HEADACHE AND FACIAL PAIN
C. Hain, MD
Page last modified:
May 12, 2019
About 21% of the adult population develops headache in
any 2-week period.
CAUSES OF HEADACHE (links provide more detail).
- Vascular (Migraine, Cluster,
arteritis, vascular malformations)
- Chiari malformation
- Sinus (about 10% of all HA, very often
- Altitude induced headaches
- Infectious (osteomyelitis, dental, encephalitis or meningitis)
- Neoplastic (i.e. brain tumor)
See here for a separate discussion of ear pain.
MISCELLANEOUS MINOR CAUSES OF HEADACHES
- Dental including TMJ (usually stress related, common), micro-abscess.
- Iatrogenic headache (due to vasodilator medications such as NTG, isordil,
- Hypertensive (25% increase in BP or > 180/130, bilateral, constant, moderately
- Ocular -provoked by near viewing or new glasses, glaucoma, rare (Gil Gouvea
R et al, 2002)
- Increased intracranial pressure and hydrocephlaus (similar to hypertensive in symptoms/signs,
very rare, worsening course)
- Decreased intracranial pressure
- Temporal arteritis (very rare). Unilateral, tender temporal artery, jaw
claudication, Polymyalgia. High sed rate. Trial of steroids if sed-rate is
- Aneurysmal (similar to migraine, rare - 28,000/year compared to 50 million
- Chiari Malformation - type I (CM-I).
Headache is common (about 50%). Characteristic headaches are brief, occipital
or nuchal, triggered by cough, straining, postural straining. Caused by transient
tonsillar herniation. There are also long-lasting headaches in CM-I
of unclear etiology.
Headaches can also be sorted by their timing:
- Chronic daily headache
- Chronic migraine
- chronic tension headache
- hemicrania continue
- medication overuse headache
- Thunderclap headache
- Subarachnoid hemorrhage
- Sentinal headache of aneurysm
- hypertensive crisis
- pituitary apoplexy
- spontaneous CSF leak
- thrombosis or expansion of unruptured aneurysm
- "primary" thunderclap headache
- exertional headache
- cough headache
- sexual headache
- Quality: throbbing, constant, shooting, shock, bizarre
- Location: hemicranial, front, back, top, sides
- Timing (may need a headache diary)
- Determine how long it takes for headache to reach maximum intensity
- Duration and periodicity
- Associations (foods like MSG or alcohol, menses, stress, sleep)
- Social history (especially, litigation)
- Past medical history (head-trauma, medications)
- Fever and weight loss suggest abnormality -- 80% of AIDs patients presenting
with new headache have incracranial mass
- Review of systems (such as previous cancer, etc).
- Family history (Migraine, Aneurysm)
- Previous studies
Examination is usually normal unless having a headache.
- Blood Pressure (important!)
- Vision and Fundi (anisometropia, papilloedema, hypertensive change)
- TMJ: crepitus/clicking, put fingers in ears and pull forward while jaw is opening.
- Myofascial pain: pain on lateral movement of jaw.
- Neck: Spurling's maneuver, check for spasm of neck muscles, try traction
- Temporal Arteries (tenderness, indurated, relieve headache)
- Carotid Compression (relieve or increase headache, avoid in vasculopaths)
- Neurological screening examination: Reflexes, Babinski, coordination
LABORATORY TESTS FOR HEADACHE
- ESR if temporal arteritis suspected
- Sinus X-rays, endoscopy or CT if sinusitis suspected
- MRI - if central signs, or increase intensity, or from Mexico (cystacercosis
- Cervical Spine - cervical headache
- LP - if meningitis suspected
- MRA if vascular lesion suspected
Tests usually not helpful
Guidelines for scans.
- MRI single most useful test.
- CT acceptable if index of suspicion is low.
- PET no indication.
- Cooper B, Lucente FE (ed). Management of facial, head and neck pain. Saunders,
- Dalessio DJ (Ed). Wolff's headache and other head pain. Oxford Univ Press,
- Diamond S, Dalessio DJ. The practicing physicians approach to headache,
3rd edition, Williams and Wilkins, 1982.
- Gil-gouvea R. and others. Headache 2002:42:256-262
- Sapir JR, Silberstein SD, Gordon CD, Hamel RL. Handbook of Headache Management,
Williams and Wilkens, Baltimore, 1993.
- Schiffman E, Haley D, Baker C, Lindgreen B. Diagnostic criteria for screening
headache patients for temporalmandibular disorders. Headache 1995:35:121-134.
- Schreiber CP and others. Prevalence of migraine in
patients with a history of self-reported or physician diagnosed "Sinus"
headache. Arch Int Med. 2004: 164: 1769-1772
- Silberstein SD. Intractable headache: inpatient and outpatient treatment
strategies, Neurology 42: 1992, supplement 2.
- Tollison and Kunkel, Ed. Headache Diagnosis and Treatment. Williams and
(C) Timothy C. Hain, MD