Headache

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

Headache

by Miami Dade on Apr 01, 2009

Accessibility

Categories

Upload Details

Usage Rights

1 Embed 3

Statistics

Headache Presentation Transcript