Headaches and Facial Pain

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Headaches and Facial Pain

Rhinology
Author Credentials 

Edward D. McCoul, MD, MPH
Associate Professor
Department of Otorhinolaryngology
Ochsner Clinic Foundation
New Orleans, LA 70121
emccoul@gmail.com

With Significant Prior Contributions from Mathew Joseph Cosenza, R.Ph, DO

Module Summary

Patients with complaints of headache and facial pain are often referred to an otolaryngologist for diagnosis and management. The spectrum of causes of headache and facial pain is broad and many treatment modalities are available. The ability to use the appropriate diagnostic aids to determine the etiology of the pain is crucial in the otolaryngologist’s efforts to relieve pain and, in some instances, intervene in a potentially life-threatening event. The otolaryngologist must be able to delineate the needs of the patient both in regards to the workup and the appropriate medical and surgical options.

Module Learning Objectives 
  1. Explain the multiple modalities required for the evaluation of the headache and facial pain patient.
  2. Discuss the classification of headache and facial pain syndromes as diagnostic entities.
  3. Summarize the interplay and overlay between variable pathologies as they relate to the perception of headache and facial pain.
  4. Recognize the signs and symptoms that could suggest headache and facial pain is a manifestation of a life-threatening illness.
  5. Cite the pharmacological, surgical, and multidisciplinary treatments of headache and facial pain.

Embryology

Learning Objectives 

Understand the common embryologic head and neck developmental abnormalities and how they can contribute to the pathogenesis of headache and facial pain.

References 
  1. Anson BJ, Davies J, Duckert LG. Embryology of the ear. In: Paparella MM, Shumrick DA, Gluckman JL, et al., editors. Otolaryngology, 3rd ed. Philadelphia: WB Saunders; 1991:3-21.
  2. Davies J, Duckert LG. Embryology and anatomy of the head, neck, face, palate, nose, and paranasal sinuses. In: Paparella MM, Shumrick DA, Gluckman JL, et al., editors Otolaryngology, 3rd ed. Philadelphia: WB Saunders; 1991:59-106.

Anatomy

Learning Objectives 
  1. Understand the anatomy of the head and neck so as to appreciate how irregular anatomic structure and altered function can precipitate headache and facial pain.
  2. Appreciate the role of the galea aponeruosis in the transmission of muscle tension headache.
  3. Understand the course of the superficial temporal artery as it relates to the distribution of pain in temporal arteritis.
  4. Recognize the function and innervation of the temporal mandibular joint and the Eustachian tube so as to realize their role in the development of headache and facial pain.
References 
  1. Anderson JE. The cranial nerves. In: Anderson JE, editor. Grant’s atlas of anatomy. 8th ed. Baltimore: Williams & Wilkins; 1983:8-1 to 8-12.
  2. Anderson JE. The head. In: Anderson JE, editor. Grant’s atlas of anatomy. 8th ed. Baltimore: Williams & Wilkins; 1983:7-1 to 7-168.
  3. Anderson JE. The neck. In: Anderson JE, editor. Grant’s atlas of anatomy. 8th ed. Baltimore: Williams & Wilkins; 1983:9-1 to 9-85.
  4. Janfaza P, Nadol JB, Galla RJ, et al. Surgical anatomy of the head and neck. Philadelphia: Lippincott Williams & Wilkins; 2001:1-884.
  5. McMinn RMH, Hutchings RT. Head, neck and brain. In: McMinn RMH, Hutchings RT, editors. Color atlas of human anatomy. 2nd ed. Chicago: Year Book Medical Publishers; 1988:9-76.

Pathogenesis

Learning Objectives 
  1. Be familiar with the classification of head and neck pain syndromes according to the International Association for the Study of Pain.
  2. Understand the concepts of ephaptic transmission, neurogenic inflammation, and muscular trigger points and appreciate how they participate in the development of pain.
  3. Be aware of the importance of psychogenic and psychosocial factors in the etiopathogenesis of headache and facial pain.
  4. Appreciate the referred pain pattern of cranial nerves V, VII, IX, and X as they can relate to the development of headache and facial pain.
References 
  1. Mongini F. Part I classification and pathophysiology. In: Mongini F, editor. Headache and facial pain. New York: Thieme; 1999:2-107.
  2. Robbins MS, Robertson CE, Kaplan E, Ailani J, Charleston L 4th, Kuruvilla D, Blumenfeld A, Berliner R, Rosen NL, Duarte R, Vidwan J, Halker RB, Gill N, Ashkenazi A. The sphenopalatine ganglion: anatomy, pathophysiology, and therapeutic targeting in headache. Headache. 2016;56:240-58.

Incidence

Learning Objectives 
  1. Understand the prevalence of headaches and the extent that people worldwide suffer from headaches.
  2. Appreciate the enormous economic impact that headaches have on our nation’s economy.
References 
  1. Cooper BC, Lucente FE. Perspectives in head and neck pain. In: Cooper BC, Lucente FE, editors. Management of facial, head and neck pain. Philadelphia: WB Saunders; 1989:1-22.
  2. Evans RW, Mathew NT. Diagnosis of headaches. In: Evans RW, Mathew NT, editors. Handbook of headache. Philadelphia: Lippincott Williams & Wilkins; 2000:1-3.

Patient Evaluation

Learning Objectives 
  1. Know the clinical features that differentiate a headache related to migraine versus that caused by an intracranial lesion.
  2. Know when imaging is indicated in the evaluation of a patient with facial pain.
  3. Discuss the evaluation of the patient with rhinogenic headache.
  4. Be familiar with the helpful questions and the elements of the headache history.
  5. Understand the key features of the most common primary and secondary headaches.
References 
  1. Biondi DM. Headaches and their relationship to sleep. Dent Clin North Am. 2001;45(4):685-700.
  2. Evans RW, Mathew NT. Diagnosis of headaches. In: Evans RW, Mathew NT, editors. Handbook of headache. Philadelphia: Lippincott Williams & Wilkins; 2000:3-21.
  3. Ginkel AG, Mann JD, Lundeen TF. Headache and facial pain. In: Bailey BJ, Pillsbury III HC, Newlands SD, editors. Head and neck surgery – otolaryngology, 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2001:221-35.
  4. Kenny TJ, Duncavage J, Bracikowski J, et al. Prospective analysis of sinus symptoms and correlation with paranasal computed tomography scan. Otolaryngol Head Neck Surg. 2001;125(1):40-43.
  5. Mongini F. Part II general clinical aspects. In: Mongini F, editor. Headache and facial pain. New York: Thieme; 1999:111-36.
  6. Mudgil SP, Wise SW, Hopper KD, et al. Correlation between presumed sinusitis-induced pain and paranasal sinus computed tomographic findings. Ann Allergy Asthma Immunol. 2002;88(2):223-26.
  7. Olesen J. Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain. Cephalalgia. 1988;8:28(Suppl 7).

Measurement of Functional Status

Learning Objectives 

Appreciate the role of patient-reported functional and quality-of-life measurement in the assessment and management of headache and facial pain disorders.

References 
  1. Bakar NA, Tanprawate S, Lambru G, Torkamani M, Jahanshahi M, Matharu M. Quality of life in primary headache disorders: A review. Cephalgia. 2016;36:67-91.
  2. Chen H, Lee JYK. The measurement of pain in patients with trigeminal neuralgia. Clin Neurosurg. 2010;57:129-33.

Imaging

Learning Objectives 
  1. Describe the indications for a computed tomography (CT) scan versus a magnetic resonance imaging (MRI) scan of the brain in a patient with head trauma or a suspected cardiovascular accident.
  2. Understand the different diagnostic modalities required to delineate diverse conditions such as Eagle’s syndrome, cervicogenic headache, or rhinopathic headache.
  3. Be familiar with the use of combination radionuclide bond and gallium scans in the diagnosis of necrotizing osteomyelitis.
References 
  1. Noyek AM, Witterick IJ, Fliss DM, et al. Diagnostic imaging. In: Bailey BJ, Pillsbury III HC, Newlands SD, editors. Head and neck surgery – otolaryngology. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2001:55-65.

Pathology

Learning Objectives 
  1. Appreciate that multiple disease processes can elicit the development of headache and facial pain.
  2. Understand the role of inflammation, malignancy, and necrosis in the development of many pain syndromes.

Treatment

Learning Objectives 

Understand that the treatment of headache and facial pain is generally grouped as symptomatic treatment or preventive therapy.

Medical Therapies

Learning Objectives 
  1. Understand when medical therapy directed at sinusitis associated headache is appropriate versus medical therapy directed at primary headache disorders are appropriate.
  2. Be aware of the use of nonsteroidal anti-inflammatory drugs, benzodiazepines, myorelaxants, antidepressants, anticonvulsants, and cortisone in the treatment of muscle tension headache, neuralgia, neuropathic pain, and cluster headache.
  3. Know the different topical agents used in the treatment of postherpetic neuralgia.
  4. Understand the use of neuroleptics, beta-blockers, calcium antagonists, ergot derivatives, and serotonin agonists in the treatment of migraines.
References 
  1. Patel ZM, Setzen M, Poetker DM, DelGaudio JM. Evaluation and management of “sinus headache” in the otolaryngology practice. Otolaryngol Clin North Am. 2014 Apr;47(2):269-87.
  2. Mongini F. Part II drug treatment. In: Mongini F, editor. Headache and facial pain. New York: Thieme; 1999:137-47.
  3. Johnson RW, Rice ASC. Postherpetic neuralgia. N Engl J Med. 2014;371:1526-33.
  4. Clark GT, Padilla M, Dionne R. Medication treatment efficacy and chronic orofacial pain. Oral Maxillofac Surg Clin North Am. 2016;28:409-21.

Surgical Therapies

Learning Objectives 
  1. Understand how to differentiate headache originating from the sinuses from headache originating from other sources.
  2. Understand the role of local and regional nerve and ganglia blocks in the treatment of head and neck pain.
  3. Understand the role of botulinum toxin in the treatment of head and neck pain disorders.
  4. Describe the invasive treatment options for temporomandibular joint (TMJ) syndrome.
References 
  1. Patel ZM, Kennedy DW, Setzen M, Poetker DM, DelGaudio JM. “Sinus headache”: rhinogenic headache or migraine? An evidence based guide to diagnosis and management. Int Forum Allergy Rhinol. 2013 Mar;3(3):221-30.
  2. Levin M. Nerve blocks in the treatment of headache. Neurotherapeutics. 2010;7:197-203.
  3. Finkel AG. Botulinum toxin and the treatment of headache: a clinical review. Headache. 2011;51:1565-72.
  4. Morra ME, Elgebaly A, Elmaraezy A, Khalil AM, Altibi AM, Vu TL, Mostafa MR, Huy NT, Hirayama K. Therapeutic efficacy and safety of botulinum toxin A therapy in trigeminal neuralgia: a systematic review and meta-analysis of randomized controlled trials. J Headache Pain 2016;17:63. 
  5. Rigon M, Pereira LM, Bortoluzzi MC, et al. Arthroscopy for temporomandibular disorders. Cochrane Database Syst Rev. 2011 May 11;(5):CD006385.

Rehabilitation

Learning Objectives 

Understand the use of biofeedback, transcutaneous electrical nerve stimulation, soft laser therapy, anesthetic injections, osteopathic manipulative therapy, chiropractic therapy, and physical therapy in the treatment of head and neck pain.

References 
  1. Lefkowitz M, Goldstein S, Lebovits A. Management of chronic pain of the head and neck: an anesthesiologist’s perspective. In: Cooper BC, Lucente FE, editors. Management of facial, head and neck pain. Philadelphia: WB Saunders; 1989:299-329.
  2. Mongini F. Part II nonpharmacological treatment. In Mongini F, editor. Headache and facial pain. New York: Thieme; 1999:156-64.
  3. Seshan TV. Rehabilitation management of neck pain. In: Cooper BC, Lucente FE, editors. Management of facial, head and neck pain. Philadelphia: WB Saunders; 1989:255-86.

Staging

Learning Objectives 

Know that there are no true staging systems for these disorders, although there are classifications within diagnostic groups.

Case Studies

  1. Childhood migraine: An 8-year-old female presents with a 2-year history of headaches associated with light and noise sensitivity. The headaches occur almost weekly with the same presentation of bifrontal pounding. Symptoms are controlled with ibuprofen and resolve in approximately an hour after lying down. The patient has a history of nasal allergy that is relived with decongestants. The patient has had no change in school responsibilities and no increased stress at home. Family history is noncontributory and neurologic exam was normal.
    1. Most likely childhood migraine.
    2. Before puberty the prevalence is the same in boys and girls (approximately 5%). After puberty 3:1 females to males.
    3. Migraines in children are usually shorter than those in adults.
    4. In children they usually occur in the frontal or temporal region bilaterally.
  2. Cluster headache: A 30-year-old male has a 6-year history of episodic headaches occurring about every 1-2 years. They usually occurred in the fall and recurred over a 2-month period on nearly a daily basis. They occur suddenly with tearing and injection in the right eye, clear rhinorrhea, with a stabbing pain around the eye and forehead.
    1. Classic cluster headache.
    2. Predominantly a disease of males, 9:1 male-to-female.
    3. Usually begins between the ages of 20 to 40.
    4. Rapid onset of headache reaching a peak at 10 to 15 minutes lasting 30 to 45 minutes.
  3. Subarachnoid hemorrhage (SAH): A 45-year-old man presents to the emergency room (ER) with a 3-day history of a severe nuchal occipital headache with generalized throbbing associated with nausea and worse with movement. He was seen last month in the ER for a similar but less severe headache. Last night he was in the ER for the above complaint and treated with zolmitriptan that provided little benefit. He has a history of hypertension and very infrequent mild headaches. Neurologic examination and blood pressure were normal on all visits.
    1. This was his worst headache and warranted a “first or worst” evaluation.
    2. The probability of demonstrating a SAH on CT scan is 74% on day 3.
    3. A lumbar puncture must be performed to exclude SAH.
    4. The classic headache resulting from a SAH is acute, severe, continuous, and generalized and is often associated with nausea, vomiting, meningismus, focal neurologic symptoms, and loss of consciousness.

Complications

Learning Objectives 
  1. Know that headaches can be a harbinger of malignant and life-threatening conditions.
  2. Realize that an appropriate workup is required to determine potentially lethal circumstances.
References 
  1. Davenport R. Acute headache in the emergency department. J Neurol Neurosurg Psychiatry. 2002;72:ii33-7.

Review

Review Questions 
  1. Discus the functional mechanics and the innervation of the TMJ and Eustachian tube in their relationship to the development of head and neck pain.
  2. What is ephaptic transmission and neurogenic inflammation? How do they mediate the expression of pain?
  3. Describe the key features of the most common headaches.
  4. Discuss the helpful questions used to elicit the important elements of the patient’s headache history.
  5. Give examples of the imaging studies and other diagnostic modalities used to aid in the evaluation of the patient with headache and facial pain.
  6. List the patient characteristics that would provoke a physician to initiate a “first or worst” headache evaluation.
  7. Discuss the different classes of pharmacologic agents used in the treatment of headache and facial pain.
  8. Describe the nonpharmacological modalities used in the treatment of headache and facial pain.
Resources 

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  1. Annual Meeting Webcasts (AMW):