1. EPILEPSY, HEADACHE
AND FACIAL PAINAFFAN SYAFIQI | AMANINA NASIR | LIYANA SUHAIMI

2. EPILEPSY

3. INTRODUCTION
• Epilepsy is a disorder characterized by recurring
seizures (also known as “seizure disorder”)
• It is a symptom of brain disease rather than a
disease itself.
• Seizure is a paroxysmal event due to abnormal,
excessive, hyper synchronous discharge from
CNS neurons
• A seizure occurs when too many nerve cells in the
brain “fire” too quickly causing an “electrical storm”

4. GROUPS AT RISK FOR EPILEPSY
About 1% of the general population develops epilepsy

5. AETIOLOGY
 In about 70% of people with epilepsy, the cause is not
known
 In the remaining 30%, the most common causes are:
– Head trauma
– Brain tumor and stroke
– Lead poisoning
– Infection of brain tissue
– Heredity
– Prenatal disturbance of brain
development

6. CLASSIFICATION
PARTIAL SEIZURE GENERALIZED SEIZURE
Simple partial
Complex partial
Simple seizure with
secondary generalization
Absence (Petit Mal)
Tonic Clonic (Grand Mal)
Tonic
Atonic
Myoclonic

7. PARTIAL SEIZURE

8. PATHOPHYSIOLOGY OF
PARTIAL SEIZURE
 Paroxysmal discharge
in a focal area
 Secondary
generalization- spread
to both hemispheres
simultaneously

9. SIMPLE PARTIAL SEIZURE
 Consciousness is fully preserved
 Motor, sensory, autonomic or psychic
symptoms
 Epilepsia partialis continua
 Jacksonian march
 Todd’s paralysis - lasts for minutes to hours
 No post-ictal syndrome (altered state of
consciousness after an epileptic seizures)

11. COMPLEX PARTIAL SEIZURE
 Consciousness is impaired in the form of
transient impairment in the patients ability
to maintain normal contact with the
environment
 Simple partial onset - aura
 Automatisms- lip smacking, chewing,
swallowing , picking movements of the
hand
 Confused following seizure

13. GENERALIZED
SEIZURE

14. PATHOPHYSIOLOGY OF
GENERALIZED SEIZURE
• Discharge spreads
simultaneously in both
hemispheres with no
single focus

15. ABSENCE SEIZURE
(PETIT MAL)
 Sudden brief lapse of consciousness
without loss of postural control
 Lasts for few seconds only
 No post-ictal confusion
 Begin in childhood
 Occur hundreds of times per day

17. GENERALIZED TONIC-CLONIC
(GRAND MAL)
 No aura
 Tonic contractions of the muscles of the body
 Often starts with a cry – laryngeal muscle contraction
 Impaired respiration
 Pooling of secretions
 HR/BP increased
 After 10-20 sec tonic phase is evolved into a clonic
phase
 Post ictal confusion / coma / myalgia / fatigue

18. GENERALIZED TONIC-CLONIC SEIZURE

19. ATONIC
 Sudden loss of postural muscle tone
lasting for 1-2 sec
 Known as “drop attack”
 Consciousness may or may not be
impaired
 There may be risk of injury
 No post ictal confusion

21. MYOCLONIC
 Sudden clonic (jerk) movement of
the limbs, face or trunk
 Objects fall from the hand as if it is
thrown away
 ‘Flying saucer epilepsy’

22. FACTORS TRIGGERING SEIZURE
1. Sleep deprivation
2. Alcohol / withdrawal
3. Physical / mental strain
4. Flashing / flickering lights
5. Infection
6. Loud noise
7. Hot water

23. HOW TO DIAGNOSE EPILEPSY
 Clinical Assessment
– Patient history
– Tests (blood, EEG, CT, MRI scans)
– Neurologic exam
 ID of seizure type
 Clinical evaluation to look for causes

24. MANAGEMENT
 Immediate
– Air way
– Breathing
– Carry the person away from
danger
– Diazepam
 Non-pharmacologic treatment
– Vagus nerve stimulation
– Lifestyle modifications

25. MANAGEMENT
LONG-TERM
 Partial seizure
– Carbamazepine
– Valproate
– Lamotrigine
– Phenytoin
 Generalized seizure
– Valproate
– Lamotrigine
– Carbamazepine
– Phenytoin
– Oxcarbazepine

26. HEADACHE

27. INTRODUCTION
 Is the symptom of pain anywhere in the region of the
head or neck
 It classified into primary and secondary headache.

28. CLASSIFICATION
PRIMARY HEADACHE SECONDARY HEADACHE
 Or idiopathic
headaches
 The headache itself is
the disease
 No organic lesion in the
background
 Treat the headache
 Or symptomatic
headaches
 The headache is only a
symptom of an
underlying disease
 Treat the underlying
disease

29. PRIMARY
HEADACHE

30. PRIMARY HEADACHE
1. Tension-type
2. Cluster type
3. Migraine (with or without aura)
4. Sinus
5. Thunderclap headache - sudden onset (SAH)

31. PRIMARY HEADACHE

32. ‘RED FLAG’ SYMPTOMS IN HEADACHE
SYMTPOMS POSSIBLE EXPLANATION
Sudden onset (maximal immediately or
within minutes)
1. Subarachnoid hemorrhage
2. Cerebral venous sinus thrombosis
3. Pituitary apoplexy
4. Meningitis
Focal neurological symptoms (other than
for typically migrainous) Intracranial mass lesion
Constitutional symptoms
 Weight loss
 General malaise
 Pyrexia
 Meningism
 Rash
Meningoencephalitis
Neoplasm
Raised intracranial pressure (worse on
wakening / lying down, associated
vomiting)
Intracranial mass lesion
New onset aged > 60 years Temporal arteritis

33. TENSION HEADACHE
 Dull pain, tightness, or pressure around your forehead or the
back of your head and neck.
 Diffuse pain in tight head-band pattern
 Bilateral, non-pulsating
 Muscle aches and trouble focusing
 Mild photophobia or phonophobia
 10 attacks lasting 30 min–7 days
 Not aggravated by routine physical activity

34. CLUSTER HEADACHE
 The pain is sharp, burning or piercing sensation
 Unilateral pain behind eye
 Short, excruciating (15 min-3 hrs)
 Usually occur in the middle of the night
 Occur daily for 2-3mths then remit for months-years
 Red, watering eyes, blocked nose, sweaty face

35. SINUS HEADACHE
 Sinus headaches are headaches that may feel like an
infection in the sinuses (sinusitis).
 Pain, pressure and fullness in your cheeks, brow or
forehead
 Evidence of discharge from the nose
 Worsening pain if you bend forward or lie down
 Stuffy nose
 Fatigue

36. MIGRAINE HEADACHE
 A neurologic disorder characterised by idiopathic,
paroxysmal, recurrent attacks of headache lasting from
2-72 hours
 Migraine can occur with or without aura (flickering
lights, spots or zig-zag lines, fortification blind spots)
 Neurological, Gastrointestinal, Autonomic involvement
 Typical characteristics:
1. Unilateral (sometimes bilateral)
2. pulsating quality
3. Accompanied by nausea & vomiting or photophobia
& phonophobia
4. Aggravated by physical activity

39. COMPARISON

40. COMPARISON

41. MANAGEMENT
 Migraine
 Improved by lifestyle changes
 Medications are either to prevent or reduce symptoms once a
migraine starts.
 Beta-blockers, antidepressants, anticonvulsants and NSAIDs
 Tension-type headaches
 NSAIDs (ibuprofen, naproxen), acetaminophen or aspirin.
 For chronic tension type headaches, amitriptyline.
 Cluster headaches
 Subcutaneous, Sumatriptan and Triptan nasal sprays.
 High flow oxygen therapy also helps with relief.
 For people with extended periods of cluster headaches, preventive
therapy can be necessary.
 Verapamil is recommended as first line treatment

42. SECONDARY
HEADACHE

43. SECONDARY HEADACHE
Secondary to structures of the head and neck
• sinusitis, glaucoma, temporomandibular joint (TMJ) pain, tooth pain.
Secondary to chronic diseases
• Hypertension
• Anaemia
Secondary to psychiatric disorder
• somatisation, psychosis.
Infections
• Meningitis
• Encephalitis
Raised ICP
• Brain tumour
• Haemorrhagic strok
• Head (SAH) and/or neck trauma
Secondary to a substance, or its withdrawal
• carbon monoxide, alcohol, medication-overuse headache

44. FACIAL PAIN

45. DEFINITION
Pain in the facial area may be due to neurological
or vascular causes, but equally well may be
dental in origin.
All the neurological and vascular causes of facial
pain (excluding headaches) are rare compared to
the dental and temporomandibular causes.

46. TRIGEMINAL
NEURALGIA

47. TRIGEMINAL NEURALGIA
 A disorder of the trigeminal nerve that causes
episodes of sharp, stabbing pain in the cheek,
lips, gums, or chin on one side of the face.
 People with this pain often wince or twitch, which
is where trigeminal neuralgia gets its French
nickname ‘tic douloureux’, meaning "painful
twitch”.
 Commonly in middle aged or elderly people
 Female > Male

48. TRIGEMINAL NERVE

49. AETIOLOGY
Usually, the problem is contact between a
normal blood vessel — in this case, an artery or
a vein — and the trigeminal nerve at the base of
your brain. This contact puts pressure on the
nerve and causes it to malfunction.

50. AETIOLOGY
Can occur as a result of aging, or it can be
related to multiple sclerosis or a similar
disorder that damages the myelin sheath
protecting certain nerves. Less commonly,
trigeminal neuralgia can be caused by a tumor
compressing the trigeminal nerve.

51. AETIOLOGY

52. TRIGGERS
1. Shaving
2. Touching your face
3. Eating
4. Drinking
5. Brushing teeth
6. Talking
7. Putting on makeup
8. Encountering a breeze
9. Smiling
10. Washing face

53. DIAGNOSIS
Trigeminal Neuralgia is mainly
diagnosed clinically
 History – Type, location and triggering factors
 Neurological examination
 MRI

54. TREATMENT
MEDICAL TREATMENT
1. Carbamazepine (Tegretol / Carbtal)
2. Phenytoin sodium (Dilantin)
3. Valproic acid
1. Microvascular decompression
SURGICAL TREATMENT

55. OTHER CAUSES OF FACIAL PAIN
 Dental (tooth abscess) – one side, jaw, sensitive to
touch
 Cluster headache – one side, stuffy nose, tearing
around the eye, 30 minutes to 2 hours.
 Shingles – painful blistering skin rash
 Sinusitis – dull pain around the eyes and cheekbones
worse bending forward
 Migraine – aura, pain on one or both sides, nausea,
throbbing or pounding headache

56. CASE #1
A 55-year old man complains that he sometimes has sudden pain on
one side of his face lasting up to 2 minutes. The pain is
excruciating and feels like an ‘electric shock’. He states it happens
when he shaves and sometimes when he is chewing food. Upon
physical examination, you notice the area of the face he points to is
the area of distribution of the fifth cranial nerve. He is otherwise
healthy and does not take any medications. You ask him if he has
ever had shingles and says no. The most likely diagnosis is
A. Temporomandibular joint dysfunction
B. Temporal arteritis
C. Cluster headache
D. Trigeminal neuralgia
E. Postherpetic neuralgia

57. CASE #2
A 60-year old man complains of extremely severe, sharp, shooting
pain in his face. He describes the episodes as being “like a bolt of
electricity” that are brought about by touching a specific area, last
about 60 seconds, and occur many times during the day. Neurologic
examination is completely normal, but it is noted that part of his face is
unshaven because he fears to touch that area. Which is the
following is the most appropriate initial treatment?
A. Anticonvulsants
B. Aspirin
C. Nonsteroidal anti-inflammatory drugs
D. Vasoconstrictor
E. Vasodilators