Headache Alina Valdes, M.D.
Causes of Headache <ul><li>Irritation of: </li></ul><ul><ul><li>pain-sensitive intracranial structures </li></ul></ul><ul>...
<ul><li>Trigeminal nerve system </li></ul><ul><ul><li>neurotransmitter serotonin </li></ul></ul><ul><li>Insensitive to pai...
Patient History <ul><li>Single most important diagnostic “test” in evaluation </li></ul><ul><li>Primary headache disorders...
<ul><li>“ POUND ing” headaches </li></ul><ul><ul><li>P ulsatile </li></ul></ul><ul><ul><ul><li>Are the headaches pulsating...
Migraine Headaches <ul><li>Clinical Features </li></ul><ul><ul><li>Episodic </li></ul></ul><ul><ul><li>Combination of neur...
<ul><li>Classification </li></ul><ul><ul><li>Migraine without aura </li></ul></ul><ul><ul><ul><li>Common  migraine </li></...
<ul><li>Characteristics </li></ul><ul><ul><li>Migraine auras often precede headache </li></ul></ul><ul><ul><ul><li>Focal n...
<ul><ul><li>In  children , often associated with </li></ul></ul><ul><ul><ul><li>Episodic abdominal pain </li></ul></ul></u...
<ul><li>Acute headache can reflect serious CNS disease </li></ul><ul><ul><li>Differential </li></ul></ul><ul><ul><ul><li>M...
<ul><ul><li>Clinical features suggesting structural lesion </li></ul></ul><ul><ul><ul><li>Symptoms </li></ul></ul></ul><ul...
<ul><li>Etiology </li></ul><ul><ul><li>Genetic predisposition </li></ul></ul><ul><ul><ul><li>Positive family history repor...
<ul><li>Treatment </li></ul><ul><ul><li>Goals </li></ul></ul><ul><ul><ul><li>Relief of acute attacks </li></ul></ul></ul><...
<ul><ul><li>Pharmacologic measures </li></ul></ul><ul><ul><ul><li>Simple analgesics  – mild or moderate pain </li></ul></u...
<ul><ul><ul><li>Specific treatment   – severe pain </li></ul></ul></ul><ul><ul><ul><ul><li>Oral ergotamine </li></ul></ul>...
<ul><ul><li>Prevention </li></ul></ul><ul><ul><ul><li>Drugs restricted to patients who have frequent attacks and willing t...
Cluster Headaches <ul><li>Clinical Features </li></ul><ul><ul><li>Uncommon: <10% of all headaches </li></ul></ul><ul><ul><...
<ul><li>Characteristics </li></ul><ul><ul><li>Associated with </li></ul></ul><ul><ul><ul><li>Congestion of nasal mucosa an...
<ul><ul><li>Attacks often awake patients, usually 2 to 3 hours after onset of sleep </li></ul></ul><ul><ul><li>Pain not re...
<ul><li>Treatment </li></ul><ul><ul><li>Abortive  for acute headache </li></ul></ul><ul><ul><ul><li>Oxygen by mask (7 to 1...
Tension-Type Headache <ul><li>Characteristics </li></ul><ul><ul><li>9 out of 10 primary headaches </li></ul></ul><ul><ul><...
<ul><ul><li>Commonly lasts for long periods of time </li></ul></ul><ul><ul><li>Does not rapidly appear and disappear in at...
<ul><li>Treatment </li></ul><ul><ul><li>Evaluate patient’s life situations and presence of anxiety or depression </li></ul...
 
Other Acute Headache Syndromes <ul><li>Cough headache </li></ul><ul><ul><li>Coughing, sneezing, laughing, or bending </li>...
<ul><li>Monosodium glutamate-induced headache </li></ul><ul><ul><li>“ Chinese restaurant syndrome” </li></ul></ul><ul><ul>...
<ul><li>Exertional headache </li></ul><ul><ul><li>May be brought on by prolonged physical exercise </li></ul></ul><ul><ul>...
<ul><li>Ice-cream headache </li></ul><ul><ul><li>Cold stimulus headache </li></ul></ul><ul><ul><li>More likely to occur if...
<ul><li>Ice-pick headache </li></ul><ul><ul><li>“ Idiopathic stabbing headache” </li></ul></ul><ul><ul><li>Produces sudden...
<ul><li>Sex headache </li></ul><ul><ul><li>Usually not of concern </li></ul></ul><ul><ul><li>Men affected more than women ...
<ul><li>Swim-goggle headache </li></ul><ul><ul><li>“ External compression headache” </li></ul></ul><ul><ul><li>Results fro...
<ul><li>Post-traumatic headache </li></ul><ul><ul><li>Often occurs after head injury </li></ul></ul><ul><ul><li>Frequency ...
<ul><li>Rebound headache </li></ul><ul><ul><li>Occurs with overuse of pain reliever or migraine-specific medication for he...
<ul><li>Orthostatic headache </li></ul><ul><ul><li>Occurs when stand up and relieved by laying down </li></ul></ul><ul><ul...
Headache Secondary to Structural Brain Disease <ul><li>Cerebrovascular disease </li></ul><ul><ul><li>Ischemic stroke </li>...
<ul><li>Infectious disease </li></ul><ul><ul><li>Meningitis </li></ul></ul><ul><ul><li>Abscess </li></ul></ul><ul><ul><li>...
<ul><li>Neoplastic disease </li></ul><ul><ul><li>Malignant brain tumor </li></ul></ul><ul><ul><li>Metastasis </li></ul></u...
Headache and Acute Sinusitis <ul><li>Head pain most prominent feature </li></ul><ul><li>Malaise and low-grade fever </li><...
<ul><li>Maxillary sinusitis </li></ul><ul><ul><li>Ipsilateral, malar, ear, and dental pain </li></ul></ul><ul><li>Frontal ...
<ul><li>Ethmoidal sinusitis </li></ul><ul><ul><li>Pain between or behind eyes with radiation to temporal area </li></ul></...
Headache and Brain Tumors <ul><li>Posterior fossa tumors, especially cerebellar </li></ul><ul><ul><li>Usually with hydroce...
Headache and Idiopathic Intracranial Hypertension   <ul><li>Also called benign intracranial hypertension </li></ul><ul><li...
<ul><li>Occasionally have visual disturbances  –   may lead to visual loss, including blindness </li></ul><ul><li>Fundosco...
<ul><li>Treatment </li></ul><ul><ul><li>Eliminate secondary causes first </li></ul></ul><ul><ul><li>Dietary counseling for...
Post-Traumatic Headache <ul><li>Associated with irritability, concentration impairment, insomnia, memory disturbance, and ...
Headache and Giant Cell Arteritis <ul><li>Over 60% of patients have headaches </li></ul><ul><li>Granulomatous vasculitis o...
<ul><li>Headache aching, worse at night and after exposure to cold </li></ul><ul><li>Superficial temporal artery frequentl...
Headache in Systemic Disease <ul><li>Endocrine/metabolic </li></ul><ul><ul><li>Malignant hypertension (e.g., pheochromocyt...
<ul><li>Pulmonary </li></ul><ul><ul><li>Hypercapnea </li></ul></ul><ul><ul><li>Sleep apnea </li></ul></ul><ul><li>Pharmaco...
Cranial Neuralgias <ul><li>Trigeminal neuralgia </li></ul><ul><ul><li>Stabbing, spasmodic pain unilaterally in one of divi...
<ul><li>Glossopharyngeal neuralgia </li></ul><ul><ul><li>Rare </li></ul></ul><ul><ul><li>Brief paroxysms of severe stabbin...
<ul><li>Postherpetic neuralgia </li></ul><ul><ul><li>Herpes zoster produces pain by involving cranial nerves in one third ...
<ul><li>Occipital neuralgia </li></ul><ul><ul><li>Occipital pain starting at base of skull </li></ul></ul><ul><ul><li>Ofte...
Reflex Sympathetic Dystrophy <ul><li>Pain and hyperesthesia and autonomic changes </li></ul><ul><li>Any type of injury can...
<ul><li>Symptoms usually develop gradually over days or weeks and divided into three stages </li></ul><ul><ul><li>Acute st...
<ul><ul><li>Atrophy </li></ul></ul><ul><ul><ul><li>Usually occurs more than 6 months after injury </li></ul></ul></ul><ul>...
Headache: Guide to Treatment <ul><li>Rest, heat or ice packs, or a long, hot shower  </li></ul><ul><li>Over-the-counter pa...
<ul><li>Headache medications fall into two broad categories: </li></ul><ul><ul><li>abortive drugs to stop or reduce pain a...
<ul><li>Abortive medications:  treat headaches </li></ul><ul><ul><li>Serotonin agonists : work by influencing the behavior...
<ul><ul><ul><ul><li>Zolmitriptan (Zomig)   — very similar to sumatriptan; tends to work faster; also effective in signific...
<ul><ul><li>Lidocaine nasal drops :   may provide short-term relief as anesthetic on nerves in nasal passages. It can ease...
<ul><li>Prophylactic medications:   prevent headaches from starting or reduce frequency and severity </li></ul><ul><ul><li...
<ul><ul><li>Cardiovascular drugs </li></ul></ul><ul><ul><ul><li>Beta-blockers and calcium channel blockers   </li></ul></u...
Neck and Back Pain <ul><li>Most patients with acute pain have self-limiting musculoskeletal disorder   – not need specific...
Cervical Spondylosis <ul><li>Degenerative disorder of cervical intervertebral discs </li></ul><ul><li>Hypertrophy of adjac...
<ul><li>Clinical disease </li></ul><ul><ul><li>Normal age-related, degenerative changes with congenital/developmental sten...
<ul><li>Differential diagnosis </li></ul><ul><ul><li>Multiple sclerosis </li></ul></ul><ul><ul><li>Amyotrophic lateral scl...
Acute Low Back Pain <ul><li>Lumbar canal stenosis from intervertebral disc disease and degenerative spondylosis will affec...
<ul><li>“ Neurogenic claudication” </li></ul><ul><ul><li>Unilateral or bilateral buttock pain worse on standing or walking...
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Headache

  1. 1. Headache Alina Valdes, M.D.
  2. 2. Causes of Headache <ul><li>Irritation of: </li></ul><ul><ul><li>pain-sensitive intracranial structures </li></ul></ul><ul><ul><li>dural sinuses </li></ul></ul><ul><ul><li>intracranial portions of trigeminal, glossopharyngeal, vagus, and upper cervical nerves </li></ul></ul><ul><ul><li>large arteries </li></ul></ul><ul><ul><li>venous sinuses </li></ul></ul><ul><li>Referred pain from muscles, tendons, joints, skin </li></ul>
  3. 3. <ul><li>Trigeminal nerve system </li></ul><ul><ul><li>neurotransmitter serotonin </li></ul></ul><ul><li>Insensitive to pain </li></ul><ul><ul><li>brain parenchyma </li></ul></ul><ul><ul><li>ependymal lining of ventricles </li></ul></ul><ul><ul><li>choroid plexus </li></ul></ul>
  4. 4. Patient History <ul><li>Single most important diagnostic “test” in evaluation </li></ul><ul><li>Primary headache disorders usually do not arise from grave underlying diseases </li></ul><ul><ul><li>Rarity of such grave conditions </li></ul></ul><ul><ul><li>Large number of patients experiencing headaches </li></ul></ul><ul><ul><ul><li>Routine diagnostic testing controversial </li></ul></ul></ul><ul><ul><ul><ul><li><1% of patients with acute headache and normal neurologic exam have significant abnormalities on CT scan or MRI </li></ul></ul></ul></ul><ul><ul><ul><ul><li>10-15% of patients with headache and abnormal neurologic symptoms or signs have significant abnormalities on neuroimaging studies </li></ul></ul></ul></ul>
  5. 5. <ul><li>“ POUND ing” headaches </li></ul><ul><ul><li>P ulsatile </li></ul></ul><ul><ul><ul><li>Are the headaches pulsating? </li></ul></ul></ul><ul><ul><li>O ne day </li></ul></ul><ul><ul><ul><li>Without medication, do the headaches last between 4 and 72 hours? </li></ul></ul></ul><ul><ul><li>U nilateral </li></ul></ul><ul><ul><ul><li>Are the headaches typically unilateral? </li></ul></ul></ul><ul><ul><li>N ausea </li></ul></ul><ul><ul><ul><li>Do you become nauseated? </li></ul></ul></ul><ul><ul><li>D isturbing </li></ul></ul><ul><ul><ul><li>Do the headaches disturb your daily activities? </li></ul></ul></ul>
  6. 6. Migraine Headaches <ul><li>Clinical Features </li></ul><ul><ul><li>Episodic </li></ul></ul><ul><ul><li>Combination of neurologic, gastrointestinal, and autonomic changes </li></ul></ul><ul><ul><li>Physical exam and lab studies usually normal </li></ul></ul><ul><ul><li>Prevalence: 15% women vs. 7% men </li></ul></ul><ul><ul><li>Peak ages at onset: adolescence and early adulthood but may begin in early childhood </li></ul></ul><ul><ul><li>Onset rare later in life (>50 years old) </li></ul></ul><ul><ul><li>May be familial </li></ul></ul>
  7. 7. <ul><li>Classification </li></ul><ul><ul><li>Migraine without aura </li></ul></ul><ul><ul><ul><li>Common migraine </li></ul></ul></ul><ul><ul><li>Migraine with aura </li></ul></ul><ul><ul><ul><li>Classic migraine </li></ul></ul></ul><ul><ul><li>Complicated migraine </li></ul></ul><ul><ul><ul><li>Hemiplegic migraine </li></ul></ul></ul><ul><ul><ul><li>Confusional migraine </li></ul></ul></ul><ul><ul><ul><li>Ophthalmoplegic migraine </li></ul></ul></ul><ul><ul><ul><li>Basilar migraine </li></ul></ul></ul>
  8. 8. <ul><li>Characteristics </li></ul><ul><ul><li>Migraine auras often precede headache </li></ul></ul><ul><ul><ul><li>Focal neurologic symptoms </li></ul></ul></ul><ul><ul><ul><ul><li>Visual phenomena: scintillating scotomata </li></ul></ul></ul></ul><ul><ul><li>Pain </li></ul></ul><ul><ul><ul><li>Often pulsating, unilateral, and frontotemporal in distribution </li></ul></ul></ul><ul><ul><ul><li>Invariably accompanied by anorexia, nausea, and vomiting </li></ul></ul></ul><ul><ul><li>Diagnosis requires presence of one of the following, especially in absence of aura </li></ul></ul><ul><ul><ul><li>Photophobia </li></ul></ul></ul><ul><ul><ul><li>Phonophobia </li></ul></ul></ul><ul><ul><ul><li>Osmophobia </li></ul></ul></ul>
  9. 9. <ul><ul><li>In children , often associated with </li></ul></ul><ul><ul><ul><li>Episodic abdominal pain </li></ul></ul></ul><ul><ul><ul><li>Motion sickness </li></ul></ul></ul><ul><ul><ul><li>Sleep disturbance </li></ul></ul></ul><ul><ul><li>Complicated migraine </li></ul></ul><ul><ul><ul><li>Major neurologic dysfunction separate from visual aura </li></ul></ul></ul><ul><ul><ul><ul><li>Hemiplegia </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Coma </li></ul></ul></ul></ul><ul><ul><ul><li>Neurologic dysfunction outlasts the headache by hours to 1 or 2 days </li></ul></ul></ul>
  10. 10. <ul><li>Acute headache can reflect serious CNS disease </li></ul><ul><ul><li>Differential </li></ul></ul><ul><ul><ul><li>Migraine </li></ul></ul></ul><ul><ul><ul><li>Cluster </li></ul></ul></ul><ul><ul><ul><li>Stroke </li></ul></ul></ul><ul><ul><ul><ul><li>Subarachnoid hemorrhage </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Intracerebral hemorrhage </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Cerebral infarction </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Arterial dissection (carotid or vertebral) </li></ul></ul></ul></ul><ul><ul><ul><li>Acute hydrocephalus </li></ul></ul></ul><ul><ul><ul><li>Meningitis/encephalitis </li></ul></ul></ul><ul><ul><ul><li>Giant cell arteritis (often chronic) </li></ul></ul></ul><ul><ul><ul><li>Tumor (usually chronic) </li></ul></ul></ul>
  11. 11. <ul><ul><li>Clinical features suggesting structural lesion </li></ul></ul><ul><ul><ul><li>Symptoms </li></ul></ul></ul><ul><ul><ul><ul><li>Worst of patient’s life </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Progressive </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Onset > 50 years of age </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Worse in early morning – awakens patient </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Marked exacerbation with straining </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Focal neurologic dysfunction </li></ul></ul></ul></ul><ul><ul><ul><li>Signs </li></ul></ul></ul><ul><ul><ul><ul><li>Nuchal rigidity </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Fever </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Papilledema </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Pathologic reflexes or reflex asymmetry </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Altered state of consciousness </li></ul></ul></ul></ul>
  12. 12. <ul><li>Etiology </li></ul><ul><ul><li>Genetic predisposition </li></ul></ul><ul><ul><ul><li>Positive family history reported in 65% to 91% of cases </li></ul></ul></ul><ul><ul><li>Susceptibility of CNS to certain stimuli </li></ul></ul><ul><ul><li>Hormonal factors </li></ul></ul><ul><ul><li>Sequence of neurovascular events </li></ul></ul><ul><ul><ul><li>Neurologic phenomena thought to be caused by spasm of cerebral vessels </li></ul></ul></ul><ul><ul><ul><li>Pain thought to be caused by subsequent dilatation of extracranial arteries </li></ul></ul></ul><ul><ul><ul><li>Evidence that diminished cerebral blood flow accompanies aura </li></ul></ul></ul>
  13. 13. <ul><li>Treatment </li></ul><ul><ul><li>Goals </li></ul></ul><ul><ul><ul><li>Relief of acute attacks </li></ul></ul></ul><ul><ul><ul><li>Prevention of pain and associated symptoms of recurrent headaches </li></ul></ul></ul><ul><ul><li>Headache diary </li></ul></ul><ul><ul><li>Nonpharmacologic measures </li></ul></ul><ul><ul><ul><li>Identify and avoid triggers </li></ul></ul></ul><ul><ul><ul><li>Diet </li></ul></ul></ul><ul><ul><ul><li>Sleep habits </li></ul></ul></ul><ul><ul><ul><li>Stress management </li></ul></ul></ul>
  14. 14. <ul><ul><li>Pharmacologic measures </li></ul></ul><ul><ul><ul><li>Simple analgesics – mild or moderate pain </li></ul></ul></ul><ul><ul><ul><ul><li>Acetaminophen </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Aspirin </li></ul></ul></ul></ul><ul><ul><ul><ul><li>NSAID’s </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Caffeine adjuvant compounds </li></ul></ul></ul></ul><ul><ul><ul><li>Antiemetics – nausea </li></ul></ul></ul><ul><ul><ul><li>Nonspecific treatment – severe pain </li></ul></ul></ul><ul><ul><ul><ul><li>Mixed analgesics </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Class III narcotics </li></ul></ul></ul></ul>
  15. 15. <ul><ul><ul><li>Specific treatment – severe pain </li></ul></ul></ul><ul><ul><ul><ul><li>Oral ergotamine </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Oral sumatriptan </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Oral or rectal neuroleptic </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Dihydroergotamine nasal spray </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Subcutaneous sumatriptan </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Intramuscular/subcutaneous dihydroergotamine </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Intravenous dihydroergotamine </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Intramuscular/intravenous neuroleptic </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Intramuscular/intravenous steroid </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Parenteral narcotic </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Narcotics: butorphanol NS </li></ul></ul></ul></ul>
  16. 16. <ul><ul><li>Prevention </li></ul></ul><ul><ul><ul><li>Drugs restricted to patients who have frequent attacks and willing to take daily medications </li></ul></ul></ul><ul><ul><ul><ul><li>Beta – adrenergic receptor blockers: propranolol, nadolol </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Tricyclic antidepressants: amitriptyline </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Serotonin reuptake inhibitors: paroxetine, sertraline </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Calcium channel blockers: verapamil </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Serotonin antagonists: methysergide </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Anticonvulsants: divalproex sodium </li></ul></ul></ul></ul>
  17. 17. Cluster Headaches <ul><li>Clinical Features </li></ul><ul><ul><li>Uncommon: <10% of all headaches </li></ul></ul><ul><ul><li>Much more common in men than women </li></ul></ul><ul><ul><li>Mean age of onset later in life than migraine </li></ul></ul><ul><ul><li>Rarely begin in childhood </li></ul></ul><ul><ul><li>Less often family history </li></ul></ul><ul><ul><li>Extreme intensity </li></ul></ul>
  18. 18. <ul><li>Characteristics </li></ul><ul><ul><li>Associated with </li></ul></ul><ul><ul><ul><li>Congestion of nasal mucosa and injection of conjunctiva on side of pain </li></ul></ul></ul><ul><ul><li>May be associated with </li></ul></ul><ul><ul><ul><li>Increased sweating of ipsilateral side of forehead and face </li></ul></ul></ul><ul><ul><ul><li>Ocular signs of Horner’s syndrome: miosis, ptosis, and eyelid edema </li></ul></ul></ul><ul><ul><li>Pain usually steady, nonthrobbing, and invariably localized retro-orbitally on one side of head but may occasionally spread to ipsilateral side of face or neck </li></ul></ul>
  19. 19. <ul><ul><li>Attacks often awake patients, usually 2 to 3 hours after onset of sleep </li></ul></ul><ul><ul><li>Pain not relieved by resting in dark, quiet area </li></ul></ul><ul><ul><li>Patients sometimes seek distracting activity </li></ul></ul><ul><ul><li>Frequently recur over period of several days or weeks with headache-free periods of varying duration in between </li></ul></ul><ul><ul><li>Precipitated by alcohol, even in small amounts </li></ul></ul>
  20. 20. <ul><li>Treatment </li></ul><ul><ul><li>Abortive for acute headache </li></ul></ul><ul><ul><ul><li>Oxygen by mask (7 to 10 L/min for 15 minutes) – effective within several minutes in 70% of patients </li></ul></ul></ul><ul><ul><ul><li>Sumatriptan </li></ul></ul></ul><ul><ul><ul><li>Dihydroergotamine </li></ul></ul></ul><ul><ul><li>Prophylactic for prevention </li></ul></ul><ul><ul><ul><li>Lithium </li></ul></ul></ul><ul><ul><ul><li>Divalproex sodium </li></ul></ul></ul><ul><ul><ul><li>Verapamil </li></ul></ul></ul><ul><ul><ul><li>Methysergide </li></ul></ul></ul><ul><ul><ul><li>Corticosteroids </li></ul></ul></ul>
  21. 21. Tension-Type Headache <ul><li>Characteristics </li></ul><ul><ul><li>9 out of 10 primary headaches </li></ul></ul><ul><ul><li>Affect men and women equally </li></ul></ul><ul><ul><li>Usually not throbbing but steady </li></ul></ul><ul><ul><li>“ Pressure feeling” or “vise-like” </li></ul></ul><ul><ul><li>Usually not unilateral </li></ul></ul><ul><ul><li>May be frontal, occipital, or generalized </li></ul></ul><ul><ul><li>Frequently pain in neck area, unlike migraine </li></ul></ul>
  22. 22. <ul><ul><li>Commonly lasts for long periods of time </li></ul></ul><ul><ul><li>Does not rapidly appear and disappear in attacks Nausea uncommon and mild, if present </li></ul></ul><ul><ul><li>No “aura” </li></ul></ul><ul><ul><li>Photophobia and phonophobia usually absent </li></ul></ul><ul><ul><li>May occur or be exacerbated by emotional stress </li></ul></ul><ul><ul><ul><li>Muscle-contraction headache </li></ul></ul></ul>
  23. 23. <ul><li>Treatment </li></ul><ul><ul><li>Evaluate patient’s life situations and presence of anxiety or depression </li></ul></ul><ul><ul><li>Tricyclic antidepressants in low doses proven most useful for prevention </li></ul></ul><ul><ul><ul><li>Amitriptyline most well documented </li></ul></ul></ul><ul><ul><ul><li>Newer agents with fewer side effects </li></ul></ul></ul>
  24. 25. Other Acute Headache Syndromes <ul><li>Cough headache </li></ul><ul><ul><li>Coughing, sneezing, laughing, or bending </li></ul></ul><ul><ul><li>Increases pressure in head </li></ul></ul><ul><ul><li>Described as bursting or explosive </li></ul></ul><ul><ul><li>Lasts seconds to minutes </li></ul></ul><ul><ul><li>Usually occurs on both sides of head and back or beneath skull </li></ul></ul><ul><ul><li>Usually affects people >55 years old </li></ul></ul><ul><ul><li>4-to-1 male predominance </li></ul></ul><ul><ul><li>>50% of people have underlying structural cause so need MRI </li></ul></ul>
  25. 26. <ul><li>Monosodium glutamate-induced headache </li></ul><ul><ul><li>“ Chinese restaurant syndrome” </li></ul></ul><ul><ul><li>Most symptoms begin within 20 to 25 minutes after consuming MSG </li></ul></ul><ul><ul><ul><li>Chest pressure </li></ul></ul></ul><ul><ul><ul><li>Face tightening and pressure </li></ul></ul></ul><ul><ul><ul><li>Burning sensation in chest, neck, or shoulders </li></ul></ul></ul><ul><ul><ul><li>Facial flushing </li></ul></ul></ul><ul><ul><ul><li>Dizziness </li></ul></ul></ul><ul><ul><ul><li>Headache across front or sides of head </li></ul></ul></ul><ul><ul><ul><li>Abdominal discomfort </li></ul></ul></ul>
  26. 27. <ul><li>Exertional headache </li></ul><ul><ul><li>May be brought on by prolonged physical exercise </li></ul></ul><ul><ul><li>Throbbing pain, gradually builds in intensity, and experienced on both sides of head </li></ul></ul><ul><ul><li>Pain can last from 5 minutes to 24 hours </li></ul></ul><ul><ul><li>Can be benign or symptomatic of underlying cause </li></ul></ul><ul><li>Hangover headache </li></ul><ul><ul><li>Alcohol increases blood flow to your brain </li></ul></ul><ul><ul><li>Headaches may be caused by impurities in alcohol or by-products produced as alcohol metabolized </li></ul></ul><ul><ul><li>Smoke-filled rooms and lack of sleep can exacerbate </li></ul></ul>
  27. 28. <ul><li>Ice-cream headache </li></ul><ul><ul><li>Cold stimulus headache </li></ul></ul><ul><ul><li>More likely to occur if overheated from exercise or hot temperatures </li></ul></ul><ul><ul><li>Pain felt in forehead, peaks 25 to 60 seconds after exposure, and lasts from several seconds to one or two minutes </li></ul></ul><ul><ul><li>Experienced by about one-third of people </li></ul></ul><ul><ul><li>>90% migraine sufferers report sensitivity to ice cream </li></ul></ul>
  28. 29. <ul><li>Ice-pick headache </li></ul><ul><ul><li>“ Idiopathic stabbing headache” </li></ul></ul><ul><ul><li>Produces sudden, brief stabbing sensation anywhere in scalp or even eye </li></ul></ul><ul><ul><li>Stab may be isolated or occur repeatedly for a few days </li></ul></ul><ul><ul><li>Most common in migraine sufferers </li></ul></ul><ul><ul><li>Not serious </li></ul></ul><ul><li>Hot dog headache </li></ul><ul><ul><li>Nitrate/nitrite-induced headache </li></ul></ul>
  29. 30. <ul><li>Sex headache </li></ul><ul><ul><li>Usually not of concern </li></ul></ul><ul><ul><li>Men affected more than women </li></ul></ul><ul><ul><li>May be one of two types </li></ul></ul><ul><ul><ul><li>More common </li></ul></ul></ul><ul><ul><ul><ul><li>Headache occurs in neck and back of skull </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Builds up during intercourse </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Believed to be caused by muscle contraction in head and scalp muscles </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Pain goes away quickly with rest </li></ul></ul></ul></ul><ul><ul><ul><li>Second type </li></ul></ul></ul><ul><ul><ul><ul><li>More severe and sharp </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Develops at height of orgasm </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Pain usually goes away in minutes </li></ul></ul></ul></ul>
  30. 31. <ul><li>Swim-goggle headache </li></ul><ul><ul><li>“ External compression headache” </li></ul></ul><ul><ul><li>Results from pressure on forehead or scalp by band around head, tight hat or goggles </li></ul></ul><ul><ul><li>Pain constant but relieved by removing goggles or headband </li></ul></ul><ul><li>Thunder-clap headache </li></ul><ul><ul><li>Occurs so suddenly patient feels like hit on head </li></ul></ul><ul><ul><li>Most cases not serious </li></ul></ul><ul><ul><li>May indicate rapid onset of migraine </li></ul></ul><ul><ul><li>Rarely caused by aneurysm or bleeding inside head </li></ul></ul>
  31. 32. <ul><li>Post-traumatic headache </li></ul><ul><ul><li>Often occurs after head injury </li></ul></ul><ul><ul><li>Frequency and severity of headache usually diminishes in 6 to 12 months </li></ul></ul><ul><ul><li>Loss of consciousness (concussion) or start of headache after head injury should be evaluated </li></ul></ul><ul><ul><li>Little relationship between severity of trauma and intensity of headache </li></ul></ul><ul><ul><li>Causes </li></ul></ul><ul><ul><ul><li>Scar formation in scalp </li></ul></ul></ul><ul><ul><ul><li>Ruptured blood vessels causing hematoma – can be drained </li></ul></ul></ul>
  32. 33. <ul><li>Rebound headache </li></ul><ul><ul><li>Occurs with overuse of pain reliever or migraine-specific medication for headache </li></ul></ul><ul><ul><li>When effect of medication wears off, pain returns with more severity </li></ul></ul><ul><ul><li>Occurs daily or nearly daily </li></ul></ul><ul><ul><li>Body unable to respond to treatments that can prevent subsequent migraines </li></ul></ul><ul><ul><li>Vary in intensity, timing, and location </li></ul></ul><ul><ul><li>Must wean patient from pain medication but worsening of symptoms initially occurs </li></ul></ul>
  33. 34. <ul><li>Orthostatic headache </li></ul><ul><ul><li>Occurs when stand up and relieved by laying down </li></ul></ul><ul><ul><li>Subsides within a minute or two of reclining </li></ul></ul><ul><ul><li>Most common after spinal tap or spinal anesthesia </li></ul></ul><ul><ul><li>Usually lasts few days and subsides spontaneously </li></ul></ul>
  34. 35. Headache Secondary to Structural Brain Disease <ul><li>Cerebrovascular disease </li></ul><ul><ul><li>Ischemic stroke </li></ul></ul><ul><ul><li>Intracerebral hemorrhage </li></ul></ul><ul><ul><li>Subarachnoid hemorrhage </li></ul></ul><ul><li>Inflammatory disease </li></ul><ul><ul><li>Cranial arteritis </li></ul></ul><ul><ul><li>Isolated central nervous system vasculitis </li></ul></ul><ul><ul><li>Tolosa-hunt syndrome </li></ul></ul><ul><ul><li>Systemic lupus erythematosus </li></ul></ul>
  35. 36. <ul><li>Infectious disease </li></ul><ul><ul><li>Meningitis </li></ul></ul><ul><ul><li>Abscess </li></ul></ul><ul><ul><li>Encephalitis </li></ul></ul><ul><ul><li>Sinusitis </li></ul></ul><ul><li>Post-traumatic </li></ul><ul><ul><li>Subdural hematoma </li></ul></ul><ul><ul><li>Empyema </li></ul></ul>
  36. 37. <ul><li>Neoplastic disease </li></ul><ul><ul><li>Malignant brain tumor </li></ul></ul><ul><ul><li>Metastasis </li></ul></ul><ul><li>Other </li></ul><ul><ul><li>Idiopathic intracranial hypertension </li></ul></ul>
  37. 38. Headache and Acute Sinusitis <ul><li>Head pain most prominent feature </li></ul><ul><li>Malaise and low-grade fever </li></ul><ul><li>Dull, aching, nonpulsatile pain </li></ul><ul><li>Exacerbated by movement, coughing, or straining </li></ul><ul><li>Improved with nasal decongestants </li></ul><ul><li>Pain most pronounced on awakening or after prolonged recumbency </li></ul><ul><li>Pain diminished with upright posture </li></ul>
  38. 39. <ul><li>Maxillary sinusitis </li></ul><ul><ul><li>Ipsilateral, malar, ear, and dental pain </li></ul></ul><ul><li>Frontal sinusitis </li></ul><ul><ul><li>Frontal headache that may radiate behind eyes and to vertex of skull </li></ul></ul><ul><ul><li>Tenderness to palpation with point tenderness on undersurface of medial aspect of superior orbital rim </li></ul></ul>
  39. 40. <ul><li>Ethmoidal sinusitis </li></ul><ul><ul><li>Pain between or behind eyes with radiation to temporal area </li></ul></ul><ul><ul><li>Eyes and orbit often tender to palpation </li></ul></ul><ul><ul><li>Eye movements may accentuate pain </li></ul></ul><ul><li>Sphenoidal sinusitis </li></ul><ul><ul><li>Pain in the orbit and vertex of skull and occasionally in frontal or occipital regions </li></ul></ul><ul><li>Chronic sinusitis </li></ul><ul><ul><li>Seldom cause of headache </li></ul></ul>
  40. 41. Headache and Brain Tumors <ul><li>Posterior fossa tumors, especially cerebellar </li></ul><ul><ul><li>Usually with hydrocephalus because CSF flow partially obstructed </li></ul></ul><ul><li>Supratentorial tumors less likely </li></ul><ul><ul><li>More frequently have altrered mental status, focal deficiencies, or seizures </li></ul></ul><ul><li>Increased intracranial pressure often associated </li></ul><ul><ul><li>Usually not primary mechanism as uniform increases in pressure not distort pain-sensitive structures </li></ul></ul>
  41. 42. Headache and Idiopathic Intracranial Hypertension <ul><li>Also called benign intracranial hypertension </li></ul><ul><li>Elevated intracranial pressure without evidence of focal lesions, hydrocephalus, or frank brain edema </li></ul><ul><li>Occurs usually between ages 15 and 45 </li></ul><ul><li>More frequent in obese women </li></ul><ul><li>Characterized by headache – usually insidious in onset, typically generalized, mild in severity, often worse in morning or after exertion </li></ul>
  42. 43. <ul><li>Occasionally have visual disturbances – may lead to visual loss, including blindness </li></ul><ul><li>Fundoscopic exam shows papilledema </li></ul><ul><li>Has been associated with drugs, corticosteroid withdrawal, and systemic disorders </li></ul><ul><li>CT usually normal – can show small ventricles </li></ul><ul><li>CSF opening pressure elevated – 250 to 450 mm Hg </li></ul>
  43. 44. <ul><li>Treatment </li></ul><ul><ul><li>Eliminate secondary causes first </li></ul></ul><ul><ul><li>Dietary counseling for weight loss </li></ul></ul><ul><ul><li>Carbonic anhydrase inhibitors (acetazolamide) and corticosteroids for headache control </li></ul></ul><ul><ul><li>Furosemide to lower CSF production second-line </li></ul></ul><ul><ul><li>Serial lumbar punctures – unpopular with patients </li></ul></ul><ul><ul><li>CSF shunting – ventriculoperitoneal shunt </li></ul></ul><ul><ul><li>Optic nerve sheath fenestration for patients with progressive visual loss </li></ul></ul>
  44. 45. Post-Traumatic Headache <ul><li>Associated with irritability, concentration impairment, insomnia, memory disturbance, and light-headedness </li></ul><ul><li>Anxiety and depression present </li></ul><ul><li>Treatment </li></ul><ul><ul><li>Amitriptyline </li></ul></ul><ul><ul><li>NSAID’s </li></ul></ul><ul><ul><li>Muscle relaxants </li></ul></ul><ul><ul><li>Anxiolytics </li></ul></ul>
  45. 46. Headache and Giant Cell Arteritis <ul><li>Over 60% of patients have headaches </li></ul><ul><li>Granulomatous vasculitis of medium and large arteries </li></ul><ul><li>More than 95% of patients >50 years old </li></ul><ul><li>Malaise, fever, weight loss, and jaw claudication </li></ul><ul><li>Polymyalgia rheumatica (painful stiffness in neck, shoulders, and pelvis) found in half of patients </li></ul><ul><li>Visual impairment from ischemic optic neuritis </li></ul>
  46. 47. <ul><li>Headache aching, worse at night and after exposure to cold </li></ul><ul><li>Superficial temporal artery frequently swollen, red, and very tender and may be pulseless </li></ul><ul><li>ESR usually elevated – mean 100 mm/hr </li></ul><ul><li>Anemia frequent </li></ul><ul><li>Temporal artery biopsy – disease segmental so may miss </li></ul><ul><li>Prednisone therapy – dramatically effective but must be given promptly to preserve vision on affected side </li></ul>
  47. 48. Headache in Systemic Disease <ul><li>Endocrine/metabolic </li></ul><ul><ul><li>Malignant hypertension (e.g., pheochromocytoma) </li></ul></ul><ul><ul><li>Acromegaly </li></ul></ul><ul><ul><li>Cushing’s disease </li></ul></ul><ul><ul><li>Carcinoid </li></ul></ul><ul><ul><li>Hyperparathyroidism </li></ul></ul><ul><ul><li>Paget’s disease </li></ul></ul>
  48. 49. <ul><li>Pulmonary </li></ul><ul><ul><li>Hypercapnea </li></ul></ul><ul><ul><li>Sleep apnea </li></ul></ul><ul><li>Pharmacologic </li></ul><ul><ul><li>Alcohol </li></ul></ul><ul><ul><li>Nitrates </li></ul></ul><ul><ul><li>Caffeine withdrawal </li></ul></ul><ul><ul><li>Analgesic withdrawal (“rebound”) headache </li></ul></ul><ul><ul><li>Others: dipyridamole, cyclosporine, tacrolimus, calcium channel antagonists </li></ul></ul>
  49. 50. Cranial Neuralgias <ul><li>Trigeminal neuralgia </li></ul><ul><ul><li>Stabbing, spasmodic pain unilaterally in one of divisions of trigeminal nerve </li></ul></ul><ul><ul><li>Lasts seconds but may occur many times in day for weeks at a time </li></ul></ul><ul><ul><li>Induced by lightest touch to particular areas of face </li></ul></ul><ul><ul><li>May be life threatening if interferes with eating </li></ul></ul><ul><ul><li>If medical treatments unsuccessful (anticonvulsants), may need surgical procedure to ablate sensory portion of nerve </li></ul></ul>
  50. 51. <ul><li>Glossopharyngeal neuralgia </li></ul><ul><ul><li>Rare </li></ul></ul><ul><ul><li>Brief paroxysms of severe stabbing unilateral pain radiate from throat to ear or vice versa </li></ul></ul><ul><ul><li>Frequently initiated by stimulation of “trigger zones” (e.g., tonsillar fossa or pharyngeal wall) </li></ul></ul><ul><ul><li>Swallowing occasionally provokes, as can yawning, talking, and coughing </li></ul></ul>
  51. 52. <ul><li>Postherpetic neuralgia </li></ul><ul><ul><li>Herpes zoster produces pain by involving cranial nerves in one third of cases </li></ul></ul><ul><ul><li>Persistent intense burning pain may follow acute illness </li></ul></ul><ul><ul><li>Discomfort may subside after several weeks or persist for months or years </li></ul></ul><ul><ul><li>Pain localized over distribution of affected nerve and associated with exquisite tenderness to light touch </li></ul></ul><ul><ul><li>First division of trigeminal nerve most frequently involved – occasionally associated with keratoconjunctivitis </li></ul></ul>
  52. 53. <ul><li>Occipital neuralgia </li></ul><ul><ul><li>Occipital pain starting at base of skull </li></ul></ul><ul><ul><li>Often provoked by neck extension </li></ul></ul><ul><ul><li>Tenderness in region of occipital nerves </li></ul></ul><ul><ul><li>Altered sensation in C2 dermatome </li></ul></ul><ul><ul><li>Treatment </li></ul></ul><ul><ul><ul><li>Use of soft collar </li></ul></ul></ul><ul><ul><ul><li>Muscle relaxants </li></ul></ul></ul><ul><ul><ul><li>Physical therapy </li></ul></ul></ul><ul><ul><ul><li>Local injection of analgesics and anti-inflammatory agents </li></ul></ul></ul>
  53. 54. Reflex Sympathetic Dystrophy <ul><li>Pain and hyperesthesia and autonomic changes </li></ul><ul><li>Any type of injury can cause </li></ul><ul><li>Often associated with marked behavioral changes </li></ul><ul><li>Diagnosis primarily clinical – patient’s history and physical exam </li></ul><ul><li>No specific diagnostic tests </li></ul>
  54. 55. <ul><li>Symptoms usually develop gradually over days or weeks and divided into three stages </li></ul><ul><ul><li>Acute stage </li></ul></ul><ul><ul><ul><li>Spontaneous aching or burning pain restricted to particular vascular, peripheral nerve, or root territory </li></ul></ul></ul><ul><ul><ul><li>Hyperpathia (pain characterized by overreaction and “aftersensation” to stimulus) and dysesthesia </li></ul></ul></ul><ul><ul><li>Dystrophic stage </li></ul></ul><ul><ul><ul><li>Usually begins 3 to 6 months after injury </li></ul></ul></ul><ul><ul><ul><li>Spontaneous burning pain and more marked hyperpathia </li></ul></ul></ul><ul><ul><ul><li>Nails cracked, grooved, or ridged ,and hair growth decreased </li></ul></ul></ul><ul><ul><ul><li>Decreased range of joint motion, muscle wasting, osteoporosis, and edema </li></ul></ul></ul>
  55. 56. <ul><ul><li>Atrophy </li></ul></ul><ul><ul><ul><li>Usually occurs more than 6 months after injury </li></ul></ul></ul><ul><ul><ul><li>Pain less prominent </li></ul></ul></ul><ul><ul><ul><li>Skin cold, pale, and cyanotic with increased or decreased sweating </li></ul></ul></ul><ul><ul><ul><li>Irreversible trophic changes in skin and subcutaneous tissues – smooth, glossy skin, with subcutaneous atrophy, tapering of digits, and fixed joints with contractures </li></ul></ul></ul><ul><li>Mainstay of treatment – sympathetic blockade </li></ul><ul><ul><li>Anti-inflammatory agents and amitriptyline may be useful in chronic burning pain </li></ul></ul><ul><ul><li>Anticonvulsants may relieve episodic allodynia (ordinarily nonpainful stimuli evoke pain) </li></ul></ul>
  56. 57. Headache: Guide to Treatment <ul><li>Rest, heat or ice packs, or a long, hot shower </li></ul><ul><li>Over-the-counter pain reliever, such as aspirin, acetaminophen or ibuprofen - minimal dose needed to relieve pain, only when necessary - overuse may cause chronic daily headaches. </li></ul><ul><li>Finding the right medication may take a period of trial and error </li></ul>
  57. 58. <ul><li>Headache medications fall into two broad categories: </li></ul><ul><ul><li>abortive drugs to stop or reduce pain after a headache starts </li></ul></ul><ul><ul><li>prophylactic drugs to prevent headaches. </li></ul></ul>
  58. 59. <ul><li>Abortive medications: treat headaches </li></ul><ul><ul><li>Serotonin agonists : work by influencing the behavior of serotonin, a nerve chemical that plays a key role in causing headaches </li></ul></ul><ul><ul><ul><li>triptans – among most effective; able to target specific serotonin receptors in the brain; generally used for migraine and cluster headaches; not been proven effective for tension headaches; manufactured in a variety of forms, so options for people who experience nausea with headaches or not able to swallow pills </li></ul></ul></ul><ul><ul><ul><ul><li>Sumatriptan (Imitrex) — effect lasts only about 5 hours; best for stopping severe migraines; available by tablet, nasal spray, and injection </li></ul></ul></ul></ul>
  59. 60. <ul><ul><ul><ul><li>Zolmitriptan (Zomig) — very similar to sumatriptan; tends to work faster; also effective in significant percentage of people for whom sumatriptan does not provide adequate relief </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Naratriptan (Amerge) — geared toward people with prolonged headaches and frequent recurrences; longer lasting effect than sumatriptan </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Rizatriptan (Maxalt) — relieves headaches more quickly than sumatriptan </li></ul></ul></ul></ul><ul><ul><li>Vasoconstrictors : work by preventing blood vessels from swelling </li></ul></ul><ul><ul><ul><li>Ergotamine tartrate (Cafergot, Wigraine, Ergostat) </li></ul></ul></ul><ul><ul><ul><li>Dihydroergotamine – available as subcutaneous injection (DHE-45) and nasal spray (Migranol) </li></ul></ul></ul>
  60. 61. <ul><ul><li>Lidocaine nasal drops : may provide short-term relief as anesthetic on nerves in nasal passages. It can ease pain within 5 minutes, but relief usually does not last more than 1 hour. </li></ul></ul><ul><ul><li>Excedrin Migraine : same formula as Excedrin Extra Strength but received FDA approval as a migraine drug after showed effectiveness against migraines in clinical trials. </li></ul></ul><ul><ul><li>Aspirin and other NSAIDS : Nonsteroidal anti-inflammatories, available as over-the-counter medications (ibuprofen — Aleve, Motrin, Advil) or by prescription can be very useful for the treatment of mild to moderate tension-type and migraine headaches. </li></ul></ul>
  61. 62. <ul><li>Prophylactic medications: prevent headaches from starting or reduce frequency and severity </li></ul><ul><ul><li>Antidepressants </li></ul></ul><ul><ul><ul><li>Tricyclic antidepressants – the most common of these drugs; also may ease headache by affecting serotonin levels; depression also linked to serotonin activity </li></ul></ul></ul><ul><ul><li>Serotonin antagonists </li></ul></ul><ul><ul><ul><li>Cyproheptadine – more commonly used for childhood migraine </li></ul></ul></ul><ul><ul><ul><li>Methysergide – used for prevention of both migraine and cluster headache; rare but potentially serious side effects when used continually for longer than 6 months </li></ul></ul></ul>
  62. 63. <ul><ul><li>Cardiovascular drugs </li></ul></ul><ul><ul><ul><li>Beta-blockers and calcium channel blockers </li></ul></ul></ul><ul><ul><li>Anti-seizure drugs </li></ul></ul><ul><ul><ul><li>Valproic acid (Depakote) can prevent migraines </li></ul></ul></ul><ul><ul><li>Riboflavin (vitamin B2) </li></ul></ul><ul><ul><ul><li>High dose (400 milligrams of riboflavin per day) may prevent migraines </li></ul></ul></ul><ul><ul><ul><li>May correct small deficiencies of B2 in the brain cells of some people with migraines </li></ul></ul></ul><ul><ul><li>Magnesium </li></ul></ul><ul><ul><ul><li>Infusions of magnesium relieve headache pain in some people who suffer from migraine </li></ul></ul></ul>
  63. 64. Neck and Back Pain <ul><li>Most patients with acute pain have self-limiting musculoskeletal disorder – not need specific therapy </li></ul><ul><li>Pain may come from </li></ul><ul><ul><li>Vertebrae and intervertebral discs </li></ul></ul><ul><ul><li>Facet joints </li></ul></ul><ul><ul><li>Muscles and ligaments of vertebral column </li></ul></ul><ul><li>Thoracic spine made for rigidity rather than mobility so disc rupture rare </li></ul>
  64. 65. Cervical Spondylosis <ul><li>Degenerative disorder of cervical intervertebral discs </li></ul><ul><li>Hypertrophy of adjacent facet joints and ligaments </li></ul><ul><li>Most common pathology seen in neuro office </li></ul><ul><li>Seen on X-ray in > 90% of population over 60 y.o. </li></ul><ul><li>Degree of anatomic abnormality not directly correlated with clinical signs and symptoms </li></ul>
  65. 66. <ul><li>Clinical disease </li></ul><ul><ul><li>Normal age-related, degenerative changes with congenital/developmental stenosis of cervical canal </li></ul></ul><ul><ul><li>May be aggravated by trauma </li></ul></ul><ul><ul><li>May present as painful, stiff neck with/without cervical root irritation or spinal cord compression </li></ul></ul><ul><ul><ul><li>With root irritation have pain and paresthesias down arm in dermatomal distribution – symptoms more common than discrete sensory loss </li></ul></ul></ul><ul><ul><ul><li>With spinal cord compression present with gait and bladder problems and evidence of spasticity in lower extremities – require investigation with imaging study like MRI or CT myelography </li></ul></ul></ul>
  66. 67. <ul><li>Differential diagnosis </li></ul><ul><ul><li>Multiple sclerosis </li></ul></ul><ul><ul><li>Amyotrophic lateral sclerosis </li></ul></ul><ul><ul><li>Subacute combined system disease (B12 deficiency) </li></ul></ul><ul><li>Treatment </li></ul><ul><ul><li>Anti-inflammatory meds </li></ul></ul><ul><ul><li>Cervical immobilization </li></ul></ul><ul><ul><li>Physical therapy for strengthening neck muscles </li></ul></ul><ul><ul><li>Surgery if progression of neuro deficit </li></ul></ul>
  67. 68. Acute Low Back Pain <ul><li>Lumbar canal stenosis from intervertebral disc disease and degenerative spondylosis will affect roots of cauda equina </li></ul><ul><ul><li>Most common levels affected are L4-5 and L5-S1 </li></ul></ul><ul><ul><ul><li>Complain of sciatica </li></ul></ul></ul><ul><ul><li>Pain improves by sitting or lying down </li></ul></ul><ul><ul><ul><li>Vs. spinal or vertebral tumors, where pain worsened </li></ul></ul></ul><ul><ul><li>Loss of normal lumbar lordosis, paraspinal muscle spasm, worsening of pain with straight-leg raising </li></ul></ul>
  68. 69. <ul><li>“ Neurogenic claudication” </li></ul><ul><ul><li>Unilateral or bilateral buttock pain worse on standing or walking and relieved by rest or flexion at waist </li></ul></ul><ul><ul><li>Pain may worsen walking downhill </li></ul></ul><ul><li>Treatment </li></ul><ul><ul><li>Short period of rest </li></ul></ul><ul><ul><li>Muscle relaxants </li></ul></ul><ul><ul><li>Analgesics </li></ul></ul><ul><ul><li>Proper posture and back exercises </li></ul></ul><ul><ul><li>Physical therapy </li></ul></ul><ul><ul><li>Surgery only if neuro signs or pathology seen on imaging studies </li></ul></ul>
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