Contiguous Structure Headaches

Patients perceive maxillary sinus pain in the cheek, gums, and upper teeth. Frontal sinus pain tends to involve the forehead, while ethmoid sinusitis causes pain behind or between the eyes. Sphenoid sinusitis is characterized by pain in variable locations, including the frontal, occipital, temporal, or vertex locations.

Symptoms lasting fewer than 7 days tend to be viral in origin. In contrast, acute bacterial rhinosinusitis presents with more than 7 days of purulent rhinorrhea, nasal congestion, facial or dental pain/pressure, an accompanying cough, halitosis, and, if severe, fever (50% of adults). Fungal sinusitis may be acute or chronic (lasting more than 12 weeks) and is of particular concern in patients who are immunocompromised. Rhinosinusitis can usually be diagnosed on clinical suspicion. However, diagnosing recurrent, chronic, or complicated disease depends on computed tomography (CT), magnetic resonance imaging (MRI), or direct visualization with nasal endoscopy. Treatment involves the appropriate antibacterial or antifungal medications.

Sphenoid sinusitis is an uncommon infection that may manifest as an acute or subacute headache associated with nausea and vomiting. It may accompany pan sinusitis but, when isolated, may not have associated nasal symptoms. It can mimic many other causes of headache, including aseptic meningitis, migraine, and trigeminal neuralgia. Excessive tearing, photophobia, and paresthesias in the trigeminal nerve distribution may accompany sphenoid rhinosinusitis. This should be considered in patients with a severe, intractable new-onset headache that worsens with coughing, bending, or walking; interferes with sleep; is progressive in severity; and does not respond well to analgesics.

TEMPOROMANDIBULAR DISORDER

Pain from the temporomandibular joint (TMJ), with its associated musculature and ligaments, can be referred to the head. The manifesting symptom is usually pain in the preauricular area, TMJ, or muscles of mastication, aggravated by jaw function. Associated ear pain is common. Patients may have TMJ noise (such as clicking or crepitus) on movement, locking on jaw opening, or limited or asymmetric jaw movement. Diagnosis is confirmed by tomograms of the maxilla and mandible, including open and closed position views of bilateral TMJs, and a panoramic radiograph to look for bony pathology. Initial treatment is conservative, with an oral appliance or bite plate and possibly physical therapy. Medication such as nonsteroidal anti-inflammatory drugs, muscle relaxants, and tricyclic antidepressants can also be tried. Rarely, surgery is indicated for medically refractory patients.

DENTAL

Inflammatory dental disease may cause intense, throbbing, poorly localized pain unilaterally that is generally provoked by stimulation of the offending tooth. This is often associated with increased sensitivity to hot and cold. Occasionally, infection of the dental pulp or apical root may cause neuralgic type pain in the second and third trigeminal divisions, which is difficult to distinguish clinically from trigeminal neuralgia. For this reason, patients with trigeminal neuralgia may undergo one or more unnecessary dental procedures before the correct diagnosis is made. Conversely, it is important to exclude true dental disease before making a diagnosis of trigeminal neuralgia.

GLAUCOMA

Acute angle–closure glaucoma occurs when the normal drainage of aqueous humor is blocked, leading to sudden increased intraocular pressure. This creates severe eye pain sometimes associated with a unilateral headache, nausea/vomiting, conjunctival injection, and a mid-dilated nonreactive pupil. Patients may describe intermittent visual blurring while “seeing halos around objects.” The severe unilateral headache may mimic migraine or cluster headache. Dim light and certain medications (e.g., anticholinergics, sympathomimetics) that result in pupillary dilation may precipitate the pain. Chronic open-angle glaucoma, the more common form of glaucoma, is not a cause of headaches.

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