Forehead Pain Research Articles

Associated Titanium Mesh and Native Bone Cranioplasty in Posttraumatic Reconstruction of Frontal Skull Defects

Cranioplasty of frontal skull defects are used for cosmetic reasons, helping correct disfigurement, but also play a critical role in protecting intracranial content from exposure and compression. Modern surgical management is based on principles of craniofacial surgery such as early one-stage repair- if possible, exposure of all fracture fragments by well-sited cosmetic incisions, precise internal fixation and definitive soft tissue management. The choice of surgical approach depends on fracture severity, complexity, patient comorbidities, and surgeon preference and experience. In large skull defects, titanium mesh reconstruction offers good alternative to other biomaterials by eliminating the time consuming task of contour moulding. The aim of the study is to provide a comprehensive review of aesthetic and functional outcomes, involving titanium mesh implants associated with native bone reconstruction of frontal area posttraumatic defects. Also, the article is related to the authors own experience, in treating several patients with posttraumatic deformity of the frontal bone, assessing forehead contour aesthetics, pain, nerve function and late cerebral complications. A retrospective study was conducted using records from 14 adult patients, between 21-74 years of age, who underwent reconstruction of depressed frontal bone fractures, by receiving titanium mesh implants, between February 2013- October 2015. All patients had a minimum follow up of 5 months by clinical examination and periodic CT-scans. In order to evaluate the experimental results we follow different clinical parameters than late complications, like facial nerve function, cosmetic outcome, and pain. According our clinical results, titanium mesh is an effective method of forehead reconstruction, which provides predictably good long term results.

Does attachment anxiety increase vulnerability to headache?

BackgroundAttachment-related anxiety and avoidance are potentially important aspects of pain experience and management, but have not been investigated in episodic headache sufferers or in relation to experimentally-evoked headache. ObjectiveTo determine whether adult insecure attachment styles were associated with sensitivity to pain or headache before, during or after stressful mental arithmetic in an episodic migraine or tension-type headache (T-TH) sample. MethodsThirty-eight participants with episodic migraine, 28 with episodic T-TH and 20 headache-free participants intermittently received a mild electric shock to the forehead before, during and after stressful mental arithmetic. ResultsA preoccupied attachment style and attachment anxiety, but not attachment avoidance, were associated with forehead pain and the intensity of headache before and after, but not during stressful mental arithmetic. These relationships were independent of Five Factor Model personality traits. Neither attachment anxiety nor avoidance was associated with episodic migraine or T-TH. ConclusionsAnxiously attached individuals may express greater pain or show a stronger attentional bias toward painful sensations than securely attached individuals. However, distraction during psychological stress may override this attentional bias.

Effect of healthy aging on renal vascular responses to local cooling and apnea

Sympathetically mediated renal vasoconstriction may contribute to the pathogenesis of hypertension in older adults, but empirical data in support of this concept are lacking. In 10 young (26 ± 1 yr) and 11 older (67 ± 2 yr) subjects, we quantified acute hemodynamic responses to three sympathoexcitatory stimuli: local cooling of the forehead, cold pressor test (CPT), and voluntary apnea. We hypothesized that all stimuli would increase mean arterial blood pressure (MAP) and renal vascular resistance index (RVRI) and that aging would augment these effects. Beat-by-beat MAP, heart rate (HR), and renal blood flow velocity (from Doppler) were measured in the supine posture, and changes from baseline were compared between groups. In response to 1°C forehead cooling, aging was associated with an augmented MAP (20 ± 3 vs. 6 ± 2 mmHg) and RVRI (35 ± 6 vs. 16 ± 9%) but not HR. In older adults, there was a positive correlation between the cold-induced pressor response and forehead pain (R = 0.726), but this effect was not observed in young subjects. The CPT raised RVRI in both young (56 ± 13%) and older (45 ± 8%) subjects, but this was not different between groups. Relative to baseline, end-expiratory apnea increased RVRI to a similar extent in both young (46 ± 14%) and older (41 ± 9%) subjects. During sympathetic activation, renal vasoconstriction occurred in both groups. Forehead cooling caused an augmented pressor response in older adults that was related to pain perception.

Clinical Outcomes following Supraorbital Foraminotomy for Treatment of Frontal Migraine Headache

Although 92 percent of patients who undergo surgical decompression of the supraorbital nerve for treatment of frontal migraine headaches through resection of the glabellar muscle group achieve at least 50 percent improvement, only two-thirds demonstrate complete resolution of symptoms. The authors investigated the role of additional decompression methods by comparing surgery outcomes between patients who underwent glabellar myectomy alone and patients who also underwent supraorbital foraminotomy. Outcome measures including migraine headache frequency, severity, and duration; Migraine Headache Index score; and forehead pain were reviewed retrospectively and analyzed statistically for 43 age-matched control patients who underwent glabellar myectomy for release of the supraorbital nerve and 43 patients who underwent glabellar myectomy with supraorbital foraminotomy from 2002 to 2010. The myectomy group statistically matched the myectomy with foraminotomy group for age, number of surgical sites, and preoperative headache characteristics (p > 0.05). For the myectomy and myectomy with foraminotomy groups, postoperative migraine frequency was 7.8 per month versus 4.1 per month, severity was 5.6 versus 4.4, Migraine Headache Index score was 26.5 versus 11.1, and persistent forehead pain was 48.8 percent versus 25.6 percent, respectively. These differences were all statistically significant (p < 0.05). Duration of headache was unchanged (p = 0.17). The supraorbital foramen is a potential site of supraorbital nerve compression that can trigger frontal migraine headache. If it is present, the authors strongly recommend foraminotomy to ensure complete release of the supraorbital nerve to optimize outcomes. Their results also support consideration of release of any fibrous bands across the supraorbital notch. Therapeutic, III.

Surgical Management of Pneumosinus Dilatans Frontalis in the Setting of Chronic Rhinosinusitis and Type III Frontal Cell

Pneumosinus dilatans (PD) represents a rare lesion of unknown etiology in which progressive enlargement of an air-filled paranasal sinus results in cosmetic and functional complications. The absence of pathologic mucosa has traditionally been considered a hallmark of this disorder. A 24-year-old man presented with 2 years of chronic rhinosinusitis and recurrent, acute episodes of severe forehead pain with worsening outward prominence of the frontal sinus during air travel. Computed tomography and findings at surgery were notable for diffuse nonpolypoid inflammatory changes of the paranasal sinuses, a type III frontal sinus cell, and PD of the frontal sinus with severe deformity and thinning of the anterior table. A bicoronal approach was used for frontal sinus obliteration and cranioplasty. Excellent cosmetic and functional results were noted at the last follow-up. To our knowledge, this is the first report of PD frontalis presenting in the setting of chronic rhinosinusitis. Surgical management of this disorder requires consideration of both the functional and cosmetic issues.

Guillain-Barré Syndrome Following H1N1 Immunization in a Pediatric Patient

To report a case of Guillain-Barré syndrome (GBS) following a dose of influenza A (H1N1) vaccine (Arepanrix). An 11-year-old boy was admitted to the hospital after presenting with facial diplegia; abdominal, forehead, and thigh pain; and acute cervical pain. He had received the Arepanrix H1N1 subcutaneous vaccine 13 days before symptom onset. The neurologic examination also revealed a symmetric bilateral paralysis of the VIIth cranial nerve and intense pain, proximal weakness of the shoulder girdles and pelvis, and preserved deep tendon reflexes. Cerebrospinal fluid analysis revealed an albuminocytologic dissociation. Therefore, a diagnosis of atypical GBS following vaccination against HINI influenza was made. Based on the clinical evaluation, laboratory test results, neurologic features, and the exclusion of alternative diagnoses, the Naranjo probability scale revealed a probable relationship between the clinical manifestations of GBS and the vaccine against influenza A (H1N1) received by the patient. This is the first published case for the 2009 influenza pandemic in children. While recent studies have found inconclusive results on the association between influenza vaccine and GBS, all suspected cases should be published for further evaluation.

Trigeminal neuralgia involving supraorbital and infraorbital nerves

Supraorbital neuralgia is a rare disorder accounting for 4% of incidence with hallmark of localized pain in or above the eyebrow, clinically characterized by the following triad: (1) forehead pain in the area supplied by the supraorbital nerve, (2) tenderness on either the supraorbital notch and (3) absolute, but transitory relief of symptoms upon supraorbital nerve blockade. The pain presents with a chronic or intermittent pattern. The persistence of protracted unilateral forehead/occular pain, tenderness over the nerve and repeated blockade effect strongly suggest the diagnosis. Surgical treatment can be used when the medical treatment fails or in patients who do not tolerate the pharmacological treatment.

A Lady with Left Sided Opthalmic Nerve Distribution Rash…….A Clinical Diagnosis!!!!

A 26-year-old lady was admitted with a sudden onset of lesions that started on the left side of the face. Past medical history revealed a mild atopic eczema for several years. Inspection showed unilateral infection of the upper half of the face. The lesions consisted of erythematous macules with scaling. Examination of the oral cavity was uneventful, whereas cervical lymph nodes were slightly enlarged. Lesional pruritus was mild. The case is discussed in this report. CLINICAL INFORMATION A 26-year-old lady was admitted with a sudden onset of lesions that started on the left side of the face. Past medical history revealed a mild atopic eczema for several years. Inspection showed unilateral infection of the upper half of the face. The lesions consisted of erythematous macules with scaling. Examination of the oral cavity was uneventful, whereas cervical lymph nodes were slightly enlarged. Lesional pruritus was mild. Figure 1 Fig 1: Erythematous Macules involving the Left upper face WHAT IS YOUR DIAGNOSIS? Herpes Zoster infecting the ophthalmic division of Trigeminal Nerve HERPES ZOSTER OPTHALMICUS....A CONCISE REVIEW INTRODUCTION Varicella-zoster virus (VZV) is a member of the Herpesviridae family. It is the etiologic agent of varicella (chickenpox), the primary infection, and herpes zoster, the reactivation. Herpes zoster ophthalmicus involves the tissues innervated by the ophthalmic division of the trigeminal nerve and accounts for 10-25% of all cases of shingles. The sequelae of herpes zoster ophthalmicus can be devastating and include chronic ocular inflammation, visual loss, and debilitating pain. After primary infection, VZV enters the dorsal root ganglia (trigeminal = herpes zoster ophthalmicus, geniculate = herpes zoster oticus), where it remains latent for the lifetime of the individual. >PATHO-PHYSIOLOGY The frequency of dermatologic involvement in herpes zoster is similar to the centripetal distribution of the initial varicella lesions. This pattern may suggest that the latency arises from the contiguous spread of the virus during varicella viremic phase from infected skin cells to sensory nerve endings with subsequent ascent to the ganglia. It also may suggest that the ganglia are infected hematogenously during the viremic phase of varicella and that the frequency of the dermatome involvement in herpes zoster reflects the ganglia most often exposed to reactivating stimuli. In immunocompetent patients, specific antibodies (immunoglobulins G, M, and A) appear more rapidly and A Lady with Left Sided Opthalmic Nerve Distribution Rash.......A Clinical Diagnosis!!!! 2 of 3 reach higher titers during reactivation (herpes zoster) than during the primary infection. The appearance of the cutaneous rash due to herpes zoster coincides with a profound VZV-specific T-cell proliferation. Interferon-alpha production appears with the resolution of herpes zoster. The patient has a long-lasting, enhanced, cellmediated immunity response to VZV. TREATMENT Treatment of acute herpes zoster ophthalmicus is optimal if started within 72 hours of rash onset. Oral antiviral drugs (e.g. Famciclovir 500 mg 3 times/d [tid], valacyclovir 1 g 3 times/d [tid], or acyclovir 800 mg 5 times/d for 7 d). Tricyclic antidepressants nortriptyline, amitriptyline, or desipramine 25 mg, adjust up to 75 mg at bedtime (qhs) for several weeks if needed (to inhibit acute and prolonged posterpetic neuralgia [PHN]). Additionally topical corticosteroids, antibiotics, cycloplegics and antivirals can also be used. Glaucoma medications; as necessary for keratitis, iritis, or glaucoma. Treat late PHN with tricycles antidepressants (as listed above) and/or capsaicin ointment daily (qid) or 4 times/day (qid) or lidocaine patches. Neurontin 30-600 mg by mouth (PO) tid and/or OxyContin SR 10-20 mg PO 2 times/day (bid) with topical medications similar to those used in acute disease. In a small study by Kanai et al, lidocaine 4% ophthalmic drops were administered to 24 patients with ophthalmic post-herpetic neuralgia in a crossover manner. A significant reduction in eye and forehead pain was observed in patients who were administered the lidocaine ophthalmic drops. Analgesic onset was noted via a visual analog scale within 15 minutes after administration and persisted for a median of 36 hours (range, 8-96 h).

前頭洞嚢胞３０症例の検討―術式と成績について―

Frontal sinus cyst is a relative common disease; however, this disease is often difficult to manage clinically since recurrence sometimes occurs even if patients are treated with surgery. We retrospectively analyzed 30 cases of the frontal sinus cyst, treated with surgery in our hospital between 1994 and 2006. The most common symptom was forehead swelling, followed by forehead pain, exophthalmos, and double vision; however, 3 (10%) cases did not have any clinical symptoms. Of 30 cases, 16 (53.3%) were postoperative cysts, and 14 (46.7%) were idiopathic cysts. Thirteen (43.3%) cases were treated by an external approach, and 12 (40.0%) cases were treated by an external approach combined with endonasal sinus surgery (ESS). Five (16.7%) cases were treated by ESS without external incision. The overall postoperative patency rate was 72.4%. The patency rate treated by the external approach, external approach combined with ESS, and ESS alone was 66.7%, 75.0%, and 80.0%, respectively. Although the number of patients treated by ESS alone was small, the clinical outcome of ESS was favorable. In several endonasal approaches, the endoscopic modified Lothrop procedure has been performed, and the postoperative clinical course is good. Thus, a modified Lothrop procedure might be a useful approach for frontal sinus cysts. The findings of the present study suggest that ESS would be the first choice of surgical approach for frontal sinus cysts.

Supraorbital neuralgia

Supraorbital neuralgia is a rare disorder clinically characterized by the following triad: 1) forehead pain in the territory supplied by the supraorbital nerve, without side shift; 2) tenderness on either the supraorbital notch or traject of the nerve; and 3) absolute, but transitory relief of symptoms upon supraorbital nerve blockade. The pain presents with a chronic or intermittent pattern. In addition, there may be signs and symptoms of sensory dysfunction (hypoesthesia, paresthesia and allodynia), and typical "neuralgic features" (lightning pain and exteroceptive precipitating mechanisms). However, sensitive and neuralgic features are not constantly present and seem to be more frequent in the secondary, usually post-traumatic, forms.

Supraorbital Neuralgia. Vågå Study of Headache Epidemiology

In a recent, hospital-based report, we described a small series of 5 patients with unilateral, more or less chronic, severe forehead pain, that could be transitorily abated by anaesthetic blockade of the supraorbital nerve and more permanently abated by 'liberation' operation directed towards the nerve exit area at the supraorbital notch. However, epidemiological data on supraorbital neuralgia are lacking. Among 1838 18-65-year-old inhabitants in Vågå (88.6% of the eligible ones), there were 10 who presented the following clinical picture: (1) Unilateral forehead/ocular pain, not diagnosed or diagnosable as any other, particular, unilateral headache; (2) Steadfast unilaterality; (3) Increased tenderness upon pressure over the exit site of the supraorbital nerve (incisura frontalis) on that side--in those who were in an active phase; (4) Foregoing trauma in the forehead/supraorbital rim area, ipsilaterally. In approximately half the cases, there was a moderate, ipsilateral sensory loss. A striking finding was the occurrence of jabs in the symptomatic area, and in synchrony with the neuralgia pain. These 10 inhabitants correspond to a prevalence of 0.5% (or 0.65% if two nontrauma cases are included).

脳膿よう，皮下膿ようを併発した前頭洞炎例

The patient was 14-year-old boy who complained of progressive forehead swelling and persistent slight fever. A CT scan revealed subcutaneous abscess, brain abscess in the right frontal lobe and frontal sinusitis. The patient underwent a drainage operation at which time bone destruction was noted in the skull, and the subcutaneous abscess was observed to be continuous with the frontal sinus.Three months after neurosurgery, forehead pain recurred again, and CT and MRI showed left pansinusitis including frontal sinusitis. Right extranasal frontal sinusectomy and maxillo-etmoidectomy was performed to prevent intracranial complication. Additionally a bony defect was noted in the posterior wall of the frontal sinus. In this patient we considered that the infection had directly spread to the brain and subcutaneous forehead through the bony defect in the wall of the frontal sinus.In cases of rhinogenic intracranial complications, the frontal sinus is considered to be the most probable origin of infection. The mechanisms for the intracranial spread of infection from the frontal sinus and the importance of surgical treatment against frontal sinusitis are also discussed.

Headache caused by drinking cold water is common and related to active migraine.

The primary aim of this study was to estimate the prevalence of cold-induced headache and to test if it is associated with migraine. Women attending a population-based mammography screening programme were asked to participate in the study. Fifty-one of 669 women (7.6%) experienced a headache after ingesting 150 ml of ice-cold water through a straw. Women who had experienced one or more migraine attacks in the last year (active migraine) were twice as likely to experience a headache from ingesting the cold water as women who had never suffered from migraine. Ninety-five women who had experienced their most recent migraine attack more than 1 year ago (inactive migraine) were not at increased risk. The prevalence of active and inactive migraine was 19.4 and 14.2%, respectively. Headache caused by drinking cold water is common in women. The results indicate that active migraine facilitates the perception of forehead pain induced by a cold palatal stimulus.

Frontal sinus malignancies

Frontal sinus malignancies comprise 2% to 3% of those occurring in the paranasal region. Patients commonly present with forehead pain and swelling, orbital disturbances, epistaxis, and nasal purulence. A combination of CT and MR imaging delineate the tumor and its relationship with the adjacent dura and periorbita. Low-grade malignancies are addressed with en bloc extirpation, with lower frontal sinus and adjacent ethmoid lesions approached through a superior rhinotomy, and more extensive lesions through a combination of a bicoronal flap and rhinotomy. Postoperative irradiation is appropriate for medium- to high-grade lesions. Small to medium defects are closed with local rotation flaps and larger defects with free flaps. Bony reconstruction can range from a split calvarial bone graft to mini plates and wire mesh.

前頭洞アスペルギルス症例

We report an extremely rare case of aspergillosis of the frontal sinus. The patient was a 47-year-old man who presented with the chief complaint of left forehead pain. A nasal examination, CT and MRI suggested mycosis of the frontal sinus. The patient subsequently underwent endoscopic sinus surgery and aspergillosis was diagnosed based on the histopathological findings. Good results were obtained with irrigation of the frontal sinus after surgery. To our knowledge, there have been only four reports of frontal sinus mycosis in Japan, including ours. Aspergillus species was the causative organism in all four cases, and intracranial invasion was present in all of the patients except the one described here.

Pyogenic Granuloma of the Cornea Induced by ???Snake Oil???

A pyogenic granuloma of the cornea developed on the vascularized cornea of a 79-year-old woman after "snake oil" accidentally dripped in her eye. The snake oil was being used to relieve forehead pain, which may have been referred. The five previously reported examples of corneal pyogenic granuloma are similar to this case in that trauma preceded development of the lesion. However, the chemical trauma induced by the snake oil appears to be a unique mechanism of injury.

The relationship of headache symptoms with severity and duration of attacks

Efforts to develop clinically useful headache classification schemes have generally focused on linking specific symptom groupings with specific headache subtypes. An alternative conceptual approach, the “severity model” of headache, considers a continuum of headache ranging from mild to severe forms with specific headache subtypes distinguished by level of severity rather than unique constellations of symptoms. A population-based telephone interview was carried out among 10,169 subjects aged 12–29 to estimate the prevalence of serious headaches and better characterize symptoms that accompany headache attacks. In an analysis of frequency of occurrence, pain and duration of recent (within 4 weeks prior to interview) headache attacks, the data revealed that common symptoms (such as forehead pain and pain in the back of the head, neck and shoulders) were reported frequently, but headaches with these symptoms were generally characterized by low levels of pain and short duration. Although not an original study objective, the data were analyzed to determine whether distinct symptom constellations could be identified or whether symptoms overlapped between headache types. Symptoms of migraine were frequently experienced concomitant with tension-type symptoms; the resultant headaches were usually characterized as moderate in intensity. In contrast, symptoms usually associated with migraine in the absence of concomitant tension-type symptoms were infrequently experienced, but resulted in headaches causing the greatest disability. The data provide some support for the severity model of headache.

A self-observation study of headache symptoms in children.

SYNOPSISThe purpose of the present study was to examine symptom configurations experienced by children with problem headache and to determine whether headache symptoms in children can be analyzed along a continuum of severity. Forty‐seven children between the ages of 8 and 17 years monitored their headache activity on a daily basis for a 3‐week period. The self‐observation data indicated that children did not show a tendency to experience their headache symptoms in terms of distinct muscle contraction and migraine symptom clusters. On the contrary, both categories of symptoms were observed to increase in frequency with increasingly problematic headaches. The presence of both muscle contraction and migraine symptoms increased in a linear fashion with the number of daily headache hours reported by the children during the self‐observation period. The measure of headache hours also correlated significantly with the total number of head pain locations and symptoms reported by the children. A regression analysis revealed that the symptom of nausea with the addition of the symptoms of dull and aching pain, bilateral forehead pain, feelings of tightness and pressure, and light sensitivity accounted for 77% of the variance associated with the severity measure of headache hours. Further support for viewing headaches in children in terms of severity came from an analysis of the time of onset of headache activity characteristic of the different children in the sample. Children with more severe headache activity experienced their attacks at an earlier time of day than children with less severe headache activity. Overall, the self‐observation data provided additional support for the severity model and supported the utility of extending the model to the study of headache disorders in children.

EXPERIMENTAL COMPARISON OF EXTRADUPAL AND I.M. MORPHINE

Morphine sulphate 3 or 4 mg was administered to the extradural space in five volunteers. Morphine 10 or 15 mg i.m. was given as control. Extradural administration resulted in an increase of pain threshold in the legs but not in the forehead. There was no significant depression of carbon dioxide response or deterioration of co-ordination or short-term memory. I.m. morphine caused an increase in forehead pain threshold, depression of the carbon dioxide response and some deterioration of cerebral function. Extradural morphine caused urinary retention in four and inability to ejaculate in three of the subjects. The principal site of action of extradural morphine appears to be regional, at spinal cord level, but it appears that autonomic function as well as pain perception can be affected.

Electrode placement, EMG feedback, and relaxation for tension headaches

Fifteen tension headache subjects were allocated to one of three groups: direct EMG feedback (from a site corresponding to the source of pain), indirect EMG feedback (from a site not corresponding to the source of the pain) and relaxation instructions. There were two base-line, six treatment and one post-treatment sessions. No significant differences were found between base-line and post-treatment EMG levels, for any of the groups; however, some significant reductions in levels were obtained within sessions. EMG levels recorded during headache attacks did not differ significantly from levels recorded during base-line. Frequency and intensity of headaches were significantly reduced, particularly in the relaxation group. At follow-up this improvement was maintained for subjects with forehead pain, but differences between the groups had disappeared.