Many types and etiologies of headache and facial pain afflict our patients, and sorting through them can be a challenge. Craniofacial experts themselves, in fact, do not attempt to remember the subtle differences between the various conditions causing craniofacial pain, but instead refer to the third edition of the International Classification of Headache Disorders (ICHD-3). (https://www.ichd-3.org/.)
The ICHD-3 can help the clinician manage patients presenting with headache as their chief complaint. An international panel of headache experts oversee the classification, which is currently published in a beta format so mistakes can be identified and corrected.
Therapeutic management varies significantly depending on the actual type of headache, and a more precise diagnosis makes a difference in treatment success. Gaining maximal diagnostic competence improves our therapeutic accuracy and affects the lives of our patients.
This important classification currently has three main sections: primary headaches, secondary headaches, and painful cranial neuropathies, other facial pains, and other headaches. A primary headache has no other etiology, and includes migraines, tension headaches, and the lesser-known headaches such as the paroxysmal hemicrania, hemicrania continua, cluster headache, short-lasting unilateral neuralgiform headaches, and primary stabbing, primary thunderclap, nummular, hypnic, and new daily persistent headaches.
A secondary headache comes from another underlying condition or emergency. The differentiation between primary and secondary headaches is critical. Primary headaches are classified as migraines, tension headaches, trigeminal autonomic cephalalgias, and other primary headache disorders. Each of these taxonomies are subclassified. Secondary headaches are the head and face pain etiologies that cause emergency physicians the most angst. Headaches caused by life-threatening conditions such as ruptured aneurysms and subarachnoid hemorrhages, subdural hematomas, cerebrovascular accidents, venous sinus thrombosis, and brain tumors are just a few of the secondary headache etiologies that can masquerade as primary headaches and trip up even seasoned EPs.
A 9-year-old boy crashed his motor bike and had a concussion, forehead contusion, and broken nose. A month later, he was still experiencing pain in his forehead, but rather than go right to CT or MRI, Dr. Mellick injected some bupivacaine for suspected post-traumatic supratrochlear neuralgia. The child's mother reported that his pain never returned.
Another major challenge is the complexity of the subclassifications of primary and secondary headaches as well as the painful cranial neuropathies and other facial pains and headaches. Without a reference tool such as the ICHD-3, the average clinician will rarely be able to make the diagnosis of the less common causes of craniofacial pain.
-Headache attributed to trauma or head or neck injury
-Headache attributed to cranial or cervical vascular disorder
-Headache attributed to nonvascular intracranial disorder
-Headache attributed to a substance or its withdrawal
-Headache attributed to infection
-Headache attributed to disorder of homeostasis
-Headache or facial pain attributed to disorder of the cranium, neck, eyes, ears, nose, sinuses, teeth, mouth, or other facial or cervical structure
-Headache attributed to psychiatric disorder
The third section of the ICHD-3 provides the diagnostic criteria for cranial neuropathies, other facial pains, and other headaches. This section outlines conditions such as trigeminal neuralgia, occipital neuralgia, optic neuritis, nine other lesser-known neuropathies and headaches without a clear-cut etiology or not fitting specific diagnostic criteria for any other headache diagnosis. Having access to the current diagnostic criteria for these uncommon and diagnostically challenging conditions is a huge potential help to the average clinician.
Painful Cranial Neuropathies and Other Facial Pains
-Nervus intermedius (facial nerve) neuralgia
-Headache attributed to ischemic ocular motor nerve palsy
-Paratrigeminal oculosympathetic (Raeder's) syndrome
-Recurrent painful ophthalmoplegic neuropathy
-Burning mouth syndrome
-Persistent idiopathic facial pain
-Central neuropathic pain
Headaches can be caused by life-threatening conditions such as aneurysms, like this patient who experienced a posterior communicating artery aneurysm and was taken for emergent aneurysm coiling.