Neurology

2.  ‘secondary’ headaches:
with a defined pathophysiological basis
 Primary headache syndromes:
of uncertain pathogenesis

3.  Increased intracranial pressure
 Idiopathic intracranial hypertension
 Meningeal irritation
 Giant cell arteritis (cranial arteritis, temporal
arteritis)
 stroke, haemorrhage, intracranial venous
sinus thrombosis or arterial dissection ,,
Metabolic disturbances, e.g. hypoxia,
hypercapnia and hypoglycaemia,
vasoactive drugs, alcohol, monosodium
glutamate, nitrites and nitrates

5.  Due to raised ICP either tumor “ usually has
a short history days to weeks the pain start
suddenly and persist, daily, nausea and
vomiting, “Effortless vomiting” or SOL.
Other focal neurological signs are more
definitive of raised ICP than headache
 Wake the patient from sleep or at morning
with headache
 Exacerbated by coughing, sneezing,
bending and lying down.

6.  Headaches of low ICP characterized by
relieving on lying down.
 Usually follow LP
 “Spontaneous low pressure headache”

7.  Young and obese women
 Raised ICP with no mass, pathophysiology is
incompletely known but may due to “impaired
CSF absorbtion”
 Patients present with morning headache,
vomiting and sometimes visual disturbance –
typically diplopia and visual obscurations, +
tinnitus
 O/E Bilateral papilloedema
 6th nerve palsy. No othe FNS.
 Ventricles are small
 High ICP with normal CSF content

8.  Resolve by weight reduction or LP.
 TRT.
- Acetazolamaide CA inhibitor
- Chlorothalidone
- Corticosteroid
- Surgical:
*Lumboperitoneal shunt
*Optic nerve fenestration

9.  intracranial venous sinus thrombosis
 hypervitaminosis A,
 disturbances of calcium metabolism,
 systemic lupus erythematosus,
 drugs, including tetracyclines and
corticosteroids

10.  Meningism or irritation of the meninges due to
inflammation or blood accumulation
 characteristically produces severe global or occipital
headache with vomiting, exacerbation of symptoms
by bright lights (photophobia) and neck stiffness
(nuchal rigidity).
 In SA haemorrhage, the pain is very sudden (within
seconds) and severe, and the patient may lose
consciousness
 In bacterial meningitis, the headache is also acute in
onset, but usually worsening over minutes or hours.
 Kernig’s sign
ch.

11.  Over 50
 Granulomatous inflammatory changes (with giant
cells) are present in branches of the external carotid
artery.
 narrowing of the lumen, then thrombotic occlusion
 Viral infection ,, autoimmunity ??
 Scalp tenderness on coping hair.
 intermittent claudication of the jaw, difficulty of
chewing
 The temporal arteries may become swollen and non-
pulsatile
 Amaurosis fugax

12.  low-grade fever, night sweats, shoulder
and/or pelvic girdle pains, malaise,
anorexia and weight loss.
 Important investigations:
-ESR > 100, CRP high
-CBC normocytic normochromic anemia
- LFT abnormal
-temporal artery biopsy. skip lesions

13.  IV hydrocortisone. 40–60 mg daily of
prednisolone become better in 24-48 hrs
treatment may be needed for 18 months- 2
yrs
 polymyalgia rheumatica
7.5–15 mg daily of prednisolone

15. Migraine is a periodic disorder
characterized by unilateral (or
sometimes bilateral) headache, which
may be associated with vomiting and
visual disturbance.

16. -common, 10% of the general population
experience at least one attach
-any age ,typically teens and twenties
-Female >male
-family history in the majority
-travel sickness and cyclical vomiting in
childhood
-relate to hypertension and head injury

17. -obscure
-Neurologic symptoms ,aura
(intercerebral vasoconstriction
-Headache phase ,subsequent
vasodilation of extracerebral vessel in
scalp and dura
-Serotoninergic pathway
-Genetic >> calcium channels

19. ● stress, particularly after the stress is over, e.g. at
weekends and holidays;
● physical exercise;
● diet – alcohol; occasionally specific dietary
triggers can be identified, e.g. cheese,
chocolate, red wine;
● hormones – the onset of migraine may follow
the menarche, and symptoms may also increase
in severity around the menopause. Attacks may
be
related to menstruation.

20. -Migraine with aura(classical migraine)
-Migraine without aura(common migraine)
-Basilar migraine (Bickerstaff variant)
-Hemiplegic and ophthalmoplegic
migraine

21. -experience vague prodromal symptoms for hours
preceding an attack, including drowsiness, mood
changes, hunger or anorexia
-classical attack begins with the aura
- Visual symptoms
-Expanding scotoma ,teichopsia,fortification
spectra
-homonymous hemianopia,or complete
blindness
- Sensory symptoms
- Dysphasia and limb weakness
The aura generally resolves after 15–20 minutes (it
may last as long as an hour ).

23. The headache of migraine is typically
unilateral and periorbital,. Pain is throbbing
in quality and may be exacerbated by
coughing, straining or bending (jolt
phenomenon). It lasts several hours
(generally between 4 and 72 hours).
Patients prefer to lie in a darkened room
and may gain relief from sleep. Associated
symptoms include photophobia, nausea,
vomiting, pallor and diuresis.

24. Migraine without aura (common migraine)
In this case, the aura is absent but patients
may experience vague prodromal
symptoms. Headache may be present
on waking but is otherwise similar to that
of classical migraine.

25. Basilar migraine (Bickerstaff variant)
This syndrome, which particularly affects
teenage female patients, is
characterized by prominent features
suggestive of vertebrobasilar ischaemia
during the aura, including vertigo,
diplopia, dysarthria, ataxia and syncope

27. Hemiplegic and ophthalmoplegic
migraine
These rare syndromes, in which migrainous
headaches are accompanied by
hemiplegia or ophthalmoplegia, with
focal neurological signs persisting for
days or weeks, should be diagnosed only
after structural causes, e.g. aneurysm,
have been excluded.

28. - History (periodicity)
- Status migrainosus
- neurological examination is normal
(except during an attack of hemiplegic
or ophthalmoplegic migraine, or unless
migrainous cerebral infarction has
occurred)
- a cranial bruit >vascular malformation

29. the differential diagnosis of transient focal
neurological symptoms is:
● migraine,
● transient cerebral ischaemia,
● epilepsy.

30. Acute attach
-dark room and sleep
-analgesic and antiemetic
-ergotamine(vasoconstrictor) OR triptans(
sumatriptan,5-HT1 receptor agonist)
Prophylaxis
-avoid dietary triggers
-oestrogen containing
preparation;OC,hormone replacement
therapy
-drugs (frequent attachs)
propranolol and other beta
blockers,pizotifen,sodium
valproate,verapamil,topiramate,methysergide

31. Despite also being characterized by
unilateral headache, this syndrome is
distinct from migraine, though the two
conditions may coexist. Histaminergic
and other humoral mechanisms are
thought to underlie the autonomic
accompaniments of the headache.

32. -Male>female
-age onset 20-60
- Severe attacks of pain around one eye (always the
same side) characteristically last 20–120 minutes and
may recur several times a day, often waking the
patient more than once at night. Alcohol may
precipitate an attack. This pattern continues for days,
weeks or months, and the patient may then be
symptom-free for many weeks, months or even years,
hence the disorder’s name.
Unlike migraine, patients with cluster headache are
often restless during an attack and may appear red
rather than pale. More pronounced autonomic
accompaniments of the pain include conjunctival
injection, lacrimation and nasal discharge or
congestion

34. -high flow 100% O2
-ergotamine ( bedtime ,best with caffine)
-Sumatriptan
-corticosteroid
*long term treatment
(methysergide,verapamil,pizotifen)
*chronic cluster headache (Lithium)
*trigeminal autonomic
syndromes>>indometacin

35. The most common headache of unknown
cause though abnormal contraction of
muscles of the head and neck has been
invoked as one putative mechanism.
Muscle contraction may be triggered by
-psychogenic factors, i.e. anxiety or
depression, -local disease of the head
and neck, e.g. cervical spondylosis or
dental malocclusion.

36. - headache vary from dull pain at various
sites, to a global pressure sensation, to
the feeling of a tight band around the
head
- are no associated symptoms
- neurological examination is normal
* Migraine and tension-type headache
frequently coexist.

37. Treatment :
- no sinister underlying cause
- 3–6-month course of a tricyclic or
related compound, e.g. amitriptyline or
dosulepin, may be helpful if tension-type
headache is frequent or persistent
-physiotherapist ( relaxation exercise)
-psychotherapy( stress management)

39. >15 days/month
causes:
-secondary headache syndrome
-chronic tension type headache
-transformed migraine
-medication overuse

40. Trigeminal neuralgia
Post-herpetic neuralgia
Atypical facial pain

41. ->50 years
-compression of the trigeminal sensory root
-idiopathic and symptomatic(tumor of the
cerebellopontine angle ,younger MS)
-unilateral facial pain within the distribution
of one or more divisions of the trigeminal
nerve(mandibular and maxillary are
most common )

42. -The pain is lancinating in quality-
brief,severe,sharp,stabbing,electric shock-like
jolts of pain.
-trigger areas (fear of provoking an attach by
washing face or shaving)
-speaking, cold breeze , chewing produce pain
-Glossopharyngeal neuralgia>pain in throat or
deep inside the ear
-normal trigeminal nerve examination ,abnormal
neurologic signs indicate tumor (MRI)
-Tic douloureux:anxiety about trigger areas may
lead to involuntary facial spasm
-analgesic unuseful,Carbamazepine ,other
drugs,surgically.

43. Patients who have suffered shingles in one of the
branches of the trigeminal nerve (often the first –zoster
ophthalmicus) may experience persistent facial pain after the
rash has healed. The pain may be very severe and intractable,
lasting 2–3years after the eruption, but sometimes responds
to tricyclic antidepressants, carbamazepine or topical application
of capsaicin
Atypical facial neuralgia
Some patients present with constant facial pain in
a non-anatomical distribution, and for which no
local cause is found. Treatment is unsatisfactory
but coexistent anxiety and/or depression may indicate
potential benefit from tricyclic and related
drugs, e.g. dosulepin.

44. -local causes of pain
:eyes,ears,nose,paranasal sinuses,throat
or teeth
- cough,exertion,and sexual intercourse
headache (benign )
*exclude cerebellar ectopia
- Coital headache (benign)
*exclude subarachnoid hemorrhage
- Ice-pick headache (benign) :sharp jabs
felt anywhere in head