Other Headaches and Facial Pains, Headache or facial pain associated with disorder of cranium or neck, B.Todd Troost

11.0: Headache or facial pain associated with disorder of cranium, neck, eyes, ears, nose sinuses, teeth, mouth, or other facial or cranial structures
11.1: Cranial bone
Periostitis and osteomyelitis of the bones of the skull and face may produce headache. Syphilitic periostitis or osteitis is now uncommon, but often involves the orbital bones. Mastoiditis is a common cause of bony pain. Frequently, in inflammatory involvement of the bones of the skull and orbit, there is localized pain and generalized headache. Malignant disease of the bone may similarly account for pain in the region of the lesion and generalized headache as well. Osteitis deformans and oxycephaly frequently are associated with generalized headache.
Elongation of the styloid process is a bony anomaly that has been associated with head pain. Although this elongation is present in about 4% of the population, only a few such individuals have pain or dysphagia (Eagle, 1949). The head pain can present in one of two major patterns. The first occurs almost exclusively in patients who have had tonsillectomy and is characterized by a sensation of a foreign body in the throat, difficulty in swallowing, dull and aching pains in the pharynx, and pain referred to the ear. The pharynx pains may be sharp, but are less severe than the momentary, lancinating pains of glossopharyngeal neuralgia. The second major pattern is that of headache and pain referable to the distribution of the internal or external carotid artery. This is presumed to be caused by pressure upon the involved artery by a medially or laterally deviated and elongated styloid process. In the case of impingement upon the internal carotid artery, the symptoms are parietal headaches and head pains throughout the distribution of the ophthalmic artery. If the external carotid artery is involved, the pain is referred to the face below the eye. This diagnosis can be suggested by palpation of the elongated process in the tonsillar fossa. Palpation is said usually to produce symptoms identical with those of which the patient complains. Roentgen studies of the pharynx confirm the diagnosis (Catlin, 1963). Eagle’s syndrome refers to patients with elongated styloidic processes and cervical facial pain. The condition was reviewed by Baugh and Stocks (1993)

Paget’s Disease
While the skull is a frequent site of involvement of Paget’s disease, headache is an uncommon complaint. Hamilton and Quesada (1973) reported two patients. One developed migraine de novo, and the second reported a marked worsening of lifelong migraine concurrent with the appearance of Paget’s disease of the skull (Hamilton and Quesada, 1973). Use of ergotamine and methysergide was ineffective, but in both patients headache attacks were impressively improved after partial control of the Paget’s disease with calcitonin or mithramycin, and not after placebo injections.
Paget’s disease is associated with increased blood flow to involved osseous structures; this was clinically evident in both of the aforementioned patients by cranial bruits, bounding scalp artery pulses, and by angiographically documented dilated meningeal and extracranial arteries. Both patients were genetically disposed to migraine, and Paget’s disease may have unmasked this predisposition.
11:2: Neck
Cervical spondylosis even with disk herniation is quite common, however, headache is not a usual feature (Brain, 1963). Some afferent fibers of the upper two, and probably the third and fourth, cervical roots converge upon the same dorsal horn cells that receive afferent innervation from the descending trigeminal spinal tract (Kerr, 1961a). This explains the observation that stimulation of the first cervical dorsal root results in orbital and frontal pain (Kerr, 1961b). There is some evidence that stimulation of the second, third, and fourth cervical nerve roots may produce headache, but no evidence that lesions below C4 do so (Edmeads, 1978). The vertebral artery, a pain-sensitive structure, may be compressed by cervical osteophytes, and this results in episodic vertebral insufficiency. This syndrome includes a lateralized pulsatile headache in 20 percent of such patients, and may be confused with migraine (Dutton and Riley, 1969). Attacks of headache and neurologic symptoms are almost always associated with certain positions of the head and neck, such as hyperextension of the neck, turning the head to one side, or neck flexion; this is a rare syndrome.
The term migraine cervicale was originally applied to the syndrome that may follow head and neck trauma (Bartschi-Rochaix, 1968) and which now appears to be more appropriately included in the post-traumatic group of disorders.
Patients with cervical spondylosis that involves the upper cervical spine often report neck and shoulder pain and occasionally suboccipital headache in conjunction with other symptoms of cervical nerve root compression. When headache is severe, it may radiate to the forehead, eye, or temple; it often occurs in the morning and appears intermittently throughout the day. Occasionally, headache is pulsatile in quality and is aggravated by neck movements and by coughing and straining. Thus, headache resulting from upper cervical spine disorders may, occasionally, be confused with migraine. Edmeads (1978) has proposed that certain features of a headache syndrome may suggest its origin from the cervical spine. They are (1) persistent, unilateral suboccipital pain; (2) reproduction or alteration of headache with neck motion; (3) abnormal postural attitudes of the head and neck; (4) aggravation or reproduction of headache by deep suboccipital pressure; (5) painful limitation of neck movements; and, most importantly, (6) signs and symptoms referable to cervical nerve roots.
Whether the headache results from lesions of the lower cervical spine is controversial; patients with preexisting migraine my experience a worsening of their headache disorder concurrent with the development of a low cervical disc, but de novo headache disorders resulting from lesions of the lower cervical spine have not been well documented. A controlled trial of cervical manipulation in migraine showed no benefit (Parker et al, 1978). Some believe that functional disorders of the cervical spine may simulate migraine (Sjaastad, 1983; Bogduk, 1984). Support for this is based, in the main, on the favorable results following local anesthetic blockade or resection of upper cervical nerve roots (Berger and Gerstenbrand, 1986). Because the upper cervical roots synapse with the descending spinal trigeminal tract, the alleviation of head pain after local blockade is predictable and cannot be construed as having identified the cause of pain. Raskin (1988) notes that to date, there have been no controlled or long-term follow-up studies reported. Raskin does not believe that disorders of the lower cervical spine produce headache.
To summarize, neck disorders are an uncommon cause of headache. Occasionally, patients with disorders that involve the upper cervical spine report recurring headache that my resemble migraine, but there is almost always a prominent suboccipital component and clinical evidence of nerve root compression. Patients with preexisting migraine may undergo an exacerbation of their headache problem. It may be concluded that cervical spine disorders only rarely mimic migraine.