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  • 2. PRIMARY HEADACHE SYNDROMES• Tension type headache• Migraine• Trigeminal Neuralgia• Atypical facial pain• Cluster headache• Benign paroxysmal headaches
  • 3. TENSION TYPE• Most common-69%• Episodic or chronic• Gradual onset , radiate forward from occiput• Bilateral, dull, tight, band like pain• Less in morning, pain increase as day goes on• No accompanying N,V, throbbing, sensitivity to light, sound or movement
  • 4. Pathophysiology• Primary disorder of CNS pain modulation• Precipitating factorsStress: usually occurs in the afternoon after long stressful work hours or after an examSleep deprivationUncomfortable stressful position and/or bad postureIrregular meal time (hunger)EyestrainCaffeine withdrawalDehydration
  • 5. 2 TheoriesMuscle tension around head and neckMalfunctioning pain filter located in brain stem, brain misinterprets information and interprets this signal as pain. One of the main neurotransmitters which is probably involved is serotonin
  • 6. Management• Paracetamol,Aspirin,NSAIDs• Behavioral approach-relaxation• Chronic-amitriptyline
  • 7. MIGRAINE• 2nd most common-16%• 15% women and 6% men• Severe, episodic, unilateral,throbbing pain• Nausea,Vomiting• Sensitivity to light ,sound, movement• Genetic predisposition
  • 8. Classical Migraine or Migrainewith AURA Symptom TriadParoxysmal headachenausea &/or vomitingaura of focal neurological events(visual) 20-25%
  • 9. AURA• flashing lights, silvery zigzag lines moving across visual field over a period of 20 minutes sometimes leaving a trail of temporary visual field loss• Sometimes-Auditory ,Olfactory, gustatory hallucinations• Sensory aura-spreading front of tingling and numbness, from one body part to another
  • 10. Rare aura:• Vertigo• Aphasia• Hemiparesis• DeliriumMigraine with limb weakness-Hemiplegic migraineSymptoms of aura do not resolve leaving permanent neurological damage-Complicated migraine
  • 11. Common Migraine or Migrainewithout AURA• Paroxysmal headache• Vomiting +/-• NO AURA
  • 12. Simplified Diagnostic Criteria forMIGRAINEAt least 2 of the + At least 1 of thefollowing: following:• Unilateral pain• Throbbing pain • Nausea/vomitting• Aggravation by • Photophobia and movement phonophobia• Moderate or severe intensity
  • 13. Clinical phases of a migraineattack Vulnerability Attack Initiation Prodrome Aura Pain Postdrome
  • 14. Triggers• Flashing lights • Menstruation• Loud sounds • Pregnancy• Strong odors • Menopause• Stress • Oral Contraceptives• Hunger • Sleep changes• Fatigue • Caffeine• Alcohol • Chocolate• Smoking • Tyramine • MSG
  • 15. Pathophysiology of Migraine • Cortical spreading depression • Vascular • Low Serotonin • Melanopsin receptor
  • 16. Cortical spreading depression ofLEAO• Dysfunction of ion channels-Quick depolarization(activation) followed by long- lasting depression over an area of cortex• Release of inflammatory mediators• Irritation of cranial nerve roots-trigeminal
  • 17. Vascular Vasoconstriction of blood vessels in brain-Aura (begins in occipital lobe) Vasodilatation of scalp blood vessels Inflammation Pain
  • 18. Migraine Pain-Trigeminovascular• Key pathway for pain is trigeminovascular input from meningeal vessels• Modulation of trigeminovascular input comes from dorsal raphe nucleus, locus coeruleus and nucleus raphe magnus
  • 19. Management• Acute attack- aspirin/paracetamol+metoclopromide/ domperidone• Severe attack-Sumatriptan• Frequent attacks- Propranolol,Amitriptyline,Sodium valproate or Topiramate
  • 20. Trigeminal Neuralgia• Lancinating pain in 2nd and 3rd divisions of trigeminal nerve• >50yrs• Severe, brief ,repetitive pain causing patient to flinch• Precipitated by touching trigger zones—washing, shaving, eating, cold wind
  • 21. Pathophysiology• Compression of trigeminal N by aberrant loop of cerebellar arteries as nerve enters brainstem• Other benign compressive lesions• Multiple sclerosis- TN occurs due to plaque of demyelination in trigeminal root entry zone
  • 22. Management• Carbamazepine-DOC• Intolerant-Gabapentin/Pregabalin• Injection of alcohol into peripheral branch of nerve• Posterior craniotomy to relieve vascular compression of trigeminal nerve
  • 23. Atypical facial pain• Persistent idiopathic facial pain• Continuous, burning/crushing,unremittent, centred over maxilla usually left side• Middle aged women• Early form of trigeminal neuralgia• Rx-Amitriptyline, Gabapentin
  • 24. Other causes of facial painSinusitis• Frontal-pain more in morning, decreases as day progresses, stooping and blowing nose increase pain• Ethmoid and Sphenoid-pain over vertex, less in morning and increase gradually
  • 25. Post herpetic neuralgia-continuous, burning pain sensitive to light touch, shingles
  • 26. THANK YOU