Headache By Dr. Osman Sadig Bukhari
<ul><li>-  HA is defined as feeling of pain, aches or  discomfort in za cranium, face or upper  neck.   -  Headache is za ...
<ul><li>- Cause vary from trivial nuisance to  serious intra cranial disease  </li></ul><ul><li>- HA may be due to disease...
<ul><li>classification of HA </li></ul><ul><li>1-  Non life threatening HA  e.g. migraine,  tension HA, cluster HA, facial...
<ul><li>HA how to diagnose? </li></ul><ul><li>History: </li></ul><ul><li>- Age, sex, occupation, etc. </li></ul><ul><li>- ...
<ul><li>Examination: </li></ul><ul><li>- temp, BP, gen ex including teeth, gums,  neck stiffness, temporal tenderness  </l...
<ul><li>Investigations: </li></ul><ul><li>- not all HA require investigations </li></ul><ul><li>- simple investigations ma...
<ul><li>- Only 5-10% of pts wz HA need brain scan </li></ul><ul><li>-  Brain scan if  :  - SOL  - focal N  signs  - if sus...
<ul><li>-  Lumber puncture if:  - acute & chronic CNS infections  - BIH  - if  Ca meningitis is suspected  - normal pressu...
<ul><li>Alarming signs: </li></ul><ul><li>- sudden onset severe HA  - fever > 39 C </li></ul><ul><li>- decreased alertness...
<ul><li>Mechanism of headache </li></ul><ul><li>- Brain substance is devoid of pain receptors  </li></ul><ul><li>- Pain re...
<ul><li>HA, D.D: </li></ul><ul><li>1- A ccording to age : migr in teenagers </li></ul><ul><li>2- A ccording to gender :- m...
<ul><li>5- A ccording to severity :- very severe and  acute in   severe & recurrent in cluster  HA, moderately severe  SAH...
<ul><li>Causes of headache </li></ul><ul><li>1-  Referred headache </li></ul><ul><li>2- Vascular headache   </li></ul><ul>...
<ul><li>Referred headache </li></ul><ul><li>-  Eyes : glucoma, irirtis, refractory errors.. </li></ul><ul><li>-  Para nasa...
<ul><li>Tension headache </li></ul><ul><li>- Commonest chronic headache </li></ul><ul><li>- Nuchal or generalized, constan...
<ul><li>- Immaging to exclude intra cranial disease </li></ul><ul><li>and to allay za anxiety of za pat </li></ul><ul><li>...
<ul><li>Migraine </li></ul><ul><li>- Migraine is a recurrent episodic, throbbing  </li></ul><ul><li>headache, associated w...
<ul><li>Mechanism of migraine </li></ul><ul><li>- Intra cerebral vasoconstriction at za onset </li></ul><ul><li>due to 5HT...
<ul><li>Clinical features of migraine </li></ul><ul><li>1-  Classic migraine :- </li></ul><ul><li>- Aura precedes or accom...
<ul><li>4-  Basilar migraine :- The headache is preceded </li></ul><ul><li>by brain stem S & S. </li></ul><ul><li>5-  Opht...
<ul><li>Precipitating factors </li></ul><ul><li>1- Dietary:- alcohol, cheese, chocolate. </li></ul><ul><li>2- Contraceptiv...
<ul><li>Differential diagnosis of migraine </li></ul><ul><li>1-  Meningitis & SAH  (acute onset) </li></ul><ul><li>2-  Thr...
<ul><li>Management of migraine </li></ul><ul><li>- Avoid ppting factors e.g. dietary, pills </li></ul><ul><li>- Start trea...
<ul><li>-  Ergotamine tartarate  is now rarely used. </li></ul><ul><li>Over dose is serious. Also avoided in vascular </li...
<ul><li>-  Sodium valporate  300mg bid. </li></ul><ul><li>-  Methysergide  ( 5HT antagonist) may cause  </li></ul><ul><li>...
<ul><li>Cluster headaches </li></ul><ul><li>- Excoriating recurrent headaches clustered  </li></ul><ul><li>around one eye ...
<ul><li>Cluster HA   Migraine </li></ul><ul><li>- sex:  male  female </li></ul><ul><li>- age:  20-40  15-20 </li></ul><ul>...
<ul><li>Pressure headaches ( ICP) </li></ul><ul><li>- Due to intracranial mass lesion displacing and </li></ul><ul><li>str...
<ul><li>Benign intracranial hypertension </li></ul><ul><li>( Pseudo tumor cerebri)-  BIH. </li></ul><ul><li>- Increased IC...
<ul><li>- Spontaneous remission may occur over Ms & yr </li></ul><ul><li>but there is always threat to vision which  </li>...
<ul><li>Temporal arteritis (giant cell </li></ul><ul><li>arteritis) </li></ul><ul><li>- There is granulomatous arteritis o...
<ul><li>- Visual symptoms include blurring of vision,  amaurosis fugax, diplopia, ophthalmoplegia  and may proceed to ipsi...
<ul><li>-  ESR, CRP & alpha2 globulins with normocytic  normochromic anaemia </li></ul><ul><li>- history, clinical ex, FBC...
<ul><li>Problem </li></ul><ul><li>36 year old lady, mother of 2, smoker & on </li></ul><ul><li>contraceptive pills. </li><...
<ul><li>CXR & CT brain are normal. </li></ul><ul><li>What is the diagnosis? </li></ul><ul><li>What is next step? </li></ul...
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Headache

  1. 1. Headache By Dr. Osman Sadig Bukhari
  2. 2. <ul><li>- HA is defined as feeling of pain, aches or discomfort in za cranium, face or upper neck. - Headache is za most common neurological symptom </li></ul><ul><li>- Almost every one have had it </li></ul><ul><li>- Not all HA have an intra cranial cause </li></ul><ul><li>or due to brain tumours </li></ul><ul><li>- Not all pts wz HA require brain scan </li></ul><ul><li>- > 75% of HA can be diagnosed by history </li></ul><ul><li>- Hypotension causes HA > HT </li></ul>
  3. 3. <ul><li>- Cause vary from trivial nuisance to serious intra cranial disease </li></ul><ul><li>- HA may be due to disease of nearby structures: sinuses, T/M joint, teeth , gums, tonsils, ears, eyes, neck, etc. </li></ul>
  4. 4. <ul><li>classification of HA </li></ul><ul><li>1- Non life threatening HA e.g. migraine, tension HA, cluster HA, facial pain, cervicogenic HA </li></ul><ul><li>2- Life threatening HA: infections (meningitis, encephalitis), intra cranial bleeding, SOL, temporal arteritis </li></ul><ul><li>HA may be acute ( migraine, SAH, meningitis) or chronic (tension HA, ICP ) </li></ul>
  5. 5. <ul><li>HA how to diagnose? </li></ul><ul><li>History: </li></ul><ul><li>- Age, sex, occupation, etc. </li></ul><ul><li>- Onset , site, duration, nature, severity, frequency, change wz cough, bending & straining, relation to menses, precipt or aggravating or relieving factors, response to TR, etc. </li></ul>
  6. 6. <ul><li>Examination: </li></ul><ul><li>- temp, BP, gen ex including teeth, gums, neck stiffness, temporal tenderness </li></ul><ul><li>- Full neurological ex including fundoscopy. </li></ul>
  7. 7. <ul><li>Investigations: </li></ul><ul><li>- not all HA require investigations </li></ul><ul><li>- simple investigations may give a diagnosis: FBC ( anaemia & high ESR in temp arteritis, leucocytosis in infections, polycythemia), BUN and E, LFT, CXR </li></ul>
  8. 8. <ul><li>- Only 5-10% of pts wz HA need brain scan </li></ul><ul><li>- Brain scan if : - SOL - focal N signs - if suspect intra cranial infection - disc margin is not clear - change in HA pattern - if suspect BIH. </li></ul>
  9. 9. <ul><li>- Lumber puncture if: - acute & chronic CNS infections - BIH - if Ca meningitis is suspected - normal pressure hydrocephalus </li></ul>
  10. 10. <ul><li>Alarming signs: </li></ul><ul><li>- sudden onset severe HA - fever > 39 C </li></ul><ul><li>- decreased alertness - trauma </li></ul><ul><li>- HA wz seizures - persistent HA </li></ul><ul><li>- HA interfering wz normal life or that cause </li></ul><ul><li>sleep disturbance </li></ul><ul><li>- change in sleep pattern </li></ul>
  11. 11. <ul><li>Mechanism of headache </li></ul><ul><li>- Brain substance is devoid of pain receptors </li></ul><ul><li>- Pain receptors are present in za meninges, </li></ul><ul><li>blood vessels in za base of za brain, extra </li></ul><ul><li>cranial vessels & face. Nerve impulses travel centrally via za 5 th , 9 th and upper cervical </li></ul><ul><li>sensory roots. </li></ul><ul><li>- Sensory receptors are stimulated mechanically </li></ul><ul><li>by stretch & distension or chemically by </li></ul><ul><li>5HT & histamine. </li></ul>
  12. 12. <ul><li>HA, D.D: </li></ul><ul><li>1- A ccording to age : migr in teenagers </li></ul><ul><li>2- A ccording to gender :- migr > in females, </li></ul><ul><li>cluster HA > in males, temp arteritis > in </li></ul><ul><li>females </li></ul><ul><li>3- A ccording to site :-frontal in sinusitis, temporal </li></ul><ul><li>in migr & temp arteritis, occipital in SAH </li></ul><ul><li>4- A ccording to timing :- new early morning HA in </li></ul><ul><li>SOL, acute HA during activity in SAH, evening </li></ul><ul><li>HA in tension HA </li></ul>
  13. 13. <ul><li>5- A ccording to severity :- very severe and acute in severe & recurrent in cluster HA, moderately severe SAH, severe & temp in temp arteritis, very severe & dull in SOL. 6- According to associated symptoms :- fever and photophobia in meningitis, HA increased by cough & sneezing in SOL; visual symptoms in SOL, BIH, migr and TIA </li></ul>
  14. 14. <ul><li>Causes of headache </li></ul><ul><li>1- Referred headache </li></ul><ul><li>2- Vascular headache </li></ul><ul><li>- migraine - temporal arteritis </li></ul><ul><li>- A/V malformation & aneurysms </li></ul><ul><li>- Severe HT - Vasodilt. from alcohol & CO2 </li></ul><ul><li>3- Tension headache 4 - meningeal irritation </li></ul><ul><li>5- Neuralgic headache </li></ul><ul><li>6- ICP </li></ul><ul><li>7- Systemic causes . </li></ul>
  15. 15. <ul><li>Referred headache </li></ul><ul><li>- Eyes : glucoma, irirtis, refractory errors.. </li></ul><ul><li>- Para nasal sinuses : sinusitis </li></ul><ul><li>- Ears : otitis media & externa </li></ul><ul><li>- Throat : tonsillitis </li></ul><ul><li>- Cervical sponylosis </li></ul><ul><li>- Teeth </li></ul><ul><li>- Tempro mandibular arthritis . </li></ul><ul><li>** Treatment is by analgesics & that of the </li></ul><ul><li>underlying cause. </li></ul>
  16. 16. <ul><li>Tension headache </li></ul><ul><li>- Commonest chronic headache </li></ul><ul><li>- Nuchal or generalized, constant or dull or tight </li></ul><ul><li>pressure pain wz local tenderness & associated </li></ul><ul><li>with anxiety or depression. </li></ul><ul><li>- Variable in duration & intensity </li></ul><ul><li>- Often ppted by stress, depression, noises and </li></ul><ul><li>fumes. </li></ul><ul><li>- No vomiting or photophobia </li></ul><ul><li>- Careful history & exam clarify za diagnosis </li></ul><ul><li>and reassures za pat. </li></ul>
  17. 17. <ul><li>- Immaging to exclude intra cranial disease </li></ul><ul><li>and to allay za anxiety of za pat </li></ul><ul><li>- Management includes: </li></ul><ul><li>- Reassurance </li></ul><ul><li>- Avoidance of ppting causes. </li></ul><ul><li>- Massage & ice bags </li></ul><ul><li>- Analgesics </li></ul><ul><li>- Treatment of za underlying anxiety and </li></ul><ul><li>depression. </li></ul>
  18. 18. <ul><li>Migraine </li></ul><ul><li>- Migraine is a recurrent episodic, throbbing </li></ul><ul><li>headache, associated wz prostration, nausea, </li></ul><ul><li>vomiting & photophobia +/_ focal neurological </li></ul><ul><li>symptoms & signs ( usually visual in classic </li></ul><ul><li>migraine). </li></ul><ul><li>- 20% of females & 6% of males will have an </li></ul><ul><li>attack in their life time. </li></ul><ul><li>- Genetic predisposition ( 50% have FH) </li></ul><ul><li>- 1 st episode before puberty is rare. </li></ul><ul><li>- Interval between attacks varies & episodes </li></ul><ul><li>last hours to days. </li></ul>
  19. 19. <ul><li>Mechanism of migraine </li></ul><ul><li>- Intra cerebral vasoconstriction at za onset </li></ul><ul><li>due to 5HT release causes transient focal neurological S & S, prodrome or aura lasting 15-60 min. </li></ul><ul><li>- Headache is due to vasodilt. of meningeal and </li></ul><ul><li>extra cranial arteries with stimulation of nerve </li></ul><ul><li>endings. This is due to release of vasoactive subst. like NO2. 5HT falls during headache. </li></ul>
  20. 20. <ul><li>Clinical features of migraine </li></ul><ul><li>1- Classic migraine :- </li></ul><ul><li>- Aura precedes or accompany za headache. </li></ul><ul><li>- Headache is throbbing & associated with nausea, vomiting, irritability, photophobia. Superficial temporal may be engorged & pulsating. Sleep may follow an attack. </li></ul><ul><li>2- Common migraine : migraine without aura. </li></ul><ul><li>3- Hemiplegic migraine : This is classic migraine </li></ul><ul><li>followed by hemiparesis recovering within </li></ul><ul><li>24 hours </li></ul>
  21. 21. <ul><li>4- Basilar migraine :- The headache is preceded </li></ul><ul><li>by brain stem S & S. </li></ul><ul><li>5- Ophthalmoplegic migraine :- There is </li></ul><ul><li>ophthalmoplegia during za attack- rare. </li></ul><ul><li>6- Facioplegic migraine . </li></ul>
  22. 22. <ul><li>Precipitating factors </li></ul><ul><li>1- Dietary:- alcohol, cheese, chocolate. </li></ul><ul><li>2- Contraceptive pills, pre & post menstrual and </li></ul><ul><li>pregnancy ( hormonal influences). </li></ul><ul><li>3- Stress </li></ul><ul><li>4- Rarely follows head injury </li></ul><ul><li>5- Rarely follows development of HT </li></ul><ul><li>6- No triggering cause in 50%. </li></ul>
  23. 23. <ul><li>Differential diagnosis of migraine </li></ul><ul><li>1- Meningitis & SAH (acute onset) </li></ul><ul><li>2- Thromboembolic TIA ( headache is rare) </li></ul><ul><li>3- Sensory epilepsy wz unilateral numbness </li></ul><ul><li>( headache unusual) </li></ul><ul><li>4- Tension headache </li></ul><ul><li>5- Cluster headache ( usually wz watery eyes) </li></ul><ul><li>6- Referred headache </li></ul>
  24. 24. <ul><li>Management of migraine </li></ul><ul><li>- Avoid ppting factors e.g. dietary, pills </li></ul><ul><li>- Start treatment early in za attack. </li></ul><ul><li>- Simple analgesics +/- anti emetics will abort </li></ul><ul><li>most attacks except za severe ones. </li></ul><ul><li>- Premenstrual migraine may respond to diuretics </li></ul><ul><li>- Triptans ( 5HT1 agonist) in severe </li></ul><ul><li>migraine e.g. sumatriptan, zolmitriptan. Thy </li></ul><ul><li>are potent extra cranial vasoconstrictor. 1 st </li></ul><ul><li>dose is followed by za 2 nd dose 2h later if </li></ul><ul><li>there is no response. Avoided in vascular dis. </li></ul>
  25. 25. <ul><li>- Ergotamine tartarate is now rarely used. </li></ul><ul><li>Over dose is serious. Also avoided in vascular </li></ul><ul><li>dis. & pregnancy. </li></ul><ul><li>Prophylaxis </li></ul><ul><li>It is used in frequent attacks disturbing work </li></ul><ul><li>and social life ( 2 attacks or more / month). </li></ul><ul><li>- B-blockers e.g. propranolol 10mgX3– 40-80mg </li></ul><ul><li>X3. </li></ul><ul><li>- Pizotifen (antihistamine & 5HT antagonist): </li></ul><ul><li>0.5mg noct increasing to 1.5mg </li></ul><ul><li>- Tricyclic antidepressants e.g. amitrypt 10-50mg </li></ul>
  26. 26. <ul><li>- Sodium valporate 300mg bid. </li></ul><ul><li>- Methysergide ( 5HT antagonist) may cause </li></ul><ul><li>retroperitoneal fibrosis. Therefore used in </li></ul><ul><li>resistant cases for short periods (3/12). </li></ul>
  27. 27. <ul><li>Cluster headaches </li></ul><ul><li>- Excoriating recurrent headaches clustered </li></ul><ul><li>around one eye & awakening the patient </li></ul><ul><li>- Less common than migraine & little genetic </li></ul><ul><li>predisposition. </li></ul><ul><li>- Male affected more than female & attacks are </li></ul><ul><li>brief. More common in heavy smokers and </li></ul><ul><li>alcohol may ppt it. </li></ul><ul><li>- Excessive lacrimation, conjunctival & nasal </li></ul><ul><li>congestion may occur, rarely transient Horners. </li></ul><ul><li>- Triptans abort za attack & O2 inhalation is </li></ul><ul><li>useful. Lithium & verapamil for prophylaxis. </li></ul>
  28. 28. <ul><li>Cluster HA Migraine </li></ul><ul><li>- sex: male female </li></ul><ul><li>- age: 20-40 15-20 </li></ul><ul><li>- frequency: several/day 1-4/month </li></ul><ul><li>- unilaterality: unilateral unilat/ bilateral </li></ul><ul><li>- nausea & V: rare common </li></ul><ul><li>- during attack: sitting rest/ quiet </li></ul>
  29. 29. <ul><li>Pressure headaches ( ICP) </li></ul><ul><li>- Due to intracranial mass lesion displacing and </li></ul><ul><li>stretching meninges & basal blood vessels </li></ul><ul><li>either directly or due to ICP. </li></ul><ul><li>- Headache increases wz cough, straining and </li></ul><ul><li>after lying down due to increased pressure and </li></ul><ul><li>cerebral oedema. </li></ul><ul><li>- There is associated evidence of ICP e.g. vomit </li></ul><ul><li>blurring of vision, focal signs, disturbed conscio </li></ul><ul><li>usnes, false localizing signs, seizures, papilloed </li></ul>
  30. 30. <ul><li>Benign intracranial hypertension </li></ul><ul><li>( Pseudo tumor cerebri)- BIH. </li></ul><ul><li>- Increased ICP without SOL, ventricular dilatation or CSF obstruction or impairment of consciousness. </li></ul><ul><li>- Occur usually in obese females wz menstrual disturbances, usually during child bearing age - Tetracyclines, vit A, pills and steroid, may be other causes. - Headache and papilloedema wz threat to vision +/- false localizing signs, but no focal </li></ul><ul><li>neurological deficit. </li></ul><ul><li>- CSF is under pressure, but CT brain is normal. </li></ul>
  31. 31. <ul><li>- Spontaneous remission may occur over Ms & yr </li></ul><ul><li>but there is always threat to vision which </li></ul><ul><li>should be monitored. </li></ul><ul><li>- Dietary advice & stopping offending the drugs - Management by: - repeated LP & diuretics. </li></ul><ul><li>- Shunt insertion - Avoid steroids because of recurrence on withdrawal. </li></ul>
  32. 32. <ul><li>Temporal arteritis (giant cell </li></ul><ul><li>arteritis) </li></ul><ul><li>- There is granulomatous arteritis of unknown </li></ul><ul><li>cause ( ? AI) occurring over the age of 60 </li></ul><ul><li>affecting extradural arteries & closely related </li></ul><ul><li>to polymyalgia rheumatica which may co exist. </li></ul><ul><li>- F:M=2:1. Age= >55 years </li></ul><ul><li>- There is severe headache over za inflammed </li></ul><ul><li>superficial temp arteries which is thickened, </li></ul><ul><li>tortuous, non pulsatile & tender. The overlying </li></ul><ul><li>skin is red & gangrenous patches over scalp </li></ul><ul><li>may be found. </li></ul>
  33. 33. <ul><li>- Visual symptoms include blurring of vision, amaurosis fugax, diplopia, ophthalmoplegia and may proceed to ipsilateral blindness within an hour in 25%. </li></ul><ul><li>- Facial pain & claudication of za mandible may </li></ul><ul><li>also occur. </li></ul><ul><li>- Constitutional symptoms wz fever, night sweats, muscle pain , malaise, anorexia & Wt loss may occur - Ischemic lesions may occur in other organs. </li></ul>
  34. 34. <ul><li>- ESR, CRP & alpha2 globulins with normocytic normochromic anaemia </li></ul><ul><li>- history, clinical ex, FBC & ESR, CRP suggest </li></ul><ul><li>diagnosis and superficial temp artery biopsy shows typical pathology </li></ul><ul><li>- Prednisolone 60-100mg given early tapered </li></ul><ul><li>as symptoms resolve(2/12) or ESR comes down. Response within hours and histology of sup temp artery normalize within 48h. TR may cont. for Ms or years. </li></ul>
  35. 35. <ul><li>Problem </li></ul><ul><li>36 year old lady, mother of 2, smoker & on </li></ul><ul><li>contraceptive pills. </li></ul><ul><li>- C/o headache for 9/12, associated with blurring </li></ul><ul><li>of vision. Headache is severe & generalized. </li></ul><ul><li>- Ex: she is slightly overweight, Bp 140/80, no </li></ul><ul><li>neck stiffness. There is bilateral papilloedema. CNS Ex </li></ul><ul><li>intact. No pyramidal or cerebellar signs. Normal </li></ul><ul><li>systemic Ex. What is the diff diagnosis? </li></ul><ul><li>- Investigation: CBC= normal, ESR= normal. </li></ul><ul><li>Blood urea, electrolytes & LFT= normal </li></ul>
  36. 36. <ul><li>CXR & CT brain are normal. </li></ul><ul><li>What is the diagnosis? </li></ul><ul><li>What is next step? </li></ul><ul><li>What is the management? </li></ul>

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