HEADPAIN—–DANIEL TODD, MD OFTEN MIXED AND COMPLEX ETIOLOGY TO FACIAL AND HEAD PAIN—-CONSIDER STRESS, DEPRESSION, ALLERGY TRIGGERS, AND CHRONIC INFECTIONS AS EXASERRBATING ELEMENTS ALWAYS ASK PT HOW MANY TYPES OF HA THEY HAVE LOOK FOR TRIGGERS, DURATION, FREQUENCY, QUALITY, SEVERITY AND ASSOC SYMPTOMS. TRUE RHINOGENIC HEADACHE A RARE ENTITY—BUT EXISTS FILL YOUR PREOP COUNSELING WITH DISCLAIMERS! RESPONDS REPEATEDLY TO TOPICAL ANESTHETICS—LIDOCAIN CONFIRMATION TEST THE PARANASAL SINUSES MAY MANIFEST BAROMETRIC HEADACHES—-RELATIVELY DEVOID OF NOCICEPTORS –TAKES A LOT OF DZ TO MANIFEST PAIN (>230MMHG OVER 1 ATMOSPHERE) NASAL VAULT—CONTACT POINTS (A PROPOSED RHINOGENIC HYPERPATHIA(RSD)) ECT… MIDDLE TURBINATE SYNDROME—UNILATERAL INTERMITTENT PERIORBITAL AND MEDIAL CANTHAL PAIN SINUS HEADACHE WORSE IN THE AM BETTER AS THE DAY PROGRESSES ALWAYS MUST EXPERIENCE THE ADDITIONAL MAJOR AND MINOR SYMPTOMS TMJ = ACOMMON ENTITY A DIARTHRODIAL(HINGING) GINGLYMOID(TRANSLATING) JOINT OCCLUSAL DYSHARMONY RESULTS IN ANT DISPLACEMENT OF THE ARTICULAR DISK AND RESULTANT MYOFASCIAL PAIN—HEADACHES IN THE TEMPORAL REGION, MALOCCLUSION AND INTERMITTENT LOCKING OF THE JAW A COMPLEX MULTI-ETIOLOGY COSTEN (1924) SYNDROME ASSOC WITH TINNITUS, DIZZINESS, FACIAL AND OTOLOGIC NEURALGIAS Dx AND Rx: NSAIDS AND A FLAT PLANE SPLINT (CONSIDER FLEXERIL AND ELAVIL) TENSION HEADACHE COMMON USUALLY BILATERAL—”BAND LIKE”—DIFFUSE CONSTANT—NONTHROBBING—USUALLY NOT DEBILITATING NO ASSOC. NAUSEA ASSOC DEPRESSION AND PERFECTIONISTIC PERSONALITY OFTEN +FH BETTER IN A RECUMBENT POSITION BETTER IN THE AM—WORSE AS THE DAY PROGRESSES CAN LAST DAYS PROBABLY DO TO FOCAL ISCHEMIA FROM CHRONIC MUSCLE CONTRACTION—BOTOX INJECTIONS SEEM TO BE HELPFUL Rs MUSCLE RELAXANTS, NSAIDS, COX 2 INHIBITORS (VIOXX, CELEBREX) MIGRAINE RECURRENT >5 ATTACKS USUALLY UNILATERAL (AT OUTSET) L>R PULSATILE “THROBBING” 8% POP FEMALE 3:1—OFTEN HORMONAL—-ONLY HEADACHE RELATED TO HORMONAL CHANGES OFTEN BEGIN WHEN YOUNG (2ND AND 3RD DECADE)—OFTEN ADOLESCENSE ASSOC WITH N/V—–”SICK HA” +FHx—80% ANOREXIA PHOTOPHOBIA PHONO/SONOPHOBIA INHIBITS ACTIVITIES OF DAILY LIVING MOTION/ACTIVITY INTOLERANCE CAN BE ASSOC WITH STRESS, MENSES, INSOMNIA, TYRAMINE, PHENYLETHAMINE, ETOH, CAFFEINE, SODIUM NITRITE(CURED MEATS), HEAD TRAUMA, WEATHER CHANGES COMMON ON WEEKENDS, BEGINNING OF HOLIDAYS, OR ON CERTAIN STRESSFUL DAYS OFTEN ASSOC WITH AURA—-30 MIN PRIOR CONSIDER IMAGING 1) IF ALWAYS ON THE SAME SIDE (AVM), OR, 2) WORST HA OF LIFE 3) 1ST HEADACHE AND AGE OVER 35. ALWAYS ASK PT HOW MANY TYPES OF HA THEY HAVE Rx CAFFIENE, ASA, NSAIDS, BUTALBITALS(ADDICTION, REBOUND) NARCOTICS, ERGOTOMINES—NOW TRIPTANS—DIRECTLY AFFECT THE NUCLEUS CAUDALIS OF THE TRIGEMINAL NUCLEUS COMMON=MIGRAINE WITHOUT AURA=HEMICRANIA SIMPLEX 85% NO AURA LAST HOURS TO DAYS (8-16 HOURS)—IF >24 HOURS = STATUS MIGRAINE (USUALLY LAST 2-72 HOURS) GRADUAL ONSET START AT AWAKENING MORE FRONTAL OFTEN MOOD CHANGES 8-12 HOURS PRIOR TO ONSET OFTEN ABATE WITH PREGNANCY POLYURIA/DIARRHEA CLASSIC=MIGRAINE WITH AURA=CLASSICAL=HEMIPERISTHETIC,HEMIPLEGIC,OPHTHALMIC, OR APHASIC MIGRAINE 10% AURA/PRODROME 1) VISUAL DISTURBANCE—SCINTILATING SCOTOMATA, TIECHOPSIA(FORTIFICATION SPECTRUM)CCENTRAL TO PERIPHERAL, PHOTOPSIA=OCCIPITAL ISCHEMIA 2) PARESTHESIAS 3) WEAKNESS 4) SPEECH ABNL (APHASIA) PREGNANCY MAY MAKE THEM WORSE COMPLICATED 5% VESTIBULAR MIGRAINE=VASOSPASTIC VERTIGO= 1 VARIANT OF COMPLICATED MIGRAINE USUALLY MINUTES TO HOURS NO HEARING LOSS NL ENT EXAM NL NEURO EXAM, NL EEG—-DIFF Dx = VERTIGINOUS TEMPORAL LOBE (ASTATIC) SEIZURES—ABNL EEG AGE RELATED CLASSIFICATION INFANTS (4 MO — 12-16 MO) PAROXYSMAL TORTICOLLIS—PREDISPOSED TO MIGRAINE CHILDREN (12MO—-4-5YRS) BENIGN PAROXYSMAL VERTIGO OF CHILDHOOD USUALLY MINUTES TO HOURS SHORT DURATION—USUALLY NO HL 20% SPONT NYSTAGMUS DURING ATTACKS MILD UNILATERAL HYPOACTIVITY ON ENG NO HA ATTACKS RECUR WITH DIMINISHED FREQ ADOLESCENCE/ADULTHOOD
BASILAR ARTERY (BICKERSTAFF=S) MIGRAINE/ VESTIBULAR MIGRAINE 70% TRUE VERTIGO/ 30% VAGUE DYSEQUILIBRIUM AND MOTION INTOLERANCE 5% DIRECT ASSOC OF VERTIGO WITH HA 65% VARIABLE ASSOC 30% NO ASSOC OF VERTIGO WITH HA HIGHLY LINKED WITH PMS (FEMALE PREPONDERANCE) USUALLY MINUTES TO HOURS 25% HAVE A UNILAT WEAKNESS ON ENG HIGHLY LINKED WITH FOOD ALLERGY (WATCH FOR PROVOKATIVE FOODS) Rx DETERMINED BY FREQUENCY OF HA’S–THINK PROPHYLACTICALLY! NASAL SPRAYS ARE THE WAVE OF THE FUTURE (IMITREX AND BUTORPHANOL(STADOL)) TEMPORAL GIANT CELL ARTERITIS—CRANIAL ARTERITIS, GRANULOMATOUS ARTERITIS A H&N VASCULITIS 50% COMORBID WITH PMR (POLYMYALGIA RHEUMATICA)—-PMR IS 2-3X MORE COMMON—-MUSCULOSKELETAL PAIN IN NECK, SHOULDERS, PELVIS ECT. ANEMIA, DEPRESSION, WT LOSS, AM STIFFNESS, FATIGUE, LOW GRADE FEVER, MALAISE FOR GREATER THAN 1 MONTH TEMPORAL ARTERITIS = A COMMON IDIOPATHIC SMALL VESSEL VASCULITIS—-RESULTANT ISCHEMIA FEMALE > MALE 90% > 60 90% UNILATERAL?/BILATERAL? HA–INTENSE PULSATILE CEPHALALGIA, HYPERALGESIA OF THE SCALP, JAWS, TONGUE, AND NECK—MASTICATORY CLAUDICATION, ODYNOPHONIA, ANOREXIA, MALAISE, FEVER, 2 OF THE TIME WILL HAVE STREAKING ERYTHEMA OVER THE TEMPPORAL ARTERY ESR > 40—OFTEN >100 LOW ALBUMIN AND HIGH IMMUNOGLOBULIN COUNTS 1/3 PTS HAVE OPHTHO INVOLVEMENT BLINDNESS IN 1/3 OF UNTREATED PTS—OFTEN HERALDED BY AMAUROSIS FUGAX IF SUSPICIOUS—START STEROIDS—60MG IV NEED TO DO TEMPORAL ARTERY BIOPSY WITHIN 72 HOURS OF STARTING STEROIDS—TAKE 6 CM SEGMENT USUALLY OF THE POST BRANCH (SKIP LESIONS–A 30% INCIDENCE)—-DO NOT INJECT WITH EPI OR YOU MAY LOSE PULSATIONS TO GUIDE THE DISSECTION—-CAN USE DOPPLER IF YOU WANT IF BIOPSY NEGATIVE GO TO THE OTHER SIDE MAY NEED TO TREAT WITH STEROIDS UP TO 2 YEARS——-NEVER MISDIAGNOSE AS MIGRAINE AND NEVER TREAT WITH ERGOTAMINES—-CAN QUICKLY GO BLIND TRIGEMINAL NEURALGIA——-TIC DOULOUREUX, HUNT’S NEURALGIA, PROSOPALGIA RECURRENT, PAROXYSMAL, IDIOPATHIC TRIGEMINAL NEURALGIA MOST COMMON NEURALGIA OFTEN TRIGGER ZONES—PRIMARILY JUST LATERAL TO NASAL ALA SUP CEREBELLAR ARTERY COULD BE IRRITATING THE NERVE (CONSIDER DECOMPRESSING THE NERVE OR BUFFERING IT WITH A SURGICAL PROCEDURE) MAY BE SET OFF BY SPEAKING, BRUSHING TEETH, SHAVING, CHEWING, OR DRINKING COLD OR HOT FLUIDS RIGHT > LEFT FEMALE > MALE, 2:1 90% > 40 (RARE BEFORE 30) V2 AND V3 = 95% DESCRIBED AS STABBING, SEARING “BOLT OF LIGHTNING”—-LASTS SECONDS TO MINUTES—–10-30 SECONDS 3% OF PTS HAVE MS 25% OF ALL PTS WITH MS HAVE TN FREQUENCY IS VERY VARIABLE NO OBJECTIVE MOTOR OR SENSORY LOSS MASS LESIONS WHICH PUSH ON THE NERVE USUALLY CAUSE HYPESTHESIA OR ANESTHESIA VS INFILTRATIVE LESIONS WHICH CAUSE PAIN
Dx: HISTORY, TRIAL OF TEGRETOL OR DILANTIN NOT A BAD IDEA TO R/O A STRUCTURAL CAUSE WITH AN MRI—--R/O MS OR MASS LESION Rx: TEGRETOL +/- DILANTIN—-OR RARELY SURGERY, NERVE ABLATION BEWARE OF THE SIDE EFFECTS OF TEGRETOL——CAN CAUSE A LIFE THREATENING APLASTIC ANEMIA—MYELOSUPPRESSION–HEPATO AND NEPHRO TOXIC CAUSALGIA/RSD (REFLEX SYMPATHETIC DYSTROPHY / RSD) —PERSISTENT BURNING FACIAL PAIN–OFTEN AFTER TRAUMA (EXASERBATED BY ACTIVITY OR STRESS) Dx: RELIEF WITH STELLATE GANGLION BLOCK Rx: SYMPATHECTOMY (STELLATE GANGLION BLOCK), MICROSURGICAL REPAIR, TENS, TEGRETOL POST TRAUMATIC NEURALGIA—-USUALLY DO TO NEUROMA OR MICRO NEUROMA FORMATION HYPERALGESIA—PAIN TO LIGHT TOUCH HYPERPATHIA—-PAIN FROM REPEATED STIMULATION ANESTHESIA DOLOROSA—PAIN FROM HYP- OR ANESTHETIC SKIN CAROTIDYNIA—-PAIN FROM CAROTID BULB PAIN ELICITED FROM PALPATION OF THE CAROTID BULB AT THE LEVEL OF THE HYOID BONE- (+ FAY SIGN) IN SOME CASES ENLARGEMENT OF THE AFFECTED CAROTID BULB (CAN BE SOME EVIDENCE OF CHRONIC INFLAMMATION—GIANT CELL FORMATION OFTEN PAIN RADIATES TO EAR OR THROAT FEMALE > MALE MEAN AGE 35 ALMOST ALWAYS UNILATERAL ETIOLOGY VIRAL VS PSYCHOSOMATIC Rx: ANTI-INFLAMMATORIES—-STEROIDS, SUPPORTIVE THERAPY EAGLE’S SYNDROME (GLOSSOPHARYNGEAL NEURALGIA, VAGOGLOSSOPHARYNGEAL NEURALGIA) ELONGATION OF THE STYOID PROCESS OR CALCIFICATION OF THE TENDONOUS ATTACHMENTS WHICH CAUSES PAIN THROUGH THE GLOSSOPHARYNGEAL NERVE CAVEATE: STYOID HAS 3 MUSCLES OF DIFFERING INNERVATION ORIGINATING FROM IT=”RIOLIN’S (FRENCH ANATOMIST) BOUQUET”—STYLOHYOID-7, STYLOGLOSSUS-12, STYLOPHARYNGEUS-9 RARE USUALLY OLDER FEMALES L>R VAGAL INVOLVEMENT CAN INCLUDE HICCUPING, N/V HA, INTENSE UNILAT PHARYNGEAL PAIN, DYSPHAGIA, ODYNOPHAGIA, PROGRESSIVE TRISMUS CAN OFTEN TRIGGER PAIN BY DEGLUTITION OR PALPATION IN THE TONSILLAR REGION 10% NO TRIGGER ZONE RARELY COULD BE THE CAUSE OF SYNCOPE BY STIM NERVE OF HERRING AFFERENTS Rx: TEGRETOL (RARELY EFFECTIVE), GLOSSOPHARYNGEAL RHIZOTOMY, RESECT STYLOID PROCESS (RADIOFREQUENCY ABLATION OR MICROVASCULAR DECOMPRESSION) GENICULATE NEURALGIA (NERVE OF HITSELBERG—-PAIN DOESN’T RADIATE) OCCIPITAL NEURALGIA-–CAN BE PRIMARY OR SECONDARY (C1 HAS NO SENSORY COMPONENT) C2—GREATER AND LESSER OCCIPITAL NERVES CLUSTER HA = HORTON’S HISTAMINIC CEPHALALGIA = SUICIDE HA ERYTHROCEPHALALGIA, ERYTHROPROSOPALGIA, NASOCILIARY NEURALGIA NOT A MIGRAINE VARIANT—-CAN DIFF FROM HEMIFACIAL MIGRAINE VIA HIGH CIP (DYNAMIC TONOMETRY) NO AURA ?A RHINOPATHIC HA—-SP GANGLION DYSFUNCTION?—MUST DIFF FROM SLUDER’S LOWER HALF HA (VAIL’S OR VIDIAN’S NEURALGIA) AND RAEDER’S SYNDROME (INCOMPLETE HORNER’S) SUDDEN, EXPLOSIVE, PAROXYSMAL ONSET—FEAR OF ONSET IS THE WORST PART FOR PATIENTS SHORT DURATION(MINUTES-HOURS)15 MIN TO 180 MIN VERY SEVERE (“POKER IN THE EYE”, UNILAT, RETRO-ORBITAL PAIN (SUICIDE HA) OFTEN WORSE WITH HEAD DEPENDENT FEQUENTLY MISDIGNOSED AS ACUTE RHINOSINUSITIS SCLERAL INJECTION LACRIMATION—EPIPHORA CLEAR RHINORRHEA—CONGESTION–NAO (DIFF ACUTE RHINOSINUSITIS–LASTS ONLY MINUTES TO HOURS) PERSPIRATION (OPPOSITE HORNERS) MIOSIS AND PTOSIS EYELID EDEMA
MALE >90% (ONLY HA WITH A MALE PREDOMINANCE) NO SIG Fhx ONSET 2ND TO 5TH DECADE ETOH COMMON USUALLY ONE SIDE IS DOMINANT WORSE WHEN LAYING DOWN N/V ARE VERY RARELY ASSOC. NO AURA–NO SONO OR PHOTOPHOBIA ALMOST ALWAYS < 2 HOURS SEASONAL (FALL/SPRING PREPONDERANCE—OFTEN A “CLUSTER” OF HA’S WHICH LASTS WEEKS TO MONTHS ALLERGY AS A CONTRIBUTING ETIOLOGY? Rx: 4% TOPICAL LIDOCAINE DROPS INTO IPSI NOSTRIL—-15 MIN HIGH RELIEF 100% O2 INDOCIN PREDNISONE ANTIHISTAMINES DHE (ERGOTOMINES)/METHYSERGIDE(SANSERT)–RP FIBROSIS IS RARE AND DOSE DEP. CALCIUM CHANNEL BLOCKERS TRIPTANS AND ERGOTOMINES AS NASAL SPRAYS OR INJECTIONS MAY BE EXCELLENT (HARLEQUIN SYNDROME=UNILAT ABSENCE OF FACIAL AUTONOMIC INNERVATION) READER’S SYNDROME = INCOMPLETE HORNER’S SYNDROME FEMALES AND LEFT SIDE PREDOMINATE THROBBING PERSISTENT HA IN V1 AND V2 DISTRIBUTION IPSI HORNER’S SYNDROME (PTOSIS, MIOSIS, AND ENOPTHALMOS) WITHOUT ANHYDROSIS (NO LOSS OF PERSPIRATION) MAY HAVE AN IPSI OPHTHALMOPLEGIA TOLOSA-HUNT SYNDROME—-PAINFUL UNILATERAL OPHTHALMOPLEGIA TRIAD OF: PERIORBITAL PAIN, OPTHALMOPLEGIA, AND REMARKABLE RESPONSE TO STEROIDS TENDS TO RECUR THOUGHT TO BE DUE TO INFLAMMATION OF THE CAVERNOUS SINUS MAY BE INDISTINGUISHABLE FROM SUP ORBITAL FISSURITIS ASTHENOPIA=EYE STRAIN—A RARE CAUSE OF HA OPTIC (RETROBULBAR) NEURITIS—VISUAL CHANGES—-BLURRED VISION, SHARP BORING RETROBULBAR PAIN—WORSENED BY EYE MOVEMENT AND PRESSURE ON THE GLOBE, DECREASED VISUAL ACUITY, OPTIC DISK ELEVATION, MARCUS GUNN AFFERENT PUPIL ACUTE GLAUCOMA—HALOS AROUND LIGHTS—ROCK HARD GLOBE RESULTS FROM AN ACUTE RISE IN PRESSURE—NOT NECESSARILY A HIGH ABSOLUTE PRESSURE UVEITIS—PHOTOPHOBIA DACROCYSTITIS—-USUALLY BLOCKAGE OF THE DUCT—INFECTIOUS SIGNS AND EPIPHORA HERPES ZOSTER OPHTHALMICUS-—HUTCHINSON’S SIGN (TIP OF NOSE=V1) AND NASOCILIARY GANGLION INVOLVEMENT RAMSAY-HUNT SYNDROME (HUNT 1907) HERPES ZOSTER OTICUS 3rd MOST COMMON CAUSE OF FP MANIFESTATION OF DORMANT VARICELLA ZOSTER VIRUS REACTIVATING IN THE EXTRAMEDULLARY CRANIAL NERVE GANGLIA(GENICULATE) DURING PERIODS OF DECREASED CMI MAY PROGRESS FOR 14-21 DAYS SEVERE OTALGIA FACIAL PARALYSIS-MORE SEVERE (15-30% FULL RECOVERY) FACIAL HYPESTHESIAS VESICULAR ERUPTION IN CONCHAL BOWL FROM AURICULAR BRANCH OF VAGUS CONVEYING GSV OF 7-(EAC AND PALATE)-SO CHECK PALATE VARYING(10%)SNHL +/-VESTIBULOPATHY OFTEN COMORBID CN DEFICITS! Rx: IV ACYLOVIR (USED TO BE DECOMPRESSION)
+/- STERIODS — ROUTINE EYE CARE SLUDER’S NEURALGIA (SLUDER’S SYNDROME, SLUDER’S HA, PTERYGOPALATINE GANGLION/MECKEL’S/SHENOPALATINE NEURALGIA) LOWER HALF HEAD ACHE OF SLUDER = VIDIAN NEURALGIA SYNONYM FOR VAIL’S SYNDROME A LANCINATING PAIN—LIKE A NAIL THROUGH THE EYE AND OUT THE IPSI MASTOID ASSOC. IPSI LACRIMATION, RHINORHEA, AND SALIVATION Dx: BY CONSISTENTLY RELEIVING THE HA WITH SP ANESTHESIA Rx: CAN CAUTERIZE THE GANGLION AND GET YEARS OF RELIEF PSEUDOTUMOR CEREBRI = BIH (BENIGN INTRACRANIAL HTN) USUALLY YOUNG FEMALES, OBESE WITH RECENT WEIGHT OR HORMONAL CHANGES PRIMARY Sx IS THE HEADACHE—USUALLY NO FOCAL NEURO SIGNS PULSATILE TINNITUS–VERY COMMON—ALSO-HYDROPIC HEARING CHANGES + PAPILLEDEMA—MUST DO FUNDOSCOPIC EXAM ASK ABOUT HYPERVITAMINOSIA (A&D), STEROIDS, BCP, LMP (?PREGNANT) TEST THYROID CT SCAN—-SLIT LIKE VENTRICLES Rx: IF PREGNANT —DELIVER SALT RESTRICTION (ETOH, CAFFEINE, ECT….) ACETAZOLAMIDE, LASIX SERIAL LP’S TROTTER SYNDROME (SINUS OF MORGAGNI SYNDROME) USUALLY A MASS IPSI ETD—CHL V1 RETROBULBAR PAIN POOR MOBILITY OF SOFT PALATE—VP INCOMPETENCE, RHINOLELIA APERTA TRISMUS (PTERYGOID INVOLVEMENT) PREAURICULAR EDEMA INF. MAXILLARY NEURALGIA