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  1. 1. PowerPoint Presentation By Dr.P.L.John Israel INTERNAL MEDICINE DEPATMENT OF
  2. 2. PowerPoint Presentation By Dr.P.L.John Israel HEADACHE
  3. 3. COMMON CAUSES <ul><li>Viral Rhinitis (Common Cold) </li></ul><ul><li>Sinusitis </li></ul><ul><li>Fevers </li></ul><ul><li>Hypertension </li></ul><ul><li>Refractive Error </li></ul><ul><li>Tension Headache </li></ul><ul><li>Hypoglycemia </li></ul><ul><li>Post ictal headache </li></ul>PowerPoint Presentation By Dr.P.L.John Israel
  4. 4. SPECIFIC CAUSES <ul><li>Migraine Headache </li></ul><ul><li>Cluster Headache </li></ul><ul><li>Temporal Arteritis </li></ul><ul><li>Post traumatic Headache </li></ul><ul><li>Thunderclap Headache </li></ul><ul><li>(Subarachnoid Haemorrhage) </li></ul>PowerPoint Presentation By Dr.P.L.John Israel
  5. 5. Specific Causes Contd.. <ul><li>Intracerebral Haemorrahage </li></ul><ul><li>Subdural Haematoma </li></ul><ul><li>Brain Abscess </li></ul><ul><li>Primary Brain Tumor </li></ul><ul><li>Metastatic Brain Tumor </li></ul><ul><li>Meningitis </li></ul><ul><li>Hydrocephalus </li></ul><ul><li>Glaucoma </li></ul>PowerPoint Presentation By Dr.P.L.John Israel
  6. 6. BRAIN <ul><li>Seat of intelligence </li></ul><ul><li>By itself is not sensitive to pain but the adjacent structures protect the brain to make sure that the brain is safe. </li></ul><ul><li>Headache is like an alerting signal </li></ul><ul><li>Face and scalp are richly supplied by pain receptors than other parts of the body in order to protect the precious contents of the skull </li></ul><ul><li>Also the nasal, oral passages , eye and ear all are delicate and highly sensitive structures which reside here and must be protected </li></ul>PowerPoint Presentation By Dr.P.L.John Israel
  7. 7. CRANIAL STRUCTURES SENSITIVE TO PAIN <ul><li>The scalp </li></ul><ul><li>Scalp blood supply </li></ul><ul><li>Head and neck muscles </li></ul><ul><li>Great venous sinuses </li></ul><ul><li>Arteries of the meninges </li></ul><ul><li>Larger cerebral arteries </li></ul><ul><li>Pain –sensitive fibers of the fifth, ninth and tenth cranial nerves </li></ul><ul><li>Parts of the dura mater at the base of the brain </li></ul>PowerPoint Presentation By Dr.P.L.John Israel
  8. 8. <ul><li>Migraine occurs commonly in </li></ul><ul><ul><li>Females – 70% </li></ul></ul><ul><ul><li>Males – 30% </li></ul></ul><ul><li>Cluster Headache occurs almost entirely in men – 90% </li></ul><ul><li>Tension Headache seen equally in both sexes </li></ul>PowerPoint Presentation By Dr.P.L.John Israel
  9. 9. Location of Headache <ul><li>Hemicranial </li></ul><ul><li>Bi-Temporal </li></ul><ul><li>Occipital </li></ul><ul><li>Frontal </li></ul><ul><li>Peri-Orbital </li></ul><ul><li>Vertex </li></ul>PowerPoint Presentation By Dr.P.L.John Israel
  10. 10. Nature of Headache <ul><li>Constant </li></ul><ul><li>Paroxysmal </li></ul><ul><li>Lancinating </li></ul><ul><li>Throbbing </li></ul>PowerPoint Presentation By Dr.P.L.John Israel
  11. 11. PowerPoint Presentation By Dr.P.L.John Israel MIGRAINE HEADACHE
  12. 12. MIGRAINE HEADACHE <ul><li>Familial Disorder characterised by periodic, Commonly unilateral , often pulsa tile headache. </li></ul><ul><li>Age of onset </li></ul><ul><ul><li>Begins in childhood , adolescents in early adult life and diminishes in frequency and severity during advancing years. (Typically begins in teenage years and seldom begins after 40yeras of age) </li></ul></ul>PowerPoint Presentation By Dr.P.L.John Israel
  13. 13. TYPES <ul><li>Classic Migraine or Neurologic Migraine </li></ul><ul><ul><li>Is characterised by aura </li></ul></ul><ul><li>Common Migraine </li></ul><ul><ul><li>Migraine without aura </li></ul></ul><ul><li>Ratio </li></ul><ul><ul><li>Classic Migraine : Common Migraine </li></ul></ul><ul><ul><li>1 : 5 </li></ul></ul>PowerPoint Presentation By Dr.P.L.John Israel
  14. 14. CLASSIC MIGRAINE <ul><li>Prodrome : </li></ul><ul><ul><li>Occurs hours to days before headache and consists of change in mood, behavior, apetite and cognition. </li></ul></ul><ul><li>Aura : </li></ul><ul><ul><li>Occurs within 1 hour of headache, and is most commonly visual or sensory </li></ul></ul><ul><ul><li>Visual Aura </li></ul></ul><ul><ul><ul><li>Most Common </li></ul></ul></ul><ul><ul><ul><li>Consist of photopsias, bright flashing lights, scintillating scotomas, field cuts and fortification spectra (zigzag lines / Teichopsia) </li></ul></ul></ul>PowerPoint Presentation By Dr.P.L.John Israel
  15. 15. <ul><ul><li>Sensory Auras </li></ul></ul><ul><ul><ul><li>Next most common feature </li></ul></ul></ul><ul><ul><ul><li>Characterized by numbness or paresthesiae in a limb </li></ul></ul></ul><ul><ul><li>Motor Weakness and aphasia are less common </li></ul></ul><ul><li>HEADACHE </li></ul><ul><ul><li>Often unilateral (Hemicranial in 60% of ages) and throbbing in nature </li></ul></ul><ul><ul><li>Follows aura with in 60 minutes and lasts 4 – 72 hrs </li></ul></ul><ul><ul><li>Is associated with </li></ul></ul><ul><ul><ul><li>nausea, </li></ul></ul></ul><ul><ul><ul><li>vomiting </li></ul></ul></ul><ul><ul><ul><li>Photophobia (aversion to light) </li></ul></ul></ul><ul><ul><ul><li>Phonophobia (aversion to sound) </li></ul></ul></ul>PowerPoint Presentation By Dr.P.L.John Israel
  16. 16. <ul><ul><li>Headache may be relieved after vomiting </li></ul></ul><ul><ul><li>Is aggravated by strain, routine physical activity or rapid movement of the head </li></ul></ul><ul><ul><li>Some relief with pressure on temporal vessels </li></ul></ul><ul><ul><li>Strong Family History (80%) </li></ul></ul><ul><li>Migraine attacks come once or twice per month, or three tp four times per year </li></ul><ul><li>There is a strong association with menstruation in females </li></ul>PowerPoint Presentation By Dr.P.L.John Israel
  17. 17. <ul><li>Common Migraine </li></ul><ul><ul><li>Symptoms are similar to classic migraine but there are no aura </li></ul></ul><ul><li>Precipitating factors </li></ul><ul><ul><li>Foods rich in tyramine (Cheese, redwine) </li></ul></ul><ul><ul><li>Foods containing monosodium glutamine (Chinese and Mexican foods) </li></ul></ul><ul><ul><li>Foods containing Nitrates (Cold cuts – bologna, salami, smoked meats) </li></ul></ul><ul><ul><li>Pickled,fermented,marinated foods (pasta salads) </li></ul></ul><ul><ul><li>Alcoholic beverages (especially red wine) </li></ul></ul><ul><ul><li>Caffeinated beverages (soft drinks, tea and coffee) </li></ul></ul>PowerPoint Presentation By Dr.P.L.John Israel
  18. 18. ETIOPATHOGENESIS OF MIGRAINE <ul><li>VASCULAR THEORY </li></ul><ul><ul><li>Vascular Theory of Migraine states that the migraine aura is due to cerebral vaso constriction and that the migraine itself is caused by vasodilatation </li></ul></ul><ul><ul><li>Cerebral blood flow is decreased during migraine with aura but there is no changes in blood flow during migraine without aura – Controversial </li></ul></ul>PowerPoint Presentation By Dr.P.L.John Israel
  19. 19. <ul><li>ROLE OF SEROTONIN </li></ul><ul><ul><li>90% in GI Tract </li></ul></ul><ul><ul><li>10% distributed in the brain and platelets </li></ul></ul><ul><ul><li>During Migraine attack, serotonin levels in the blood may decrease where as urinary concentration may increase. </li></ul></ul><ul><ul><li>This shift in serotonin level may trigger changes in blood vessels and blood flow and also alter pain perception in the brain. </li></ul></ul>PowerPoint Presentation By Dr.P.L.John Israel
  20. 20. <ul><li>ROLE OF SEROTONIN </li></ul><ul><ul><li>Serotonin may thus play a role in the cause of migraine </li></ul></ul><ul><ul><li>Amtriptyline, nortryptyline & sumatriptan which have an effect on serotonin metabolism are therefore useful in migraine headache. </li></ul></ul>PowerPoint Presentation By Dr.P.L.John Israel
  21. 21. <ul><li>SUBSTANCE - P </li></ul><ul><ul><li>The intra and extra cranial vessels are innervated by small unmyelinated fibers derived from trigeminal nerve and subserve both pain and autonomic function. </li></ul></ul><ul><ul><li>Activation of these fibers releases substance P and other peptides into the vessel valve. </li></ul></ul><ul><ul><li>The peptides dilate the cerebral vessels and increase there permeability causing a throbbing headache. </li></ul></ul>PowerPoint Presentation By Dr.P.L.John Israel
  22. 22. Nitric Oxide <ul><ul><li>Nitric Oxide generated by endothelial cells has been implicated as the cause of pain in migraine headache . </li></ul></ul>PowerPoint Presentation By Dr.P.L.John Israel
  23. 23. BASILAR MIGRAINE <ul><li>Basilar artery or vertebra basilar migraine </li></ul><ul><ul><li>Less common form </li></ul></ul><ul><ul><li>Prominent brain symptoms </li></ul></ul><ul><ul><li>Seen usually in young women with a family history of migraine </li></ul></ul><ul><ul><li>Have visual aura and may even develop temporary cortical blindness </li></ul></ul><ul><ul><li>There may be associated vertigo, staggering, inco-ordination of limbs, dysarthria and tingling both hands and feet and around the mouth </li></ul></ul>PowerPoint Presentation By Dr.P.L.John Israel
  24. 24. BASILAR MIGRAINE contd….. <ul><ul><li>Exceptionally there can be period of coma or quadriplegia . </li></ul></ul><ul><ul><li>The symptoms lost 10-30minutes followed by headache which may be occipital </li></ul></ul><ul><ul><li>Some patients at the onset of headache may faint, or become confused or stuporous and this stage may persist for several hours or longer. </li></ul></ul>PowerPoint Presentation By Dr.P.L.John Israel
  25. 25. Ophthalmoplegic Migraine <ul><li>Characterised by recurrent unilateral headaches associated with weakness of extra ocular muscles </li></ul><ul><li>Transient 3 rd nerve palsy with ptosis with or without involvement of the pupil is the usual picture. </li></ul><ul><li>6 th nerve is early effected common in children </li></ul><ul><li>Paresis may persist even after headache for days to weeks. </li></ul><ul><li>Occasionally opthalmoparesis may remian permanent. </li></ul>PowerPoint Presentation By Dr.P.L.John Israel
  26. 26. Retinal Migraine or Ocular Migraine <ul><li>Characterised by retinal or optic nerve ischemia. </li></ul><ul><li>There may be retinal haemorrhages or narrowing of retinal venules during and attack . </li></ul><ul><li>Mono ocular blindness, disc edema may occur and vision recovers only partially after several months. </li></ul><ul><li>The retinal or ciliary circulation may be involved. </li></ul>PowerPoint Presentation By Dr.P.L.John Israel
  27. 27. Post Traumatic Migraine <ul><li>Occurs following trivial head injury there may be loss of sight, headache confusion for hours or days before recovering </li></ul><ul><li>In others there may be hemiparesis or aphasia </li></ul>PowerPoint Presentation By Dr.P.L.John Israel
  28. 28. Abdominal Migraine <ul><li>Seen in young children </li></ul><ul><li>Instead of complaining of headache the child appears limp and pale and complains of abdominal pain. </li></ul><ul><li>There may be vomiting and fever </li></ul><ul><li>There may also be disturbances in mood along with abdominal pain . </li></ul>PowerPoint Presentation By Dr.P.L.John Israel
  29. 29. Hemiplegic Migraine <ul><li>The infant, child or adult has episodes of hemiparesis that may outlast the headache. </li></ul><ul><li>Has autosomal dominant trait with a family history (familial hemiplegic migraine). </li></ul>PowerPoint Presentation By Dr.P.L.John Israel
  30. 30. Complicated Migraine Or Migranous Infarction <ul><li>Here the temporary nerologic symptom of migraine headache may remain permanent </li></ul><ul><li>Ex : A Homonymous visual field defect </li></ul><ul><li>Platelet aggregation, edema of the arterial wall increased coagulability of blood, intense prolonged spasm of vessels have all been implicated in the pathogenesis of arterial occlusion and strokes that complicate migraine </li></ul>PowerPoint Presentation By Dr.P.L.John Israel
  31. 31. <ul><li>In children with mitochondrial disease (MELAS- M itochondrial Myopathy- E ncephalopathy L actic A cidosis and S troke like Episodes ) </li></ul><ul><li>And in adults with rare vasculopathy </li></ul><ul><li>(CADASIL – C erebral A utosomal D ominant A rteriopathy with S ubcortical I nfarcts and L euko Encephalopathy ) , Migraine is prominent feature </li></ul>PowerPoint Presentation By Dr.P.L.John Israel
  32. 32. STATUS MIGRAINOSUS <ul><li>Continuous migraine with unilateral throbbing and disabling headache. </li></ul><ul><li>May follow head injury or viral headache . </li></ul>PowerPoint Presentation By Dr.P.L.John Israel
  33. 33. Premenstrual / Menstrual Migraine <ul><li>Is thought to be due to withdrawal of estrogens. </li></ul><ul><li>Migraine attacks tend to cease during pregnancy in 75-80% of patients </li></ul><ul><li>Oral contraceptive pills or associated with increased frequency and severity of migraine and may be even be associated with permanent neurologic deficit. </li></ul>PowerPoint Presentation By Dr.P.L.John Israel
  34. 34. FOOTBALLERS MIGRAINE <ul><li>Sudden jarring of the head may precipitate the migraine attack in susceptible footballers </li></ul>PowerPoint Presentation By Dr.P.L.John Israel
  35. 35. TREATMENT OF MIGRAINE <ul><li>Treatment of Acute Attack </li></ul><ul><li>(Primary treatment) </li></ul><ul><li>Prophylactic treatment </li></ul>PowerPoint Presentation By Dr.P.L.John Israel
  36. 36. Treatment of Acute attack (Primary Treatment) <ul><li>Mild attack of migraine </li></ul><ul><ul><li>Acetaminophen </li></ul></ul><ul><ul><li>NSAIDS </li></ul></ul><ul><li>Severe attack </li></ul><ul><ul><li>Ergot alkaloids : </li></ul></ul><ul><ul><ul><li>Ergotamine /Dihydroergotamine (DHE) </li></ul></ul></ul><ul><ul><ul><li>Best given at the on set of attack </li></ul></ul></ul><ul><ul><li>Is an α adrenergic agonist with a strong serotonin receptor affinity and has a vasoconstrictor action. </li></ul></ul>PowerPoint Presentation By Dr.P.L.John Israel
  37. 37. <ul><ul><li>Available as oral, sublingual, injectable and inhalation forms </li></ul></ul><ul><ul><ul><li>1 – 2mg every half an hour (Dose ) Sublingual or to be swallowed </li></ul></ul></ul><ul><ul><ul><li>Maximum dose (8mg) </li></ul></ul></ul><ul><ul><li>A Single dose of promethazine (Phenergan) 50mg or Metaclopramide (Reglan) 20mg given along with ergotamine relaxes the patient and allays nausea and vomiting. </li></ul></ul><ul><ul><li>Caffeine 100mg is thought on slim evidence to potentiate the effects of ergot and other medications for migraine </li></ul></ul><ul><ul><li>Reduces headache in 70-75% of patients. </li></ul></ul>PowerPoint Presentation By Dr.P.L.John Israel
  38. 38. 5HT Receptor Agonists <ul><li>Sumatriptan </li></ul><ul><ul><li>Is effective at stopping acute attack of migraine headache </li></ul></ul><ul><ul><li>Can be given subcutaneously 6mg </li></ul></ul><ul><ul><li>As intranasal spray 20mg </li></ul></ul><ul><ul><li>Or orally 50-100mg </li></ul></ul><ul><ul><li>Provide relieve in 70% patients . </li></ul></ul><ul><li>Side Effects </li></ul><ul><ul><li>Chest tightness & flushing </li></ul></ul><ul><ul><li>Should not be used concomitantly with ergotamines or inpatients with heart disease </li></ul></ul>PowerPoint Presentation By Dr.P.L.John Israel
  39. 39. Other 5HT Receptor Agonists <ul><li>Zolmitriptan 2.5 to 5mg </li></ul><ul><li>Rizatriptan 10mg </li></ul><ul><ul><li>Doses can be repeated if needed in 2hrs </li></ul></ul>PowerPoint Presentation By Dr.P.L.John Israel
  40. 40. MIDRIN <ul><li>Is a combination medication that consists of dichloralphenazone (a muscle relaxant), isometheptene (a vasospasm agent) and acetaminophen . </li></ul><ul><li>May be used as abortive therapy ( 2tabs with onset of headache ) and one tab every hour after that , up to 5 tabs total . </li></ul><ul><li>As prophylaxis ( 1tab 2-3times per day ) </li></ul>PowerPoint Presentation By Dr.P.L.John Israel
  41. 41. Prophylactic Treatment <ul><li>When headache occur at frequency of 2-3 per month the following drugs have been effective of prophylactic agents </li></ul><ul><ul><li>Beta –Blockers </li></ul></ul><ul><ul><ul><li>Inderal – 20mg TID can increase up to 240mg /day </li></ul></ul></ul><ul><ul><ul><li>Atenolol – 40 to 160mg/day </li></ul></ul></ul><ul><ul><ul><li>Timolol - 20 to 40 mg /day </li></ul></ul></ul><ul><ul><ul><li>Metoprolol – 100 to 200 mg /day </li></ul></ul></ul>PowerPoint Presentation By Dr.P.L.John Israel
  42. 42. <ul><li>Sodium valproate - 500mg/day (upto 1000mg /day) </li></ul><ul><li>Calcium channel blockers </li></ul><ul><ul><li>Verapamil - 180 to 240mg /day </li></ul></ul><ul><ul><li>Nifedepine - 30 mg /day </li></ul></ul><ul><li>Tricyclic Antidepressants (Amitriptyline,Imipramine) </li></ul><ul><ul><li>Amitriptyline – 25mg HS – OD increase upto 200mg/day (increase 25mg /week) </li></ul></ul><ul><ul><li>Side effects </li></ul></ul><ul><ul><ul><li>Dry mouth </li></ul></ul></ul><ul><ul><ul><li>Constipation </li></ul></ul></ul><ul><ul><ul><li>Urinary hesitancy </li></ul></ul></ul><ul><ul><ul><li>Sedation </li></ul></ul></ul><ul><ul><ul><li>Weight gain, </li></ul></ul></ul>PowerPoint Presentation By Dr.P.L.John Israel
  43. 43. <ul><li>Methysergide </li></ul><ul><ul><li>Serotonin agonist , vasoconstrictor . Highly effective for primary treatment but has side effects on prolonged use (Retroperitoneal fibrosis, Pulmonary fibrosis) </li></ul></ul><ul><ul><li>Dose : 2 to 6 mg/day </li></ul></ul><ul><li>Other Drugs </li></ul><ul><ul><li>Clonidine – 0.5mg TID/day </li></ul></ul><ul><ul><li>Cyproheptadine – 4 to 16mg /day </li></ul></ul><ul><ul><li>Flunarazine – 5 to 10mg/day </li></ul></ul><ul><ul><li>Indomethacin – 150 to 200mg /day </li></ul></ul>PowerPoint Presentation By Dr.P.L.John Israel
  44. 44. CLUSTER HEADACHE <ul><li>Also known has </li></ul><ul><ul><li>Paroxysmal nocturnal cephalalgia </li></ul></ul><ul><ul><li>Migrainous neuralgia </li></ul></ul><ul><ul><li>Histamine cephalalgia </li></ul></ul><ul><ul><li>Red Migraine </li></ul></ul><ul><ul><li>Erythromelalgia of the Head </li></ul></ul>PowerPoint Presentation By Dr.P.L.John Israel
  45. 45. CLUSTER HEADACHE <ul><li>So called because these headaches occur during a short time span. </li></ul><ul><li>The cluster then recurs periodically . </li></ul><ul><li>A typical cluster of headaches may last 4-8weeks with 1-2 headaches/day during the cluster. </li></ul><ul><li>Patient may be free 6months to 1year before another cluster of headache occurs. </li></ul><ul><li>They may be distinctly seasonal. </li></ul><ul><li>Young adult Men (20-50 yrs age) are more affected then women </li></ul><ul><li>Male to Female ratio 5:1 </li></ul>PowerPoint Presentation By Dr.P.L.John Israel
  46. 46. SYMPTOMS <ul><li>Abrupt onset of headache originating in the eye and spreading over the temporal area. </li></ul><ul><li>Pain extremely severe and last 20-60minutes </li></ul><ul><li>The headache associated with </li></ul><ul><ul><li>Nasal stuffiness </li></ul></ul><ul><ul><li>Rhinorrhoea </li></ul></ul><ul><ul><li>Redness of the Eye </li></ul></ul><ul><ul><li>Flush and edema of the cheek </li></ul></ul>PowerPoint Presentation By Dr.P.L.John Israel
  47. 47. SYMPTOMS <ul><ul><li>There may also be partial Horner’s Syndrome with ptosis and miosis on the side of The Head pain. These autonomic phenomena are similar to those elicited by local action of histamine and was therefore previously called Horton’s Histamine Headaches </li></ul></ul><ul><ul><li>These headaches are usually nocturnal, between 1-2hrs after the onset of sleep are several times during the night and day not associated with aura or vomiting. The headache recurs with remarkable regularity each day for periods that last over 6-12weeks </li></ul></ul>PowerPoint Presentation By Dr.P.L.John Israel
  48. 48. CAUSE AND MECHANISM OF CLUSTER HEADACHE <ul><li>Not clear </li></ul><ul><li>Probably due to paroxysmal parasympathetic discharge mediated through the greater superficial petrosal nerve and sphenopalatine ganglion </li></ul>PowerPoint Presentation By Dr.P.L.John Israel
  49. 49. CLUSTER MIGRAINE <ul><li>These persons have characteristics of both migraine headache as well as cluster headache </li></ul>PowerPoint Presentation By Dr.P.L.John Israel
  50. 50. TREATMENT <ul><li>Ergotamine 2mg at bedtime </li></ul><ul><li>Inhalation of 100% oxygen for 10 – 15min at onset of the headache </li></ul><ul><li>Intranasal lidocaine or sumatriptan </li></ul><ul><li>Methysergide 2-8 mg/day </li></ul><ul><li>Prednisolone - 75mg / day for 3days and then taper the dose </li></ul><ul><li>Verapamil – upto 480mg /day </li></ul><ul><li>Lithium – 600 to 900mg/day (blood level of lithium must be between 0.7 to 1.2 meq/Lt) </li></ul><ul><li>Indomethacin – 75 to 200mg /day </li></ul>PowerPoint Presentation By Dr.P.L.John Israel
  51. 51. PowerPoint Presentation By Dr.P.L.John Israel Thank YoU PowerPoint Lecture Presented by Dr.P.L.John Israel Prof & HOD , Department of Internal Medicine