Headaches and Facial Pain: Introduction

Headaches and Facial Pain: Introduction

• Professor gave everything a bit disorganized, skipped slides but the information will be summarized

Concept, Epidemiology, and Etiopathogenesis of Headaches

• Headaches or Cephalgia, which are subjective symptoms, are the most frequent pathology in Neurology and Primary healthcare
• More than 300 causes of headaches, 90% that are Migraines and Tension Headaches
• Important to distinguish between primary and secondary headaches

Primary Headaches

• Represent 90% of cases
• These are generated by an anomaly of neurotransmitters
• Pain genesis occurs in the CNS.
• Neurological exam results are normal.
• Insist on clinical history
• Two considered primary are Migraines and Tension Headaches

Secondary Headaches

• Pain genesis does not occur in the CNS.
• Examples include Headaches from Meningitis, Subarachnoid Hemorrhage (induces an intense headache), Anemia, HTA crisis, or a hangover.
• Cause must be identified.
• The cause could be life threatening.
• Contrary to primary ones, the exam is pathological (nuchal rigidity in subarachnoid hemorrhage, high fever + rigidity in meningitis, brain tumor, etc.).

Physiopathology of Headaches

• Head pain occurs due to structures sensitive to pain
• Structures sensitive to pain:
• Scalp; such as cellulitis or a pimple of the scalp.
• Periosteum
• Meninges contain many sensitive structures Ej.:Meningitis, hematoma, subarachnoid hemorrhage, any process that causes inflammation, displacement, torsion.
• Structures within the meninges, specially pathologies involve the Cereal Falx
• Tentorium Cerebelli
• Vascular structures include arteries (base of the cranium, mainly the arteries of the Circle of Willis), with arterial dilation, inflammation, traction, displacements, etc. and veins (dural sinuses)
• Cranial pairs contain sensitive components, mainly linked the the trigeminal nerve, which innervates all intracranial structures
• Trigeminal Nerve: sensibility to the front part of the face due to its branches (ophthalmic (V1), maxillary (V2), and mandibular (V3)), but does not cross the midline, so the neck is not originated by it, originates in the roots
• Cervical Roots: evidently also have sensitive components, can cause pain, in charge of the back of the cranium

Migraines

• Pulsatile, hemicranial (unilateral), inflammation of the intracranial arteries
• Heart pulse becomes painful
• More frequent in women than men
• Hormonal connection

Peripheral Events and Migraines

• Peripheral events play a key role
• Pain results from stimulation of peripheral nociceptors.
• Activation of CNS and peripheral nervous system inappropriately
• Pain caused by activation and sensitization of the trigeminovascular system
• "Sterile" inflammation of meningeal vessels, triggered by activation of sensory nerves
• Neuropeptide messenger CGRP is important in migraine
• Activation of meningeal nociceptors leads to release of vasoactive, pro-inflammatory peptides like substance P and CGRP3

Migraine Triggers

• Stress: the most frequent
• Altered sleep patterns.
• Dietary factors include fasting, alcohol, and certain foods
• Hormonal changes are more prevalent for women such as menstruation or menopause
• Physical Effort

Migraine Clinic

• Migraines are unilateral, pulsatile pain, worse than physical effort that can be acompanied by nausea or vomiting, including photophobia, phonophobia and olfactophobia
• Migraine patients are in a state of hyperexcitability and are bothered by most things, totally incapacitated so they must remain in the dark for 24-48 hours
• Graph indicates migraines typically happen in middle aged women while diminishing after the age of 50 due to hormonal relation

Migraines with Aura

• Migraine is characterized by visual symptoms along with the possibility of it being sensitive or producing aphasia
• Visual Symptoms: make up 85% of the total, non-unequivocal expression, can appear in irritative manifestations of luminous phenomes such as visual deficit, alternating or intercalating both
• Photopsias: consists of multiple fleeting luminous spot flashes, general spontaneous presentation, commonly increase with coughs or mobilisation of the head
• Scotoma in fortification spectrum: alteration of vision with presence of a band with shining edge that moves across the visual field, singular vision that persists with eyes closed

Migraines: Continued

• Seeing in mosaic: altered image through multiple fragments like a broken mirror that have different sizes and shapes
• Sensitive Symptoms: With Migranes the neurological expression that accompanies is referenced close to 40% of patients, typically a subjective disorder, such as paresthesia, described as a unilateral tingling, the hand or face, moving to the rest of the body, tends to diminish from the area of origin
• Motor Symptoms: described as a distinguished entity, named familiar hemiplegic migraine, exclusively happens with auras during its crises within a familiar context
• Hemiplegia indicates paralysis one side of the body
• People with this migraine will experiment temporary weakness on one side of the body
• It implies the face, arm or leg, also causes temporary numbness or/and tingling
• Speech Difficulty, also Vision or Confusion present.
• Language disorders appear as a manifestation of aura in 20% of patients with this type
• Typically corresponds to dysarthria
• Aphasia concerns the capacity of the brain to produce and understand language
• Paraphasia involves a person that produces words that were not intended for the individual

Migraine Complications

• Migranous Status: When the migraine reaches more than 3 days, patient must go to urgent care and require parental treatment
• Migrainous Infarction: rare, affects vertebrobasilar territory, occurs in young women, smokers, use contraceptives, important to control risks, as migraines are important
• Aura is a incomplete symptom for 3 weeks, confirmed by TAC or RM
• Chronic Migrane: when pain appears more than 15 days a month for 3 months consecutive

Migraine Treatment

Crisis Treatment

• The main treatment is analgesics
• For light headaches; use analgesics and aines at high doses, the most used are naproxen and ibuprofen.
• if there is no change the 2 hours the should switch or escalate the "ladder"
  • Paracetamol 1000mg
  • Aspirin 500-1000mg
  • Naproxen 500-1000mg
  • Ibuprofen 600-1200mg
  • Ketorolaco 10 - 30 mg
• If the Cephalgia is moderate use Triptanes because its effective on migraine
• Block Serotonin Receptors
• For vasoconstriction reduce the effect
• Sumatriptan was the first; Rizatriptan and Zolmitriptan are the most used due to its short life:
• Sumatriptan with 14% and 1.5-2.5 T Max, 2 Vida Media
• Zolmitriptan with 40- 45% and 1.5 for its T Max and 3 for its Life Span
• Naratiptan goes 63-70% and a 3 of Tempo Max and Life Span of 6
• Rizatriptan has a 45 % and a 1.1.-1.5 and a 2 as its average Life Span
• Eletriptan has 50, 1 for its Tempo and 5 for the Life
• Almotriptan 70 in 20 for a Tempo and only another 3 for how long life
• Emphasis on how it is exclusive for migraines

Prophylactic Treatment

• Crises are incapacitating a 20-30% of migranous, is used monthly for a low dosage
• More used Beta Blockers
• Calcium Antagonist should be considered and is not recommended for people young or old
• Antidepressants of the Tricycles
• Anticomicials, Ines and Ciproheptadine
• Topiramato is an antiapileptic, works in most circumstances produces phychosis and has to be removed

Cluster Headache

• Trigeminal-autonomic primary headache
• Predominately appears in young men
• Clinic of localizing pain in the temple unilaterally or in the periorbital region
• Always on the same side, abrupt appearance and remission

Pain and Symptoms Explained

• pain is accompanied by intense lacrimation, conjunctival congestion, palpebral edema, sensation of nasal stuffiness with watery rhinorrhea, always ipsilateral with the pain

Pain in Contradiction to Migraines

• During cases the patient presents psychomotor restlessness, moving around the room.
• Attacks are brief
• The episodes present on average 1-3 times in 24 hours that typically last for about 15 to 3 hours
• Circadian rhythm, appears during siesta and down, also called "wakeup headache"
• Seasonal rhythm, usually appearing in spring and fall.

Cluster Headache Treatments

• Same treatment as migraine, using analgesics and AINES in high doses
• Triptans: Sumatriptan 6 mg subcutaneously is the most effective drug for treating cluster headache attacks, or any other Triptan.
• If the crisis is not very strong, oral administration is possible

Other Cluster Headache Treatments

• Administration of pure oxygen
• Administer 7 liters per minute with 100% purity for 10-20 minutes

Cluster Headache: Prophylactic Treatment

• In case the pain remains for weeks, consist on Prednisone 40-80 mg or Verapmil 240-280 in doses or Lithium Carbonate 200-400mg per 12 hours

Tension Headache

• Most frequent cause of headaches and neurological consultation, nerve tension, is emotional and physical
• Bilateral, oppressive, non pulsating, mild intensity with possible nausea
• Patients underperform, not an invalidating pain like migraines
• Associated to anxiety and depression, maintenance insomnia due to genetic trait, it is possible for a person to develop more conflicts

International Society Headache and Criterias

• Oppressive or fastening pain Qualities is in A
• Mild to moderate intensity in 1
• Bilateral location in 2
• Does not aggravate to climb stair or routine activities in 3
• Must have two characteristics from B
  • No vomiting in 1
• Only one follows nausea,photophobia and phonophobia

Tension Headache Preventive Treatment

• Tricyclic antidepressants, such as Amitriptyline and Mianserina
• Selective serotonin reuptake inhibitors (SSRIs), such as Sertralina and Escitalopram
• Mix and match the SSRIs

Headaches not Associated to Structural Lesions

Ice Cream Headache

• Intense paroxysmal pain triggered by cold
• The headache is of short duration
• Deep, radiates to the frontal or vertex regions
• More frequent in migraineurs

Ice Pick Like Headache

• Brief and intense pain
• Lasts one second
• More common in migraineurs
• Punctate in that it can last a fraction or a couple of seconds
• Mainly located in the orbit region, parietal
• Is usually found in subjects with migraine

Benign Coughing Headache

• Headache that appears with cough
• Responds to indomethacin
• There is frequent runny nose in the intense stages
• Presents more in men and appears when coughing, valsalva maneuver without relation to structure
• It is resolved with the cough ceasing, and it can be resolved with a sub press dose like sleep to resolve tension

Coital Headache

• Explosive holocranial, occurs prior and can't be confused with A migraine
• During sex a mimetic symphatic discharger (A y NA), is produce which is a hypertensive crisis that release the headache.

Hyponic Headache

• Uncommon benign headache
• Appears in elder people that are 6
• Appears in dreams and cannot be connected with Sleep Apnea Obstructive
• Recurrence that Provokes the wake off every night around the same time.
• In occasions can be present
• Can last between 15 or 60 Min and repeats approx.. two hours later. at Times coincide with the sweet dream and can be associated to the fase REM .

Post-traumatic migraine

• Caused in the absence of injury in that there is no brain injury and is know for bilaterality and opression
• Is associate to Sickness and dizziness, has the characteristics to have tension

Headaches Associate to Vascular Anomalies

Ischemic Stroke

• Not typical is to be present in a manner that there is a great headache, to the 2 4 -4 8 hrs when the edema cerebral appears.

Hemorrhagic Stroke

• Intraparen chymatous : Depends on the level of the hemorrhage even the Dolor is cause for that effect

SHE Cefaleas

• Headaches that Course with High endocrine Tension
• Hypertensive Encephalopathy
• AVC: Vascular Accident Cerebra is something that produces High Tension
  • Hemorrhage under the brain
  • Hematoma Under the skin
• Severe Hypertension endrocaneal benign
• Hydrocephaly

Cefalea by Hypotension Licuoral

• Treat the Dolor by means a Puncture Lumba. and the mechanism Produces
• Aument with the positive of Errecet Cefalea caused with abuse of analgesics.
• People who treat them constantly and by not obtaining what they one they Abuse
• Suffer to be
• Intense,chronic and debilitating
• Suffer psychological
• Have to be admitted in the Treatment

Pharmacs That Prodoce Cefalea

• A reference of farcs when yoy should avoid using on patients

Cephaleal of Origin that are Structural

• The Cervix
• Also know s LATIGAZOS
• Dolor Cervizal is that radiates through the zone

Ophtalmology is to cause of Cefalea

• Visual Refracction Issues
• Glaucoma
• Neuritis optica ( manifest like dolor iand get to be
• ORL origins
• Sinus issues
• Mucoceles

Important Ideas

• Hemicrancial : migrains
• Dolor Bilateral and OPRESIVO- HEADACHES