HEADACHES
Isha Dave B.Sc (Hons), M.C Optom (UK)
Practicing Optometrist and Educator
To view more presentations and article...
Headaches
• International Headache society
Classification of headache
– 62 types of classifiable headache
• 12 groups + no...
Glaser J, 1999
NEURO-
OPHTHALMOLOGY
Pub: Lippincott Williams and
Wilkins, Philadelphia
Most common causes:
• Primary
– tension
– migraine
– idiopathic stabbing
– exertional
– cluster
• Secondary
– Head injury
...
Primary headaches
• Tension type 69%
• Migraine 16%
• Cluster headache 0.1%
• Facial pain
Tension type headache
• Chronic or episodic
• Normally:
– bilateral, occipital, parietal or posterior neck
– Dull band-lik...
Pathophysiology
• Due to muscle contraction
• Commonly associated with psychological
problems
Routine referral to GP
Recom...
• Episodic headache
• Sensory sensitivity
• 5 phases
– 1. Prodrome - affects 60%
– 2. Aura - affects 20%
– 3. Headache - a...
1. Prodrome
• An awareness that an attack is going to
happen
• can be psychological symptoms
– depression, euphoria, menta...
2. Aura
• Focal neurological symptoms
– sensory
• visual, auditory, numbness, tingling
– motor
• ophthalmoplegia, hemipleg...
3. Headache
• Onset 60 minutes after aura finishes
• Headache described as:
– Moderate to severe
– throbbing
– Unilateral
...
4. Termination
• The pain fades
5. Postdrome
Can last 24 - 48 hours.
Tiredness
General malaise
To view more presentations ...
Common migraine
• No aura
– Unilateral pulsating headache
– associated with nausea, vomiting, photophobia or
phonophobia
–...
Classic migraine - the aura
• Most commonly aura are ocular
– binocular and confined to one hemifield
– can be monocular
•...
Visual aura
• Teichopsia
– Fortification spectra
• Hemianopia
– scintillating scotomata
– Water running down windscreen
– ...
Pathophysiology
• Thought to be vascular in origin
– Vessel constriction corresponds to aura
– Vessel dilation corresponds...
Management
• Reassurance
– not life threatening
– not associated with serious illness
– exception can be young women on ‘t...
Cluster headache
migrainous neuralgia
• Severe, unilateral head or face pain
– lasts 15 to 180 minutes
– occurs in cluster...
Headache characteristics
• Starts around one eye or cheek
• spreads across head
• reaches a peak in a few minutes
• lasts ...
Pathophysiology
• Cause unknown
– no demonstrable pathology
• fMRI
– Hypothalamic activity
To view more presentations and ...
Facial pain
• Trigeminal neuralgia
– Affects distribution of trigeminal nerve
– intense jabs of pain
• Repetitive
• lasts ...
Pathophysiology
• Trigemminal neuralgia
– Compression of Vth nerve root leaving pons
• usually an aneurysm or other vascul...
Secondary headaches
• Post-traumatic
• Vascular
– temporal arteritis
– aneurysm
– arteriovenous malformation
• Raised intr...
Post-traumatic headache
• Chronic or acute
• Associated with severe head trauma
• Not necessarily a definable injury
• Inj...
Pathophysiology
• May be no obvious intracranial trauma
To view more presentations and articles, visit www.eyenirvaan.com
Vascular - Temporal Arteritis
• Also known as giant cell arteritis
• Normally only in over 60’s
• headache
– normally cons...
Pathophysiology
• Arteritis affecting external carotid and
ophthalmic arteries
• elevated erythrocyte sedimentation rate
M...
Vascular - Aneurysm
• Recurring headaches may precede a burst
aneurysm
– Often severe headache
• Ruptured aneurysm
– sudde...
Arteriovenous Malformation
• Specific recurring headache
– throughout life
• Ruptured AVM
– sudden severe headache
– stiff...
Pathophysiology
• Aneurysm
– Focal damage near site of lesion
– Burst aneurysm of major vessel life threatening
• Arterio-...
Raised intracranial pressure
• Headache characteristics
– normally intermittent
– non specific, non localised
– dull, not ...
Pathophysiology
• Traction on pain sensitive structures
– intra-cranial, extra-cerebral
– such as meninges
Management
If a...
Ocular pathology
• Ocular disease causing general headache
– conjunctivitis, corneal lesions, anterior uveitis, angle
clos...
Pathophysiology
• Specific to the ocular disease
• Why this presents as headache is unknown
Management
To view more presen...
• Suffered by everyone at times
• Can indicate life threatening disease
• Should be considered serious when:
– they recur ...
Management
• Keep a headache diary
• Treat any related signs that can be treated in
optometric practice
• If systemic or p...
THANK YOU
To view more presentations and articles, visit www.eyenirvaan.com
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Headaches presentation at www.eyenirvaan.com

  1. 1. HEADACHES Isha Dave B.Sc (Hons), M.C Optom (UK) Practicing Optometrist and Educator To view more presentations and articles, visit www.eyenirvaan.com
  2. 2. Headaches • International Headache society Classification of headache – 62 types of classifiable headache • 12 groups + non classifiable – Primary headache • Groups 1 - 4 – Secondary headache • Groups 5 - 12 To view more presentations and articles, visit www.eyenirvaan.com
  3. 3. Glaser J, 1999 NEURO- OPHTHALMOLOGY Pub: Lippincott Williams and Wilkins, Philadelphia
  4. 4. Most common causes: • Primary – tension – migraine – idiopathic stabbing – exertional – cluster • Secondary – Head injury – Inflammation/ Infection (e.g. Meningitis – Raised intracranial pressure – Space Occupying Lesion – Vascular (E.g. Aneurysm) – Hunger/ thirst/ lack of sleep To view more presentations and articles, visit www.eyenirvaan.com
  5. 5. Primary headaches • Tension type 69% • Migraine 16% • Cluster headache 0.1% • Facial pain
  6. 6. Tension type headache • Chronic or episodic • Normally: – bilateral, occipital, parietal or posterior neck – Dull band-like pressure – occur daily • Associated with – sleeplessness – stress or emotional conflict • Differential diagnosis with migraine difficult To view more presentations and articles, visit www.eyenirvaan.com
  7. 7. Pathophysiology • Due to muscle contraction • Commonly associated with psychological problems Routine referral to GP Recommend treatment or advice on associated psychological problems. Management To view more presentations and articles, visit www.eyenirvaan.com
  8. 8. • Episodic headache • Sensory sensitivity • 5 phases – 1. Prodrome - affects 60% – 2. Aura - affects 20% – 3. Headache - affects 80% – 4. Termination – 5. Postdrome Migraine To view more presentations and articles, visit www.eyenirvaan.com
  9. 9. 1. Prodrome • An awareness that an attack is going to happen • can be psychological symptoms – depression, euphoria, mental slowness, hyperactivity • can be neurologic phenomena – photophobia, phonophobia – Nausea / vomitting • can be general – coldness, loss of appetite, food cravings
  10. 10. 2. Aura • Focal neurological symptoms – sensory • visual, auditory, numbness, tingling – motor • ophthalmoplegia, hemiplegia • Develops over 5 - 20 minutes • Normally lasts less than 60 minutes • ‘prolonged aura’ last up to a week • the effects of a ‘migranous infarction’ will last longer To view more presentations and articles, visit www.eyenirvaan.com
  11. 11. 3. Headache • Onset 60 minutes after aura finishes • Headache described as: – Moderate to severe – throbbing – Unilateral – Aggravated by movement • Associated with: – photophobia or phonophobia – poor concentration – nausea, vomiting
  12. 12. 4. Termination • The pain fades 5. Postdrome Can last 24 - 48 hours. Tiredness General malaise To view more presentations and articles, visit www.eyenirvaan.com
  13. 13. Common migraine • No aura – Unilateral pulsating headache – associated with nausea, vomiting, photophobia or phonophobia – Aggravated by physical activity – 5 attacks needed for diagnosis To view more presentations and articles, visit www.eyenirvaan.com
  14. 14. Classic migraine - the aura • Most commonly aura are ocular – binocular and confined to one hemifield – can be monocular • retinal migraine – can be ocular motor • ophthalmoplegic migraine • can be non-ocular – range of motor or sensory deficits • Hemi-sensory or vertigo – can result in complete hemiplegia • Two episodes required for diagnosis
  15. 15. Visual aura • Teichopsia – Fortification spectra • Hemianopia – scintillating scotomata – Water running down windscreen – Heat haze – Broken up / cracked mirror • Tunnel vision – Very rarely total visual loss
  16. 16. Pathophysiology • Thought to be vascular in origin – Vessel constriction corresponds to aura – Vessel dilation corresponds to headache • Pain from Intra-cranial, extra-cerebral vessels • Physiological trigger unknown • Genetic influence – many have positive family history • Many have an external trigger – tiredness, certain foods or drinks, bright lights • fMRI suggests pontine / midbrain activity
  17. 17. Management • Reassurance – not life threatening – not associated with serious illness – exception can be young women on ‘the pill’ • No known cure • Change in lifestyle can reduce frequency – Avoid triggers • Write a ‘headache diary’ • Medication – Pain relief during acute attack – Preventative if > 5 attacks per month
  18. 18. Cluster headache migrainous neuralgia • Severe, unilateral head or face pain – lasts 15 to 180 minutes – occurs in clusters • 1 - 8 attacks daily over a period of days or weeks • can be associated with – Restlessness / facial flushing – Conjunctival injection, lacrimation, eye lid oedema – nasal congestion / rhinorrhoea (runny nose) – Horners (sympathetic ophthalmoplegia) • Pupil constriction and partial ptosis • Predominantly affects men To view more presentations and articles, visit www.eyenirvaan.com
  19. 19. Headache characteristics • Starts around one eye or cheek • spreads across head • reaches a peak in a few minutes • lasts 30 minutes - a few hours • Intense pain – sufferers bang head against wall – burn head with hot compressors • Wakes patient in early hours To view more presentations and articles, visit www.eyenirvaan.com
  20. 20. Pathophysiology • Cause unknown – no demonstrable pathology • fMRI – Hypothalamic activity To view more presentations and articles, visit www.eyenirvaan.com
  21. 21. Facial pain • Trigeminal neuralgia – Affects distribution of trigeminal nerve – intense jabs of pain • Repetitive • lasts only seconds, with an ache in between • Mostly affects mandibular or maxillary region • can affect ophthalmic division, but not in isolation – Onset usually after age 50 years • Atypical facial pain – Diffuse ache – Not conforming to distribution of Vth Nerve
  22. 22. Pathophysiology • Trigemminal neuralgia – Compression of Vth nerve root leaving pons • usually an aneurysm or other vascular lesion • Atypical facial pain – Dental pain / disease – Nasopharyngeal neoplasm – Psychological illness To view more presentations and articles, visit www.eyenirvaan.com
  23. 23. Secondary headaches • Post-traumatic • Vascular – temporal arteritis – aneurysm – arteriovenous malformation • Raised intracranial pressure – CSF pressure – SOL • Ocular pathology
  24. 24. Post-traumatic headache • Chronic or acute • Associated with severe head trauma • Not necessarily a definable injury • Injury may or may not have involved concussion • starts immediately or after several weeks • can last several months • dull general ache – may have localised areas of higher intensity.
  25. 25. Pathophysiology • May be no obvious intracranial trauma To view more presentations and articles, visit www.eyenirvaan.com
  26. 26. Vascular - Temporal Arteritis • Also known as giant cell arteritis • Normally only in over 60’s • headache – normally constant – gradual onset to a diffuse severe aching – superficial scalp tenderness - temporal – worse at night and in the cold • jaw claudication • associations – fever, anaemia, weight loss, AION or ophthalmoplegia
  27. 27. Pathophysiology • Arteritis affecting external carotid and ophthalmic arteries • elevated erythrocyte sedimentation rate Management: Immediate referral to Eye Emergency Department Maybe a precurser to a stroke or coronary AION 70% other eye affected within 10 days
  28. 28. Vascular - Aneurysm • Recurring headaches may precede a burst aneurysm – Often severe headache • Ruptured aneurysm – sudden, excruciating headache – stiff neck – vomiting – altered behaviour – may have focal lesions • IIIrd nerve palsy if posterior communicating artery affected • hemiparesis if middle cerebral artery affected
  29. 29. Arteriovenous Malformation • Specific recurring headache – throughout life • Ruptured AVM – sudden severe headache – stiff neck – homonymous field defect typical of occipital AVM To view more presentations and articles, visit www.eyenirvaan.com
  30. 30. Pathophysiology • Aneurysm – Focal damage near site of lesion – Burst aneurysm of major vessel life threatening • Arterio-venous malformation – Focal damage near site of lesion – haemorrhage results in increased ICPManagement Referral to GP same day Immediate referral to casualty if: Suspect burst aneurysm or AVM Aneurysm on major vessel
  31. 31. Raised intracranial pressure • Headache characteristics – normally intermittent – non specific, non localised – dull, not throbbing – worse after exercise – may waken patient from sleep – transient headache on coughing To view more presentations and articles, visit www.eyenirvaan.com
  32. 32. Pathophysiology • Traction on pain sensitive structures – intra-cranial, extra-cerebral – such as meninges Management If associated with papilloedema or other neurological signs refer to GP within one week, with recommendation for neurological investigation. To view more presentations and articles, visit www.eyenirvaan.com
  33. 33. Ocular pathology • Ocular disease causing general headache – conjunctivitis, corneal lesions, anterior uveitis, angle closure glaucoma, optic neuritis, orbital tumours and pseudo tumours, Tolosa Hunt syndrome. • Ocular pain or pain on eye movements – paratrigeminal syndrome, ocular motor nerve palsies, carotid cavernous fistula, naso-pharyngeal tumours • Asthenopic symptoms – incorrect refractive error correction, ocular motor imbalance, convergence insufficiency, ocular neurosis
  34. 34. Pathophysiology • Specific to the ocular disease • Why this presents as headache is unknown Management To view more presentations and articles, visit www.eyenirvaan.com
  35. 35. • Suffered by everyone at times • Can indicate life threatening disease • Should be considered serious when: – they recur frequently – are continuous – exist in conjunction with other neurological symptoms • When in doubt - refer Headaches To view more presentations and articles, visit www.eyenirvaan.com
  36. 36. Management • Keep a headache diary • Treat any related signs that can be treated in optometric practice • If systemic or psychological factors are suspected recommend a GP referral – with an urgency dependent on severity, frequency and suspected cause • Urgent referral to casualty is recommended if suspect – an intracranial haemorrhage – cerebral aneurysm – temporal arteritis
  37. 37. THANK YOU To view more presentations and articles, visit www.eyenirvaan.com

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