Headaches and Facial Pain

A migraine is not just a bad headache. Migraines are caused by irritation of the trigeminal nerve, which provides sensation to the face and head. It is not caused by the brain itself and does not imply there is a problem with the brain.

Symptoms: Intense, throbbing pain, usually on one side of the head but it can be on both sides. This pain can last from a few hours to several days and is often accompanied by other symptoms such as nausea, vomiting, and sensitivity to light and sound. Some patients are awakened from sleep by their migraines.

Migraines can occur with or without an aura. An aura is a warning the migraine is coming and can be anything from an odd sensation, to abdominal pain, to seeing flashing lights or wavy lines, to difficulty concentrating. It usually starts before the migraine pain begins.

Triggers: See the list of common headache triggers in the next section. Avoiding these triggers is the basis for control of migraines.

Risk Factors: Family history of migraine, age (migraines usually begin during adolescence or young adulthood and some women get migraines as they go through menopause), head trauma, bruxism (teeth grinding or jaw clenching, often done unconsciously), and temporomandibular joint (TMJ) syndrome.

Treatments: Medications – both for acute migraines and for migraine prevention.
If migraine frequency is more than 4-6 migraines per month, migraine prevention becomes important to prevent both worsening of migraines and medication overuse headaches.

Medications may be oral, injected, or IV infusions. Other treatments include physical therapy, neurostimulation, and biofeedback. The treatment for migraines remains the same, whether or not the patient experiences an aura.

All headaches, including migraines, have triggers that can provoke them or make them worse. Some triggers are common to everyone while others are specific to each person. General triggers that are common to everyone include:

• Lack of sleep
• Poor eating habits
• Dehydration
• Dry eyes
• Caffeine withdrawal
• Stress
• Too much artificial light
• Overuse of computers, tablets, and cellphones
• Hormonal contraceptives

Most people also have specific triggers. These are typically certain foods or smells that will trigger a headache. There is a common misconception that red wine, cheese, or chocolate trigger migraines. This is not the case. Some people may be sensitive to any or all of those things but most people can have them without triggering a headache. Paying close attention to the patterns of your headaches will help identify which specific triggers affect you.

This is a type of headache that occurs when the occipital nerve at the back of the head becomes irritated or inflamed.

Symptoms: Sharp, shooting pain in the back of the head, neck, or behind the eyes. The pain might feel like an electric shock or a burning sensation. Untreated occipital neuralgia can also cause migraines.

Triggers: Brushing your hair or turning your head, too much pressure on the back of the head.

Risk Factors: Trauma or surgery at the back of the head. This leads to scar tissue formation that entraps the nerve and causes pain.

Treatments: Medication, physical therapy, and occipital nerve blocks. In cases where there is nerve entrapment by scar tissue that does not resolve with occipital nerve blocks alone, a simple surgical release by a plastic surgeon can help.

This condition causes facial pain that occurs when the trigeminal nerve, which provides facial sensation, becomes irritated or inflamed.

Symptoms: Sudden, acute bursts of severe facial or dental pain that feel like an electric shock or an intense, stabbing pain on one side of the face. These bursts of pain can last from a few seconds to a couple of minutes and may occur in quick succession.

Triggers: Chewing, speaking, or even lightly touching the face.

Risk Factors: Blood vessel compressing the trigeminal nerve just as it exits the base of the brain at the brainstem, multiple sclerosis, and some tumors. Often, there is no identifiable cause.

Treatments: Medication, trigeminal nerve blocks, surgery to relieve pressure on the nerve (if indicated).

Many people with this condition come to believe that surgery will cure them. Unless there is clear evidence of nerve compression, surgery is unlikely to provide lasting pain control. There are many people who have had more than one such procedure and continue to have pain. Most patients need to continue to take medications even after a successful surgery.

Trigeminal neuralgia is not a dental problem. Some people go so far as to have teeth extracted thinking this will relieve their pain. Unless there is a dental condition irritating the nerve, there is usually no need to have teeth extractions to treat trigeminal neuralgia.

Medication Overuse Headache (MOH), also known as rebound headache, occurs due to the overuse of any type of pain-relieving headache medications.

Symptoms: Persistent headaches that occurs almost daily or daily. The headaches often start upon waking and may improve temporarily with medication, only to return as the medication wears off. Other symptoms can include nausea, irritability, difficulty concentrating, and restlessness.

Triggers: Frequent or excessive use of pain-relieving medications, including over-the-counter medications.

Risk Factors: Pre-existing headache disorders that are not controlled, chronic stress or anxiety, lack of preventive treatment.

Treatments: Discontinue the overused medications.

This process can be challenging and may require medical supervision to manage withdrawal symptoms, even of over-the-counter medications. Treatment also includes using of preventive medications to reduce headache frequency and non-pharmacological therapies such as cognitive-behavioral therapy (CBT) and biofeedback. In some cases, hospitalization may be necessary to safely manage withdrawal and initiate a new treatment regimen.

Cluster headaches are a type of severe headache that occurs in cyclical patterns or clusters.

Symptoms: Intense, burning or piercing pain on one side of the head, usually around the eye. The pain can last from 15 minutes to three hours. It may occur several times a day, typically at the same time each day and often at night. These headaches occur for a period of days, weeks, or months and then resolve completely, although it frequently returns for another cycle of headaches.

Other symptoms can include a red or watery eye, a drooping eyelid, nasal congestion, or a runny nose on the affected side. Because these are not migraines, patients do not get auras and lying in a dark, quiet room may not help.

Triggers: Alcohol, strong smells, and certain foods (which specific food varies by patient)

Risk Factors: Men are more likely to experience cluster headaches than women.
Age between 20 and 50 years-old.
Tobacco use.
Having a family history of cluster headaches.
Disrupted sleep

Treatments: Medication, oxygen therapy. Some patients keep a cylinder of oxygen at home to provide fast-acting relief of these headaches.