Headache and Facial Pain2

7/29/2019 Headache and Facial Pain2

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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 articulationbetween the mandiblar condyle and the skull, specifically thearticular eminence of the temporal bone.

This bilateral joint functions to open and close the jaws and toapproximate the teeth of the opposing arches during

mastication. The articulation consists of parts of the mandible and

temporal bones, which are covered by dense, fibrousconnective tissue and are surrounded by several ligaments.

Interposed between the two bones is a fibrous articular disc,compartmentalizing the joint into two separate synovial-linedcavities.

Several pairs of muscles attached to the mandible producethe movements





Innervation

Sensory innervation of the TMJ is mediatedthrough the mandibular division of the trigeminal

nerve.

Pain-sensitive elements within the TMJ include the

joint capsule, the posterior attachment tissues, andthe 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 accountsfor 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, myofascialpain.

has been described as dull or achy and is associatedwith the presence of trigger points in muscles, tendons,or fascia.

it may be associated with stress and oral habits(developmental factors) or poor sleep, posturalabnormalities, and depression.

The major characteristics of myofascial pain includetrigger points in muscles and local and referred pain.

The trigger points may present clinically as active or latent. When active, digital palpation produces painreferral to a distant site.

When latent, local tenderness to palpation may bepresent, but no distant referral occurs.



Imaging

Imaging may define the disk position andits movement during function.

Initially imaging is done with the mouthclosed; sequences are then repeated

with the mouth open. Evaluating how the disk-condyle

complex moves during these excursionsis useful.

Panoramic, transcranial, andtomographic studies are used toevaluate the bone.

MRI remains the gold standard of

diagnostic imaging for soft tissues andthe best method to assess disk osition.



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 anti-

inflammatory drugs and muscle relaxants.

The use of tricyclic antidepressants, selective serotonin-norepinephrine 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 servingthe 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, multiplesclerosis, 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 createsinflammation 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 thatusually 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 suchas lidocaine.



Headache





Migraine

Migraine is in essence an episodicdisorder 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 cerebelliare 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 intononspecific and migraine-specific treatments.

Nonspecific treatments, such as aspirin,

acetaminophen, nonsteroidal antiinflammatory

drugs, opiates, and combination analgesics, areused 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 episodicheadache disorder marked by

frequent attacks of short-lasting,

severe, unilateral head pain withassociated autonomic symptoms.



Typical cluster headache location isretro-orbital, periorbital, and

occipitonuchal.

Maximum pain is normally retro-orbitalin 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 thesame 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 Horner’s 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, includingmastication, 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 anabortive 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 wasnormally 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.



Thanks



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Headache and Facial Pain2