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Head, neck and facial pain

Head, neck and facial pain. A pain in the head, face or a pain in the neck?. AIMS. TO DISCUSS HEAD, FACE AND NECK PAIN AND THE POSSIBLE CAUSES. OBJECTIVES. To consider the innervation of the head and neck region To understand some of the physiological relationships

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Head, neck and facial pain

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  1. Head, neck and facial pain A pain in the head, face or a pain in the neck?

  2. AIMS • TO DISCUSS HEAD, FACE AND NECK PAIN AND THE POSSIBLE CAUSES

  3. OBJECTIVES • To consider the innervation of the head and neck region • To understand some of the physiological relationships • To know some of the conditions giving rise to pain

  4. INNERVATION OF THE HEAD AND NECK REGION • Trigeminal nerve • Branches from C2, C3, C4 and C5 • Afferent impulses from the Trigeminal and cervical region converge in the 2nd cervical segment of spinal cord

  5. RELEVANT NEUROLOGY • Trigeminal nerve and ganglion • Cervical nerves, mainly C2 • Sphenopalatine ganglion • Cutaneous nerve supply

  6. Head, face and neck pain • Pain in the face: -Trigeminal or neck • Pain in the head:-supplied by C2 and C3 • Pain in the neck:- supplied by C2-C5 • Pain in or around the ears:-supplied by C2

  7. HISTORY • Very important • Ensure it is very detailed • Enquire about the function of all parts of the head and neck • Ensure you understand the time sequence of events and symptoms • Ask about sympathetic symptomatology

  8. Site Sort Severity Onset Duration Radiation Associated factors Precipitating factors Relieving factors Red flags (night pain, loss of sensation, symptoms elsewhere) HISTORY

  9. EXAMINATION • Full Cranial Nerve examination • Full neurological examination of the neck and arms • Check for trigger points in neck, around occiput, Sternocleidomastoid, Masseters, Pterygoids, Temporalis, behind the ear. Check common acupuncture points

  10. CLASSIFICATION OF FACIAL PAIN • Local disease • Neurological disorders • Psychogenic conditions • Referred pain

  11. PAIN IN JUST THE FACE • Trigeminal Neuralgia • TMJ pain • Trigeminal autonomic syndromes • Atypical facial pain • Very occasionally a C2 problem • Glossopharyngeal neuralgia • VII/VIII complex (N intermedius)

  12. TRIGEMINAL NEURALGIA • Symptom rather than specific disease. • Can be due to a specific lesion which is causing destruction, irritation or demyelination.

  13. CAUSES OF TRIGEMINAL NEURALGIA • Idiopathic • Vascular compression. • Tumour. • Aneurysm. • M.S. • Demyelinating peripheral neuropathies.

  14. FEATURES • Episodic, recurrent unilateral facial pain. • Lasts a few seconds, occurring many times a day. • V2 > V3 > V1. • Triggers are trivial events. • 2.7:100 000 men and 5.0: 100 000 women. • 50 - 60 years. • Neurology normal.

  15. MEDICAL TREATMENT • Gabapentin 1.2g – 1.8g daily • Carbamazepine up to 1000 - 1200mg/day. • Phenytoin. • Baclofen. • Clonazepam. • Valproic Acid.

  16. SURGICAL TREATMENT • R.F Trigeminal Ganglion. • Injection of Gylcerol into cistern of Meckel’s Cave. • Microvascular decompression of Trigeminal Nerve. • Peripheral Neurectomy of a branch of Trigeminal Nerve.

  17. TMJ PAIN • Pain in the joint and masticatory muscles • Dull ache/ear ache • Radiates to temporal, masseteric, occipital and mastoid areas • Associated with other stress induced syndromes • Females > males

  18. The problem • Emotional stress • Muscle hyperactivity • Bruxism • Joint overloading

  19. Examination • Tender mandibular condyles and maxillary tuberosities • Tender Temporalis, Masseter and Pterygoid muscles

  20. Treatment • Simple analgesia • TCA • Local Anaesthetic injections • Botulium Toxin • Acupuncture

  21. MYOFASCIAL PAIN • Associated with tender muscles of the face, head and neck • Can be primary or secondary

  22. HISTORY AND EXAMINATION • History is vague and difficult to decipher • Examination reveals multiple trigger points within the facial and neck musculature • Travell shows these trigger points well

  23. Treatment • Acupuncture • Physiotherapy • TENS • Local anaesthetic and steroid injections

  24. PAIN IN JUST THE NECK • Cervical facets • Cervical discs • Cervical ligaments • Cervical muscles • Sternocleidomastoid and Strap muscles • Has there been any neck trauma?

  25. CERVICAL PAIN • Originates from C2 and C3 • May have neck pain • Often have facial pain/head pain • Distribution is C2/C3 • Can involve the Trigeminal region

  26. History • Pain on neck movement • Feeling of pressure on their head • Feel as if they cannot support their head

  27. Examination • Limited neck movement, usually extension, lateral flexion • Tender cervical muscles • Tender cervical facets

  28. Treatment • Physiotherapy • TENS • Acupuncture • Local anaesthetic blocks

  29. PAIN IN /AROUND EARS • Parotid gland • Submandibular • Masseter/Pterygoids • Within the ear • From previous surgery (a type of CRPS) • Cervicogenic

  30. ATYPICAL FACIAL PAIN • Diagnosis of exclusion • Other pathology has been ruled out

  31. Treatment • Reassurance • CBT • ACP/Tens • Baclofen • Gabapentin • Amitriptyline

  32. HEADACHES • Migraine +/- aura • Tension type • Trigeminal autonomic cephalagias • Medication overuse • Cervicogenic

  33. SERIOUS CAUSES OF HEADACHE • Intracranial tumours • Meningitis • Subarachnoid Haemorrage • Giant cell arteritis • Primary closed angel glaucoma • Idiopathic intracranial hypertension • Carbon Monoxide poisoning

  34. SUMMARY • Anatomy • Physiological links • Common syndromes

  35. THANK YOU

  36. Useful references • NICE guidelines on Neuropathic pain • UHL guidelines on neuropathic pain (intranet LMSG web site and inpatient web site) • BASH guidelines. www.bash.org.uk

  37. ANATOMY • Head and face supplied by Trigeminal nerve and the first 3 cervical nerves • Afferent impulses from the Trigeminal and cervical region converge in the 2nd cervical segment of spinal cord

  38. PAIN SYNDROMES • TRIGEMINAL NEURALGIA • TMJ PAIN • ATYPICAL FACIAL PAIN • MYOFASCIAL PAIN • CERVICAL PAIN

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