7 Facial Pain & Headache Flashcards Preview

-Study Focus > 7 Facial Pain & Headache > Flashcards

Flashcards in 7 Facial Pain & Headache Deck (22):
1

What is the difference between primary and secondary headache?

What is the difference between primary and secondary headache?

A headache is labeled a primary headache if it occurs in the absence of a disorder that is known to cause headaches. A secondary headache is a new headache that occurs in close temporal relation to another disorder that is known to cause headache. Headaches can also be categorized as having both primary and secondary components, such as a primary headache that becomes chronic or at least two-fold worsened by another headache-causing disorder.

2

What is the differential diagnosis for facial pain?

What is the differential diagnosis for facial pain?

  • Primary Headache:
    • Tension-type headache
    • Migraine headache
    • Trigeminal autonomic cephalalgias
  • Secondary Headache:
    • Trigeminal neuralgia
    • Persistent idiopathic facial pain
    • Temporomandibular disorder
    • Headache attributed to acute and/or chronic rhinosinusitis
    • Trauma or injury to the head and/or neck
    • Cranial or cervical vascular disorder
    • Neoplasm
    • Substance abuse and/or withdrawal
    • Intracranial infection
    • Somatization disorder
    • Headache attributed to disorder of eyes (acute glaucoma, refractive error, heterophoria, heterotropia)
    • Psychotic disorder

3

What is the prevalence of headache?

What is the prevalence of headache?

Worldwide headache prevalence for the adult population is 46% for headache in general, 42% for tension-type headache, 11% for migraine, and 3% for chronic daily headache. Based on years lived with disability, headaches are one of the 10 most disabling conditions, and one of the five most disabling for women.

4

How do you diagnose and treat tension-type headache?

How do you diagnose and treat tension-type headache?

Tension-type headaches are diagnosed by history: episodic headache, typically bilateral, pressing or tightening in quality, of mild to moderate intensity, and lasting minutes to days. The pain does not worsen with routine physical activity and is not associated with nausea. Photophobia or phonophobia may be present. Treatment consists of aspirin, acetaminophen, or NSAIDs for occasional mild tension-type headache while more severe headaches usually require a prescription analgesic. Amitriptyline is the most effective prophylactic pharmaceutical for tension-type headaches.

5

What is the adult diagnostic criteria for migraine headache without aura?

What is the adult diagnostic criteria for migraine headache without aura?

For a headache to meet ICHD-III (3rd edition of the International Classification of Headache Disorders) criteria as a migraine without aura, a person must suffer at least five headaches that include the following characteristics: (1) must last between 4-72 hours; (2) have at least two of the following: unilateral location, pulsating quality, moderate/severe pain intensity, or aggravation by physical activity; (3) must have either nausea and/or vomiting or photophobia/phonophobia; (4) must not meet other criteria.

6

Why do migraine headaches occur?

Why do migraine headaches occur?

Cortical spreading depression (CSD) is the currently accepted etiology for migraine with aura. CSD is a transient neuronal and glial cell excitation followed by long-lasting depression, slowly propagating across the cerebral cortex and gray matter. During CSD, there are significant changes in the levels of extracellular ions and neurotransmitters (such as glutamate, acetylcholine, and substance P), leading to activation of dural nociceptors and central trigeminovascular neurons in the superficial and deep laminae of the trigeminocervical complex contributing to the clinical manifestation of migraines.

7

What is the first-line medical option for abortive therapy for migraine headache?

What is the first-line medical option for abortive therapy for migraine headache?

Triptans are the main first-line medical option for abortive therapy for migraines. They are synthetic serotonin analogs that activate the 5-HT1B and 5-HT1D serotonin receptors, constricting cranial blood vessels and inhibiting release of proinflammatory neuropeptides.

8

Is “sinus headache” recognized as a type of headache?

Is “sinus headache” recognized as a type of headache?

The ICHD-III lists “sinus headache” as a type of secondary headache. Specifically, sinus headache has been divided into headache attributed to acute or chronic rhinosinusitis.

9

Is imaging necessary to diagnose someone with a sinus headache?

Is imaging necessary to diagnose someone with a sinus headache?

While imaging can help contribute to diagnosing someone with a sinus headache, it is not mandatory. ICHD-III states that headache attributed to rhinosinusitis must demonstrate clinical, endoscopic, and/or imaging evidence of current or past infection or inflammation. In addition, evidence of headache causation is established by at least two of the following: (1) headache with a temporal relation to rhinosinusitis, (2) headache correlates with rhinosinusitis symptoms, (3) headache is exacerbated by pressure over the sinuses, (4) headache localizes to side of rhinosinusitis.

10

What percentage of patients presenting with complaints of sinus headache will meet IHS for migraine headache syndrome?

What percentage of patients presenting with complaints of sinus headache will meet IHS for migraine headache syndrome?

Many patients that have a chief complaint of sinus headache actually fulfill IHS criteria for migraine. One large study screened patients with a history of sinus headache and found that 88% actually fulfilled IHS criteria for migraine-type headache.

11

Describe the diagnostic criteria and initial management of trigeminal neuralgia.

Describe the diagnostic criteria and initial management of trigeminal neuralgia.

Trigeminal neuralgia is characterized by paroxysmal attacks of severe facial pain. Diagnosis is based on five characteristics: (1) paroxysmal, (2) provoked by light touch, (3) confined to the trigeminal distribution, (4) unilateral, (5) normal clinical sensory exam. First-line pharmacotherapy is carbamazepine.

12

What is the most common division of trigeminal nerve to be affected by post-herpetic trigeminal neuropathy?

What is the most common division of trigeminal nerve to be affected by post-herpetic trigeminal neuropathy?

The first division of the trigeminal nerve is most commonly affected in post-herpetic trigeminal neuropathy. However, the second and third divisions can also be involved. Post-herpetic trigeminal neuropathy is unilateral head and/or facial pain persisting or recurring for at least 3 months in the distribution of one or more branches of the trigeminal nerve, with variable sensory changes, caused by herpes zoster. Typically, the pain is burning and may be pruritic. Patients can also have sensory abnormalities and allodynia in the affected territory. Pale or light purple scars may be present as sequelae of the herpetic eruption. Postherpetic neuralgia occurs in about 10% of patients with herpes zoster ophthalmicus. Treatment is difficult and often ineffective. Tricyclic antidepressants, gabapentin, pregabalin, opioids, and lidocaine patches are medical options with inconsistent efficacy. Denervation procedures have been used in the past, but little evidence has supported their use and these have largely been abandoned.

13

What is persistent idiopathic facial pain?

What is persistent idiopathic facial pain?

Persistent idiopathic facial pain, formerly referred to as atypical facial pain, is a type of secondary headache. It is a type of facial and/or oral pain that occurs in the absence of clinical neurologic deficit and dental etiology. It can have many types of presentations but must recur daily for more than 2 hours per day over greater than 3 months. Treatment includes tricyclic antidepressants and/or other medications used to treat neuropathic pain, such as gabapentin.

14

Describe contact point headaches.

Describe contact point headaches.

Contact point headaches are assumed to be associated with an intranasal contact point, where two structures within the nasal cavity meet (most commonly a large septal spur). The contact point can be identified on clinical exam with endoscopy or radiologically. It is believed that stimulation from the mucosal contact point can result in referred pain of the face due to the cross innervation of the trigeminal nerve. Therefore, there should be a correlation between the headache and contact point regarding time, symptoms, and location. ICHD-III recognizes contact point headaches as a category of secondary headaches that are attributed to a disorder of the nasal mucosa, turbinates, or septum.

15

Is there evidence that patients with headache and contact points may benefit from surgical intervention?

Is there evidence that patients with headache and contact points may benefit from surgical intervention?

Level 4 evidence suggests a potential benefit from surgery in these patients. However, interestingly, the majority of people who have mucosal contact points have no associated facial pain. There is also debate whether the improvement in facial pain following removal of contact points in some patients may be due to cognitive dissonance and/or neuroplasticity. A trial of topical anesthesia to the contact point region can be used as a diagnostic test prior to considering surgical intervention.

16

What are the three groups of temporomandibular disorders?

What are the three groups of temporomandibular disorders?

  1. Muscle disorders with myofascial pain
  2. Disc displacement with or without reduction
  3. Arthralgia, arthritis, arthrosis

17

What is the prevalence of temporomandibular disorders?

What is the prevalence of temporomandibular disorders?

In a meta-analysis of TMD patients, 45.3% patients had Group I disorders (myofascial), 41.1% had Group II disorders (disc displacement), and 30.1% had group III disorders (arthralgia, arthritis, arthrosis). Some patients may have more than one type. Group I and Group II disorders are more common in the general population, each with a prevalence of approximately 10%.

18

Describe the criteria for diagnosis of TMJ pain disorders.

Describe the criteria for diagnosis of TMJ pain disorders.

  • Criteria for temporomandibular pain:
    • Pain should relate directly to jaw movements and mastication.
    • Tenderness to palpation of the muscles of mastication and/or over the temporomandibular joint.
    • Confirmation of presence and location of pain source with relief from anesthetic blocking.
  • Criteria for temporomandibular dysfunction:
    • Interference with mandibular movement
    • Restriction of mandibular movement
    • Sudden change of occlusal relationship of teeth

First-line treatment for TMJ disorders typically involves conservative management with analgesics, anti-inflammatory agents, application of local heat, and bite appliances. If these fail, in severe cases, surgical management may be considered.

19

What is the CSF pressure level used as a cut-off for diagnosing idiopathic intracranial hypertension (IIH)?

What is the CSF pressure level used as a cut-off for diagnosing idiopathic intracranial hypertension (IIH)?

25 cm H2O is the common pressure limit used as diagnostic criteria for IIH. However, children can have normal opening pressures of up to 28 cm H2O. This is measured by lumbar puncture performed in the lateral decubitus position, without sedative medications or other medications that have the potential to alter intracranial pressure.

20

What causes the neurologic symptoms of migraine headache?

What causes the neurologic symptoms of migraine headache?  Controversy

Did the exact causative mechanism of the symptoms of migraine headache is still controversial. Recent literature has supported that the cortical spreading depression that initiates migraines leads to release of pro-inflammatory mediators, such a substance P, calcitonin gene-related peptide, and neurokinin A. These inflammatory pathways provide a persistent stimulus that sensitizes trigeminal nerve endings. The parenchymal inflammatory response and trigeminal stimulation leads to pain

21

Is there a role for empiric triptan therapy in patients with a diagnosis of sinus headache?

Is there a role for empiric triptan therapy in patients with a diagnosis of sinus headache?  Controvery.

Studies have shown that a high percentage of patients with a self- or physician diagnosis of sinus headache may have a migraine-type headache. It has been proposed that in empiric migraine therapy (triptans) may be employed in patients with sinus headache, with one study demonstrating improvement in 82% of patients that had a diagnosis of sinus headache.

22

 Is there a role for interventional therapy in patients with facial pain and headache?

Is there a role for interventional therapy in patients with facial pain and headache? Controversy.

Febrile for interventional procedures is still being defined, such as the use of neural blockade in the anterior ethmoid and sphenopalantine region with a steroid and local anesthesia mixture. Radiofrequency ablation of the pterygopalatine ganglion has also been anecdotally described, but the efficacy of these treatment options in the possible complications is still poorly understood.

Decks in -Study Focus Class (79):