evaluation of headache,eye pain

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evaluation of headache,eye pain

  1. 1. THE PATIENT WITH HEAD,OCULAR, OR FACIAL PAIN
  2. 2. EVALUATION OFHEADACHE• HISTORY – Nature of the headache – Daily pattern of hedache – Location – Associated symptoms – Precipitating or alleviating factors – Overall pattern – Family history
  3. 3. • VAST MAJORITY OF PATIENTS WITH HEADACHE HAVE NORMAL VISUAL ACUITY• PE: • BP, Pulse • Meningeal signs • Symmetry of cranial nerve and motor functions
  4. 4. TYPES OF HEADACHE• PRIMARY – Migraine – Tension- type – Cluster• SECONDARY
  5. 5. NEUROIMAGING?• Sudden onset of severe headache• Unexplained change in headache pattern• Unresponsive to medical therapies• HA related to physical exertion or change in body position• New onset of headache after the age of 50 years• New headaches in immunosuppressed patients• (+) focal neurologic signs• (+) fever, neck stiffness, change in mental status, behavioral changes
  6. 6. MIGRAINE• Condition consisting of repetitive bouts of headache• F>M• (+) familial tendency• (+) history of motion sickness in childhood• Onset- puberty or young adulthood• Decrease after menopause
  7. 7. Characteristic:• unilaterality, pulsating, N/V, photophobia, aggravated by physical activitiesExacerbated by:• menstruation, pregnancy, hunger, stress, certain foods and sleep deprivation
  8. 8. I. Migraine with aura• Classic migraine• 30%• Visual aura: begins w/ a small scotoma near fixation that gradually expands, then breaks up• < 45 minutes• Followed by HA on the contralateral side of the head• Untreated: 4 to 72 hrs
  9. 9. II. Migraine without aura• Common migraine• 65%• No preceding neurologic symtoms• Global• Can last hours to days
  10. 10. III. Migraine aura w/oHeadache• Acephalgic migraine• 5%• Visual aura:• Scintillating scotoma, transient homonymous hemianopia, peripheral VF constriction, transient monocular visual loss, episodic diplopia ( vertical)
  11. 11. EVALUATION• Headache or aura always occur on the same side• Headache precedes the aura• Neurologic deficit, persists after aura resolves• Features of aura are atypical
  12. 12. Tension -type headache• Chronic• Aching• Worse at the end of day• Precipitated by stress• Associated with depression
  13. 13. TREATMENT• Reassurance• Avoid precipitating factors:• Chocolates, nitrates, MSG, cheese, caffeine, red wine, alcohol, nuts, shellfish• OCPs• Stress, change in sleep patterns, strong scents such as perfume, cigarette smoke and exercise
  14. 14. • Acute relief: dihydroergotamine, sertonergic agents, NSAIDS• * analgesic rebound headache• Prophylactic treatment:• Disrupted functions of daily life• Beta blockers, Ca channel blockers, TCA, SSRIs, sodium valproate, NSAIDS
  15. 15. CLUSTER HEADCHE• Men• 30’s to 40’s• Cigarette smokers• Pain localized behind 1 eye• Tearing, conjunctival injection, rhinorrhea• < 2 hrs
  16. 16. • Difficult to treat• Inhaled oxygen, methysergide, subcutaneous sumatriptan or dihydroergotamine• Prednisone tapered for 10- 14 days• Verapamil- prophylaxis
  17. 17. OCULAR AND ORBITALCAUES OF PAIN• Refractive errors and starbismus• KS, Keratitis, AACG, intraocular inflammation• Recurrent erosion syndrome• Scleritis• Optic neuritis
  18. 18. PHOTOPHOBIA• Keratitis• Uveitis• Chorioretinitis• Menigeal irritation• migraine
  19. 19. FACIAL PAIN• Most often, pain in the eye area is a manifestation of headache• Dental disorders, sinus disease
  20. 20. 1. Trigeminal neuralgia• Tic douloureux• Caused by vascular compression of CN V• Demyelinating dse, posterior fossa mass lesion• Unilateral• chewing , tooth brushing, cold wind• Normal sensory function• MRI• Treatment:• gabapentin, carbamezepine, phenytoin, baclfen, clonazepam, valproic acid• Rhizotomy, decompression of CN V
  21. 21. 1. Trigeminal neuralgia• Tic douloureux• Caused by vascular compression of CN V• Demyelinating dse, posterior fossa mass lesion• Unilateral• chewing , tooth brushing, cold wind• Normal sensory function• MRI• Treatment:• gabapentin, carbamezepine, phenytoin, baclfen, clonazepam, valproic acid• Rhizotomy, decompression of CN V
  22. 22. • 2. Glossopharyngeal neuralgia• 3. Carotidynia- neck pain that radiates to ipsilateral face and ear• 4. Carotid dissection- (+) sympathetic dysfunction• 5. Temporomandibular disease
  23. 23. 6. HZO-• pain before vesicle eruption• Gabapentin, TCA, lidocaine patch7. Neoplastic process8. Mental nerve neuropathy- numb chin• Saroidosis, lymphoma, mets breast Ca
  24. 24. Thank you

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