38. Cervicogenic Headache and Orofacial Pain

1. 38. Cervicogenic Headache and Orofacial Pain

2. Cervicogenic headache

3. 공통점 • pain that starts in the neck, mostly unilateral, aggrevated by neck movement or awkward head positioning, and relieved by local anesthetic blockade of the occipital nerve • 0.4-2.5% among the general population and 15-20% among patients with chronic headache • female, 평균연령은 42.9세 • CGH의 pain이 발생하는 구조 -> post. cranial fossa, vertebral a, occipital condyles, upper cervical facet joints, intervertebral discs, nerve roots, and cervical m and their bone attachments

4. mechanism "cervicotrigeminal relay" (CTR) and trigeminovascular system (TVS)

5. neck에서 받아들여진 nociceptive impulses을 temporal, frontal, orbital regions의 head pain으로 인식하게 함 treatment • NSAIDs medications, occipital nerve blocks, radiofrequency neurotomy of the cervical disc, epidural steroid injections, cervical manipulation, and surgery

6. Orofacial pain

7. 1. Orofacial pain of neuropathic origin • results from involvement of cranial nerves (trigeminal, facial, glossopharyngeal, vagus, hypoglossal) 1) Central pain • infrequent cause • central poststroke pain (thalamic pain) - m/c cause • 모든 stoke환자 중 1-2%에서 발생하고 thalamus 침범한 경우 중 20%에서 facial pain이 발생 2) Trigeminal neuralgia A. Tic douloureux • defined as a sudden, usually unilateral, severe, brief, stabbing, recurrent pain felt in the distribution of one or more branches of the fifth cranial nerve • trigeminal root compression이 일차적인 원인인 것으로 생각됨 • vascular loops compressing or contacting the trigeminal nerve root -> 80% 이상에서 관찰됨

8. B. Trigeminal neuralgia secondary to trauma • trauma, surgery, peripheral lesions 후에 발생 C. Acute herpes zoster : trigeminal distribution • latent varicella zoster virus가 trigeminal, geniculate ganglion에 있다가 host의 면역력이 떨어지면서 infection이 trigeminal nerve branches, facial nerve branches를 침범하여 발생 • recurrent viral infection • Trigeminal herpes zoster 또는 Ramsay Hunt synd.과 증상이 비슷하기 때문에 진단을 위해 반드시 laboratory exam이 필요 (elevated antibody level of varicella zoster virus) D. Postherpetic neuralgia: trigeminal distribution • acute trigeminal herpes zoster의 eruption이 치료된 후에도 trigeminal division에 지속되는 somatosensory abnormalities로 chronic pain이 있는 것이 특징적 • postherpetic neuralgia는 rash 후에 3개월 이상 지속됨 • burning pain with hyperalgesia, allodynia, and dysesthesia • diagnosis - Hx. of eruptions in the affected area and the presence of somatosensory abnormalies • serum varicella zoster antibody level은 chronic case에서 진단에 도움이 안 됨

9. E. Raeder's synd • severe stabbing paroxysms in the first division of trigeminal nerve with sympathetic nervous system paralysis • 중년 남성에서 ptosis와 miosis를 동반한 severe, throbbing, supraorbital headache • The headache is intermittent for several weeks or months 3) Geniculate neuralgia or Ramsay Hunt syndrome • geniculate ganglion level의 facial n와 함께 가는 afferent fiber의 acute herpetic involevement 때문에 발생 • concha와 mastoid area 주위에 typical vesicle이 생기고 몇 일 후 auditory meatus lancinating pain이 느껴짐 • Typical cases of Ramsay Hunt syndrome -> the triad of auricular vesicles, ipsilateral peripheral facial palsy, vestibular/cochlear symptoms

10. 4) Nervus intermedius neuralgia/Geniculate neuralgia • episodic, severe lancinating pain in the ear canal or post. pharynx as the main presenting symptom • etiology is unknown 5) Glossopharyngeal neuralgia • episodic, severe, stabbing, recurrent pains in the distribution of the glossopharyngeal nerve • pain may radiate to the external auditory meatus or to the neck • nerve roots의 vascular impingement가 주된 원인으로 생각됨 6) Superior laryngeal neuralgia • sudden, brief, recurrent, lancinating pain in the throat and laryngeal area • deep ear, angle of the jaw에서 느껴짐 • yawning, coughing, swallowing, gargling에 의해 유발되기도 함 • glossopharyngeal neuralgia와 임상 증상이 유사하여 감별이 어렵다 • superior laryngeal n.의 local block이 진단에 유용하다

11. 7) Hypoglossal/Vagus neuralgia • paroxysmal unilateral pain affecting the angle of the jaw, thyroid cartilage, piriform sinus, and posterior aspect of the tongue (rare conditions) • glossopharyngeal neuralgia, carotidynia와 감별이 어렵다 8) Tolosa-Hunt syndrome • episodic unilateral pain in the ocular area associated with ipsilateral paresis of oculomotor nerves and the first branch of the trigeminal nerve • 40대 성인에 주로 발생 9) SUNCT syndrome • SUNCT (short-lasting, unilateral, neuralgiform pain with conjunctival injection and tearing) • idiopathic condition • 50대 성인에서 보임 • unilateral pain episode는 2분 이하로 지속되며 orbit나 periorbital area에 나타남 • rhinorrhea, lacrimation, conjunctival irritation이 특징적

12. 2. Non-neuropathic orofacial pain 1) Extraoral pain A. Temporomandibular disorder • collective term - clinical complaints involving the muscle of mastication, the temporomandibular joint (TMJ), and/or associated orofacial structures • most common source of complaint is not the TMJ but the muscles of mastication B. Temporomandibular intracapsular joint disorders • temporomandibular joints의 functional disorders와 관련된 sign이 주된 finding이다 • do not produce painful symptoms • 3가지로 분류됨 : derangements of the condyle-disc complex, structural incompatibility of the articular surface, and inflammatory joint disorders

13. C. Masticatory muscle disorders • most common temporomandibular disorder complaint of patients seeking treatment in the dental office D. Carotidynia • unilateral continuous aching or throbbing pain, usually starting in the ipsilateral anterior neck • pathology is unknown • carotid a의 tenderness(특히 bifurcation 주위)가 가장 흔한 특징 E. Sinusitis • continuous aching or throbbing pain in the infraorbital, temporal, frontal, ear, upper molar, and/or premolar region due to inflammation of the sinuses • early stage에서 pain은 unilateral, 반대편 sinuses로 침범하면서 통증 생김 • purulent discharge from the sinus ostia and radiographic opacity in ipsilateral and/or bilateral sinuses are observed -> 진단 내릴 수 있음

14. 2) Intraoral pain A. Glossodynia, atypical odontalgia, and burning mouth syndrome • not condition but syndromes • 다른 가능한 원인을 R/O 한 후에 진단 • 40대 이후에 발병 • continuous sore, throbbing, or burning pain in the tongue, teeth, periodontal tissues, or whole mouth • pain의 강도는 moderate • no pathology or distinct somatosensory anomaly • often have a psychosomatic aspect B. Cracked tooth syndrome • This pain results from an incomplete (cracked tooth) or a complete tooth fracture (split tooth) • cracked tooth induces dental pulp sensitization and pulpitis, and deep periodontal pockets can give rise to severe pain

15. 3. Treatment considerations with emphasis on trigeminal neuralgia 1) Conservative management : pharmacotherapeutic options A. Carbamazepine • tricyclic imipramine • trigeminal neuralgia의 management에 drug of choice • 하지만 약간의 side effect를 가지고 있기 때문에 저 용량으로 사용해야 함 • carbamazepine으로 치료받는 환자의 20%가 side effect를 경험 • dizziness, diplopia, nausea 등이 흔한 부작용 • hematologic (anemia, thrombocytopenia, and agranulocytosis)의 심한 부작용도 생길 수 있음 B. Oxcarbazepine • partial seizure에 사용되는 약물 • carbamazepine과 마찬가지로 trigeminal neuralgia 같은 neuropathic pain의 치료에 효과적 • 정확한 기전은 밝혀지지 않음 • drug plasma level과 hematologic profile을 monitoring 하지 않아도 되는 장점이 있음 • 심한 부작용이 없음

16. C. Gabapentin • anticonvulsant agent • no direct GABA-mimetic action, exact mechanism of action is yet unknown • 위험한 부작용이 적다 • 몸에서 대사되지 않음 • blood level monitoring이 필요 없음 • 가장 흔한 S/E는 sleepiness, dizziness, and ataxia D. Baclofen • skeletal m relaxant that is also structurally related to GABA • effective adjuvant for management of trigeminal neuralgia • ataxia, lethargy, and nausea 같은 S/E를 피하기 위해 gradual dosing이 추천됨 E. Clonazepam • benzodiazepine • effective in myoclonic epileptic states • carbamazepine therapy에 반응하지 않는 trigeminal neuralgia에 효과적 • 하지만 통증의 경감 정도가 충분하지 않다 • S/E - somnolence, ataxia, fatique

17. 2) Role of psychology 3) Role of acupuncture 4) Surgical management • medical treatment가 효과가 없을 때 • gangliolysis, microvascular decompression