1. THE PATIENT WITH HEAD,
OCULAR, OR FACIAL PAIN

2. EVALUATION OF
HEADACHE
• HISTORY
– Nature of the headache
– Daily pattern of hedache
– Location
– Associated symptoms
– Precipitating or alleviating factors
– Overall pattern
– Family history

3. • VAST MAJORITY OF PATIENTS WITH
HEADACHE HAVE NORMAL VISUAL ACUITY
• PE:
• BP, Pulse
• Meningeal signs
• Symmetry of cranial nerve and motor functions

4. TYPES OF HEADACHE
• PRIMARY
– Migraine
– Tension- type
– Cluster
• SECONDARY

5. NEUROIMAGING?
• Sudden onset of severe headache
• Unexplained change in headache pattern
• Unresponsive to medical therapies
• HA related to physical exertion or change in body position
• New onset of headache after the age of 50 years
• New headaches in immunosuppressed patients
• (+) focal neurologic signs
• (+) fever, neck stiffness, change in mental status, behavioral
changes

6. MIGRAINE
• Condition consisting of repetitive bouts of
headache
• F>M
• (+) familial tendency
• (+) history of motion sickness in childhood
• Onset- puberty or young adulthood
• Decrease after menopause

7. Characteristic:
• unilaterality, pulsating, N/V, photophobia,
aggravated by physical activities
Exacerbated by:
• menstruation, pregnancy, hunger, stress,
certain foods and sleep deprivation

8. I. Migraine with aura
• Classic migraine
• 30%
• Visual aura: begins w/ a small scotoma
near fixation that gradually expands,
then breaks up
• < 45 minutes
• Followed by HA on the contralateral side
of the head
• Untreated: 4 to 72 hrs

10. II. Migraine without aura
• Common migraine
• 65%
• No preceding neurologic symtoms
• Global
• Can last hours to days

11. III. Migraine aura w/o
Headache
• Acephalgic migraine
• 5%
• Visual aura:
• Scintillating scotoma, transient
homonymous hemianopia, peripheral VF
constriction, transient monocular visual
loss, episodic diplopia ( vertical)

13. EVALUATION
• Headache or aura always occur on the same
side
• Headache precedes the aura
• Neurologic deficit, persists after aura resolves
• Features of aura are atypical

14. Tension -type headache
• Chronic
• Aching
• Worse at the end of day
• Precipitated by stress
• Associated with depression

15. TREATMENT
• Reassurance
• Avoid precipitating factors:
• Chocolates, nitrates, MSG, cheese,
caffeine, red wine, alcohol, nuts,
shellfish
• OCPs
• Stress, change in sleep patterns,
strong scents such as perfume,
cigarette smoke and exercise

16. • Acute relief: dihydroergotamine, sertonergic
agents, NSAIDS
• * analgesic rebound headache
• Prophylactic treatment:
• Disrupted functions of daily life
• Beta blockers, Ca channel blockers, TCA, SSRIs,
sodium valproate, NSAIDS

17. CLUSTER HEADCHE
• Men
• 30’s to 40’s
• Cigarette smokers
• Pain localized behind 1 eye
• Tearing, conjunctival injection,
rhinorrhea
• < 2 hrs

18. • Difficult to treat
• Inhaled oxygen, methysergide, subcutaneous
sumatriptan or dihydroergotamine
• Prednisone tapered for 10- 14 days
• Verapamil- prophylaxis

19. OCULAR AND ORBITAL
CAUES OF PAIN
• Refractive errors and starbismus
• KS, Keratitis, AACG, intraocular
inflammation
• Recurrent erosion syndrome
• Scleritis
• Optic neuritis

20. PHOTOPHOBIA
• Keratitis
• Uveitis
• Chorioretinitis
• Menigeal irritation
• migraine

21. FACIAL PAIN
• Most often, pain in the eye area is a
manifestation of headache
• Dental disorders, sinus disease

22. 1. Trigeminal neuralgia
• Tic douloureux
• Caused by vascular compression of CN V
• Demyelinating dse, posterior fossa mass lesion
• Unilateral
• chewing , tooth brushing, cold wind
• Normal sensory function
• MRI
• Treatment:
• gabapentin, carbamezepine, phenytoin, baclfen,
clonazepam, valproic acid
• Rhizotomy, decompression of CN V

23. 1. Trigeminal neuralgia
• Tic douloureux
• Caused by vascular compression of CN V
• Demyelinating dse, posterior fossa mass lesion
• Unilateral
• chewing , tooth brushing, cold wind
• Normal sensory function
• MRI
• Treatment:
• gabapentin, carbamezepine, phenytoin, baclfen,
clonazepam, valproic acid
• Rhizotomy, decompression of CN V

24. • 2. Glossopharyngeal neuralgia
• 3. Carotidynia- neck pain that radiates to
ipsilateral face and ear
• 4. Carotid dissection- (+) sympathetic
dysfunction
• 5. Temporomandibular disease

25. 6. HZO-
• pain before vesicle eruption
• Gabapentin, TCA, lidocaine patch
7. Neoplastic process
8. Mental nerve neuropathy- numb chin
• Saroidosis, lymphoma, mets breast Ca

27. Thank you