Facial Pain and Headache

1

What is the difference between primary and secondary headache?

A headache is labeled a primary headache if it occurs in the absence of a disorder that is known to cause headaches. A secondary headache is a new headache that occurs in close temporal relation to another disorder that is known to cause headache. Headaches can also be categorized as having both primary and secondary components, such as a primary headache that becomes chronic or at least two-fold worsened by another headache-causing disorder.

2

What is the differential diagnosis for facial pain?

• Primary headache: Common types include tension-type headache, migraine headache, and trigeminal autonomic cephalalgias.

Other primary headache disorders: Primary cough headache, primary exercise headache, primary thunderclap headache, cold-stimulus headache, external pressure headache, primary stabbing headache, nummular headache, hypnic headache, and new daily persistent headache.

• Secondary headache: Trigeminal neuralgia, persistent idiopathic facial pain, temporomandibular disorder, headache attributed to cranial or cervical disorder, substance abuse and/or withdrawal, intracranial infection, headache attributed to disorder of the eyes (acute glaucoma, refractive error, heterophoria, heterotropia), and psychiatric disorder.

3

What is the prevalence of headache?

Worldwide headache prevalence for the adult population is 46% for headache in general, 42% for tension-type headache, 11% for migraine, and 3% for chronic daily headache. Based on years lived with disability, headaches are 1 of the 10 most disabling conditions and 1 of the 5 most disabling for women.

4

How do you diagnose and treat tension-type headache?

Tension-type headaches are episodic and typically bilateral, pressing or tightening in quality, of mild to moderate intensity, and last from minutes to days. The pain does not worsen with routine physical activity and is not associated with nausea. Photophobia or phonophobia may be present. Other International Classification of Headache Disorders – 3rd edition (ICHD-III) diagnoses should be ruled out. Treatment consists of aspirin or NSAIDs for occasional mild tension-type headache; the addition of caffeine can make treatment more effective. Acetaminophen is preferred in pregnancy. More severe headaches can require a prescription analgesic. Amitriptyline is the most effective prophylactic pharmaceutical for tension-type headaches.

5

What are the adult diagnostic criteria for migraine headache without aura?

For a headache to meet ICHD-III criteria as a migraine without aura, a person must suffer at least five headaches that include the following characteristics: (1) must last between 4 and 72 hours; (2) have at least two of the following: unilateral location, pulsating quality, moderate/severe pain intensity, or aggravation by physical activity; (3) must have either nausea and/or vomiting or photophobia/phonophobia during headache; and (4) must not meet other criteria.

6

Why do migraine headaches occur?

Cortical spreading depression (CSD) is the currently accepted etiology for migraine with aura. CSD is transient neuronal and glial cell excitation followed by long-lasting depression, slowly propagating across the cerebral cortex and gray matter. During CSD, there are significant changes in the levels of extracellular ions and neurotransmitters (such as glutamate, acetylcholine, and substance P), leading to activation of dural nociceptors and central trigeminovascular neurons in the superficial and deep laminae of the trigeminocervical complex, contributing to the clinical manifestation of migraines.

7

What is the first-line medical option for abortive therapy for migraine headache?

Triptans are the main first-line medical option for abortive therapy for migraines. They are synthetic serotonin analogs that activate the 5-HT1B and 5-HT1D serotonin receptors, constricting cranial blood vessels and inhibiting release of proinflammatory neuropeptides.