Headache Harrison

1. Headache
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3. Pain and Headache
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4. Pain Sensitive Structures
Intracranial Structures
● cranial sinuses and veins
● arteries of the dura mater
● arteries of the base of the brain and their major branches
● parts of the dura mater near the large vessels
Extracranial Structures
● skin, scalp, fascia
● mucosa
● arteries
Nerves
● trigeminal, facial, glossopharyngeal and vagus nerves
● upper three cervical nerves
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5. Neurologic Examination
New onset and Severe Headaches
● Meningitis
● Subarachnoid hemorrhage
● Epidural or Subdural hematoma
● Glaucoma
● Tumor
● Purulent sinusitis
Recurrent Headaches
● Otologic problem
● Dental problem
● Trauma
Diagnostic Tests:
● CT scan or MRI
● Lumbar puncture
● Fundoscopy
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6. Migraine
● Unilateral, throbbing or
pulsatile quality felt over the
fronto-parietal or retro-orbital
area
● Lasts few hours to days
● Generally Infrequent
● Severe intensity
● Associated with visual
disturbances, vomiting
● Aggravated by certain foods,
stress, hormones
● (+) Family history
Timing: Occur any time of day
Freq: 1 to 10 per month
(average 1.5)
Onset: Gradual onset, peak, then
subsidence
Duration 4 to 72 hours (adults)
2 to 48 hours
(children)
Location: Unilateral 60%
Pain: Moderate to severe
50% pulsating, 50%
tight,
pressure
Aggravated by movement
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8. Migraine Triggers:
● Diet
● Sleep deprivation or
excess
● Hormonal changes
● Environmental factors
● Physical exertion
● Stress and anxiety
● Head trauma
Migraine without aura
Migraine with aura
Acephalgic migraine
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11. Tension Headaches
● Bilateral, bandlike , more posterior
in origin
● Constricting, compressing quality
● Lasts minutes to hours, can occur
daily
● Aggravated by fatigue, poor posture
and emotional burdens
● Present in type A personalities
● Normal neurologic examination
● With identifiable “stressor”
Treatment:
● Acetaminophen, aspirin, or NSAIDs
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12. Cluster Headaches
● Similar to migraine in quality
● Common among males
● Attacks are nocturnal, within 1-2
hours of falling asleep
● Accompanied by lacrimation
and conjunctival and nasal
congestion
● Occurs in “clusters” lasting for
weeks separated by months or
years of headache freedom
● Normal neurologic examination
Treatments:
Sumatriptan (20 mg) and zolmitriptan (5 mg)
nasal sprays
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14. Trigeminal neuralgia
● Involves one side of the face
● Short jabs/lightning like stabs of
pain along the cheek and corner
or the mouth repeated
throughout the day; mistaken as
dental pain
● Worse with yawning, laughing,
chewing and brushing of teeth
● Does not respond well to
common analgesics
● Common among elderly
● Normal neurologic examination
Treatments:
Sumatriptan (20 mg) and zolmitriptan (5 mg)
nasal sprays
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15. Vascular-Related Headaches
● Throbbing, maybe uni- or
bilateral
● Maybe associated with
dizziness and vomiting
● Worsens with coughing and
exertion, bearing down or
doing a Valsalva maneuver
● With coexisting vascular
disease like hypertension,
vasodilatation with nitrate use
Treatments:
Relieved with control of BP or
discontinuation of medications
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16. Headache from Subarachnoid Hemorrhage
● Thunderclap onset
● Throbbing, bilateral
● “worst headache of my life”
● Maybe associated with dizziness and
vomiting, seizures, loss of
consciousness
● Worsens with coughing and exertion,
bearing down or doing a Valsalva
maneuver
● Associated papilledema and
hemorrhages on fundoscopy; neck
rigidity on meningeal testing; may have
focal neurologic deficits referable to the
site of ruptured artery
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17. Headache from CNS Infection
● Generalized, bilateral,
progressive intensity
● Maybe associated with
vomiting, FEVER at onset,
sensorial change, seizures,
delirium
● May have (+) neck rigidity
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18. Headache from CNS Tumor
● May start focal and in weeks
and months become
generalized
● Progressive intensity and
frequency over weeks and
months
● Worse in the middle of the night
or upon waking up
● (+) papilledema in 50% of cases
● May have associated vomiting,
blurring of vision and neurologic
signs related to the site of the
tumor
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19. Headache Danger Signs
● Sudden onset of new severe
headache
● first headache in adulthood
● progressively worsening
headache
● onset with exertion, coughing,
straining and/or sexual activity
● with drowsiness, malaise,
confusion, memory loss,fever,
weakness, blurring, clumsiness or
loss of balance
● Abnormal vital signs-BP/T
● altered sensorium
● unequal poorly reactive pupils
● papilledema/retinal hge
● meningeal irritation
● focal weakness or sensory loss
● asymmetrical reflexes/ (+)babinski
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20. Thank You!
References:
Headache Peter J. Goadsby Chapter 13.
Harrison's Principles of Internal Medicine, 20e J. Larry Jameson, Anthony S. Fauci, Dennis L.
Kasper, Stephen L. Hauser, Dan L. Longo, Joseph Loscalzo
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