Transcript What is Headache?

Headache
Introduction
Almost everyone gets headaches. A lot of the time, they're
caused by something simple — such as staying up too late,
running around in the sun too long, or the stress of a big
exam. But some people get headaches that come often or
last for a long time.
So how do you know if a headache is just a passing pain or
something more? And what should you do about it?
What is Headache?
 A headache is pain or discomfort in the head, scalp.
 Headache is defined as pain in the head that is located
above the eyes or the ears, behind the head (occipital),
or in the back of the upper neck.
Epidemiology
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More than 90% of adult will experience headaches over a oneyear period.
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Over 15% of these will consult their physician because of it.
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The 7th leading presenting complaint in medical care in the
U.S.
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Higher in women, 70% of all migraine sufferers are women.
Pathophysiology
 Intracranial disease can produce pain in only a limited
number of ways. With rare exception, stimulation or
destruction of the brain itself does not produce pain. The
following intracranial structures are pain-sensitive:
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Meningeal arteries
Proximal portions of the cerebral arteries
Dura at the base of the brain
Venous sinuses
Cranial nerves 5, 7, 9, and 10, and cervical nerves 1, 2, and 3
 Headaches often result from traction to or irritation of
the meninges and blood vessels.
 The muscles of the scalp and face may similarly be
sensitive to pain.
Classification of Headache
 Primary : no underlying disease
 accounts for more than 90 % of cases
 Includes :
Tension Headache.
Migraine.
Cluster headache.
 Secondary :
 accounts for less than 10 % of cases.
 Underlying causes : infection, tumor, CVA, trauma,
drug withdrawal, metabolic disorders.
 it could be critical or reversible.
What do we see in our Clinics
 40-50%
Tension Headache.
 20-25%
Common Migraine.
 5-7%
Sinusitis.
 5-8%
Withdrawal from caffeine, opiates and.
Alcohol.
 3-5%
Classical Migraine.
History
 Location.
 Intensity.
 Character.
 Associated symptoms (nausea ,vomiting ,blurred vision …).
 Prodromal symptoms (as in migraine ).
 Precipitating factors.
 History of trauma.
 Medication.
 Previous imaging results.
 Impact on work and activity.
 Family history.
History
 Describe the Headache
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How many different types of headache do you experience?
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Has there been a recent change in your headaches or are these of recent onset?
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Have you ever been seen by a medical provider for your headaches?
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What years:
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Where:
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What type of medical providers:
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Have you had a Head CT (Cat scan) or MRI?
 Describe your most bothersome recent headache:
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Which side of your head is affected? [Both Sides] [Left] [Right]
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Where is your headache located?
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[Entire head] [Forehead] [Temple] [Side of head] [Back of head]
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[Behind the Eye] [Cheek] [Teeth] [Jaw]
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What does your headache feel like?
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[Throbbing] [Sharp, stabbing] [Constricting like a vise] [Ache]
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How severe has your most recent headache been?
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[Mild - relieved with Tylenol or Motrin]
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[Moderate - difficult to concentrate at work or home]
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[Severe - took time off work]
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[Horrible – worst pain of my life]
 Symptoms associated with your headaches
 Are your headaches preceded by an Aura
 Any Environmental changes make your headaches worse
 Timing of your headaches
 Are certain events associated with the headache?
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[Menses]
[Stress]
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[Fatigue]
[Intercourse]
[Lack of Sleep]
[Exercise]
[Fasting]
[Exertion]
What have you used to relieve your headache:
[Excedrin] [Tylenol] [Motrin, Naprosyn, Aleve or similar medication]
[Midrin] [Fiorinal or Firoicet] [DHE, Ergotamine or similar medication]
[Imitrex]
[Oxygen]
 Have you used any medications to prevent headache?
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[Amitrytiline] [Verapamil] [Propranolol, Atenolol or similar
medication]
 Do you use?
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Medications: [Nitroglycerin] [Indomethacin] [Birth
Control Pills]
[Estrogen]
[Reserpine]
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Caffeine
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Alcohol
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Drugs: [Anabolic Steroids]
[Crack] [Methamphetamine]
Drugs ]
Smoking
[Marijuana] [Cocaine]
[Heroin] [LSD]
[Other
 Do you have any of the following symptoms or conditions below:
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Eye Strain
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Sinusitis
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Allergic Rhinitis
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Ear Disease:
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TMJ
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Neck pain
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High Blood Pressure
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Head Injury
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Brain Disease
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Mental Illness
 Family history:
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Headache
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Early onset of HTN
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Malignancies
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CVA
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Cardiac Disease
Physical Examamination
 General look
 Vital Signs :
 Tachycardia
 Stress
 Intracranial Lesion
 Blood pressuer (hypertension)
 Pain
 Hypertensive headache
 Intracranial Lesion
 Temperature (Fever)
• Viral Syndrome.
• Temporal Arteritis
• Meningitis
• encephalitis
• Acute Sinusitis
 Altered level of consciousness ( With or without Neurological
Deficit):
 Causes of Focal neurologic deficits
CVA
 Causes of Non-focal neurologic deficits
 meningitis
 Subarachnoid hemorrhage
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 Eye examination
 Refractive Error
 Pupil reaction
 Visual fields
 Abnormal eye movements (e.g. Nystegmus)
 Fundoscopic exam for Papilledema
 Skin Findings suggestive of intracranial neoplasm
 Neurofibromatosis
 Tuberous Sclerosis
 Vascular examination ( it is a must)
 Carotid bruite.
 Temporal artery bruit or pain.
 Complete neurological exam
 Cranial Never Exam
 Motor exam
 Deep Tendon Reflexs
 Signs of Meningeal irritation
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Nuchal Rigidity on Passive neck flexion
Investigation (Based on
Diagnosis):
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CBC
Thyroid function test
ESR
KFT , LFT
Serology
EEG
CT Scan
MRI
Angiogram
LP
Red Flags
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50 yrs old especially if the first new headache.
Sudden onset
Worsening pattern, increase in frequency and severity.
Headache with systemic manifestation (fever ,skin rash…)
Focal neurological symptoms and signs.
Trigger with cough ,exertion ,valsalva maneuver :SAH or
mass.
Pregnancy /post partum
New headache in patient with serious medical illness
Headache with BP >200/130
Significant trauma.
((PRIMARY HEADACHE))
Tension Headache
 The most common type.
 affecting most women and men at some time in their
lives, and can impair job productivity and interfere
with family and social time.
 During childhood there is no male or female
predominance for tension-type headache, but during
adulthood it is more commonly experienced by
women.
Clinical Features of Tension
Headache
 Dull aching like band squeezing the head ,feeling of pressure or
tightening
 Bilateral (bitemporal or occipital nuchal ).
 Duration : 30 min -7 days
 Poorly responsive to ordinary analgesia
 On examination :tender scalp and neck muscles
 Mild-moderate in severity
 Frequent family history : Female Adulthood
 No Nausea and Vomiting.
Classification
 Infrequent Episodic:
• Less than 1 episode per month and 12 episodes per year.
 Frequent :
• 1-15 per month for 3 months
 Chronic
• >15 per month , > 3 month
TREATMENT
 Life style regulation, decrease stress ,diet change.
 NSAIDS (ibuprofen 400 -600 mg 3 times daily),
acetaminophen.(does not work well)
 Muscle relaxants , the most important.
 Prophylaxis :antidepressants ( amitriptyline 10 -75 mg
PO daily) , B-blocker.
 If sever ,same as migraine.
Migraine headaches
 It includes migraine with aura. 15% & migraine without aura 85%
 5% men . 15-17% women ( F:M 3:1)
 60% of patient have Family history .
 Unilateral (doesn't necessarily include headache as a symptom).
 Onset in teens (10-20 years old) & peak age at 40
Migraine Without Aura
(formerly common migraine)
• Attack lasting 4 to 72 hrs
• Attack is associated with at least 2 of the following:
*unilateral location
* pulsating quality
*moderate to severe intensity
* aggravated by routine physical activity
• During The Attack, at least one of the following: nausea,
vomiting, photophobia, phonophobia
• Organic disease must be excluded
Migraine With Aura
(formerly classic migraine)
 Typically, classical migraine attack starts with a non-
specific prodrome of malaise & irritability followed by the
‘aura’ of focal neurological event, & then a severe
throbbing hemicranial headache with photophobia &
vomiting.
 During the headache phase patients prefer to be in quiet,
darkened room & to sleep.
 The headache may persist for several days
Clinical Manifestation
 At least 3 of the following:
*Aura (neurological symptoms -Mainly visual alterations) 20 to
30 Min before the headache.
*No single aura lasts more than 60 min.
*Attack follows aura
rarely, aura and Attack begin simultaneously, or Attack may
precede aura.
*No evidence of organic disease
 At least 2 attacks fulfill the above criteria
Aura
 Visual
 Parallel zigzag lines
 Scotoma
 Flashing lights
 Speech----------dysphasia
 Sensory----------tingling
What triggers Migraine ??
 Stress and Relaxation.
 Fatigue.
 Change in sleep habit.
 Weather.
 Bright light.
 Hormonal factors (menstruation, ovulation, exogenous estrogen
,pregnancy ).
 Dietary factors: fasting, caffeine withdrawal ,cheeses (?)
,chocolates, alcohol (red wine)
Management
 Identification & avoidance of precipitants or exacerbating factors
may prevent attacks.
 Treatment of an acute attack
 Simple analgesic with aspirin or paracetamol
 Antiemetic ; metaclopramide (10 mg ) or domperidone
 Severe attacks can be treated with one of the ‘triptans’,(
sumatriptans ,rizatriptan ) which are 5-HT agonist that are
potent vasoconstrictor of the extracranial arteries.
 Ergotamine preparations should be avoided since they easily
lead to dependence.
 If attacks are frequent, they can often be prevented as
prophylaxis by
- propranolol (80-160mg daily, in a sustained released
preparation )
- Tricyclic ( amitriptyline, 10-50mg at night, or sodium
valproate, 300-600mg/day )
 Admit if the severe headache > 2 days.
Migraine Headache in
Children
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Prevalence : up to 7 % of children.
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By age of 3 years, 10-14% of all children complain of headache.
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1.
2.
Signs and Symptoms:
School related problems.
Abdominal Pain without Explanation.
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Family History: Strong FH of MH and Depression in the mother side.
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Less than 5 % of children present with aura.
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Rarely It is unilateral, usually it is frontal and associated with nausea
and photosensitivity.
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They tend to sleep After the Attack.
What can we do to prevent my
child's headaches?
 Taking good care of your child can decrease their frequency and
severity of his/her headaches
 Drink plenty of fluid (4-8 glasses per day)
 Caffeine should be avoided
 Regular and sufficient sleep (8-10 hours)
 Eat balanced meals at regular times ( to avoid Hypoglycemia)
 Minimize stress and over commitments
 Follow prescribed treatment plan
Cluster Headache
 Much less frequent than migraine & tension
Attacks.
 Affects 1:1000 men and 1:6000 women .(M:F 6:1)
 Affect patients in 3rd and 4th decades.
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 Most severe and recurrent Attacks seen in practice.
 Location: strictly unilateral periorbital or temporal
pain lasting 15 – 90 or 180 min.
 Almost always in the same side
 No Family History.
 Unlike migraine and tension headache, cluster headache
generally isn't associated with triggers
 The time from Onset to Accurate diagnosis is 8 years.
 Frequency: occur in ”clusters” (1-8/day),(4-6wks)pain, free(3-6mo)
 Associated with Autonomic features (tearing, congestion, sweating)
conjunctival injection, lacrimation, nasal congestion, rhinorrhea,
miosis, ptosis)
 Ask about Suicidal Ideation or Attempts.( They Seriously
consider suicide)
 At least 5 attacks fulfilling these criteria.
 No evidence of organic disease or family history.
 Precipitants: smoking, alcohol, stress histamine.
Treatment of Cluster Headache
Acute treatment:
 100% Oxygen via face mask at 7-10 L/min for 10-15min.
 Sumatriptan (imitrix) 6mg IM repeat after 1hr.
 Dihydroergotamine DHE 1mg IM or IV.
 Lignocane spay 4% intranasal.
 Unusually High dose of Steriods given under the supervision
of specialized, well trained neurologist in head clinic centers.
Treatment
o warn patients about smoking, and exposure to
fumes/chemicals, stress
o Verapamil 80 mg
o Lithium 300 - 900 mg per day
o Prednisone 40 mg per day in divided doses,
tapered over 3 weeks
o Ergotamine 2 mg 2 hrs before bedtime to
prevent nocturnal attacks
o Divalproex sodium 600 - 2000 mg per day
((Secondary Headache))
Reversible Secondary
 Non-CNS Infections
 Focal
 Systemic
 Sinusitis
 Drug Related
. Post analgesia use
 Post Lumbar Puncture
Critical secondary
 Vascular
 Subarachnoid Hemorrhage
 Intraparenchymal Hemorrhage
 Epidural Hematoma
 Subdural Hematoma
 Stroke
 Cavernous Sinus thrombosis
 Arteriovenous Malformation
 Temporal Arthritis
 Carotid or Vertebral Artery Dissection
 Endocrine
 Pheochromocytoma
 Metabolic
 Hypoxia
 Hypoglycemia
 Hypercapnia
 High altitude cerebral edema
 Preeclampsia
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CNS Infection
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Meningitis
Encephalitis
Cerebral Abscess
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Tumors
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Pseudo tumor Cerebri
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Ophthalmic
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Drug Related
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Glaucoma
Iritis
Optic neuritis
Nitrates
MAOI’s
Alcohol Withdrawal
Toxic
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CO poisoning
Non-CNS Infections
 Systemic– viral syndromes, bacteremia, fever may often cause
generalized headache
 Antipyretic for fever, definitive treatment for source of infection
 Sinusitis– inflammation of ethmoid, frontal, sphenoid or maxillary
sinus
 Fever, malaise, headache and toothache, purulent discharge,
postnasal drip, sore throat, facial pain/pressure
 Antibiotics and nasal decongestants, antipyretics for fever and
analgesia
 Dental Infections—Caries and/or periapical abscess
 Toothache, jaw pain, earache, tooth tender to percussion
 Treatment involves covering exposed tooth, analgesia, abscess
drainage if appropriate
 Ear Infections
 Otitis Media– middle ear infection with ear pain/fullness, decreased
hearing, vertigo, fever. Treat with antibiotics, antipyretics
 Otitis Externa– External Ear infection with itching, decreased
hearing, fever, tender external ear. Treated with antibiotic drop.
Post Lumbar Puncture
 Headache is secondary to loss of CSF
 Persistent headache due to CSF leak after LP
 Definitive Treatment is Blood Patch
 Keep patient supine +/- Trendellenberg
Temporal Arteritis
 Autoimmune Vasculitis characterized by:
- Patients > 50 years old
- women > men .
- Suspect if new sever headache in female patients
- temporal headache, accompanied by marked scalp
tenderness
- Pulsating temporal artery (absent late stage)
- jaw claudication (masseter, temporalis tongue)
- visual disturbance (be aware of unilateral blindness in 24
hr)
- there may be associated constitutional symptoms of
anorexia, fatigue, weight loss, fever, depression & general
malaise.
 Investigation : ESR usually elevated above 50 mm/hr
 Treatment with steroids( usually high dose), biopsy for definitive
diagnosis, risk for blindness if untreated
A) Tender, Pulsating temporal
artery. B) Cross section of T.A.
Subarachnoid Hemorrhage
 1/10,000 in U.S.
 ¾ are under 65 Years old, many are in their fourth decade
(younger than 50).
 Women are frequently affected than men.
 Usually, sudden onset of very severe ‘thunderclap’ headache
(usually occipital ) which last for hours or even days, often
accompanied by vomiting. (sever Headache -----seizure------dilated pupils and coma)
 Headache may come with neck stiffness and signs of meinigism
(signs of meningial irritation)
 Caused by aneurysm or AVM rupture
 Risk Factors
1.
2.
Smoking,HTN,Alcohol
Family History :First dergee relatives
 May be associated with an abnormal finding on neurological
examination, with signs of raised intracranial pressure (papilledema,
nausea, vomiting, cranial nerve palsies) or with palsy of the third cranial
nerve.
 Diagnosis: CT scan , MRA (carotid-cerebral Angiogram)
 Treatment: support ABCs, Emergent neuron-surgical consult. definitive
treatment is coiling or clipping and Ca channel Blocker ( nimodipine –
very Expensive- Very Effective)
TMJ syndrome
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The patient complains of pain in the TMJ region, usually Unilateral.
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It gets worse as the day goes by
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Described as dull and aching pain.
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Aggravated by Trauma and clenching of the teeth
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X-ray is not Helpful in Diagnosis.
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Treated :
1) Heat Compressors, 15 min , 4-6 times a day
2) Soft Diet.
3) NSAID and Muscle Relaxant for trismus, such as Diazepam.
4) Refer to Maxillo-Facial Surgeon / periodontal Dentist/
prosthodontist
Dentist
5) Physical Therapy.
Trigeminal Neuralgia
(tic douloureux )
 TN occurs most often in people over age 50, but it can occur at any age,
and is more common in women than in men.
 Episodes can last for days, weeks, or months at a time and then
disappear for months or years.
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 In the days before an episode begins, some patients may experience a
tingling or numbing sensation or a somewhat constant and aching pain.
 The attacks often worsen over time, with fewer and shorter pain-free
periods before they recur.
 The intense flashes of pain can be triggered by vibration or contact with
the cheek (such as when shaving, washing the face, or applying makeup,
brushing teeth, eating, drinking, talking, or being exposed to the wind.(
Trigeminal Neuralgia
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Primary---Most of the cases are Idiopathic.
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1.
2.
3.
4.
5.
Secondary--Multiple Sclerosis.
Brain Stem Tumors.
Herps; Post Herpitic Neuralgia
Rheumatoid Arthritis
Sjögren's Syndrome.
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1.
2.
3.
Distribution:
Opthalmic
4%
Maxillary
35%
Mandibular 30%
Treament:
1. Treat the underlying cause.
2. Treatment options include medicines such as anticonvulsants
and tricyclic antidepressants, surgery, and complementary
approaches GABA pentine( neurintine), Lamotrigen, Baclofen,
and Carbamazipine
3. Typical analgesics and opioids are not usually helpful in treating
the sharp, recurring pain caused by TN.
4. Complementary techniques, usually in combination with drug
treatment. These techniques include acupuncture, biofeedback,
vitamin therapy, nutritional therapy, and electrical stimulation
of the nerves.
Ophthalmic
 Glaucoma
 Acute angle closure: obstruction of aqueous humor outflow
leading to increased intraocular pressure and possible
blindness
 Sudden onset of painful vision loss associated with headache,
nausea, vomiting, somnolence
 Exam: decreased visual acuity unilaterally, conjunctival
injection, hazy cornea, fixed/mid-position or dilated
unreactive pupil
 Needs emergent ophthalmology referral
 Don’t forget Iritis and Optic neuritis.( localized Ophthalmic
Pain)
Drug Related Headache
 Nitrates: symptomatic hypotension, hypo
perfusion
 MAOIs: orthostatic hypotension, but can have
hypertensive crisis when taken with
sympathomimetic amines, L-dopa, narcotics or
tyramine containing foods (Aged cheese)
 Alcohol withdrawal: treat with benzodiazepines
Tumors
 Tumor: 70% with headache, classically worse in the morning, positional,
nausea and vomiting
 Intracranial tumours
 Rarely produce headache until quite large
 Epilepsy is a cardinal symptom
 paroxysmal, classically waking the patient from sleep at night and
associated with projectile vomiting
 Focal neurological signs are generally present
 the headaches may become continuous and intensify with activities
that increase intracranial pressure (eg, Valsalva maneuver, coughing,
sneezing)
 Pseudo tumor cerebri: headache worse with awakening, valsalva, cough,
bending( Idiopathic Intracranial pressure increment)
 Signs of increased ICP: papilledema, diplopia, visual deficits
 Linked with OCP use, vit A, tetracycline use, thyroid disorders
 Diagnosed with CT for hydrocephalus, LP
 Treatment diuretics, repeat LP, CSF shunt or optic nerve sheath
fenestration
Other Causes of Morning
Headache
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Waking up with headache over age of 40:
1.
2.
3.
4.
5.
6.
Carbon Monoxide exposure (garage worked, Mine workMonday morning headache)
Caffeine Dependant Headache.
Cervical strain Headache.
Alcohol Hang over Headache.
Heavy Smoker.
Cluster Headache (usually is a morning headache)
Afternoon-Evening Headache
 Hypermetropia.
 Astigmatism
 TMJ syndrome.
 Jaw Claudicating.
Metabolic
 Hypoxia
 Hypoglycemia
 Hypercapnia
 High Altitude Cerebral Edema
 Due to acute hypoxia from rapid ascent
 Headache, anorexia, nausea, vomiting, weakness, altered mental
status seizure/coma/death
 Treat with immediate descent, 100%O2, Dexamethasone
 Preeclampsia: after 20th week of pregnancy—BP >160/110, proteinuria,
peripheral edema
 May progress to eclampsia (above + seizures)
 Definitive treatment is delivery, may use hydralazine for HTN,
magnesium sulfate for seizure
Toxic
 Carbon Monoxide Poisoning
 CO competes with O2 for Hgb binding with 250x affinity
 Suspect with confined space fire, car engine left on,
several household members sick at same time
 Headache, nausea, vomiting, malaise, chest pain,
weakness, apathy, cherry red skin, abnormal reflexes,
altered mental status
 Treat with O2