OTHER HEADACHES  

A host of other conditions are associated with headache (Table 1) including specific syndromes such as trigeminal neuralgia, systemic diseases such as temporal arteritis, and entities such as muscle contraction, intracranial neoplasms, and vascular anomalies.  Some of these are described briefly below, but are covered in more detail in standard textbooks^{14,15,202,203} and reviews of the headache literature.^204,205

Trigeminal neuralgia or tic douloureux is a facial pain characterized by repetitive attacks of lightening‑like jabs of lancinating pain in the maxillary and mandibular divisions of the trigeminal nerve. The ophthalmic division may be involved, but is rarely the sole location.  The onset is usually in the sixth or seventh decade with women being affected slightly more than men (3:2). The usual cause is vascular cross compression of the sensory root entry zone of the fifth nerve as it enters the pons, but multiple sclerosis and cerebellopontine angle tumors may also produce the syndrome.  Both sides of the face may rarely be involved with pains occurring asynchronously on opposite sides.  Bilaterality in a person under 50 suggests multiple sclerosis. 

The paroxysmal attacks last only seconds reaching maximal intensity immediately, often with a deep aching pain persisting between the paroxysms.  The pain is often described as "electric" and is frequently triggered by talking, chewing, touching the lips, or by cold exposure.  The neurologic examination is normal in most patients, but some, even with classic tic, have a small area of numbness medially on the upper lip.  Any neurologic deficit or the presence of the condition in a patient under 50  necessitates a magnetic resonance scan to rule out tumor or multiple sclerosis.  

Medical therapy is successful in the majority of patients and includes carbamazepine, baclofen, phenytoin, clonazepan and valproic acid alone or  in combination.^14,206  Surgical therapy includes vascular decompression^207-209 and a variety of percutaneous procedures aimed at destruction of the pain fibers of the trigeminal nerve.^14,209,210

Atypical facial pain is a less well defined complex involving pain in the face.  The pain tends to be deep, aching, more diffuse, sometime superficial, but longer in duration than attacks of trigeminal neuralgia.  There may or may not be alterations of facial sensation.  The pain is not necessarily localized to the sensory distribution of the trigeminal nerve and is often poorly characterized by the patient.  The pain responds poorly to medical or surgical therapy and is usually accompanied by various degrees of psychological impairment.  Such patients should be thoroughly evaluated to rule out organic causes such as nasopharyngeal neoplasm and dental abnormality, but in the absence of defined pathology may be treated symptomatically with non‑addicting analgesics, antidepressants, and psychotherapy.