headache
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HeadacheHeadacheBy Dr. Osman Sadig By Dr. Osman Sadig
BukhariBukhari
- - HA is defined as feeling of pain, aches HA is defined as feeling of pain, aches or discomfort in za cranium, face or or discomfort in za cranium, face or upper neck.upper neck. - - Headache is za most common Headache is za most common neurological symptom neurological symptom
- - Almost every one have had itAlmost every one have had it
- - Not all HA have an intra cranial causeNot all HA have an intra cranial cause
or due to brain tumoursor due to brain tumours
- - Not all pts wz HA require brain scanNot all pts wz HA require brain scan
> - > - 75%75% of HA can be diagnosed by of HA can be diagnosed by historyhistory
- - Hypotension causes HA > HTHypotension causes HA > HT
- -Cause vary from trivial nuisance to Cause vary from trivial nuisance to serious intra cranial disease serious intra cranial disease
- - HA may be due to disease of nearby HA may be due to disease of nearby structures: sinuses, T/M joint, structures: sinuses, T/M joint, teeth , gums, tonsils, ears, eyes, teeth , gums, tonsils, ears, eyes, neck, etcneck, etc..
classification of HAclassification of HA
11 - -Non life threatening HANon life threatening HA e.g. e.g. migraine, tension HA, cluster migraine, tension HA, cluster HA, facial pain, cervicogenic HA, facial pain, cervicogenic
HAHA
22 - -Life threatening HA:Life threatening HA: infections infections (meningitis, encephalitis), intra (meningitis, encephalitis), intra cranial bleeding, SOL, temporal cranial bleeding, SOL, temporal arteritisarteritis
HA may be acute ( migraine, SAH, HA may be acute ( migraine, SAH, meningitis) or chronic (tension meningitis) or chronic (tension HA, ICP )HA, ICP )
HA how to diagnoseHA how to diagnose?? HistoryHistory::
- -Age, sex, occupation, etcAge, sex, occupation, etc..
- - Onset , site, duration, nature, Onset , site, duration, nature, severity, frequency, change wz severity, frequency, change wz cough, bending & straining, cough, bending & straining, relation to menses, precipt or relation to menses, precipt or aggravating or relieving factors, aggravating or relieving factors,
response to TR, etc response to TR, etc . .
ExaminationExamination::
- -temp, BP, gen ex including teeth, temp, BP, gen ex including teeth, gums, neck stiffness, temporal gums, neck stiffness, temporal
tendernesstenderness
- - Full neurological ex including Full neurological ex including fundoscopyfundoscopy..
InvestigationsInvestigations::
- -not all HA require investigationsnot all HA require investigations
- - simple investigations may give a simple investigations may give a diagnosis: FBC ( anaemia & high diagnosis: FBC ( anaemia & high ESR in temp arteritis, leucocytosis ESR in temp arteritis, leucocytosis in infections, polycythemia), BUN in infections, polycythemia), BUN and E, LFT, CXRand E, LFT, CXR
- -Only 5-10% of pts wz HA need brain Only 5-10% of pts wz HA need brain scanscan
- - Brain scan ifBrain scan if : : - SOL - focal N signs - SOL - focal N signs - if suspect intra cranial infection - if suspect intra cranial infection - disc margin is not clear - disc margin is not clear - change in HA pattern - change in HA pattern - if suspect BIH - if suspect BIH . .
- -Lumber puncture if: Lumber puncture if: - acute & chronic CNS - acute & chronic CNS infections - BIH infections - BIH - if - if Ca meningitis is Ca meningitis is suspected - normal suspected - normal
pressure hydrocephaluspressure hydrocephalus
Alarming signsAlarming signs:: - -sudden onset severe HA - fever > 39 sudden onset severe HA - fever > 39
CC
- - decreased alertness - traumadecreased alertness - trauma
- - HA wz seizures - persistent HA wz seizures - persistent HAHA
- - HA interfering wz normal life or that HA interfering wz normal life or that causecause
sleep disturbancesleep disturbance
- - change in sleep patternchange in sleep pattern
Mechanism of headacheMechanism of headache - - Brain substance is devoid of pain receptorsBrain substance is devoid of pain receptors
- - Pain receptors are present in za meningesPain receptors are present in za meninges,,
blood vessels in za base of za brain, extrablood vessels in za base of za brain, extra
cranial vessels & face. Nerve impulses cranial vessels & face. Nerve impulses travel centrally via za 5travel centrally via za 5thth, 9, 9thth and upper and upper cervicalcervical
sensory rootssensory roots . .
- - Sensory receptors are stimulated Sensory receptors are stimulated mechanicallymechanically
by stretch & distension or chemically byby stretch & distension or chemically by
5HT & histamine5HT & histamine..
HA, D.DHA, D.D:: 11 - -AAccording to ageccording to age: migr in teenagers: migr in teenagers
22 - -AAccording to genderccording to gender:- migr > in females:- migr > in females,,
cluster HA > in males, temp arteritis > incluster HA > in males, temp arteritis > in
femalesfemales
33 - -AAccording to siteccording to site:-frontal in sinusitis, temporal:-frontal in sinusitis, temporal
in migr & temp arteritis, occipital in SAHin migr & temp arteritis, occipital in SAH
44 - -AAccording to timingccording to timing:- new early morning HA in:- new early morning HA in
SOL, acute HA during activity in SAH, eveningSOL, acute HA during activity in SAH, evening
HA in tension HAHA in tension HA
55 - -AAccording to severityccording to severity:- very severe :- very severe and acute inand acute in severe & recurrent in severe & recurrent in cluster HA, moderately severe cluster HA, moderately severe SAH, severe & temp in temp SAH, severe & temp in temp arteritis, very severe arteritis, very severe & dull in SOL. & dull in SOL. 6- 6- According to associated symptomsAccording to associated symptoms:- :- fever and photophobia in fever and photophobia in meningitis, HA increased by meningitis, HA increased by cough & sneezing in SOL; visual cough & sneezing in SOL; visual symptoms in SOL, BIH, migr symptoms in SOL, BIH, migr and TIAand TIA
Causes of headacheCauses of headache 11 - -Referred headacheReferred headache
22 - -Vascular headacheVascular headache
- - migraine - temporal arteritismigraine - temporal arteritis
- - A/V malformation & aneurysmsA/V malformation & aneurysms
- - Severe HT - Vasodilt. from alcohol & Severe HT - Vasodilt. from alcohol & CO2CO2
33 - -Tension headache Tension headache 4 - meningeal irritation 4 - meningeal irritation
55 - -Neuralgic headacheNeuralgic headache
66 - -ICPICP
77 - -Systemic causesSystemic causes..
Referred headacheReferred headache - - EyesEyes: glucoma, irirtis, refractory errors: glucoma, irirtis, refractory errors....
- - Para nasal sinusesPara nasal sinuses: sinusitis: sinusitis
- - EarsEars: otitis media & externa: otitis media & externa
- - ThroatThroat: tonsillitis: tonsillitis
- - Cervical sponylosisCervical sponylosis
- - TeethTeeth
- - Tempro mandibular arthritisTempro mandibular arthritis..
** ** Treatment is by analgesics & that of theTreatment is by analgesics & that of the
underlying causeunderlying cause..
Tension headacheTension headache - - Commonest chronic headacheCommonest chronic headache
- - Nuchal or generalized, constant or dull or tightNuchal or generalized, constant or dull or tight
pressure pain wz local tenderness & pressure pain wz local tenderness & associatedassociated
with anxiety or depressionwith anxiety or depression..
- - Variable in duration & intensityVariable in duration & intensity
- - Often ppted by stress, depression, noises andOften ppted by stress, depression, noises and
fumesfumes..
- - No vomiting or photophobiaNo vomiting or photophobia
- - Careful history & exam clarify za diagnosisCareful history & exam clarify za diagnosis
and reassures za patand reassures za pat..
- - Immaging to exclude intra cranial diseaseImmaging to exclude intra cranial disease
and to allay za anxiety of za patand to allay za anxiety of za pat
- - Management includesManagement includes::
- - ReassuranceReassurance
- - Avoidance of ppting causesAvoidance of ppting causes..
- - Massage & ice bagsMassage & ice bags
- - AnalgesicsAnalgesics
- - Treatment of za underlying anxiety Treatment of za underlying anxiety andand
depressiondepression..
MigraineMigraine - - Migraine is a recurrent episodic, throbbingMigraine is a recurrent episodic, throbbing
headache, associated wz prostration, headache, associated wz prostration, nauseanausea,,
vomiting & photophobia +/_ focal vomiting & photophobia +/_ focal neurologicalneurological
symptoms & signs ( usually visual in classicsymptoms & signs ( usually visual in classic migrainemigraine.).)
- - 20%20% of females & 6% of males will have anof females & 6% of males will have an attack in their life timeattack in their life time..
- - Genetic predisposition ( 50% have FH)Genetic predisposition ( 50% have FH) - - 11stst episode before puberty is rare episode before puberty is rare..
- - Interval between attacks varies & episodesInterval between attacks varies & episodes last hours to dayslast hours to days..
Mechanism of migraineMechanism of migraine - - Intra cerebral vasoconstriction at za Intra cerebral vasoconstriction at za
onsetonset
due to 5HT release causes transient focal due to 5HT release causes transient focal neurological S & S, prodrome or neurological S & S, prodrome or
aura lasting 15-60 minaura lasting 15-60 min . .
- - Headache is due to vasodilt. of meningeal Headache is due to vasodilt. of meningeal andand
extra cranial arteries with stimulation of extra cranial arteries with stimulation of nervenerve
endings. This is due to release of endings. This is due to release of vasoactive subst. like NO2. 5HT falls vasoactive subst. like NO2. 5HT falls
during headacheduring headache . .
Clinical features of migraineClinical features of migraine 11 - -Classic migraineClassic migraine-:-:
- - Aura precedes or accompany za headacheAura precedes or accompany za headache..
- - Headache is throbbing & associated with Headache is throbbing & associated with nausea, vomiting, irritability, photophobia. nausea, vomiting, irritability, photophobia. Superficial temporal may be engorged & Superficial temporal may be engorged & pulsating. Sleep may follow an attack pulsating. Sleep may follow an attack..
22 - -Common migraineCommon migraine: migraine without aura: migraine without aura..
33 - -Hemiplegic migraineHemiplegic migraine: This is classic migraine: This is classic migraine
followed by hemiparesis recovering withinfollowed by hemiparesis recovering within
2424 hourshours
44 - -Basilar migraineBasilar migraine:- The headache is :- The headache is precededpreceded
by brain stem S & Sby brain stem S & S..
55 - -Ophthalmoplegic migraineOphthalmoplegic migraine:- There is:- There is
ophthalmoplegia during za attack- rareophthalmoplegia during za attack- rare..
66 - -Facioplegic migraineFacioplegic migraine..
Precipitating factorsPrecipitating factors 11 - -Dietary:- alcohol, cheese, chocolateDietary:- alcohol, cheese, chocolate..
22 - -Contraceptive pills, pre & post Contraceptive pills, pre & post menstrual andmenstrual and
pregnancy ( hormonal influences)pregnancy ( hormonal influences)..
33 - -StressStress
44 - -Rarely follows head injuryRarely follows head injury
55 - -Rarely follows development of HTRarely follows development of HT
66 - -No triggering cause in 50%No triggering cause in 50%..
Differential diagnosis of migraineDifferential diagnosis of migraine 11 - -Meningitis & SAHMeningitis & SAH (acute onset) (acute onset)
22 - -Thromboembolic TIAThromboembolic TIA ( headache is rare) ( headache is rare)
33 - -Sensory epilepsy wz unilateral Sensory epilepsy wz unilateral numbnessnumbness
( ( headache unusualheadache unusual))
44 - -Tension headacheTension headache
55 - -Cluster headacheCluster headache ( usually wz watery ( usually wz watery eyes)eyes)
66 - -Referred headacheReferred headache
Management of migraineManagement of migraine - - Avoid ppting factors e.g. dietary, pillsAvoid ppting factors e.g. dietary, pills
- - Start treatment early in za attackStart treatment early in za attack.. - - Simple analgesicsSimple analgesics +/- anti emetics will +/- anti emetics will
abortabort most attacks except za severe onesmost attacks except za severe ones..
- -Premenstrual migraine may respond to Premenstrual migraine may respond to diureticsdiuretics
- - TriptansTriptans ( 5HT1 agonist) in severe ( 5HT1 agonist) in severe migraine e.g. sumatriptan, zolmitriptan. Thymigraine e.g. sumatriptan, zolmitriptan. Thy are potent extra cranial vasoconstrictor. 1are potent extra cranial vasoconstrictor. 1stst
dose is followed by za 2dose is followed by za 2ndnd dose 2h later if dose 2h later if there is no response. Avoided in vascular there is no response. Avoided in vascular
disdis . .
- - Ergotamine tartarateErgotamine tartarate is now rarely used is now rarely used.. Over dose is serious. Also avoided in vascularOver dose is serious. Also avoided in vascular
dis. & pregnancydis. & pregnancy..
ProphylaxisProphylaxis It is used in frequent attacks disturbing workIt is used in frequent attacks disturbing work
and social life ( 2 attacks or more / month)and social life ( 2 attacks or more / month).. - - B-blockersB-blockers e.g. propranolol 10mgX3– 40- e.g. propranolol 10mgX3– 40-
80mg80mg X3X3..
- - PizotifenPizotifen (antihistamine & 5HT antagonist) (antihistamine & 5HT antagonist):: 0.5mg noct increasing to 1.5mg0.5mg noct increasing to 1.5mg
- - Tricyclic antidepressantsTricyclic antidepressants e.g. amitrypt 10- e.g. amitrypt 10-50mg50mg
- - Sodium valporateSodium valporate 300mg bid 300mg bid..
- - MethysergideMethysergide ( 5HT antagonist) may ( 5HT antagonist) may causecause
retroperitoneal fibrosis. Therefore used inretroperitoneal fibrosis. Therefore used in
resistant cases for short periods (3/12)resistant cases for short periods (3/12)..
Cluster headachesCluster headaches - Excoriating recurrent headaches clustered
around one eye & awakening the patient - Less common than migraine & little genetic
predisposition. - Male affected more than female & attacks
are brief. More common in heavy smokers and
alcohol may ppt it. - Excessive lacrimation, conjunctival & nasal
congestion may occur, rarely transient Horners.
- Triptans abort za attack & O2 inhalation is useful. Lithium & verapamil for prophylaxis.
Cluster HACluster HA MigraineMigraine - - sex: male femalesex: male female
- - age: 20-40 15-20age: 20-40 15-20
- - frequency: several/day frequency: several/day 1-4/month1-4/month
- - unilaterality: unilateral unilat/ unilaterality: unilateral unilat/ bilateralbilateral
- - nausea & V: rare commonnausea & V: rare common
- - during attack: sitting rest/ during attack: sitting rest/ quietquiet
Pressure headaches ( ICP)Pressure headaches ( ICP) - - Due to intracranial mass lesion displacing andDue to intracranial mass lesion displacing and
stretching meninges & basal blood vesselsstretching meninges & basal blood vessels
either directly or due to ICPeither directly or due to ICP..
- - Headache increases wz cough, straining andHeadache increases wz cough, straining and
after lying down due to increased pressure andafter lying down due to increased pressure and
cerebral oedemacerebral oedema..
- - There is associated evidence of ICP e.g. vomitThere is associated evidence of ICP e.g. vomit
blurring of vision, focal signs, disturbed conscioblurring of vision, focal signs, disturbed conscio
usnes, false localizing signs, seizures, papilloedusnes, false localizing signs, seizures, papilloed
Benign intracranial hypertensionBenign intracranial hypertension ( ( Pseudo tumor cerebriPseudo tumor cerebri -) -)BIHBIH..
- - Increased ICP without SOL, ventricular Increased ICP without SOL, ventricular dilatation or CSF obstruction or impairment dilatation or CSF obstruction or impairment
of consciousnessof consciousness . .- - - Occur usually in obese females wz Occur usually in obese females wz
menstrual disturbances, usually during menstrual disturbances, usually during child bearing age - Tetracyclines, vit A, pills child bearing age - Tetracyclines, vit A, pills and steroid, may be other causes. and steroid, may be other causes. - Headache and - Headache and papilloedema wz threat to vision +/- false papilloedema wz threat to vision +/- false localizing signs, but no focallocalizing signs, but no focal
- neurological deficitneurological deficit..- - - CSF is under pressure, but CT brain is CSF is under pressure, but CT brain is
normal normal . .
- - Spontaneous remission may occur over Spontaneous remission may occur over Ms & yrMs & yr
but there is always threat to vision whichbut there is always threat to vision which
should be monitoredshould be monitored..
- - Dietary advice & stopping offending the Dietary advice & stopping offending the drugs - Management by: drugs - Management by: - repeated LP & diuretics - repeated LP & diuretics . .
- - Shunt insertion Shunt insertion - Avoid steroids because of recurrence - Avoid steroids because of recurrence
on withdrawalon withdrawal . .
Temporal arteritis (giant cellTemporal arteritis (giant cell arteritisarteritis))
- - There is granulomatous arteritis of unknownThere is granulomatous arteritis of unknown cause ( ? AI) occurring over the age of 60cause ( ? AI) occurring over the age of 60
affecting extradural arteries & closely relatedaffecting extradural arteries & closely related to polymyalgia rheumatica which may co to polymyalgia rheumatica which may co
existexist.. - - F:M=2:1. Age= >55 yearsF:M=2:1. Age= >55 years
- - There is severe headache over za inflammedThere is severe headache over za inflammed superficial temp arteries which is thickenedsuperficial temp arteries which is thickened,,
tortuous, non pulsatile & tender. The tortuous, non pulsatile & tender. The overlyingoverlying
skin is red & gangrenous patches over scalpskin is red & gangrenous patches over scalp may be foundmay be found..
- -Visual symptoms include blurring of vision, Visual symptoms include blurring of vision, amaurosis fugax, diplopia, amaurosis fugax, diplopia, ophthalmoplegia and may proceed to ophthalmoplegia and may proceed to ipsilateral blindness within an hour in ipsilateral blindness within an hour in 25%25%..
- - Facial pain & claudication of za mandible Facial pain & claudication of za mandible maymay
also occuralso occur.. - - Constitutional symptoms wz fever, night Constitutional symptoms wz fever, night
sweats, muscle pain , malaise, anorexia & sweats, muscle pain , malaise, anorexia & Wt loss may occur Wt loss may occur - Ischemic lesions may occur in other - Ischemic lesions may occur in other organsorgans . .
- - ESR, CRP & alpha2 globulins with ESR, CRP & alpha2 globulins with normocytic normochromic anaemianormocytic normochromic anaemia
- - history, clinical ex, FBC & ESR, CRP history, clinical ex, FBC & ESR, CRP suggestsuggest
diagnosis and superficial temp artery diagnosis and superficial temp artery biopsy shows typical pathologybiopsy shows typical pathology
- - Prednisolone 60-100mg given early Prednisolone 60-100mg given early taperedtapered
as symptoms resolve(2/12) or ESR comes as symptoms resolve(2/12) or ESR comes down. Response within hours and down. Response within hours and histology of sup temp artery normalize histology of sup temp artery normalize within 48h. TR may cont. for Ms or within 48h. TR may cont. for Ms or yearsyears..
ProblemProblem 3636 year old lady, mother of 2, smoker & onyear old lady, mother of 2, smoker & on
contraceptive pillscontraceptive pills.. - - C/o headache for 9/12, associated with C/o headache for 9/12, associated with
blurringblurring of vision. Headache is severe & generalizedof vision. Headache is severe & generalized.. - - Ex: she is slightly overweight, Bp 140/80, noEx: she is slightly overweight, Bp 140/80, no
neck stiffness. There is bilateral papilloedema. neck stiffness. There is bilateral papilloedema. CNS Ex CNS Ex
intact. No pyramidal or cerebellar signs. intact. No pyramidal or cerebellar signs. NormalNormal
systemic Ex. What is the diff diagnosissystemic Ex. What is the diff diagnosis?? - - Investigation: CBC= normal, ESR= normalInvestigation: CBC= normal, ESR= normal..
Blood urea, electrolytes & LFT= normalBlood urea, electrolytes & LFT= normal
CXR & CT brain are normalCXR & CT brain are normal..
What is the diagnosisWhat is the diagnosis??
What is next stepWhat is next step??
What is the managementWhat is the management??