Chronic Headache and Facial Pain
Chronic headache and facial pain encompass several common chronic pain conditions that significantly disrupt daily life, work, and wellbeing. Migraine, chronic tension-type headache (CTTH), cluster headache, new daily persistent headache (NDPH), and temporomandibular disorders (TMD) often overlap with mood, sleep, and stress factors, making multidisciplinary care essential for meaningful relief. [1][2][3][4]
MIGRAINE: EPISODIC AND CHRONIC
Migraine affects ~15% of adults, transforming to chronic migraine (>15 headache days/month) in 1-2% through central sensitisation and medication overuse.[2][1]
SYMPTOMS
Throbbing, often unilateral pain (moderate-severe), aggravated by routine activity.
Nausea/vomiting, photophobia, phonophobia, osmophobia.
Aura (visual, sensory, speech) in 25-30%; prodrome/postdrome phases.[1]
TRIGGERS AND MECHANISMS
Hormonal changes, sleep disruption, stress, foods, CGRP-mediated trigeminovascular activation.[2]
MANAGEMENT
• Acute: Triptans, NSAIDs, gepants (ubrogepant).
• Preventive: CGRP-mAbs (erenumab), beta-blockers, topiramate, lifestyle.[4]
CHRONIC TENSION-TYPE HEADACHE (CTTH)
CTTH (≥15 days/month >3 months) affects 2-3%, linked to central nociceptive processing and myofascial tension.[1][2]
SYMPTOMS
Bilateral pressing/tightening pain (mild-moderate), no nausea, minimal aggravation by activity.[2]
MANAGEMENT
Bilateral pressing/tightening pain (mild-moderate), no nausea, minimal aggravation by activity.[2]
CLUSTER HEADACHE
The most severe primary headache, affecting 0.1% (mostly men), with circadian attacks in "clusters" lasting weeks-months.[1]
SYMPTOMS
Unilateral excruciating pain around eye/temple (burning/stabbing), lasting 15-180 minutes, 1-8x/day.
Autonomic features: tearing, nasal congestion, eyelid droop, restlessness/agitation.[2]
MANAGEMENT
Acute: High-flow oxygen (12-15L/min), subcutaneous sumatriptan.
Preventive: Verapamil (first-line), lithium, steroids bridge.[4]
NEW DAILY PERSISTENT HEADACHE (NDPH)
NDPH features sudden-onset daily headache persisting >3 months, often post-viral or stress-related, affecting younger adults.[1]
SYMPTOMS
Daily continuous pressure/throbbing pain; may mimic CTTH or low-pressure headache. Associated fatigue, neck pain, cognitive symptoms.[2]
MANAGEMENT
Rule out secondary causes (CSF leak, Chiari); amitriptyline, topiramate, nerve blocks; multidisciplinary approach.[4]
TEMPOROMANDIBULAR DISORDERS (TMD)
TMD (jaw/joint/muscle pain) affects 5-12%, multifactorial with central sensitisation in chronic cases.[5][6]
SYMPTOMS
TMD (jaw/joint/muscle pain) affects 5-12%, multifactorial with central sensitisation in chronic cases.[5][6]
MANAGEMENT
Soft diet, splints, physiotherapy, NSAIDs, CBT for bruxism/stress.[6][7]
OVERLAPS AND PSYCHIATRIC INTERFACE
Comorbidity common: migraine+TMD (30%), CTTH+anxiety/depression (2x risk). PTSD worsens chronicity.[4]
INTERVENTIONAL PAIN PROCEDURES FOR CHRONIC HEADACHE/FACIAL PAIN
When conservative treatments fail, targeted procedures provide diagnostic clarity and relief:[8]
OCCIPITAL NERVE BLOCKS
Local anaesthetic ± steroid around greater/lesser occipital nerves; effective for CTTH, NDPH, new migraine (60-70% response), repeatable monthly.[8]
SPHENOPALATINE GANGLION BLOCKS
For cluster/migraine; topical lidocaine or radiofrequency ablation reduces attack frequency.[8]
TRIGEMINAL NERVE BLOCKS/PERIPHERAL BRANCHES
Supraorbital, infraorbital, mental nerve blocks for TMD, trigeminal neuralgia, facial pain.[8]
RADIOFREQUENCY ABLATION
Pulsed RFA of occipital nerves (6 to 12 months of relief); sphenopalatine/gasserian ganglion for refractory cluster/TN.[8]
TMJ-SPECIFIC INTERVENTIONS
Intra-articular steroid/hyaluronic acid, arthrocentesis, Botox for masseter.[6]
NEUROMODULATION
SPG stimulation, occipital nerve stimulation for intractable chronic migraine/cluster.[8] Expectations: 50-80% get ≥50% relief 3-6 months; diagnostic value guides next steps. Combine with preventives/rehab.[8]
MULTIDISCIPLINARY MANAGEMENT PRINCIPLES
• Lifestyle: Sleep hygiene, hydration, triggers, and aerobic exercise.
• Psychological: CBT, mindfulness for stress/coping.
• Rehabilitation: Physiotherapy, graded exposure.[4]
With tailored care addressing overlaps, many reduce headache burden and improve function.[4]
REFERENCES
https://en.wikipedia.org/wiki/List_of_chronic_pain_syndromes
https://www.painaustralia.org.au/about-pain/painaustralia-common-formsof-pain
https://www.upmc.com/services/rehab/crs/conditions/temporomandibularjoint-disorders
https://www.mayoclinic.org/diseases-conditions/tmj/diagnosistreatment/drc-20350945
https://www.webmd.com/oral-health/temporomandibular-disorders-tmd
