4 headache jaber amin


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  • Although headaches often interfere with daily activities at
    home or in the workplace, many people do not seek medical
    attention for their headaches. Consequently, many headache
    sufferers remain undiagnosed and possibly undertreated.
  •  a transient visual, sensory, language, or motor disturbance which signals that the headache will soon occur
  • hangovers result in unpleasant physical and mental symptoms including fatigue, headache, dizziness, and vertigo.
    MSG:monosodium glutamate to improve food taste when mixed with other substances. 
  • Many people with headache or facial pain incorrectly diagnose
    themselves with “sinus headache.” Migraines and cluster headaches often have symptoms related to the nose and sinuses,
    such rhinorrhea, pain behind the eye (frontal sinus), and facial
  • 4 headache jaber amin

    1. 1. Headache Jaber Amin AL-Manasia 5th year medical student Presented to: Dr. Amaal Al Nemry
    2. 2. :Objectives .defenition-1 .epidemiology-2 .primary causes-3 .secondary causes- 4 .evaluation and diagnosis- 5 .mangment-6
    3. 3. Headache is pain in any part of the head, including the scalp, face (including the orbitotemporal area), and interior of the head. Headache is one of the most common reasons patients seek medical attention.
    4. 4. Headache is common, with a lifetime prevalence of about 90% of the general population. It accounts for 4.4% of consultations in primary care and 30% neurology outpatient consultations. The 8th most common outpatient diagnosis for family physicians and the 13th for general internists. As many as 4.5 million americans will experience recurrent headaches.
    5. 5. Identify patients w/ treatable headache disorders, Diagnose the likely cause of the headaches, Prescribe appropriate interventions, Help patients changes in their lifestyle or environment to reduce the severity of headaches. 5
    6. 6. DIFFERENTIAL DIAGNOSIS Primary Headache (90%) Secondary Headache (10%) result from processes that manifest themselves primarily as head pain. manifestations of another process. No Organic Pathology: • Migraine • Cluster headache • Tension headache Sinusitis caffeine withdrawal neck arthritis viral infections meningitis Temporal artritis Pseudotumer cerebri Trigeminal neuralgia Subarachnoid hemorrhage
    7. 7. Migraine Chronic, genetically linked primary headache Affects > 10% of adults (most common headache seen in primary care) usually begin in late childhood or early adulthood (but the diagnosis may be delayed several years) Women>>>men among adults ( ratio is equal in children ).
    8. 8. ,,,cont . The presentation of migraine is variable Because neurologic symptoms may either precede (“aura”) or accompany the headache, migraine can sometimes be confused with serious causes of headache, such as a transient ischemic stroke. (TIA). Because patients with migraine often report pain in the face or around (or behind) one eye, they are sometimes misdiagnosed as having sinus headaches.
    9. 9. :Diagnostic criteria for migraine International Headache Society ( IHS )Criteria for the Diagnosis of Migraine
    10. 10. The frequency, severity, and associated symptoms of frequency severity migraine can vary between patients and within a given lifetime. Fluctuations in serum estrogen concentration in women (e.g., phase of the menstrual cycle, pregnancy) are often associated with onset, remission, or change in .severity of migraine-related symptoms Other known “triggers” include certain foods, caffeine, sleep deprivation, psychosocial stressors,or changes in . weather or barometric pressure .Daily pain diaries can help identify such triggers
    11. 11. Tension–type headache  Tension-type headache is the most common cause of headache overall with a prevelance of ( 30 – 80 % ) in the general community  Tension-type headaches are usually mild or moderate in severity and are often self-treat  They are commonly episodic but can develop into daily or near-daily headaches.  Many patients with tension-type headaches describe bilateral symptoms or a “headband-like” pain.  Tension-type headache and migraine can occur concomitantly in the same patient
    12. 12. IHS diagnostic criteria for tension-type headaches states that 2 of the : following characteristics must be present )Pressing or tightening (nonpulsatile quality Frontal-occipital location Bilateral - Mild/moderate intensity Not aggravated by physical activity
    13. 13. :Tension-type headache history is Duration of 30 minutes to 7 days * *insomia No nausea or vomiting (anorexia may occur) * *difficulty concentrating Photophobia or phonophobia * *no prodrome Minimum of 10 previous headache episodes; fewer than 180 days per* " year with headache to be considered "infrequent May occur acutely under emotional distress or intense worry* Often present upon rising or shortly thereafter Muscular tightness or stiffness in neck, occipital, and frontal regions* Duration of more than 5 years in 75% of patients with chronic* headaches New headache onset in elderly patients should suggest etiologies* other than tension headache
    14. 14. M N G EM T A A EN • Careful assessment followed by discussion of likely precipitants and explanation of the fact that the symptoms are not due to any sinister underlying pathology is more likely to be beneficial than analgesics. • Excessive use of analgesics, particularly of codeine, may actually worsen the headache (analgesic headache). • Physiotherapy (with muscle relaxation and stress management) is usually beneficial, and low-dose amitriptyline (10 mg nocte increased gradually to 30-50 mg) sometimes helps.
    15. 15. Cluster headache not common (0.3% to 0.4% ) are more prevalent in males classic presentation is described as a series of headaches occurring close together over 6 to 12 weeks and so named cluster severe, intense, unilateral pain lasting from several seconds to many minutes. Concurrent symptoms include ipsilateral lacrimation, rhinorrhea, and ptosis. The headache is also always on the same side, no matter how many months lapse between episodes.
    16. 16. Cluster headache
    17. 17. A. At least 20 attacks fulfilling criteria B – D B. Severe or very severe unilateral orbital, supraorbital and/or Temporal pain lasting 15 – 180 min if untreated : C. Headache is accompanied by at least one of the following Ipisilateral conjunctival injection and/or lacrimation . 1 Ipsilateral nasal congestion and/or rhinorrhoea. 2 Ipsilateral eyelid oedema. 3 Ipsilateral forehead and facial sweating. 4 Ipsilateral miosis and/or ptosis. 5 Sense of restlessness or agitation. 6 D. Attacks have a frequency from one every other day to eight Per day E. Not attributed to another disorder
    18. 18. M N G EM T A A EN • Acute attacks can usually be halted by subcutaneous injections of sumatriptan or by inhalation of 100% oxygen. • Preventative therapy with the agents used for migraine is often ineffective but attacks can be prevented in some patients by verapamil (80-120 mg 8-hourly), methysergide (4-10 mg daily, for a maximum of 3 months only) or short courses of oral corticosteroids. • Patients with severe and debilitating clusters can be helped with lithium therapy, although the usual precautions concerning the use of this drug should be observed.
    19. 19. Comparison of key features distinguishing migraine , tension , and cluster headaches   Migraine Tension Cluster Laterali ty Unilateral )(60% Bilateral )Unilateral (exclusive Intensit y Moderate or severe Mild or moderate Severe Pain descriptor ) (variable Pulsating )(50% Pressing or tightening Boring, piercing Physica l activity Aggravation by physical activity Does not worsen with physical activity Restlessness or agitation during attack Associated Nausea and/or / photophobia phonophobia No nausea, but may rarely have photophobia or phonophobia Ipsilateral symptoms; conjunctival injection, lacrimation, nasal congestion, rhinorrhea, forehead and facial sweating, miosis, ptosis, eyelid edema Duratio n hr 72–4 Minutes to days to 180-min cluster periods- 15 symptom s
    20. 20. Sinusitis & “sinus headache Symptoms suggesting a nasal or sinus :etiology (rhinosinusitis) include purulence in the nasal cavity nasal obstruction altered smell (hyposmia or anosmia) and/or fever.
    21. 21. ,…Cont Patients who self-treat presumed sinus headaches with decongestants often report incomplete resolution of and present in the primary care office seeking . antibiotics One their pain estimate is that 70% to 80% of patients presenting with “sinusitis causing a headache” may actually have migraine or could be classified as having probable migraine based on the presence of most but .not all of the IHS criteria
    22. 22. Chronic daily headache 3% and 5% of adults worldwide experience headaches daily or nearly daily. Paradoxically, the very medications commonly used to treat episodic headaches (including over-the-counter analgesics, especially acetaminophen, and migraine-specific medications such as triptans) are implicated in the transformation of episodic to chronic headaches, especially if consumed more often than 2 days per week over several months. Family physicians should be aware that this is a common condition associated with a significant burden of suffering, and that effective treatment of migraine and tension-type headache without the overuse of medication may help prevent the development of this difficult to- treat condition.
    23. 23.  Raised intracranial pressure may be caused by mass lesions (especially tumours), cerebral oedema, obstruction to CSF circulation (causing hydrocephalus) or impaired CSF absorption, as in idiopathic intracranial hypertension and cerebral venous obstruction, Characterized by : (secondary)Headache, Impairment of conscious level, Papilloedema, Vomiting, bradycardia, arterial hypertension. :Headache • Worse in morning, improves through the day • • • • • Associated with morning vomiting Worse bending forward Worse with cough and straining Relieved by analgesia Dull ache, often mild
    24. 24. Pseudotumor cerebri
    25. 25.  Pseudotumor cerebri occurs when the pressure inside your skull (intracranial pressure) increases for no obvious reason.  When no underlying cause for the increased intracranial pressure can be discovered, pseudotumor cerebri may also be called idiopathic intracranial hypertension.  Symptoms mimic those of a brain tumor, but no tumor is present.  Pseudotumor cerebri can occur in children and adults, but it's most common in obese women of childbearing age.
    26. 26. :signs and symptoms Moderate to severe headaches that may originate behind-1 your eyes, wake you from sleep and worsen with eye .movement Ringing in the ears that pulses in time with your heartbeat-2 Nausea, vomiting or dizziness-3 Blurred vision-4 Brief episodes of blindness, lasting only a few seconds and-5 (affecting one or both eyes (visual obscurations Difficulty seeing to the side-6 (Double vision (diplopia-7 (Seeing light flashes (photopsia-8 Neck, shoulder or back pain-9
    27. 27. :RISK FACTORS Obesity Obese women under the age of 44 are nearly 20 times more likely to .develop the disorder Medications Growth hormone Oral contraceptives Tetracycline Discontinuation of steroids Excess vitamin A :Health problem Addison's disease Lyme disease Mononucleosis Polycystic ovary syndrome Sleep apnea Underactive parathyroid glands Head injury Kidney disease Lupus
    28. 28. :Tests and diagnosis Eye exams If pseudotumor cerebri is suspected, we will look for a distinctive type of swelling — called papilledema — in the back of the eye. We will also undergo a visual fields test to see if there are any blind spots in patient vision besides normal blind spot in each .eye where the optic nerve enters the retina Brain imaging CT or MRI scans can rule out other problems that can cause .similar symptoms, such as brain tumors and blood clots Spinal tap (lumbar puncture) A lumbar puncture — which involves inserting a needle between two vertebrae in lower back — can determine how high the .pressure is inside your skull
    29. 29. Trigeminal neuralgia
    30. 30.  Trigeminal neuralgia is a chronic pain condition that affects the trigeminal nerve, which carries sensation from your face to your brain.  Trigeminal neuralgia affects women more often than men, and it's more likely to occur in people who are older than 50. .
    31. 31. :Signs and symptoms Episodes of severe, shooting or jabbing pain that may -1 .feel like an electric shock Spontaneous attacks of pain or attacks triggered by things such as -2 touching the face, chewing, speaking and brushing teeth Bouts of pain lasting from a few seconds to several seconds - 3 Pain in areas supplied by the trigeminal nerve, including the -4 .cheek, jaw, teeth, gums, lips, or less often the eye and forehead Pain affecting one side of your face at a time-5 .Attacks becoming more frequent and intense over time -6
    32. 32. Trigeminal neuralgia can occur as a result of aging, or it can be related to multiple sclerosis or a similar disorder that damages the . myelin sheath protecting certain nerves Less commonly, trigeminal neuralgia can be caused by a tumor . compressing the trigeminal nerve Some people may experience trigeminal neuralgia due to a brain lesion or other abnormalities. In other cases, a cause can't be .found Triggers Shaving Stroking your face Eating Drinking Brushing your teeth Talking Putting on makeup Smiling Washing your face
    33. 33. Tests and diagnosis Diagnosis of trigeminal neuralgia mainly based on description of the :pain, including Type. Pain related to trigeminal neuralgia is sudden, shock-like and* .brief Location* Triggers. Trigeminal neuralgia-related pain usually is brought on by* light stimulation of your cheeks, such as from eating, talking or even .encountering a cool breeze .A neurological examination. Touching examination,reflexes testingMagnetic resonance imaging (MRI). to determine if multiplesclerosis or a tumor is causing trigeminal neuralgia. Sometimes we may ask for MRA to view the arteries and veins and highlight blood flow (.(magnetic resonance angiogram
    34. 34. Temporal arteritis
    35. 35. Giant cell arteritis is an inflammation of the lining of * . your arteries :signs and symptoms Persistent, severe head pain and tenderness,-1 usually in temple area Vision loss or double vision-2 Scalp tenderness — it may hurt to comb your hair-3 or even to lay your head on a pillow, especially where the arteries are inflamed Jaw pain (jaw claudication) when you chew or-4 open your mouth wide Fever-5 Unexplained weight loss-6
    36. 36. Risk factors .The exact cause of giant cell arteritis isn't known • :several factors can increase risk • Age. Giant cell arteritis affects older adults almost exclusively — the average age at onset of the disease is 70, and it rarely occurs in people .younger than 50 Sex. Women are about two times more likely to develop giant cell .arteritis Northern European — especially Scandinavian — .Although giant cell arteritis can affect anyone, people born in Northern European . countries appear to have higher rates of giant cell arteritis Polymyalgia rheumatica. People with polymyalgia rheumatica have stiffness and aching in the neck, shoulders and hips. About 15 percent .of people with polymyalgia rheumatica also have giant cell arteritis
    37. 37. complication ,Blindness. This is the most serious complication of giant cell arteritis .Sudden painless and perminant .Aortic aneurysm .Stroke
    38. 38. :Tests and diagnosis Giant cell arteritis can be difficult to diagnose because its early symptoms resemble those of many common conditions. For this reason, your will try to .rule out other possible causes of the problem :tests Physical exam. In addition to asking about symptoms and medical history, paying particular attention to your temporal arteries. Often, one or both of these arteries are tender with a reduced pulse and a hard, cord-like feel and .appearance Blood tests.1- erythrocyte sedimentation rate. This test measures how quickly red blood cells fall to the bottom of a tube of blood. Red cells that drop rapidly .may indicate inflammation in the body (.C-reactive protein (CRP- 2 Biopsy. The best way to confirm a diagnosis of giant cell arteritis is by taking a .small sample (biopsy( of the temporal artery If you have giant cell arteritis, the artery will often show inflammation that includes abnormally large cells, called giant cells, which give the disease its .name
    39. 39. imaging tests may also be used for diagnosing giant* cell arteritis and for monitoring treatment. Possible :tests include .(Magnetic resonance angiography (MRA .Doppler ultrasound .(Positron emission tomography (PET
    40. 40. worst headache of my life  sudden and severe headache reaching maximal intensity within minutes and lasting an hour or more  may be accompanied by focal neurologic signs or other symptoms such as nausea, vomiting, photophobia, neck stiffness, seizures, or altered level of consciousness
    41. 41. worst headache of my life  It’s important not to miss SAH because early diagnosis and treatment is essential to improving outcomes.  Asking about headache severity in the context of previous headaches helps to ascertain the severity without suggestion or prompting of the patient with the words “worst headache of my life,” which is not very sensitive or specific as a screening question for SAH.
    42. 42. HISTORY • Age at onset • Presence or absence of aura and prodrome • Frequency, intensity and duration of attack • Number of headache days per month • Time and mode of onset • Quality, site, and radiation of pain • Associated symptoms and abnormalities • Family history of migraine • Precipitating and relieving factors • Effect of activity on pain
    43. 43. …CONT • Relationship with food/alcohol • Response to any previous treatment • Any recent change in vision • Association with recent trauma • Any recent changes in sleep, exercise, weight, or diet • State of general health • Change in work or lifestyle (disability) • Change in method of birth control (women) • Possible association with environmental factors • Effects of menstrual cycle and exogenous hormones (women)
    44. 44. :PHYSICAL EXAMINATION 1. Blood pressure measurement. 2. Neurological examination: • Optic neuritis usually present as sudden, severe unilateral loss of vision suggests • • lesion in optic nerve pathway/ pituitary mass may present as unilateral field defect. Glaucoma present as holes around light 3. Fundoscopy: presence of papillodema might be sign of intracranial mass, psudotumorcerebri, encephalitis or meningitis 4. Examination of cerebellar system 5. Examine for neck brui/check for temporal and neck arteries.
    45. 45. :RED FLAGS • SUGGESTING SERIOUS PROGRESSIVE OR LIVE-THREATENING DISEASE IN PATIENTS WITH HEADACHE “Red Flags” Headache that is sudden, explosive, (The worst headache of my life) Headache with focal neurological signs or symptoms or papillodema Headache of new in onset, that is constant, prevents sleep, and progressive over age of 50 local tenderness, absence of temporal pulse, or jaw claudication Headache in the elderly patient accompanied by focal neurological symptoms Headache accompanied by fever, stiff neck, photophobia or other systemic signs Headache hours to weeks after trauma especially in elderly Headache first occurring with exertion Diagnosis Intracranial hemorrhage Tumor, subdural hematoma ,epidural bleeding Intracranial mass , temporal arteritis Temporal arteritis (TA) Cerebro- Vascular Accident(CVA) Meningitis, encephalitis Subdural hematoma Rupture aneurysm
    46. 46. attacks
    47. 47. References: 1.Essentials of family medicine ( Sloane( 6th edition 2012 2.Clinical medicine (Kumar(7th edition 2009 3.Diagnosis and management of headache in adults; Scottish Intercollegiate Guidelines Network, 2008 4.Adult health clinical guidelines (HSS( 2006 5.www.migraine.ca