Chapter 18 Cranial and Facial Pain
Headache is an exceedingly common symptom that affects virtually everyone at some time in their life. It is estimated that nearly half of the world’s adult population has an active headache disorder (Robbins et al., 2010). Headache is one of the most common reasons for outpatient healthcare visits in the United States. Patients with head and/or face pain typically present for medical attention because the discomfort is severe, interferes with work and/or leisure activities, or raises the patient’s or family’s concern about a serious underlying cause.
Headache disorders are classified as primary or secondary (Box 18.1) (International Headache Society Classification Subcommittee, 2004). The primary headache disorders do not have an underlying structural cause, but all the primary headache disorders can be simulated by secondary conditions. The diagnosis of head and face pain depends on three elements: the history, neurological and general examinations, and appropriate investigations if needed. Treatment of headaches is discussed in Chapter 69.
Box 18.1
International Classification of Headache Disorders, 2nd Edition
The Secondary Headaches
Headache attributed to head and/or neck trauma
Headache attributed to cranial or cervical vascular disorder
Headache attributed to nonvascular intracranial disorder
Headache attributed to substance or its withdrawal
Headache attributed to infection
Headache attributed to disorder of homeostasis
Headache or facial pain attributed to disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cranial structures
Data from International Headache Society, 2003-2005.
History
The gold standard for diagnosis and management of headache is a careful interview and neurological and general medical examinations (De Luca and Bartleson, 2010). In the vast majority of patients with headache, the neurological and general examinations will be normal, so the diagnosis is based entirely on the history, and clinicians are well advised to spend most of their time interviewing the patient.
History-taking for head and face pain is similar to that for other presenting complaints, but several specific aspects should be addressed. The questions listed in Box 18.2 are useful, and the discussion that follows illustrates some responses and their implications. Usually one begins by asking the patient to describe their symptoms or, alternatively, simply by asking how they can be helped. This approach allows patients to relax and say what they had planned to say. Usually the patient will speak for less than 2 minutes if not interrupted (Langewitz et al., 2002). Once the patient has had an opportunity to speak, directed but open-ended questions (see Box 18.2) can be asked.
Box 18.2 Useful Questions to Ask the Patient with Headache
How many types of headache do you have?
When and how did each type begin?
If the headaches are episodic, what is the frequency and duration?
How long does it take for your headaches to reach maximal intensity?
How long do your headaches last?
When do the headaches tend to occur, and what factors trigger your headaches?
Where does your pain start, and how does it evolve?
What is the quality and the severity of your pain?
Is the pain steady or pulsating (throbbing), or both?
Are there symptoms that herald the onset of your headache?
What are they, when do they begin, and how long do they last?
Are there symptoms that accompany your headaches?
Do you get nauseated with your headaches?
Does light and/or noise bother you a lot more when you have a headache than when you don’t?
Do your headaches limit your ability to work, study, or do what you need to do for at least 1 day?
Does anything aggravate your pain (e.g., exertion)?
Are your headaches getting better or worse, or are they about the same?
What treatments have been used to treat the headaches, both acutely and preventively?
Is there a family history of headaches?
What prior testing have you had?
Do you have other medical or neurological problems?
What do you think might be causing your headaches?
Onset of Headaches
A stable headache disorder of many years’ duration is almost always of benign origin. Migraine headaches often begin in childhood, adolescence, or early adulthood. A headache of recent onset obviously has many possible causes, including the new onset of either a benign or serious condition. “Recent onset” has been defined differently by various authors; the typical range is from 1 to 12 months. In general, the more recent the onset, the more worrisome. The “worst ever” headache, an increasingly severe headache, or change for the worse in an existing headache pattern all raise the possibility of an intracranial lesion. Headaches of instantaneous onset suggest an intracranial hemorrhage, usually in the subarachnoid space, but also can be caused by intracerebral hemorrhage, cerebral venous thrombosis, arterial dissection, pituitary apoplexy, spontaneous intracranial hypotension, benign angiopathy of the central nervous system (CNS), acute hypertensive crisis, and idiopathic primary thunderclap headache (Ju and Schwedt, 2010). Onset of a new headache in patients older than 50 years raises suspicion of an intracranial lesion (e.g., subdural hematoma) or giant cell (temporal or cranial) arteritis (GCA). A history of antecedent head or neck injury should be sought; even a relatively minor injury can be associated with subsequent development of epidural, subdural, subarachnoid, or intraparenchymal hemorrhage and posttraumatic dissection of the carotid or vertebral arteries (Dziewas et al., 2003). However, posttraumatic headaches can occur following head injury in the absence of any significant pathology.
Temporal Profile
A chronic daily headache without migrainous or autonomic features is likely to be a chronic tension-type headache. Untreated migraine pain usually peaks within 1 to 2 hours of onset and lasts 4 to 72 hours. Cluster headache is typically maximal immediately (if the patient awakens with the headache in progress) or peaks within minutes (if it begins while awake). Cluster headaches can last 15 to 180 minutes (usually 45 to 120 minutes). Headaches similar to cluster but lasting only 2 to 30 minutes and occurring several times a day are typical of episodic or chronic paroxysmal hemicrania, both of which are more common in women and are prevented by indomethacin (Goadsby et al., 2010). Primary stabbing headaches (“ice-pick pains”) are momentary, lasting only seconds. Stabbing pains are more common in patients with migraine and cluster headaches. Tension-type headaches commonly build up over hours and last hours to days to years. Headache that is daily and unremitting from onset, usually in patients without prior headaches, is classified as new daily-persistent headache and may have features suggestive of migraine or tension-type headache. A chronic, continuous, unilateral headache of moderate severity with superimposed attacks of more intense pain, associated with autonomic features, suggests the diagnosis of hemicrania continua, an indomethacin-responsive syndrome. Occipital neuralgia and trigeminal neuralgia manifest as brief shocklike pains, often triggered by stimulation in the territory served by the affected nerve. Occasionally a dull pain in the same nerve distribution persists longer, often after a series of brief, sharp pains. Short-lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT) is a rare syndrome consisting of paroxysms of first-division trigeminal nerve pain, lasting 5 to 240 seconds but occurring 3 to 200 times per day with the associated autonomic symptoms for which it is named (Goadsby et al., 2010)
Time of Day and Precipitating Factors
Cluster headaches often awaken patients from a sound sleep and may occur at the same time each day in an individual person. Hypnic headaches typically affect older patients and regularly awaken the patient at a particular time of night. Unlike cluster headaches, they are usually diffuse and not associated with autonomic phenomena (Donnet and Lanteri-Minet, 2009
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