Head and Neck Pain

Abstract

• 1. Characteristics of dental pain:

  • (a) Chronic widespread pain is a risk factor.

  • (b) Facial pain is derived only from teeth pulp.

  • (c) Estradiol and prolactin are involved in pain sensitisation.

  • (d) Dental pulp is innervated by large myelinated fibres.

  • (e) Myelinated afferents innervate the whole of the teeth.

• 2. Characteristics of dental pain:

  • (a) Inflammation of dental pulp presents as sharp stabbing pain.

  • (b) Human dental pulp expresses calcitonin gene-related peptide (CGRP).

  • (c) μ opioid agonists are not effective in dental pulp pain.

  • (d) Pulp inflammation is prevented by good immune response.

  • (e) Altered sodium channel expression is seen.

• 3. Characteristics of oral cancer pain:

  • (a) The most common cause of malignancy is squamous cell carcinoma.

  • (b) Pain is the presenting symptom.

  • (c) True spontaneous pain is seen.

  • (d) Oral pain may be a manifestation of treatment of breast and colon carcinoma.

  • (e) Osteoradionecrosis is seen only with radiotherapy.

• 4. Characteristics of temporomandibular joint pain:

  • (a) Generalised arthritis is one of the risk factors.

  • (b) Difficulty in chewing is one of the risk factors.

  • (c) Seen more in men than women.

  • (d) Can be a manifestation of skeletal muscle disorder.

  • (e) The most common treatment is conservative.

• 5. Characteristics of burning mouth syndrome:

  • (a) Presents as burning pain in the lips.

  • (b) May be seen secondary to diabetes.

  • (c) Intermittent spasms of severe pain are seen.

  • (d) Is mostly a sensory neuropathy.

  • (e) Cognitive behavioural therapy is useful.

• 6. Characteristics of burning mouth syndrome include:

  • (a) Oral mucosa shows normal appearance.

  • (b) Symptoms are present for at least 2 months.

  • (c) Acidic foods reproduce symptoms.

  • (d) Dysgeusia presents as diminished ability to detect bitter flavours.

  • (e) Increased levels of IL-2 and IL-6 are seen.

• 7. Temporomandibular joint pain:

  • (a) Presents as joint pain that gets relieved with rest.

  • (b) Morning stiffness of jaw lasts for more than 2 h every day.

  • (c) Radiologic features are not seen.

  • (d) Hyaluronic injections are helpful.

  • (e) Joint lavage helps relieve neuropathic pain.

• 8. Neurovascular headache:

  • (a) Is related to the dura mater and its associated vasculature.

  • (b) Vasodilation induced as a result of pain is mostly limited to ophthalmic division of trigeminal nerve.

  • (c) Trigeminovascular system is involved.

  • (d) Parasympathetic autonomic involvement leads to lacrimation and nasal stuffiness.

  • (e) Cranial pain can cause vasodilation.

• 9. Characteristics of migraine:

  • (a) Represents sensitivity to normal sensory input.

  • (b) Familial hemiplegic migraine is because of involvement of potassium channel.

  • (c) Sporadic hemiplegic migraine involves glutamate receptors.

  • (d) Changes in cerebellum are seen.

  • (e) SUNCT is associated with injection and tearing.

• 10. Diagnosis of migraine:

  • (a) Is generally a continuous pain.

  • (b) Aura is present in 80% of patients.

  • (c) Aura is present more frequently in tension-type headache.

  • (d) Migraine is seen more frequently in females.

  • (e) Headache in response to triggers is characteristic.

• 11. Chronic daily headache:

  • (a) Presents as headache for more than 6 months.

  • (b) Incidence is 20%.

  • (c) Headache in those >50 years old can be because of temporal arteritis.

  • (d) Headache worsening on supine position with Valsalva manoeuvre can occur with anterior fossa abnormalities.

  • (e) Medication overuse headache is one of the common reasons for daily headache.

• 12. Characteristics of chronic migraine headache:

  • (a) Headache must respond to triptans for at least 8 days for its diagnosis.

  • (b) Is seen in 20% of population.

  • (c) Psychosocial factors are an association.

  • (d) History of the head and neck is a major risk factor.

  • (e) Typically ipsilateral autonomic features are seen.

• 13. Characteristics of chronic tension-type headache:

  • (a) Association with depression is seen.

  • (b) Is usually unilateral.

  • (c) Is associated with nausea and vomiting.

  • (d) Lifestyle management is the main treatment.

  • (e) Topiramate is effective in treatment.

• 14. All are true about hemicrania continua except:

  • (a) Presents as continuous headache.

  • (b) Is seen more commonly in males than females.

  • (c) Is usually associated with autonomic features.

  • (d) Usually responds to conservative management.

  • (e) Indomethacin dosage should be slowly tapered.

• 15. Episodic migraine:

  • (a) Is seen more in males than females.

  • (b) Is mostly unilateral.

  • (c) Is frequently associated with vomiting.

  • (d) Auras are present in 60% of patients.

  • (e) Aura consists of positive features.

• 16. Classic migraine:

  • (a) Presents with only visual auras.

  • (b) Food items may precipitate migraine.

  • (c) Seizures may be seen.

  • (d) Triptans are effective in 100% of the population.

  • (e) Symptoms become less with age.

• 17. Cluster headache:

  • (a) Is a bilateral continuous pain.

  • (b) May continue for 1 year.

  • (c) High altitude may be a trigger factor.

  • (d) Is not associated with autonomic features.

  • (e) The diagnosis is critical.

• 18. Characteristics of cluster headache:

  • (a) Mostly seen in females.

  • (b) Autonomic features last only for the duration of the attacks.

  • (c) Management is mostly conservative.

  • (d) Can occur in association with trigeminal neuralgia.

  • (e) Attacks can be terminated with greater occipital nerve blocks.

• 19. Cluster headache:

  • (a) Circadian pattern is seen.

  • (b) Mostly involves the maxillary area.

  • (c) Aura may be present.

  • (d) Females show bimodal pattern.

  • (e) Surgical treatment may be required.

• 20. SUNCT syndrome:

  • (a) Mostly unilateral headache is seen in association with cranial autonomic features.

  • (b) Conjunctival tearing and injection are always seen.

  • (c) Frequency of attacks can exceed up to 100/day.

  • (d) Is similar to trigeminal neuralgia.

  • (e) Responds to anticonvulsants.

• 21. Tension headache:

  • (a) Is mostly bilateral.

  • (b) Is seen more in females than males.

  • (c) Diagnosis is based on tenderness on manual palpation.

  • (d) Tricyclic antidepressants are first-line treatment for prophylaxis.

  • (e) Is divided into infrequent and frequent types.

• 22. Pathophysiology of tension headache includes:

  • (a) Increased hardness of pericranial muscles may be seen.

  • (b) Tender muscles may represent central sensitisation.

  • (c) Temporal or spatial summation of peripheral stimuli plays a role in headache.

  • (d) Amitriptyline decreases exteroceptive silent period 2 in tension headache.

  • (e) Is associated with nitric oxide supersensitivity.

• 23. Management of tension headache:

  • (a) Tricyclic antidepressants are effective as prophylactic agents.

  • (b) Botulinum toxin is helpful for chronic headaches.

  • (c) Behavioural therapies have no role in the treatment.

  • (d) Acupuncture has significant effect in management.

  • (e) Oromandibular splints may be of help.

• 24. Glossopharyngeal neuralgia:

  • (a) Continuous pain in the sensory division of the ninth cranial nerve is seen.

  • (b) Is seen more frequently than trigeminal neuralgia.

  • (c) Pain is typically seen in the distribution of glossopharyngeal nerve.

  • (d) Bradycardia and cardiac arrest may be seen.

  • (e) Tumours of the head and neck may cause it.

• 25. Treatment of glossopharyngeal neuralgia:

  • (a) Anticonvulsants are the first-line treatment.

  • (b) Gabapentin treatment may cause rash.

  • (c) Baclofen may cause hepatic side effects.

  • (d) Single glossopharyngeal nerve block usually abolishes the pain.

  • (e) Management of intractable lesion is conservative.

• 26. Giant cell arteritis:

  • (a) Pathophysiology involves vasculitis of small arteries.

  • (b) Inflammatory markers are seen in 100% of patients.

  • (c) May be associated with polymyalgia rheumatica.

  • (d) Temporal artery biopsy shows infiltration with mononucleated cells.

  • (e) Peripheral pulses may be absent.

• 27. Clinical features of giant cell arteritis include:

  • (a) Pain is present in 100% of patients.

  • (b) Prominent pulsations in the arteries are characteristic.

  • (c) Visual loss is gradual.

  • (d) May be accompanied with aortic dissection and rupture.

  • (e) Hemiparesis may be seen.

• 28. Giant cell arteritis:

  • (a) Giant cells on histologic examination are essential for diagnosis.

  • (b) Therapy should be delayed until a diagnosis by biopsy is made.

  • (c) Increased alkaline phosphatase levels may be seen.

  • (d) Activated CD4 cells and macrophages contribute to the pathology.

  • (e) «halo» sign is diagnostic on ultrasound.

• 29. Occipital neuralgias:

  • (a) Mostly seen with position causing hyperextension of the head.

  • (b) Continuous dull ache is typical.

  • (c) Nerve blockade is diagnostic.

  • (d) Radio frequency lesioning can increase the duration of pain relief.

  • (e) Arnold-Chiari malformation may mimic occipital neuralgia.

• 30. Ocular innervation:

  • (a) Sensory areas run with first division of trigeminal ganglion.

  • (b) Short ciliary nerves carry postganglionic sympathetic axons.

  • (c) Upper eyelid is supplied by ophthalmic nerve.

  • (d) Conjunctiva is supplied by maxillary nerve.

  • (e) The retina receives direct trigeminal innervation.

• 31. Ocular sensory innervation:

  • (a) Major sensory nerves are thinly myelinated or unmyelinated.

  • (b) Corneal innervation has varicosities.

  • (c) Axons that penetrate corneal stroma are typically myelinated.

  • (d) The number of corneal nerve terminals decreases gradually with age.

  • (e) The choroid and iris are innervated by sensory nerve fibres.

• 32. Physiology of ocular sensory innervation:

  • (a) Seventeen percent of corneal sensory nerve fibres are polymodal receptors.

  • (b) Polymodal fibres fire when the temperature is more than 45°.

  • (c) Fifty percent of axons innervating the cornea respond to mechanical force.

  • (d) Mechanically insensitive fibres are present in the cornea.

  • (e) Polymodal nociceptor and mechanonociceptor have small receptor fields.

• 33. Pain due to ocular disease:

  • (a) Subconjunctival haemorrhage may induce severe pain.

  • (b) After corneal injury, sub-basal nerve density heals faster than the epithelium.

  • (c) Disturbances in cold receptor activity can contribute to pain of dry eye.

  • (d) Retinitis and endophthalmitis are painful because of highly sensitive retina.

  • (e) Orbital tumours are painful.

• 34. Ocular pain:

  • (a) Retrobulbar neuritis is seen in multiple sclerosis.

  • (b) Painless diplopia may be seen with cavernous sinus involvement.

  • (c) Phantom eye pain is seen in significant number of patients.

  • (d) Ocular pain may be associated with disappearance of corneal reflex.

  • (e) Involvement of anterior segment of the eye can aggravate migraine.