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Headache
 

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    Headache Headache Presentation Transcript

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