Clinical Diagnosis of Headache and Facial Pain The clinical diagnosis of headache and facial pain depends on characterization of the mode of onset of pain (▶ Fig. 19.1). For example, an acute, recent onset is usually related to an emergency, whereas episodic pain, with pain-free intervals between attacks, is usually related to a benign, primary headache or facial pain disorder. Progressive, permanent pain over a few days or a few weeks is usually related to an intracranial space-occupying lesion. A long-standing, chronic headache is usually related to a benign process. Fig. 19.1 Diagnosis of headache and facial pain. CSF, cerebrospinal fluid. The following characteristics of the pain guide further evaluation: Location of pain (diffuse, hemicrania, periorbital, occipital, or cervical) Side of pain (unilateral, alternating, or bilateral) Type of pain (dull, constant, or throbbing) Duration of pain (without treatment) Severity of pain (using a scale from 1 to 10, particularly considering its impact on activities) Frequency of episodes (per day, week, or month) Temporal profile (age of onset, recent worsening, and progressive) Precipitating factors Prodromes (i.e., early symptoms preceding onset) Associated symptoms and signs (nausea, vomiting, photophobia, tearing, ocular redness, visual loss, Horner syndrome, diplopia, and sleep apnea) Treatments tried and their efficacy Clinical evaluation should include a detailed neurologic examination, including cranial nerve examination; a funduscopic examination looking for disc edema, which would reveal papilledema from raised intracranial pressure, and spontaneous venous pulsations, which would suggest normal intracranial pressure; palpation of the temporal arteries (for patients > age 50); blood pressure and temperature; and a general physical examination. In most cases, the cause of headache or facial pain is identified at this point. The International Headache Society (IHS) has proposed a classification of headaches according to their underlying mechanisms. It is important to recognize the primary headaches or facial pain (usually benign disorders) and differentiate them from the secondary headaches and facial pain, which reveal an underlying disease. Further investigations are obtained when a secondary cause of pain is suspected (▶ Fig. 19.2). Fig. 19.2 Evaluation of the patient with acute head or facial pain. All patients with headaches need an examination of the ocular fundus to look for disc edema (this is part of the clinical examination and is not included in the ancillary tests). *The type of brain imaging obtained urgently varies based on local resources and protocols. CBC, complete blood count; CRP, C-reactive protein; CSF, cerebrospinal fluid; CT, computed tomography; CTA, computed tomographic angiography; ESR, erythrocyte sedimentation rate; MRA, magnetic resonance angiography; MRI, magnetic resonance imaging; MRV, magnetic resonance venography. Pearls Blood pressure should be checked in all headache patients (acute or chronic). Examination of the ocular fundus is required in all patients presenting with chronic or new-onset headaches. The presence of optic nerve head edema suggests raised intracranial pressure. Giant cell arteritis should be considered in all patients > age 50 who present with any type of headache or facial pain. Intraocular pressure and detailed ocular examination need to be performed in patients with recurrent, unilateral pain localized around the eye. The following classification is adapted from the Headache Classification Subcommittee of the International Headache Society. International Classification of Headache Disorders, 3rd ed. (ICHD-III). Cephalalgia 2013;33(9):629–808. In each subgroup, we have detailed only disorders that may present with neuro-ophthalmic symptoms and signs. Primary headaches Migraine Migraine with visual aura Tension-type headache and new daily persistent headache Cluster headache and other trigeminal autonomic cephalalgias Cluster headache (episodic and chronic) Paroxysmal hemicrania (episodic and chronic) Short-lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT) Other primary headaches Hemicrania continua Secondary headaches Headaches attributed to head and/or neck trauma Headaches attributed to cranial or cervical vascular disorders Ischemic and hemorrhagic strokes Unruptured and ruptured vascular malformations (aneurysm, arteriovenous malformation, dural arteriovenous fistula, cavernous angioma, Sturge–Weber syndrome) Giant cell arteritis Central nervous system vasculitis Carotid or vertebral artery dissection Reversible vasoconstriction syndrome Cerebral venous thrombosis Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) Mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes (MELAS) Pituitary apoplexy Headaches attributed to nonvascular intracranial disorders High cerebrospinal fluid (CSF) pressure Low CSF pressure Meningeal processes Intracranial neoplasms Chiari malformation Headaches attributed to a substance or its withdrawal Headaches attributed to infection Meningitis, encephalitis, intracranial abscess Headaches attributed to disorders of homeostasis Hypoxia High altitude Sleep apnea Dialysis Arterial hypertension Hypoglycemia Headaches or facial pain attributed to disorders of the cranium, neck, eyes, ears, nose, sinuses, teeth, mouth, or other facial or cranial structures Acute glaucoma Refractive errors Heterophoria or heterotropia Ocular inflammatory disorders (uveitis, scleritis, orbital inflammation, optic neuritis) Headaches attributed to psychiatric disorder Cranial neuralgias, central and primary facial pain, other headaches Cranial neuralgias and central causes of facial pain Trigeminal neuralgia (classic, symptomatic) Nasociliary neuralgia Supraorbital neuralgia Optic neuritis Herpes zoster Other headaches, cranial neuralgia, central or primary facial pain
19.1.1 Other Characteristics of the Pain
19.2 Clinical Evaluation of the Patient with Headache/Facial Pain
19.3 Classification of Headache and Facial Pain
Ento Key
Fastest Otolaryngology & Ophthalmology Insight Engine
