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Mellss med yr3 headache
1) Tension- type Headache
2) TrigeminalAutonomic Cephalgias
a) Cluster headache
b) Paroxysmal hemicrania
c) SUNCT/SUNA
3) Chronic Daily Headache
4) Other Primary Headache
 Chronic head-pain
syndrome
 Diagnosis:
 No nausea, vomiting,
photophobia,
phonophobia,
 No throbbing sensation
 No aggravation with
movement
 Differential diagnosis :
 MIGRAINE
 Certain patient may
haveTTH with migraine
Characteristic
Site : Bilateral
Onset: Builds slowly
Character: Tight, bandlike discomfort
Timing: continuously for many days
or episodic or chronic (>15
days/m).
Severity Flunctuates
 Pathophysiology :incompletely understood.
 Due to a primary disorder of CNS pain
modulation or genetic .
 Treatment
 Simple analgesics (acetaminophen, aspirin, or
NSAIDs)
 Relaxation
 Triptans inTTH with migraine.
 ChronicTTH :amitriptyline
 Group of primary headaches
 Cluster headache
 Paroxysmal hemicrania
 Sunct /suna
 Differential diagnosis:
 Sinus headache, trigeminal neuralgia, primary stabbing headache,
and hypnic headache
 IncreasedTACs presentation may be due to pituitary tumor.
Charact
Associat
ion:
lacrimation, conjunctival injection,nasal
congestion
Timing: Short , occur > 1/d
Severity Severe
 Rare (0.1%.)
 M>F
 Patients tend to move
during attacks (pacing/
rocking/ rubbing their
head for relief)
 Unilateral photophobia/
phonophobia on the same
side of the pain
S •Unilateral,retroorbital,
O •50% nocturnal , explosive
C •deep , stabbing
A •ipsilateral conjunctival injection/
lacrimation /rhinorrhea /nasal congestion /
ptosis
T •recurs at same hour for same duration
•daily 1-2 short attacks X 8 - 10 w/y followed
by a pain-free interval (<1y)
•Chronic ( no period of sustained remission)
S •excruciating ,nonfluctuating,
 Acute attack
 100% oxygen at
10-12L/min for
15-20min
 Sumatriptan
6mg SC
 Nasal sprays
▪ Sumatriptan (20
mg)
▪ zolmitriptan (5
mg)
Short –term
prevention
Long-term prevention
Episodic cluster
headache
Episodic & prolonged
chronic cluster headache
Prednisone 1 mg/kg
up to
Verapamil 160–960 mg/d
60 mg qd, tapering Lithium 400–800 mg/d
over 21 days Methysergide 3–12 mg/d
Topiramate 100–400 mg/d
Methysergide 3–12
mg/d
Gabapentin 1200–3600 mg/d
Verapamil 160–960
mg/d
Melatonin 9–12 mg/d
Ergotamine 1-2mg Deep brain stimulation of
posterior hypothalamus
 Male:female ratio is 1:1.
 Treatment
 Indomethacin (25–75 mg tid),
 Topiramate
 Piroxicam
 Secondary PH
 If patient requires high doses
indomethacin (>200 mg/d)
 Sella turcica lesions
(arteriovenous malformation,
cavernous sinus meningioma,
epidermoid tumors.)
 Bilateral PH
 Raised CSF pressure
Charact.
Site : Unilateral , retroorbital
Associat
ion:
lacrimation and nasal
congestion
Timing: Frequent(>5/d) ,
short ( 2-45min) and
rapid course(<72h)
Severity excruciating
SUNCT (short-lasting unilateral
neuralgiform headache attacks with
conjunctival injection and tearing)
SUNA (short-lasting unilateral
neuralgiform headache attacks with
cranial autonomic symptoms)
 Basic patterns
 short-lived single stab
 groups of stabs
 a longer attack ("saw-tooth" )
 Differential diagnosis
 trigeminal neuralgia (TN)
 Secondary (Symptomatic) SUNCT
 Posterior fossa or pituitary lesions.
 Pituitary function tests ,brain MRI
Charac.
Site : unilateral orbital or
temporal
Character: stabbing or throbbing
Association: ipsilateral conjunctival
injection and
lacrimation
Timing: >20 attacks, lasting for
5–240s , no refractory
period
Exacerbatin
g factors:
Cutaneous triggers
Severity severe
 AbortiveTherapy
 IV lidocaine(hospitalized
patients.) to arrest
symptoms
 PreventiveTherapy
 Goal:minimize disability
and hospitalization
 Medical approaches
▪ Lamotrigine, 200–400 mg/d.
▪ Topiramate and gabapentin.
▪ Carbamazepine, 400–500
mg/d
 Surgical approaches
▪ Microvascular
decompression or
destructive trigeminal
procedures
▪ Greater occipital nerve
injection
▪ Occipital nerve stimulation
▪ deep-brain stimulation of
the posterior hypothalamic
region
 Short-term prevention
(intractable cases)
▪ IV lidocaine
▪ occipital nerve stimulation.
Cluster
Headache
Paroxysmal
Hemicrania
SUNCT
Gender M > F F = M F ≈M
Type Stabbing, boring Throbbing, boring,
stabbing
Burning, stabbing,
sharp
Severity Excruciating Excruciating Severe to
excruciating
Site Orbit, temple Orbit, temple Periorbital
Attack
frequency
1/alternate day–8/d 1–40/d (>5/d for more
than half the time)
3–200/d
Duration 15–180 min 2–30 min 5–240 s
Alcohol trigger Yes No No
Cutaneous
triggers
No No Yes
Abortive
treatment
Sumatriptan injection
or nasal spray
Oxygen
No effective treatment Lidocaine (IV)
Prophylactic
treatment
Verapamil
Methysergide
Lithium
Indomethacin Lamotrigine
Topiramate
Gabapentin
 >15days/month
Primary Secondary
<4 h Daily >4 h Daily Posttraumatic
• Head injury
• Iatrogenic
• Postinfectious
Chronic cluster
headache
Chronic migraine
Chronic paroxysmal
hemicrania
Chronic tension-type
headache
Inflammatory
• Giant cell arteritis
• Sarcoidosis
• Behçet's syndrome
SUNCT/SUNA Hemicrania continua Chronic CNS infection
Hypnic headache New daily persistent
headache
Medication-overuse
headache
 If it is a medically
intractable
disablingCDH
 Occipital nerve
stimulation
 Most are female
 Onset >60 years.
 Differential diagnosis:
 Poorly controlled hypertension.
 Treatment:
 Lithium carbonate (200–600 mg) at
bedtime
 Verapamil (160 mg)
 Methysergide (1–4 mg at bedtime)
 One to two cups of coffee
/caffeine, 60 mg orally, at bedtime
 Flunarizine, 5 mg nightly.
Chara
c.
Site : Uni/bilateral
Onset
:
a few hours after sleep
Chara
cter:
generalized /throbbing
Timin
g:
15 – 30 min , <3
repetitions/ night
Sever
ity
moderately severe
 Essential features :
 Moderate , continuous unilateral pain with fluctuations of severe pain
 Complete resolution of pain with indomethacin
 Associated with conjunctival injection, lacrimation, and photophobia
on same side
 Age of onset :11 to 58 years.
 Woman: man = 2:1
 Treatment
 IM injection of 100 mg indomethacin
 Oral indomethacin (initial,25 mg tid, then 50 mg tid,75 mg
 Topiramate
 Patients unable to tolerate indomethacin
▪ Occipital nerve stimulation
 Abrupt onset / gradual Primary NDPH
 Migrainous type
 unilateral
headache,throbbing pain,
nausea, photophobia,
phonophobia
 Treatment :preventive
therapies of migraine
 Featureless type
 refractory to treatment
 86% headache-free after
2 years
Primary
NDPH
Secondary NDPH
Migrainous-
type
Subarachnoid
hemorrhage
Featureless
(tension-type)
Low CSF volume
headache
Raised CSF pressure
headache
Posttraumatic
headache
Chronic meningitis
i. Low CSFVolume Headache
 Dull, throbbing
occipitofrontal headache
that not present on waking
up , worsen as day progress
and relieved by
recumbency position
 Cause :
 CSF leak after lumbar puncture
(within 48 h -12 d)
 index events (epidural injection
or vigorous Valsalva
maneuver)
 Differential diagnosis:
 Postural orthostatic
tachycardia syndrome [POTS ]
 Investigations:
 Brain MRI -diffuse meningeal
enhancement, chiari
malformation
 Spinal MRI, CT
 Treatment
 Bed rest
 IV caffeine (500 mg in 500 ml
saline administered over 2 h)
 Abdominal binder
 Autologous blood patch
 Oral theophylline(intractable
pain)
ii. RaisedCSFVolume Headache
 Generalized headache present on waking and improves as the day goes on,
worse with recumbency.
 Investigations
 Funduscopy-papilledema
 MRI, including an MR venogram
 Lumbar puncture
 Differential diagnosis:
 Obstructive sleep apnea
 Poorly controlled hypertension
 Idiopathic intracranial hypertension without visual problems
 Treatment
 Acetazolamide (250–500 mg bid)
 Topiramate
 Severe disabled patient that do not respond to medication -intracranial pressure
monitoring ,shunting
iii. Post-traumatic Headache
 Headache that remit after several weeks or persist after the trauma
associated with dizziness, vertigo and impaired memory
 Injury to the head
 Carotid dissection and subarachnoid hemorrhage,and following intracranial surgery
 Infection (viral meningitis / parasitic infection)
 Differential diagnosis:
 Chronic subdural hematoma
 Iatrogenic low CSF volume headache
 Treatment
 Tricyclic antidepressants (amitriptyline)
 Anticonvulsants (topiramate, valproate, and gabapentin)
 MAOI (phenelzine)
 Resolves within 3–5 years
Increased headache frequency
and induce - refractory daily
headache due to overuse of
analgesic for headache
Management : Outpatients
 Reduce and stop analgesic
(reduce dose by 10% every
1–2 w)
 A small dose NSAID
 Naproxen, 500 mg bid (
overuse problems with more
frequent dosing )
 Preventive medication (when
analgesic is stopped)
Management : Inpatients
Failed at outpatient withdrawal/
significant medical condition
 Withdrawn analgesics
 Antiemetics and fluids
 Clonidine (opiate withdrawal )
 Aspirin 1 g IV (acute intolerable
pain during day)
 IM chlorpromazine (night)
 After effect of withdrawn
substance settles (3-5d)
 IV dihydroergotamine (DHE)
every 8 h for 5 days + 5-HT3
antagonists (ondansetron/
granisetron) or domperidone oral/
suppository
a) PRIMARY STABBING HEADACHE
 Features:
 Stabbing pain
 Lasting from 1 to many seconds or minutes
 Occurring as a single or series of stab
 No associated cranial autonomic features
 No cutaneous triggering of attacks
 Recurrence at irregular intervals (hours to days).
 "Ice-pick pains" or "jabs and jolts."
 More common in patients with other primary headaches (migraine,
TACs, and hemicrania continua)
 Treatment:
 Indomethacin (25–50 mg two to three times daily
b) PRIMARY COUGH HEADACHE
 Generalized headache that begins suddenly
 Lasts for several minutes
 Precipitated by coughing, preventable by avoiding coughing
 Exclude serious etiology :
 Chiari malformation /any lesion causing obstruction of CSF pathways
/displacing cerebral structures.
 Cerebral aneurysm, carotid stenosis, and vertebrobasilar disease.
 Can resemble benign exertional headache (patients is typically
younger)
 Treatment:
 Indomethacin 25–50 mg two to three times daily
 Lumbar puncture
c) PRIMARY EXERTIONAL
HEADACHE
 Features resembling both
cough headache and migraine
 Precipitated by any form of exercise
 Pulsatile
 5 min - 24 h,
 Bilateral and throbbing at onset
 Migrainous features
 Prevented by avoiding excessive
exertion,
 Mechanism :unclear. ???
 Possible etiologies:
 Cardiac cephalgia
 Pheochromocytoma
 Intracranial lesions and stenosis of
the carotid arteries
Treatment:
 Modest and progressive
exercise regimens
 Indomethacin 25 to 150 mg
daily
 Prophylactic measures.
 Indomethacin (50 mg)
 Ergotamine (1 mg orally)
 Dihydroergotamine (2 mg by
nasal spray)
 Methysergide (1–2 mg orally
given 30–45 min before
exercise)
d) PRIMARY SEX HEADACHE
 Dull bilateral headache that intensify at
orgasm.
 Prevented by ceasing sexual activity
before orgasm.
 Types :
 Dull ache in head and neck
 Sudden, severe, explosive headache
 Postural headache after coitus
 5–12% are caused by subarachnoid
hemorrhage
 Occur more in men than women
 Subside within 5min -2 h. ( In patient who
stop sexual activity when notice headache)
 Subside within 6 months.
 More common in patients with
exertional headache and migraine
Treatment:
 Recur irregularly and infrequently
 Reassurance and advice about ceasing
sexual activity
 Recurs regularly or frequently
 Propranolol 40 to 200 mg/d
 Diltiazem, 60 mg tid.
 Ergotamine (1 mg) or
 Indomethacin (25–50 mg) 30–45 min prior
to sexual activity
e) PRIMARYTHUNDERCLAP
HEADACHE
 Differential diagnosis
 Subarachnoid hemorrhage
 Cervicocephalic arterial dissection
 Cerebral venous thrombosis.
 Ingestion of tyramine-containing
foods in a patient taking MAOIs
 Pheochromocytoma.
 If posterior leukoencephalopathy
present,
▪ Cerebral angiitis,
▪ Drug toxicity
(cyclosporine,methotrexate or cocaine)
▪ Postpartum angiopathy.
 Excluding subarachnoid
hemorrhage
 Patients do very well over the
long term.
 Some developed migraine or
tension-type headache.
 Investigations :
 Neuroimaging (CT or, when
possible, MRI with MR
angiography)
 CSF examination
 Cerebral angiography
 Treatment with nimodipine
1) Tension- type
Headache
2) TrigeminalAutonomic
Cephalgias
a) Cluster headache
b) Paroxysmal hemicrania
c) SUNCT/SUNA
3) Chronic Daily
Headache
a) Primary (<4h/day and
>4h/day)
b) Secondary
4) Other Primary
Headache
a) Stabbing Headache
b) Exertional Headache
c) Cough Headache
d) Sex Headache
e) Thunderclap Headache
 Harrison’s Principle of Internal Medicine, 18th
Edition,Volume 1
 Davidson’s Principles and Practice of
Medicine, 22nd Edition
Mellss med yr3 headache

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Mellss med yr3 headache

  • 2. 1) Tension- type Headache 2) TrigeminalAutonomic Cephalgias a) Cluster headache b) Paroxysmal hemicrania c) SUNCT/SUNA 3) Chronic Daily Headache 4) Other Primary Headache
  • 3.  Chronic head-pain syndrome  Diagnosis:  No nausea, vomiting, photophobia, phonophobia,  No throbbing sensation  No aggravation with movement  Differential diagnosis :  MIGRAINE  Certain patient may haveTTH with migraine Characteristic Site : Bilateral Onset: Builds slowly Character: Tight, bandlike discomfort Timing: continuously for many days or episodic or chronic (>15 days/m). Severity Flunctuates
  • 4.  Pathophysiology :incompletely understood.  Due to a primary disorder of CNS pain modulation or genetic .  Treatment  Simple analgesics (acetaminophen, aspirin, or NSAIDs)  Relaxation  Triptans inTTH with migraine.  ChronicTTH :amitriptyline
  • 5.  Group of primary headaches  Cluster headache  Paroxysmal hemicrania  Sunct /suna  Differential diagnosis:  Sinus headache, trigeminal neuralgia, primary stabbing headache, and hypnic headache  IncreasedTACs presentation may be due to pituitary tumor. Charact Associat ion: lacrimation, conjunctival injection,nasal congestion Timing: Short , occur > 1/d Severity Severe
  • 6.  Rare (0.1%.)  M>F  Patients tend to move during attacks (pacing/ rocking/ rubbing their head for relief)  Unilateral photophobia/ phonophobia on the same side of the pain S •Unilateral,retroorbital, O •50% nocturnal , explosive C •deep , stabbing A •ipsilateral conjunctival injection/ lacrimation /rhinorrhea /nasal congestion / ptosis T •recurs at same hour for same duration •daily 1-2 short attacks X 8 - 10 w/y followed by a pain-free interval (<1y) •Chronic ( no period of sustained remission) S •excruciating ,nonfluctuating,
  • 7.  Acute attack  100% oxygen at 10-12L/min for 15-20min  Sumatriptan 6mg SC  Nasal sprays ▪ Sumatriptan (20 mg) ▪ zolmitriptan (5 mg) Short –term prevention Long-term prevention Episodic cluster headache Episodic & prolonged chronic cluster headache Prednisone 1 mg/kg up to Verapamil 160–960 mg/d 60 mg qd, tapering Lithium 400–800 mg/d over 21 days Methysergide 3–12 mg/d Topiramate 100–400 mg/d Methysergide 3–12 mg/d Gabapentin 1200–3600 mg/d Verapamil 160–960 mg/d Melatonin 9–12 mg/d Ergotamine 1-2mg Deep brain stimulation of posterior hypothalamus
  • 8.  Male:female ratio is 1:1.  Treatment  Indomethacin (25–75 mg tid),  Topiramate  Piroxicam  Secondary PH  If patient requires high doses indomethacin (>200 mg/d)  Sella turcica lesions (arteriovenous malformation, cavernous sinus meningioma, epidermoid tumors.)  Bilateral PH  Raised CSF pressure Charact. Site : Unilateral , retroorbital Associat ion: lacrimation and nasal congestion Timing: Frequent(>5/d) , short ( 2-45min) and rapid course(<72h) Severity excruciating
  • 9. SUNCT (short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing) SUNA (short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms)  Basic patterns  short-lived single stab  groups of stabs  a longer attack ("saw-tooth" )  Differential diagnosis  trigeminal neuralgia (TN)  Secondary (Symptomatic) SUNCT  Posterior fossa or pituitary lesions.  Pituitary function tests ,brain MRI Charac. Site : unilateral orbital or temporal Character: stabbing or throbbing Association: ipsilateral conjunctival injection and lacrimation Timing: >20 attacks, lasting for 5–240s , no refractory period Exacerbatin g factors: Cutaneous triggers Severity severe
  • 10.  AbortiveTherapy  IV lidocaine(hospitalized patients.) to arrest symptoms  PreventiveTherapy  Goal:minimize disability and hospitalization  Medical approaches ▪ Lamotrigine, 200–400 mg/d. ▪ Topiramate and gabapentin. ▪ Carbamazepine, 400–500 mg/d  Surgical approaches ▪ Microvascular decompression or destructive trigeminal procedures ▪ Greater occipital nerve injection ▪ Occipital nerve stimulation ▪ deep-brain stimulation of the posterior hypothalamic region  Short-term prevention (intractable cases) ▪ IV lidocaine ▪ occipital nerve stimulation.
  • 11. Cluster Headache Paroxysmal Hemicrania SUNCT Gender M > F F = M F ≈M Type Stabbing, boring Throbbing, boring, stabbing Burning, stabbing, sharp Severity Excruciating Excruciating Severe to excruciating Site Orbit, temple Orbit, temple Periorbital Attack frequency 1/alternate day–8/d 1–40/d (>5/d for more than half the time) 3–200/d Duration 15–180 min 2–30 min 5–240 s Alcohol trigger Yes No No Cutaneous triggers No No Yes Abortive treatment Sumatriptan injection or nasal spray Oxygen No effective treatment Lidocaine (IV) Prophylactic treatment Verapamil Methysergide Lithium Indomethacin Lamotrigine Topiramate Gabapentin
  • 12.  >15days/month Primary Secondary <4 h Daily >4 h Daily Posttraumatic • Head injury • Iatrogenic • Postinfectious Chronic cluster headache Chronic migraine Chronic paroxysmal hemicrania Chronic tension-type headache Inflammatory • Giant cell arteritis • Sarcoidosis • Behçet's syndrome SUNCT/SUNA Hemicrania continua Chronic CNS infection Hypnic headache New daily persistent headache Medication-overuse headache
  • 13.  If it is a medically intractable disablingCDH  Occipital nerve stimulation
  • 14.  Most are female  Onset >60 years.  Differential diagnosis:  Poorly controlled hypertension.  Treatment:  Lithium carbonate (200–600 mg) at bedtime  Verapamil (160 mg)  Methysergide (1–4 mg at bedtime)  One to two cups of coffee /caffeine, 60 mg orally, at bedtime  Flunarizine, 5 mg nightly. Chara c. Site : Uni/bilateral Onset : a few hours after sleep Chara cter: generalized /throbbing Timin g: 15 – 30 min , <3 repetitions/ night Sever ity moderately severe
  • 15.  Essential features :  Moderate , continuous unilateral pain with fluctuations of severe pain  Complete resolution of pain with indomethacin  Associated with conjunctival injection, lacrimation, and photophobia on same side  Age of onset :11 to 58 years.  Woman: man = 2:1  Treatment  IM injection of 100 mg indomethacin  Oral indomethacin (initial,25 mg tid, then 50 mg tid,75 mg  Topiramate  Patients unable to tolerate indomethacin ▪ Occipital nerve stimulation
  • 16.  Abrupt onset / gradual Primary NDPH  Migrainous type  unilateral headache,throbbing pain, nausea, photophobia, phonophobia  Treatment :preventive therapies of migraine  Featureless type  refractory to treatment  86% headache-free after 2 years Primary NDPH Secondary NDPH Migrainous- type Subarachnoid hemorrhage Featureless (tension-type) Low CSF volume headache Raised CSF pressure headache Posttraumatic headache Chronic meningitis
  • 17. i. Low CSFVolume Headache  Dull, throbbing occipitofrontal headache that not present on waking up , worsen as day progress and relieved by recumbency position  Cause :  CSF leak after lumbar puncture (within 48 h -12 d)  index events (epidural injection or vigorous Valsalva maneuver)  Differential diagnosis:  Postural orthostatic tachycardia syndrome [POTS ]  Investigations:  Brain MRI -diffuse meningeal enhancement, chiari malformation  Spinal MRI, CT  Treatment  Bed rest  IV caffeine (500 mg in 500 ml saline administered over 2 h)  Abdominal binder  Autologous blood patch  Oral theophylline(intractable pain)
  • 18. ii. RaisedCSFVolume Headache  Generalized headache present on waking and improves as the day goes on, worse with recumbency.  Investigations  Funduscopy-papilledema  MRI, including an MR venogram  Lumbar puncture  Differential diagnosis:  Obstructive sleep apnea  Poorly controlled hypertension  Idiopathic intracranial hypertension without visual problems  Treatment  Acetazolamide (250–500 mg bid)  Topiramate  Severe disabled patient that do not respond to medication -intracranial pressure monitoring ,shunting
  • 19. iii. Post-traumatic Headache  Headache that remit after several weeks or persist after the trauma associated with dizziness, vertigo and impaired memory  Injury to the head  Carotid dissection and subarachnoid hemorrhage,and following intracranial surgery  Infection (viral meningitis / parasitic infection)  Differential diagnosis:  Chronic subdural hematoma  Iatrogenic low CSF volume headache  Treatment  Tricyclic antidepressants (amitriptyline)  Anticonvulsants (topiramate, valproate, and gabapentin)  MAOI (phenelzine)  Resolves within 3–5 years
  • 20. Increased headache frequency and induce - refractory daily headache due to overuse of analgesic for headache Management : Outpatients  Reduce and stop analgesic (reduce dose by 10% every 1–2 w)  A small dose NSAID  Naproxen, 500 mg bid ( overuse problems with more frequent dosing )  Preventive medication (when analgesic is stopped) Management : Inpatients Failed at outpatient withdrawal/ significant medical condition  Withdrawn analgesics  Antiemetics and fluids  Clonidine (opiate withdrawal )  Aspirin 1 g IV (acute intolerable pain during day)  IM chlorpromazine (night)  After effect of withdrawn substance settles (3-5d)  IV dihydroergotamine (DHE) every 8 h for 5 days + 5-HT3 antagonists (ondansetron/ granisetron) or domperidone oral/ suppository
  • 21. a) PRIMARY STABBING HEADACHE  Features:  Stabbing pain  Lasting from 1 to many seconds or minutes  Occurring as a single or series of stab  No associated cranial autonomic features  No cutaneous triggering of attacks  Recurrence at irregular intervals (hours to days).  "Ice-pick pains" or "jabs and jolts."  More common in patients with other primary headaches (migraine, TACs, and hemicrania continua)  Treatment:  Indomethacin (25–50 mg two to three times daily
  • 22. b) PRIMARY COUGH HEADACHE  Generalized headache that begins suddenly  Lasts for several minutes  Precipitated by coughing, preventable by avoiding coughing  Exclude serious etiology :  Chiari malformation /any lesion causing obstruction of CSF pathways /displacing cerebral structures.  Cerebral aneurysm, carotid stenosis, and vertebrobasilar disease.  Can resemble benign exertional headache (patients is typically younger)  Treatment:  Indomethacin 25–50 mg two to three times daily  Lumbar puncture
  • 23. c) PRIMARY EXERTIONAL HEADACHE  Features resembling both cough headache and migraine  Precipitated by any form of exercise  Pulsatile  5 min - 24 h,  Bilateral and throbbing at onset  Migrainous features  Prevented by avoiding excessive exertion,  Mechanism :unclear. ???  Possible etiologies:  Cardiac cephalgia  Pheochromocytoma  Intracranial lesions and stenosis of the carotid arteries Treatment:  Modest and progressive exercise regimens  Indomethacin 25 to 150 mg daily  Prophylactic measures.  Indomethacin (50 mg)  Ergotamine (1 mg orally)  Dihydroergotamine (2 mg by nasal spray)  Methysergide (1–2 mg orally given 30–45 min before exercise)
  • 24. d) PRIMARY SEX HEADACHE  Dull bilateral headache that intensify at orgasm.  Prevented by ceasing sexual activity before orgasm.  Types :  Dull ache in head and neck  Sudden, severe, explosive headache  Postural headache after coitus  5–12% are caused by subarachnoid hemorrhage  Occur more in men than women  Subside within 5min -2 h. ( In patient who stop sexual activity when notice headache)  Subside within 6 months.  More common in patients with exertional headache and migraine Treatment:  Recur irregularly and infrequently  Reassurance and advice about ceasing sexual activity  Recurs regularly or frequently  Propranolol 40 to 200 mg/d  Diltiazem, 60 mg tid.  Ergotamine (1 mg) or  Indomethacin (25–50 mg) 30–45 min prior to sexual activity
  • 25. e) PRIMARYTHUNDERCLAP HEADACHE  Differential diagnosis  Subarachnoid hemorrhage  Cervicocephalic arterial dissection  Cerebral venous thrombosis.  Ingestion of tyramine-containing foods in a patient taking MAOIs  Pheochromocytoma.  If posterior leukoencephalopathy present, ▪ Cerebral angiitis, ▪ Drug toxicity (cyclosporine,methotrexate or cocaine) ▪ Postpartum angiopathy.  Excluding subarachnoid hemorrhage  Patients do very well over the long term.  Some developed migraine or tension-type headache.  Investigations :  Neuroimaging (CT or, when possible, MRI with MR angiography)  CSF examination  Cerebral angiography  Treatment with nimodipine
  • 26. 1) Tension- type Headache 2) TrigeminalAutonomic Cephalgias a) Cluster headache b) Paroxysmal hemicrania c) SUNCT/SUNA 3) Chronic Daily Headache a) Primary (<4h/day and >4h/day) b) Secondary 4) Other Primary Headache a) Stabbing Headache b) Exertional Headache c) Cough Headache d) Sex Headache e) Thunderclap Headache
  • 27.  Harrison’s Principle of Internal Medicine, 18th Edition,Volume 1  Davidson’s Principles and Practice of Medicine, 22nd Edition

Editor's Notes

  1. Peri symp deficit due to parasym activation with injury to ascending sympathetic fibers surrounding a dilated carotid artery as it passes into the cranial cavity.
  2. Suma sc rapid onset and shorten attack to 15-20 min
  3. To differentiate TN : have refractory period many stabs between which the pain does not completely resolve, thus giving a "saw-tooth" phenomenon with attacks lasting many minutes.
  4. Monoamine oxidase inhibitors