Headaches and Facial Pain

1.10.1 Review the sensory innervation to the ear and discuss pathways of referred pain.

Levine HL. Otorhinolaryngologic causes of headache. Med Clin North Am. 1991 May;75(3):677-9. PMID:2020222

1.10.2 Discuss sinonasal innervation.

Levine HL. Otorhinolaryngologic causes of headache. Med Clin North Am. 1991 May;75(3):677-9. PMID:2020222

1.10.3 Brain parenchyma is pain insensitive. Explain the source of pain with migraines.

1.10.4 What is Eagle’s syndrome? Trotter’s syndrome?

1.10.5 Differentiate temporomandibular joint disorder from myofascial pain-dysfunction syndrome.

1.10.6 Characterize migraines. Discuss the treatment to include drugs, behavior modification, etc. How do migraines differ from cluster headaches?

Binder WJ, Brin MF, Blitzer A, Schoenrock LD, Pogoda JM. Botulinum toxin type A (BOTOX) for treatment of migraine headaches: an open-label study.Otolaryngol Head Neck Surg. 2000 Dec;123(6):669-7. PMID:11112955 

1.10.7 Discuss the classic presentation of temporal arteritis? Why is this a “headache emergency”?

1.10.8 Differentiate trigeminal neuralgia from atypical facial pain. How would you treat each?

1.10.9 Is sinus surgery effective in the management of patients with headaches?

Parsons DS, Batra PS. Functional endoscopic sinus surgical outcomes for contact point headaches. Laryngoscope. 1998 May;108(5):696-70. PMID:9591548

Becker DO, Cunning DM. Directed functional endoscopic sinus surgery and headaches. Arch Otolaryngol Head Neck Surg. 2000 Oct;126(10):1274-6. PMID:11031419 

1.10.10 What is the anterior ethmoid nerve syndrome?

1922 - Sluder first described the syndrome

• • Forehead pain, right or left sided, more or less limited between the brows, extending above the supraciliary ridge and below into the nasal bones, occasionally referred to the orbit or nasal cavity

  • Not intense

  • Not associated with eye use

  • Irregular development, may become constant

1949: THE ANTERIOR ETHMOIDAL NERVE SYNDROME Referred Pain and Headache from the Lateral Nasal Wall

Definition

• • A series of symptoms resulting from irritation of the terminal branches of the anterior ethmoidal nerve (see Wikipedia)

Symptoms

• • referred pain chiefly of the sinus type but may also take the form of headache, sometimes of a migrainous character

1963: The Anterior Ethmoid Nerve Syndrome

Diagnosis

• • Confirmed with application of cocaine to the entry point where the nerve lies in the nasal fossa

  • Likewise, touching the contact point should reproduce the pain prior to topical anesthesia  

http://www.fauquierent.net/contactheadache.htm

AKA Sluder’s neuralgia, a type of contact point headache (think of sciatica)

• • Usually starts after URI

  • Pain localized to a single location, unilateral

  • Often mistaken as migraine

  • Pain can be sharp or shooting

  • Decongestants like Sudafed seem to work best to provide temporary relief

CT / MRI may be useful to identify an anatomical compression and / or rule out other pathology

2005: Craniofacial pain and anatomical abnormalities of the nasal cavities

Anatomy (also, see link here and see Wikipedia - Anterior ethmoidal foramen)

AEN pathway

• • leaves the orbit through the foramen and anterior ethmoid canal to enter into the anterior cranial fossa

  • after passing through the dura and bone, it reaches the nasal cavity through the fissure close to crista galli

  • goes down through the sulcus on the internal aspect of the nose bone and then is exteriorized by going through the nose bone and superior lateral cartilage as external nasal nerve

  • In the nasal cavity, there are medial branches to the septum and lateral branches to the anterior portions of the medium and superior concha and to the lateral wall anterior to them

Pathophysiology

• • The anatomical characteristics of the anterior ethmoid nerve, that is, its superficial pathway concerning the nasal mucosa and the narrow bone canals that it crosses, makes it susceptible to pathological processes

  • The innervation of the anterior portion of the medium concha and the corresponding region of the septum by the anterior ethmoid nerve can be confirmed by stimulating these areas, which will cause pain in the distribution of infra and supra-troclear nerves, skin divisions of the ophthalmic branch, corresponding to inner canthus and supraorbital region

2011: Pulsed radiofrequency treatment of the anterior ethmoidal nerve under nasal endoscopic guidance for the treatment of postherpetic neuralgia

• • The nerve can be ablated through a transnasal endoscopic approach

More on anatomy