Headache

PowerPoint Presentation By Dr.P.L.John Israel INTERNAL MEDICINE DEPATMENT OF

PowerPoint Presentation By Dr.P.L.John Israel HEADACHE

COMMON CAUSES
Viral Rhinitis (Common Cold)
Sinusitis
Fevers
Hypertension
Refractive Error
Tension Headache
Hypoglycemia
Post ictal headache
PowerPoint Presentation By Dr.P.L.John Israel

SPECIFIC CAUSES
Migraine Headache
Cluster Headache
Temporal Arteritis
Post traumatic Headache
Thunderclap Headache
(Subarachnoid Haemorrhage)

Specific Causes Contd..
Intracerebral Haemorrahage
Subdural Haematoma
Brain Abscess
Primary Brain Tumor
Metastatic Brain Tumor
Meningitis
Hydrocephalus
Glaucoma

BRAIN
Seat of intelligence
By itself is not sensitive to pain but the adjacent structures protect the brain to make sure that the brain is safe.
Headache is like an alerting signal
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
Also the nasal, oral passages , eye and ear all are delicate and highly sensitive structures which reside here and must be protected

CRANIAL STRUCTURES SENSITIVE TO PAIN
The scalp
Scalp blood supply
Head and neck muscles
Great venous sinuses
Arteries of the meninges
Larger cerebral arteries
Pain –sensitive fibers of the fifth, ninth and tenth cranial nerves
Parts of the dura mater at the base of the brain

Migraine occurs commonly in
Females – 70%
Males – 30%
Cluster Headache occurs almost entirely in men – 90%
Tension Headache seen equally in both sexes

Location of Headache
Hemicranial
Bi-Temporal
Occipital
Frontal
Peri-Orbital
Vertex

Nature of Headache
Constant
Paroxysmal
Lancinating
Throbbing

PowerPoint Presentation By Dr.P.L.John Israel MIGRAINE HEADACHE

MIGRAINE HEADACHE
Familial Disorder characterised by periodic, Commonly unilateral , often pulsa tile headache.
Age of onset
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)

TYPES
Classic Migraine or Neurologic Migraine
Is characterised by aura
Common Migraine
Migraine without aura
Ratio
Classic Migraine : Common Migraine
1 : 5

CLASSIC MIGRAINE
Prodrome :
Occurs hours to days before headache and consists of change in mood, behavior, apetite and cognition.
Aura :
Occurs within 1 hour of headache, and is most commonly visual or sensory
Visual Aura
Most Common
Consist of photopsias, bright flashing lights, scintillating scotomas, field cuts and fortification spectra (zigzag lines / Teichopsia)

Sensory Auras
Next most common feature
Characterized by numbness or paresthesiae in a limb
Motor Weakness and aphasia are less common
HEADACHE
Often unilateral (Hemicranial in 60% of ages) and throbbing in nature
Follows aura with in 60 minutes and lasts 4 – 72 hrs
Is associated with
nausea,
vomiting
Photophobia (aversion to light)
Phonophobia (aversion to sound)

Headache may be relieved after vomiting
Is aggravated by strain, routine physical activity or rapid movement of the head
Some relief with pressure on temporal vessels
Strong Family History (80%)
Migraine attacks come once or twice per month, or three tp four times per year
There is a strong association with menstruation in females

Common Migraine
Symptoms are similar to classic migraine but there are no aura
Precipitating factors
Foods rich in tyramine (Cheese, redwine)
Foods containing monosodium glutamine (Chinese and Mexican foods)
Foods containing Nitrates (Cold cuts – bologna, salami, smoked meats)
Pickled,fermented,marinated foods (pasta salads)
Alcoholic beverages (especially red wine)
Caffeinated beverages (soft drinks, tea and coffee)

ETIOPATHOGENESIS OF MIGRAINE
VASCULAR THEORY
Vascular Theory of Migraine states that the migraine aura is due to cerebral vaso constriction and that the migraine itself is caused by vasodilatation
Cerebral blood flow is decreased during migraine with aura but there is no changes in blood flow during migraine without aura – Controversial

ROLE OF SEROTONIN
90% in GI Tract
10% distributed in the brain and platelets
During Migraine attack, serotonin levels in the blood may decrease where as urinary concentration may increase.
This shift in serotonin level may trigger changes in blood vessels and blood flow and also alter pain perception in the brain.

ROLE OF SEROTONIN
Serotonin may thus play a role in the cause of migraine
Amtriptyline, nortryptyline & sumatriptan which have an effect on serotonin metabolism are therefore useful in migraine headache.

SUBSTANCE - P
The intra and extra cranial vessels are innervated by small unmyelinated fibers derived from trigeminal nerve and subserve both pain and autonomic function.
Activation of these fibers releases substance P and other peptides into the vessel valve.
The peptides dilate the cerebral vessels and increase there permeability causing a throbbing headache.

Nitric Oxide
Nitric Oxide generated by endothelial cells has been implicated as the cause of pain in migraine headache .

BASILAR MIGRAINE
Basilar artery or vertebra basilar migraine
Less common form
Prominent brain symptoms
Seen usually in young women with a family history of migraine
Have visual aura and may even develop temporary cortical blindness
There may be associated vertigo, staggering, inco-ordination of limbs, dysarthria and tingling both hands and feet and around the mouth

BASILAR MIGRAINE contd…..
Exceptionally there can be period of coma or quadriplegia .
The symptoms lost 10-30minutes followed by headache which may be occipital
Some patients at the onset of headache may faint, or become confused or stuporous and this stage may persist for several hours or longer.

Ophthalmoplegic Migraine
Characterised by recurrent unilateral headaches associated with weakness of extra ocular muscles
Transient 3 rd nerve palsy with ptosis with or without involvement of the pupil is the usual picture.
6 th nerve is early effected common in children
Paresis may persist even after headache for days to weeks.
Occasionally opthalmoparesis may remian permanent.

Retinal Migraine or Ocular Migraine
Characterised by retinal or optic nerve ischemia.
There may be retinal haemorrhages or narrowing of retinal venules during and attack .
Mono ocular blindness, disc edema may occur and vision recovers only partially after several months.
The retinal or ciliary circulation may be involved.

Post Traumatic Migraine
Occurs following trivial head injury there may be loss of sight, headache confusion for hours or days before recovering
In others there may be hemiparesis or aphasia

Abdominal Migraine
Seen in young children
Instead of complaining of headache the child appears limp and pale and complains of abdominal pain.
There may be vomiting and fever
There may also be disturbances in mood along with abdominal pain .

Hemiplegic Migraine
The infant, child or adult has episodes of hemiparesis that may outlast the headache.
Has autosomal dominant trait with a family history (familial hemiplegic migraine).

Complicated Migraine Or Migranous Infarction
Here the temporary nerologic symptom of migraine headache may remain permanent
Ex : A Homonymous visual field defect
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

In children with mitochondrial disease (MELAS- M itochondrial Myopathy- E ncephalopathy L actic A cidosis and S troke like Episodes )
And in adults with rare vasculopathy
(CADASIL – C erebral A utosomal D ominant A rteriopathy with S ubcortical I nfarcts and L euko Encephalopathy ) , Migraine is prominent feature

STATUS MIGRAINOSUS
Continuous migraine with unilateral throbbing and disabling headache.
May follow head injury or viral headache .

Premenstrual / Menstrual Migraine
Is thought to be due to withdrawal of estrogens.
Migraine attacks tend to cease during pregnancy in 75-80% of patients
Oral contraceptive pills or associated with increased frequency and severity of migraine and may be even be associated with permanent neurologic deficit.

FOOTBALLERS MIGRAINE
Sudden jarring of the head may precipitate the migraine attack in susceptible footballers

TREATMENT OF MIGRAINE
Treatment of Acute Attack
(Primary treatment)
Prophylactic treatment

Treatment of Acute attack (Primary Treatment)
Mild attack of migraine
Acetaminophen
NSAIDS
Severe attack
Ergot alkaloids :
Ergotamine /Dihydroergotamine (DHE)
Best given at the on set of attack
Is an α adrenergic agonist with a strong serotonin receptor affinity and has a vasoconstrictor action.

Available as oral, sublingual, injectable and inhalation forms
1 – 2mg every half an hour (Dose ) Sublingual or to be swallowed
Maximum dose (8mg)
A Single dose of promethazine (Phenergan) 50mg or Metaclopramide (Reglan) 20mg given along with ergotamine relaxes the patient and allays nausea and vomiting.
Caffeine 100mg is thought on slim evidence to potentiate the effects of ergot and other medications for migraine
Reduces headache in 70-75% of patients.

5HT Receptor Agonists
Sumatriptan
Is effective at stopping acute attack of migraine headache
Can be given subcutaneously 6mg
As intranasal spray 20mg
Or orally 50-100mg
Provide relieve in 70% patients .
Side Effects
Chest tightness & flushing
Should not be used concomitantly with ergotamines or inpatients with heart disease

Other 5HT Receptor Agonists
Zolmitriptan 2.5 to 5mg
Rizatriptan 10mg
Doses can be repeated if needed in 2hrs

MIDRIN
Is a combination medication that consists of dichloralphenazone (a muscle relaxant), isometheptene (a vasospasm agent) and acetaminophen .
May be used as abortive therapy ( 2tabs with onset of headache ) and one tab every hour after that , up to 5 tabs total .
As prophylaxis ( 1tab 2-3times per day )

Prophylactic Treatment
When headache occur at frequency of 2-3 per month the following drugs have been effective of prophylactic agents
Beta –Blockers
Inderal – 20mg TID can increase up to 240mg /day
Atenolol – 40 to 160mg/day
Timolol - 20 to 40 mg /day
Metoprolol – 100 to 200 mg /day

Sodium valproate - 500mg/day (upto 1000mg /day)
Calcium channel blockers
Verapamil - 180 to 240mg /day
Nifedepine - 30 mg /day
Tricyclic Antidepressants (Amitriptyline,Imipramine)
Amitriptyline – 25mg HS – OD increase upto 200mg/day (increase 25mg /week)
Side effects
Dry mouth
Constipation
Urinary hesitancy
Sedation
Weight gain,

Methysergide
Serotonin agonist , vasoconstrictor . Highly effective for primary treatment but has side effects on prolonged use (Retroperitoneal fibrosis, Pulmonary fibrosis)
Dose : 2 to 6 mg/day
Other Drugs
Clonidine – 0.5mg TID/day
Cyproheptadine – 4 to 16mg /day
Flunarazine – 5 to 10mg/day
Indomethacin – 150 to 200mg /day

CLUSTER HEADACHE
Also known has
Paroxysmal nocturnal cephalalgia
Migrainous neuralgia
Histamine cephalalgia
Red Migraine
Erythromelalgia of the Head

CLUSTER HEADACHE
So called because these headaches occur during a short time span.
The cluster then recurs periodically .
A typical cluster of headaches may last 4-8weeks with 1-2 headaches/day during the cluster.
Patient may be free 6months to 1year before another cluster of headache occurs.
They may be distinctly seasonal.
Young adult Men (20-50 yrs age) are more affected then women
Male to Female ratio 5:1

SYMPTOMS
Abrupt onset of headache originating in the eye and spreading over the temporal area.
Pain extremely severe and last 20-60minutes
The headache associated with
Nasal stuffiness
Rhinorrhoea
Redness of the Eye
Flush and edema of the cheek

SYMPTOMS
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
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

CAUSE AND MECHANISM OF CLUSTER HEADACHE
Not clear
Probably due to paroxysmal parasympathetic discharge mediated through the greater superficial petrosal nerve and sphenopalatine ganglion

CLUSTER MIGRAINE
These persons have characteristics of both migraine headache as well as cluster headache

TREATMENT
Ergotamine 2mg at bedtime
Inhalation of 100% oxygen for 10 – 15min at onset of the headache
Intranasal lidocaine or sumatriptan
Methysergide 2-8 mg/day
Prednisolone - 75mg / day for 3days and then taper the dose
Verapamil – upto 480mg /day
Lithium – 600 to 900mg/day (blood level of lithium must be between 0.7 to 1.2 meq/Lt)
Indomethacin – 75 to 200mg /day

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

Headache

by Praveen Nagula

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