Association with nausea and/or photophobia and phonophobia.
migraine without aura
Diagnostic criteria of migraine?
At least five attacks fulfilling criteria B-D. (hindi mo pwedeng i-diagnose ang patient at the first visit)
- Headache attacks lasting 4-72 hr (untreated or unsuccessfully treated).
- Headache has at least two of the following four characteristics:
- unilateral location
- pulsating quality
- moderate or severe pain intensity aggravation by or causing avoidance of routine physical activity (eg, walking or climbing stairs)
- During headache at least one of the following:
- nausea and/or vomiting
- photophobia and phonophobia.
- Not better accounted for by another ICHD-3 diagnosis.
migraine with aura aka?
Previously used terms: Classic or classical migraine; ophthalmic, hemiparaesthetic, hemiplegic or aphasic migraine; migraine accompagnée; complicated migraine
Recurrent attacks, lasting minutes, of unilateral fully reversible visual, sensory or other central nervous system symptoms that usually develop gradually and are usually followed by headache and associated migraine symptoms.
migraine with aura
Migraine with aura diagnostic criteria
Diagnostic criteria:
- At least two attacks fulfilling criteria B and C.
- One or more of the following fully reversible aura symptoms:
- visual
- sensory
- speech and/or language
- motor
- brainstem
- retinal
- At least three of the following six characteristics:
- at least one aura symptom spreads gradually over ≥5 minutes
- two or more aura symptoms occur succession
- each individual aura symptom lasts 5-60 minutes
- at least one aura symptom is unilateral (this is important)
- at least one aura symptom is positive
- the aura is accompanied, or followed within 60 minutes, by headache
when should you use the word probable migraine?
probable is for first time. you must document 5 incidents.
Diagnostics for migraine?
Diagnostics:
- History is the most important diagnostic tool.
- Neuroimaging reserve for cases with atypical features, focal signs.
- EEG:
when do you consider EEG for migraine?
- Consider only if associated symptoms suggest a seizure disorder.
- No useful headache subtype groups are defined by EEG.
- EEG is not able to identify patients with structural cause of headaches.
Common triggers of migraine that is associated with diet
o Caffeine withdrawal o Packaged meats o MSG o Dairy o Fatty foods o Aged cheese o Red wine o Beer o Champagne o Chocolate
what type of management is this? Shown to be effective
• 30-50% reduction of migraine frequency
• Modalities:
o Relaxation training
o Thermal biofeedback with relaxation training
o Electromyogram biofeedback
o Cognitive behavioral therapy
behavioral
what does abortive management of migraine mean?
it means treating the headache once it has begun or kapag malapit na mag migraine
in abortive therapy when to treat?
- Early
- Within 2 hours
- Treatment during prodrome or aura is even more effective
mild to moderate headache, what medications?
• NSAIDS o Ibuprofen o Naproxen o Diclofenac o Tolfenamic acid o Indomethacin suppository • Aspirin • Tylenol • Combinations
if severe migraine, will you give OTC meds?
• If severe symptoms are present, then don’t bother with OTC preparations
o Improved outcomes with migraine specific therapy
• Consider route of administration
• Consider contraindications/PMH
first line drug in severe headache?
TRIPTANS
More effective & Less nausea
• Contraindications: CAD & Cost
what are the routes for triptans?
Oral, Intranasal & Subcutaneous
MOA of Triptans?
o Selective serotonin agonist
o 5HT1B/1D
what drug is this? pharmacokinetics and dynamics:
o Both long and short acting available
o Long acting more effective during aura but take longer to act
o Short acting has more side effects
triptans
give sample drugs of triptans?
o Sumatriptan (subq/nasal/oral) o Almotriptan (oral) o Eletriptan (oral) o Frovatriptan (oral) o Naratriptan (oral) o Rizatriptan (oral/ODT) o Zolmitriptan (oral) Available in PH is Sumatriptan and Zolmitriptan
what are some specific concerns for triptans?
o Teratogenicity
o Menstrual migraine
o Subq not effective during prodrome/aura & has more contraindications
Dihydroergotamine MOA?
Non-selective serotonin agonist
Route of dihroergotamine?
Routes o Nasal o Subq o IM o IV
Contra indications of Dihydroergotamine
• Contraindications
o Pregnancy (category X)
o Cannot be used with a triptan
o IV contraindicated in CAD
what are the adjuncts in the therapy of migraine?
anti emetics
caffeine
Steroids
Anti emetic for migraine
Metoclopromide both as adjunct and mono therapy
o Ondansetron IV/oral/ODT
rules to live by in people with migraine
o Headache diary o Patience o No right agent o Consider: ▪ Side effects ▪ Other benefits
what anti htn drug has best evidence for migraine
beta blockers
what antidepressant hassome benfit in migraine?
Tricyclics and mirtazepine
consideration when giving valproate
If patient have cardiac problem, then avoid valproate”
If patient is heavy avoid Valproate because it can cause weight gain
anticonvulsant drug for migraine with weight loss benefit?
Topiramate
o Prolonged (>72h), intractable migraine o Associated nausea and vomiting
status migranosus
to prevent stroke in migraine,avoid estrogen containing OCPs in patients:
• WHO
o Avoid estrogen containing OCPs:
▪ Migraine + over age of 35
▪ Migraine with aura
• ACOG o Avoid estrogen containing OCPs: ▪ Migraine + over age of 35 ▪ Migraine + focal neurologic signs ▪ Migraine + smoking
injectable preventive therapies for migraine?
o OnabotulinumtoxinA o 3 monoclonal antibodies (mAbs) targeting calcitonin gene related peptide (CGRP): ▪ Fremanezumab ▪ Galcanezumab ▪ CGRP receptor (erenumab)
OnabotulinumtoxinA is approved for chronic migraine, and erenumab, fremanezumab, and galcanezumab are approved for episodic and chronic migraine.
Some serious causes of secondary headache?
• Related to increased intracranial pressure
o Mass lesion – tumor, vascular malformation
o Intrinsic increase in intracranial pressure – pseudotumor cerebri
• Other causes
o Subarachnoid hemorrhage
o AVM, aneurysm
o Meningeal irritation
o Stroke
o Hypertensive encephalopathy
how to know if headache is related to increase in ICP?
• Severe occipital headache
o Sneezing, coughing, any Valsalva maneuver, or change in head position exacerbates the pain
o Pain is worse in the morning or awakens the patient from sleep
o Projectile vomiting without nausea and focal seizures may occur
Pain is worse in the morning or awakens the patient from sleep. What is the mechanism of this?
Pag tulog ka bumabagal yung respiratory rate mo, mas relax ka. Pag naghahypoventilate ka tumataas yung carbon dioxide. If there is accumulation of carbon dioxide, your blood vessels dilate. Vasodilatation leads to cerebral perfusion and you further increase the intracranial pressure. Kaya ang isang gamot (or solusyon) sa high ICP ay hyperventilation to drive off the carbon dioxide para hindi masyadong mataas yung (volume ng) blood coming to the brain just enough for cerebral perfusion
Red flag in patients with migraine
o Systemic signs/ symptoms/ disease/ fever, Myalgias, weight loss, history of malignancy or AIDS
o Neurologic signs or symptoms (altered mentation, seizure, papilledema, focal neurologic findings)
o Onset sudden /thunderclap headache
o Older age/ new onset of headache after age 50
o Pattern change from previous headaches (especially if rapidly progressive in severity and frequency)
Indications for neuroimaging in a child with headache?
- Trigeminal autonomic cephalalgia including cluster headaches in child or adolescent
- An acute secondary headache (i.e., headache with known underlying illness or insult)
- Headache in children <6 yr old or any child that cannot adequately describe their headache
- Brief cough headache in a child or adolescent • Headache worst on first awakening or that awakens the child from sleep
- Migrainous headache in the child with no family history of migraine or its equivalent
