Headache and Facial Pain
Headache & Facial Pain
Chronic headache is a very common condition that accounts for 4.4% of primary care consultations (6.4% females and 2.5% males). The most common varieties of headache seen on chronic pain clinics include cervicogenic (coming from the neck), tension type headache and chronic migraine.
There are no blood tests or scans that can confirm these conditions and help make the diagnosis. Furthermore, with these headache types, clinical examination is usually normal. This means that the variant of headache is usually diagnosed on the history alone.
Do I Need a Brain Scan?
The vast majority of headache variants are known as primary headache. This means that the headache itself is the main condition, and that it has not been caused by another condition.
The main presentations of primary headache are:
- Tension-type headache
- Cluster headache and other trigeminal autonomic cephalalgias
- Other primary headaches
These conditions are usually diagnosed from the description of the pain and further scans and investigations are not necessary.
Certain ‘red flags’ can be identified in the history that would suggest that this is a secondary headache (i.e. it is a symptom of another condition) and that a brain scan or blood tests might be necessary.
Potential Secondary Headache Red Flags—“SNOOP-IT”
- SYSTEMIC SYMPTOMS (fever, weight loss)
- NEUROLOGIC SYMPTOMS or abnormal signs (confusion, impaired alertness or consciousness)
- ONSET: sudden, abrupt, or split-second (Thunderclap headache)
- OLDER: new onset and progressive headache, especially in middle i.e. age over 50 years (giant cell arteritis)
- PREVIOUS HEADACHE HISTORY: first headache or different (change in attack frequency, severity, or clinical features) i.e. has the pattern of headache changed?
- Infection i.e. meningitis, encephalitis
If these features are not present in your description of your headache, your headache is almost certainly one of the primary headaches and further scans are not necessary.
What are the commonest types of headache and facial pain seen at a pain clinic?
The commonest types of headache and facial pain seen at the chronic pain clinic include
- Tension type headaches
- Occipital neuralgia
- Cervical pain
- Trigeminal neuralgia
- Temporomandibular joint pain
- Atypical facial pain
- Facial migraine
What treatments can be offered for my chronic headache / facial pain?
Your chronic pain specialist will take a full history, consider any ‘red flags’ that may be present and decide if any further investigations are necessary.
You will then get a plan for the management of your headache / facial pain, tailored for your own particular needs.
Treatments that may be offered for your headache include
- Appropriate pharmacotherapy – using a wide range of drugs including tricyclic antidepressants (TCA’s), anti-epileptic drugs (AED’s), tryptans and NSAID’s (anti-inflammatory drugs)
- Botulinum Toxin A (Botox) treatment (Approved for the treatment of chronic migraine)
- Radiofrequency (RF) treatment for trigeminal neuralgia
- Physiotherapy for cervicogenic headache
- Cognito-behavioural therapies – can help with coping and acceptance
What is Medication Overuse Headache?
It has long been known that ergotamine, the active ingredient of many of the older migraine medications (Tryptans), can cause headache if taken too frequently. It has also recently emerged that painkillers containing codeine (i.e. cocodamol) can exacerbate headache if taken too frequently. Headache sufferers tend to take this drug up to four times per day. These are the two groups of drugs most strongly linked with medication overuse headache (MOH).
It is likely that the headache is due to a sort of withdrawal syndrome once the positive effects of each dose have worn off.
The natural reaction is to take more medication, to provide short term relief, but this can again lead to further headache after some hours. People taking high dose analgesia usually need to be seen in specialist clinics as sudden and complete withdrawal of medications may lead to a severe withdrawal headache, that can last up to between 2–10 days. This headache may come alongside other symptoms, such as anxiety. During this period, it is important to drink plenty of water to keep well hydrated.