Surat Tanprawate, MD, MSc(Lond.), FRCP(T) Neurology Division, Faculty of Medicine Chiang Mai University
Outline
Headache and facial pain vs ENT conditions Central vertigo Neuro-otologic syndrome
11. Headache or facial pain attributed to disorder of the Headache attributed to . (specic causes) cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other 3. Part 3: painful cranial neuropathies facial or cervical structure
cranial neuralgias
Otalgia
Migraine introduction
Cause
Genetic
Pathophysiology! - Aura! - vasodilatation! - neurogenic inammation! - peripheral and central sensitization! - Trigemino vascular system! Neurotransmitter! - Serotonergic system! - Dopaminergic system! Structural and functional brain change! - Brain stem activation
constant
acute on chronic
Clinical: chronic and transform migraine, allodynia, neck pain! ! Anatomical: PAG, central sensitization
Evolution of Migraine
Tension-type headache
Dull aching, constant, mild to moderate pain Bilateral location Featureless headache
Sinus headache often self-diagnosed or diagnosed in primary care setting 810 pts with diagnosed as migraine; 78% stated that they were having sinus headache 100 self-diagnosed sinus headache pt.; 86% met criteria for migraine (only 3% had acute sinusitis)
841 subjects had migraine, out of which 226 reported accompanying unilateral autonomic symptoms 26.9%
Migraine features:
Pain: throbbing/dull aching Location: unilateral/bilateral/alternate site Associated symptoms: photo-/phonophobia, nausea/vomiting
Tension-type headache
Pressure-tightening-constant-frontal pain: misdiagnosed as sinus headache Hints: location, sinus symptoms, response to medication
Headache attributed to rhinosinusitis! Acute sinus headache! A. Frontal headache accompanied by pain in one or more regions of the face, ears or teeth and fullling criteria C and D B. Clinical, nasal endoscopic, CT and/or MRI imaging and/or acute-on-chronic rhino sinusitis C. Headache and facial pain develop simultaneously with onset or acute exacerbation of rhino sinusitis D. Headache and/or facial pain resolve within 7 days after remission or successful treatment of acute or acuteon-chronic rhinosinusitis
A. Purulent discharge in nasal passage either spontaneous or by suction B. Pathological nding in one or more tests; X-ray, transillumination, CT/MRI C. Simultaneous onset of headache and sinusitis D.Headache location; 1. frontal, 2. maxillary, ethmoiditis, sphenoiditis E. Headache disappears after treatment of acute sinusitis
11. Headache or facial pain attributed to disorder of the cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cervical structure
Clinical, nasal endoscopic and/or imaging evidence Temporal relation/waxes and wanes with degree of congestion Exacerbated by pressure applied over paranasal sinus Ipsilateral to unilateral rhinosinusitis chronic pathology causes persistent headache?: controversy
Deviation of nasal septum Hypertrophy of turbinates Atrophy of sinus membranes Mucosal contact disease
Intermittent pain localised to the periorbital and medial canthal or temporozygomatic regions and fullling criteria C and D Clinical, nasal endoscopic and/or CT imaging evidence of mucosal contact points without acute rhinosinusitis Evidence that the pain can be attributed to mucosal contact based on at least one of the following:
pain corresponds to gravitational variations in mucosal congestion as the patient moves between upright and recumbent postures abolition of pain within 5 minutes after diagnostic topical application of local anaesthesia to the middle turbinate using placebo- or other controls1
Pain resolves within 7 days, and does not recur, after surgical removal of mucosal contact points
ICHD-II 2004
Migraine vs Vertigo
New diagnostic criteria of Vestibular migraine (A1.1.6) : ICHD-III Beta version 2013
A. At least ve episodes fullling criteria C and D" B. A current or past history of 1.1 Migraine without aura or 1.2 Migraine with aura" C. Vestibular symptoms of moderate or severe intensity, lasting between 5 minutes and 72 hours D. At least 50% of episodes are associated with at least one of the following three migrainous features:"
1. headache with at least two of the following four characteristics: unilateral location, pulsating quality, moderate or severe intensity, aggravation by routine physical activity" 2. Photophobia/phonophobia" 3. Visual aura"
E. Not better accounted for by another ICHD-III diagnosis or by another vestibular disorder ICHD-III Beta 2013
Truth about VM
VM may be not associated with migraine headache Temporal relation of vestibular symptoms - headache is variable Duration of dizziness/vertigo range from seconds to days Vestibular symptoms; spontaneous vertigo/gait instability/ visual motion sensitivity/dizziness induced by head movement During an attack-nystagmus is common
peripheral
central
shared vestibular system and migraine generator
posterior insular cortex anterior insular orbitofrontal cortex posterior and anterior cingulate gyri
Non-specic medication
(Imigran)
(Zomig)
Group 1! Anti-epileptic drug! - Na valproate - Topiramate Anti-depressants! - Amitryptyline Beta-blockers! - Metoprolol - Propranolol - Timolol Other ! -Petasites (butterbur)
!
prophylactic;
nortriptylline, verapamil, metoprolol, topiramate, unarizine, valproic acid, lamotrigine CAI: acetazolamine
Otalgia
No pathology of the ear can cause headache without concomitant otalgia Primary otalgia+/- headache: structural lesion of pinna, external auditory canal, tympanic membrane or middle ear
middle ear
2nd & 3rd cervical roots (great auricular nerve and lesser occipital nerve)
base of skull
Description:
A rare disorder characterized by brief paroxysmal of pain felt deeply in the auditory canal, sometimes radiating to the parietooccipital region. It may develop without apparent cause or as a complication of Herpes zoster
A severe, transient, stabbing, unilateral pain experienced in the ear, base of the tongue, tonsillar fossa and/or beneath the angle of the jaw. It is commonly provoked by swallowing, talking and/or coughing, and may remit and relapse in the fashion of classical trigeminal neuralgia.
an intraoral burning sensation, recurring daily for more than 2 hours per day over more than 3 months, without clinically evident causative lesion
Neck-Tongue Syndrome
Vertigo
Time-course-onset: acute, chronic recurrent Otological symptoms: hearing loss Neurological symptoms: neuro signs Ophthalmologic symptoms: nystagmus Associated symptoms: headache, nausea/vomiting Triggers: position, Special test: MRI, Audiogram, nystagmography
Rapid onset of sustained vertigo, nausea and vomiting (in association with nystagmus, unsteady gait, and and head motion intolerance) days to weeks Classical symptoms
Unilateral (fascicular) lesion of the entry zone of the eight nerve, vestibular nucleus lesions, vestibulocerebellar lesions No sign of other brain stem lesions
Features; latency of onset of symptoms after positioning, duration of nystagmus bouts, course of nystagmus during an attack, vertigo Paroxysmal downbeat, upbeat, or torsional nystagmus -> lesion of central origin
Benign paroxysmal positioning nystagmus vs Central positioning nystagmus and vertigo (pseudo-BPPV)
Features Latency following precipitating positioning manoeuvre Duration of attack Direction of nystagmus Fatigability Course of nystagmus and vertigo in an attack Vertigo Nausea/vomitting Natural course of the condition Associated neurological s/s Brain imagining BPPV 1-15 sec (shorter in h-BPPV) 5-6 sec (longer in h-BPPV) During stimulation in the plane of the affected canal Typical, rare in h-BPPV Crescendo-decrescendo typical, no common in h-BPPV Typical
Rare on single precipitating manoeuvre (associated with intense nystagmus
Spontaneous recovery within weeks possible None possible, often cerebellar and other oculomotor sign Normal; lesions of the dorsal vermis a/ o dorsolateral to the fourth ventricle
Neuro-otalgic syndrome
Hearing loss
Central hearing loss
-
Cortical deafness
Conduction HL
Sensorineural HL
Genetic
-
Acquire
Syndromic: Alport syndrome, Treacher-Collin syndrome, Usher syndrome etc Neurobromatosis type 2 (NF 2) Mitochondrial disease
MELAS
Encephalopathy Cochlear origin; (seizures+/symmetric dementia); stroke gradual onset like; mitochondrigl SNHL myopathy
MERRF
Short statue; dementia;optic Myoclonus;epilepsy; atrophy;cardiomyo cerebellar myopathy pathy;WPW synd; neuropathy Cardiac conduction Retinitis block;cerebellar pigmentosa;aphthal syndrome;short moplegia stature;impair intellect
KSS
MELAS;mitochondrial encephalomyopathy, lactic acidosis and stroke like episodes MERRF; myoclonic epilepsy with ragged red bres KSS; Kearns-Sayre syndrome
Cortical deafness
unable to hear sounds but has no apparent damage to the anatomy of the human ear (damage to primary auditory cortex)
auditory agnosia;
amusia;
Thank you