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Headache and facial pain

Abeer Derawi

Headache and facial pain

For you as dental students its very important to understand what is facial pain rather than teeth, usually facial pain categorized in one of these classifications: Secondary to pain of tooth origin Pain of Muscle and Joint Origin Pain of Nerve Origin Headache including Migraines (tension & cluster headache ) Others :Eyes, ears, sinus, parotid gland( otitis media, orbitalcellulitis, sinusitis and mumps)

1) Pain of Muscle and Joint Origin:

Usually we have pain of temporomandibular joint may occur in 10% of the US population, most of them have it as a chronic period rather than an acute one. TMJ anatomy Look at the figure bellow you can see the synovial cavity which is very important, here most of the pathophysiology would occur for the TMJ; we have the condyle of the mandible that is resting in the temporal bone and it forms a synovial joint which is a capsulated joint with a synovial fluid inside , so if we have any of these components inflamed we will have TMJ inflammation.

So ,,, Temporomandibular joint (TMJ) is the site of articulation between the mandiblar condyle and the skull, usually acts to open and close your mouth, specifically the articular eminence of the temporal bone. The articulation consists of parts of the mandible and temporal bones, which are covered by dense, fibrous connective tissue and surrounded by several ligaments. We have several pairs of muscles attached to the mandible produce the movements (muscles of mastication): medial pterygoid ,lateral pterygoid temporalis and the maseter. The nerve which supply it is the mandibular division of the trigeminal nerve V3. It's not only a motor, its also a major sensory of the face, it has pain-sensitive elements within the TMJ inside the synovial capsule, so if this capsule become inflamed theV3 would actually has sensation , this is an implication for you ,because as you remember V3 has the inferior alveolar nerve which the one that responsible for innervation of the mandible and the lower teeth so sometimes TMJ patients although they have a localized TMJ pain but also being supplied by V3 (inferior alveolar nerve branch) so it may radiate to the lower jaw !{ its an important one of the differential diagnoses in the lower teeth that you should keep in mind}

So its actually an inflammation within the joint accounts for TMJ pain, and the dysfunction is caused by a disk-condyle incoordination. It starts as inflammation that cause irritation at the TMJ , this TMJ pain would make you not able to open your mouth properly and this will make the diskcondyle incoordination , this is the secondary effect of the problems of TMJ. {keep in mind that it may radiate to the lower jaw !} The etiology for TMJ usually include parafunctional behaviors, macrotraumas or microtraumas, changes in the occlusion, and behavioral influences. Sometimes patients may have anteriorly located articulation of TMJ with the temporal bone, sometimes even a trauma cause TMJ pain . Its Known as a disk derangement disorder, articular disk displacement is the most common temporomandibular arthropathy and is characterized by an abnormal
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relationship or misalignment of the articular disk relative to the condyle, so this is the consequence of starting problem. Its a cascade starts as inflammation in the TMJ secondary to trauma, secondary to misalignment that will lead to incoordination . Sometimes TMJ problems may be associated with Myofascial pain which typically occurs in patients that have stress in their life ,they will have some sorts of tender points related to the muscles in their face. So - Its regional muscle pain or we call it myofascial pain. - these painful episodes usually when we palpate the muscle will have a pain which makes it dull or achy in nature that associated with the presence of trigger points in muscles, tendons, or fascia. - Most of the time its associated with trigger points in their body that we call it myalgia rheumatic. - it may be associated with stress and oral habits (developmental factors) or poor sleep, postural abnormalities, and depression. - The major characteristics of myofascial pain include trigger points in muscles and local and referred pain. - The trigger points may present clinically as active or latent. When active, digital palpation produces pain referral to a distant site.When latent, local tenderness to palpation may be present, but no distant referral occurs. This is actually related to the active inflammatory process, we dont completely understand why it happens , usually its associated to social background these patient are depressed enough . If you want to investigate paints with myofascial pain usually you have a disk position and it is moving during the function so we do x-ray for the patient during the active movement , we take it when the mouth is opened then we repeated with closed mouth and we can see the inflammatory process that can occur in the TMJ . evaluating how the condyle complex moves during these excursions is very useful because sometimes its simple inflammatory that can be treated with non steroidal but if its misdiagnosed and mistreated it may lead to the cascade that we discussed (inflammatory process with the disk capsule derangement ) and so you might need even MRI. (MRI remains the gold standard of diagnostic imaging for soft tissues and the best method to assess disk position).
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Manegment : The most important thing to diagnose the TMJ is the Patient Education and SelfCare , if you have an inflammatory process at the TMJ so simply just ask the patient not to move his TMJ that often so you rest the inflammatory process and the patient become better , so : Ask the patient to avoid any thing that move the TMJ or using the muscles of mastication for a while . Patients should be instructed to avoid chewy foods, especially chewing gum. They can be taught to avoid clenching their jaws during the day, to apply heat or ice, and to perform jaw-stretching exercises. Pharmacological therapy: the most common medications include nonsteroidal anti-inflammatory drugs and muscle relaxants. The use of tricyclic antidepressants for patient with Myofascial pain, selective serotonin-norepinephrine reuptake inhibitors, and antiepileptic drugs are also important in pain management , because most of the problems are psychiatric.

2) Neurological causes:
- trigeminal neuralgia - Glossopharyngeal neuralgia. - Post-herpetic neuralgia. - Temporal arteritis. Trigeminal neuralgia: (most important one ) TN is a neurologic condition that affects less than 1 percent of the population in the United States but about 14 percent of those with nerve-related (neuropathic) pain, more often in women, generally appearing in middle or late middle age. The trigeminal nerve is the major nerve serving the face. It has three branches carry sensations from the eyes, mouth, and jaw to the brain (ophthalmic , maxillary and the mandibular).

The pain of TN typically originates in the maxillary nerve, which runs along the cheekbone and serves the nose, upper lip, and upper teeth, or the mandibular branch, which controls sensation in the lower cheek, lower lip, and jaw( unlikely to be in the ophthalmic ). TN are classical and symptomatic,classical TN is the most common occurring suddenly with no obvious trigger. - Symptomatic TN is related to some underlying condition such as a tumor, aneurysm, multiple sclerosis, meningitis, or Lyme disease.(usually the most difficult to treat) - Classical TN: the pain occurs when a vein or artery presses upon the trigeminal nerve where it enters the brain stem, the contact creates inflammation that damages the nerve by stripping its myelin sheath interfering with the ability of a nerve to conduct sensation normally( severe pain) Symptoms : - Very painful, sharp, electric-like spasms that usually last a few seconds or minutes but can become constant , usually its episodic pain - Pain on one side of the face, often around the eye, cheek, and lower part of the face (although it can occur on both sides of the face) - Pain triggered by touch or sounds and sometimes even cold weather - Pain triggered by common, everyday activities, such as brushing teeth, chewing, drinking, eating, lightly touching the face, shaving the face (anything that move your jaw stimulate the maxillary artery so the patient will have electrical pain). Treatment : - Medical: AED including carbamazepine, pregabalin or Gabapentin. - Surgical: Peripheral nerve blocks involve the doctor attempting to block the nerve with anesthetics such as lidocaine.

Headache
We have primary headache which doesnt has any underlying mass / entiology in the brain , it can be classified into : Migraine, tension, cluster and other primary headache . Definitely tension like headache is the most common which is a band like headache secondary to muscular contraction ( front-occipitals muscle) and this can has spasm related to stressors physical or emotional, so we call it tension like headache that come in episodes usually occur at the late time of the day and released by simple analgesia and rest . Secondary headache is associated with underlying etiology, it might be secondary to trauma, vascular disease, intracranial pressure, substances abuse(cocaine),infections and so many other etiology. Migrain ) ( : Classically this patient will has pain in one side of the head and this can be associated with other autonomic symptoms for example lacrimation. Migraine is in essence an episodic disorder whose key marker is headache with certain associated features : Unilateral, bilateral in 40% Throbbing, worse with movement Moderate to severe. Associated with nausea/ vomiting/photo or photosensitivity (patient has the attack of pain secondary to flashes of light or abnormal sounds). - May occur with or without aura ,migraine aura is defined as a focal neurological disturbance manifesting as visual, sensory, or motor symptoms (may see stars dots or lines, feel parasthesia or has hemiparesis), its seen in about 30% of patients.

Why do we have autonomic manifestations secondary to the headache? The intracranial contents above the tentorium cerebelli are innervated by the trigeminal nerve which located in the Pons and one of the most important autonomic nuclei located in the Pons as well ,So once the trigeminal nerve is being stimulated it will release substances that will cause vasodilatation, and this vasodilatation would aggravate the migraine headache , the sitmulation will go to the nuclei of the nerve inside the Pons which is very adjacent to the autonomic nuclei and so we will have what is called trigeminovascular system small fibers enter the Pons down to the trigeminal nucleus which is associated to the autonomic nuclei . During the attack : - The trigeminovascular system is activated - Trigeminal neuron supplying the dural vessels release many substances that result in vessel dilatation. - Polysynaptic connections between the TNC and the superior salivatory nucleus explain the ipsilateral autonomic symptoms(rhinorrhea, lacrimation and eye redness).

Treatment : Treatments for attacks can be divided into nonspecific and migraine-specific treatments: - Nonspecific treatments, (simple analgesia) such as aspirin, acetaminophen, nonsteroidal antiinflammatory drugs, opiates, and combination analgesics, are used to treat a wide range of pain disorders. - Specific treatments, (related to the pathophysiology of the disease vasodilatation) including ergotamine, dihydroergotamine, and the triptans.(vasoconstricting agents). Preventive treatment: in order to decrease the frequency, duration, severity, and tractability of acute attacks, we can use one of these options: AED, antidepressant, beta blockers.

Cluster headache Cluster headache is a stereotypical episodic headache disorder , you cant misdiagnose i. - It is marked by frequent attacks of short-lasting, severe, unilateral head pain with associated autonomic symptoms. - Typical cluster headache location is retro-orbital, periorbital, and occipitonuchal, (usually around the eye) associated with eye autonomic symptoms as red eye and lacrimation . - Maximum pain is normally retro-orbital in greater than 70% of patients. Pain quality is described as boring, stabbing, burning, or squeezing. - Cluster headache intensity is always severe, never mild. - The one-sided nature of cluster headaches is a trademark (retro-orbital or periorbital). - Cluster sufferers will normally experience cluster headaches on the same side of the head their entire life (unilateral ). Only in 15% of patients will the headaches shift to the other side of the head at the next cluster period, and side shifting during the same cluster cycle will only occur in 5% of patients. - The duration of individual cluster headaches is between 15min up to 3 hours. - Attack frequency is between 1 and 3 attacks per day . - Cluster headache is marked by its associated autonomic symptoms, which typically occur on the same side as the head pain, but can be bilateral. - Lacrimation is the most common associated symptom, occurring in 73% of patients - followed by conjunctival injection in 60% (red eye) - nasal congestion in 42% - rhinorrhea in 22% - partial Horners syndrome in 16% to 84%. Triggers : There are several distinct triggers associated with cluster headache including hot weather, alcohol, nitroglycerin, histamine. Treatment : Oxygen inhalation is an excellent abortive therapy for cluster headache. The treatment either abortive or preventive :

- abortive treatment : most of the time we use 100% oxygen for 15 min and this is the treatment of choice, we can give ergots, sumatriptan which are vasoconstrictions . - preventive agents : Verapamile , Ca-channel blockers and Toperamate (anti epileptic). Sunct syndrome : The syndrome of short-lasting, unilateral neuralgiform headache attacks associated with autonomic disturbances of conjunctival injection, tearing, rhinorrhea, or nasal obstruction. How can we differentiate this from cluster headache ? definitely it is brief attack of moderate to severe head pain while cluster stats as severe and the patient describe it as progressing symptoms so its not cluster , because cluster starts as severe then abates , in addition to this the typical age of onset 40-70 years but for cluster is younger.

So we have: - orbital or periorbital distribution. - Head pain can radiate to the temple, nose, cheek, ear, and palate. - The pain is normally side locked and remains unilateral throughout an entire attack. - stabbing, burning, pricking, or electric shocklike sensation. Pain duration is - extremely short, lasting between 5 and 240 seconds, with an average duration of 10 to 60 seconds. ( this is the third and the most important way to differentiate it from cluster ) - attack frequency ranges anywhere from1 to more than 80 episodes a day. Triggering maneuvers, including mastication, nose blowing, coughing, forehead touching, eyelid squeezing, neck movements (rotation, extension, and flexion), and ice-cream eating.

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Treatment : By the time a patient with SUNCT would take an abortive medication the attack theoretically would already be completed. Preventive agents that have previously been tried include: aspirin, paracetamol, indomethacin, naproxen, ergotamine, DHE, sumatriptan, prednisone, verapamil, valproate, lithium, propranolol, amitriptyline, and carbamazepine.

Hemicrania Continua: This is a female predominance syndrome, it is continuous daily head pain, which is present 24 hours per day, 7 days per week, fluctuating it might be mild, moderate or severe intensity. Symptoms : include nausea, vomiting, photophobia, and phonophobia just like migraine headache ( but migraine doesnt last for 7 days). Treatment :usually we give Indomethacin to alleviate both the headache and aura.

Forgive me for any mistake Good Luck Abeer Derawi

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