Headache & Facial PainHeadache & Facial Pain

John F. Rothrock, M.D.John F. Rothrock, M.D.Professor & Vice Chair, UAB NeurologyProfessor & Vice Chair, UAB Neurology

Headache Diagnosis: Primary Headache Diagnosis: Primary vsvs Secondary Secondary

When is “migraine” When is “migraine” reallyreally migraine?migraine?

19 yo Female university coed reports 10 years 19 yo Female university coed reports 10 years of episodic, unilateral, pulsatile headache, of episodic, unilateral, pulsatile headache,

often heralded by “sparkles & blind spots” in often heralded by “sparkles & blind spots” in the right periphery of vision. Midrin no long the right periphery of vision. Midrin no long

helps.helps.

““Secondary” HeadacheSecondary” Headache

subarachnoid hemorrhagesubarachnoid hemorrhagemeningitismeningitis ICP too high or lowICP too high or lowcerebral sinus thrombosiscerebral sinus thrombosispituitary apoplexypituitary apoplexy… … and many moreand many more

Clues to Secondary HeadacheClues to Secondary Headache

fever, seizure, behavioral change, etcfever, seizure, behavioral change, etcage >55age >55posterior locationposterior locationneurological deficitneurological deficitabrupt onset/severe intensity: abrupt onset/severe intensity:

“thunderclap”“thunderclap”

““Primary” HeadachePrimary” Headache

tension-typetension-typemigrainemigraineclusterclusterall the restall the rest

Recurrent Disabling HeadacheRecurrent Disabling Headache

it’s usually migraineit’s usually migraine

What is Migraine?What is Migraine?

prevalenceprevalencecostcostclinical definitionclinical definitionclinical phenotypes/ “chronification”clinical phenotypes/ “chronification”

What Causes Migraine?What Causes Migraine?

vascular theoryvascular theory trigeminovascular theorytrigeminovascular theorycentral theorycentral theory

Trigeminal Nucleus Caudalis Receives Afferent Messages and Acts as a Sensory Relay Center

Cortical Spreading DepressionCortical Spreading Depression

migraine generator?migraine generator?

Trigeminal Nucleus Caudalis Receives Afferent Messages and Acts as a Sensory Relay Center

Facial PainFacial Pain

typical” typical” vs.vs. “atypical” “atypical”

““symptomatic” symptomatic” vs.vs. “primary” “primary”

Trigeminal Neuralgia: DiagnosisTrigeminal Neuralgia: DiagnosisTable 1Table 1 Trigeminal Neuralgia: IHS Diagnostic Criteria Trigeminal Neuralgia: IHS Diagnostic Criteria

A. A. Paroxysmal attacks of facial or frontal pain which last a few Paroxysmal attacks of facial or frontal pain which last a few seconds to less than two minutesseconds to less than two minutes

B. B. Pain has at least 4 of the following characteristics:Pain has at least 4 of the following characteristics:(1) (1) distribution along one or more distributions of distribution along one or more distributions of

the the trigeminal nerve.trigeminal nerve.(2) (2) sudden, intense, sharp, superficial, stabbing or sudden, intense, sharp, superficial, stabbing or burning in quality.burning in quality.

C.C. No neurologic deficitNo neurologic deficitD.D. Attacks are stereotyped in the individual patient.Attacks are stereotyped in the individual patient.E. E. Exclusion of other causes of facial pain by history, physician Exclusion of other causes of facial pain by history, physician

examination and special investigations when necessary.examination and special investigations when necessary.

Trigeminal Neuralgia: TreatmentTrigeminal Neuralgia: Treatment

pharmacologicpharmacologic

““procedural”procedural”

anesthesia dolorosaanesthesia dolorosa

““Atypical” / Symptomatic Facial PainAtypical” / Symptomatic Facial Pain

carotid dissectioncarotid dissection

giant cell (“temporal” arteritis)giant cell (“temporal” arteritis)

acute V-Z & post-herpetic acute V-Z & post-herpetic neuralgianeuralgia

Tolosa – Hunt syndromeTolosa – Hunt syndrome