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New Treatments for Headache and Facial Pain

With cluster headache, each headache episode goes on for about 5-10 minutes. Still unilateral, but the duration is brief. Muscle tension or tension-type of headache is a more continuous headache. The duration is important. Precipitating factors: cluster headache, alcohol is a very important precipitating factor. If you have headaches when you bend down, look for increased intracranial pressure.

What are some of the common problems? Migraine, cluster, chronic paroxysmal hemicrania is usually in females. Unilateral, severe, sharp, five to ten minute pains, but you have many bouts. Ten, 15, 20 a day. Whereas cluster is half-hour, one-hour headache bouts, two, three, four in 24 hour cycle. So thatís the difference. Sex is difference, duration, number of attacks is different. Chronic paroxysmal hemicrania dramatically responds to Indocin.

Migraine with aura or without aura. Unilateral throbbing, exertional vomiting, photophobia, phonophobia, go for migraine. A variant called ophthalmoplegic migraine will give you headaches and third nerve palsy, unilaterally.

Childhood migraine may give headaches and vomiting, but it does one other unique thing. It gives you episodic confusion. Something like non-convulsive status epilepticus, or childhood migraine may be manifest by episodic confusion only, without headaches. Cyclical vomiting in small children is considered a variant of migraine. Status migrainosus is migraine lasting more than one hour.

There is a physiological phenomenon called spreading depression. If you put potassium chloride on the brain surface, the neurons get suppressed. They donít work for a little bit. In experimental situations, this kind of depression spreads from the central spot more anteriorally.

Now the second important thing that has come up in the last several years is the role of the trigeminal nerve. Stimulate the trigeminal nerve, the trigeminal ganglion, impulses go in the wrong direction. If you look more peripherally you see blood vessel changes. You have vasodilatation, you have edema, you have CGRP, calcitonin gene-related protein, and substance P released in the blood vessel wall. Now some of these changes - I said about vasodilatation and plasma leakage - so there is a sterile inflammation taking place in the blood vessel wall.

When the sagittal sinus is stimulated  in experimental animals, producing a brain insult, what happens is ome of the brainstem neurons light up. C-phos expression means itís an acute change. These neurons are getting ready to fight. These kind of changes you see even in the C1 and the C2 regions, all the way down from the brainstem to C2. Some kind of non-specific insult can activate brainstem C1, C2 neurons, which includes the trigeminal system.

There is some evidence that migraine may actually be an ion channel-opathy. There is an entity called hemiplegic, familial hemiplegic migraine. They have migraine, they have hemiplegia and it is familial. Now the gene for that is in the 19th chromosome. Now there are some other potassium channel diseases that are linked to the similar area on the 19th chromosome.

In pregnancy, if you have patients with migraine, late in pregnancy donít use nonsteroidals. They may inhibit uterine contraction apparently. In early pregnancy - I looked up in some books - the chapters by the better clinicians, they say itís okay. Just very small dose, one or two may be all right. The same thing with antidepressants and calcium channel blockers.

Cluster headache. If you can do 100% oxygen, 6 liters, 8 liters, for about ten minutes, go ahead and do it. Lidocaine spray is the new stuff out. Imitrex; there is evidence that it works for cluster too. Steroids, Depakote is useful - there is literature - for prevention.

Trigeminal neuralgia in older people. The pain is brief. Look for trigger points, like chewing, brushing, washing the face, shaving. Now remember, most people will have pain in number II and III branch of the 5th. The pain in the first branch is uncommon. Examination should be normal. If you have someone with trigeminal pain with numbness, itís not trigeminal neuralgia, itís trigeminal neuropathy. You look for a primary problem. Trigeminal neuroma or vasculitis.

Chronic paroxysmal hemicrania pain is similar to cluster headache. Itís in females. The headache is brief but you have a dozen or two dozen headaches each day. Sometimes you can have migraine aura without headaches.