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  1. 1. HEADACHE
  2. 2. PRIMARY HEADACHE SYNDROMES• Tension type headache• Migraine• Trigeminal Neuralgia• Atypical facial pain• Cluster headache• Benign paroxysmal headaches
  3. 3. TENSION TYPE• Most common-69%• Episodic or chronic• Gradual onset , radiate forward from occiput• Bilateral, dull, tight, band like pain• Less in morning, pain increase as day goes on• No accompanying N,V, throbbing, sensitivity to light, sound or movement
  4. 4. Pathophysiology• Primary disorder of CNS pain modulation• Precipitating factorsStress: usually occurs in the afternoon after long stressful work hours or after an examSleep deprivationUncomfortable stressful position and/or bad postureIrregular meal time (hunger)EyestrainCaffeine withdrawalDehydration
  5. 5. 2 TheoriesMuscle tension around head and neckMalfunctioning pain filter located in brain stem, brain misinterprets information and interprets this signal as pain. One of the main neurotransmitters which is probably involved is serotonin
  6. 6. Management• Paracetamol,Aspirin,NSAIDs• Behavioral approach-relaxation• Chronic-amitriptyline
  7. 7. MIGRAINE• 2nd most common-16%• 15% women and 6% men• Severe, episodic, unilateral,throbbing pain• Nausea,Vomiting• Sensitivity to light ,sound, movement• Genetic predisposition
  8. 8. Classical Migraine or Migrainewith AURA Symptom TriadParoxysmal headachenausea &/or vomitingaura of focal neurological events(visual) 20-25%
  9. 9. AURA• flashing lights, silvery zigzag lines moving across visual field over a period of 20 minutes sometimes leaving a trail of temporary visual field loss• Sometimes-Auditory ,Olfactory, gustatory hallucinations• Sensory aura-spreading front of tingling and numbness, from one body part to another
  10. 10. Rare aura:• Vertigo• Aphasia• Hemiparesis• DeliriumMigraine with limb weakness-Hemiplegic migraineSymptoms of aura do not resolve leaving permanent neurological damage-Complicated migraine
  11. 11. Common Migraine or Migrainewithout AURA• Paroxysmal headache• Vomiting +/-• NO AURA
  12. 12. Simplified Diagnostic Criteria forMIGRAINEAt least 2 of the + At least 1 of thefollowing: following:• Unilateral pain• Throbbing pain • Nausea/vomitting• Aggravation by • Photophobia and movement phonophobia• Moderate or severe intensity
  13. 13. Clinical phases of a migraineattack Vulnerability Attack Initiation Prodrome Aura Pain Postdrome
  14. 14. Triggers• Flashing lights • Menstruation• Loud sounds • Pregnancy• Strong odors • Menopause• Stress • Oral Contraceptives• Hunger • Sleep changes• Fatigue • Caffeine• Alcohol • Chocolate• Smoking • Tyramine • MSG
  15. 15. Pathophysiology of Migraine • Cortical spreading depression • Vascular • Low Serotonin • Melanopsin receptor
  16. 16. Cortical spreading depression ofLEAO• Dysfunction of ion channels-Quick depolarization(activation) followed by long- lasting depression over an area of cortex• Release of inflammatory mediators• Irritation of cranial nerve roots-trigeminal
  17. 17. Vascular Vasoconstriction of blood vessels in brain-Aura (begins in occipital lobe) Vasodilatation of scalp blood vessels Inflammation Pain
  18. 18. Migraine Pain-Trigeminovascular• Key pathway for pain is trigeminovascular input from meningeal vessels• Modulation of trigeminovascular input comes from dorsal raphe nucleus, locus coeruleus and nucleus raphe magnus
  19. 19. Management• Acute attack- aspirin/paracetamol+metoclopromide/ domperidone• Severe attack-Sumatriptan• Frequent attacks- Propranolol,Amitriptyline,Sodium valproate or Topiramate
  20. 20. Trigeminal Neuralgia• Lancinating pain in 2nd and 3rd divisions of trigeminal nerve• >50yrs• Severe, brief ,repetitive pain causing patient to flinch• Precipitated by touching trigger zones—washing, shaving, eating, cold wind
  21. 21. Pathophysiology• Compression of trigeminal N by aberrant loop of cerebellar arteries as nerve enters brainstem• Other benign compressive lesions• Multiple sclerosis- TN occurs due to plaque of demyelination in trigeminal root entry zone
  22. 22. Management• Carbamazepine-DOC• Intolerant-Gabapentin/Pregabalin• Injection of alcohol into peripheral branch of nerve• Posterior craniotomy to relieve vascular compression of trigeminal nerve
  23. 23. Atypical facial pain• Persistent idiopathic facial pain• Continuous, burning/crushing,unremittent, centred over maxilla usually left side• Middle aged women• Early form of trigeminal neuralgia• Rx-Amitriptyline, Gabapentin
  24. 24. Other causes of facial painSinusitis• Frontal-pain more in morning, decreases as day progresses, stooping and blowing nose increase pain• Ethmoid and Sphenoid-pain over vertex, less in morning and increase gradually
  25. 25. Post herpetic neuralgia-continuous, burning pain sensitive to light touch, shingles
  26. 26. THANK YOU