Headache, facial pain and cranial nerve palsy (1)

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Information about Headache, facial pain and cranial nerve palsy (1)

Published on March 12, 2014

Author: magician10k

Source: slideshare.net

DR MOHAMED ALMAGHRABY PROF OF INTERNAL MEDICINE

 Headache affects most people at least occasionally.  Headache denotes pain or discomfort from the level of the brows back to the suboccipital region.

Pain sensitive structures leading to headache are:  Cranial venous sinuses with afferent veins  Arteries at base of the brain and their major branches  Arteries of the dura  Dura near base of brain and large arteries  All extracranial structures

Primary headache  It is a condition in which headache is a primary manifestation with no underlying disease.  It is usually benign and recurrent Secondary headache  It is a condition in which headache is a secondary manifestation of an underlying disease process. It is usually sudden and progressive

 Migraine  Tension type headache  Cluster headache  Other benign headache

 It is the most common of the primary headache disorders  It is due to pain from vascular structures and muscular sources  More common in women  Episodic and chronic forms  Pain characteristics: pressing/tightening quality, mild to moderate severity, bilateral location and no aggravation by routine physical activity

 It is an idiopathic recurring headache disorder  Attacks last 4-72 hours  Typically headache is unilateral, have a pulsating quality, moderate to severe in intensity  Aggravated by routine physical activity  Associated with nausea, vomiting, photophobia and phonophobia  May be preceded by visual, sensory, motor or autonomic manifestations (AURA)

 Symptomatic therapy: analgesics such as paracetamol and non steroidal anti- inflammatory drugs  Specific abortive therapy: given to shorten the attack or decrease the severity of headache as ergotamine and sumatriptan  Prophylactic (preventive) therapy: beta blockers, calcium channel blockers and tricyclic antidepressants.

 It is extremely severe headache  Unilateral headache that produce pain in the area around and above the eye  Attacks lasts 15 minutes to 3 hours  Occurring as often as 8 times daily and lasts from weeks to months

 Aneurysms, arteriovenous malformation [AVMs] and subarachnoid hemorrhage  Meningitis  Stroke  Trigeminal neuralgia  Temporal arteritis  Hypertension  Benign intracranial hypertension  Lumbar puncture headache  Referred headache: due to diseases of the eye, ear, nasal sinuses, mouth and teeth  Psychogenic headache: in cases of depression and anxiety states, usually in the form of sense of pressure or bandage around the head

 Onset after age 50  Sudden onset  Increased frequency and severity  New onset with risk factors for HIV or cancer  Associated with systemic illness (fever, rash)  Altered consciousness  Significant trauma

 Facial pain must be distinguished from headache.  The most common cause of facial pain by far is dental; provocation by hot, cold, or sweet foods is typical.  Trigeminal and, less commonly, glossopharyngeal neuralgia are frequent causes of facial pain. Neuralgias are painful disorders characterized by paroxysmal, fleeting, often electric shock–like episodes that are frequently caused by demyelinating lesions of nerves.  Vague, poorly localized, continuous facial pain is characteristic of nasopharyngeal carcinoma.

 Function: smell  Its lesion causes anosmia  Bilateral anosmia is usually due to local cause in the nose as common cold

 Function: vision  Its lesion causes total blindness in one eye if there is complete section of one optic nerve

 Function: it is purely motor and is responsible for lifting the upper eyelid, turning the eye upward, downward and medially, constricting the pupil and accommodating the eye  Its lesion causes squint, diplopia and ptosis (drooping of the upper eyelid) with dilated pupil and loss of accommodation

3rd NERVE PALSY

 Function: purely motor turning the eye downward and laterally  Its lesion causes squint and diplopia

 Function: it contains both sensory and motor fibers  It carries sensation from the face through three divisions; optic, maxillary and mandibular nerves  It supplies motor fibers to muscles of mastication  Its lesion causes: A- sensory affection: loss of the sensation on the corresponding side of the face with loss of corneal reflex B- motor affection: weakness of the muscles of mastication on the same side of the lesion

 It is severe stabbing pain along one or more of the sensory branches of trigeminal nerves over the face  It is of unknown cause  The attack may be precipitated by movements of the jaws as chewing, laughing, brushing of the teeth  Between the paroxysms of pain, the patient is asymptomatic  Treatment: analgesics, anticonvulsant as carbamazepine, lesioning of the gasserian ganglion (either by radiofrequency or glycerol injection) or posterior fossa craniotomy to releive the compression of trigeminal nerve

 Function: supply the lateral rectus muscle of the eye ball, responsible for turning the eye laterally  Its lesion causes squint, diplopia on looking outwards towards the paralysed side

 Function: both motor and sensory a- supplies the muscles of facial expression, the auricular muscles, the stapedius, the posterior belly of the digastric, and the styloid muscle b- recieves taste fibers of the anterior 2/3 of the tongue, the floor of the mouth and the palate c- supplies the submandibular and sublingual salivary glands and the lacrimal gland  The upper part of its motor nucleus is bilaterally supplied from the pyramidal tracts of both sides, while the lower part is unilaterally supplied from the pyramidal tracts of the opposite side only

Facial nerve lesion The lesion may be  UMNL affecting the pyramidal tracts above the facial nucleus  LMNL affecting the facial motor nucleus or the nerve itself

In UMNL:  The angle of the mouth will sag  Obliteration of the nasolabial fold on the affected side  Saliva will dribble from the corner of the mouth  Inability to expose the teeth fully on the affected side  Inability to blow the teeth on the affected side

In LMNL: There are in addition:  Inability to close the eye  Inabilty to raise the eye brows with absence of wrinkles of the forehead on the affected side

Definition: unilateral facial paralysis of sudden onset and unknown cause Etiology: it is due to ischemia and edema of the facial nerve caused by cold exposure, secondary to viral and/or autoimmune reactions Clinical picture: acute onset of pain behind the ear, complete paralysis of the facial muscles on the affected side of LMN nature, impairment of taste sensation of the anterior 2/3 of the tongue on the same side

Treatment:  Measures to prevent corneal drying as natural tears, isotonic saline and methyl cellulose drops  Medical: corticosteroids, vitamins and antiviral (acyclovir)  Physiotherapy  Surgical: hypoglossal facial nerve anastomosis if no improvement after 6-12 months

 Function: the cochlear division conducts nerve impulses concerned with sound, while the vestibular division conducts nerve impulses concerning the position and movements of the head  Its lesion causes tinnitus, deafness, vertigo, ipsilateral incoordination and spontaneous nystagmus

 Function: motor to the stylopharyngeus and superior constrictor muscles of the pharynx, sensory from the pharynx, tonsils and posterior 1/3 of the tongue and taste sensation from posterior 1/3 of the tongue  Its lesion causes loss of taste and common sensations from the posterior 1/3 of the tongue and loss of pharyngeal reflex on the same side of the lesion

 Function: 1. motor to the soft palate, pharynx and larynx 2. sensory from the skin over the external auditory meatus and the mucous membrane lining the gastrointestinal tract and respiratory tract 3. autonomic fibers to the heart, the gastrointestinal tract and the bronchial tree  Its lesion causes hoarseness or absence of voice

 Function: the cranial part joins the vagus nerve and shares in the innervation of the soft palate pharynx and larynx. The spinal part supplies strenomastoid and trapezius muscles  Its lesion causes weakness of the sternomastoid and trapezius muscles

 Function: carries motor fibers to the muscles of the tongue  Its lesion causes unilateral deviation of the tongue

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