A CRITICAL ACUTE ALGIA:
There are two clinical pictures to distinguish.
Vascular algebra of the face or “cluster headache”:
It most often affects the young man, in the form of a very painful crisis :
– strictly one-sided and always on the same side;
– predominantly orbital and temporal;
– lasting from 30 seconds to 2 hours, repeated from 1 to 8 times per day;
– occurring by “access” or episodes 1-2 times a year;
– accompanied by conjunctival injection with tearing, rhinorrhea or congestion
nasal, facial sweating and, in half of the cases, Claude Bernard-Horner’s syndrome.
The treatment of the crisis may be intranasal instillation, in the sphenopalatine pit, of a solution of lidocaine, or inhalation of oxygen at a flow rate of 7 to 8 liters / minute; but triptans are currently more effective: subcutaneous injection or nasal spray sumatriptan (Imigrane) or taking a tablet of Zolmitriptan (Zomig).
Preventive treatment is propranolol (Avlocardyl) or even Désernil, lithium or corticosteroids, this under close supervision. Alcohol must be banned.
A variant is chronic paroxysmal hemicrania, characterized by the very high frequency of seizures (5 to 30 per day) and affecting mainly women. The complete disappearance of seizures on indomethacin is a good diagnostic criterion.
Trigeminal neuralgia essential:
It usually occurs after the age of 50 to 60 years and affects three women for one man.
It is an intense, paroxysmal, one-sided flashing facial pain, like electric shock, grinding or stabbing for a few seconds or minutes,
– Spontaneous or triggered by speech, chewing, or even the simple contact of a cutaneous or mucosal territory called “trigger zone”;
– which can lead to a motor anomaly type of grimace: it is the “tic painful of the face” of Trousseau;
– occurring by access (variable frequency), diurnal, separated by a free interval;
– and whose topography is that of the V2 (upper maxillary nerve) especially, less often that of V3 (lower maxillary nerve) or that of V2 + V3, much more rarely that of V1 (ophthalmic nerve of Willis).
The neurological examination is normal: no abnormality of the other cranial nerves.
No further examination is useful for the diagnosis.
Medical treatment is Tegretol (much more effective than Liorésal, Dihydan or the Rivotril).
In case of failure or if the Tégrétol is poorly tolerated, it is necessary to have recourse to the specialist: selective thermocoagulation of the ganglion of Gasser percutaneously or microsurgical vascular decompression of the trigeminal nerve will be proposed according to the age or the ground.
Trigeminal neuralgia is different from symptomatic (or secondary) neuralgia the same nerve, which is not paroxysmal but durable, without trigger area, and which has various neurological disorders. It is then necessary to look for a cause: MS, syringobulbia, Wallenberg syndrome, tumors of the pontocerebellar angle, cholesteatoma, meningioma, meningo-radiculitis, Sjogren’s syndrome, sarcoidosis … A neurological opinion, the scanner or the MRI are here indispensable.
ALGIA NOT EVOLVING BY CRISES:
These painful pictures are multiple, it is necessary to listen to the patient to make the diagnosis.
Acute sinusitis:
ACUTE MAXILLARY INUSITIS:
It follows a rhinitis, baths, dives, more rarely a dental extraction or abscess, it is usually unilateral and results in:
– Lateronasal headaches sometimes pulsating, increased by the inclination of the head forward;
– rhinorrhea ± purulent, cough and fever (<38.5 ° C in general).
The diagnosis is established by Blondeau-type images showing opacity, sometimes a liquid level.
ACUTE FRONTAL SUSPENSION:
It results in over-orbital headaches, sometimes tearing and photophobia. Cranial images or scanner are indicated.
ACUTE SPHENOIDAL INUSITIS:
It is rare, but serious. It causes retro-orbital headaches which radiate towards the vertex and the occiput, which are often nocturnal and insomniating and resist analgesics. The scanner is essential for diagnosis.
Algia of stomatological origin:
They are related:
– a Costen syndrome (temporomandibular dysfunction), expressed by crunches, protrusion, subluxation of the mandible;
– to a disorder of the dental articulate;
– to an included canine developing …
All things involved in stomatological care.
Ophthalmic zoster:
It has a special place since it is “visible”. Front, lacrimal or nasal localization depending on the branch of the ophthalmic nerve is sometimes very painful. It should be known that the pain can precede the eruption, characteristic by its erythema and its vesicles. Ophthalmological advice is essential because of the risk of keratitis or iridocyclitis.The treatment is aciclovir (Zovirax) or valaciclovir (Zélitrex) orally.
Do not forget the shingles of the geniculate ganglion, which causes an eruption in the Ramsay-Hunt area (external auditory canal, conch of the ear).
Erysipelas of the face and malignant staphylococcal of the face:
The erysipelas of the face (with its red plaque and peripheral rim) and the malignant staphylococcal of the face (succeeding a medio-facial boil) have a significant aspect. Erysipelas, due to group A streptococcus, is a treatment with penicillin G IV relayed by oral amoxicillin after obtaining apyrexia. Staphylococcal disease requires emergency hospitalization for parenteral antibiotic therapy.