1. HEADACHE & FACIAL PAIN
Ahmed Alarfaj,MD

2. INTRODUCTION
• Major reason for seeking medical care.
• 90% is vasculr headache.
• 10% is mixture of inflammation,traction or
dilatation of pain sensitive structure.

3. PATHOPHYSIOLOGY
• Pain
• Referred pain
– Pattern of referred pain

4. CLINICAL ASSESSMENT
• History
– Hx of present illness
– Past medical hx
– Family hx
– Social hx
• Physical examination

5. CLINICAL ASSESSMENT
• Clinical features suggesting serious cause
– Crescendo
– Early morning
– Vomiting
– Fever
– Seizures & other neurological symptomes
– Worst headache in my life
– Known malignancy
– Tenderness

6. Facial pain
Typical Neuralgias
1) Trigeminal neuralgia
• 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.
• Unknown aetiology, an arterial loop
pushing on the sensory root in the
posterior fossa.
• Females affected more than males
• Analgesics, surgery, destruction of the
sensory neuron, division of nerve root.

7. Facial pain
Typical Neuralgias
2) Glossopharyngeal neuralgia
• Unknown cause
• Equal both sexes
• Severe, sudden episodes of pain
in the tonsil region one side only,
ipsilateral ear.
• Pain - severe for 1-2 hours, recur
daily
• Treated like trigeminal

8. Facial pain
Typical Neuralgias
3) Sluder’s neuralgia and Vidian
neuralgia
• Intractable pain in the nose, eye,
cheek and lower jaw.
• Could be due to lesion of the
sphenopalatine ganglion, or
vidian nerve.
• Analgesics, vidian neurectomy

9. Facial pain
• Posttraumatic neuralgia
– Neuroma
– Parietal & occipital
– 90% recovery

10. Facial Pain
Atypical facial pain
 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

11. Symptomatic Neuralgias
Intracranial lesions
1) Central lesions
• Tumours of the brain stem, M.S.,
thrombotic lesions, metastasis, occult
naso-pharyngeal ca.
• No precipitant, sensory loss.
2) Post herpetic neuralgia
• Herpes zoster may affect trigeminal
nerve ganglion
• Vesicular rash covers one division
commonly the 1 st with severe pain.

12. Symptomatic Neuralgias
Extracranial lesions
1) Sinus disease
• Infective and neoplastic lesions of the
paranasal sinus.
• Facial pain & dental pain, loss teeth.
• Clinical suspicion.
• Treatment
2) Dental neuralgia
• Dental carries
• Dental extraction
3) Temporomandibular joint pain

13. Headache
Headache is one of the commonest
symptoms in medical practice.
Aetiology :
1) Raised intracranial pressure
 Due to tumours, abscesses, subdural
haematoma, brain haemorrhage.
2) Inflammation of the brain and
meninges
 e.g. meningitis, cerebritis, others

14. Headache
3) Migraine
 Congenital predisposition
 Triggered by hunger, certain foods, sleep -
too much or too little, hormonal variations,
stress.
 Pathology-vascular dilatation
 Females affected more than males
 ? Proceeded by aura usually visual,
paraesthesiae of hands, weakness
 Headache is unilateral or bilateral, affects
any area of the head, aching or throbbing
often accompanied by nausea and
vomiting
 Diagnosis - by history alone
 Treatment - prevention by avoiding
precipitating factors, appropriate
medication .

15. Headache
4) Tension headache
 More common in adult females
 Positive family history (40%)
 Maybe associated with migraine
 Produced by persistent contraction of
the muscles of the neck, head and
face
 Caused by emotional tension,
secondary to other headaches,
posture habit
 Treated by analgesics, muscle
relaxants, physiotherapy

16. Headache
5) Cluster headache
 90% are men
 Age 20 - 30
 Attacks occur in groups, no aura
 Caused by vascular dilatation of
branches of external carotid
 Triggered by histamines, alcohol
 Treated by analgesics, anti-
histamine, steroids

17. Pains from head and neck
muscles
Pain from temporalis muscles
 Can arise from grinding teeth at
night (bruxism), impacted wisdom
teeth, temporomandibular joint
dysfunction, anxiety when the
patient clenches the jaws too
tightly
Treatment: Refer to interested
dental surgeon .

18. Pains from head and neck
muscles
Pain from upper neck muscles
 Can radiate over the head
Treatment by physio-therapist or
rheumatologist
Pain from frontalis muscles
 Usually due to bad posture at work
or while driving
Treatment: physio-therapy

19. Pains from head and neck
muscles
Cervical spondylosis
 Pain mediates upwards from the neck to
the occiput or vertex to the front of the
head, down to the shoulders
 Due to cervical discs prolapse
 Diagnosis - x-ray
Treatment: Physio-therapy, referral to
rheumatologist

20. Pains from head and neck
muscles
Temporal arteritis
 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
Treatment: Cortisone, analgesics

21. Pains from head and neck
muscles
Psychologic headache
 Usually accompanied by
depression, anxiety
 No organic lesion