Headache and Facial pain

Assessment

Evaluate people who present with headache and any of the following features, and consider the need for further investigations and/or referral*:

• Worsening headache with fever
• Sudden-onset headache reaching maximum intensity within 5 minutes
• New-onset neurological deficit
• New-onset cognitive dysfunction
• Change in personality
• Impaired level of consciousness
• Recent (typically within the past 3 months) head trauma
• Headache triggered by cough, valsalva (trying to breathe out with nose and mouth blocked) or sneeze
• Headache triggered by exercise
• Orthostatic headache (headache that changes with posture)
• Symptoms suggestive of giant cell arteritis
• Symptoms and signs of acute narrow-angle glaucoma
• A substantial change in the characteristics of their headache

Consider further investigations and/or referral for people who present with new-onset headache and any of the following:

• Compromised immunity, caused, for example, by human immunodeficiency virus (HIV) or immunosuppressive drugs
• Age under 20 years and a history of malignancy
• A history of malignancy known to metastasise to the brain
• Vomiting without other obvious cause

Consider using a headache diary to aid the diagnosis of primary headaches.

If a headache diary is used, ask the person to record the following for a minimum of 8 weeks:

• Frequency, duration and severity of headaches
• Any associated symptoms
• All prescribed and over the counter medications taken to relieve headaches
• Possible precipitants
• Relationship of headaches to menstruation

Diagnosis

Tension-Type Headache, Migraine (With or Without Aura) and Cluster Headache

Diagnose tension-type headache, migraine or cluster headache according to the headache features in the table.

Table: Diagnosis of Tension-Type Headache, Migraine and Cluster Headache

¹ Headache pain can be felt in the head, face or neck.
² See the recommendations below for further information on diagnosis of migraine with aura.
³ The frequency of recurrent headaches during a cluster headache bout.
⁴ The pain-free period between cluster headache bouts.
⁵ Chronic migraine and chronic tension-type headache commonly overlap. If there are any features of migraine, diagnose chronic migraine.
⁶ NICE has developed technology appraisal guidance on Botulinum toxin type A for the prevention of headaches in adults with chronic migraine  (headaches on at least 15 days per month of which at least 8 days are with migraine).

Migraine with Aura

Suspect aura in people who present with or without headache and with neurological symptoms that:

• Are fully reversible and
• Develop gradually, either alone or in succession, over at least 5 minutes and
• Last for 5–60 minutes

Diagnose migraine with aura in people who present with or without headache and with one or more of the following typical aura symptoms that meet the criteria for suspecting aura above:

• Visual symptoms that may be positive (for example, flickering lights, spots or lines) and/or negative (for example, partial loss of vision)
• Sensory symptoms that may be positive (for example, pins and needles) and/or negative (for example, numbness)
• Speech disturbance

Consider further investigations and/or referral for people who present with or without migraine headache and with any of the following atypical aura symptoms that meet the criteria for suspecting aura above:

• Motor weakness or
• Double vision or
• Visual symptoms affecting only one eye or
• Poor balance or
• Decreased level of consciousness

Menstrual-Related Migraine

Suspect menstrual-related migraine in women and girls whose migraine occurs predominantly between 2 days before and 3 days after the start of menstruation in at least 2 out of 3 consecutive menstrual cycles.

Diagnose menstrual-related migraine using a headache diary (see the recommendations concerning headache diary in the section "Assessment" above) for at least 2 menstrual cycles.

Medication Overuse Headache

Be alert to the possibility of medication overuse headache in people whose headache developed or worsened while they were taking the following drugs for 3 months or more:

• Triptans, opioids, ergots or combination analgesic medications on 10 days per month or more or
• Paracetamol, aspirin or a non-steroidal anti-inflammatory drug (NSAID), either alone or in any combination, on 15 days per month or more

Management

All Headache Disorders

Consider using a headache diary:

• To record the frequency, duration and severity of headaches
• To monitor the effectiveness of headache interventions
• As a basis for discussion with the person about their headache disorder and its impact

Consider further investigations and/or referral if a person diagnosed with a headache disorder develops any of the features listed in the first bulleted list under "Assessment" above.

Do not refer people diagnosed with tension-type headache, migraine, cluster headache or medication overuse headache for neuroimaging solely for reassurance.

Information and Support for People With Headache Disorders

Include the following in discussions with the person with a headache disorder:

• A positive diagnosis, including an explanation of the diagnosis and reassurance that other pathology has been excluded 
• The options for management
• Recognition that headache is a valid medical disorder that can have a significant impact on the person and their family or carers

Give the person written and oral information about headache disorders, including information about support organisations.

Explain the risk of medication overuse headache to people who are using acute treatments for their headache disorder.

Tension-Type Headache

Acute Treatment

Consider aspirin**, paracetamol or an NSAID for the acute treatment of tension-type headache, taking into account the person's preference, comorbidities and risk of adverse events.

Do not offer opioids for the acute treatment of tension-type headache.

Prophylactic Treatment

Consider a course of up to 10 sessions of acupuncture over 5–8 weeks for the prophylactic treatment of chronic tension-type headache.

Migraine With or Without Aura

Acute Treatment

Offer combination therapy with an oral triptan and an NSAID, or an oral triptan and paracetamol, for the acute treatment of migraine, taking into account the person's preference, comorbidities and risk of adverse events. For young people aged 12–17 years consider a nasal triptan in preference to an oral triptan.

For people who prefer to take only one drug, consider monotherapy with an oral triptan, NSAID, aspirin** (900 mg) or paracetamol for the acute treatment of migraine, taking into account the person's preference, comorbidities and risk of adverse events.

When prescribing a triptan start with the one that has the lowest acquisition cost; if this is consistently ineffective, try one or more alternative triptans.

Consider an anti-emetic in addition to other acute treatment for migraine even in the absence of nausea and vomiting.

Do not offer ergots or opioids for the acute treatment of migraine.

For people in whom oral preparations (or nasal preparations in young people aged 12–17 years) for the acute treatment of migraine are ineffective or not tolerated:

• Offer a non-oral preparation of metoclopramide or prochlorperazine
• Consider adding a non-oral NSAID or triptan if these have not been tried

Prophylactic Treatment

Discuss the benefits and risks of prophylactic treatment for migraine with the person, taking into account the person's preference, comorbidities, risk of adverse events and the impact of the headache on their quality of life.

Offer topiramate or propranolol for the prophylactic treatment of migraine according to the person's preference, comorbidities and risk of adverse events. Advise women and girls of childbearing potential that topiramate is associated with a risk of fetal malformations and can impair the effectiveness of hormonal contraceptives. Ensure they are offered suitable contraception.

If both topiramate and propranolol are unsuitable or ineffective, consider a course of up to 10 sessions of acupuncture over 5–8 weeks or gabapentin (up to 1200 mg per day) according to the person's preference, comorbidities and risk of adverse events.

For people who are already having treatment with another form of prophylaxis such as amitriptyline, and whose migraine is well controlled, continue the current treatment as required.

Review the need for continuing migraine prophylaxis 6 months after the start of prophylactic treatment.

Advise people with migraine that riboflavin (400 mg once a day) may be effective in reducing migraine frequency and intensity for some people.

Sphenopalatine block

What is an sphenopalatine ganglion permanent block?

A ganglion is a bundle of interconnected nerves that are important for pain in a certain area of the body. One such ganglion is known as the sphenopalatine ganglion and it is important in the treatment of some types of facial pain. Test blocks of this ganglion can help to relieve the pain. Before we perform a permanent block of this ganglion we first do a test block to see if this helps to relieve your pain. The sphenopalatine ganglion is located next to the jaw on the outer side of the face behind the nose and can be reached with a needle. In a permanent block of the sphenopalatine ganglion small electrical currents are administered through a needle resulting in heating of the ganglion. Only the small nerves of the ganglion are blocked resulting in a block of the pain signals. Since the thick nerves are spared the function of the ganglion remains normal.

 

Side view of the skull. The box at bottom right is an enlargement (see text).

 

What should I be aware of before undergoing an sphenopalatine ganglion permanent block?

Any of the following situations should be reported to your pain specialist if he proposes an sphenopalatine ganglion permanent block:

• If you are pregnant: since X-Ray equipment is used, pregnant women may not undergo a sphenopalatine ganglion permanent block and a new appointment has to be made.
• If you are ill or have a fever on the day of treatment you cannot undergo a sphenopalatine ganglion permanent block, in which case a new appointment will have to be made.
• If you are allergic to iodine, bandages, anaesthetics or contrast fluids, you should notify your pain specialist before the appointment for treatment is made.
• If you are taking blood thinners, you should notify that your pain specialist before the appointment for treatment is made. He will then consider whether the use of certainmedications should be ceased temporarily.

How should I prepare for an sphenopalatine ganglion permanent block?

• No special preparations, such as an overnight bag, are necessary because the treatment is carried out on an outpatient basis.
• You may eat before treatment and take your normal medication.
• N.B.: this does not include blood thinners, as mentioned above.
• Make sure you have someone to take you home, because you may not drive for 24 hours.

How does an sphenopalatine ganglion permanent block work?

• The treatment will be performed in the surgical day-care centre, where you will be asked to change into a surgical gown. This gown closes at the back.
• A nurse will escort you to the treatment room, where there is a treatment table, an X-ray machine and television monitors.
• You will be positioned on the treatment table on your back.
• The blood pressure and the amount of oxygen in your blood will be controlled during the treatment.
• A drip will be placed in your hand.
• The right place of the block is estimated with aid of fluoroscopy.
• This place is marked on the skin with a felt pen.
• The area around this site is then disinfected with a cold, red liquid.
• The pain specialist covers the area with sterile drapes.
• After a local anesthetic has been applied to the skin, the pain specialist, by means of fluoroscopy (via the television monitor), will insert the needles in the correct place.
• The treatment is performed under light anaesthesia.
• Some contrast fluid is also injected to enable the position of the needle to be clearly visible.
• Then small electrical currents are administrated near the sphenopalatine ganglion.
• You will feel a tingling sensation.
• When you feel this, you must tell the treating pain specialist straight away, and not wait for it to become painful.
• The pain specialist will ask you where you feel the sensation and you don't have to point the place with your finger.
• By means of a special device, the pain specialist can read the distance from the needle to the sphenopalatine ganglion.
• If the needle is in the right place the permanent sphenopalatine ganglion block is performed.
• The pain specialist will administrate a radiofrequency (RF) electrical current via the needle to block the sphenopalatine ganglion.
• Nowadays instead of a radiofrequency (RF) electrical current also a pulsed radiofrequency (PRF) electrical current can be used to block the sphenopalatine ganglion.
• The difference is that instead of one single radiofrequency electrical current an interrupted (pulsed) series of small electrical currents is used. These small currents produced less heat near the sphenopalatine ganglion.
• Less heat of the small currents does not lead to interruption of the sphenopalatine ganglion but results more in modulation of the ganglion to decrease the pain.
• You will then be asked to get dressed and make an appointment at the pain clinic after six to eight weeks with your own pain specialist.
• The effect of treatment will be checked and further policy will discuss with you.

When can I expect pain relief after the treatment?

• After pains can occur following an sphenopalatine ganglion block. This may last a week but will eventually disappear.
• The optimum results of treatment are seen after six to eight weeks.
• Around this time, a new appointment with your pain specialist will be made.

Trigeminal neuralagia

The International Headache Society classifies trigeminal neuralgia (TN) into classical and symptomatic TN, with the latter being clinically indistinguishable from the former. The only identifiable difference between the 2 conditions is that in symptomatic TN, a causative lesion (other than vascular compression) can be detected, and has been demonstrated in imaging or posterior fossa exploration (International Classification of Headache Disorders-II). In clinical practice, 2 phenotypic forms of TN are usually recognized, typical and atypical TN. The hallmark of typical TN is paroxysmal pain, which is lancinating in nature and occurs unilaterally in a trigeminal distribution. Paroxysmal pain is present in atypical TN as well, but patients often report it along with diffuse and chronic pain, which persist beyond the duration of a typical paroxysm, in the same trigeminal distribution areas. The paroxysmal pain distinguishes atypical TN from persistent idiopathic facial pain, which was previously known as atypical facial pain.

Carbamazepine is the drug of choice in the initial treatment of idiopathic TN. However, some patients develop adverse effects while some others do not show sustained pain relief. For cases in which conservative treatment is not successful, invasive treatment can be considered. The available options include surgical microvascular decompression (MVD), surgical sectioning of a portion of the sensory component of the trigeminal nerve, stereotactic radiation therapy or gamma knife treatment, percutaneous balloon microcompression, percutaneous glycerol rhizolysis, and percutaneous radiofrequency (RF) thermocoagulation of the Gasserian ganglion. In addition to the operative risks inherent in surgical techniques, all neurodestructive methods present risks of sensory loss, dysesthesia, anesthesia dolorosa, corneal anesthesia, and facial muscle weakness.

Pulsed radiofrequency (PRF) treatment is defined as the delivery of short pulses of RF via a needle tip, thereby avoiding thermal lesions. This technique had been performed for various other conditions and has been shown to be effective and safe. There are contrasting opinions regarding the use of PRF treatment for TN, but in our opinion, one of the main reasons for this discrepancy is the insufficient PRF dose used in most studies.