1. Headaches + Facial pain Dr Gary Kroukamp

2. Introduction: Each of us experienced sporadically/ chronically headache Each of us experienced sporadically/ chronically headache 40% worldwide population suffers with severe, disabling headache at least annually 40% worldwide population suffers with severe, disabling headache at least annually Common ailment Common ailment Presenting symptom of *benign course Presenting symptom of *benign course *life-threatening *life-threatening

3. Evaluation: Complete history – age, rate of onset, intensity, quality, location, duration + response on Rx Complete history – age, rate of onset, intensity, quality, location, duration + response on Rx Pressure-like pain –chamber derived pain Pressure-like pain –chamber derived pain Sharp/ shooting pain –neuritic pain Sharp/ shooting pain –neuritic pain Throbbing pain – vascular pain Throbbing pain – vascular pain Burning/ aching – muscular pain Burning/ aching – muscular pain

4. Continue: Associated symptoms – N + V, fever, diplopia, syncope, photophobia, neck stiffness Associated symptoms – N + V, fever, diplopia, syncope, photophobia, neck stiffness An aura present An aura present Precipitating factors - head movements, stress, medications, alcohol Precipitating factors - head movements, stress, medications, alcohol Past medical history – head injuries, intracranial infections/processes, past surgeries Past medical history – head injuries, intracranial infections/processes, past surgeries

5. Examination: Complete head + neck examination (BP) Complete head + neck examination (BP) Neurological examination + cranial nerves Neurological examination + cranial nerves Eyes with fundoscopy Eyes with fundoscopy Temporomandibular joint (TMJ) Temporomandibular joint (TMJ) Teeth + trigger points in muscles Teeth + trigger points in muscles Psychometric testing Psychometric testing

6. Investigations: Lab tests – FBC, U+E, ANCA, RF, ANF Lab tests – FBC, U+E, ANCA, RF, ANF EEG – findings on neurologic examination EEG – findings on neurologic examination EMG – primary muscle disease/ neuropathy EMG – primary muscle disease/ neuropathy Radiographic – X-ray of TM-joint Radiographic – X-ray of TM-joint - X-ray of cervical spine - X-ray of cervical spine - CT / MRI - CT / MRI

7. Tension-Type Headache: Most common 69%- M; 88%-F Most common 69%- M; 88%-F Types – Episodic < 15 days/ month Types – Episodic < 15 days/ month - Chronic > 15 days/ month - Chronic > 15 days/ month Last 30min- 7 days, mild to moderate, pressing or tightening, not limit activities Last 30min- 7 days, mild to moderate, pressing or tightening, not limit activities Rx: 1)Stress reduction + physical exercises Rx: 1)Stress reduction + physical exercises 2)Low Benzo/ Amytriptilline/ NSAIDS

8. Migraine: Most studied + high incidence of limitation of productivity + loss quality of life Most studied + high incidence of limitation of productivity + loss quality of life Onset 2 nd -3 rd decade Onset 2 nd -3 rd decade Moderate to severe, pulsating for 4-72 H Moderate to severe, pulsating for 4-72 H With/ without aura + triggering factors With/ without aura + triggering factors Rx: 1)5-HT receptor( Sumatriptan),Ergotamine Rx: 1)5-HT receptor( Sumatriptan),Ergotamine 2)Prochlorperazine, SSRI, B-/ Ca-blockers, Botox, NSAIDS

9. Cluster Headache: Known as suicide headache Known as suicide headache Intensely severe, burning unilateral in orbit / supraorbital/ temporal area 15-180 min Intensely severe, burning unilateral in orbit / supraorbital/ temporal area 15-180 min Associated with autonomic hyperactivity Associated with autonomic hyperactivity Male dominance, with alcohol use Male dominance, with alcohol use Rx:1)Ca-blocker, Ergotamine, Lithium for 6- 8weeks then taper Rx:1)Ca-blocker, Ergotamine, Lithium for 6- 8weeks then taper

10. Temporal arteritis: Daily headaches of moderate to severe continuous intensity, scalp sensitivity, fatigue Daily headaches of moderate to severe continuous intensity, scalp sensitivity, fatigue 95% > 60yrs with dilated arteries on scalp 95% > 60yrs with dilated arteries on scalp ↑ESR + artery biopsy in area ↑ESR + artery biopsy in area Rx:1)High dose of steroids dramatic decrease in headache + taper Rx:1)High dose of steroids dramatic decrease in headache + taper 2)Active disease for 2 yrs

11. Chronic daily headache: CDH occuring 6 days/ week for 6 months CDH occuring 6 days/ week for 6 months Bilateral frontal/ occipital non-throbbing moderate to severe headache most of day Bilateral frontal/ occipital non-throbbing moderate to severe headache most of day Rx:1)High dose steroids prevents vision loss Rx:1)High dose steroids prevents vision loss

12. Trigeminal Neuralgia: Also tic doloureux- paroxysmal pain attacks lasting few seconds to less than 2min Also tic doloureux- paroxysmal pain attacks lasting few seconds to less than 2min Severe + distributed along branches of CN V with sudden, sharp, intense burning pain Severe + distributed along branches of CN V with sudden, sharp, intense burning pain Between attacks no facial numbness/ taste/ smell Between attacks no facial numbness/ taste/ smell Precipitate with eating/ talking/ washing face Precipitate with eating/ talking/ washing face Rx:1)Carbamazepine, TCA, NSAIDS, surgery when medical Rx failed Rx:1)Carbamazepine, TCA, NSAIDS, surgery when medical Rx failed

13. Glossopharyngeal Neuralgia: Pain attacks in distribution of CN IX Pain attacks in distribution of CN IX Unilateral in post. pharynx, soft palate, base of tongue, ear, mastoid or side of neck Unilateral in post. pharynx, soft palate, base of tongue, ear, mastoid or side of neck Precipitate by swallowing, yawning, coughing or phonation Precipitate by swallowing, yawning, coughing or phonation Rx:1)Carbamazepine, TCA, NSAIDS, surgery when medical Rx failed Rx:1)Carbamazepine, TCA, NSAIDS, surgery when medical Rx failed

14. Post-traumatic Neuralgia: Trauma induce pain syndromes to neuroma Trauma induce pain syndromes to neuroma Occipital/ parietal regions most common Occipital/ parietal regions most common Neuritic pain (sharp/ shooting pain) Neuritic pain (sharp/ shooting pain) Poor wound closure, infections, FB, hematoma Poor wound closure, infections, FB, hematoma Begins 2-6 months after injury Begins 2-6 months after injury Rx:1)Carbamazepine, TCA, NSAIDS,BOTOX Rx:1)Carbamazepine, TCA, NSAIDS,BOTOX 2)Surgical excision

15. Post-herpetic Neuralgia: Pain persists 2/> months after skin eruption of varicella-zoster virus Pain persists 2/> months after skin eruption of varicella-zoster virus CN V 2 nd most common CN V 2 nd most common Rx:1)Anticonvulsants with TCA/ baclofen Rx:1)Anticonvulsants with TCA/ baclofen

16. Temporomandibular Disorders: Temporal headache, otalgia, facial pain + limited jaw opening Temporal headache, otalgia, facial pain + limited jaw opening Spontaneously(60%), Event (40%) Spontaneously(60%), Event (40%) Classify – Internal derangements Classify – Internal derangements - Degenerative joint disease(DJD) - Degenerative joint disease(DJD) - Myofascial pain - Myofascial pain Rx:1)Physiotherapy + NSAIDS Rx:1)Physiotherapy + NSAIDS

17. Pseudotumor Cerebri: Intermittent headache of variable intensity Intermittent headache of variable intensity CN VI palsy/ NAD CN VI palsy/ NAD Papilloedema + high CSF pressures Papilloedema + high CSF pressures Rx:1)Acetazolamide + Furosemide Rx:1)Acetazolamide + Furosemide

18. Intracranial Processes: Primary/ Metastatic tumours 30% present with headache Primary/ Metastatic tumours 30% present with headache Dull, lateralized + mild with increasing intensity + frequency Dull, lateralized + mild with increasing intensity + frequency SDH- fluctuating level of consciousness with moderate headache SDH- fluctuating level of consciousness with moderate headache SAH- sudden onset of severe generalized headache SAH- sudden onset of severe generalized headache

19. CNS Infection: Headache, fever, neck stiffness, photophobia Headache, fever, neck stiffness, photophobia Include epidural abscess, fungal, TB, AIDS, autoimmune disease( sarcoidosis) Include epidural abscess, fungal, TB, AIDS, autoimmune disease( sarcoidosis) Dx:1)LP with CSF studies Dx:1)LP with CSF studies 2)CT/ MRI Rx:1)Appropriate IV A/B Rx:1)Appropriate IV A/B

20. Hypertension: Chronic untreated hypertension cause headache Chronic untreated hypertension cause headache Diastolic pressure >115 mmHg Diastolic pressure >115 mmHg Throbbing with nausea Throbbing with nausea Rx:1)Antihypertensive Rx:1)Antihypertensive 2)Investigate for complications

21. Acute Sinusitis: Constant, dull + aching headache Constant, dull + aching headache Worsened with head movements forward Worsened with head movements forward Over inflamed mucosa + refer to other areas in face and neck Over inflamed mucosa + refer to other areas in face and neck Dx:1)Nasal endoscopy + CT of sinusses Dx:1)Nasal endoscopy + CT of sinusses Rx:1)A/B + Decongestants Rx:1)A/B + Decongestants 2)Surgical drainage needed/ not

23. The end