Approach to a case of Headache in Ophthalmology OPD

1. APPROACH TO A CASE OF
HEADACHE
Dr. Akshat Tyagi
Junior Resident
Dept. of Ophthalmology
Subharti Medical College

2. Importance
• Headache is one of the most common presenting complaint in
Ophthalmology OPD.
• More patients of headache consult an ophthalmologist before consulting a
neurologist.
• May signify serious intracranial problems.
• Depending on the cause our role is of:
• a primary treating physician or
• a supporting referring physician.

3. Pathogenesis of Headache
• Spasm, strain, inflammation and trauma to the cervical and cranial musculature.
• Strain to intrinsic ocular muscles (decreased distance visual acuity, decreased
ability to accommodate or converge).
• Ear, nasal and sinus congestion.
• Inflammation, compression or traction to the cranial or cervical nerves, intra-
cranial or extra-cranial arteries, large intracranial veins or their dural envelope.

4. • Meningeal irritation.
• Raised intracranial pressure.
• Referred pain from the jaw, teeth and the area of distribution of the
glossopharyngeal, vagus and the first three cervical nerves.

5. Classification of Headache
• Two classes:
• primary headache
• secondary headache (secondary to another disorder)
• Primary headache disorders include the following:
• Migraine
• Tension Type headache
• Trigeminal autonomic cephalgias (including cluster headache, chronic paroxysmal
hemicrania etc.)
• Secondary headache has numerous causes.

6. Disorders causing Secondary Headaches:
• Extracranial causes
• Strain to intrinsic ocular muscles (decreased ability to accommodate or converge).
• Glaucoma
• Uveitis
• Sinusitis
• Middle Ear infections
• Dental disorders (infection, TMJ dysfunction)

7. • Intracranial causes
• Brain tumors
• Intracranial Haemorrhage (ICH, SDH, SAH)
• Idiopathic Intracranial Hypertension
• Infections (Abscess, Meningitis, Encephalitis)
• Vascular Disorders (Ischaemic stroke, Vasculitis, Venous Sinus Thrombosis)

8. Other causes include:
• Malignant Hypertension
• Hypoxia
• Hypercapnia
• Analgesic Overuse
• Drugs like Nitrates, Estrogen etc.

9. Visual Acuity & Tonometry
History
Local Examination
Torch light and Slit lamp Examination (including fundoscopy)
Other relevant investigations (eg. BP)
Diagnosis & Management
Approach to a case of Headache in
Ophthalmology OPD

10. Check Visual Acuity and
ask for any associated visual disturbance?
If “Yes”:
• Migraine with Aura
• Headache attributed to Refractive Errors
• Presbyopia
• Convergence weakness
• Computer Vision Syndrome
• Acute Angle Closure Glaucoma
• Uveitis
• Malignant Hypertension
• Idiopathic Intracranial Hypertension
• Giant Cell Arteritis
If “No”:
Neurological causes:
• Tension type Headache
• Migraine without Aura
• Cluster Headache
ENT causes:
• Sinusitis
• Middle ear infection
• Eustachian tube Catarrh
Early Herpes Zoster (Prodromal Phase)

11. History
History of present illness includes questions about the headache's characteristics:
• Location
• Duration
• Severity
• Onset (eg, sudden, gradual)
• Character (eg, throbbing, constant, intermittent, pressure-like)
• Exacerbating and remitting factors (eg, sleep, light, sounds, odours, chewing) are noted
• Associated Symptoms (Vomiting, Fever, Eye Redness, Visual disturbances, rhinorrhoea)

12. Mild-Moderate in
severity, Non-specific
(character) and Frontal
& Bilateral in location:
• Headache due to
Refractive Errors
• Presbyopia (>45years)
• Convergence
Weakness (Usually
young adults)
• Computer Vision
Syndrome (H/O
Prolonged screen
time)
Non-specific
(character) and
Generalized in location:
• Malignant
Hypertension (H/O
HTN)
• Idiopathic
Intracranial
Hypertension
(Obese Female of
Childbearing age,)
Throbbing/Pulsating
(character) and
Unilateral in location:
• Migraine with Aura
(is A/W Nausea,
Vomiting,
photophobia,
sonophobia)
• Giant Cell Arteritis
(>55years, pain
when combing hair,
visual disturbances,
jaw claudication)
Severe, Non-Specific
(character) and Unilateral in
location:
• Acute (congestive) angle
closure Glaucoma
(Increased IOP,
Ocular/Periocular pain,
Nausea, Vomiting,
Redness, Coloured
Halos, Diminution of
Vision)
Moderate, Non-Specific
(character) and Unilateral
and Periorbital in location:
• Uveitis (Photophobia,
Diminution of vision,
Redness)

13. • Non-specific (character) and Frontal/Occipital & Bilateral in location:
• Headache due to Refractive Errors
• Presbyopia
• Convergence Weakness
• Computer Vision Syndrome

14. Headache due to Refractive Errors:
• Hyperopia, Astigmatism, Incorrect
glasses,
• Age is usually <20 years
• Clinical Features:
• Recurrent & mild headache,
• Absent on awakening & aggravated
by prolonged tasks,
• Ocular fatigue, discomfort,
lacrimation
• Blurry vision, or inability to keep the
eyes open
• Rx- Correction of the refractive error.
Convergence Insufficiency
• VA might be 6/6
• More common in young adults (<30 years)
• Clinical Features:
• Recurrent & mild headache,
• Absent on awakening & aggravated by
prolonged near tasks,
• Ocular fatigue, discomfort, lacrimation
• Diplopia
• Blurred vision at near, frequent loss of
place when reading
• The words seem to float on the page
• Rx- Orthoptic therapy

15. Presbyopia
• Age of onset >45 years in emmetropes & earlier in hypermetropes
• Headache is
• Recurrent & mild,
• Absent on awakening & develops on near work
• H/O Blurring of near vision
• Need to work from progressively greater distances
• Rx
• Glasses

16. Computer Vision Syndrome
• H/O prolonged screen time
• Any age group
• Clinical Features
• Blurred vision, or inability to keep the eyes open
• Ocular fatigue, discomfort, lacrimation
• Burning, dryness, redness, gritty sensation, tearing and irritation.
• Shoulder pain, neck pain, neck stiffness and backache.
• Rx-
• 20-20-20 rule, Lubricants
• Room lighting, Increase screen contrast.

17. Non-specific (character) and Generalized in location
ALWAYS EVALUATE FUNDUS (Undilated => Dilated)
Malignant Hypertension
• H/O HTN, Smoking (usually in older population, can
be seen in young as well)
• O/e
• Usually normal Anterior Segment.
• Reduced Visual Acuity.
• On Fundoscopy According to Keith-Wagener-
Barker Classification of HR:
• Obvious arterial narrowing with focal
irregularities with
• Retinal hemorrhages, exudates, cotton
wool spots, or retinal oedema with
• Papilledema
• Is a marker of Malignant Hypertension.
• Check BP
• Mx- Urgently refer to physician.
Idiopathic Intracranial Hypertension
• Obese women, childbearing age.
• Headache most common symptom.
• Transient episodes of visual loss (usually lasting
seconds): following changes in posture or Valsalva
manoeuvres.
• Ask for: Pulsatile tinnitus- which exacerbates with
postural changes. Specific sign.
• O/E
• Visual acuity is usually affected in advanced
disease.
• Bilateral Papilledema is the hallmark sign (rest
fundus normal).
• Mx- Referral to a Neurologist
Papilledema

20. Throbbing/Pulsating (character) and unilateral in location:
• Migraine with Aura
• Giant Cell Arteritis

21. Giant cell Arteritis (Temporal Arteritis)
• Ophthalmologic Emergency.
• Age >55years (median age 75)
• F>M (4:1)
• H/O
• Headache can be frontal, occipital or temporal
• Amaurosis Fugax (Precede 8.5 days prior to permanent vision loss due to AAION),
• Pain while combing their hair or placing their head on a pillow,
• Fever,
• Weight loss,
• Jaw or tongue claudication (Cramp like pain while chewing) is pathognomonic
• Myalgias
• O/E
• Thickened, tender, inflamed and nodular arteries
i.e. Superficial temporal arteritis, (subtle sign)
• PALPATION: Localized or diffuse scalp tenderness,

22. • Anterior Segment examination is normal.
• FUNDOSCOPY: to check for AAION (characterized by acute monocular vision loss accompanied by
optic disc edema)
• VA is <6/60 or even no PL (21%)
• Optic disc is “chalk white”, and may be accompanied by
• Disc hemorrhage,
• Cotton wool spots.
• Mx
• ESR >60mm/1sthour
• Temporal Artery Biopsy
• Steroid treatment should be started immediately

23. Migraine
• 2nd Most common cause (1year prevalence is 15% in general population)
• UNDERDIAGNOSED AND UNTREATED
• Onset usually in adolescence and <35 years of age
• Prevalence highest between 35-40 years of age
• F>M (3:1)
• Since the disorder tends to remit with older age, an onset of migraine after the age of 50 years
should arouse suspicion of a secondary headache disorder.
• Headache:
• Usually Severe
• Sudden onset
• Unilateral
• Progresses over next hour after onset
• Duration: Hours to days
• Pulsating or Throbbing
• A/W Nausea, Vomiting, Photophobia, Phonophobia
• Worsens with activity

24. Types:
1. Migraine with Aura (Classical Migraine)
• Aura followed by Headache with autonomic nervous system dysfunction
(pallor, nausea, vomiting) & photophobia/phonophobia
2. Migraine without Aura (Common Migraine)
• Headache with autonomic nervous system dysfunction (pallor, nausea,
vomiting) & photophobia/phonophobia
• No finding on eye examination.

25. Migraine with Aura
• Aura= A subjective sensation that precedes and indicates the onset of a neurological
episode.
• 90% of cases have visual Aura
• Visual aura:
• flickering, scintillating, crescent-shaped, bright geometric figure/scotoma usually
in central visual field
• Typically bilateral
• Usually last for an hour
• Other auras:
• unilateral altered or abnormal sensation/paraesthesia (2nd most common)
• weakness or disturbance of speech (dysphasia)

26. Starts with a small scotoma usually central that is scintillating, colored, fortifying and expanding
towards the periphery (B–C) that eventually breaks up (D). The times shown represent minutes from
the onset of the visual aura

27. • The International Headache Society criterion for the diagnosis of migraine
with aura is the presence of three out of four of the following:
• One or more fully reversible aura symptoms.
• At least one aura symptom develops gradually over longer than 4 minutes,
or two or more symptoms occur in succession.
• No single aura symptom lasts longer than 60 minutes.
• Headache follows the aura within 60 minutes, but may begin before or
during the aura.

28. Treatment:
• General measures include the elimination triggering factors:
• coffee, chocolate, alcohol, cheese, oral contraceptives, stress, lack of sleep and long
intervals without food.
• Treatment of Acute Attack:
• For moderate headaches
• Analgesics like ACETAMINOPHEN (500-1000 mg) P.O. along with
• Antiemetics like METOCLOPRAMIDE (10 mg) or DOMPERIDONE (10 mg)
• For severe headaches
• NSAID like IBUPROFEN (400-800 mg) P.O. for headaches lasting <12hours, NAPROXEN
(275 - 825 mg) P.O. for headaches lasting >12hours
• or INJ. KETOPROFEN 30 mg I.M. and INJ. DICLOFENAC 75mg I.M.
• Antiemetics like METOCLOPRAMIDE (10 mg) or DOMPERIDONE (10 mg)

29. If no relief:
Triptans or Ergotamine
(Avoid both in cerebrovascular diseases and hypertension)
SUMATRIPTAN 50 or 100mg P.O. (with NAPROXEN 550mg), the time
of onset of action is about 30 min or
INJ SUMATRIPTAN 6 mg s.c. acts within 10mins or
SUMATRIPTAN Nasal spray 20 mg per puff dose can be given
Sumatriptan not effective?
RIZATRIPTAN 5 mg or 10 mg P.O.
For refractory Headaches
INJ DEXAMETHASONE 4mg to 8mg
I.V./I.M.

30. Prophylactic therapy:
When to prescribe?
• Patients with disabling migraine which interferes with their occupational activity,
• Patients with more than two attacks per month ,
• those with significant vomiting, photophobia or phonophobia,
• Patients not responding to acute therapy or with contraindications.
• Betablockers
• PROPANOLOL 60-320mg P.O
• METAPROLOL 50-100mg P.O.
• Anticonvulsants
• TOPIRAMATE 100-200mg P.O.
• DIVALPROEX SODIUM 500-1000mg P.O.

31. Cluster Headache
• Uncommon
• Onset 20 to 40 years
• M>F (4:3)
• Headache:
• Sudden onset
• Unilateral
• Severe suicide headache
• Lasts 15 to 180 mins
• Occurs at same time each day
• Ocular finding might be there (Associated Ipsilateral
autonomic symptoms of eye, nose, face)
• Symptoms relieved by
• Acute Attacks:
• Oxygen (100 percent oxygen at 10 litre/min
for 15 minutes),
• INJ. SUMATRIPTAN 6 mg S.C.
• Prophylaxis:
• LITHIUM 300-600 mg/day P.O., VERAPAMIL
(160-720 mg/day) P.O.
Tension Headache
• Common (lifetime prevalence between 30% and 78%)
• Onset can be in adolescence or adulthood
• F>M (3:2)
• H/O Stress/Anxiety
• Headache:
• Gradual onset
• Bilateral (occipitofrontal)
• Dull ache/Squeezing band like
• No ocular finding.
• Associated symptoms:
• Sleep disturbance
• Fatigue
• Symptoms relieved by:
• Analgesics
• Alleviating stress

32. Sinusitis
• Headache is
• Dull-aching character,
• Frontal/Facial in Location
• Usually Bilateral (Can be unilateral if only one sinus involved)
• More intense upon waking-up in the morning,
• A/W
• Rhinorrhoea or
• Anosmia or
• Post Nasal Drip or
• Fever
• On Local Examination:
• Headache is exacerbated by pressure applied over the paranasal sinuses.
• Eye examination is normal.
• Mx
• Referral to an ENT specialist

33. Thank You