Orofacial Cluster Headache

Orofacial pain disorders: An overview and diagnostic approach

Background:

Non-dental orofacial pain disorders are not uncommon, but idiopathic or primary facial pain syndromes are rare. Inadequate recognition of these disorders usually leads to unsatisfactory and unmet treatment needs.

Methods:

We conducted a narrative review with a literature search in PubMed until December 2021, focusing on current guidelines and the recently published International Classification of Orofacial Pain (ICOP).

Results:

In this paper, we provide an updated overview of the common orofacial pain disorders following the ICOP, covering the classification, epidemiology, pathophysiology, clinical approaches, and treatment options. Additionally, we propose a pragmatic approach focusing on the attack duration to improve distinguishing orofacial disorders.

Conclusion:

The introduction of ICOP offers the opportunity to better coordinate and concentrate scientific efforts, which lays the foundation for the identification of the disease mechanism of facial pain disorders and the optimization of the currently still insufficient therapeutic strategies.

Facial presentations of migraine, TACs, and other paroxysmal facial pain syndromes

Objective

To assess the prevalence of facial pain (V2 and/or V3) presentations among nearly 3,000 patients with headache treated in a university tertiary care center.

Methods

Between 2010 and 2018, we routinely assessed the prevalence of facial pain presentations of all patients with primary headaches.

Results

Of 2,912 patient datasets, 291 patients reported facial pain either as an independent or as an additional symptom. Among patients with migraine, 2.3% (44 of 1,935) reported a facial involvement, most commonly in V2. Of these, 18 patients (40.9%) experienced the pain predominantly in the face. In patients with cluster headache, 14.8% (42 of 283) reported a facial involvement, of which 31.0% perceived the pain predominantly in the face. A facial involvement was seen in 45.0% of patients with paroxysmal hemicrania (9 of 20), 21.4% of patients with hemicrania continua (9 of 42), and 20.0% of patients with short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing/short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms (3 of 15). In addition, we present 6 patients who reported a constant side-locked facial pain with superseded well-defined facial pain attacks of 10- to 30-minute duration that appeared several times per day.

Conclusion

Our data suggest that a facial involvement in primary headaches is infrequent but not uncommon. A sole facial presentation of primary headache symptomatology seems to be exceptionally rare. We describe 3 different types of facial pain involvement and, in this context, distinguish patients with paroxysmal orofacial pain syndromes that have not been previously described. These patients may represent a new entity that could tentatively be called constant unilateral facial pain with added attacks.

Persistent idiopathic facial pain

Background

Persistent idiopathic facial pain (PIFP) is a chronic disorder recurring daily for more than two hours per day over more than three months, in the absence of clinical neurological deficit. PIFP is the current terminology for Atypical Facial Pain and is characterized by daily or near daily pain that is initially confined but may subsequently spread. Pain cannot be attributed to any pathological process, although traumatic neuropathic mechanisms are suspected. When present intraorally, PIFP has been termed ‘Atypical Odontalgia’, and this entity is discussed in a separate article in this special issue. PIFP is often a difficult but important differential diagnosis among chronic facial pain syndromes.

Aim

To summarize current knowledge on diagnostic criteria, differential diagnosis, pathophysiology and management of PIFP.

Methods

We present a narrative review reporting current literature and personal experience. Additionally, we discuss and differentiate the common differential diagnoses associated with PIFP including traumatic trigeminal neuropathies, regional myofascial pain, atypical neurovascular pains and atypical trigeminal neuropathic pains.

Results and conclusion

The underlying pathophysiology in PIFP is still enigmatic, however neuropathic mechanisms may be relevant. PIFP needs interdisciplinary collaboration to rule out and manage secondary causes, psychiatric comorbidities and other facial pain syndromes, particularly trigeminal neuralgia. Burden of disease and psychiatric comorbidity screening is recommended at an early stage of disease, and should be addressed in the management plan. Future research is needed to establish clear diagnostic criteria and treatment strategies based on clinical findings and individual pathophysiology.

Differences in clinical characteristics and frequency of accompanying migraine features in episodic and chronic cluster headache

Introduction: Data on clinical differences between episodic (eCH) and chronic cluster headache (cCH) and accompanying migraine features are limited.

Methods: History and clinical features of 209 consecutive cluster headache patients (144 eCH, 65 cCH; male:female ratio 3.4 : 1) were obtained in a tertiary headache centre by face-to-face interviews. Relationship between occurrence of accompanying symptoms, pain intensity, comorbid migraine, and circannual and circadian rhythmicity was analysed.

Results: 99.5% of patients reported a minimum of one ipsilateral cranial autonomic symptom (CAS); 80% showed at least three CAS. A seasonal rhythmicity was observed in both eCH and cCH. A comorbid headache disorder occurred in 25%. No significant difference was detected between patients with comorbid migraine and without regarding occurrence of phonophobia, photophobia or nausea during cluster attacks. Patients with comorbid migraine reported allodynia significantly ( p = 0.022) more often during cluster attacks than patients without comorbid migraine.

Conclusion: Occurrence of CAS and attack frequency, as well as periodic patterns of attacks, are relatively uniform in eCH and cCH. Multiple CAS are not related to pain intensity. Allodynia during cluster attacks is a frequent symptom. The unexpectedly high rate of accompanying migrainous features during cluster attacks cannot be explained by comorbid migraine.

Cluster headache: clinical features and therapeutic options

BACKGROUND

Cluster headache is the most common type of trigemino-autonomic headache, affecting ca. 120 000 persons in Germany alone. The attacks of pain are in the periorbital area on one side, last 90 minutes on average, and are accompanied by trigemino-autonomic manifestations and restlessness. Most patients have episodic cluster headache; about 15% have chronic cluster headache, with greater impairment of their quality of life. The attacks often possess a circadian and seasonal rhythm.

METHOD

Selective literature review

RESULTS

Oxygen inhalation and triptans are effective acute treatment for cluster attacks. First-line drugs for attack prophylaxis include verapamil and cortisone; alternatively, lithium and topiramate can be given. Short-term relief can be obtained by the subcutaneous infiltration of local anesthetics and steroids along the course of the greater occipital nerve, although most of the evidence in favor of this is not derived from randomized clinical trials. Patients whose pain is inadequately relieved by drug treatment can be offered newer, invasive treatments, such as deep brain stimulation in the hypothalamus (DBS) and bilateral occipital nerve stimulation (ONS).

CONCLUSION

Pharmacotherapy for the treatment of acute attacks and for attack prophylaxis is effective in most patients. For the minority who do not gain adequate relief, newer invasive techniques are available in some referral centers. Definitive conclusions as to their value cannot yet be drawn from the available data.

[Impact of physiotherapy, massages and lymphatic drainage in migraine therapy]

Physical treatment, spinal manipulative therapy and massages are often recommended to treat migraine as a prophylactic therapy. Clinical experience and theoretical concepts support their usefulness. However, data on these therapies are scarce. On the basis of the available studies, it is impossible to determine whether or not these therapies are effective. There is a lack of well-designed prospective, randomized controlled trials with a sufficiently long follow-up to observe these therapies. Due to the high acceptance of physical treatment on the one hand and preconceptions about drug treatment on the other, these types of therapies may be an alternative option for some patients if their efficacy is established. A cost-benefit analysis of theses therapies should consider the long amount of time required for them compared with drug intake.

Pain remapping in migraine: a novel characteristic following trigeminal nerve injury

The location of pain during the headache phase of migraine varies between individuals as well as between attacks in some individuals. We have observed a "remapping" or a change in the location of migraine pain following injury to the trigeminal system that is a novel characteristic to migraine and has not been described in other trigeminal pain syndromes of the head, neck, and face. Recognition of this clinical feature implies that the pathophysiology of migraine is impressionable and may be why diagnosis and treatment are often delayed.