Headaches presentation at www.eyenirvaan.com

HEADACHES
Isha Dave B.Sc (Hons), M.C Optom (UK)
Practicing Optometrist and Educator
To view more presentations and articles, visit www.eyenirvaan.com

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

Glaser J, 1999
NEURO-
OPHTHALMOLOGY
Pub: Lippincott Williams and
Wilkins, Philadelphia

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

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-like pressure
– occur daily
• Associated with
– sleeplessness
– stress or emotional conflict
• Differential diagnosis with migraine difficult

Pathophysiology
• Due to muscle contraction
• Commonly associated with psychological
problems
Routine referral to GP
Recommend treatment or advice on associated
psychological problems.
Management

• Episodic headache
• Sensory sensitivity
• 5 phases
– 1. Prodrome - affects 60%
– 2. Aura - affects 20%
– 3. Headache - affects 80%
– 4. Termination
– 5. Postdrome
Migraine

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

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

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

4. Termination
• The pain fades
5. Postdrome
Can last 24 - 48 hours.
Tiredness
General malaise

Common migraine
• No aura
– Unilateral pulsating headache
– associated with nausea, vomiting, photophobia or
phonophobia
– Aggravated by physical activity
– 5 attacks needed for diagnosis

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

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

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

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

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

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

Pathophysiology
• Cause unknown
– no demonstrable pathology
• fMRI
– Hypothalamic activity

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

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

Secondary headaches
• Post-traumatic
• Vascular
– temporal arteritis
– aneurysm
– arteriovenous malformation
• Raised intracranial pressure
– CSF pressure
– SOL
• Ocular pathology

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.

Pathophysiology
• May be no obvious intracranial trauma

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

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

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

Arteriovenous Malformation
• Specific recurring headache
– throughout life
• Ruptured AVM
– sudden severe headache
– stiff neck
– homonymous field defect typical of
occipital AVM

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

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

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.

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

Pathophysiology
• Specific to the ocular disease
• Why this presents as headache is unknown
Management

• 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

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

THANK YOU

Headaches presentation at www.eyenirvaan.com

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