what to do about a headaches when you have bells palsy
Bell's Palsy: Diagnosis and Management
Am Fam Dr.. 2007 Oct 1;76(seven):997-1002.
Patient information: Run into related handout on Bell's palsy, written past the authors of this article.
Commodity Sections
- Abstract
- Clinical Presentation
- Etiology and Differential Diagnosis
- Evaluation
- Treatment
- Complications
- References
Bell'due south palsy is a peripheral palsy of the facial nervus that results in muscle weakness on one side of the face. Affected patients develop unilateral facial paralysis over one to three days with forehead involvement and no other neurologic abnormalities. Symptoms typically acme in the first week and and then gradually resolve over three weeks to three months. Bell's palsy is more common in patients with diabetes, and although information technology can affect persons of any age, incidence peaks in the 40s. Bell's palsy has been traditionally defined as idiopathic; nevertheless, one possible etiology is infection with herpes simplex virus type i. Laboratory evaluation, when indicated past history or risk factors, may include testing for diabetes mellitus and Lyme disease. A common short-term complication of Bell's palsy is incomplete eyelid closure with resultant dry eye. A less mutual long-term complication is permanent facial weakness with muscle contractures. Approximately 70 to 80 percentage of patients will recover spontaneously; yet, treatment with a seven-mean solar day class of acyclovir or valacyclovir and a tapering form of prednisone, initiated within iii days of the onset of symptoms, is recommended to reduce the fourth dimension to full recovery and increase the likelihood of consummate recuperation.
Bell's palsy is an idiopathic, acute peripheral-nerve palsy involving the facial nervus, which supplies all the muscles of facial expression. The facial nervus as well contains parasympathetic fibers to the lacrimal and salivary glands, as well as limited sensory fibers supplying taste to the anterior two thirds of the tongue (Figure 1). Bell's palsy is named after Sir Charles Bell (1774–1842), who showtime described the syndrome along with the anatomy and function of the facial nerve. The annual incidence of Bell's palsy is 15 to 30 per 100,000 persons, with equal numbers of men and women affected. There is no predilection for either side of the face. Bell's palsy has been described in patients of all ages, with peak incidence noted in the 40s. It occurs more commonly in patients with diabetes and in pregnant women. Patients who have had one episode of Bell's palsy have an 8 percent take a chance of recurrence.1,2
SORT: KEY RECOMMENDATIONS FOR PRACTICE
| Clinical recommendation | Evidence rating | References |
|---|---|---|
| Patients with Bell's palsy should be treated within three days of the onset of symptoms with a vii-solar day course of oral acyclovir (Zovirax) or valacyclovir (Valtrex), plus a tapering course of oral prednisone. | B | 15–17 |
| Patients with complete paralysis who do not improve in two weeks on medication should exist referred to an otolaryngologist for evaluation for other causes of facial nervus palsy. | C | 19,20 |
| Patients should exist monitored for eye irritation and be prescribed eye lubrication. Patients with corneal abrasions should be referred to an ophthalmologist. | C | ane,23 |
Figure i.
Anatomy of the facial nervus.
Clinical Presentation
- Abstract
- Clinical Presentation
- Etiology and Differential Diagnosis
- Evaluation
- Handling
- Complications
- References
Patients with Bell's palsy typically complain of weakness or complete paralysis of all the muscles on one side of the face. The facial creases and nasolabial fold disappear, the forehead unfurrows, and the corner of the mouth droops. The eyelids will not close and the lower lid sags; on attempted closure, the eye rolls upwardly (Bell'due south phenomenon). Eye irritation often results from lack of lubrication and abiding exposure. Tear production decreases; nonetheless, the eye may appear to tear excessively because of loss of lid control, which allows tears to spill freely from the center. Food and saliva can puddle in the affected side of the oral cavity and may spill out from the corner. Patients often complain of a feeling of numbness from the paralysis, but facial sensation is preserved.
Patients with Bong's palsy normally progress from onset of symptoms to maximal weakness inside three days and nearly always inside i calendar week. A more insidious onset or progression over more than 2 weeks should prompt reconsideration of the diagnosis. Left untreated, 85 percent of patients will show at least fractional recovery inside three weeks of onset.iii
Etiology and Differential Diagnosis
- Abstract
- Clinical Presentation
- Etiology and Differential Diagnosis
- Evaluation
- Treatment
- Complications
- References
Bell'due south palsy is believed to be acquired by inflammation of the facial nerve at the geniculate ganglion, which leads to compression and possible ischemia and demyelination. This ganglion lies in the facial culvert at the junction of the labyrinthine and tympanic segments, where the nerve curves sharply toward the stylomastoid foramen. Classically, Bong'due south palsy has been divers equally idiopathic, and the crusade of the inflammatory process in the facial nerve remains uncertain. Recently, attention has focused on infection with canker simplex virus type 1 (HSV-1) as a possible cause because research has found elevated HSV-1 titers in affected patients. However, studies take failed to isolate viral DNA in biopsy specimens, leaving the causative role of HSV-1 in question.four,5
Many weather condition can produce isolated facial nerve palsy identical to Bell'south palsy. Structural lesions in the ear or parotid gland (due east.chiliad., cholesteatoma, salivary tumors) can produce facial nerve compression and paralysis. Other causes of peripheral nervus palsies include Guillain-Barré syndrome, Lyme affliction, otitis media, Ramsay Hunt syndrome (an outbreak of herpes zoster in the facial nerve distribution), sarcoidosis, and some influenza vaccines. Although these weather tin can present equally isolated facial nerve palsies, they usually have additional features that distinguish them from Bell's palsy.
Patients with Lyme disease often have a history of tick exposure, rash, or arthralgias. Facial nerve palsies from astute and chronic otitis media have a more gradual onset, with accompanying ear pain and fever. Patients with Ramsay Hunt syndrome have a pronounced prodrome of pain and oft develop a vesicular eruption in the ear culvert and pharynx, although cases without the vesicular eruption (i.e., zoster sine herpete) have been reported. Polyneuropathies (e.chiliad., Guillain-Barré syndrome, sarcoidosis) volition more often affect both facial nerves. Tumors will present with a more insidious onset of symptoms over weeks or months.
Central nervous system lesions (e.g., multiple sclerosis, stroke, tumor) tin can too cause facial nervus palsy. Still, some motor neurons to the forehead cantankerous sides at the level of the brainstem, then the fibers in the facial nerve going to the brow come up from both cerebral hemispheres (Figure 2). Supranuclear (cardinal) lesions affecting the facial nerve will not paralyze the forehead on the affected side, resulting in a unilateral facial paralysis with brow sparing. Often, in that location will exist at least some weakness of extremities on the affected side as well. Table 1i,6–viii summarizes the differential diagnosis of Bell'due south palsy.
Figure 2.
Patients with (A) a facial nervus lesion and (B) a supranuclear lesion with forehead sparing.
Table 1
Differential Diagnosis for Facial Nerve Palsy
| Disease | Crusade | Distinguishing factors |
|---|---|---|
| Nuclear (peripheral) | ||
| Lyme disease | SpirocheteBorrelia burgdorferi | History of tick exposure, rash, or arthralgias; exposure to areas where Lyme disease is endemic |
| Otitis media | Bacterial pathogens | Gradual onset; ear pain, fever, and conductive hearing loss |
| Ramsay Hunt syndrome | Herpes zoster virus | Pronounced prodrome of pain; vesicular eruption in ear canal or pharynx |
| Sarcoidosis or Guillain-Barré syndrome | Autoimmune response | More often bilateral |
| Tumor | Cholesteatoma, parotid gland | Gradual onset |
| Supranuclear (central) | Forehead spared | |
| Multiple sclerosis | Demyelination | Boosted neurologic symptoms |
| Stroke | Ischemia, hemorrhage | Extremities on afflicted side ofttimes involved |
| Tumor | Metastases, primary brain | Gradual onset; mental status changes; history of cancer |
Influenza vaccines in the by have been associated with peripheral neuropathies. Although influenza vaccines currently bachelor in the Us have not been associated with Bong's palsy,9–11 a recently developed Swiss intranasal vaccine was found to take a very high gamble of postvaccine facial nerve palsy and has been withdrawn from use.12 Considering influenza vaccines alter annually, public health officials should be notified of any cases of Bong's palsy occurring in the six weeks following vaccine administration.
Evaluation
- Abstruse
- Clinical Presentation
- Etiology and Differential Diagnosis
- Evaluation
- Treatment
- Complications
- References
A patient with an acute onset of unilateral facial weakness most likely has Bell'south palsy. A careful history of the onset and progress of paralysis is important because gradual onset of more than two weeks' elapsing is strongly suggestive of a mass lesion. Medical history should include contempo rashes, arthralgias, or fevers; history of peripheral nerve palsy; exposure to flu vaccine or new medications; and exposure to ticks or areas where Lyme disease is endemic. The physical examination should include conscientious inspection of the ear canal, tympanic membrane, and oropharynx, too every bit evaluation of peripheral nerve function in the extremities and palpation of the parotid gland. In order to appraise forehead involvement, concrete test should too include evaluation of cranial nerve function, including all facial muscles.
Laboratory testing is not usually indicated. However, considering diabetes mellitus is present in more 10 percent of patients with Bong'south palsy, fasting glucose or A1C testing may be performed in patients with additional run a risk factors (e.g., family history, obesity, older than 30 years).13 Antibiotic therapy may be of benefit; therefore, Lyme antibody titers should be performed if the patient's history suggests possible exposure. Signs and symptoms atypical for Bell'due south palsy should prompt further evaluation. Patients with insidious onset or forehead sparing should undergo imaging of the head. Those with bilateral palsies or those who do not improve within the first ii or three weeks after onset of symptoms should be referred to a neurologist
Handling
- Abstruse
- Clinical Presentation
- Etiology and Differential Diagnosis
- Evaluation
- Treatment
- Complications
- References
CORTICOSTEROIDS
Oral corticosteroids have traditionally been prescribed to reduce facial nerve inflammation in patients with Bong's palsy. Prednisone is typically prescribed in a 10-twenty-four hour period tapering course starting at 60 mg per day. A 2004 Cochrane review and meta-analysis of three randomized controlled trials comparing corticosteroids with placebo institute small and statistically nonsignificant reductions in the percentage of patients with incomplete recovery after six months (relative hazard [RR] = 0.86; 95% confidence interval [CI], 0.47 to 1.59) and the percentage of patients with cosmetic complications (RR = 0.86; 95% CI, 0.38 to 1.98).fourteen However, these trials included only 117 patients; larger prospective trials are needed to found the benefit of corticosteroids.
ANTIVIRALS
Because of the possible role of HSV-1 in the etiology of Bell's palsy, the antiviral drugs acy-clovir (Zovirax) and valacyclovir (Valtrex) have been studied to determine if they have any benefit in handling. Either acyclovir 400 mg tin can be given five times per day for seven days or valacyclovir ane yard tin can be given iii times per day for 7 days. Although a 2004 Cochrane review found bereft evidence to support the use of these antivirals solitary,fifteen 2 recent placebo-controlled trials demonstrated full recovery in a higher percentage of patients treated with an antiviral drug in combination with prednisolone than with prednisolone alone (100 pct versus 91 percent and 95 percent versus 90 per centum).xvi,17 Still, no do good was seen when handling was delayed more four days after the onset of symptoms (86 percent versus 87 percent).17
SPONTANEOUS RECOVERY
It is difficult to establish a statistically meaning benefit of handling in placebo-controlled trials because Bell'due south palsy has a high rate of spontaneous recovery. The Copenhagen Facial Nerve Study evaluated 2,570 persons with untreated facial nerve palsy, including one,701 with idiopathic (Bell's) palsy and 869 with palsy from other causes; 70 percent had complete paralysis. Office returned within three weeks in 85 percent of patients, with 71 percentage of these patients recovering total function. Of the 29 pct of patients with sequelae, 12 percent rated information technology slight, 13 percent rated it mild, and four percent rated it severe.three Because of these findings, some persons accept questioned whether treatment for Bell'due south palsy should exist routinely indicated; nonetheless, patients who have incomplete recovery will take obvious corrective sequelae and will often exist dissatisfied with their outcome.18
Given the safety profile of acyclovir, valacyclovir, and short-class oral corticosteroids, patients who present within iii days of the onset of symptoms and who do not have specific contraindications to these medications should be offered combination therapy. Patients who present with consummate facial nerve paralysis have a lower rate of spontaneous recovery and may exist more than probable to benefit from treatment.1–3,nineteen
OTHER TREATMENTS
In the by, surgical decompression within three weeks of onset has been recommended for patients who have persistent loss of function (greater than ninety percent loss on electroneurography) at 2 weeks. Yet, the most widely cited study supporting this approach only reported results for a total of 34 treated patients at three different sites, included a nonrandomized control group, and lacked a blinded evaluation of outcome.xx
The most common complication of surgery is postoperative hearing loss, which affects iii to 15 percent of patients. Based on the meaning potential for harms and the paucity of data supporting do good, the American Academy of Neurology does not currently recommend surgical decompression for Bell's palsy.19
Some published studies have reported do good with acupuncture versus steroids and placebo, but all had serious flaws in written report pattern and reporting.21Tabular array ii summarizes the available treatments.
Tabular array 2
Medications for Handling of Bell'southward Palsy
| Medication | Dosing | Renal adjustment | Hepatic adjustment | Adverse reactions | Price* |
|---|---|---|---|---|---|
| Acyclovir (Zovirax) | Adults: 400 mg v times daily for seven days | Creatinine clearance:
| Undefined | Gastrointestinal upset, headache, dizziness, elevated liver enzymes, aplastic anemia (rare) | $66 to $76 (generic) $132 (make) |
| Children older than two years: lxxx mg per kg daily divided every half-dozen hours for five days, with a maximal dose of iii,200 mg daily | |||||
| Valacyclovir (Valtrex) | Adults and children older than 12 years: 1 g three times daily for seven days | Creatinine clearance:
| None | Gastrointestinal upset, headache, dizziness, elevated liver enzymes, aplastic anemia (rare) | $208 (make) |
| Prednisone or prednisolone | Adults: sixty mg daily for five days, so 40 mg daily for v days | None | Undefined | Headache, nervousness, edema, elevated claret pressure, elevated glucose | $three (generic) $6 (brand) |
| Children: ii mg per kg daily for vii to 10 days |
Complications
- Abstract
- Clinical Presentation
- Etiology and Differential Diagnosis
- Evaluation
- Treatment
- Complications
- References
Patients with Bell's palsy may be unable to close the eye on the affected side, which tin can lead to irritation and corneal ulceration. The eye should be lubricated with artificial tears until the facial paralysis resolves. Permanent eyelid weakness may require tarsorrhaphy or implantation of gold weights in the upper lid. Facial disproportion and muscular contractures may require cosmetic surgical procedures or botulinum toxin (Botox) injections. In these cases, consultation with an ophthalmologist or corrective surgeon is needed.22,23
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REFERENCES
bear witness all references
one. Gilden DH. Clinical practice. Bong's palsy. N Engl J Med. 2004;351:1323–31. ...
2. Morris AM, Deeks SL, Hill MD, Midroni K, Goldstein WC, Mazzulli T, et al. Annualized incidence and spectrum of illness from an outbreak investigation of Bong's palsy. Neuroepidemiology. 2002;21:255–61.
3. Peitersen East. Bell's palsy: the spontaneous course of 2,500 peripheral facial nerve palsies of unlike etiologies. Acta Otolaryngol Suppl. 2002:4–30.
4. Linder T, Bossart W, Bodmer D. Bell'south palsy and herpes simplex virus: fact or mystery?. Otol Neurotol. 2005;26:109–13.
five. Stjernquist-Desatnik A, Skoog E, Aurelius E. Detection of herpes simplex and varicella-zoster viruses in patients with Bell's palsy by the polymerase concatenation reaction technique. Ann Otol Rhinol Laryngol. 2006;115:306–11.
6. Makeham TP, Croxson GR, Coulson Due south. Infective causes of facial nerve paralysis. Otol Neurotol. 2007;28:100–three.
vii. Redaelli de Zinis LO, Gamba P, Balzanelli C. Acute otitis media and facial nerve paralysis in adults. Otol Neurotol. 2003;24:113–seven.
8. Keane JR. Bilateral 7th nerve palsy: analysis of 43 cases and review of the literature. Neurology. 1994;44:1198–202.
9. Zhou W, Pool V, DeStefano F, Iskander JK, Haber P, Chen RT, for the VAERS Working Group. A potential signal of Bell's palsy after parenteral inactivated influenza vaccines: reports to the Vaccine Agin Event Reporting System (VAERS) —U.s.a., 1991–2001. Pharmacoepidemiol Drug Saf. 2004;13:505–ten.
10. Izurieta HS, Haber P, Wise RP, Iskander J, Pratt D, Mink C, et al. Agin events reported following live, cold-adapted, intranasal influenza vaccine [Published correction appears in JAMA 2005;294:3092]. JAMA. 2005;294:2720–5.
11. Zhou W, Puddle 5, Iskander JK, English language-Bullard R, Ball R, Wise RP, et al. Surveillance for safety after immunization: Vaccine Adverse Issue Reporting Arrangement (VAERS) —United States, 1991–2001 [Published correction appears in MMWR Morb Mortal Wkly Rep 2003;52:113]. MMWR Surveill Summ. 2003;52:1–24.
12. Mutsch M, Zhou Due west, Rhodes P, Bopp Thousand, Chen RT, Linder T, et al. Utilise of the inactivated intranasal flu vaccine and the chance of Bong's palsy in Switzerland. N Engl J Med. 2004;350:896–903.
13. Adour K, Wingerd J, Doty HE. Prevalence of concurrent diabetes mellitus and idiopathic facial paralysis (Bell's palsy). Diabetes. 1975;24:449–51.
fourteen. Salinas RA, Alvarez G, Ferreira J. Corticosteroids for Bell's palsy (idiopathic facial paralysis). Cochrane Database Syst Rev. 2004;(4):CD001942.
xv. Allen D, Dunn L. Aciclovir or valaciclovir for Bell's palsy (idiopathic facial paralysis). Cochrane Database Syst Rev. 2004;(3):CD001869.
sixteen. Hato N, Yamada H, Kohno H, Matsumoto Due south, Honda N, Gyo K, et al. Valacyclovir and prednisolone treatment for Bell'due south palsy: a multicenter, randomized, placebo-controlled study. Otol Neurotol. 2007;28:408–xiii.
17. Hato North, Matsumoto S, Kisaki H, Takahasi H, Wakisaka H, Honda N, et al. Efficacy of early on treatment of Bell's palsy with oral acyclovir and prednisolone. Otol Neurotol. 2003;24:948–51.
18. Gillman GS, Schaitkin BM, May Thousand, Klein SR. Bell's palsy in pregnancy: a study of recovery outcomes. Otolaryngol Head Cervix Surg. 2002;126:26–30.
19. Grogan PM, Gronseth GS. Practice parameter: steroids, acyclovir, and surgery for Bong's palsy (an prove-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2001;56:830–half dozen. Accessed April 17, 2007, at: http://world wide web.aan.com/professionals/practice/pdfs/gl0064.pdf.
20. Gantz BJ, Rubinstein JT, Gidley P, Woodworth GG. Surgical management of Bell'south palsy. Laryngoscope. 1999;109:1177–88.
21. He L, Zhou D, Wu B, Li Northward, Zhou MK. Acupuncture for Bell's palsy. Cochrane Database Syst Rev. 2004;(ane):CD002914.
22. Bulstrode NW, Harrison DH. The miracle of the late recovered Bell's palsy: treatment options to improve facial symmetry. Plast Reconstr Surg. 2005;115:1466–71.
23. Holland NJ, Weiner GM. Recent developments in Bong's palsy. BMJ. 2004;329:553–7.
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