An Otolaryngologic Quandary: Diagnosis and Treatment of Pain Syndromes of the Head and Neck

Table 1 lists some of the most common primary conditions causing orbital pain.

Overall, Dr. Zimmer emphasized that diagnosing and treating orbital pain requires a multidisciplinary approach involving otolaryngology, ophthalmology, neurology, and neurosurgery.

Vestibular Migraine

A pain syndrome that is becoming more recognized and therefore increasingly looked for is vestibular migraine, according to Peter Weber, MD, of the Department of Otolaryngology at the Cleveland Clinic.

Thought to be a genetic condition rather than a vascular event, vestibular migraine is characterized by headaches with central episodic vertigo. As such, differentiating this pain syndrome from Ménière’s disease, which can also be related to headache or migraine-type conditions in up to 30% of the cases, is important because of their different treatments.

Treatment is completely different, said Dr. Weber, adding that a typical case of Ménière’s disease is treated with a diuretic or low-salt diet, whereas medications to prevent headaches from developing are needed to treat a vestibular migraine.

If a patient has been treated appropriately for regular Ménière’s disease with no significant benefit and if they have a type of headache history typical of a migraine event, he said, the next step may be to try to treat for vesticular migraine.

Diagnosis rests on a careful headache history. According to Dr. Weber, in people with this syndrome, the headache creates the dizzy episode and/or fullness in the ears, hearing loss, or tinnitus. It can come before or after a dizzy episode or sometimes may occur at a different time.

The most effective treatment for this condition is prevention, with data suggesting improved efficacy with reduced side effects with the newer therapeutic agents topiramate (25 mg/day slowly titrated to 100 mg/day) or venlafaxine (37.5 mg/day slowly titrated to 150 mg/day). Other prophylactic agents that can be used include anticonvulsants (eg, divalproex), other antidepressants (eg, amitriptyline), and beta blockers (eg, propanolol, timolol).

Treatment of acute vertigo episodes include benzodiazepines (eg, lorazepam, diazepam) and agents to treat motion sickness (eg, promethazine, meclizine). Agents use to treat migraine headaches (eg, triptans) have no effect on the vertigo, said Dr. Weber.

Oropharyngeal Pain Syndrome

Of the four main causes of oropharyngeal pain-trauma, inflammation, cancer, and various syndromes-inflammation, predominantly due to viral infection, is the most common, according to Paul J. Donald, MD, of the Department of Otolaryngology-Head and Neck Surgery at University of California, Davis.

The key challenge in treating this type of oropharyngeal pain is to differentiate between viral and bacterial infections. Correct diagnosis can often be made by taking a careful history and thorough physical examination, said Dr. Donald. Signs of inflammation can include burning in the oropharynx by gastric acid or cricopharyngeal spasm.