Headache

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Introduction
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Relevant anatomy
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Classification
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Specific entity
 Introduction

•
International Association for the Study of Pain
– an unpleasant sensory and emotional experience
associated with actual or potential tissue damage
or described in terms of such damage
Relevant anatomy
 Sinus Innervation
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Ophthalmic and maxillary branches of 5th
cranial nerve
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Greater superficial petrosal branch of 7th
cranial nerve
 Frontal Sinus
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Ophthalmic branch
of 5th cranial nerve
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Pain referred to
forehead and
anterior cranial
fossa
 Anterior Ethmoid
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Ophthalmic division
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Anterior ethmoid
nerve off nasociliary
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Anterior septum,
turbinates,
ostiomeatal
complex
Posterior Ethmoid and Sphenoid
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Maxillary division
– Posterior ethmoid nerve

– Posterior septum, parts of

superior and middle turbinates

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Ophthalmic division
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Greater superficial
petrosal nerve
 Maxillary Sinus
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Maxillary division of
5th cranial nerve
– Posterior superior alveolar

– Infraorbital

– Anterior superior alveolar

Classification
 International headache society classification of headache
& facial pain
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Part I - Primary headaches
– Migraine

– Tension-type headache

– Cluster headache and other trigeminal autonomic cephalalgias

– Other primary headaches

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Part II - The secondary headaches
– Headache attributed to head and neck trauma

– Headache attributed to cranial or cervical vascular disorder

– Headache attributed to non-vascular intracranial disorder

– Headache attributed to a substance or its withdrawal

 Headache attributed to disorder of ears
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Diagnostic criteria
– A. Headache accompanied by otalgia and fulfilling criteria C and D

– B. Structural lesion of the ear diagnosed by appropriate investigations

– C. Headache and otalgia develop in close temporal relation to the

structural lesion

– D. Headache and otalgia resolve simultaneously with remission or

successful treatment of the structural lesion

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Comments
– There is no evidence that any pathology of the ear can cause headache
without concomitant otalgia.

– Structural lesions of the pinna, external auditory canal, tympanic

membrane or middle ear may give rise to primary otalgia associated
 Headache attributed to Nose &
PNS
Diagnostic criteria:
– A. Frontal headache accompanied by pain in one or more regions of the face,
ears or teeth and fulfilling criteria C and D

– B. Clinical, nasal endoscopic, CT and/or MRI imaging and/or laboratory

evidence of acute or acute-on-chronic rhinosinusitis

– C. Headache and facial pain develop simultaneously with onset or acute

exacerbation of rhinosinusitis

– D. Headache and/or facial pain resolve within 7 days after remission or

successful treatment of acute or acute-on-chronic rhinosinusitis

Note
– 1. Clinical evidence may include purulence in the nasal cavity, nasal
obstruction, hyposmia/ anosmia and/or fever.

– 2. Chronic sinusitis is not validated as a cause of headache or facial pain

unless relapsing into an acute stage
 Headache attributed to Nose & PNS
Conditions that are often considered to induce
headache are not sufficiently validated as causes of
Headache
– deviation of nasal septum, hypertrophy of
turbinates, atrophy of sinus membranes

Migraine and tension-type headache are often confused

and attributed as rhinosinusitis because of similarity in
location of the headache.
– concomitant clinical features such as facial pain,
nasal congestion and headache triggered by weather
changes
– None of these patients have purulent nasal
discharge or other features diagnostic of acute
rhinosinusitis
 Headache or facial pain attributed to
temporomandibular joint

•
Diagnostic criteria:
– A. Recurrent pain in one or more regions of the head and/or face fulfilling
criteria C and D

– B. X-ray, MRI and/or bone scintigraphy demonstrate TMJ disorder

– C. Evidence that pain can be attributed to the TMJ disorder, based on at least
one of the following:
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1. pain is precipitated by jaw movements and/or chewing of hard or tough food

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2. reduced range of or irregular jaw opening

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3. noise from one or both TMJs during jaw movements

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4. tenderness of the joint capsule(s) of one or both TMJs

– D. Headache resolves within 3 months, and does not recur, after successful
treatment of the TMJ disorder
Specific entity
Rhinosinusitis

 Inflammation of nasal mucosa and sinuses

 Acute RS: Symptoms lasting less then 4 weeks and
complete resolution
 Subacute Rs: Duration 4-12 weeks
 Chronic RS: Duration ~ 12 weeks.
 Causes of acute mostly viral or bacterial
 Chronic is multifactorial cause

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frontal sinusitis

 Frontal headache.
 comes up on waking, gradually increases and reaches its peak
by about mid day and then starts subsiding. It is also called “office
headache” because of its presence only during the office hours.
 Tenderness. just above the medial canthus
 Oedema of upper eyelid
 Nasal discharge

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Medical Treatment
 Antimicrobial drugs.
 Nasal decongestant drops
 Steam inhalation.
 Analgesics
 Hot fomentation
 Surgical treatment
 Most cases of acute maxillary sinusitis respond to
medical treatment
 Trephination of frontal sinus.
 frontal sinus is drained externally.
 Functional endoscopic sinus surgery

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maxillary sinusitis
 Headache.
 Usually, this is confined to forehead and may
thus be confused with frontal sinusitis
 Tenderness
 Nasal discharge
 Redness and oedema of cheek
 Postnasal discharge

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ETHMOID SINUSITIS
 Ethmoid sinuses are more often involved in infants and
young children.
 1. Pain. It is localized over the bridge of the nose,
medial and deep to the eye.
 2. Oedema of lids.
 3. Nasal discharge.
 SPHENOID SINUSITIS
 Headache. Usually localized to the occiput or vertex.
Pain may also be referred to the mastoid region.
 Postnasal discharge

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Complications of otitis media
 PETROSITIS
 Spread of infection from middle ear and mastoid to the
petrous part of temporal bone
 Fever, headache, vomiting
 (i) external rectus palsy (VIth nerve palsy), (ii) deep-seated ear or
retro-orbital pain (Vth nerve involvement) and (iii) persistent ear
discharge. Gradenigo syndrome
 CT scan of temporal bone will show bony details of the petrous apex
and the air cells while MRI helps to differentiate diploic marrow-
containing apex from the fluid or pus.pus.

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 Most cases of acute petrositis can now be cured with
antibacterial therapy
 Cortical, modified radical or radical mastoidectomy
 If already done- The fistulous tract should be found out,
which is then curetted and enlarged to provide free drainage

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EXTRADURAL ABSCESS

 Persistent headache on the side of otitis media.

 2. Severe pain in the ear.
 3. General malaise with low-grade fever.
 4. Pulsatile purulent ear discharge.
 Diagnosis is made on contrast-enhanced CT or MRI
 1. Cortical or Modified Radical or Radical Mastoidectom
 Extradural abscess is evacuated by removing
overlying bone till the limits of healthy dura are
reached
 2. An Antibiotic Cover

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SUBDURAL ABSCESS

 Infection spreads from the ear by erosion of bone and

dura or by thrombophlebitic process in which case
intervening bone remains intact.
 Pus rapidly spreads in subdural space causing pressure
symptoms,
 (i) meningeal irritation, (ii) thrombophlebitis of cortical
veins of cerebrum and (iii) raised intracranial tension.

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MENINGITIS

 Blood-borne infection is common in infants and

children; in adults, it follows chronic ear disease,
which spreads by bone erosion or retrograde
thrombophlebitis
 1. There is rise in temperature (102-104 °F) often with
chills and rigors.
 2. Headache.
 3. Neck rigidity.
 4. Photophobia and mental irritability.
 5. Nausea and vomiting (sometimes projectile).
 6. Drowsiness which may progress to delirium or coma.
 7. Cranial nerve palsies and hemiplegia. 24/02/20
OTOGENIC BRAIN ABSCESS

 Fifty per cent of brain abscesses in adults and

twentyfive per cent in children are otogenic in origin
 In adults, abscess usually follows chronic suppurative
otitis media with cholesteatoma,
 while in children, it is usually the result of acute otitis
media.
 Cerebral abscess is seen twice as frequently as
cerebellar abscess.

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 Brain abscess is often associated with other
complications,
 such as extradural abscess, perisinus abscess,
meningitis, sinus thrombosis and labyrinthitis, and thus
the clinical picture may be overlapping

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 1. Symptoms and Signs of Raised Intracranial Tension
 2. Localizing Features Temporal lobe abscess
 (i) Nominal aphasia.
 (ii) Homonymous hemianopia
 (iii) Contralateral motor paralysis.
 (iv) Epileptic fits.
 (v) Pupillary changes and oculomotor palsy.

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 Cerebellar abscess
 (i) Headache involves suboccipital region
 (ii) Spontaneous nystagmus
 (iii) Ipsilateral hypotonia and weakness.
 (iv) Ipsilateral ataxia.

 Medical treatment.
 High doses of antibiotics are given parenterally.
 Neurosurgical
 (i) repeated aspiration through a burr hole, (ii) excision
of abscess and (iii) open incision of the abscess and
evacuation of pus

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LATERAL SINUS
THROMBOPHLEBITIS
 It is an inflammation of inner wall of lateral venous
sinus with formation of an intrasinus thrombus.

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OTITIC HYDROCEPHALUS

 It is characterized by raised intracranial pressure with

normal CSF findings.
 Lateral sinus thrombosis accompanying middle ear
infection causes obstruction to venous return. If
thrombosis extends to superior sagittal sinus, it will also
impede the function of arachnoid villi to absorb CSF.
 1. Severe headache,
 2. Diplopia due to paralysis of VIth cranial nerve
 3. Blurring of vision due to papilloedema or optic
atrophy

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 The aim is to reduce CSF pressure to prevent optic
atrophy and blindness.
 This is achieved medically by acetazolamide and
corticosteroids and repeated lumbar puncture or
placement of a lumbar drain.
 Sometimes, draining CSF into the peritoneal cavity
(lumboperitoneal shunt)

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Malignant (Necrotizing) Otitis
Externa
 inflammatory condition caused by pseudomonas
infection usually in the elderly diabetics, or in those on
immunosuppressive drugs.
 excruciating pain and appearance of granulations in the
ear canal.
 Infection may spread to the skull base
 and jugular foramen causing multiple cranial nerve
palsies.
 posteriorly to the mastoid and medially into the middle
ear and petrous bone

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 Treatment:

 (I) Control of diabetes.

 (ii) Toilet of ear canal. Remove discharge, debris and
 granulations or any dead tissue or bone.
 (iii) Antibiotic

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•
Other
Carotidynia
pain syndromes
– Self limited inflammation of carotid fascia or
adventitia
– Induced by viral infection
– May be secondary to carotid dissection /
endarterectomy
– Unilateral ache involving upper neck, face and ear
with throbbing headache
– younger and middle aged & elderly
– Treatment
• NSAID’s, stellate ganglion block

– May recover spontaneously

Sphenopalatine neuralgia/contact point
pain
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Sleuder – 1908
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Vascular origin
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Paroxysms upto 3 episodes / day
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Symptoms
– Pain resembles sinusitis
– rhinorrhoea, lacrimation, injected conjunctiva, swollen
nasal mucous memb, facial flushing, photophobia
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Touching middle turbinate – mucosal contact
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Cocainisation abolishes symptoms
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Trt – submucous resection / cryotherapy
Thank you
 30 yes old male presented with complaints of headache for past 2
years
 Complaints of nasal block 2 years
 History of headache for 2 years more during morning hours relieved
with Medication
 History of nasal discharge present
 No H/o photophobia , giddiness, vomiting
 On examination:
 Nose: mucoid discharge present
 Mucosa normal
 Rt ITH present
 Mild DNS to left


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 Investigations

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