David S. Klein, M.D.
Headache and Facial Pain
Essential to the successful treatment of headache is the establishment of an accurate diagnosis. Without an accurate diagnosis, treatment is destined to be incomplete in the best of circumstances, and it is destined to be a failure in the worst of circumstances.
Pain is one of the most common complaints that brings a patient to the attention of the physician, and headache is one of the most common complaints. In order to better understand the treatment of the symptom of pain, it is best to understand the disease process that is causing the pain.
The most common causes of headache can be broken down, as follows:
- Neuralgia: Pain due to nerve pathology or irritation.
- Vascular causes and Migraine: Pain due to pathological changes in the blood vessels of the head, face, neck and brain.
- Sinus: Pain due to inflamation, pressure and infection of the hollow, air filled portions of the skull, known as (calvarial) sinuses.
- Enthesopathic: Pain due to inflammation, irritation or traction on points of fibromuscular attachment.
- Tumor: Pain due to pressure, or traction on the membrances surrounding the brain, meninges (membranes that enclose the brain), bone, and other structures.
Each of these areas will be discussed separately.
I. Trigeminal Neuralgia (TN) is probably the most common cause of perimenstrual headache, chronic sinusitis headache, and pain due to "TMD." Trigeminal neuralgia is clearly the most commonly missed diagnosis in patients that suffer from headache and facial pain.
The Trigeminal Nerve, also known as the 'Fifth Cranial Nerve, CN-V' has three main divisions, each of which divide in a very predictable way. The pain that results from most cases of TN involves irritation and/or compression of these terminal divisions and branches as they pass through muscular and tendinous tunnels in the skull and face.
The Trigeminal Nerve is known as a 'sensory nerve,' in that it carries few, if any somatic muscular nerve bundles. It is also well known but often forgotten that the CN-V also consists of a large number of autonomic nerve bundles. It is damage to the autonomics that causes most of the symptoms and pain.
Treatment of TN is best accomplished with a combination of oral anti-convulsants used in combination. Oral baclofen and clonazepam is very useful and inexpensive. Oral gabapentin (Neurontin) is not that effective, but it can be expensive. Topical gabapentin combined with ketoprofen seems to be the most effective, but it needs to be custom compounded by a pharmacist familiar with this preparation.
NOTE: The DVD on head and neck pain goes into detail as to the diagnosis and treatment of this disorder.
II. Migraine:
The term 'migraine' has come to imply a headache of of a severe or incapacitating nature. In fact, migraine does not imply severity, at all. Migraine Headache results from a predictable biochemical reaction that results in contraction and vasodilitation of the blood vessels that pass through the membranes that surround the brain.
Treatment of migraine is directed at controlling the muscles that form the arterial wall, either preventing the initial contraction, or dealing with the subsequent over-relaxation and inflammation.
Not all medications or medication combinations work for all patients, and medications may work for some headaches, but not all in individual patients. The most interesting class of medications for true migraine are known as 'tryptans.'
More to come......
David S. Klein, MD, FACA, FACPM, FACMIMS
Director, Pain Center of Orlando
www.suffernomore.com