Sex, Gender, and Orofacial Pain

This review examines gender prevalence in orofacial pain to elucidate underlying factors that can explain such differences. This review highlights how gender affects (1) the association of hormonal factors and pain modulation; (2) the genetic aspects influencing pain sensitivity and pain perception; (3) the role of resting blood pressure and pain threshold; and (4) the impact of sociocultural, environmental, and psychological factors on pain.

Primary Headaches

The primary headaches are composed of multiple entities that cause episodic and chronic head pain in the absence of an underlying pathologic process, disease, or traumatic injury. The most common of these are migraine, tension-type headache, and the trigeminal autonomic cephalalgias. This article reviews the clinical presentation, pathophysiology, and treatment of each to help in differential diagnosis. These headache types share many common signs and symptoms, thus a clear understanding of each helps prevent a delay in diagnosis and inappropriate or ineffective treatment. Many of these patients seek dental care because orofacial pain is a common presenting symptom.

[Clinical management of migraine]

The migraine is historically one of the most studied primary headaches. There are many studies about migraine aura and its implications. Exists many physiopathological mechanisms that explain the migraine aura. The most studied is the Prolonged Cortical Depression. In spite of aura is a short timed and innocuous phenomena, there are cases that it could be a disabling condition. In this review we discuss the treatment options for pain and aura symptoms in migraine.

Trigemino-autonomic headache related to Gasperini syndrome

We report the association of ipsilateral trigemino-autonomic headache to a case of right-sided nuclear facial and abducens palsy (Gasperini syndrome), ipsilateral hypacusis and right hemiataxia, caused by the occlusion of the right anterior inferior cerebellar artery. Short-lasting attacks of mild to moderate ipsilateral fronto-periorbital head pain, accompanied by lacrimation and mild conjunctival injection during more severe attacks, were present from the onset of symptoms, with a gradual worsening over the next few months and remitting during naproxen therapy. Magnetic resonance imaging showed an infarct in the right cerebellar peduncle, extending toward the pontine tegmentum, also involving the ipsilateral spinal trigeminal nucleus and tract and the trigeminal entry zone. Gasperini syndrome may be accompanied by ipsilateral trigemino-autonomic head pain.

[Trigeminal autonomic cephalgias. After initial diagnosis, consider secondary causes]

Trigeminal autonomic cephalgias (TAC) are classified as primary headache syndromes. The use of instrumental procedures including neuroimaging in the diagnostic workup of the TACs is controversially discussed in the literature. Several case reports have been previously published, reporting trigeminal autonomic cephalgias related to structural lesions. We contribute two of our own cases of symptomatic TACs and demonstrate that a "classic" clinical presentation does not preclude a symptomatic etiology. Thus, we advocate a systematic diagnostic evaluation including neuroimaging in every patient presenting with symptoms indicative of TAC for the first time.

[The hypothalamus in SUNCT syndrome: similarities and differences with the other trigeminal-autonomic cephalalgias]

INTRODUCTION

SUNCT belongs to the group of trigeminal-autonomic cephalalgias (TAC) --cluster headache and paroxysmal hemicranias--, since its shares a series of features with them. SUNCT was finally included in this group when the hypothalamus was proved to play a key role in its pathophysiology, an aspect that it has in common with other TAC. However, its clinical resemblance to trigeminal neuralgia of the first branch is notable, although it is accepted that the genesis of the trigeminal neuralgia is peripheral.

DEVELOPMENT

The article presents the evidence available to date that has made it possible to associate the hypothalamus with SUNCT, as well as outlining its similarities and differences with respect to other TAC. This evidence is clinical, hormonal, from functional neuroimaging (activation of the posteroinferior hypothalamus) and from therapeutic outcomes (with deep hypothalamic stimulation). Likewise, a detailed description is provided of both the neuroanatomical bases (the hypothalamus as part of the neural networks involved in processes concerned with behaviour, memory, antinociceptive control, waking-sleep control and other circadian rhythms, etc.) and the neurochemical bases (orexins, somatostatin and endogenous opiates) that would support the hypotheses which researchers are attempting to establish to fit the evidence discussed earlier, which would have many points that overlap from one TAC to another.

CONCLUSIONS

The question as to whether the hypothalamus is the/a generator of TAC or whether it is an element that allows its development remains open to debate, as does the issue of which would be the most plausible explanation for the phenotypic differences between them. Future studies will allow the enigma of SUNCT and the other TAC to be explained.

Cranial autonomic symptoms in patients with pituitary adenoma presenting with headaches

Different types of symptomatic trigeminal autonomic cephalalgias (TACs) have been reported in patients with pituitary adenoma. We investigated the significance of the presence of cranial autonomic symptoms (CAS) in patients with pituitary adenoma presenting with headaches. The records of patients with pituitary adenoma from 1998 to 2004 in our headache clinic were reviewed including headache profile, presence or absence of CAS, and the characteristics of the pituitary adenoma. CAS were ascertained if one or more autonomic symptoms defined for the diagnosis of TACs in the International Classification of Headache Disorders, 2nd edition (ICHD-2) was identified. Thirty-three patients (24F/9M) with pituitary adenoma presenting with headache were recruited for this study: 18 with CAS (55%) and 15 without. Chronic migraine was the most common headache phenotype (n=16, 48%). Three patients were diagnosed as hemicrania continua-like and three, cluster headache-like. In the group with CAS (CAS+), the sides of the tumor were significantly concordant with the sides of headaches (kappa=0.58, p<0.001) and those of CAS (kappa=0.67, p<0.001). However, this relationship was not demonstrated in those without CAS (CAS-) (kappa=0.07, p=0.61). Compared with the patients in the CAS- group, the patients in the CAS+ group had higher frequencies of macroadenoma (78% vs. 40%, p=0.027) and acromegaly (50% vs. 7%, p=0.009). The presence and absence of CAS in pituitary adenoma-associated headache were associated with different characteristics of the underlying pituitary adenomas including side concordance and incidence of acromegaly and macroadenoma. The pathogeneses for headache might differ between these two groups.

Symptomatic trigeminal autonomic cephalalgia associated with allodynia in a patient with multiple sclerosis

A patient with symptomatic trigeminal autonomic cephalalgia (TAC) provides a chance to understand the pathophysiology and anatomic correlates of TAC. A 28-year-old woman experienced intermittent sharp and excruciating pain over her right temporal, ear and neck regions for 3 days. The headaches lasted 10-20 minutes each, occurred 1-2 times a day, and were accompanied by prominent ipsilateral lacrimation and conjunctival injection. The patient had hiccups, 4-limb numbness and impaired visual acuity in both eyes. She had also had 3 episodes of left-side optic neuritis in the past half year. Neurologic examination showed brushing allodynia over the right face and scalp during the headache attacks. The visual acuity of her right eye was 6/60 and that of the left eye was 1/60. Brain magnetic resonance imaging showed non-enhancing lesions on the right lateral tegmentum of the lower pons where the spinal trigeminal nucleus is located and the floor of the 4th ventricle. The patient was diagnosed as having multiple sclerosis with symptomatic TAC. Her headaches, autonomic signs and allodynia subsided 3 days after pulse therapy and gabapentin treatment were given. We suggest that the spinal trigeminal nucleus lesion was responsible for the symptomatology of TAC and cutaneous allodynia in our patient.

Trigeminal Autonomic Cephalgias Due to Structural Lesions

Trigeminal autonomic cephalgias (TACs) include cluster headache, paroxysmal hemicrania, and short-lasting unilateral neuralgiform headache with conjunctival injection and tearing. Associated structural lesions may be found, but a causal relationship is often difficult to establish. We sought to identify clinical predictors of underlying structural abnormalities by reviewing previously described and new TAC and TAC-like cases associated with a structural lesion. We found that even typical TACs can be caused by an underlying lesion. Clinical warning signs and symptoms are relatively rare. We recommend neuroimaging in all patients with a TAC or TAC-like syndrome.

[Primary cephaleas. A revision of their diagnosis and therapeutic approach]

This review focuses on primary headaches, its diagnosis and treatment. For the IHS specialists they are: migraine, tension-type headache (TTH), cluster and others. Migraine: the second in prevalence and the first in morbility, clinical features and differences between migraine with (Ma) and without aura (Mo).

EPIDEMIOLOGY

10% prevalence and 3:1 women to men proportion. Patophysiology: primary central nociception disorder with secondary vascular involvement.

TREATMENT

specific and non-specific, acute and preventive. Psychiatric disorders and migraine: there is evidence of clinical and pharmacological links, mainly between Ma and several psychiatric disorders. Migraine in childrens: important clinical and therapeutic differences from adult, importance of family approach. Migraine and hormones: the importance of estrogen drop, as trigger factor, treatment. Migraine and epilepsy: both shares neuronal hyperexcitability pattern. Migraine and stroke: vascular and ischemic factors involved. Evidence-based medicine: improves treatment's results and studies outcome evaluation. TTH: first in prevalence, still highly subdiagnosed. Main clinical presentations: episodic and chronic.

EPIDEMIOLOGY

slight female preponderance. Patophysiology and trigger factors: the role of limbic nociceptive system, sedentarism stress and muscular tension.

TREATMENT

pharmacological and non-pharmacological. Cluster headache: low prevalence but high daily-living activities impact, effective treatment. Other primary headaches: variability of trigger factors and role of desensitization process.

CONCLUSION

we remark the complexity of headache and the of physicians' role: to relief patients suffering, throughout a precise diagnosis and treatment.