head, neck and facial pain

Head, neck and facial painHead, neck and facial pain

A pain in the head, face or a pain A pain in the head, face or a pain in the neck?in the neck?

AIMSAIMS

TO DISCUSS HEAD, FACE AND NECK TO DISCUSS HEAD, FACE AND NECK PAIN AND THE POSSIBLE CAUSESPAIN AND THE POSSIBLE CAUSES

OBJECTIVESOBJECTIVES

To consider the innervation of the head and To consider the innervation of the head and neck regionneck region

To understand some of the physiological To understand some of the physiological relationshipsrelationships

To know some of the conditions giving rise To know some of the conditions giving rise to painto pain

INNERVATION OF THE HEAD AND INNERVATION OF THE HEAD AND NECK REGIONNECK REGION

Trigeminal nerveTrigeminal nerve Branches from C2, C3, C4 and C5Branches from C2, C3, C4 and C5 Afferent impulses from the Trigeminal and Afferent impulses from the Trigeminal and

cervical region converge in the 2cervical region converge in the 2ndnd cervical cervical segment of spinal cordsegment of spinal cord

RELEVANT NEUROLOGYRELEVANT NEUROLOGY

Trigeminal nerve and ganglionTrigeminal nerve and ganglion Cervical nerves, mainly C2Cervical nerves, mainly C2 Sphenopalatine ganglionSphenopalatine ganglion Cutaneous nerve supplyCutaneous nerve supply

Head, face and neck painHead, face and neck pain

Pain in the face: -Trigeminal or neckPain in the face: -Trigeminal or neck Pain in the head:-supplied by C2 and C3Pain in the head:-supplied by C2 and C3 Pain in the neck:- supplied by C2-C5Pain in the neck:- supplied by C2-C5 Pain in or around the ears:-supplied by C2Pain in or around the ears:-supplied by C2

HISTORYHISTORY

Very importantVery important Ensure it is very detailedEnsure it is very detailed Enquire about the function of all parts of the Enquire about the function of all parts of the

head and neckhead and neck Ensure you understand the time sequence Ensure you understand the time sequence

of events and symptomsof events and symptoms Ask about sympathetic symptomatologyAsk about sympathetic symptomatology

HISTORYHISTORY

SiteSite SortSort SeveritySeverity OnsetOnset DurationDuration

RadiationRadiation Associated factorsAssociated factors Precipitating factorsPrecipitating factors Relieving factorsRelieving factors Red flags (night pain, Red flags (night pain,

loss of sensation, loss of sensation, symptoms elsewhere)symptoms elsewhere)

EXAMINATIONEXAMINATION

Full Cranial Nerve examinationFull Cranial Nerve examination Full neurological examination of the neck Full neurological examination of the neck

and armsand arms Check for trigger points in neck, around Check for trigger points in neck, around

occiput, Sternocleidomastoid, Masseters, occiput, Sternocleidomastoid, Masseters, Pterygoids, Temporalis, behind the ear. Pterygoids, Temporalis, behind the ear. Check common acupuncture pointsCheck common acupuncture points

CLASSIFICATION OF FACIAL CLASSIFICATION OF FACIAL PAINPAIN

Local diseaseLocal disease Neurological disordersNeurological disorders Psychogenic conditionsPsychogenic conditions Referred painReferred pain

PAIN IN JUST THE FACEPAIN IN JUST THE FACE

Trigeminal NeuralgiaTrigeminal Neuralgia TMJ painTMJ pain Trigeminal autonomic syndromesTrigeminal autonomic syndromes Atypical facial painAtypical facial pain Very occasionally a C2 problemVery occasionally a C2 problem Glossopharyngeal neuralgiaGlossopharyngeal neuralgia VII/VIII complex (N intermedius)VII/VIII complex (N intermedius)

TRIGEMINAL NEURALGIATRIGEMINAL NEURALGIA

Symptom rather than specific disease.Symptom rather than specific disease. Can be due to a specific lesion which is Can be due to a specific lesion which is

causing destruction, irritation or causing destruction, irritation or demyelination.demyelination.

CAUSES OF TRIGEMINAL CAUSES OF TRIGEMINAL NEURALGIANEURALGIA

IdiopathicIdiopathic Vascular compression.Vascular compression. Tumour.Tumour. Aneurysm.Aneurysm. M.S.M.S. Demyelinating peripheral neuropathies.Demyelinating peripheral neuropathies.

FEATURESFEATURES

Episodic, recurrent unilateral facial pain.Episodic, recurrent unilateral facial pain. Lasts a few seconds, occurring many times Lasts a few seconds, occurring many times

a day.a day. VV2 2 > V> V3 3 > V> V1.1.

Triggers are trivial events.Triggers are trivial events. 2.7:100 000 men and 5.0: 100 000 women.2.7:100 000 men and 5.0: 100 000 women. 50 - 60 years.50 - 60 years. Neurology normal.Neurology normal.

MEDICAL TREATMENTMEDICAL TREATMENT

Gabapentin 1.2g – 1.8g dailyGabapentin 1.2g – 1.8g daily Carbamazepine up to 1000 - 1200mg/day.Carbamazepine up to 1000 - 1200mg/day. Phenytoin.Phenytoin. Baclofen.Baclofen. Clonazepam.Clonazepam. Valproic Acid.Valproic Acid.

SURGICAL TREATMENTSURGICAL TREATMENT

R.F Trigeminal Ganglion.R.F Trigeminal Ganglion. Injection of Gylcerol into cistern of Meckel’s Injection of Gylcerol into cistern of Meckel’s

Cave.Cave. Microvascular decompression of Trigeminal Microvascular decompression of Trigeminal

Nerve.Nerve. Peripheral Neurectomy of a branch of Peripheral Neurectomy of a branch of

Trigeminal Nerve.Trigeminal Nerve.

TMJ PAINTMJ PAIN

Pain in the joint and masticatory musclesPain in the joint and masticatory muscles Dull ache/ear acheDull ache/ear ache Radiates to temporal, masseteric, occipital Radiates to temporal, masseteric, occipital

and mastoid areasand mastoid areas Associated with other stress induced Associated with other stress induced

syndromessyndromes Females > males Females > males

The problemThe problem

Emotional stressEmotional stress Muscle hyperactivityMuscle hyperactivity BruxismBruxism Joint overloadingJoint overloading

ExaminationExamination

Tender mandibular condyles and maxillary Tender mandibular condyles and maxillary tuberositiestuberosities

Tender Temporalis, Masseter and Pterygoid Tender Temporalis, Masseter and Pterygoid musclesmuscles

TreatmentTreatment

Simple analgesiaSimple analgesia TCATCA Local Anaesthetic injectionsLocal Anaesthetic injections Botulium ToxinBotulium Toxin AcupunctureAcupuncture

MYOFASCIAL PAINMYOFASCIAL PAIN

Associated with tender muscles of the face, Associated with tender muscles of the face, head and neckhead and neck

Can be primary or secondaryCan be primary or secondary

HISTORY AND EXAMINATIONHISTORY AND EXAMINATION

– History is vague and difficult to decipherHistory is vague and difficult to decipher– Examination reveals multiple trigger points Examination reveals multiple trigger points

within the facial and neck musculaturewithin the facial and neck musculature– Travell shows these trigger points wellTravell shows these trigger points well

TreatmentTreatment

AcupunctureAcupuncture PhysiotherapyPhysiotherapy TENSTENS Local anaesthetic and steroid injectionsLocal anaesthetic and steroid injections

PAIN IN JUST THE NECKPAIN IN JUST THE NECK

Cervical facetsCervical facets Cervical discsCervical discs Cervical ligamentsCervical ligaments Cervical musclesCervical muscles Sternocleidomastoid and Strap musclesSternocleidomastoid and Strap muscles Has there been any neck trauma?Has there been any neck trauma?

CERVICAL PAINCERVICAL PAIN

Originates from C2 and C3Originates from C2 and C3 May have neck painMay have neck pain Often have facial pain/head painOften have facial pain/head pain Distribution is C2/C3Distribution is C2/C3 Can involve the Trigeminal regionCan involve the Trigeminal region

HistoryHistory

Pain on neck movementPain on neck movement Feeling of pressure on their headFeeling of pressure on their head Feel as if they cannot support their headFeel as if they cannot support their head

ExaminationExamination

Limited neck movement, usually extension, Limited neck movement, usually extension, lateral flexionlateral flexion

Tender cervical musclesTender cervical muscles Tender cervical facetsTender cervical facets

TreatmentTreatment

PhysiotherapyPhysiotherapy TENSTENS AcupunctureAcupuncture Local anaesthetic blocksLocal anaesthetic blocks

PAIN IN /AROUND EARSPAIN IN /AROUND EARS

Parotid glandParotid gland SubmandibularSubmandibular Masseter/PterygoidsMasseter/Pterygoids Within the earWithin the ear From previous surgery (a type of CRPS)From previous surgery (a type of CRPS) CervicogenicCervicogenic

ATYPICAL FACIAL PAINATYPICAL FACIAL PAIN

Diagnosis of exclusionDiagnosis of exclusion Other pathology has been ruled outOther pathology has been ruled out

TreatmentTreatment

ReassuranceReassurance CBTCBT ACP/TensACP/Tens BaclofenBaclofen GabapentinGabapentin AmitriptylineAmitriptyline

HEADACHESHEADACHES

Migraine +/- auraMigraine +/- aura Tension typeTension type Trigeminal autonomic cephalagiasTrigeminal autonomic cephalagias Medication overuseMedication overuse CervicogenicCervicogenic

SERIOUS CAUSES OF HEADACHESERIOUS CAUSES OF HEADACHE

Intracranial tumoursIntracranial tumours MeningitisMeningitis Subarachnoid HaemorrageSubarachnoid Haemorrage Giant cell arteritisGiant cell arteritis Primary closed angel glaucomaPrimary closed angel glaucoma Idiopathic intracranial hypertensionIdiopathic intracranial hypertension Carbon Monoxide poisoningCarbon Monoxide poisoning

SUMMARYSUMMARY

AnatomyAnatomy Physiological linksPhysiological links Common syndromesCommon syndromes

Useful referencesUseful references

NICE guidelines on Neuropathic painNICE guidelines on Neuropathic pain UHL guidelines on neuropathic pain UHL guidelines on neuropathic pain

(intranet LMSG web site and inpatient web (intranet LMSG web site and inpatient web site)site)

BASH guidelines. www.bash.org.ukBASH guidelines. www.bash.org.uk

ANATOMYANATOMY

Head and face supplied by Trigeminal nerve Head and face supplied by Trigeminal nerve and the first 3 cervical nervesand the first 3 cervical nerves

Afferent impulses from the Trigeminal and Afferent impulses from the Trigeminal and cervical region converge in the 2cervical region converge in the 2ndnd cervical cervical segment of spinal cordsegment of spinal cord

PAIN SYNDROMESPAIN SYNDROMES

TRIGEMINAL NEURALGIATRIGEMINAL NEURALGIA TMJ PAINTMJ PAIN ATYPICAL FACIAL PAINATYPICAL FACIAL PAIN MYOFASCIAL PAINMYOFASCIAL PAIN CERVICAL PAINCERVICAL PAIN