Transcript عرض تقديمي من PowerPoint

headache
 Headache is one of the commonest
neurological complain reported at neurology
clinic

path physiology
Intracranial pain sensitive structures include: the
arteries of the circules of willis &the first few
centimeters of their median sized branches
Meningeal arteries
Large veins &dural venous sinuses
Extra cranial sensitive structures:
external carotid arteires, scalp ,neck muscle
,skin & cutaneous nerves, cervical nerve &nerve
roots, mucosa of the sinus &teeth ..
Case history
 25 y old f with h/o : ER h/o sever headache
,diffuse ,dull in nature ,not relived by
analgesia,aggrevated by cough ,sneezing.
 Assosiated with vomiting
 No other neurological symptoms.
 She gave h/o of chronic infrequent headache
,which tension type and less sever, relieved by
analgesia
 She is single
 Recently She was following with dermatology
doctor and he gave her tablets for facial peeling
O/E




Neurological exam :
HF:N
Speech :normal
Cranial nerves: fundoscopic
exam:papilledema
 Motor, sensory, coordination :normal
Is this headache serious?
headache
 Primary (benign)

secondary
e.g(Migraine,tension,cluster)



serious
brain
meninges
parenchyma
vacsular
CSF
systemic
referred
HPT
ear,teeth
anemia
eye,sinus
Secondary causes (serious)




Structural causes
Meninges: meningitis
parenchyma : encephalitis ,abscess, tumor
Vascular: hemorrhage, venous thrombosis,
giant cell arterities
 Csf: increase CSF pressure (hydrocephalus
,pseudotumor cerebri) ,decrease CSF
pressure…leak
 Careful history and examination should be
done to differentiate between benign and
serious headache
Age
 Migraine headache: child hood or early
adulthood
 Giant cell arteritis: >50 y
 New onset headache in elderly should be
always a concern
Onset
 Headache of many years duration &with
little changes is almost always of benign
origin
 New onset headache in old age or
increasingly sever headache ….serious
headache..
 Hyperacute : SAH
periodicity:
 episodic headache is benign
 Migraine ,Cluster headache
 a daily constant headache ..tension type
duration
 Migraine: 4-72 h
 Cluster:1/2-2h
 Tension headache :build up over hours lasts
days to years
Location
 unilateral headache:migraine,cluster,temporal
arterities .
 Tension headache : generalized ,frontal or
posterior cervical region
 Carotid dissection commonly present with
neck,face,and head pain usually ipsilateral to the
dissection
 Local pain :superfacial structures
Nature
 Nature:
 throbbing: vascular
 Tension :fullness, tightness, pressure like
aura,& associated symptoms
 migraine: aura; focal cerebral symptoms
associated with lasts from 20-30 min, precedes
the headache
 Sensory, motor,autonomic,..
 Cluster headache: ptosis,lacrimation, conjuctival ,
nasal congestion
 Headcahe +fever …..infection
 Transient visual obscuration, diplopia,tinnitus
…increase intracranial pressure
aura,& associated symptoms
 Jaw clawdication: temporal arteritis
 Headache: progressive+ central nervous
symptoms is suggestive …structural brain
lesion
Aggravating & relieving






Aggravating
Cough, straining……intracranial pressure
Activity., stress…..migraine, tension type
Sitting: CSF hypotension
Relieving:
Rest…….migraine,tension
Drug history
 Oral contraceptive… Cerebral vein
thrombosis, migraine
 Steroid withdrawal
 Retin A tablets
 Warfarin : Hge
pseudotumor cerebri
 Postpartum :
cerebral venous thrombosis
 Recurrent abortion
FH
 migraine
exam
 v/s: fever ,BP
 General: sinus tenderness
 Eye ,throat ,ear exam
exam
 Normal exam: benign headache
 Papilledema: increased intracranial pressure
 Focal neurological finding……serious
 Complicated migraine….neurological signs
 Horner syndrome: cluster headache
 Scalp tenderness, pulsless: temporal arteritis
Is this headache serious?








Characteristics of headache with serious underlying pathology
History :
Explosive onset and severe at onset
No similar headaches in the past
you have a constant headache, which is gradually getting worse;
Altered mental status
Age over 50
Immunosuppression





Physical examination :
Neurologic abnormalities
Decreased level of consciousness
Meningismus
Papilledema
Work up
 If history and exam is suggestive of serious
headache
 Brain image: CT brain, mri brain
 If suspect cerebral vein throbosis..CT venogram
,MRV

 if fever or ? SAH …LP
Go back to the case
Case history
 25 y old f with h/o : ER h/o sever headache
,diffuse ,dull in nature ,not relived by
analgesia,aggrevated by cough ,sneezing.
 Assosiated with vomiting
 No other neurological symptoms.
 She gave h/o of chronic infrequent headache
,which tension type and less sever, relieved by
analgesia
 She is single
 Recently She was following with dermatology
doctor and he gave her tablets for facial peeling
O/E




Neurological exam :
HF:N
Speech :normal
Cranial nerves: fundoscopic
exam:papilledema
 Motor, sensory, coordination :normal
Work up




CT brain : normal
MRI brain:N
MRV: N
LP: increased CSF pressure, protein,
glu,cell count were normal

Pseudo tumor cerebri
 ( Idiopathic Intracranial Hypertension )
Home message
Careful history and exam including
(opthalmoscopic) exam is the key to
differentiate benign from serious headache.