headache and facial pain dr. abdulrahman hagr mbbs frcs(c) assistant professor king saud university...
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Headache and Facial painHeadache and Facial pain
Dr. Abdulrahman Hagr MBBS FRCS(c)Dr. Abdulrahman Hagr MBBS FRCS(c)Assistant Professor King Saud University Assistant Professor King Saud University
Otolaryngology ConsultantOtolaryngology ConsultantOtologist, Neurotologist & Skull Base Otologist, Neurotologist & Skull Base
SurgeonSurgeonKing Abdulaziz HospitalKing Abdulaziz Hospital
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Headache and Facial painHeadache and Facial pain
Dr. Abdulrahman Hagr MBBS FRCS(c)Dr. Abdulrahman Hagr MBBS FRCS(c)Assistant Professor King Saud University Assistant Professor King Saud University
Otolaryngology ConsultantOtolaryngology ConsultantOtologist, Neurotologist & Skull Base Otologist, Neurotologist & Skull Base
SurgeonSurgeonKing Abdulaziz HospitalKing Abdulaziz Hospital
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Epidemiology
• 75% of adults have at least one headache/year
• 10% will seek physician evaluation
• 10% have emergent secondary cause
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Headache ClassificationHeadache Classification
• Primary v Secondary
• Paroxysmal v Chronic
• Episodic v Recurrent
• Mild to moderate v Moderate to severe
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History
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Headache history• Onset
• Site
• Character
• Duration
• Frequency
• Diurnal pattern
• Associated symptoms
• Aggravating factors
• Relieving factors
• Treatment
• Ideas
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Headache pattern
• Acute
• Intermittent
• Chronic
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History• Where does it hurt?
– Unilateral/bilateral– Frontal/occipital/facial
• What is the character of the pain?– Pulsatile– Steady– Shocklike– Tightness
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HistoryWhat other symptoms do you experience?
• Nausea• Vomiting• LOC• Flushing• Lacrimation• Drop attack• Neck stiffness• Photophobia• Dizziness
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Physical Exam
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Physical Exam• Vital signs
– fever, hypertension, hypoxia• Head/face
– trauma, bruits, tenderness• Eyes
– conjunctiva, cornea, pupils, fundi:papilledema• Ears
– OM or hemotympanum• Mouth
– Teeth, TMJ
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Physical Exam• Neck
– pain/stiffness/tenderness– Carotid and/or vertebral bruits
• Skin– rash
• Neurologic– Mental status– Pupils, EOM, Visual fields– Focal deficits– Horner's syndrome– Ataxia
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Diagnostic Alarms
• Onset after age 50
• Sudden onset
• Increased frequency and severity
• New onset with risk factors for HIV or cancer
• Associated with systemic illness (fever, meningismus, rash)
• Altered consciousness or focal neurologic deficits
• Papilledema
• Significant trauma
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Diagnostic Studies
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Diagnostic Studies• Computerized tomography
– Hemorrhage, tumor, abscess, AVM
• Lumbar puncture
– Hemorrhage, infection, increased CSF pressure
• Limited indications for MRI, MRA, or Angiography
• Laboratory studies based on suspected etiologies
– ESR: Temporal arteritis
– Carboxy-hemoglobin: Carbon monoxide
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Primary Headache
Migraine
TensionCluster
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Tension Headache• 10+ episodes
• 30 min- 7 days
• 2 of the following• Bilateral
• Non-pulsating pressure
• Mild/moderate intensity
• Unrelated to activity
• Both of the following• No nausea or vomiting
• Either one of photophobia or phonophobia
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Migraine Without Aura At least 5 attacks Duration
Headache attacks lasting 4 hours to 3 days (untreated). Pain characteristics (at least 2+)
Pulsating quality Limited Activity Unilateral location Stairs Aggravation
Associated symptoms (at least 1) Nausea, vomiting, or both Photophobia or phonophobia
H&P and Dx tests do not suggest underlying disease (0)
5, 4, 3, 2+, 1 & 0
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Migraine With AuraAura characertistics (At least 3 )
1. One or more aura symptoms Fully reversible
Indicating focal cerebral cortical or brain-stem dysfunction
2. At least 1 aura symptom develops gradually over >4 minutes or 2 or more symptoms occur in succession
3. Headache begins within 60 minutes of aura onset
4. No single aura symptom lasts > 60 minutes
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Migraine TriggersMigraine Triggers
• Sleep deprivation/excess
• Caffeine ingestion or caffeine withdrawal
• Fasting
• Sex hormones
• Most migraines have no trigger
• Strong familial pattern
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Cluster Headache
• Rare, 0.4% population
• Lasting 15-180 minutes
• Severe
• Unilateral, orbital or temporal pain• 1 every other day to 8/day (Cluster )
• Secondary to trigeminal nerve dysfunction
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Cluster Headache
Associated with
• Conjunctival injection
• Lacrimation
• Nasal congestion
• Rhinorrhea
• Miosis,
• Ptosis
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Treatment of Primary Headache
Tension Oral Analgesics (NSAIDS, Acetaminophen)
Migraine NSAIDS Reglan or compazine (10 mg IV ) Serotonin agonists Sumitriptan Narcotics IV or IM
Cluster 100% oxygen Intranasal lidocaine ? NSAIDS Migraine specific therapies
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Red Flags for Headache
• Sudden Onset: – SAH
– AVM
– Mass lesion
• Worsening pattern: – Mass
– SDH
– Medication overuse
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Red Flags for Headache• Focal neuro signs:
– Mass lesion
– AVM
– Collagen vascular disease
– CVA
• Trigger with cough, exertion, valsalva:– SAH
– Mass
– Sinusitis
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Red Flags for Headache
• Headache with fever, stiff neck or rash: – Meningitis
– Encephalitis
– Systemis infection
– Collagen vascular disease
– Arteritis
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Headache ClassificationCritical Secondary
• Vascular– Hemorrhage– Stroke– Cavernous Sinus thrombosis– AVM– Temporal Arteritis– Carotid or Vertebral Artery
Dissection
• CNS Infection
• Tumor
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Headache Classification
Critical Secondary (cont)
• Endocrine
• Metabolic
• Non-CNS Infections
• Opthalmic
• Drug Related
• Toxic
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Secondary Headache Temporal arteritis
Mass lesions
Tumor, abscess, arteriovenous malformation
Metabolic
Hypoglycemia, fever, hypothyroid, anemia
Glaucoma
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Secondary Headache
Trigeminal Neuralgia
Post-concussion syndrome
Sinusitis without complication
Post-lumbar puncture
Diet
Medications
Fatigue, postexertion, postcoital
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• Tear in – Middle meningeal artery – Dural sinus rarely
• Direct trauma with – LOC Lucid interval Coma
• Lethargy, vomiting, ipsilateral dilated pupil (herniation)
Epidural Hematoma
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Subdural Hematoma• Hematoma between dura mater and
subarachnoid
• History of – Falls
– Head trauma
– Elderly
– Anticoagulation
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Subdural Hematoma• Suspect
– Bruise – Scalp laceration – Lethargy– Vomiting– Ipsilateral dilated pupil
• Treatment: – Support ABCs– Definitive treatment is neurosurgical evacuation
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Subarachnoid Hemorrhage• 1/10,000 in U.S.• Young, median age 50 • 50% mortality at 6 months• 50% with initially normal exam, vitals, absence of
neck stiffness• Caused by anneurysm or AVM rupture• Diagnosis: CT detects 93% in 24hr• Treatment: support ABCs, definitive treatment is
coiling or clipping
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Stroke• 80% ischemic
• Hemorrhagic
– HTN, elderly, prior CVA, bleeding diathesis,
vascular malformation, cocaine use
• Embolus
– A-fib, Valve replacement, recent MI, HTN,
CAD, DM
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AssessmentAssessment• Level of Consciousness• Vision (fields and eye movement)• Motor (strength, pronator drift)• Cerebellar function (gait, finger to nose,….)• Sensation• Language
– Dysarthria: inability to articulate– Aphasia: defect in language processing
• Cranial Nerve
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Temporal ArteritisTemporal Arteritis• 20 per 100,000
• > 50 Y
• Women>men
• Risk for blindness if untreated
• Dx ESR, Biopsy for definitive diagnosis,
• Treatment with steroids
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Temporal ArteritisTemporal ArteritisAutoimmune Vasculitis characterized by• Temporal headache• Visual disturbance (amaurosis fugax)• Claudication (masseter, temporalis tongue)• Scalp tenderness• Pulsating temporal artery (absent late stage)• Decreased visual acuity• Weakness• Weight loss
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Carotid or Vertebral Dissection
• Characterized by– Headache
– Vertigo
– Unilateral Horner Syndrome
• Suspect if sudden neck rotation or extension urgent imaging and neurosurgery
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CNS Infection• Meningitis: inflammation of arachnoid and pia
mater caused by bacteria, virus or fungi
• Headache, stiff neck, fever, chills, photophobia, confusion, phonophobia, nausea, vomiting, seizures (more common in children), rash, petechiae, Brudzinski or Kernig signs
• Protect yourself first– Fever + headache = mask
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Brudzinski’s and Kernig’s signsBoth signs of meningeal irritation
•Kernig’s sign:•Resistance to extension of the leg while the hip is flexed
•Brudzinski’s sign:•Flexion of the hips and knees in response to neck flexion
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Non-CNS Infection
• Viral syndromes• Bacteremia• Fever may often cause
generalized headache
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Opthalmic Glaucoma• Acute angle closure: obstruction of aqueous humor outflow leading to
increased intraocular pressure and possible blindness
• Associated with – Sudden onset painful vision loss – Nausea, vomiting– Somnolence
• Exam with – Decreased vision– Conjunctival injection, hazy cornea, – Dilated unreactive pupil
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Opthalmic• Iritis: inflamation of the Iris
– Risk if sarcoid, STDs, collagen vascular dz– Blurred vision, deep eye pain, photophobia, red eye– Exam with conjunctival injection, cell and flare
• Optic Neuritis
• Needs emergent opthomology referral
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Non-CNS Infection
Sinusitis• Fever, malaise, • Anosmia• Toothache• Purulent discharge• Postnasal drip• Sore throat, facial pain/pressure
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Non-CNS Infection
Sinusitis Treatment• Antibiotics• Nasal decongestants• Antipyretics for fever and analgesia
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Non-CNS Infections
Dental Infections (Caries and/or periapical abscess)
• Toothache• Jaw pain• Earache• Tooth tender to percussion
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Non-CNS Infections
Treatment involves – Covering exposed tooth– Analgesia– Abscess drainage
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Ear Infections
Otitis Media– middle ear infection • Ear pain/fullness• Decreased hearing• Vertigo• Fever
Treatment with • Antibiotics• Antipyretics
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Ear InfectionsOtitis Externa– External Ear infection
– Itching– Decreased hearing– Fever– Tender external ear.
Treated with – Antibiotic drops. – Caution if diabetic for malignant OE
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Raised pressure headache• Non-specific• Aggravated by
– Bending– Coughing– Sneezing– Waking
• Associated with N&V, visual blurring• Papilloedema
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CasesCases
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Case #1Case #1CHARACTER THROBBING
QUALITY UNILATERAL
SEVERITY DISABLING
ONSET MAXIMAL IN 1 HOUR
DURATION HOURS
RELIEF NSAID INADEQUATE
FREQUENCY 2-4 PER WEEK
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DIAGNOSIS #1DIAGNOSIS #1
MIGRAINEMIGRAINE
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Cases• 2 y M • Fever• Stiff neck• L.O.C• +ve Kernig’s sign
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Thanks