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Approach to headache

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HEADACHE
APPROACH TO THE PATIENT
Headache: Introduction
• Headache is among the most common reasons patients
seek medical attention.
• Primary headaches
• Benign
• Recurrent
• No organic disease as their cause
• Secondary headaches
• Underlying organic disease
• Primary headache often results in considerable disability
and a decrease in the patient's quality of life.
Common Causes of Headache
Primary Headache Secondary Headache
Type % Type %
Tension-type 69 Systemic
infection
63
Migraine 16 Head injury 4
Idiopathic
stabbing
2 Vascular
disorders
1
Exertional 1 Subarachnoid
hemorrhage
<1
Cluster 0.1 Brain tumor 0.1
Approach to headache
Primary Headache Disorders
• More common
• Migraine, with or without
aura
• Tension type
• Cluster
• Less common
• Paroxysmal hemicrania
• SUNCT (short-lasting unilateral
neuralgiform headache attacks with
conjunctival injection and tearing)
• Primary Stabbing Headache
• Primary Cough Headache
• Cold-stimulus
• Benign cough
• Benign exertional
Secondary Headache Disorders
• Associated with non-vascular
intracranial disorder
• Benign intracranial
hypertension
• Intracranial infection
• Low CSF pressure
• Associated with noncepalic
infection
• Viral infection
• Bacterial infection
• Associated with vascular disorders
• Subarachnoid hemorrhage
• Acute ischemic cerebrovascular
disorder
• Unruptured vascular
malformation
• Arteritis
• Carotid or vertebral artery pain
• Venous thrombosis
• Arterial hypertension
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Approach to headache

  • 2. Headache: Introduction • Headache is among the most common reasons patients seek medical attention. • Primary headaches • Benign • Recurrent • No organic disease as their cause • Secondary headaches • Underlying organic disease • Primary headache often results in considerable disability and a decrease in the patient's quality of life.
  • 3. Common Causes of Headache Primary Headache Secondary Headache Type % Type % Tension-type 69 Systemic infection 63 Migraine 16 Head injury 4 Idiopathic stabbing 2 Vascular disorders 1 Exertional 1 Subarachnoid hemorrhage <1 Cluster 0.1 Brain tumor 0.1
  • 5. Primary Headache Disorders • More common • Migraine, with or without aura • Tension type • Cluster • Less common • Paroxysmal hemicrania • SUNCT (short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing) • Primary Stabbing Headache • Primary Cough Headache • Cold-stimulus • Benign cough • Benign exertional
  • 6. Secondary Headache Disorders • Associated with non-vascular intracranial disorder • Benign intracranial hypertension • Intracranial infection • Low CSF pressure • Associated with noncepalic infection • Viral infection • Bacterial infection • Associated with vascular disorders • Subarachnoid hemorrhage • Acute ischemic cerebrovascular disorder • Unruptured vascular malformation • Arteritis • Carotid or vertebral artery pain • Venous thrombosis • Arterial hypertension
  • 7. Secondary Headache Disorders • Associated with head trauma • Acute post-traumatic headache • Associated with substance use or withdrawal • Acute use or exposure • Chronic use or exposure • Associated with metabolic disorders • Hypoxia • Hypercapnia • Mixed hypoxia & hypercapnia • Dialysis
  • 8. Anatomy and Physiology of Headache • Relatively few cranial structures are pain- producing; • the scalp, • middle meningeal artery, • dural sinuses, • falx cerebri, and • proximal segments of the large pial arteries. • The ventricular ependyma, choroid plexus, pial veins, and much of the brain parenchyma are not pain-producing.
  • 9. Clinical Evaluation of Acute, New-Onset Headache • In new-onset and severe headache, the probability of finding a potentially serious cause is considerably greater than in recurrent headache. • Patients with recent onset of pain require prompt evaluation and appropriate treatment • In most cases, CT or MRI study. • In some circumstances, a lumbar puncture (LP) eyes by funduscopy, intraocular pressure measurement, and refraction; cranial arteries by palpation is required
  • 10. Headache Symptoms that Suggest a Serious Underlying Disorder "Worst" headache ever First severe headache Subacute worsening over days or weeks Abnormal neurologic examination Fever or unexplained systemic signs Vomiting that precedes headache Pain induced by bending, lifting, cough Pain that disturbs sleep or presents immediately upon awakening Known systemic illness Onset after age 55 Pain associated with local tenderness, e.g., region of temporal artery
  • 11. Migraine • Migraine is a neurovascular disease caused by neurogenic inflammation and characterized by severe, recurring headaches • It usually characterized by the severe pain on one side of the head as compare to the pain in rest of the head second most common cause of headache, • Women > men. • It is usually an episodic headache associated with certain features such as sensitivity to light, sound, or movement; nausea and vomiting often accompany the headache.
  • 12. Migraine contd… • Headache can be initiated or amplified by various triggers, including glare, bright lights, sounds, or other afferent stimulation; hunger; excess stress; physical exertion; stormy weather or barometric pressure changes; hormonal fluctuations during menses; lack of or excess sleep; and alcohol or other chemical stimulation.
  • 13. Classification of Migraine headache 1)Migraine without Aura or common migraine Does not give any warning signs before the onset of headache. It occurs in about 70 to 80% of migraine patients 2)Migraine with Aura Give some warning signs “ called aura” before the actual headache begins. Approximate, 20 to 30% migraine sufferers experience aura. The most common aura is visual and may include both positive and negative (visual field defects) features.
  • 14. Negative scotoma. Loss of local awareness of local structure Positive Scotoma. Additional structures One side loss of perception. Zigzag structure
  • 15. Classification of Migraine headache contd. 3)Retinal migraine- It involves attacks of monocular scotoma or even blindness of one eye for less than an hour and associated with headache. 4)Childhood periodic syndromes that involve cyclical vomiting (occasional intense periods of vomiting), abdominal migraine (abdominal pain, usually accompanied by nausea), and benign paroxysmal vertigo of childhood (occasional attacks of vertigo). They may be precursors or associated with migraine. 5)Complications of migraine describe migraine headaches and/or auras that are unusually long or unusually frequent, or associated with a seizure or brain lesion
  • 16. Pathogenesis Vascular theory- • Intracerebral blood vessel constriction – aura • Intracranial/extra cranial blood vessel vasodilatation-headache Serotonin theory- • Decreased serotonin levels linked with migraine • Specific serotonin receptors found in blood vessels of brain
  • 17. Pathogenesis • Dysfunction of Activation of cells in the trigeminal nucleus results in the release of vasoactive neuropeptides, particularly calcitonin gene–related peptide (CGRP), at vascular terminations of the trigeminal nerve and within the trigeminal nucleus. • Data also support a role for dopamine in the pathophysiology of migraine. Most migraine symptoms can be induced by dopaminergic stimulation. Moreover, there is dopamine receptor hypersensitivity in migraineurs. • Mutations involving the Cav2.1 (P/Q)–type voltage-gated calcium channel CACNA1A gene are now known to cause FHM 1 familial hemiplegic migraine
  • 19. Symptoms Accompanying Severe Migraine Symptom Patients Affected, % Nausea 87 Photophobia 82 Lightheadedness 72 Scalp tenderness 65 Vomiting 56 Visual disturbances 36 Paresthesias 33 Vertigo 33 Photopsia 26 Alteration of consciousness 18 Diarrhea 16 Fortification spectra 10 Syncope 10 Seizure 4
  • 21. MIGRAINE MANAGMENT Non pharmacological treatment • Identification of triggers • Meditation • Relax techniques • Psychotherapy Pharmacological treatment • Abortive treatment • Preventive treatment
  • 23. MODE OF ACTION ERGOTAMINE • Structurally similar to amines serotonin dopamine • Causes constriction of blood vessels • Wide range of effect TRIPTANS • Serotonin is involved in migraine attack • Triptans mimic the action of serotonin • Triptans act on receptors at smooth muscle cells of brain vessels • They are an advance over ergots
  • 24. PREVENTIVE THERAPY • Beta blockers – e.g.. Propanolol • Calcium channel blocker – eg.verapamil • TCA3 – amitriptylene • SSRI’s –fluxetine • anticonvulsant- - sodium valproate • Anti histaminic - cyproheptadine NEED FOR PROPHYLACTIC TREATMENT • Abortive drugs should not be used for more than 2-3 times a week • Long term prophylaxis improves quality of life by reducing frequency and severity of attacks
  • 25. INDICATION OF PROPHYLAXIS • Patients who have very frequent headaches (more than 2- 3/week) • Attack duration> 48hrs • Headache severity is extreme • Migraine attacks are accompanied by severe aura • Contraindication to acute treatment • Unacceptable adverse effects occur with acute migraine treatment • Patients preference
  • 26. Tension-Type Headache • The term tension-type headache (TTH) is commonly used to describe a chronic head-pain syndrome characterized by bilateral tight, band like discomfort. • The pain typically builds slowly, fluctuates in severity, and may persist more or less continuously for many days. • The headache may be episodic or chronic (present >15 days per month).
  • 27. Clinical Features • Completely without accompanying features such as nausea, vomiting, photophobia, phonophobia, osmophobia, throbbing, and aggravation with movement. • In clinical practice, dichotomizing patients on the basis of the presence of associated features (migraine) and the absence of associated features (TTH) is highly recommended.
  • 28. Pathophysiology • Primary disorder of CNS pain modulation alone, unlike migraine, which involves a more generalized disturbance of sensory modulation. . • The name tension-type headache implies that pain is a product of nervous tension, but there is no clear evidence for tension as an etiology. • Muscle contraction has been considered to be a feature that distinguishes TTH from migraine, but there appear to be no differences in contraction between the two headache types.
  • 29. Treatment: Tension-Type Headache • The pain of TTH can generally be managed with simple analgesics such as acetaminophen, aspirin, or NSAIDs. • Behavioral approaches including relaxation can also be effective. • TRIPTANS in pure TTH are NOT HELPFUL, although triptans are effective in TTH when the patient also has migraine. • For chronic TTH , AMITRIPTYLINE is the only proven treatment Other TCA, SSRI and the benzodiazepines have not been shown to be effective.
  • 30. Cluster Headache Rare INCIDENCE only0.1%. THE PAIN IS  often excruciating in intensity, nonfluctuating, explosive in quality. periodic onset nocturnal • recurs at about the same hour The typical cluster headache patient has daily bouts of 1-2 attacks of short-duration unilateral pain for 8 to 10 weeks a year; usually followed by a pain-free interval little less than 1 year. • Patients tend to move about during attacks, WHILE PATIENTS WITH MIGRAINE REMAIN SILENT
  • 32. Cluster Headache Gender Pain M > F 3:1 Type Stabbing, boring Severity Excruciating Site Orbit, temple Attack frequency 1/alternate day–8/d Duration of attack 15–180 min Autonomic features Yes Migrainous featuresb Yes ; Nausea, photophobia, or phonophobia; photophobia and phonophobia are typically unilateral on the side of the pain Alcohol trigger Yes Cutaneous triggers No
  • 33. Treatment: Cluster Headache • The most satisfactory treatment is the administration of drugs to prevent cluster attacks until the bout is over • ACUTE ATTACK TREATMENT  Many patients respond very well to oxygen inhalation. This should be given as 100% oxygen at 10–12 L/min for 15–20 min.  Sumatriptan 6 mg SC is rapid in onset and will usually shorten an attack to 10–15 min; there is no evidence of tachyphylaxis.  Sumatriptan (20 mg) and zolmitriptan (5 mg) nasal sprays are both effective • ORAL SUMATRIPTAN IS NOT EFFECTIVE
  • 34. Preventive Management of Cluster Headache Short-Term Prevention Long-Term Prevention Episodic Cluster Headache Episodic Cluster Headache & Prolonged Chronic Cluster Headache Prednisone 1 mg/kg up to 60 mg qd, tapering over 21 days Verapamil 160–960 mg/d Lithium 400–800 mg/d Methysergide 3–12 mg/d Methysergide 3–12 mg/d Verapamil 160–960 mg/d Topiramatea 100–400 mg/d Greater occipital nerve injection Gabapentina 1200–3600 mg/d Melatonina 9–12 mg/d