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Headache andFacial pain for

Dentist’54Surat Tanprawate, MD, MSc(Lond.), FRCPT

Division of NeurologyChaing Mai University

Tuesday, 31 May 2011



Pain

René Descartes, FrenchPhilosopher31 March 1596 – 11 February 1650




Headache and Pain Sensitive Structure

Meninges

Venous sinus

Neural structure :-glossopharyngeal n.-trigeminal n.

-upper cervical n.

Artery :-dural a.-carotid a.-basilar a.




International Classicat ion of Headache Disorder-2004

International Classication of

Headache Disorder 2004

http://ihs-classication.org

Part 1 . The primary headaches

- Migraine, TTH, CH and otherTACs, and other primary headachedisorder

Part II . The secondary headaches

-Headache attributed to ....

Part III . Cranial neuralgias,central and primary facial pain andother headaches


http://ihs-classification.org/





Description and Criteriahttp://ihs-classication.org

Description

Criteria






Patient presents withcomplaint of a headache

Critical rst step:Hx taking, physical exam

Red ag signs or alarmingsigns

Meets criteria for primaryheadache disorder?

Migraineheadache

Tension-typeheadache

Cluster

headache andother TACs

Chronic dailyheadache (CDH)

Red ag signs

Investigation

Secondaryheadachedisorder

Other (rare)headachedisorder

(+)(-)

(+)




Alarming signs and

symptoms• “Alarming s/s suggest the possibility of

secondary headache

• The studies

• Headache sample (specic or non-

specic)• Pool analyzed data => guideline




Normal neurologicalexamination

Abnormal neurologicalexamination

Focal neurologic s/sother than typical visual

or sensory aura

Papilledema

Temporalprole

Concurrentevent

Provokingactivity

Age

Age> 50

Sudden onset-SAH, ICH, masslesion (posteriorfossa)

Worsening headache-Mass lesion, SDH,MOH

Pregnancy, postpartum-Cerebral veinthrombosis, carotiddissection, pituitaryapoplexy

Headache withcancer, HIV, systemicillness (fever,arteritis, collagenvascular disease)

Neck stiffness

Triggered by cough,exertion or Valsava-SAH, mass lesion

Worse in themorning-IICP

Worse on awakening-Low CSF pressure




To Divide Primary

HeadacheCommon primaryheadache disorder

Chronic dailyheadache

(CDH)

Other (unusual)primary headache

disorder

Remember thecriteria

-Migraine-Tension-typeheadache-Cluster headacheand other TACs

ApproachCDH

Identify thetriggers and

associatedfactors

Modied from Bigal M. E. et al. J Headache Pain . 2007; 8: 263-272




Diagnostic criteria of commonprimary headache disorder

Migraine without aura Infrequent ETTH

ICHD-II Cephalalgia .2004Migraine with typical aura needs 2 attacksIn children, the attack may last 1-72 hours




Cluster headacheCluster headacheand others TACs

“Short lasting, unilateral,severe headache

accompanying with

autonomic symptoms”

ICHD-II Cephalalgia .2004




Common primary headache disorder

Migraine and Tension-type headache




Early migraine

description

Hippocrates (c.460-c.370 B.C.)

"He seemed to see somethingshining before him like a light ,

usually in part of the right eye ; atthe end of a moment, a violent pain

supervened in the right temple ,then in all the head and neck....

vomiting , when it becamepossible, was able to divert thepain and render it more moderate."

JMS Pearce . JNNP 1986;49:1097-1103Tuesday, 31 May 2011



"He seemed to see somethingshining before him like a light ,

usually in part of the right eye ; at the end of a moment, a violent pain

supervened in the right temple , then in all the head and neck....

vomiting , when it becamepossible, was able to divert thepain and render it more moderate."

Migraine with aura =

“Classic migraine”




ʻʻ On a distinct form oftransient hemiopsia ʼʼ byDr. Hubert Airy in 1870.

ʻʻ Teichopsia ʼʼ (Greek for

ʻʻ

townwall vision ʼʼ )




The “Classic” Migraine =Migraine with aura




The different faces of migraine

Classic migraine

MA:various aura types Headache

Migrainevariant

- Typical aura-Atypical aura

-Change headachecharacter in CM/TM

Clinicalmanifestation




Migraine Aura

Michael B. R. et al. Brain 1996: 119, 355-361

n=163

99% 31%

6%

18%

Typical aura :-Visual-Sensory-Speech




Typical aura

• Typical aura consisting of visual and/orsensory and/or speech symptoms.Gradual development , duration nolonger than one hour , a mix of positive and negative features and completereversibility characterize the aura which isassociated with a headache that does notfulll criteria for Migraine without aura.




Visual aura

Typical visual aura is simple




Only migraine without auraOnly migraine with auraBoth types

Launer LJ et al. Neurology 1999;53:537-42

Migraine without aura is more common(previously called common migraine)

Population-based study




Zig-zag lines (fortication)

Zig-zag lines in migraine aura

Visual Aura

Table of Fortication, from the 1728Olomouc (c.1757) bastion fortress intoday's Czech Republic




Alice in WonderlandSyndrome (AWS)

Somesthetic metamorphopsia.Distortion of body and space

Did Lewis Carroll draw inspirationfrom migraine auras?

Alice in Wonderland. By Lewis Carroll




MigraineVariant

Childhood periodic syndromesthat are commonly precursorsof migraine-Cyclic vomiting syndrome-Abdominal migraine-Benign paroxysmal vertigo of childhood

Retinalmigraine

Basilar

migraine

Persistent aurawithoutinfarction

Complication of migraine-Chronic migraine-Status migrainosus-Persistent aura withoutinfarction

-Migrainous infarction

Migrainetriggeredseizure

Hemiplegicmigraine

Typical aurawithoutheadache




Tension-type headache

• Most common headache type

•Featureless headache, uncertain pathophysiology(mental or muscular cause?)

• HRQoL of Headache

• ETTH > CTTH = EM > CM/TM

• When migraine become chronic, the headache’scharacters are similar to TTH




TTH diagnostic criteria




Uncommon primary

headache disorder

Cluster headache, and other TACsOther primary headache disorder


h



Patient presents withcomplaint of a headache

Critical rst step:Hx taking, physical exam

Red ag signs or alarmingsigns

Meets criteria for primaryheadache disorder?

Migraineheadache

Tension-typeheadache

Clusterheadache andother TACs

Chronic dailyheadache (CDH)

Red ag signs

Investigation

Secondaryheadachedisorder

Other (rare)primary

headache

(+)(-)

(+)




Trigeminal AutonomicCephalalgia

“The most severe headache ever”




TACs“A group of primary headache disorders

characterized by strictly unilateral headpain that occurs in association withipsilateral cranial autonomic

features ”

- Cluster headache (CH)

- Paroxysmal hemicrania (PH)

- Short-lasting unilateral neuralgiform headacheattacks with conjunctival injection and tearing/

cranial autonomic features (SUNCT/SUNA)Tuesday, 31 May 2011



Cohen AS. Headache 2007

TACs subtypes




Other headache disorder

Short durationLong duration

Triggered Not triggered

Physicalactivity

Sleep

Hypnic

headache-Primary cough

headache-Primary exertionalheadache-Primary headacheassociated withsexual activity

-Primary stabbingheadache-Primarythunderclapheadache

-Hemicrania continua-New daily-persistentheadache (NDPH)

http://ihs-classication.orgTuesday, 31 May 2011





Cranial Neuralgias andOther causes of Facial

pain




Structure based approach

• Musculoligamentous based

• Dentoalveolar based• Neurological based

• Trigeminal Autonomic

Cephalalgias(TACs)

• Cranial neuralgias




Clinicalclues

• Localisation

• Time pattern

• Onset, circadian distribution,Course and progression

• Duration

• Quality

• Intensity• Precipitating and alleviating factor

• Associated symptoms and signs




Clinical classication of

facial pain syndromes1. Neuralgias

2. Facial pain syndrome with cranial nervesigns and symptoms

3. Trigeminal autonomic cephalalgias(TACs)

4. Pure facial pain without neurological signs




1. Neuralgias

• The presence of sudden, sharp, aching,lancinating, burning, and stabbing pain lastingfrom only a few seconds to less than 2 minand recurring repeatedly within shortperiods of time, which is often triggered bysensory or mechanical stimuli




ICHD-II, 2004




Trigeminal Neuralgia

• 70% of patients are older than 60 years atonset

• Clinical hallmark:

• brief electric shock-like pains

• abrupt in onset and termination

• limited to the distributions of the trigeminalnerve

• commonly stimuli: mechanical




Classical trigeminal neuralgia

Symptomatic trigeminal neuralgia

“TN caused by a demonstrable structural lesion”




2. Facial pain syndrome withcranial nerve signs and symptoms

• pain in the face accompanied by s/s caused by alesion of one or several cranial nerve

• pain around the eye+optic n. or ocular motorsystem dysfunction

• pain with disturb facial sensation, facial palsy,hyperacusis

• pain with disturbed balance

• pain with dysphagia, dysphonia, or dysarthria




4. Facial pain without

neurological signs• Disorder of the

temporomandibular joint

• Disorder of the oral structures orsalivary gland

• Rhinosinus-related headache




Headache attributed to disorder of teeth, jaws or related

structures• Headache accompanied by pain in the teeth and/

or jaw(s) and fullling criteria C and D

• Evidence of disorder of teeth, jaws, or related structures

• Headache and pain in teeth and/or jaw(s) developin close temporal relation to the disorder

• Headache and pain in teeth and/or jaw(s)resolve within 3 months after successfultreatment of the disorder




Headache attributed totemporomandibular joint(TMJ) disorder

• Recurrent pain in one or more regions of the head and/or face fulllingcriteria C and D

• X-ray, MRI and/or bone scintigraphy demonstrate TMJ disorder

• Evidence that pain can be attributed to the TMJ disorder, based on at leastone of the following:

• pain is precipitated by jaw movements and/or chewing of hard or toughfood

• reduced range of or irregular jaw opening

• noise from one or both TMJs during jaw movements

• tenderness of the joint capsule(s) of one or both TMJs

• Headache resolves within 3 months , and does not recur, after successfultreatment of the TMJ disorder





International Classicat ion of Headache Disorder-2004

International Classication of

Headache Disorder 2004

http://ihs-classication.org

Part 1 . The primary headaches

- Migraine, TTH, CH and otherTACs, and other primary headachedisorder

Part II . The secondary headaches

-Headache attributed to ....Part III . Cranial neuralgias,central and primary facial pain andother headaches







My deepest gratitudeto...

Dr Siwaporn ChankrachangDepartment of Neurology, CMU,Chiangmai, Thailand

Dr Manjit MatharuHeadache Group, Institute of Neurology,Queen Square, London, UK

Thank you for your attention

headache for dentist 54

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