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Headache & Facial Pain. John F. Rothrock, M.D. Professor & Vice Chair, UAB Neurology. Headache Diagnosis: Primary vs Secondary. When is “migraine” really migraine?.
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Headache Diagnosis: Primary vs Secondary
When is “migraine” reallymigraine?
19 yo Female university coed reports 10 years of episodic, unilateral, pulsatile headache, often heralded by “sparkles & blind spots” in the right periphery of vision. Midrin no long helps.
“Secondary” Headache
- subarachnoid hemorrhage
- meningitis
- ICP too high or low
- cerebral sinus thrombosis
- pituitary apoplexy
… and many more
Clues to Secondary Headache
- fever, seizure, behavioral change, etc
- age >55
- posterior location
- neurological deficit
- abrupt onset/severe intensity: “thunderclap”
“Primary” Headache
- tension-type
- migraine
- cluster
- all the rest
Recurrent Disabling Headache
- it’s usually migraine
What is Migraine?
- prevalence
- cost
- clinical definition
- clinical phenotypes/ “chronification”
What Causes Migraine?
- vascular theory
- trigeminovascular theory
- central theory
Trigeminal Nucleus Caudalis Receives Afferent Messages and Acts as a Sensory Relay Center
Cortical Spreading Depression
- migraine generator?
Trigeminal Nucleus Caudalis Receives Afferent Messages and Acts as a Sensory Relay Center
Facial Pain
- typical” vs. “atypical”
- “symptomatic” vs. “primary”
Trigeminal Neuralgia: Diagnosis
Table 1 Trigeminal Neuralgia: IHS Diagnostic Criteria
A. Paroxysmal attacks of facial or frontal pain which last a few seconds to less than two minutes
B. Pain has at least 4 of the following characteristics:
(1) distribution along one or more distributions of the trigeminal nerve.
(2) sudden, intense, sharp, superficial, stabbing or burning in quality.
C. No neurologic deficit
D. Attacks are stereotyped in the individual patient.
E. Exclusion of other causes of facial pain by history, physician examination and special investigations when necessary.
Trigeminal Neuralgia: Treatment
- pharmacologic
- “procedural”
- anesthesia dolorosa
“Atypical” / Symptomatic Facial Pain
- carotid dissection
- giant cell (“temporal” arteritis)
- acute V-Z & post-herpetic neuralgia
- Tolosa – Hunt syndrome
