Evaluation of Headache and Facial Pain

    Headache is the most common medical complaint of mankind.  It has been estimated that more than 40 million Americans have headaches severe enough to require medical care.  Even though this is a common complaint many physicians approach its treatment with much trepidation.    Obtaining a targeted history is the most important portion of the evaluation of the patient suffering form headache and facial pain.  From the history, physicians should be able to recognize the emergence of a specific constellation of symptoms that point to a working diagnosis in most patients with headache and/or facial pain.  This also allows a physician to determine the difference between life threatening illness and a chronic problem.

        Table 1:  Overlapping Symptoms of Headache and
                        Facial Pain Syndromes:  Pain

• Chronicity  The length of illness helps determine sick from well.   Generally, headaches that have been present for 20-30 years are in and of themselves not associated with progressive and life-threatening neurological disease.   Conversely, the sudden onset of severe headache or the sudden change in the character of a headache or facial pain syndrome may fall in the category of "sick" until proven otherwise.  Patients in this category deserve a high level of concern.  One still needs to be aware of other disease processes that can cause the headaches like cerebral abscess and malignancy.
• Age of Onset.  Headaches that begin in childhood through the second decade of life are most often vascular in nature.  Headaches and facial pain that begin later in life are statistically most commonly psychogenic ills, such as tension-type headaches, nonneurogenic atypical facial pain, and fibromyalgia.
      Pitfalls in the age-onset portion of the targeted history center around two facts.
      1) As one gets older, the chances of s;systemic illness such as hypertension, glaucoma, and stroke and cancer increase.
      2) Children, adolescents, and young adults can all suffer from these systemic illnesses, albeit rarely.  Unfortunately, from the point of view of chronological age, these systemic diseases are rarely suspected in this age group.
• Duration and Frequency of Pain.
  This may provide the best clues to the diagnosis and classification.    Although most headaches syndromes may occur in a seemingly sporadic and random nature; however, careful questioning may reveal an identifiable pattern that may aid diagnosis.  A headache diary kept for three months is often helpful. 
      In general, vascular headaches and trigeminal neuralgia tend to occur in an episodic fashion, the duration of pain ranging from minutes in the case of cluster headache and trigeminal neuralgia to hours in the case of migraine.  cluster headache may be seasonal, with peak occurrences in the spring and fall.  Headaches and facial pain of organic origin (e.g., sinus disease, brain tumor) tend to be continuous, with acute exacerbation caused by exercise, change in position and Valsalva's maneuver, for example.  These pain syndromes will worsen over time if the underlying organic disease is not correctly  diagnosed and treated, or if it the disease does not resolve spontaneously.  Pain that is present on a daily basis and persists for months to years most likely falls under the tension-type  or nonneurogenic atypical facial pain category.
  Onset to Peak Time. When coupled with the information obtained in the duration and frequency portion of the targeted history, the onset to peak time may help further narrow the diagnostic possibilities  A rapid onset-to-peak time (seconds to minutes) should increase suspicion of organic disease.  Of particular concern are headaches that worsen with such activities as exercise, Valsalva's; maneuver, and bending forward.  Notable exceptions to this rule are cluster headache and trigeminal neuralgia.
      Migraine tend to evolve over several hours. Tension-type headache and nonneuralgic atypical facial pain evolve over a period of hours to days and then tend to remain constant.  Pitfalls when drawing conclusions regarding the onset-to-peak   time of a headache of facial pain syndrome include the special situation in which a syndrome with a slow onset-to-peak time (e.g., migraine) producing the "co-existent" or "mixed headache" syndrome

    Table 2           Overlapping Symptoms of Headache
            and Facial Pain Syndromes:  Location

• Location. The location of headache or facial pain provides additional information about the classification f a headache syndrome.  Pain localized to an anatomical structure should be evaluated in the cont4ext of common disease entities for that structure (e.g., otitis media, dental pain).
      Vascular headache is usually unilateral, although the side may change during an attack.  Cluster headache is usually localized to the ocular and retroocular region, whereas migraine tends to involve the entire hemicranium.
     Tension-type headache is usually bilateral but can be unilateral, often involving the frontal, temporal and occipital regions.  Associated neck symptomology often coexists.  It may manifest as band or caplike tightness in the aforementioned anatomical areas.
      Trigeminal Neuralgia generally involves only one division of the trigeminal nerve(>98%).
      Special attention should be given to any atypical manifestation or poorly localized pain, because pain referred from tumors of the hypopharynx and posterior fossa can easily be misdiagnosed.  Pain that is occipital or unilateral but becomes holocranial during Valsalva's maneuver is suggestive of intracranial pathology and probable increased intracranial pressure.
          Table 3              Factors That Cause Concern
  

  New Headache of recent onset ("the first")

  New Headache of unusual severity("the worst")

  Headache associated with neurological dysfunction

  Headache associated with systemic illness (especially infection)

  Headache that peaks rapidly

  Headache associated with exertion

  Focal headache

  Sudden change in previously stable headache pattern

  Headache associated with Valsalva's maneuver

  Nocturnal headache

Suggested Reading on Headaches

1. The Practicing Physician's Approach to Headache.  Diamond S. Williams          &Wilkins, Baltimore. 1982
2.Wolff's Headache (Dalessio DJ ed) Robinson CA.  Oxford Press New York           1980.

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