3Headaches

Age
Sex
Prevalence

Etiology
Pathogenesis
Triggers

Clinical Features/
Diagnosis

Migraine

F>M
More in
poor
People with
European
descent

Genetic
Trigeminal activation
neurogenic inflammation
increased vasodilation and
permeability of terminal
branches of ECA (occipital
and superficial temporal
branches)

Diagnosis
o 5 attacks
o Each attack lasts 4 hr-3 days
o Unilateral pain
o Pulsatile
o Moderate-severe
o Aggravated exercise
o Nausea/vomiting
o Sensitivity to light or sound

Management

Prognosis/
Complications

Symptomatic tmt (<2 attacks/week)

o Serotonin agonists (triptans)
o Dihydroergotamine
o APAP
o NSAIDs
ASA
Ibuprofen
Naproxen
o Caffeine
o Butorphanol (nasal spray)
Preventative tmt (>2 attacks/week)
o B-blockers
o CCB (verapamil, nifedipine)
o TCA
o Anticonvulsants
Carbamazepine
Phenytoin
valproate

Symptomatic tmt:
o Oxygen stops pain
o Ergotamine, DHE
o Serotonin Agonists
Sumatriptan
Preventative tmt:
o Verapamil
o Lithium
o Valproate
o Capsaicin
o Lidocaine topical

Complications
o Stroke (when migraine
lasts >1 week)
o Seizures
o Persistent aura

VASCULAR HEADACHES

Chronic Migraine
Status migrainosus
Clusted HA

>40y/o
Males

Chronic
Paroxysmal
Hemicrania

F>M

Tension Type
Heachace

F>M

Hypothalamus abnormality
o Diminishes carotid
chemoreceptor activity
o Pain caused by dilation of
blood vessels which creates
pressure on trigeminal nerve
Tobbaco may trigger CHA
(nicotine)

Hypothalamus abnormality

>15days/month for 3 months

Lasts for more than 3 days
Severe, throbbing pain
Unilateral
Supraorbital, temporal location
1 hour duration
Several attacks per day
Patient will awaken 1 hour after falling
asleep with pain
Patients pace back and forth
Short tempered during attack
Parasympathetic signs: nasal congestion,
miosis, lacrimation, sweating
Stabbing, icepick sensation
Eye, tooth, TMJ
Short duration (sec min)
Several attacks per day
30min 1 week duration
Bilateral
Pressure/tightening, dull, band-like (nonpulsating)
Mild/moderate pain
Alleviated by exercise
NO nausea/vomiting

Indomethacin 100% effective

Symptomatic tmt
o NSAIDS
o Caffeine
Preventive tmt
o B-blockers (propranolol, atenolol)
o TCAs (amitriptyline)
o Some antidepressants can trigger
TTH
o Behavioral

o Exercise
o Relaxation

< 1 day/month

Occurs in people who are

taking meds for a long time
Triggered by discontinuation
of:
o NSAIDs
o Narcotics
o Tranquilizers
o Migraine meds

Severe HA
Nausea/Vomiting
Vertigo (dizziness)
Depression

Infrequent TTH

Frequent TTH
Chronic TTH
New Daily
Headache

1-15 days/month for at least 3 months

>15 days/month for at least 3 months
Frequent episodic TTH, but
Persists for more than 3 days without
remission
Sudden onset w/o specific cause or trigger

Combat related
Rebound
Headaches

Cervicogenic HA

EPISODIC NEUROPATHIC PAIN

Unilateral pain
Initiated by touch of trigger zone
Shock-like, electrical or burning.
Seconds to mins
Mild to severe
2nd and 3rd divisions most often involved

Trigeminal
Neuralgia

>60y
2:1 F

Compression of trigeminal n.
by vessel or tumor
o Acoustic neuroma
o Cholesteotoma
o Meningioma
Demyelinization (MS can
cause TN)
Idiopathic

Glossopharyngeal
Neuralgia

100X less
prevalent
than TN

Same as TN

Unilateral pain
Face, throat, ear, base of tongue, tonsils or
beneath angle of mandible, TMJ
Trigger: swallowing, chewing, talking,
yawning
Brief episodes
Shock-like/electrical

Abruptly discontinue meds

Preventive tmt at the time of medication
discontinuation:
o TCAs
o SSRIs
o Anticonvulsants (gabapentin,
tompriamate)
o B-blockers
Prednisone
Antiemetics (metoclopramide)
Naproxen
Dihydroergotamine
Behavioral tmt
Exercise

1st line of tmt - medications.

o Anticonvulsants
Clonazepam
Carbamazepine
Dilantin/phenytoin
Gabapentin
Topiramate
o TCA
o Baclofen
2nd line of tmt surgery
o Radiofrequency gangliolysis
o Glycerol chemoneurolysis
o Microvascular decompression
o Rhizotomy
o neuroectomy
Same as TN

Reoccurences/remissions

Post-herpetic
Neuralgia

Elderly

Pain secondary to herpes

zoster infection of a nerve
distribution

Nervus
Intermedius
Neuralgia

Associated with HZ

Superior
laryngeal
neuralgia

Complex regional
pain syndrome/
Causalgia

Sympathetic NS is causing
pain
Trauma, surgery, infection
Aggravated by stress, visual
and auditory stimuli

Atypical
periodontal
neuralgia
Burning mouth
syndrome

Rapid control of HZ infection

Antivirals decrease pain in acute stage,
but not risk of neuralgia
Corticosteroids
TCA
o amitryptiline
Anti-convulsants
o Gabapentin
o carbamazepine

Idiopathic
C-fiber degeneration in oral

Pain or burning from oral tissues

o Tip and sides of tongue

Clonazepam
Alpha-lipoic acid

Atypical Facial
Pain
Atypical
Odontolgia
(Phantom tooth
syndrome,
persistent
idiopathic
orofacial pain)

Unilateral
Severe continuous burning/stabbing pain
o Allodynia, hyperalgesia
Pain develops during the acute phase of HZ
and persists for more than 3 months after
herpetic eruption (may persist for daysyears)
Nerves: facial, auditory, trigeminal
o 15% trigeminal
o 80% V1
Hearing loss, loss of taste, facial weakness
Deep ear pain
Brief duration (secs-mins)
Disturbed lacrimation, salivation, taste
Trigger in posterior wall of auditory canal
Pain in throat, submandibular region, ear
Triggered by swallowing, turning head,
straining voice
Trigger zone on lateral neck
Extremities, face
Autonomic dysfunction:
o Acute: hot, perspiration, edema
o Chronic: cold, pale, cyanotic
Motor dysfunction:
o Weakness
o Tremor
Sensory dysfunction:
o Allodynia
o Hyperalgesia
o Burning
Trophic dysfunction:
o Acute: hair and nail growth
o Chronic: decreased hair and nail growth
CONTINUOUS NEUROPATHIC PAIN

Diagnosis:
o Rule out all other possible conditions
Constant, persistent pain
Varies in intensity
Diagnosis:
o After ruling out local dental diseases

>40y
3:1 F

After dental procedure or

trauma pain doesnt resolve
o RCT
o Crown prep
o Extraction
o Cleaning

Same as TN

Same as TN
Nerve block with lidocaine

Alpha 1 and alpha 2 agonist

o Clonidine
o Phentolamine

Topical agents
o Capsaicin
o anesthetic
TCA (amitriptyline)
Anticonvulsants (gabapentin)

1/3 pain resolves in 1-2

years
1/3 pain decreases, but
continues
1/3 pain continues at
same level

Smilar to Atypical
odontologia

tissues

o Palate
o Lips
Tongue appearance is normal
Diagnosis:
o Rule out local causes
o Candida
o Tongue parafunction (crenation)
o Xerostomia
o Nutritional deficiencies (pernicious
anemia)
o

TCA
Maxillary acrylic stents to cover palate