Headache and facial pain

Dr. Mones Obeidat Dr.SalmaYahya

Facial pain

Facial pain problems fall into one of five recognizable categories:

Pain of Tooth Origin Pain of Muscle and Joint Origin Pain of Nerve Origin Headache including Migraines Others :
Eyes, ears, sinus, parotid gland( otitis media, orbitalcellulitis, sinusitis and mumps)

Pain of Muscle and Joint Origin

1.

Temporomandibular disorders.
Pain in the temporomandibular joint (TMJ) may occur in 10% of the US population. 75% of the population has a sign or symptom during their lifetime, but fewer than 5% need therapeutic intervention.

TMJ anatomy

Temporomandibular joint (TMJ) is the site of articulation between the mandiblar condyle and the skull, specifically the articular eminence of the temporal bone. This bilateral joint functions to open and close the jaws and to approximate the teeth of the opposing arches during mastication. The articulation consists of parts of the mandible and temporal bones, which are covered by dense, fibrous connective tissue and are surrounded by several ligaments. Interposed between the two bones is a fibrous articular disc, compartmentalizing the joint into two separate synovial-lined cavities. Several pairs of muscles attached to the mandible produce the movements

Innervation
Sensory innervation of the TMJ is mediated through the mandibular division of the trigeminal nerve. Pain-sensitive elements within the TMJ include the joint capsule, the posterior attachment tissues, and the discal ligaments. The posterior attachment is highly innervated, richly vascularized, and frequently implicated in the pathophysiology of joint pain. In contrast, the intraarticular disk is largely devoid of neural or vascular tissue but plays a vital role in maintaining condylar stability during mandibular movement.

Etiology
inflammation within the joint accounts for TMD pain, and the dysfunction is caused by a disk-condyle incoordination. The etiology for TMD may include parafunctional behaviors, macrotraumas or microtraumas, changes in the occlusion, and behavioral influences.

Known as a disk derangement disorder, articular disk displacement is the most common temporomandibular arthropathy and is characterized by an abnormal relationship or misalignment of the articular disk relative to the condyle.

Myofascial pain

Characterized by a regional muscle pain, myofascial pain. has been described as dull or achy and is associated with the presence of trigger points in muscles, tendons, or fascia. it may be associated with stress and oral habits (developmental factors) or poor sleep, postural abnormalities, and depression. The major characteristics of myofascial pain include trigger points in muscles and local and referred pain. The trigger points may present clinically as active or latent. When active, digital palpation produces pain referral to a distant site. When latent, local tenderness to palpation may be present, but no distant referral occurs.

Imaging
Imaging may define the disk position and its movement during function. Initially imaging is done with the mouth closed; sequences are then repeated with the mouth open. Evaluating how the disk-condyle complex moves during these excursions is useful. Panoramic, transcranial, and tomographic studies are used to evaluate the bone. MRI remains the gold standard of diagnostic imaging for soft tissues and the best method to assess disk position.

Management

Patient Education and Self-Care

It is essential to keep in mind that TMDs are self-limiting. Patients should be instructed to avoid chewy foods, especially chewing gum. They can be taught to avoid clenching their jaws during the day, to apply heat or ice, and to perform jaw-stretching exercises.

Pharmacological therapy
the most common medications include nonsteroidal antiinflammatory drugs and muscle relaxants. The use of tricyclic antidepressants, selective serotoninnorepinephrine reuptake inhibitors, and antiepileptic drugs are also important in pain management.

Neurological causes:
Trigeminal neuralgia. Glossopharyngeal neuralgia. Post-herpetic neuralgia. Temporal arteritis.

Trigeminal Neuralgia.

TN is a neurologic condition that affects less than 1 percent of the population in the United States but about 14 percent of those with nerve-related (neuropathic) pain. more often in women, generally appearing in middle or late middle age.

What causes trigeminal neuralgia?

The trigeminal nerve is the major nerve serving the face. Its three branches carry sensations from the eyes, mouth, and jaw to the brain. The pain of TN typically originates in the maxillary nerve, which runs along the cheekbone and serves the nose, upper lip, and upper teeth, or the mandibular branch, which controls sensation in the lower cheek, lower lip, and jaw.

TN are classical and symptomatic. Classical TN is the most common, occurring suddenly with no obvious trigger. Symptomatic TN is related to some underlying condition such as a tumor, aneurysm, multiple sclerosis, meningitis, or Lyme disease. For the classical TN: the pain occurs when a vein or artery presses upon the trigeminal nerve where it enters the brain stem, the contact creates inflammation that damages the nerve by stripping its myelin sheath interfering with the ability of a nerve to conduct sensation normally( severe pain)

symptoms of trigeminal neuralgia (TN) include:

Very painful, sharp, electric-like spasms that usually last a few seconds or minutes but can become constant Pain on one side of the face, often around the eye, cheek, and lower part of the face (although it can occur on both sides of the face) Pain triggered by touch or sounds Pain triggered by common, everyday activities, such as brushing teeth, chewing, drinking, eating, lightly touching the face, shaving the face.

Treatment

Medical: AED including carbamazepine, pregabalin or Gabapentin. Surgical: Peripheral nerve blocks involve the doctor attempting to block the nerve with anesthetics such as lidocaine.

Headache

Migraine
Migraine is in essence an episodic disorder whose key marker is headache with certain associated features. Unilateral, bilateral in 40%. Throbbing, worse with movement Moderate to severe. Associated with nausea/ vomiting/photo or photosensitivity.

May occur with or without aura. Migraine aura is defined as a focal neurological disturbance manifesting as visual, sensory, or motor symptoms (may see stars dots or lines, feel parasthesia or has hemiparesis). It is seen in about 30% of patients.

pathophysiology

Intracranial contents above the tentorium cerebelli are innervated by the trigeminal nerve. The dura mater and vessels supplying the meninges have sensory and autonomic innervation ( trigeminovascular system ). Small fibers enter the pons down to the trigeminal nucleus caudalis (TNC)

During the attacke:

The trigeminovascular system is activated Trigeminal neuron supplying the dural vessels release many substances that result in vessel dilatation. Polysynaptic connections between the TNC and the superior salivatory nucleus explain the ipsilateral autonomic symptoms(rhinorrhea, lacrimation and eye redness).

Treatments for attacks can be divided into nonspecific and migraine-specific treatments. Nonspecific treatments, such as aspirin, acetaminophen, nonsteroidal antiinflammatory drugs, opiates, and combination analgesics, are used to treat a wide range of pain disorders. Specific treatments, including ergotamine, dihydroergotamine, and the triptans.(vasoconstricting agents).

Preventive treatment: On the basis of a of the frequency, duration, severity, and tractability of acute attacks. Options: AED, antidepressant, beta blockers.

Cluster headache

Cluster is a stereotypical episodic headache disorder marked by frequent attacks of short-lasting, severe, unilateral head pain with associated autonomic symptoms.

Typical cluster headache location is retro-orbital, periorbital, and occipitonuchal. Maximum pain is normally retro-orbital in greater than 70% of patients. Pain quality is described as boring, stabbing, burning, or squeezing. Cluster headache intensity is always severe, never mild.

The one-sided nature of cluster headaches is a trademark. Cluster sufferers will normally experience cluster headaches on the same side of the head their entire life. Only in 15% of patients will the headaches shift to the other side of the head at the next cluster period, and side shifting during the same cluster cycle will only occur in 5% of patients. The duration of individual cluster headaches is between 15 and180 minutes.

Attack frequency is between 1 and 3 attacks per day. Cluster headache is marked by its associated autonomic symptoms, which typically occur on the same side as the head pain, but can be bilateral. Lacrimation is the most common associated symptom, occurring in 73% of patients followed by conjunctival injection in 60%, nasal congestion in 42% rhinorrhea in 22% partial Horners syndrome in 16% to 84%.

several distinct triggers, including alcohol, nitroglycerin, histamine, hot weather. Oxygen inhalation is an excellent abortive therapy for cluster headache. Treatment: abortive and preventive.

SUNCT SYNDROME

The syndrome of short-lasting, unilateral neuralgiform headache attacks with conjunctival injection and tearing. brief attacksb of moderate to severe head pain with associated autonomic disturbances of conjunctival injection, tearing, rhinorrhea, or nasal obstruction. The typical age of onset is between 40 and 70.

orbital or periorbital distribution. Head pain can radiate to the temple, nose, cheek, ear, and palate. The pain is normally side locked and remains unilateral throughout an entire attack. stabbing, burning, pricking, or electric shocklike sensation. Pain duration is extremely short, lasting between 5 and 240 seconds, with an average duration of 10 to 60

seconds.

attack frequency ranges anywhere from1 to more than 80 episodes a day.

triggering maneuvers, including mastication, nose blowing, coughing, forehead touching, eyelid squeezing, neck movements (rotation, extension, and flexion), and ice-cream eating.

Treatment:

By the time a patient with SUNCT would take an abortive medication the attack theoretically would already be completed. Preventive agents that have previously been tried include: aspirin, paracetamol, indomethacin, naproxen, ergotamine, DHE, sumatriptan, prednisone, verapamil, valproate, lithium, propranolol, amitriptyline, and carbamazepine.

HEMICRANIA CONTINUA

female predominance. continuous daily head pain, which is present 24 hours per day, 7 days per week,mild to moderate intensity. with headache-exacerbation period, pain was normally severe. affecting the temple or periorbital region. It is always present on the same side of the head. Migrainous symptoms include nausea, vomiting, photophobia, and phonophobia. Indomethacin alleviates both the headache and aura.

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