Headaches – Oral Medicine Pacific

Headaches and Dental Providers:

Patients may present to dental providers with complaints of facial pain that may be associated with headache. Facial pain may progress to headache and contribute to the overall pain experience. TMD is a common cause of pain and can progress to headache, often in the temporal region. When TMD is associated with cervical pain, headache pain can be more complex. Myofascial pain can be associated with broader pain complaints and may be associated with tension type headaches, refer pain to the ears. Various vascular pain can present in the face and be associated with broader vascular pain complaints. It is important for the dental provider to be aware of various forms of headache, and when facial pain including associated with TMD may occur. Oral Medicine and orofacial pain providers are familiar with the forms of headache and can provide support for patient care with combined facial pain and headaches. This report briefly reviews the major classifications of headache.

Migraine

Migraine is typically described as a unilateral headache with pulsating quality of moderate to severe intensity. It is often aggravated by physical activity. It is associated with nausea, vomiting, photophobia and phonophobia.

The International Headache Society defines migraine as an “idiopathic, recurring headache disorder manifesting as attacks lasting 4 – 72 hours”.

The diagnostic feature of migraine with aura is a complex of symptoms which gradually develop over 5 – 20 minutes and usually last less than 60 minutes. The prodrome symptoms include scotomata (blind spots), teichopsia (fortification spectra), photopsia (flashing lights), and visual or auditory hallucinations.

A large majority of people with migraine have a positive family history of migraine headaches. A large majority of migraine sufferers are female.

Headache onset tends to be in the adolescence years to the twenties. Migraine tends to diminish in the fifth and sixth decades.

Headache triggers can include stress, fatigue, lack of sleep and excess sleep, fasting or missing a meal, vasoactive substances in foods, caffeine, alcohol, menses, changes in barometric pressure, changers in altitude.

Medications that can precipitate a migraine include reserpine, nitrates, indomethacin, oral contraceptives, post menopausal hormones.

Personality features are a topic of debate and include perfectionism, rigidity, and compuliveness. Migraineurs tend to build situations too difficult to handle.

Types of migraine include migraine with aura, migraine without aura, status migraine, menstrual migraine, migraine equivalents and complicated migraine.

Over-the-counter analgesics and nonsteroidal anti-inflammatories are often the first line treatment. Mixed analgesics containing barbiturates or narcotic preparations are also used frequently. Migraine specific medications such as triptans in tablet, nasal and intramuscular formulations are the latest medications for symptomatic treatment. Preventive treatment includes medications taken daily to decrease the severity and frequency of the headache attack. These medications include beta blockers, calcium channel blockers, antidepressants, anticonvulsants, ergot derivatives and nonsteroidal anti-inflammatories.

Tension Type Headache

The International Headache Society defines tension type headache as recurrent episodic headaches lasting minutes to days. The pain is usually a pressure or tightening sensation of mild to moderate intensity on both sides of the head. There tend to be no associated symptoms with the headache and there is no exacerbation with physical activity.

Tension Type Headaches are described as either episodic (occurring less than 15 episodes per month) or chronic (occurring 15 episodes or greater per month).

The tension type headaches are dominant in females and can occur at any age, but typically between the age of 20 – 40 years. A family history of headache may be noted.

The pain is often described as steady and nonpulsating, bitemporal or bioccipital tightness. People will describe either a bandlike sensation, viselike ache, a weight, pressure sensation, drawing or soreness. The site of the headache is usually the forehead, temples, back of the head or neck.

Cluster Headaches

Cluster has been known by several different names including Horton’s Headache, ciliary or migrainous neuralgia, histaminic cephalalgia, Vidian and Sluder’s Neuralgia. The International Headache Society defines Cluster as “attacks of severe, strictly unilateral pain, orbital, supraorbital and / or temporally, lasting 15 – 180 minutes and occurring from once every other day to 8 times per day.

Episodic Cluster consists of headaches occurring in periods of 7 days to 1 year, divided by pain-free periods of 14 days or more.

Chronic Cluster consists of attacks of mare than 1 year without remission or remission less than 14 days.

The associated symptoms include conjunctival injection, lacrimation, nasal congestion, rhinnorhea, sweating and facial flushing on the ipsilateral side, partial Horner’s Syndrome.

The pain of Cluster Headache is noted for its severity. It is often described as throbbing, pulsating, severe or constant. Patients will depict the pain as sharp, stabbing or knife-like into the eye. People desire to be upright and moving during an attack in contrast to migraineurs who prefer rest and quiet.

The name is derived from the cluster periods in the spring and the fall. During a cluster period, alcohol will trigger an attack. Patients are often awoken at night from cluster headaches. Cluster, as opposed to migraine, is a primarily male disorder. The onset is usually between the age of 20 – 40 years.

Treatment may include oxygen inhalation, dihydroergotmaine, triptans, sphenopalatine blockade, intranasal lidocaine or capsaicin, indomethacin or opioids. Preventive treatment may include calcium channel bockers, steroids, lithium, ergotamine derivatives, divalproex sodium, neuroloeptics and occasionally opioids

Chronic Paroxysmal Hemicrania

The International headache Society defines Chronic Paroxysmal Hemicrania as a “frequent, short-lasting attacks of unilateral pain, usually in the orbital, supraorbital or temporal region that last from 2 – 45 minutes”.

Characteristic frequency is 5 or more attacks per day with a range of 1 – 40 per day.

The pain is associated with autonomic symptoms such as conjunctival injection, lacrimation, nasal congestion, rhinorhea, ptosis or eyelid edema.

Chronic paroxysmal hemicrania tends to be more common among females than males. The age of onset is in the twenties.

The pain is usually unilateral over the ophthalmic distribution of the Trigeminal nerve, but has been reported in the occipital region. Pain is excruciating, may be throbbing. People with CPH tend to be still and quiet. Episodic Paroxysmal Hemicrania is responsive to indomethacin. Long-term therapy may require gastrointestinal protection.

Hypnic Headache

HH is a rare headache associated with men and women after age 60. The attacks are generally bilateral, throbbing pain and associated 2-4 hours after sleep. It is usually a short lasting pain of 15 minutes to 3 hours. There tends to be an absence of autonomic features. The similarities to Cluster Headache have suggested a relationship to Cluster, but thus far none has been proven. The nocturnal association and possible disturbances to the biological clock have implicated serotonin in this headache as well. Response has been found with lithium as well as caffeine and indomethacin.

SUNCT

SUNCT is short for short-lasting, unilateral, neuralgiform headache with conjunctival injection and tearing. It is noted by its short attack duration of 30 – 60 seconds, autonomic features, cyclical pattern and males more prevalent than females. There is no effective treatment noted for SUNCT so far.

Trigeminal Neuralgia

Trigeminal neuralgia is classically defined as a sharp and shooting electric-type pain in one or more divisions of the trigeminal nerve. The pain tends tobe unilateral, but can be bilateral in some 3-5% of patients. Age of onset tends to be after 50 years of age. Multiple sclerosis should be suspected in those younger than 50 years. The intense attacks tend to occur for a few seconds although patients often describe a dull achein between attacks. Usually non-painful stimuli or triggers such as brushing the teeth, chewing, talking, shaving or a cold breeze to the face can often initiate the pain response. Cranial nerve assessment is usually normal. Atypical response to light touch or pin prick could suggest a compressive lesion involving the trigeminal nerve.

Medications used in the treatment of trigeminal neuralgia include carbamazepine, oxcarbazepine, phenytoin, baclofen, divalproex sodium, gabapentin, clonazepam, pimozide, topiramate and lamotrigine

Surgical treatment includes vascular decompression, gamma knife radiosurgery, rhizotomy, glycerol injection. Recurrence is still common with surgical intervention.

Glossopharyngeal Neuralgia

GN is also a unilateral pain around the jaw, throat, ear, larynx or tongue. The shrp paroxysmal pain can last up to 1 minute and refer from the oral pharynx to the ear. Deep and continuous pain may last between the sharp attacks of pain. GN is less common than TN. Diagnosis is usually by history and eliminating other disease.

Medication management is similar to that of Trigeminal Neuralgia. Surgical intervention involves sectioning of the glossopharyngeal and vagal upper rootlets.

Facial Pain of Unknown Cause (aka Atypical Facial Pain)

The term atypical facial pain is often used, but poorly defined and even more poorly treated. Many have suggested a better descriptor be facial pain of unknown origin. Clinically, a unilateral and sometimes bilateral pain or discomfort in the areas of the cheeks, eyes, temples, gums, nose, or jaw can be described as atypical facial pain. Some would argue that this is too wide an area to be under one diagnostic umbrella. A thorough pain history and examination may enlighten the clinician as to other causes to the chief complaint. Facial pain of unknown origin should be left as a category of last resort and not as a classifiable diagnostic entity.

While these forms of headache may occur alone, they may be part of a more complex pattern, including facial pain, which may contribute to the overall pain complaints. In addition, vascular pain may present as facial symptoms, complicating the diagnosis. Diagnosis will allow selection of specific treatment and prophylactic management.