Headache Lecture For Student

8,294 views

Published on

0 Comments
15 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
8,294
On SlideShare
0
From Embeds
0
Number of Embeds
6
Actions
Shares
0
Downloads
478
Comments
0
Likes
15
Embeds 0
No embeds

No notes for slide
  • The cause or type of most headaches can be determined by a careful history and physical examination. The clinical imperative is to recognize the warning signals, which should raise red flags and prompt further diagnostic testing. In the absence of worrisome features in the history or examination, the task is then to diagnose the primary syndrome based upon the clinical features. If there are atypical features or a lack of response to conventional therapy, the diagnosis should be questioned and the possibility of a secondary headache disorder revisited. Since migraine and TTH account for over 90% of the primary headache disorders in clinical practice, this discussion will focus on their clinical features, the warning signals of serious secondary headaches, and the role of diagnostic testing in the evaluation of headache.
  • In both males and females, the prevalence distribution of migraine is an inverted U-shape curve. Prevalence rises through early adult life and then falls after middle life. The second important point to emphasize on this slide is that, at all post-pubertal ages, migraine is substantially more common in women than in men. The prevalence of migraine varies as a function of age. Migraine is a disorder that is most prevalent between the ages of 25 and 55. Part of the reason the condition has such a big impact in the workplace is that it affects people during their peak productive years. Lipton RB, Stewart WF. Migraine in the United States: a review of epidemiology and health care use. Neurology. 1993;43(suppl 3):S6-S10.
  • Headache Lecture For Student

    1. 1. Headache and increased intracranial pressure
    2. 2. Causes of Headaches <ul><li>1. Traction, tension, or displacement of pain-sensitive structures </li></ul><ul><li>2. Distention or dilation of intracranial arteries </li></ul><ul><li>3. Inflammation of pain-sensitive structures </li></ul><ul><li>4. Obstruction of CSF pathways with consequent increased intraventricular pressure </li></ul><ul><li>5. Primary central pain: involvement of pain-modulating systems </li></ul>
    3. 3. Tentorium cerebri Meninges
    4. 4. Vascular-arteries
    5. 5. Cranial nerves
    6. 6. The Fifth cranial nerve <ul><li>Trigeminal nerve </li></ul><ul><li>V1 (Ophthalmic)  sensation </li></ul><ul><li>V2 (Maxillary)  sensation </li></ul><ul><li>V3 (Mandibular)  sensation </li></ul>
    7. 7. Trigeminal neuralgia <ul><li>Intense momentary spasms of pain make the patient wince </li></ul><ul><li>Pain occur in the face, usually radiating from the corner of the mouth or from the gums towards the cheek and ear </li></ul><ul><li>Sudden electric-shock-like quality </li></ul><ul><li>Pain triggered by touching, shaving, cold winds, eating </li></ul><ul><li>Usually occur in elderly. If occurs in young adults, multiple sclerosis should be suspected. </li></ul>
    8. 8. Headache classification <ul><li>Pain sensitive </li></ul><ul><li>meninges </li></ul><ul><li>vascular </li></ul><ul><li>nerves </li></ul>Headache Primary Secondary Migraine Tension Cluster Miscellaneous Extracranial Intracranial
    9. 9. Secondary headache <ul><li>Intracranial </li></ul><ul><li>Extracranial </li></ul>
    10. 10. What should be asked when you see a patient with headache ??
    11. 11. History <ul><li>Temporal profile </li></ul><ul><ul><li>Age of onset </li></ul></ul><ul><ul><li>Time to maximum intensity </li></ul></ul><ul><ul><li>Frequency </li></ul></ul><ul><ul><li>Time of the day </li></ul></ul><ul><ul><li>Duration </li></ul></ul><ul><li>Headache feature </li></ul><ul><ul><li>Location </li></ul></ul><ul><ul><li>Quality of pain </li></ul></ul><ul><ul><li>Severity of pain </li></ul></ul>
    12. 12. <ul><li>Associated symptoms and signs </li></ul><ul><ul><li>Before, during, and after headache </li></ul></ul><ul><li>Aggravating or precipitating factors </li></ul><ul><ul><li>Trauma </li></ul></ul><ul><ul><li>Medical conditions; pregnancy, obese women, pheochromocytoma, HIV-cryptococcal meningitis, metastatic disease </li></ul></ul><ul><ul><li>Triggers : menstruation, loud noise, heat, alcohol, stress </li></ul></ul><ul><ul><li>Activity and postures </li></ul></ul><ul><ul><li>Pharmacologic : drug-abused headache, oral contraceptive pills </li></ul></ul>
    13. 13. <ul><li>Relieving factors </li></ul><ul><ul><li>Nonpharmacologic </li></ul></ul><ul><ul><li>Pharmacologic </li></ul></ul><ul><li>Evaluation and treatment history </li></ul><ul><li>Psychosocial history </li></ul><ul><ul><li>Substance use </li></ul></ul><ul><ul><li>Occupational and personal life </li></ul></ul><ul><ul><li>Psychologic history </li></ul></ul><ul><ul><li>Sleep history </li></ul></ul><ul><ul><li>Impact of headache </li></ul></ul><ul><li>Family history </li></ul>
    14. 14. Headache <ul><li>Primary headache </li></ul><ul><li>Secondary headache </li></ul>
    15. 15. DIAGNOSIS AND TESTING Red flag Primary headache? Secondary headache Diagnostic testing Detailed history and physical examination Atypical features No Yes
    16. 16. Red flags in the diagnosis of headache(1) <ul><li>Sudden onset headache </li></ul><ul><ul><li>Subarachnoid hemorrhage </li></ul></ul><ul><li>Worsening pattern headache </li></ul><ul><ul><li>Mass lesion, subdural hematoma </li></ul></ul><ul><ul><li>Medication overuse </li></ul></ul><ul><li>Headache with systemic illness </li></ul><ul><ul><li>Meningitis, encephalitis </li></ul></ul><ul><ul><li>Systemic infection </li></ul></ul><ul><ul><li>Collagen vascular disease, arteritis </li></ul></ul>
    17. 17. Red flags in the diagnosis of headache(2) <ul><li>Focal neurological signs or symptoms </li></ul><ul><ul><li>Mass lesion </li></ul></ul><ul><ul><li>AVM </li></ul></ul><ul><li>Triggered by cough, exertion, or Valsalva </li></ul><ul><ul><li>SAH </li></ul></ul><ul><ul><li>Mass lesion </li></ul></ul><ul><li>New headache type in a patient </li></ul><ul><ul><li>with cancer : metastasis </li></ul></ul><ul><ul><li>With HIV : opportunistic infection, tumor </li></ul></ul>
    18. 18. Causes of Secondary headache Intracranial Paracranial Extracranial <ul><li>Head trauma </li></ul><ul><li>Vascular disorders </li></ul><ul><li>Nonvascular disorder </li></ul><ul><li>Disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth, other facial or cranial structures </li></ul><ul><li>Substances or their withdrawal </li></ul><ul><li>Noncephalic infection </li></ul><ul><li>Metabolic disorder </li></ul>
    19. 19. Sinusitis <ul><li>Pain is </li></ul><ul><li>localized to the cheek : maxillary sinusitis </li></ul><ul><li>To the forehead : frontal sinusitis </li></ul><ul><li>Midline behind the nose : ethmoid and sphenoid sinusitis </li></ul>* the pain is throbbing and tenderness of overlying skin
    20. 20. Posttraumatic headaches <ul><li>Mild head injury and postconcussion syndrome </li></ul><ul><ul><li>Mild head injury >= 75% of all brain injuries </li></ul></ul><ul><ul><li>Mild closed head injury </li></ul></ul><ul><ul><li>50% of patient with mild Head injury will develop postconcussion syndrome </li></ul></ul>
    21. 21. Postconcussion syndrome <ul><li>Headache : within 14 days or 3 months </li></ul><ul><li>Cranial nerve signs and symptoms </li></ul><ul><li>Psychologic and somatic complaint </li></ul><ul><li>Cognitive impairment </li></ul><ul><li>Rare sequelae </li></ul><ul><ul><li>Subdural and epidural hematoma, cerebral venous thrombosis, seizure </li></ul></ul>
    22. 23. Subarachnoid hemorrhage (SAH) <ul><li>Abrupt onset : subarachnoid hemorrhage(SAH) </li></ul><ul><li>Headache on awakening after lying down or occur everyday : suspect raised intracranial pressure </li></ul><ul><li>Focal neurological deficit : brain tumor, stroke, abscess, encephalitis </li></ul>
    23. 24. Subarachnoid hemorrhage (SAH) <ul><li>Headache occurs in about 90% of SAH patient </li></ul><ul><li>Classic : acute, severe, continuous, and generalized and is often associated with nausea, vomiting, meningismus, focal neurologic symptoms, and loss of consciousness </li></ul><ul><li>“ worst headache of my life” </li></ul>
    24. 25. Investigation in suspected SAH <ul><li>CT brain </li></ul><ul><ul><li>First 24 hrs ---- detect SAH ~95% </li></ul></ul>
    25. 26. Investigation in suspected SAH <ul><li>Lumbar puncture in suspected SAH with normal CT or MRI brain </li></ul><ul><ul><li>Differentiate traumatic tap from SAH by xanthochromia (colored supernatant) </li></ul></ul>
    26. 27. Further investigation for SAH <ul><li>4 vessel cerebral arteriogram </li></ul><ul><li>MRA (magnetic resonance angiography) </li></ul><ul><li>Spiral (helical) CT angiography </li></ul>
    27. 28. Stroke <ul><li>Headaches may be due to electrochemical or mechanical stimulation of trigeminovascular afferent system </li></ul><ul><li>Headache occurred in infarcts, parenchymal hemorrhage, TIA, lacunar infarcts </li></ul><ul><li>Quality, onset, duration of headache varied widely </li></ul>
    28. 29. Clinical manifestations of headache in stroke <ul><li>Unilateral and focal headache </li></ul><ul><li>Mild to moderate severity </li></ul><ul><li>Abrupt or gradual in onset </li></ul><ul><li>throbbing or nonthrobbing </li></ul><ul><li>More often ipsilateral than contralateral to side of cerebral ischemia </li></ul><ul><li>Associated symptoms : nausea, vomiting, light and noise sensitivity </li></ul>
    29. 30. Unruptured AVM and migraine <ul><li>Migraine-like headaches with and without visual symptoms </li></ul><ul><li>Typical migraine-like due to an AVM </li></ul><ul><ul><li>Unusual associated signs (papilledema, field cut, bruit) </li></ul></ul><ul><ul><li>Short duration of headache attacks </li></ul></ul><ul><ul><li>Brief scintillating scotoma </li></ul></ul><ul><ul><li>Absent family history </li></ul></ul><ul><ul><li>Atypical sequence of aura, headache and vomiting </li></ul></ul><ul><ul><li>seizure </li></ul></ul>
    30. 31. MRI T1 and Angiogram of AVM
    31. 32. Carotid and vertebral artery dissections <ul><li>Dissections occur due to penetration of circulating blood through an intimal tear into subintimal, medial, and, less commonly adventitial layers of vascular wall </li></ul>
    32. 33. Clinical manifestation of carotid or vertebral artery dissection <ul><li>Head, face, orbital, or neck pain </li></ul><ul><li>Cerebral ischemic symptoms </li></ul><ul><li>SAH [intracranial artery dissection] </li></ul><ul><li>Incomplete ipsilateral Horner’s syndrome [extracranial ICA dissection] </li></ul><ul><li>Subjective or objective bruits </li></ul>
    33. 34. Character of headache in artery dissection <ul><li>Onset : gradual 75%, thunderclap headache 10-20%, </li></ul><ul><li>Constant, steady aching or steady sharp pain or less commonly as throbbing </li></ul>
    34. 35. Headache in CVT <ul><li>Usually due to raised intracranial pressure </li></ul><ul><ul><li>Diffuse, progressive and constant </li></ul></ul><ul><li>Almost always associated with </li></ul><ul><ul><li>Papilledema </li></ul></ul><ul><ul><li>Focal deficits </li></ul></ul><ul><ul><li>Partial/ generalized seizures </li></ul></ul>
    35. 36. Diagnostic evaluation in CVT <ul><li>CT brain </li></ul><ul><ul><li>Exclude cerebral infarction and hemorrhage </li></ul></ul><ul><ul><li>‘ Empty delta sign’ ; nonenhancing clot within the sinus is present in only 35% </li></ul></ul><ul><li>MRI and MRV </li></ul><ul><ul><li>Best way to detect CVT </li></ul></ul><ul><li>Lumbar puncture ---should be avoided if there is a large cerebral infarction or hemorrhage </li></ul><ul><ul><li>Document elevated intracranial pressure and help exclude infectious or leptomeningeal malignancy </li></ul></ul>
    36. 37. MRV of Superior sagittal, transverse sinus thrombosis
    37. 38. Temporal arteritis (Giant cell arteritis) <ul><li>Systemic panarteritis that selectively involves arterial walls with significant amount of elastin </li></ul><ul><li>50% of patient with temporal arteritis have polymyalgia rheumatica </li></ul><ul><li>15% of patient with polymyalgia rheumatica have temporal arteritis </li></ul><ul><li>Mean age of onset ~70 years </li></ul>
    38. 39. <ul><li>Temporal arteritis (giant cell arteritis) </li></ul>
    39. 40. Temporal arteritis (Giant cell arteritis) <ul><li>Headache 60-90% </li></ul><ul><ul><li>Often throbbing </li></ul></ul><ul><ul><li>Intermittent or continuous </li></ul></ul><ul><ul><li>Severe </li></ul></ul><ul><ul><li>Location : temporofrontal, temple, not involve temple, generalized </li></ul></ul><ul><ul><li>50% tenderness or decreased pulsation of superficial temporal artery </li></ul></ul>
    40. 41. Temporal arteritis (cont) <ul><li>Intermittent jaw claudication 38% </li></ul><ul><li>Neurologic manifestation are common </li></ul><ul><ul><li>Ophthalmologic findings ; visual loss, ophthalmoparesis </li></ul></ul><ul><ul><li>Mononeuropathies and peripheral neuropathies </li></ul></ul><ul><ul><li>TIA or stroke </li></ul></ul><ul><ul><li>others </li></ul></ul>
    41. 42. Diagnosis of temporal arteritis <ul><li>Based on clinical suspicion that is usually confirmed by laboratory testing </li></ul><ul><li>3 best test : westergren ESR, C-reactive protein(CRP), temporal artery biopsy </li></ul>
    42. 43. Headache due to severe HT <ul><li>Usually bioccipital throbbing </li></ul><ul><li>Can be generalized or frontal throbbing </li></ul><ul><li>Often present in the morning on awakening </li></ul><ul><li>Diastolic BP usually elevated to 120 mmHg or higher </li></ul>
    43. 44. Headaches and neoplasms <ul><li>Brain tumors are an uncommon cause of headache </li></ul><ul><li>8% of patient with headaches and brain tumors have a normal neurological examination </li></ul><ul><li>Papilledema is present in 40% </li></ul><ul><li>Headache related to size of tumor and amount of midline shift </li></ul>
    44. 45. Headaches and neoplasms (cont) <ul><li>Most common location of headaches is bifrontal </li></ul><ul><li>Most of headache are intermittent with moderate to severe intensity </li></ul><ul><li>‘ classic’ brain tumor headache---severe, worse in the morning, associated N/V---occurs in a minority of patients </li></ul>
    45. 46. Headache and intracranial pressure
    46. 48. Pseudotumor cerebri (idiopathic intracranial hypertension) <ul><ul><li>Neurological examination is normal except papilledema, visual loss, cranial nerve VI palsy </li></ul></ul><ul><ul><li>CSF pressure is increased (>20 cm H2O in nonobese and >25 cmH2O in obese patient) </li></ul></ul><ul><ul><li>CSF analysis is normal except decreased protein </li></ul></ul><ul><ul><li>No hydrocephalus or mass lesion </li></ul></ul><ul><ul><li>There are no other identifiable causes </li></ul></ul>
    47. 49. Pseudotumor cerebri <ul><li>>90% of patients are young obese women </li></ul><ul><li>Usually Primary or idiopathic </li></ul><ul><li>Secondary causes and associations </li></ul><ul><ul><li>Intracranial mass </li></ul></ul><ul><ul><li>Obstruction of ventricular system </li></ul></ul><ul><ul><li>Cerebral venous thrombosis </li></ul></ul><ul><ul><li>Meningitis/ encephalitis </li></ul></ul><ul><ul><li>Medications : Vitamin A, Minocycline, Anabolic steroids, Corticosteroid withdrawal </li></ul></ul>
    48. 50. Clinical manifestation of Pseudotumor cerebri <ul><li>Headache </li></ul><ul><ul><li>Pulsatile, daily, continuous </li></ul></ul><ul><ul><li>Unilateral, bilateral, frontal, occipital </li></ul></ul><ul><ul><li>[ bifrontotemporal is the most common ] </li></ul></ul><ul><ul><li>Nausea/vomiting </li></ul></ul><ul><ul><li>Orbital pain </li></ul></ul><ul><li>Papilledema </li></ul><ul><ul><li>Visual symptoms : transient visual obscuration, diplopia, visual loss, cranial nerve VI palsy </li></ul></ul>
    49. 51. Diagnostic evaluation of Pseudotumor cerebri <ul><li>CT or MRI brain </li></ul><ul><ul><li>Exclude tumor or hydrocephalus </li></ul></ul><ul><li>Lumbar puncture </li></ul><ul><ul><li>If the scans show no other explanation for papilledema </li></ul></ul><ul><ul><li>Measure opening pressure </li></ul></ul><ul><ul><li>CSF analysis should be normal except low protein level in some cases </li></ul></ul><ul><li>Ophthalmologist consultation </li></ul><ul><ul><li>Evaluate fundus, visual acuity, visual field </li></ul></ul>
    50. 52. Management of Pseudotumor cerebri <ul><li>Treat causes </li></ul><ul><li>Treatment of idiopathic Pseudotumor cerebri </li></ul><ul><ul><li>Lose weight for obese patients </li></ul></ul><ul><ul><li>Repeated LP to reduce pressure to 12-17.5 cm H2O </li></ul></ul><ul><ul><li>Medication for persistent headache </li></ul></ul><ul><ul><ul><li>drug for migraine headache </li></ul></ul></ul><ul><ul><ul><li>Diuretics </li></ul></ul></ul><ul><ul><ul><li>Acetazolamide </li></ul></ul></ul><ul><ul><li>Surgical treatments for papilledema and headache </li></ul></ul><ul><ul><ul><li>Optic nerve sheath fenestration </li></ul></ul></ul><ul><ul><ul><li>Lumboperitoneal shunt </li></ul></ul></ul>
    51. 53. Low CSF pressure headache <ul><li>Most often due to </li></ul><ul><ul><li>Post LP </li></ul></ul><ul><ul><li>Spontaneous occurrence </li></ul></ul><ul><ul><li>CSF shunt overdrainage </li></ul></ul>
    52. 54. Diagnostic evaluation of low CSF pressure headache <ul><li>Repeat LP : opening pressure 0-7cmH2O or in normal range </li></ul><ul><li>CSF analysis: normal or moderate, primarily lymphocytic pleocytosis, RBC, elevate protein </li></ul><ul><li>MRI brain : diffuse meningeal enhancement with gadolinium or subdural fluid collection </li></ul>
    53. 55. Intracranial hypotension
    54. 56. Post-Lumbar puncture headache <ul><li>Most common complication of lumbar puncture </li></ul><ul><li>Risk factors </li></ul><ul><ul><li>Female </li></ul></ul><ul><ul><li>Age 18-30 years </li></ul></ul><ul><ul><li>Lesser body mass index </li></ul></ul><ul><ul><li>Prior chronic or recurrent headache </li></ul></ul><ul><ul><li>Prior PLPH </li></ul></ul><ul><ul><li>Larger-diameter needle, perpendicular orientation of bevel, not reinsert the stylet </li></ul></ul>
    55. 57. Clinical manifestation of PLPH <ul><li>Bilateral, frontal, occipital, generalized pressure or throbbing occurring in upright position and decreasing or resolving when supine </li></ul><ul><li>Worse with headache movement, coughing, straining, sneezing, jugular venous compression </li></ul><ul><li>Begins within 48 hrs or 72 hrs </li></ul><ul><li>Additional symptoms : neck stiffness, nausea, vomiting </li></ul>
    56. 58. Headaches caused by Vasoactive substances <ul><li>Dilation of intracranial vessels </li></ul><ul><ul><li>Throbbing in nature and made worse by sudden head movement </li></ul></ul><ul><li>Examples </li></ul><ul><ul><li>Alcohol </li></ul></ul><ul><ul><li>Marijuana </li></ul></ul><ul><ul><li>Cocaine </li></ul></ul><ul><ul><li>Monosodium glutamate “Chinese restaurant syndrome” </li></ul></ul><ul><ul><li>Nitrite and Nitrates </li></ul></ul><ul><ul><li>Histamine headache </li></ul></ul><ul><li>Rebound headache : nicotine and caffeine </li></ul>
    57. 59. Headache due to infection and inflammation <ul><li>HIV and headache </li></ul><ul><ul><li>Cryptococcal meningitis, neurosyphilis, tuberculous meningitis, toxoplasmosis, CMV encephalitis, tumors, sinusitis, medications, primary headache </li></ul></ul><ul><li>Brain abscess </li></ul><ul><li>Meningitis and encephalitis </li></ul><ul><li>Drug-induced aseptic meningitis : NSAIDs, ATBs, vaccines, others,… </li></ul>
    58. 60. Metabolic disorders and headache <ul><li>Fever </li></ul><ul><li>Hypoxia </li></ul><ul><li>Hypercapnia </li></ul><ul><li>Hypoglycemia </li></ul><ul><li>Dialysis </li></ul><ul><li>High altitude </li></ul><ul><li>Decompression sickness </li></ul><ul><li>Hyperventilation syndrome </li></ul>
    59. 61. Primary Headache <ul><li>Migraine </li></ul><ul><li>Tension-type headache </li></ul><ul><li>Cluster </li></ul>
    60. 62. Headache type Migraines Tension-type Cluster Age at onset 10-40 20-50 15-40 Location Hemicranial Bilateral Unilateral peri/retro-orbital duration Several hours to 3 days 30 min to 7days+ 30-120 min Frequency/timing Variable Variable 1-8/day, nocturnal attacks severity Moderate to severe Dull ache may wax/wane Excruciating quality Throbbing, steady ache Band-like pressure Boring, piercing Associated features N/V, photo/phono/osmophobia, scotoma, neurologic deficits Generally none Ipsilateral conjunctival injection, lacrimation, nasal congestion, rhinorrhea, miosis, facial sweating
    61. 63. Migraine headache
    62. 64. Age- And Gender-specific Prevalence Of Migraine Lipton RB, Stewart WF. Neurology . 1993. Migraine Prevalence (5)
    63. 65. Migraine Without Aura
    64. 66. Migraine without aura <ul><li>A . At least 5 attacks fulfilling criteria B - D </li></ul><ul><li>B . Headache attacks lasting 4-72 hours ( untreated or unsuccessfully treated ) </li></ul><ul><li>C . Headache has at least 2 of the following characteristics : </li></ul><ul><li>- Unilateral location </li></ul><ul><li>- Pulsating quality </li></ul><ul><li>- Moderate or severe pain intensity </li></ul><ul><li>- Aggravation by or causing avoidance of routine physical activity ( eg, walking or climbing stairs ) </li></ul><ul><li>D . During headache at least 1 of the following : </li></ul><ul><li>- Nausea and / or vomiting </li></ul><ul><li>- Photophobia and phonophobia </li></ul><ul><li>E . Not attributed to another disorder </li></ul><ul><li>  </li></ul>
    65. 67. Migraine With Aura
    66. 68. Typical aura with Migraine headache(1) <ul><li>A . At least 2 attacks fulfilling criteria B - D </li></ul><ul><li>B . Aura consisting of at least 1 of the following, but no motor weakness : </li></ul><ul><li>- Fully reversible visual symptoms including positive features ( eg, flickering lights, spots or lines ) and / or negative features ( ie, loss of vision ) </li></ul><ul><li>- Fully reversible sensory symptoms including positive features ( ie, pins and needles ) and / or negative features ( ie, numbness ) </li></ul><ul><li>- Fully reversible dysphasic speech disturbance </li></ul>
    67. 69. Typical aura with Migraine headache(2) <ul><li>C . At least two of the following : </li></ul><ul><li>- Homonymous visual symptoms and / or unilateral sensory symptoms </li></ul><ul><li>- At least one aura symptom develops gradually over > /= 5 minutes and / or different aura symptoms occur in succession over > /= 5 minutes </li></ul><ul><li>- Each symptom lasts > /= 5 and < /= 60 minutes </li></ul><ul><li>D . Headache fulfilling criteria B - D for “Migraine without aura” begins during the aura or follows aura within 60 minutes </li></ul><ul><li>E . Not attributed to another disorder </li></ul><ul><li>  </li></ul>
    68. 70. Visual Aura
    69. 71. Aura-Numbness
    70. 72. <ul><li>1. Prodrome </li></ul><ul><li>2. Aura </li></ul>Phases of Migraine Attack 3. Headache 4. Postdrome
    71. 73. Migraine Treatment <ul><li>Reassure and educate patient </li></ul><ul><li>Identify and remove triggers </li></ul><ul><li>Start a wellness program : exercise, balanced meals, adequate sleep, smoking cessation </li></ul><ul><li>pharmacotherapy </li></ul><ul><li>physical therapy </li></ul><ul><li>psychological therapy </li></ul>
    72. 74. Migraine Triggers <ul><li>Stress and emotion </li></ul><ul><li>Hormonal changes </li></ul><ul><li>Diet </li></ul><ul><li>Environmental factors </li></ul><ul><li>Too much or too little sleep </li></ul><ul><li>Physical factors </li></ul>
    73. 75. Acute vs Preventive Therapy <ul><li>Acute (Abortive) : Taken after attack has begun to relieve pain and disability and stop progression </li></ul><ul><li>Preventive Therapy : Taken daily to reduce attack frequency, severity, and duration </li></ul>
    74. 76. Acute Migraine Medications <ul><li>Non-specific </li></ul><ul><ul><li>NSAIDs : naproxen, ibuprofen </li></ul></ul><ul><ul><li>Combination analgesics : acetaminophen/aspirin/caffeine </li></ul></ul><ul><ul><li>Neuroleptics/antiemetics : metoclopramide, prochlorperazine </li></ul></ul><ul><li>Specific </li></ul><ul><ul><li>Ergotamine/DHE </li></ul></ul><ul><ul><li>Triptans : sumatriptan, zolmitriptan </li></ul></ul><ul><ul><li>CGRP antagonist :olcegepant, MK-0974 </li></ul></ul>
    75. 77. Migraine Prevention <ul><li>Classes of preventive drugs: </li></ul><ul><ul><li>Antiepileptics : topiramate, valproate, gabapentin </li></ul></ul><ul><ul><li>Tricyclic antidepressant : amitryptyline, nortriptyline </li></ul></ul><ul><ul><li>SNRI : venlafaxine, duloxetine </li></ul></ul><ul><ul><li>Beta-blockers : propanolol </li></ul></ul><ul><ul><li>Calcium channel blockers : flunarizine </li></ul></ul><ul><ul><li>Other treatment : magnesium, riboflavin, co-enzyme Q10, feverfew, butterbur root, botulinum toxin </li></ul></ul><ul><ul><li>No efficacy : nimodipine, clonidine, fluoxetine </li></ul></ul>
    76. 78. Tension-type Headache
    77. 79. Tension - type headache ( TTH ) <ul><li>- Headache lasting from 30 minutes to 7 days </li></ul><ul><li>- Headache has at least 2 of the following characteristics : </li></ul><ul><li>- Bilateral location </li></ul><ul><li>- Pressing / tightening ( non - pulsating ) quality </li></ul><ul><li>- Mild or moderate intensity </li></ul><ul><li>- Not aggravated by routine physical activity such as walking or climbing stairs </li></ul><ul><li>- Both of the following : </li></ul><ul><li>- No nausea or vomiting ( anorexia may occur ) </li></ul><ul><li>- No more than one of photophobia or phonophobia </li></ul><ul><li>- Not attributed to another disorder </li></ul><ul><li>  </li></ul>
    78. 80. TTH management <ul><li>Simple analgesic : acetaminophen, aspirin, NSAIDs </li></ul><ul><li>Behavioral approach : relaxation </li></ul><ul><li>Triptans in pure TTH are not helpful </li></ul><ul><li>For chronic TTH : amitryptyline </li></ul>
    79. 81. Cluster Headache <ul><li>Severe unilateral pain </li></ul><ul><li>Associated with lacrimation, sweating, ptosis, conjunctival injection, and eyelid edema </li></ul><ul><li>May be precipitated by alcohol, histamine, or nitroglycerine </li></ul>
    80. 82. Cluster Headache <ul><li>A . At least 5 attacks fulfilling criteria B - D </li></ul><ul><li>B . Severe or very severe unilateral orbital, supraorbital and / or temporal pain lasting 15-180 minutes if untreated </li></ul><ul><li>C . Headache is accompanied by at least 1 of the following : </li></ul><ul><li>- Ipsilateral conjunctival injection and / or lacrimation </li></ul><ul><li>- Ipsilateral nasal congestion and / or rhinorrhea </li></ul><ul><li>- Ipsilateral eyelid edema </li></ul><ul><li>- Ipsilateral forehead and facial sweating </li></ul><ul><li>- Ipsilateral miosis and / or ptosis </li></ul><ul><li>A sense of restlessness or agitation </li></ul><ul><li>D . Attacks have a frequency from 1 every other day to 8 / day </li></ul><ul><li>E . Not attributed to another disorder </li></ul>
    81. 83. Treatment of Cluster Headache <ul><li>Acute treatment </li></ul><ul><ul><ul><li>100% Oxygen inhalation </li></ul></ul></ul><ul><ul><ul><li>Rapid acting DHE </li></ul></ul></ul><ul><ul><ul><li>Sumatriptan subcutaneously </li></ul></ul></ul>
    82. 84. Cluster Headache Preventive Treatment <ul><li>Short-term </li></ul><ul><ul><li>Prednisolone 1 mg/kg/d tapering over 21 days </li></ul></ul><ul><ul><li>Verapamil </li></ul></ul><ul><ul><li>Greater occipital nerve injection </li></ul></ul><ul><li>Long-term </li></ul><ul><ul><li>verapamil </li></ul></ul><ul><ul><li>Lithium </li></ul></ul><ul><ul><li>Topiramate </li></ul></ul><ul><ul><li>Gabapentin </li></ul></ul><ul><ul><li>melatonin </li></ul></ul>
    83. 85. Thank you for your attention

    ×