Neurology

II

DR.ABDELWAHAB MOHAMED
HEADACHE

DR.ABDELWAHAB MOHAMED
 HEADACHE

Headache, is a Pain in the Head, that is located

above the eyes, ears, behind the head or in the back
of the neck.
Facial pain (Headache) is the commonest symptom
in a dental clinic.
 HEADACHE
Types
• 1ry (Primary) headache

• 2ry (Secondary) headache

• 1ry (Primary) headache

o No underlying disease or structural problems.

o It represents more than 90% of all headaches.

• 2ry (Secondary) headache

o 2ry to an underlying disease or structural

problems.
 1ry headache

1. Tension headache.

2. Migraine headache.

3. Cluster headache.
1ry headache
 Tension Type Headache
(TTH)

.
Tension Type Headache (TTH):
Prevalence

•Commonest type of 1ry headache.

•It represents more than 75% of All cases of
headaches.
•Approximately 25% of the population have TTH.
 Tension Type Headache (TTH):
Prevalence , Gender
More common in WOMEN
It affects three women to every two men.
Tension Type Headache (TTH):
Pathogenesis
• Tension , of the Muscle of the face, scalp, neck
and even the shoulders.
Tension Type Headache (TTH):
Precipitating factors, Triggers
Stress,
• Physical stress, stressful work hours, eyestrain,
uncomfortable or bad posture.
• Physiological stress, sleep deprivation, prolonged
fasting.
• Psychological or Emotional stress
 Tension headache, Presentation
• Site, Bilateral, Located on bi-temporal or above eyes, the
back of the head, or even around the head (band like).
• Character, Dull aching pain.
• Severity, Mild to moderate.
• Duration, from 30 minutes to several hours or even days.
• It does not worsen with the routine physical activity.
• It may be associated with muscle tenderness (Allodynia).
Tension headache:
Treatment
• Pharmacologic therapy;
Analgesics,
NSAIDs as ibuprofen and aspirin or paracetamol.
Tension headache : Treatment
Non-pharmacologic Therapy;
• Balanced Meals and Adequate Sleep
• Stretching exercise
• Massage
Migraine:
 Migraine; Prevalence

• It affects approximately 14% of the population.

• Commonly starts in 1st & 2nd decades.
 Migraine; Prevalence

Gender
• It is more common in women, women to men 3:1.
 Migraine;
• Migraines are due to a mixture of genetic and
environmental factors.
• 60% of migraineurs have a positive family history.
Migraine,
Pathogenesis (Pathophysiology),

Neuro-Vascular headache
Migraine, Pathogenesis (Pathophysiology)
Vascular ,

Vasodilatation

Intra-cranial
blood vessels
Migraine,
Pathogenesis,

Neural,
Cortical spreading depression
 Migraine :
Precipitating factors, Triggers
• Migraine attacks may be induced by triggers:
 Migraine, Presentation:
There are possible four phases of the migraine,
1. The prodrome, warning signal, which occurs hours or
even days before the headache.
2. The aura, which precedes the headache occurs in only
25% of migraineurs, Typical Migraine.
3. The pain (headache)
4. The postdrome, following the end of the attack.
Migraine,
Aura

Aura, Transient Neurological symptoms, mainly

visual, but may be sensory , speech or motor.
Migraine,
Aura

Headache

• Aura may precede the headache phase.

• Migraine with aura appears in less than 1/3 of
cases (Typical Migraine)
• Migraine without aura is more common, appears
in more than 2/3 of cases (Common Migraine)
Migraine, Presentation

• Site, Unilateral
• Character, Throbbing & Pulsating
• Severity, Moderate to Severe
(debilitating)
• Duration, lasts from 4 to 72 hours
• Worse by physical activity
• Associated with nausea / vomiting
& Sensitivity to light (photophobia)
or to sound (phonophobia)
Common Migraine,
Migraine Without Aura
Migraine : Treatment
Abortive (Acute) treatment

Vasodilatation

Ergotamine Triptan
Migraine : Treatment
Abortive (Acute) treatment
Migraine : Treatment
Abortive (Acute) treatment

• NSAIDs, as ibuprofen, paracetamol and aspirin.

 Cluster
Headache
Prevalence
• The least common type of 1ry headache.
• It affects approximately 0.1-0.2% of the general
population.
 Cluster
Headache

Gender
• More Common in Male, Middle ages Men.
• Male : female is 5:1
 Cluster Headache

Pathogenesis,
• The exact cause is unknown ? Vasodilatation of
intracranial blood vessels (Migrainous Neuralgia)
 Cluster
Headache

Precipitating factors

• Vasodilators

• Alcohol
 Cluster
Headache

Presentation
•Site - Unilateral, typically around the eye in the
periorbital, or temporal regions
•Character - Severe pain (excruciating, suicidal).
•Duration - 15 minutes to 3 hours and usually
starts & ends suddenly.
 Cluster
Headache

• Cluster, attacks of headache occur in Groups,

usually 1-8 attacks / day.
• They my last for 4-6 weeks and then may
disappear for several months or even years
before another attacks develop.
 Cluster
Headache

• Attacks may occur in the same time of the day.

Most of the attacks occur at night, awaken the
patient from sleep (Alarm Clock Headache).
 Cluster Headache

•Accompanied by Autonomic (Vascular) changes:

 Flushing
 Eye congestion & Lacrimation
 Miosis, ptosis and lead oedema
 Nasal congestion & rhinorhea
 Cluster Headache

Abortive (Acute) treatment

Vasodilatation

Ergotamine Triptan
 Cluster
Headache

•Emergency treatment

100% oxygen for 15 min. may abort attack

• 2ry (Secondary) headache
2ry headache

Facial Pain
Causes of facial pain
???????
Oral causes Extra-oral
causes.
 Oral causes

Teeth &
supporting tissues

Oral mucosa

Jaw & TMJ

 1-Diseases of the teeth and
supporting tissues
• Pulpits
• Pericoronitis
• Periodontitis
• Periodontal abscess
• Periapical abscess
• Acute ulcerative gingivitis
• Space infection
Herpes Aphthous ulcers

2-Oral mucosa

Neoplasm
 3-Diseases of
the jaw
1.Fracture.

2.Infection :
a. Osteomyelitis.
b. Infected cysts.

3.Malignant neoplasm.
 4-Diseases of
the TMJ

Arthritis

Myofacial pain dysfunction

 Myofacial pain dysfunction
 Occlusion Disharmony or alteration of vertical
dimensions of the jaw leads to dysfunction of
masticatory apparatus. This leads to Spasm of
muscles of mastication, pain & tenderness.
 Masticatory pain

TMJ Myofacial
disease pain disorder
 Extra-oral
1. Ears causes
2. Eyes.

3. Nasal sinuses.

4. Salivary glands.

5. Vascular pain .

6. Neurological, intracranial & neuralgia .

7. psychosomatic pain.
 Eye
• Glaucoma
Nasal Sinuses
Sinusitis

(acute & chronic )

 Salivary Glands

Sjögren's
Acute Parotitis syndrome

Sialadenitis Malignant neoplasm

Vascular pain:

a.Migraine

b.Cluster Headache

c.Temporal arteritis
Temporal arteritis
 Temporal arteritis
Pathology,
 Auto-immune Inflammation of temporal artery,
(Giant Cell Arteritis)
 Temporal arteritis
Prevalence,
 more common in Women
 The age of onset is >55 years
 Temporal arteritis
Clinical picture
• Headache, jaw claudication, scalp pain &
tenderness especially on combing hair.
• Visual problems
 Temporal arteritis

Diagnosis :
1. High ESR & CRP

2. Temporal artery biopsy

 Temporal arteritis
Treatment
• Steroids (Cortisone),
• Cortisone should be given early. Why?
to prevent irreversible Blindness, due to spread
of the inflammation to the ophthalmic artery.
 Vascular pain:

Angina & myocardial infarction.

Neurological disorders
 Neurological disorders
 Intracranial lesions:

• Brain tumour.

• Subarachnoid hge

• Meningitis
NEURALGIAS

Painful disorders of the Nerves

 NEURALGIAS

• Trigeminal Neuralgia.

• Glossopharyngeal Neuralgia.

• Post-herpetic neuralgia.
 Trigeminal Neuralgia
Anatomy

TRIGEMINAL NERVE :
 Trigeminal Neuralgia
Prevalence

• Incidence, 4-8 in 100,000

• Age, elderly

• Sex, female> male

Trigeminal Neuralgia: (Tic Douloureux)

Facial Pain
Paroxysms of
• Sudden Unilateral
in the distribution
• Severe of the Trigeminal
nerve, (commonly
• Sharp
the mandibular
• Lancinating division)

• Short duration
(sec.)
Touching upper lip& gum.

Cold drafts

washing
Chewing
 Trigeminal Neuralgia:
Treatment
• Medications :
 Carbamazepine ( Tegretol ) 200 mg ,
 Gabapentin (Neurontin)
 Phenytoin (Epanutin).
 Trigeminal Neuralgia:
Treatment
• Surgical:
• Micro-Vascular Decompression (MVD) of
trigeminal nerve.
• Radio-frequency
• Radiosurgery , Gama knife.
Anatomy

GLOSSOPHARYNGEAL NERVE
Pain
Paroxysm of
• Sudden Unilateral
in the distribution
• Severe of
• Sharp Glossopharyngeal
nerve
• Lancinating (in the back of the
tongue & throat)
• Short duration
(seconds)
 Glossopharyngeal Neuralgia
Treatment
• Medications : Carbamazepine ( Tegretol ) 200 mg ,
Gabapentin and phenytoin.
 Post-herpetic neuralgia
Neuralgia affect nerves after recovery from
herpes zoster infection.
After initial exposure, HZ virus lies
dormant in certain nerve fibers
 It may become active as a result of :

immunity Aging

stress
 Post-herpetic neuralgia
Severe Sharp Lancinating Pain with herpetic
Vesicles take a dermatome distribution.
 Post-herpetic Neuralgia:
• Treatment

• Carbamazepine 200 mg

• Anti-viral, Acyclovir
 Psychosomatic pain

•There is no organic cause

•exacerbated by anxiety, stress or depression

•Usually diagnosed by exclusion

Medication Overuse headache

Frequent use of Analgesics (? > 15 days/month)

may cause Medication Overuse headache.
Questions?

DR.ABDELWAHAB MOHAMED
DR.ABDELWAHAB MOHAMED