Headache and facial pain

Abstract

Pain involving structures of the head, including the face, is a common symptom presenting to different specialties and comprises >25% of neurology outpatient referrals in the UK. Facial manifestations of headache disorders, and the common involvement of the neck in both primary and secondary headache disorders, can cause presentation of these conditions to specialties such as maxillofacial surgery, ENT and spinal surgery. Such phenotypes may lead to diagnostic dilemma amongst treating clinicians. Headache is also a common reason to present acutely to hospital, and therefore carries significant burden for emergency and acute medical departments. It is therefore essential for clinicians and their trainees from a wide range of medical and surgical disciplines to understand and recognize important causes of headache and facial pain. This will ensure prompt diagnosis and management of serious acute causes of secondary headache (including thunderclap headache) to limit morbidity and mortality, and to manage the more common severe presentations of a primary headache disorder such as migraine, to reduce hospital admissions and lengths of stay by ensuring prompt diagnosis, treatment and onward management under the appropriate service. Whilst recognizing headache red flags and secondary headache disorders are vital, primary headache disorder presentations are far more common and require an equal level of diagnostic precision and treatment. In the vast majority of these cases, neurological examination and radiological tests will be normal and therefore the history is of extreme importance. This article summarizes the acute assessment of headache, some acute headache presentations, and important aspects of the headache history and examination to allow rapid and effective diagnosis and management.