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Approach to a_case_of_headache
- 1. Speaker: Dr.PARMINDER SINGH Chairperson: Dr.B.L.BHARDWAJ APPROACH TO A PATIENT WITH HEADACHE 1
- 2. To learn about the major types of headaches To understand the difference between primary and secondary headaches Be familiar with the ‘RED FLAGS’ To understand when and how to investigate headache 2
- 3. Extra-cranial pain sensitive structures: ◦ Sinuses ◦ Eyes/orbits ◦ Ears ◦ Teeth ◦ TMJ ◦ Blood vessels Intra-cranial pain sensitive structures: ◦ Arteries ◦ Veins ◦ Meninges ◦ Dura 3
- 4. Sensory stimuli from head are conveyed to CNS via- Trigeminal nerves- for structures above the tentorium in the anterior and middle fossae of the skull C1, C2, C3 – for structures in the posterior fossa and inferior surface of tentorium 4
- 5. Broadly headaches are divided primarily into 2 main types by Headache classification committee of International Headache Society: PRIMARY HEADACHES - Those in which headache and its associated features are disease in themselves SECONDARY HEADACHES – Those that are caused exogenously 5
- 6. The Primary Headaches 1. Migraine 2. Tension-type headache 3. Cluster headache and other trigeminal autonomic cephalgias 4.Other primary headaches:- a. Primary stabbing headache b. Primary cough headache c. Primary exertional headache 6
- 7. d. Primary headache associated with sexual activity – Pre orgasmic - Orgasmic e.Hypnic headache f. Primary thunderclap headache g. Hemicrania continua h. New daily persistant headache 7
- 8. 8
- 9. The Secondary Headaches Headache attributed to – 1. Head and/or neck trauma 2. Cranial or cervical vascular disorder 3. Non-vascular intracranial disorder 4. Substance or its withdrawal 5. Infection 6. Disorder of homeostasis 9
- 10. 7. Disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth, or other facial or cranial structures. 8. Psychiatric disorders Cranial neuralgias, central and primary facial pain and other headaches 10
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- 13. RED FLAGS 1. Head or neck injury 2. New onset or new type or worsening pattern of existing headache 3. New level of pain(e.g. worst ever) 4. Abrupt or split-second onset 5. Triggered by valsalva manouvre/cough 6. Triggered by exertion 7. Triggered by sexual activity 8. Headache during pregnancy/peurperium 13
- 14. 9. Age>50 yrs 10. Neurological signs/symptoms 11. Systemic illness a. Fever b. Nuchal rigidity c. Weight loss d. Scalp artery tenderness 12. Secondary risk factors a. Cancer b. Immunocompromised host c. Recent travel 14
- 15. YELLOW FLAGS 1. Wakes patient from sleep at night 2. New onset side – locked headache 3. Postural headaches 15
- 16. RED FLAGS Head or neck injury CONSIDERATIONS Hemorrhage Epidural Subdural Subarachnoid Intraparenchymal Dissection Carotid arteries Vertebral arteries 16
- 17. New onset or new type or worsening pattern of existing headache New level of pain (e.g. “worst ever”) Mass lesion Subdural hematoma Medication overuse Meningoencephaliti s Subarachnoid hemorrhage 17
- 18. Abrupt or split-second onset Intraparenchymal hemorrhage Bleed into a mass or AVM Dissection Cerebral venous thrombosis Pituitary apoplexy Spontaneous intracranial hypotension Reversible cerebral vasoconstriction syndrome Acute hypertensive crisis Mass lesion esp.post fossa Primary thunderclap headache 18
- 19. Triggered by Valsalva manouver or cough Triggered by exertion Chiari malformation Mass lesion Subarachnoid hemorrhage Dissection Angina equivalent Pheochromocytoma 19
- 20. Triggered by sexual activity( Pre- orgasmic,orgasmic) Headache during pregnancy or puerperium Subarachnoid hemorrhage Dissection Cortical venous/cranial sinus thrombosis Pituitary apoplexy 20
- 21. Age > 50 yrs Neurologicalsigns or symptoms(seizures,con fusion,impaired alertness,weakness, papilloedema etc.) Brain tumour(primary, metastatic) Cerebrovascular diseases Giant cell arteritis Mass lesion AVM CTD Benign intracranial hypertension Meningoencephalitis 21
- 22. Systemic illness Fever Nuchal rigidity Weight loss Scalp artery tenderness Meningoencephalitis Meningeal carcinomatosis Lyme disease Collagen vascular diseases Malignancy Giant cell arteritis 22
- 23. Secondary risk factors Cancer Immunocompromis ed host Recent travel Metastatic disease Opportunistic infection Meningoencephaliti s 23
- 24. YELLOW FLAGS Wakes patient from sleep at night Sleep related disorders(e.g. Obstructive sleep apnea) Rebound withdrawal headaches Poorly controlled hypertension 24
- 25. New onset side- locked headaches Postural headaches Head trauma Dissection Intracranial aneurysm Lung carcinoma Spontaneous intracranial hypotension Post lumbar puncture headache 25
- 26. Affects 15% of the general population Female > Males Family History present in 70% Pathophysiology: vascular vs neurologic Precipitants: caffeine, chocolate, alcohol, cheese, BCP/HRT, menses, stress 26
- 27. Diagnostic criteria: 1. 5 attacks in 6 months 2. Headaches lasting 4-72 h with >/= 2: - unilateral - pulsatile - moderate to severe in intensity - aggravated by activity 3. Associated with >/= 1: - nausea/vomiting - photophobia/phonophobia 27
- 28. Subtypes: ◦ Auras – visual or sensory ◦ Scintillating scotoma ◦ Fortification spectra ◦ Ophthalmoplegic ◦ CN III palsy ◦ Vertbrobasilar ◦ hemiplegic 28
- 29. Scintillating Scotomas Progression of a typical aura over 30 minutes BMJ 2002; 325:881-6 29
- 30. Mild attacks: NSAIDS +/- dopamine antagonists ◦ eg. ASA 650-1300 mg q4h + metoclopromide 10 mg PO/IV Moderate attacks: ◦ NSAIDS (ibuprofen 400-800 mg PO q2-6h) ◦ 5-HT1 receptor agonists Selective – sumatriptan 50-100 mg PO Nonselective – ergot 1-2 mg PO q1h x 3 CMAJ 1997; 156: 1273-87 30
- 31. Severe & Ultra-severe attacks: ◦ First line: DHE 0.5-1 mg q1h IM/SC/IV sumatriptan 50-100 mg PO or 6 mg SC ◦ Second line: chlorpromazine 50 mg IM Prochlorperazine 5-10 mg IV/IM dexamethasone 12-20 mg IV CMAJ 1997; 156: 1273-87 31
- 32. Consider if >/3 attacks/month, impaired quality of life: ◦ B-blockers ◦ Calcium channel blockers ◦ TCA (amitriptyline) ◦ NSAIDS ◦ Valproic acid ◦ 5HT2 Antagonists (methysergide, pizotyline) CMAJ 1997; 156: 1273-87 32
- 33. Most common type, typically brought on by stress, lasting 30 min to 7 d Diagnostic Criteria >/= 2: ◦ Pressing/tightening, non-pulsating ◦ Mild-moderate ◦ Bilateral ◦ Not worsened by ADLs ◦ Photo or phonophobia (not coincident) ◦ Not associated with N/V Treatment: reassurance, NSAIDS 33
- 34. Diagnostic criteria:- A. At least 5 attacks fulfilling B-D; B. Severe or very severe unilateral orbital, supraorbital, and/or temporal pain lasting 15-180 min if untreated; C. Headache is accompanied by at least 1 of the following: 1. I/L conj. Injection/lacrimation 2. I/L nasal congestion/rhinorrhoea 3. I/L forehaed and facial swelling 4. I/L eyelid edema 5. I/L miosis and/or ptosis 6. A sense of restlessness/agitation D. Attacks have frequency from 1 every other day to 8/day 34
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- 38. PRIMARY STABBING HEADACHE Pain confined to head, rarely facial. Stabbing pain lasting 1 to many sec and occuring as a single stab or series of stabs Recurring at intervals of hours to days PRIMARY COUGH HEADACHE B/L headache of sudden onset, lasting minutes, precipitated by coughing Prevented by avoiding coughing Diagnosed only after structural lesions, such as posterior fossa tumour, have been excluded by neuroimaging 38
- 39. HYPNIC HEADACHE Headache of moderate to severe nature that typically occur few hrs after going to sleep Last from 15–30 mins Typically generalised although may be unilateral and can be throbbing Falling back to sleep only to be awoken by further attack few hrs later with upto 3 repetitions of this pattern over night 39
- 41. PRIMARY THUNDERCLAP HEADACHE(TCH) Defined as severe headache reaching maximal intensity within seconds to a minute Thunderclap headache is a NEUROLOGICAL EMERGENCY Numerous etiologies ranging from benign to life-threatening have been reported most notable being aneurysmal subarachnoid hemorrhage 41
- 42. DISORDERS A/W TCH:- 1. Subarachnoid hemorrhage 2. Unruptured intracranial aneurysm(“Sentinal Headache”) 3. Cervical artery dissection 4. Stroke( H’ragic>Ischemic) 5. Cerebral venous sinus thrombosis 42
- 43. 6. Intraparenchymal hemorrhage 7. Spontaneous intracranial hypotension 8. Reversible cerebral vasoconstrictn synd. 9. Reversible post. Leukoencephalopathy 10. Infections- intracranial,sinusitis 11. Primary TCH 43
- 44. REVERSIBLE CEREBRAL VASOCONSTRICTION SYNDROME:- Diagnostic criteria- 1. TCH with/without other neurological signs/symptoms 2. No evidence for aneurysmal SAH 3. Normal/near normal CSF 4. Angiographic documentation of multifocal segmental cerebral artery vasoconstriction 5. Reversal of vasoconstriction within 12 wks of onset 44
- 45. RCVS includes- 1. Call-Fleming syndrome 2. Benign angiopathy of CNS 3. CNS pseudovasculitis 4. Isolated benign cerebral vasculitis 5. Benign acute cerebral vasculopathy 45
- 46. 6. Drug induced cerebral vasculopathy(cannabis,sympathomimetic,serotonergi c agents) 7. Postpartum angiopathy 8.Acute hypertension(Pheochromocytoma) 9.Reversible Posterior Leukoencephalopathy 10. Bath headache 11. Orgasmic headache 46
- 47. CVS- CCBs Antiarrhythmics α1 adrenergic antagonists α2 adrenergic agonists β adrenergic antagonists ACE inhibitors Angiotensin II inhibitors Nitrates Diuretics Phosphodiesterase inhibitors Antimicrobials Immunologic/antiinflammatory 47
- 48. Gastrointestinal- H2 blockers/ PPIs 5HT3 antagonists Endocrinological- Gonadotropin inhibitors Dopamine receptor agonists Psychiatric- Antidepressants/antipsychotics Sedative/hypnotics Misc- Antiobesity Statins Retinoids Prostaglandins Agents for erectile dysfunction 48
- 49. Primary >4hrs daily- 1. Chr. Migraine 2. Chr. Tension headache 3. Hemicrania continua 4. New daily persistant headache Secondary 1. Post traumatic 2. Inflammatory 3. Chr CNS infection 4. Substance abuse headache 49
- 50. <4 hrs 1. Chr. Cluster headacahe 2. Chr. paroxysmal hemicrania 3. SUNCT 4. Hypnic headaache 50
- 51. Primary 1.Migranious type 2.Featureless(tension- type) Secondary 1. SAH 2. Low CSF volume headache 3. Raised CSF volume headache 4. Post traumatic 5. Chr. Meningitis 51
- 52. 1. Imaging studies: CT and MRI Plain X-ray films Cerebral angiography- MRA and CTA Myelography and radioisotope cisternography 2. CSF examination 3. Electrophysiological testing 4. General medical tests 52
- 53. MRI preferred:- 1. Vascular disease- Cerebral/venous infarction 2. Neoplastic disease a. Brain tumors esp. in POST. FOSSA b. Skull base tumors c. Meningeal carcinomatosis d. Pituitary tumors 53
- 54. 3. Infections- Cerebritis/abscess/meningitis /encephalitis 4. Others- Chiari malformation CSF hypotension Foramen magnum/upper Cx spine lesions Pituitary apoplexy CADASIL,MELAS,SMART 54
- 55. CT preferred:- 1. Fractures (calvarium) 2. Acute hemorrhage (SAH,intracerebral) 3. Paranasal sinus and mastoid air cells Diseases Draw b/w MRI/CT:- MR/CT angiography- Vasculitis Intracranial aneurysm Dissections MR/CT venography- Cerebral venous thrombosis 55
- 56. CT - Increased lifetime risk of cancer - Anaphylaxis and renal insufficiency MRI - Increased detection of incidental findings - Nephrogenic systemic fibrosis 56
- 57. Cerebral angiography - Access site hematoma (4.2%) - Strokes(0.14%) - Deaths(0.06%) LP - Post-LP headaches - Persistent CSF leaks - Bleeding - Low back pain - Infection 57
- 58. It is important to differentiate between Primary and Secondary Headaches “HISTORY” is the most important diagnostic tool in evaluation of headache Early recognition of RED FLAGS in a case of headache is invaluable Not all cases of headache require neuroimaging, judicious use of investigations must be done weighing their benefits and harms… 58
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