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Headache and facial pain
Dr. Mones Obeidat
Dr.SalmaYahya
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Facial pain
Facial pain problems fall into one of five recognizable categories:
Pain of Tooth Origin
Pain of Muscle and Joint Origin
Pain of Nerve Origin
Headache including Migraines
Others :Eyes, ears, sinus, parotid gland( otitis media,
orbitalcellulitis, sinusitis and mumps)
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Pain of Muscle and Joint Origin
1. Temporomandibular disorders.
Pain in the temporomandibular joint
(TMJ) may occur in 10% of the US
population. 75% of the population has a sign or
symptom during their lifetime, but fewer
than 5% need therapeutic intervention.
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TMJ anatomy
Temporomandibular joint (TMJ ) is the site of articulationbetween the mandiblar condyle and the skull, specifically thearticular eminence of the temporal bone.
This bilateral joint functions to open and close the jaws and toapproximate the teeth of the opposing arches during
mastication. The articulation consists of parts of the mandible and
temporal bones, which are covered by dense, fibrousconnective tissue and are surrounded by several ligaments.
Interposed between the two bones is a fibrous articular disc,compartmentalizing the joint into two separate synovial-linedcavities.
Several pairs of muscles attached to the mandible producethe movements
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Innervation
Sensory innervation of the TMJ is mediatedthrough the mandibular division of the trigeminal
nerve.
Pain-sensitive elements within the TMJ include the
joint capsule, the posterior attachment tissues, andthe discal ligaments.
The posterior attachment is highly innervated,
richly vascularized, and frequently implicated in the
pathophysiology of joint pain. In contrast, the intraarticular disk is largely devoid
of neural or vascular tissue but plays a vital role in
maintaining condylar stability during mandibular
movement.
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Etiology
inflammation within the joint accountsfor TMD pain, and the dysfunction is
caused by a disk-condyle
incoordination. The etiology for TMD may include
parafunctional behaviors,
macrotraumas or microtraumas,changes in the occlusion, and
behavioral influences.
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Known as a disk derangement disorder, articular
disk displacement is the most common
temporomandibular arthropathy and is
characterized by an abnormal relationship or misalignment of the articular disk relative to the
condyle.
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Myofascial pain
Characterized by a regional muscle pain, myofascialpain.
has been described as dull or achy and is associatedwith the presence of trigger points in muscles, tendons,or fascia.
it may be associated with stress and oral habits(developmental factors) or poor sleep, posturalabnormalities, and depression.
The major characteristics of myofascial pain includetrigger points in muscles and local and referred pain.
The trigger points may present clinically as active or latent. When active, digital palpation produces painreferral to a distant site.
When latent, local tenderness to palpation may bepresent, but no distant referral occurs.
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Imaging
Imaging may define the disk position andits movement during function.
Initially imaging is done with the mouthclosed; sequences are then repeated
with the mouth open. Evaluating how the disk-condyle
complex moves during these excursionsis useful.
Panoramic, transcranial, andtomographic studies are used toevaluate the bone.
MRI remains the gold standard of
diagnostic imaging for soft tissues andthe best method to assess disk osition.
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Management
Patient Education and Self-Care
It is essential to keep in mind that TMDs are self-limiting.
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.
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Pharmacological therapy
the most common medications include nonsteroidal anti-
inflammatory drugs and muscle relaxants.
The use of tricyclic antidepressants, selective serotonin-norepinephrine reuptake inhibitors, and antiepileptic drugs
are also important in pain management.
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Neurological causes:
Trigeminal neuralgia.
Glossopharyngeal neuralgia.
Post-herpetic neuralgia.
Temporal arteritis.
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Trigeminal
Neuralgia. 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.
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What causes trigeminal neuralgia?
The trigeminal nerve is the major nerve servingthe face.
Its three branches carry sensations from the
eyes, mouth, and jaw to the brain.
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.
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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, multiplesclerosis, meningitis, or Lyme disease.
For the classical TN: the pain occurs when a vein
or artery presses upon the trigeminal nerve where
it enters the brain stem, the contact createsinflammation that damages the nerve by stripping
its myelin sheath interfering with the ability of a
nerve to conduct sensation normally( severe pain)
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symptoms of trigeminal neuralgia (TN)
include:
Very painful, sharp, electric-like spasms thatusually last a few seconds or minutes but can
become constant
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
Pain triggered by common, everyday activities,
such as brushing teeth, chewing, drinking,
eating, lightly touching the face, shaving the
face.
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Treatment
Medical: AED including carbamazepine, pregabalin
or Gabapentin.
Surgical: Peripheral nerve blocks involve the doctor
attempting to block the nerve with anesthetics suchas lidocaine.
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Headache
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Migraine
Migraine is in essence an episodicdisorder 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.
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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).
It is seen in about 30% of patients.
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pathophysiology
Intracranial contents above the tentorium cerebelliare innervated by the trigeminal nerve.
The dura mater and vessels supplying the
meninges have sensory and autonomic innervation
( trigeminovascular system ). Small fibers enter the pons down to the trigeminal
nucleus caudalis (TNC)
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During the attacke: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).
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Treatments for attacks can be divided intononspecific and migraine-specific treatments.
Nonspecific treatments, such as aspirin,
acetaminophen, nonsteroidal antiinflammatory
drugs, opiates, and combination analgesics, areused to treat a wide range of pain disorders.
Specific treatments, including ergotamine,
dihydroergotamine, and the
triptans.(vasoconstricting agents).
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Preventive treatment: On the basis of
a of the frequency, duration, severity,
and tractability of acute attacks. Options: AED, antidepressant, beta
blockers.
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Cluster headache
Cluster is a stereotypical episodicheadache disorder marked by
frequent attacks of short-lasting,
severe, unilateral head pain withassociated autonomic symptoms.
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Typical cluster headache location isretro-orbital, periorbital, and
occipitonuchal.
Maximum pain is normally retro-orbitalin greater than 70% of patients. Pain
quality is described as boring,
stabbing, burning, or squeezing. Cluster headache intensity is always
severe, never mild.
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The one-sided nature of cluster headaches is a
trademark.
Cluster sufferers will normally experience cluster
headaches on the same side of the head their
entire life. 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 thesame cluster cycle will only occur in 5% of patients.
The duration of individual cluster headaches is
between 15 and180 minutes.
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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%,
nasal congestion in 42%
rhinorrhea in 22%
partial Horner’s syndrome in 16% to 84%.
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several distinct triggers, including
alcohol, nitroglycerin, histamine, hot
weather. Oxygen inhalation is an excellent
abortive therapy for cluster headache.
Treatment: abortive and preventive.
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SUNCT SYNDROME
The syndrome of short-lasting, unilateral
neuralgiform headache attacks with conjunctival
injection and tearing.
brief attacksb of moderate to severe head pain with
associated autonomic disturbances of conjunctival
injection, tearing, rhinorrhea, or nasal obstruction.
The typical age of onset is between 40 and 70.
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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. attack frequency ranges anywhere from1 to more
than 80 episodes a day.
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triggering maneuvers, includingmastication, 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 anabortive 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.
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HEMICRANIA CONTINUA
female predominance. continuous daily head pain, which is present 24
hours per day, 7 days per week,mild to moderate
intensity.
with headache-exacerbation period, pain wasnormally severe.
affecting the temple or periorbital region.
It is always present on the same side of the head.
Migrainous symptoms include nausea, vomiting,photophobia, and phonophobia.
Indomethacin alleviates both the headache and
aura.
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Thanks