Approach to headache or facial pain: Clinical sciences

Chapters:

Watch video only

Introduction 0:00–0:33

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 a headache or facial pain, first perform an ABCD E assessment to determine if they are stable or unstable, if unstable, stabilize their airway breathing and circulation.

Unstable Patient 0:33–1:04

You might need to intubate your patient and provide mechanical ventilation. Next, obtain IV access and put your patient on continuous vital sign monitoring and cardiac telemetry.
Finally, you might need to manage increased intracranial pressure. Ok.
Let's go back and talk about stable patients. In this case, obtain a focused history and physical examination including a funduscopic exam.

Trigeminal neuralgia 1:04–1:49

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, toothbrushing or chewing. The physical exam is usually normal, but sometimes you might find a sensory loss in the face.
Finally, if the funduscopic exam is normal, diagnose trigeminal neuralgia. All right.
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.

Headache 1:49–3:12

You might notice altered mental status or focal neurologic deficits. Finally, the funduscopic 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 snoop 10 criteria.
These include systemic symptoms such as fever, neoplasm, neurologic deficits, sudden onset of headache and older age greater than 50.
The 10 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.

Tension headache 3:12–4:15

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.

Cluster headache 4:15–5:19

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 three 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 meiosis 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.

Migraine 5:19–6:03

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 activities such as walking.
Finally, in contrast to tension type headaches, migraines are associated with nausea, vomiting, photophobia and photophobia.
If your patient meets the criteria, diagnose migraines. All right, let's go back and take a look at individuals who are presenting with red flags.

Secondary HA6:03–6:26

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.

Giant cell arteritis 6:26–7:32

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 on the side of the head.
Finally, if the funduscopic 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 the biopsy reveals transmural inflammation, multinucleated giant cells and mononuclear infiltrates diagnose giant cell arteritis.
Let's move on to infectious meningitis which is associated with headache fever and neck stiffness. History might also reveal nonspecific symptoms like nausea and vomiting but also sensitivity to light confusion and seizures.

Meningitis 7:32–8:35

The physical exam reveals signs of meningeal irritation, including nuchal rigidity and positive Brodzinski and Koenig signs.
Next, you might find altered mental status or focal neurologic deficits depending on whether there is increased intracranial pressure or not.
The funduscopic exam might show papilledema with these findings, consider infectious meningitis, obtain a CSF sample for basic labs culture and PCR if the CSF analysis reveals an elevated white blood cell count, elevated protein and a positive culture or PCR diagnose infectious meningitis.
Now, let's look at medication, overuse headaches. In this case, your patient will report worsening of preexisting headaches and chronic use of medications used to treat headaches including nsaids, acetaminophen, triptans and opioids.

Medication overuse headache 8:35–9:33

Patients usually report that the medications are becoming less effective, meaning they have to take more medicine to get any relief.
If the physical exam and fundoscopy are normal, consider a medication overuse headache and assess the criteria for diagnosis.
First, a person with a preexisting headache disorder is experiencing headaches at least 15 days per month. Second, there should be at least three months of regular overuse of one or more medications used to treat headaches.
If your patient meets these two criteria, diagnose medication, overuse headache, which usually resolves after reducing or stopping the overused medications.
Finally, let's focus on idiopathic intracranial hypertension which is typically seen in obese biological females of reproductive age.

Idiopathic intracranial hypertension 9:33–11:08

The patient reports headaches that are more severe with valsalva maneuvers such as sneezing or coughing. Additionally, they report episodes of visual disturbances such as transient vision loss or double vision.
In some cases, a patient might mention hearing pulsating sounds known as pulsatile tinnitus, which occurs due to turbulent blood flow and narrowed, transverse and sigmoid venous sinuses.
On the exam. You might find visual field loss, decreased visual acuity and abducens nerve palsy.
For example, in a case of unilateral abducence nerve palsy. When the patient tries to look straight ahead, the affected eye will drift medially toward the nose, causing double vision on lateral gaze towards the unaffected side.
The patient will adduct the affected eye normally toward the nose which improves their double vision. Finally, if the fundoscopy reveals papilledema, consider idiopathic intracranial hypertension.
So be sure to obtain a brain MRI and venography. Also, you should perform a lumbar puncture to check the opening pressure and obtain a CSF sample.
For analysis. If the brain MRI and venography are normal, the opening pressure is 25 centimeters of water or greater.
And the CSF analysis is normal diagnose idiopathic intracranial hypertension. Now switching gears and moving on to individuals with secondary headaches and abnormal head.

Subarachnoid hemorrhage11:08–12:28

Ct findings in this case, consider vascular etiologies such as subarachnoid hemorrhage and venous sinus thrombosis. Patients with subarachnoid hemorrhage typically report the worst headache of their life which is often called a thunderclap headache because the pain is maximum at onset.
In some cases a few days or a few weeks before the patient's presentation, they had a milder sudden headache called a warning or sentinel headache.
This type of headache occurs due to aneurysmal wall stretching or minor aneurysmal leak and is often a sign of impending aneurysmal rupture.
Also, they might report cardiovascular risk factors such as hypertension and tobacco use as well as a family history of cerebral aneurysms.
The physical exam reveals nuchal rigidity, possibly in combination with an altered mental status and focal neurologic deficits.
Additionally, the funduscopic exam reveals papilledema with or without a boat shaped hemorrhage called a subhyaloid hemorrhage.
Finally, if the head ct reveals a hemorrhage in the subarachnoid space, diagnose subarachnoid hemorrhage. Next, let's take a look at venous sinus thrombosis.

Venous sinus thrombosis12:28–13:35

These patients report progressive worsening of their headache that might be associated with nausea, vomiting, confusion and even seizures.
Some important risk factors include infections such as COVID-19 and mastoiditis, but also pregnancy and the use of oral contraceptives.
Other important risk factors include recent head trauma, neurosurgical procedures and genetic or acquired thrombophilia.
On physical exam. You might find altered mental status and focal neurologic deficits.
The head ct will reveal a hyper density or filling defect in one of the dural venous sinuses at this point, consider venous sinus thrombosis.
So, immediately obtain CT or Mr venography. If venography reveals a thrombus in a dural venous sinus diagnose venous sinus thrombosis.
Here's a clinical pearl patients with intracranial neoplasms or abscesses might also present with progressive headaches.
All right, as a quick recap if the patient presents with facial pain, consider trigeminal neuralgia. However, if the patient presents with a headache, assess for red flags using the snoop 10 criteria.

Review13:35–14:12

If absent, think of primary headaches, like tension type headache and migraine. On the other hand, if red flags are present, obtain a head CT if the head CT is normal, consider giant cell arteritis, meningitis, medication, overuse headache and idiopathic intracranial hypertension.
However, if the head CT is abnormal, think subarachnoid hemorrhage or venous sinus thrombosis.