Approach to headache or facial pain: Clinical sciences

Headache and facial pain are common presentations that can occur due to various benign and concerning conditions. Primary headaches, which are not caused by other conditions, include tension-type headache, cluster headache, and migraine. On the flip side, secondary headaches are a presentation of an underlying condition, such as giant cell arteritis, infectious meningitis, and subarachnoid hemorrhage.

Now, if your patient presents with headache or facial pain, first perform an ABCDE assessment to determine if they are stable or unstable. If unstable, stabilize their airway, breathing, and circulation. You might need to intubate your patient and provide mechanical ventilation. Next, obtain IV access, and put your patient on continuous vital signs monitoring and cardiac telemetry. Finally, you might need to manage increased intracranial pressure.

Okay, let’s go back and talk about stable patients. In this case, obtain a focused history and physical examination, including a fundoscopic exam. First, let’s focus on facial pain, more specifically trigeminal neuralgia. These patients typically report recurrent, unilateral facial pain lasting a few seconds to minutes, often described as sharp pain or electric shock. The pain is usually precipitated by minor stimuli such as shaving, tooth brushing, or chewing.

The physical exam is usually normal, but sometimes, you might find a sensory loss in the face. Finally, if the fundoscopic exam is normal, diagnose trigeminal neuralgia.

Alright, now let’s focus on individuals presenting with headaches. Next to the headache, history might reveal visual disturbances, fever, nausea, and vomiting. On the exam, you might notice altered mental status or focal neurologic deficits. Finally, the fundoscopic exam could be normal, or it might show optic disc edema, also known as papilledema, which occurs due to increased intracranial pressure.

These findings are suggestive of headaches, so your next step is to assess for red flags using the SNNOOP10 criteria.

These include Systemic symptoms, such as fever; Neoplasm; Neurologic deficits; sudden Onset of headache; and Older age, greater than 50.

The ten Ps include Pattern change in headache; Positional headache, meaning that the quality changes depending on the patient’s position, such as standing versus laying down; headaches Precipitated by activities that increase intracranial pressure, such as sneezing or coughing; Papilledema; Progressive headache; Pregnancy; Painful eye; Posttraumatic headache; Pathology of the immune system such as HIV; and Painkiller overuse.

If red flags are absent, consider primary headache and ask about the laterality of headaches. If the headache is bilateral, consider a tension-type headache, so assess the criteria for tension-type headaches.

These headaches can last minutes to days and must meet at least two of the following four characteristics.

First, these headaches are associated with a pressing or tightening sensation. Sometimes, your patient will describe this feeling as having a non-pulsating band of pressure around the head.

Next, headaches should be bilateral and mild to moderate in intensity, but they should not worsen by routine physical activity, such as walking. Finally, tension type headaches are usually not associated with nausea, vomiting, photophobia, or phonophobia. However, some patients might present with either photophobia or phonophobia, not both. If your patient meets these criteria, diagnose tension-type headaches.

On the flip side, if the headache is unilateral, consider cluster headaches or migraine. Next, assess whether the headache is associated with either restlessness or ipsilateral autonomic features, such as lacrimation and rhinorrhea. If either of those characteristics is present, suspect cluster headaches and assess the criteria. The patient should describe headaches as severe, unilateral pain in the orbital, supraorbital, or temporal region that typically lasts 15 minutes to 3 hours. These headaches are frequent and occur at least every other day, sometimes multiple times a day.

As mentioned, they should be associated with restlessness or agitation and/or ipsilateral autonomic features, including conjunctival injection or lacrimation; nasal congestion or rhinorrhea; eyelid edema; forehead and facial sweating; and miosis or ptosis. If the patient meets these criteria, diagnose cluster headache.

Now, let’s go back and look at individuals reporting no restlessness or ipsilateral autonomic features. In this case, suspect migraine headaches and assess whether your patient meets the criteria for migraines. Migraines last hours to days and have at least two of the following four features: unilateral in location; pulsating quality; moderate to severe pain intensity; and they are worsened by, or cause avoidance of, routine physical activity such as walking. Finally, in contrast to tension-type headaches, migraines are associated with nausea, vomiting, photophobia, and phonophobia. If your patient meets the criteria, diagnose migraines.

Alright, let’s go back and take a look at individuals who are presenting with red flags. In this case, consider a secondary headache, and obtain a head CT. If the CT is normal, consider conditions like giant cell arteritis, meningitis, medication overuse headache, and idiopathic intracranial hypertension.

First, let’s discuss giant cell arteritis, also known as temporal arteritis, which is typically seen in individuals 50 years of age and older. In addition to headache, history reveals pain over the scalp or temple, vision loss, and pain with chewing, which is known as jaw claudication. Additionally, there might be a history of polymyalgia rheumatica.

The exam might show tenderness to palpation along the course of the temporal artery in front of the ear and the side of the head.

Finally, if the fundoscopic exam shows optic disc swelling and pallor, consider giant cell arteritis.

Next, obtain labs, including erythrocyte sedimentation rate (ESR) and CRP; and a temporal artery biopsy. If the erythrocyte sedimentation rate and CRP are elevated and biopsy reveals transmural inflammation, multinucleated giant cells, and mononuclear infiltrates, diagnose giant cell arteritis.