THE PATIENT WITH HEAD, OCULAR, OR FACIAL PAIN

EVALUATION OF HEADACHE• HISTORY– Nature of the headache– Daily pattern of hedache– Location– Associated symptoms– Precipitating or alleviating factors– Overall pattern– Family history

• VAST MAJORITY OF PATIENTS WITH HEADACHE HAVE NORMAL VISUAL ACUITY

• PE:• BP, Pulse• Meningeal signs• Symmetry of cranial nerve and motor functions

TYPES OF HEADACHE

• PRIMARY– Migraine– Tension- type – Cluster

• SECONDARY

NEUROIMAGING?

• Sudden onset of severe headache• Unexplained change in headache pattern• Unresponsive to medical therapies• HA related to physical exertion or change in body position• New onset of headache after the age of 50 years• New headaches in immunosuppressed patients• (+) focal neurologic signs• (+) fever, neck stiffness, change in mental status, behavioral

changes

MIGRAINE

• Condition consisting of repetitive bouts of headache

• F>M• (+) familial tendency• (+) history of motion sickness in childhood• Onset- puberty or young adulthood• Decrease after menopause

Characteristic:• unilaterality, pulsating, N/V, photophobia,

aggravated by physical activitiesExacerbated by:• menstruation, pregnancy, hunger, stress,

certain foods and sleep deprivation

I. Migraine with aura

• Classic migraine• 30%• Visual aura: begins w/ a small scotoma

near fixation that gradually expands, then breaks up

• < 45 minutes• Followed by HA on the contralateral side

of the head• Untreated: 4 to 72 hrs

II. Migraine without aura

• Common migraine• 65%• No preceding neurologic symtoms• Global• Can last hours to days

III. Migraine aura w/o Headache• Acephalgic migraine• 5%• Visual aura:• Scintillating scotoma, transient

homonymous hemianopia, peripheral VF constriction, transient monocular visual loss, episodic diplopia ( vertical)

• Headache or aura always occur on the same side

• Headache precedes the aura• Neurologic deficit, persists after aura resolves• Features of aura are atypical

EVALUATION

Tension -type headache

• Chronic• Aching• Worse at the end of day• Precipitated by stress• Associated with depression

TREATMENT

• Reassurance• Avoid precipitating factors:• Chocolates, nitrates, MSG, cheese,

caffeine, red wine, alcohol, nuts, shellfish

• OCPs• Stress, change in sleep patterns,

strong scents such as perfume, cigarette smoke and exercise

• Acute relief: dihydroergotamine, sertonergic agents, NSAIDS

• * analgesic rebound headache• Prophylactic treatment:• Disrupted functions of daily life• Beta blockers, Ca channel blockers, TCA, SSRIs,

sodium valproate, NSAIDS

CLUSTER HEADCHE

• Men • 30’s to 40’s• Cigarette smokers• Pain localized behind 1 eye• Tearing, conjunctival injection,

rhinorrhea• < 2 hrs

• Difficult to treat• Inhaled oxygen, methysergide, subcutaneous

sumatriptan or dihydroergotamine• Prednisone tapered for 10- 14 days• Verapamil- prophylaxis

OCULAR AND ORBITAL CAUES OF PAIN• Refractive errors and starbismus• KS, Keratitis, AACG, intraocular

inflammation• Recurrent erosion syndrome• Scleritis• Optic neuritis

PHOTOPHOBIA

• Keratitis• Uveitis• Chorioretinitis• Menigeal irritation• migraine

FACIAL PAIN

• Most often, pain in the eye area is a manifestation of headache

• Dental disorders, sinus disease

1. Trigeminal neuralgia• Tic douloureux• Caused by vascular compression of CN V• Demyelinating dse, posterior fossa mass lesion• Unilateral • chewing , tooth brushing, cold wind• Normal sensory function• MRI• Treatment:• gabapentin, carbamezepine, phenytoin, baclfen,

clonazepam, valproic acid• Rhizotomy, decompression of CN V

1. Trigeminal neuralgia• Tic douloureux• Caused by vascular compression of CN V• Demyelinating dse, posterior fossa mass lesion• Unilateral • chewing , tooth brushing, cold wind• Normal sensory function• MRI• Treatment:• gabapentin, carbamezepine, phenytoin, baclfen,

clonazepam, valproic acid• Rhizotomy, decompression of CN V

• 2. Glossopharyngeal neuralgia• 3. Carotidynia- neck pain that radiates to

ipsilateral face and ear• 4. Carotid dissection- (+) sympathetic

dysfunction• 5. Temporomandibular disease

6. HZO-• pain before vesicle eruption• Gabapentin, TCA, lidocaine patch7. Neoplastic process8. Mental nerve neuropathy- numb chin• Saroidosis, lymphoma, mets breast Ca

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