Headache and Facial Pain Disorders
What you must know
Apply ICHD criteria for primary headaches. Migraine: recurrent, 4-72 hours, unilateral, pulsating, moderate-severe, aggravated by activity, with nausea or photophobia/phonophobia. Tension-type: bilateral, pressing, mild-moderate, not aggravated by activity. Cluster: severe unilateral orbital/temporal pain with ipsilateral autonomic features (lacrimation, rhinorrhea, ptosis, miosis) and restlessness. Trigeminal autonomic cephalalgias share autonomic features. Also know headache attributed to TMD and persistent idiopathic facial pain.
Clinical reasoning
Red flags (SNOOP): systemic symptoms, neurologic signs, sudden onset, older age at onset, pattern change, positional features, papilledema, pregnancy-related, and pain refractory to usual treatment. Autonomic features localize to the trigeminal-autonomic reflex and point to TACs, not to sinus disease.
Traps
Migraine is often mislabeled as sinus headache when facial pressure and congestion accompany it. Cluster headache is frequently misdiagnosed as dental or TMJ pain because of its unilateral facial distribution. Tension-type headache is bilateral and lacks autonomic features. Persistent idiopathic facial pain is continuous, poorly localized, and not explained by examination.
Worked example
A 40-year-old has 90-minute attacks of severe right periorbital pain with tearing and nasal congestion, occurring nightly. This meets cluster headache criteria (TAC with autonomic features and circadian pattern), not sinusitis. First-line acute treatment is high-flow oxygen and triptans; verapamil is used for prophylaxis.
Rule of thumb
Autonomic features + severe unilateral periorbital pain = TAC. Bilateral pressing pain without autonomic features = tension-type.