Psychiatry

2. • Headache or Cephalalgia is “a diffuse pain in various parts of the head,not confined
to the distribution of any nerve”.
• Headache is the most common pain problems encountered in family practice.
• Some intracranial structures have receptors for pain like major venous
sinuses,arteries round the base of the brain,the meningeal arteries,the dura of
anterior & posterior fossae and all extra cranial tissues.
• The most important mechanism underlying headache are:
1. Vasodilation
2. Traction on intracranial structures
3. Inflammation
4. Muscle spasm
5. Referred pain and
6. Psychogenic headache.

3. 1.HEADACHE DUE TO VASODILATION:
Vascular Headache
Abrupt elevation of blood pressure may cause headache.
It typically throbbing in nature.
Eg:Migraine,Chronic Hypertension
2.HEADACHE DUE TO TRACTION:
Traction on great vessels and dura athe base of the brain cause headache.
Pain is increased by sudden movement of the head.
Eg:Cerebral tumour
3.HEADACHE DUE TO INFLAMMATION:
Meningeal irritation due to Meningitis,Haemorrhage
Produces headache which is increased by head movement,coughing or straining.
Neck rigidity is an importsnt sign of meningeal inflammation.

4. 4.HEADACHE DUE TO MUSCLE SPASM:
Most common mechanism of headache.
Intensity vary from a feeling of tightness to a true aching pain.
Usually bilateral.
5.REFERRED HEADACHE:
Disease of structures in the head may cause pain referred to the cranium.
Eye disease such as glaucoma & iritis cause frontal headache.
Nasal and sinus disease cause pain in the molar,nasal and frontal areas.
Dental,aural and temporo-mandibular joint disease may cause pain spreading beyond
the primary area of pain.
6.PSYCHOGENIC HEADACHE:

5. • The International Classification Of Headache Disorders -2 (ICHD-2) was developed in
order to provide specific operational criteria for the major headache syndromes.
The three basic subtypes of headaches or facial pain in the ICHD-2 system:
Primary headache syndrome
 Migraine without aura/Migraine with aura
 Tension-type headache
 Cluster headache
 Secondary headache syndrome

6. Secondary headache syndromes:
• Headache attributed to head & neck trauma
• Headache attributed to cranial/cervical vascular disorder
• Headache attributed to non-vascular intracranial disorder
• Headache attributed to a substance or its withdrawl
• Headache attributed to infection
• Headache attributed to disorder of homeostasis,
• Headache or facial pain attributed to disorder of
cranium,neck,eyes,ears,nose,sinuses,teeth,mouth or other cranial structures
• Headache attributed to psychiatric disorder.

8. MIGRAINE:
EPIDEMIOLOGY:
• Worldwide,migraine affects nearly 15% of people.
• Rates of migraine is lower in Asia and Africa.
• Women(19%) > Men(11%). There is slight predominance in boys during pre
pubertal years.
• Commonly begin between ages 15-24,highest prevalence in ages 35-45.
• Chronic migraines in about 1.4 – 2.2 % of population.
CHARACTERISTICS:
• Unilateral, may move to the other side
• “Throbbing” ”Pulsatile” in nature.
• Lasts for 3 hours to 4 days.
• Moderate to Severe.
• Worsens with physical activity.
• Associated with Nausea ,Vomitting,Photophobia and Phonophobia.

9. AURA:
• Aura are complex neurological symptom that precede or
accompany migraine or occur in isolation.
Common types:
Visual Aura
• Photopsia/Flashing of lights
• Scotoma (came from the Greek word for darkness: skotos):
a blind spot or area of reduced vision surrounded by a
normal visual fieldPositive & Negative Scotoma
• Scintillating scotoma
• Fortification scotoma
Sensory Aura/Motor Aura

10. PHASES OF MIGRAINE:
Unlike most headahes,migraine has distinct stages,although not all sufferers experience
each one.
1. Prodrome(60%) which occurs hours or days before the headache.
2. Aura(30%) ,which immediately precedes the headache.
3. Headache(100%) or Pain Phase
4. Postdrome(70%),the effects experienced following the end of a migraine attack

12. PATHPHYSIOLOGY:
• Cortical Spreading Depression starts from Occipital lobe to forward.
• The distal Trigeminal nerve terminals initiate cascade of events by releasing
Substance P,Neurokinin A ,Calcitonin Gene-Related Peptide (CGRP) and
others(Serotonin,Glutamate ,Prostaglandins and Inflammatory cytokines) which bind
to the receptors of intracranial blood vessels causing Vasodilation & Plasma protein
extravasationSterile inflammation,HEADACHE is experienced.
• Signals reach Trigeminal Nucleus Caudalis in Brain stemThalamusSensory
Cortex.
• Sensitization of 1st order neuron is Peripheral sensitization which is the reason for
throbbing type of pain.

14. MANAGEMENT OF MIGRAINE:
Pharmacological treatments:
• Propanolol & Timolol.Adverse effects are anhedonia,lassitude and
irritability.Caution in prescribing to patients with depression.
• Divalproex sodium & Topiramate.Used as migraine prophylactic agents and in
chronic migraine.
• Amitriptyline,a TCA has strong efficacy.Side effects:Weight gain and Sedation.
• Drugs with lesser efficacy & tolerability:Other ACE,TCA,CCB,MAOI,NSAIDS

15. Acute Treatment of Migraine:
Almotriptan(12.5mg)
Eletriptan(80mg)
Frovatriptan(2.5mg)
Naratriptan(2.5mg)
Rizatriptan(10mg)
Zolmitriptan(2.5mg)
Sumatriptan(50mg)
Others:Ergot derivatives,NSAIDS,Aspirin(325mg)
Non pharmacological Treatment:
• Biofeedback
• Relaxation training
• Cognitive behavioural therapy
• Herbal treatment such as with Feverfew- Tanacetum parthenium
• Dietary supplements such as Magnesium,Vitamin D

16. MIGRAINE VARIANTS:
1.Migraine without aura or Common Migraine
2.Migraine with aura or Classic Migraine
3.Basilar Migraine:
• A less-common form of migraine syndrome with prominent brainstem symptoms
like vertigo,staggering,incoordination of the limbs,dysarthria & tingling in both
hands and feet.
4.Ophthalmoplegic & Retinal Migraine:
• Recurrent unilateral headache associated with weakness of extra ocular muscles.
• A transient 3rd nerve palsy with ptosis,with/without involvement of pupil.
• Retinal migraine is migraine with visual disturbance or even temporary blindness in
one eye.
5.Migraine in Young children:
• Child appears limp,pale and complaints of abdominal pain ,vomiting(Abdominal
migraine)
• Another variant in child is episodic vertigo & staggering followed by headache.

17. 6.Migraine followed by Head injury
7.Familial hemiplegic migraine/Sporadic hemiplegic migraine
• Mutation in two genes: CACNA1A and SCNA1.
8.Status Migrainosus:
• As many as 3 or 4 attacks may occur each week,leaving the scalp on one side
continuously tender.
• Migraine that lapses into a condition of daily or virtually severe continuous
headache.
9.Migraine with CSF Lymphocytic Pleocytosis or
Headache with Neurological Deficits and CSF Lymphocytosis (HaNDL)
• Migraine in susceptible individuals with aseptic meningitis.

18. TENSION TYPE HEADACHE (TTH)
• Common type of primary headache.
• Female > Male
• Age of onset (25 to 30 years) .The peak prevalence between ages 30 to 39 and
decreases slightly with age.
• Tension type headaches (TTH) are recurrent episodes of headache lasting from 30
minutes to 7 days.
• The pain is typically pressing or tightening in quality,non-pulsating.
• Mild to moderate intensity
• Bilateral in location
• Does not worsen with the routine physical activity.
• No associated symptoms, but photophobia or phonophobia may be present.
• Other terms such as Psychogenic headache, stress headache, psychomyogenic
headache. However, the term “tension type headache” (TTH) has been chosen by
the ICHD I in 1988 and have been retained by ICHD II in 2004 . The words “tension”
and “type” underscore its uncertain pathogenesis and indicate that some kind of
mental tension(Stress,Hunger,Sleep deprivation) may play a causative role.

19. CLUSTER HEADACHE:
• Also called as Horton’s Disease.
• Cluster refers to a “clustering in time” with the
headache bouts occurring everyday to several
times a day over a period of days to
weeks,followed by a lengthy headache-free
interval.
• Male > Female
• Unilateral,Retro-orbital in location.
• Severe.
• Lacrimation,Congestion,Rhinorrhoea,Drooping of
eyelids and agitation.
• Pain lasts for 15-180 minutes.
• If left untreated,attack frequency will range from
one to 8 attacks every 24 hours.
• Rx-Oxygen,Ergots,Triptans.

20. HEADACHE DIARY/SUBJECTIVE ASSESSMENT:
• Quality
• Frequency,Intensity,Duration,Location
• Radiation
• Onset: Gradual,Sudden(Thunderclap)
• Any associated symptoms
• Any aggrevating/relieving symptoms
• Past medical history
Systemic disease/HIV/Trauma
• Treatment history
Analgesic abuse,Recreational drugs,Birth control pills.
• Family history:
Migraine/Subarachnoid haemorrhage/Stroke
• Also ask about:
 Amount of sleep the previous night
 Emotional condition
 Food consumed in the past 24 hours
Tyramine rich food,Chocolate,Cheese,Alcohol particularly Red wine

21. RED FLAG SIGNS:
“Worst” headache ever/Thunderclap
First Severe Headache
Abnormal Neurological Examination
Fever
Vomitting that precedes headache
Pain induced by Coughing,Bending,Lifting
Pain that disturbs sleep or presents immediately upon awakening
Age > 50
Headache with local tenderness-region of temporal artery.

22. THANK YOU!