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