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In one International study done in primary care offices, a total of 377 patients
returned completed diaries. Of the 94% who consulted their primary care
physicians for headache, 76% had migraine and 18% had migrainous headache.
Few patients had tension-type headache. If a "sinus headache" was diagnosed,
it would have been coded as "Other"; therefore, this would represent a small
percentage of the total study's population.
For the US patients in this study, the results were almost identical. Of the 162
patients who returned diaries, 75% of those who consulted their primary care
physicians with headache had migraine, and 19% had migrainous headache.
Few of these patients (4%) had tension-type headache.
However, when surveying the general population, what we see is a larger
prevalence of tension-type headache. This suggests that patients with tensiontype headache do not frequent primary care physicians for medical care. In
contrast, patients with migraine seek medical treatment.
Dowson A, Dahlof C, Tepper S, Newman L. Prevalence and diagnosis of migraine in a primary
care setting. Cephalalgia 2002;22:590-591.
Rasmussen BK, Jensen R, Schroll M, Olesen J. Epidemiology of headache in a general
population a prevalence study. J Clin Epidemiol 1991;44:1147-1157.

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This study investigated the diagnosis and clinical outcome of patients

who went to the emergency department for treatment of headache. Fifty
seven patients treated for acute primary headache in the emergency
department completed a questionnaire. Overall, 95% of the 57
respondents met International Headache Society diagnostic criteria
specifically for migraine. However, only 32% received an actual diagnosis
of migraine. Fifty nine 59% were diagnosed as having "cephalgia" or
"headache NOS" (not otherwise specified). All patients had taken
nonprescription medications, 24% received opioids, and 7% received a
migraine-specific medication; 65% percent received a "migraine cocktail"
comprised of a variable mixture of a nonsteroidal anti-inflammatory
agent, a dopamine antagonist, and/or an antihistamine. Forty nine 49%
had never taken a triptan.
All 57 patients reported that they had to rest or sleep after being
discharged, and they were unable to return to normal function.
Additionally, 60% of the patients reported either recurrent or persistent
headache 24 hours after being discharge from the emergency
department.
Blumenthal HJ, Weisz MA, Kelly KM, Mayer RL, Blonsky J. Treatment of primary
headache in the emergency department. Headache. 2003;43(10):1026-1031.

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Frontal sinus innervation is derived from the ophthalmic branch of the trigeminal
nerve. Irritation of the mucosa of the frontal sinus therefore produces pain in the
forehead or anterior cranial fossa related to the dural and cutaneous distribution of
the nerve.

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The ophthalmic division of the 5th cranial nerve also innervates the anterior ethmoid
air cells via the anterior ethmoidal nerve, a branch of the nasociliary. The anterior
ethmoids may also receive some innervation from the small supraorbital branch that
supplies the frontal sinus. The anterior ethmoid nerve has the largest territory of
innervation within the nasal cavity and supplies the anterior septum and lateral nasal
wall, including the superior, middle and inferior turbinates and middle meatus.

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The posterior ethmoid air cells and sphenoid sinus derive most of their sensory
innervation from the maxillary division of the 5th cranial nerve via the inconsistently
present posterior ethmoid nerve. The maxillary division supplies the posterior
septum and a large portion of the superior and middle turbinates as well. Some of
the innervation of the territory of the posterior ethmoid and sphenoid sinuses is
derived from branches of the greater superficial petrosal branch of the 7th cranial
nerve, and the ophthalmic branch of the trigeminal nerve.

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The maxillary sinuses are innervated by the posterior superior alveolar, infraorbital
and anterior superior alveolar nerves, all of which are branches of the maxillary
division of the trigeminal nerve.

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Was 96 pages and now is 160 pages!!! 13 pages for migraine alone.

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Was 96 pages and now is 160 pages!!! 13 pages for migraine alone.

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. The vast majority of patients, 60%-70% have combined muscle and joint pain with
muscle pain dominating the clinical picture. These patients usually have tenderness
to palpation of the muscles of mastication.

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DJD has a similar presentation, with pain at joint movement and crepitus over the
joint. The painful stage usually lasts less than a year. Long-standing DJD causes
flattening of the condyle and osteophyte formation making it easily recognizable
radiographically.

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NSAIDs and physical therapy are the mainstays of treatment for TMD. Similar to
tension headache, biofeedback and trigger point injection may be beneficial.
Benzodiazepines are useful for muscle pain, but chronic use may lead to dependence
and tolerance. Muscle relaxants are of little benefit. In chronic muscle pain,
antidepressants may be more useful that analgesics or anxiolytics. TCA are useful in
those patients with sleep disturbance, or SSRIs may be used for patients intolerant of
TCA.

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