Headache : Causes and management

1. HEADACHE :
CAUSES AND MANAGEMENT
Anees Kurikkal
2008 MBBS
MES Medical College

2. DEFINITION
• Headache is defined as a pain or discomfort
between the orbit and the occipital region
arising from extracranial and/ or intracranial
pain sensitive structures.

3. CLASSIFICATION
• Headaches can be classified broadly into
– Primary headaches
– Secondary headaches

4. • Primary headaches are those in which
headache and its associated features are the
disorder in itself, whereas secondary
headaches are those caused by exogenous
disorders( like headache due to RTI)
• Primary headache often results in
considerable disability and a decrease in the
patient's quality of life

5. CLASSIFICATION

6. PATHOPHYSIOLOGY OF HEADACHE
• Pain usually occurs when peripheral
nociceptors are stimulated in response to
tissue injury, visceral distension, or other
factors .Pain can also result when pain-
producing pathways of the peripheral or
central nervous system (CNS) are damaged or
activated inappropriately. Headache may
originate from either or both mechanisms.

7. • Relatively few cranial structures are pain-
producing; these include 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.

8. INTRACRANIAL PAIN SENSITIVE
STRUCTURES
• Dura near vessels
• Cranial nerves 5,7,9,10
• Circle of Willis and proximal continuations
• Meningeal arteries
• Large veins in the brain and dura

9. EXTRA CRANIAL PAIN SENSITIVE
STRUCTURES
• Mucous membrane of nose and Para nasal
sinuses, Middle ear cleft.
• Skin of Ext Auditory Canal
• Scalp and neck muscles
• Scalp vessels
• Orbital contents
• Teeth and gums

10. ETIOLOGY
• Naso-sinus causes
 Sinusitis
 Vacuum headache
 Sinonasal tumors
 Trauma
 Contact Neuralgia (Sluder’s
neuralgia)
• Ear causes
 Complications of otitis media
 Malignant otitis externa
 Herpes zoster oticus
• Ophthalmic
 Refractive error
 Eye strain
 Retrobulbar neuritis
 Dacryocystitis
 Orbital tumors
 Glaucoma
• Vascular
 Migraine
 Cluster headache
 Temporal arteritis

11. ETIOLOGY CONTND.
• Neuralgias
 Trigeminal neuralgia
 Glossopharyngeal neuralgia
 Cervical neuralgia
 Sluder’s syndrome
• Dental
 Malocclusion
 TMJ dysfunction
 Caries teeth
 Apical abscess
• Drugs
– Vasodilators
– OCPs
– Caffeine
• Tension head ache
 Muscle contraction headache
 Head injury
 psychological
• Intracranial
 Tumors
 Meningitis/encephalitis
 Brain abscess
 SOL
 Benign intracranial HT
• Systemic causes
– HTN
– Hypoglycemia
– Hypoxia
– Post alcohol hangover

12. MIGRAINE
• Most common type of headache
• Headache – throbbing type along the arteries,
which could be unilateral or bilateral
• Headache comes in paroxysms. Frequency and
duration of each attack is variable.
• Aura usually present in classical migraine

13. • Nausea, vomiting
• Photophobia, phonophobia
• Precipitating factors:
– mental stress
– Diet like chocolate,cheese etc
• Relieving factors
– Rest/sleep
– Staying in silent and dark room

14. TREATMENT
• Analgesics and anti emetics given in acute
attacks (Metoclopramide 5-10mg/day with
paracetamol/aceclofenac)
• If not responding, vasoconstrictors (ergot
alkaloids) are given
• Sumatriptan (50–100 mg tablet at onset; may
repeat after 2 h (max 200 mg/d) )
• Prophylaxis – topiramate, flunarizine,
propranalol

15. CLUSTER HEADACHE
• Horton’s cephalgia or histamine cephalgia
• Less common, but more severe than migraine
• No aura
• Headache comes in clusters of 1 to 7 episodes
each day for a week or more followed by
symptom free interval for weeks or months.
• Males are commonly affected than females
• Severe unilateral pain around the eye assoc. with
conjunctival injection, rhinorrhea, transient
Horner’s syndrome occasionally.

16. TREATMENT
• Mechanism
serum histamine level raised during attack,
hence called histamine cephalgia
• Treatment
Ergotamine, methisergide
Inhalation of 100% oxygen
Sumatriptan
Prednisolone 30mg daily for 10 days (refractory
cases)

17. TENSION HEADACHE
• A common form of headache experienced by everyone.
• Diffuse dull aching band like headache worse on
touching scalp aggravated by noise assoc with tension
but not with other physical symptoms.
• Last from few hours to few days.
• Worse towards the end of the day.
• Headache is due to persistent contraction of scalp and
posterior neck muscles.
• Bilateral and frequently localizes to occipital nuchal
area.

18. TREATMENT
• NSAIDs
• Short course of diazepam
• Reassurance
• Antidepressants are used rarely

20. TEMPORAL ARTERITIS
• Common in elderly
• Severe throbbing type of headache
• Usually involving superficial temporal artery
• Pain while chewing or talking due to ischemia of
masseter muscle following jaw claudication
• Assoc. blindness and diplopia
• Weight loss, lassitude, polymyalgia rheumatica
(genzd. muscle aches)

22. TREATMENT
• Investigation
ESR raised
CRP, alkaline phosphatase may be elevated
Biopsy - diagnostic
• Treatment
Prednisolone 60mg daily and gradually
reduced to 5mg daily

23. POST TRAUMATIC HEADACHE
• Follows head injury
• More similar to migraine or tension type of
headache
• Light headedness, irritability, difficulty in
concentration
• Underlying neurological defects looked for and
appropriate treatment given

24. FACIAL NEURALGIA
• Neuralgias are extremely painful conditions distributed
along the course of the cutaneous supply.
 Trigeminal neuralgia
 Glossopharyngeal neuralgia
 Sluder’s neuralgia(contact neuralgia)
 Cervical neuralgia
 Raeder’s neuralgia
 Ramsay Hunt syndrome
 TMJ dysfunction

25. TRIGEMINAL NEURALGIA
• Synonyms – Tic Douloureux, Suicide disease
• Episodes of intense, stabbing, electric shock
like pain in the areas of the face where the
branches of trigeminal nerve are distributed.
• Most often affect on one side of face.
• Exact cause not known, probably due to
abnormal loop of vessels over the nerve
intracranially.

26. • The three major sensory divisions of the trigeminal
nerve consist of the ophthalmic, maxillary, and
mandibular nerves

27. Clinical features
• Most often after 50yrs
• Pain along distribution of nerve, sharp shooting type
• Pain triggered by casual activities like brushing,putting
makeup etc.
Treatment
• Usually treated by anticonvulsants like Tegretol or
neurontin
• Antidepressant drugs
• Neurosurgical procedures (to reduce the sensitivity )

28. GLOSSOPHARYNGEAL NEURALGIA
• Triggering zone is often in the tonsillar area and
extends to the ipsilateral area.
• Pain is also felt in the back of tongue or posterior
pharyngeal wall.
• Precipitated by swallowing, eating, or irritation of
tonsillar region.
• Xylocaine test may be helpful in reducing pain.
• Stylalgia – glossopharyngeal neuralgia due to
elongated styloid process.
• Anticonvulsants , intracranial section of IX nerve

29. RAMSAY HUNT NEURALGIA
• Rare
• Due to invovement of geniculate ganglion by
herpes zoster virus

30. TMJ DYSFUNCTION
• Malocclusion, improper positioning of
mandibular condyle within glenoid fossa
• Due to contraction of masticatory muscles
• unequal bite may cause spasm
• Treatment
NSAIDs
Massage
Joint rest
Muscle relaxant exercise
Condylectomy for joint ankylosis

31. PARA-TRIGEMINAL NEURALGIA
(RAEDER’S SYNDROME)
• Retro-ocular pain
• May be associated with dilated pupil
• Occur due to encroachment of vessel into
para-trigeminal region
Treatment
• Neuroendoscopic surgical decompression

32. SINUSITIS
• Sinusitis refers to inflammation of the mucosa
of one or more Para nasal sinuses where the
mucociliary clearance function is affected due
to anatomical or pathological abnormalities
leading to blockage of the sinus ostium

33. TYPES
• ACUTE
 Frontal sinusitis
 Maxillary sinusitis
 Ethmoiditis
 Sphenoidal sinusitis
• CHRONIC SINUSITIS

34. ACUTE FRONTAL SINUSITIS
• Severe headache, periodic in nature, confined to
frontal region.
• Starts in the morning, subsides in the afternoon –
office headache
• Precipitated on bending, straining, coughing.
• unilateral or bilateral
• Usually affects the medial canthus region and root of
nose.
Investigations
• X-ray of PNS
• Diagnostic nasal endoscopy
• CT scan of ostiomeatal complex

35. • Medical
• Broad spectrum antibiotic - amoxycillin + clavulanate.
• Anaerobic infection – metronidazole
• Observation for complications
• Systemic decongestants – pseudoephedrine
hydrochloride combined with mucolytic promotes
drainage.
• Local decongestants – oxymetazoline or
xylometazoline.
• Analgesics – aceclofenac.

36. • Surgical
• Frontal sinus trephination
• Endoscopic sinus surgery
• Endoscopic frontal recess clearance

37. ACUTE MAXILLARY SINUSITIS
• Pain over the cheek following upper
respiratory infection
• may radiate to the teeth or the frontal region.
• Aggravated on straining or bending forwards.
Investigations
• X-ray PNS
• Diagnostic nasal endoscopy
• CT

38. • Medical
• Infection of dental origin – antibiotic coverage
for anaerobic infection.
• Surgical
• Middle meatal maxillary sinusostomy
• Irrigation of maxillary sinus with isotonic
saline by antral puncture
• Infected tooth if any should be extracted.

39. ACUTE SPHENOIDAL SINUSITIS
• Headache may be vertical, frontal, occipital or
central
• May radiate to temporal region
• Postnasal drip and hawking

40. Investigations
• CT scan
• Nasal endoscopy
Treatment
• Medical
 Broad-spectrum antibiotics
 Nasal decongestants
 Anti inflammatory
 Anti histamines
 Nasal irrigation with saline
 Mucolytics
 Steam inhalation
• surgical
 endoscopic sphenoidotomy

41. ACUTE ETHMOIDITIS
• Most common sinus involved in children
• Pain between the eyes associated with frontal
headache.
• Nasal discharge, usually purulent
• Post nasal drip assoc with nocturnal cough
• Constitutional symptoms – fever, bodyache

42. Investigations
• CT scan of osteomeatal complex
Treatment
• Amoxycillin + clavulanic acid for 3wks
• Nasal decongestants
• Analgesics, anti- inflammatory

44. REFERENCES
• 1. Textbook of ENT and head and neck surgery,
HAZARIKA
• 2. Harrison's Principles of Internal Medicine
17th edition
• 3.Handbook of headache, Evans and Mathew

45. THANK YOU ..