Dolor De Cabeza

HEADACHE AND FACE PAIN
Overview
Headache and facial pain are common complaints in the emergency and outpatient setting.
The lifetime prevalence of headache is greater than 90%.[1] Most patients who present with
headache have 1 of the following 3 main headache syndromes: migraine, cluster headache, or
tension headache.[2]
However, headache and facial pain can have numerous other etiologiesthat are important for
the clinician to consider. The reader is referred to the International Headache Society (IHS)
classification for an exhaustive compilation of all headache and facial pain etiologies.
In the evaluation of headache and facial pain, the primary goal for the otolaryngologist is to
make a distinction between sinogenic and nonsinogenic causes of headache and facial pain.Relevant Neuroanatomy
The trigeminal nerve (cranial nerve V) and its constituent 3 major branches provide most
somatosensory innervation to the head and face region. The trigeminal nerve originates in the
lateral pons then divides into the following 3 divisions from the gasserian ganglion: the
ophthalmic (V-1), the maxillary (V-2), and the mandibular (V-3) divisions.
The ophthalmic division (V-1)provides sensory innervation to most of the upper third of the
head and face, including (but not limited to) the skin of the eyelids, eyebrow, forehead, and
nose and part of the mucous membranes of the nasal cavity.[3] Ethmoidal branches supply the
mucous membranes of the ethmoid sinuses. An intracranial branch called the tentorial nerve
of Arnold supplies the tentorium, superior surface ofthe transverse and straight dural sinuses,
and the inferior two thirds of the falx cerebri.[4]
The maxillary division (V-2) innervates several key areas in the midface region including the
upper teeth, the floor and anterior region of the nasal cavity, and the skin of the lateral nose
and malar region. The sphenopalatine branches innervate the lining of the maxillary sinuses,
and the middlemeningeal branch supplies portions of the floor of the middle fossa dura.[5]
The mandibular branch (V-3) supplies the teeth and gums of the mandible, the skin of the
lower face, the temporomandibular joint (TMJ) and also the dura of the lateral portion of the
middle fossa and most of the cranium.[5]
The trigeminal system is the main source for sensory innervation to the supratentorial dura,venous sinuses, and meningeal arteries. The 7th, 9th, and 10th cranial nerves also contain
somatosensory pain fibers that synapse with trigeminal pain axons.[5]
Sinogenic Facial Pain and Headache
Sinusitis
The International Headache Society (IHS) classification system lists the following criteria for a
diagnosis for sinus headache:[6]

1. Frontal headache that is accompanied by pain in one ormore regions of the face, ears,
or teeth and that fulfills criteria C and D
2. Clinical, nasal endoscopic, or CT and/or MRI and/or laboratory evidence of acute or
acute-on-chronic rhinosinusitis
3. Headache and facial pain that develop simultaneously with the onset or acute
exacerbation of rhinosinusitis
4. Headache, facial pain, or both that resolve within 7 days of remission or successfultreatment of acute or acute-on-chronic rhinosinusitis
Most sinonasal pain is referred and is deep, aching, and usually nonpulsatile. The location of
pain can help localize which sinus may be particularly involved, as follows:[7]





Frontal sinus - Frontal, vertex, and retro-orbital pain
Maxillary sinus - Malar region and upper teeth pain
Ethmoid sinus - Nasion and retro-orbitalpain and pain that radiates to the temporal
area
Sphenoid sinus - Vertex, occipital, frontal, and retro-orbital pain

Patients with facial pain secondary to acute sinusitis have coexisting symptoms such as nasal
obstruction, hyposmia, or purulent nasal discharge and have endoscopic signs of disease such
as purulent drainage, inflammation, and edema.[8, 9]
Pain severity and radiographic...