Headache Harrison

1. Headache
presentation by
Dr Yasam Jeji Maheswara Sai
1st yr Post Graduate
MD General Medicine
Moderator
Dr T Mouleswara kumar
Associate Professor
General Medicine
MIMS
Dr P.CH. Mishra
Proff & HOD
Department of General Medicine
MIMS

2.  Definition : pain or discomfort in the head or upper neck region, the pain originates from
tissues and structures that surround brain or skull
 International headache society
 Primary Headche – headache features are disorder itself
which often results in considerable disability and ↓QUALY
 Secondary Headache -- exogenous disorders which are mostly by URTI and are rarely .
worrisome

5. Origin
 Stimulated nociceptors due to
Tissue injury
visceral distension
other factors
damage pain producing pathway
central
peripheral

6.  Pain sensitive structures
scalp
meningeal arteries
dural sinuses
flax cerebri
proximal segments of large pial arteries
 Pain insensitive structures
Ventricular ependyma
choroid plexus
plial veins
brain parenchyma

7. Primary Headache
 Involves - Trigemino vascular complex
Large intracranial vessels
dural mater
peripheral nerves of trigeminal nerve
Pathway 5th CN + C1 C2 nerve roots --trigeminocervical complex
Dorsal horns of upper cervical spinal cord
caudal portion of trigeminal nerve
ventroposteromedial thalamus
cortex

8.  Modulation
from trigeminal nociceptors at all levels of pain pathway
via Hypothalamus and brainstem structures
 Trigeminal autonomic cephalalgias ( TACs ) symptoms
lacrimation
conjunctival injection
Nasal congestion
rhinorrhea
periorbital swelling
aural fullness
ptosis

9. Primary headaches are not vascular
headaches
 Migraine and other primary headaches
 Do not manifest vascular changes
 Treatment outcomes cannot be predicted by vascular effects

10. Approach to New Onset Headache
 In New onset headache probability of potential serious cause is greater than than
reccurent headaches when red flag signs are present
 History and examination
cranial arteries palpation
passive cervical spine movement
cvs and renal status
BP monitoring ,CUE
fundoscopy , IOP management , refraction
Checklist of red flags
MRI / CT
LP if advised by physician
Psycological consulation at last to r/o depression and anxiety as their relation exits with
headpain

11. Clues to identify secondary
 ICH --- SAH
acute < 5 min
severe > 5 min
stiff neck but no fever
----ruptured aneurysm , Av malf ,intraparenchymal H”Ge
high BP in majority cases
present with headache alone
---- CT can miss
small H’Ge
below foramen magnum

12.  Meningitis
stiff neck with fever
acute , severe Headache
accentuation of pain with eye movement
MISTAKEN FOR MIGRAINE
LP is mandatory
Brain tumor --- 30% patients presents with chief complaint of headache
intermittent deep dull aching moderate intensity
worsen with exertion / positional change
asso with nausea & vomiting
sleep disturbances
vomiting precedes Headache

13.  Amenorrhea/ Galactorea
prolactin secreting pituitary adenoma
Malignancy – cerebral metastasis
ca meningitis or both
Pain after bending , lifting or coughing
post fossa mass
chiari malformation
low CSF volume

14.  Glaucoma - HA start with severe eye pain
asso with nausea & vomiting
eye is often red with fixed dilated pupil
Gaint cell arteritis – elderly female
pain increases gradually over few hours before the peak . .
. intensity is reached
explosive occasionally
dull and boring type
polymyalgia rheumatica
jaw claudicaton
fever , weight loss
scalp tenderness
difficulty to comb or rest over the pillow
red tender nodules , streaky red skin
50 % develop blindness
high ESR / CRP but not always

16. Medication – overuse Headache
 Medication overuse Can aggravate headache frequency
Markedly impair the effect of preventive medicines
State of refractory daily or near daily headache
 On stopping analgesics
substantial improvement in the severity and frequency
especially with opioids or barbiturates

17. OPD management
 Analgesic to be reduced & eliminated
reduce dose by 10% every 1-2 weeks
Rescue for residual effect
a small dose NASIDS is not a problem for patients
Once patient has reduced the analgesic use substantially
preventive medication is to be introduced

18. IPD management
 Day 1 Acute medication are withdrawn
hydration and antiemetics are to be administered as required
. Clonidine for opiod withdrawl symptoms
If pain is intolerable
aspirin 1g IV , chlorpromazine IM at night
 Day 3-5 withdrawl symptoms disappear
IV ( DHE ) dihydroerogotamie TID _ 5 days
induces significant remission
that allows a preventive medicine to be established

19. Primary chronic daily Headache
 MCA (monoclonal antibody) to CGRP or its receptor
effective in chr Migraine in phase II/ III RCT over placebo
Non invasive neuro modulatory approaches
single pulse transcranial magnetic stimulation
Non invasive vagal nerve stimulation
modulate thalamic processing / brainstem mechanism respectively
chronic cluster headache
chronic paroxysomal hemicrania
SUNA & SCUNT

20. NEW DAILY PERSISTANT HEADACHE
 Headache in all days
Onset
begins abruptly
patient can clearly recall the moment of onset
Evolves over 3 days – to the max upper limit possible
priority is to distinguish primary / secondary cause

22. Low CSF volume Headache
 Onset :
headache from day 1 to the next day
generally not present on waking but worsens during the day
Positional
begins when pt sits or stands upright
resolves on reclining
Site and character
occipitofrontol
dull ache but may be throbbing

23. Etiology of low CSF vol headache
 CSF leak following LP ( most common )
10-30 % incidence
begins in 48hrs can be delayed upto 12 days
temporary relief with caffeine beverages
epidural injection
vigorous valsalva such as lifting , straining , coughing , clearing ET in airplane
DD – postural orthostatic tachycardia syndrome

24.  Mechanism :
low volume rather low pressure
IOC :
MRI with gadolinium – shows diffuse meningeal enhancement
MRI spine with T2 weighting – reveals leak
Source of leak
spinal MRI with appropriate sequences
CT
MR myelography
111 In-DTPA csf study

25.  Management
bed rest initially
if pain is persistant ‘
IV caffeine 500mg in 500ml NS @ 2hr
ECG to screen arrhythmia before administering
if needed caffeine can be given twice before going for additional test
If unsuccessful ---- abdominal binder
If interactable ---- oral theophylline
If leak identified --- autologous blood patch

26. Headache of raised ICT
 Generalise headache
present on waking up
improves as the day goes on
worsen with recumbency
Visual obscurations are frequent
Dx straightforward if papilledema
possible even in pt without fundoscopic changes
frontal visual field testing helps
DD ---uncontrolled HTN , OSA

27.  Investigation
MRI with MR Venogram
CSF pressure on removal of 20-30 ml
Management :
Acetazolamide 250-500 mg BD ---improves in weeks
if ineffective : Topiramate
CA inhibitor , weight loss
neuronal membrane stabilization
if still refractory :
ICP monitoring and may require shunting

28. Post traumatic headache
 Injury / Infection/ surgery / SAH
can trigger headache
last for month or year after the event with
dizziness , vertigo , impaired memory
May remit after several weeks / months / years after injury
CNS examination is normal
CT /MRI are unreavealing
Mimc --- SDH

31. Migraine
 Most common headache related and indeed
neurologic cause of disability in the world
2nd most common cause of headache

32. Pathogenesis of migraine
 sensory sensitivity that is characteristic of migraine is probably due to dysfunction
of monoaminergic sensory control systems located in the brainstem and
hypothalamus
 Activation of cells in the trigeminal nucleus results in the release of calcitonin
gene–related peptide (CGRP), at vascular terminals of the trigeminal nerve and
within the trigeminal nucleus.
 the involvement of the neurotransmitter 5-hydroxytryptamine (5-HT; also known
as serotonin)is seen

33. Brainstem pathway that modulate sensory input
 Trigeminovascular input from meningeal vessels
passes through trigeminal ganglion , synapses on 2nd order neuron in TCC
these neurons project into quintothalamic tract
after decussating in brainstem , synapses with neurons in thalamus
 Important modulation of Trigeniovascular nociceptive input
comes from dorsal raphe nucleus , locus ceruleus and nucleus raphae magnus

35.  Migraine genetics Familial hemiplegic migraine(FHM)
FHM 1 ___: cav2.1 (P/Q) type voltage gated ca channel CACNA1A
FHM2 ---- Na K ATPase gene
FHM3 ___neuronal voltage gated Na channel SCN1A
Functional neuroimaging :
brain stem involvement in migraine
posterior hypothalamic gray matter region suprachiasmatic nucleus in
. cluster headache

40. Non pharmacological treatment
 Avoid trigger _ when pt can identify triggers
A regulated lifestyle
healthy diet , regular exercise
regular sleep patterns
avoid excess caffine / alcohol
avoid stress
Practical tip : lower the avoidable stress by Yoga, meditation , hypnosis
conditioning techniques such as biofeedback

47. Tension type headache

48. Cluster headache

49. Acute attack of cluster headache
 Mostly nocturnal ,unilateral , periodicity
 O2 inhalation 10-12 L/min for 15-20 min
sumatriptan 6mg s/c rapid onset shorten attack to 10-15 min
Suminat 20 & zolmitriptan 5mg nasal sprays
nVNS
2min stimulation cycles applied consequetively at the onset of .headache on side of pain
can be repeated after 9min
Preventive measures :
limited use of glucocorticoids
greater occipital nerve injection with glucocorticoids , lidocaine

51. Primary paroxysmal hemicrania
 M: F – 1:1
 Site tends to be retroorbital ,can be seen all over the head
Features : unilareral
very severe pain
short lasting attacks 2-45 min
very frequent attacks >5 /day
marked autonomic features ipsilateral to pain are seen
rapid course < 72hrs excellent response to indomethacin
nVNS can be useful

52. Secondary paroxysmal hemicrania
 Lesions in
sella turcica
Av malformation
cavernous sinus meningioma
pituitary pathology
epidermoid tumors
More likely in pt requiring high doses of indomethacin > 200mg/day
MRI is indicated to R/o pituitary lesion

53. SUNCT/SUNA
 SUNT : severe U/L orbital /temporal pain
stabbing / throbbing quality
diagnosis : require 20 attacks
lasting for 5-240 sec
ipsilateral conjunctival injection & lacrimation
Suspect SUNCT – cutaneous triggers without refractory periods between attacks .
. lack of response to indomethacin
Secondary SUNCT – can be seen in posterior fossa / pituitary lesions
r/o by pituitary function test & MRI brain with pituitary views

54.  Treatment :
IV lidocaine which arrest symptoms
can be used in hospitalised pt
Prevention :
lamotrigine 200-400 mg/dl
topiramate & gabapentin can also be used
occipital nerve stimulation

56. Hemicrania continua
 Onset 10-70 yrs
women twice affected than men
moderate and continuous
U/L associated with severe pain
ass with autonomic feautures
conjunctival injection , lacrimation , photophobia on affected side
Treatment :
inj indomethacin 100mg IM is diagnostic tool
oral dose of 25mg f/b 50mg /75mg TID can be given
occipital nerve stimulation in pt unable to tolerate indomethacin

57. Primary cough headache
 Generalized headache
due to cough
begins shuddenly
last for seconds / several minutes upto few hours
R/O secondary causes
Arnold chairi malformation
any lesion obstructing CSF pathways
cerebral aneurysm , carotid stenosis
vertebrobasilar disease
Treatment :
indomethacin 25-50 mg BD /TID
some may require LP

58. Primary exercise headache
 Pulsatile quality of migraine headache
last < 48hr
B/l often throbbing
migraine feautures may be seen
Secondary cause :
cardiac cephalgis - anginal pain refered to head
probably by central connections of vagal afferents
may present as exercise headache
 Treatment : Indomethacin at daily doses from 25–150 mg is generally effective.
prevention : Indomethacin (50 mg), a gepant , ergotamine (1 mg orally), and
dihydroergotamine (2 mg by nasal spray) are used.

59. Headache with sexual activity
 Mostly in men
 3 types
1 b/l in head & neck intensifies on excitement
2 shudden severe explosion occuring at orgasm
3 postural headache after coitus
Secondary causes like SAH in 5-12%
Treatment : propranolol 40-200mg/day
CCB _ diltiazem 60mg TID
Indomethacin 25-50 mg 30-45 min before activity is helpful

60. Primary thunderclap headache
 Reversible cerebral segmental vasoconstriction
resolves spontaneously by 12 weeks
Treatment : Nimodipine is useful
DD: sentinel bleed of IC aneurysm
cervico cephalic arterial dissection
cerebral venous thrombosis
pheochromocytoma
pt on MAOIs taking sympatomimitic drug / thiamine containing food cheese
reaction

61. Cold stimulus headache
 Ingestion / inhalation of cold substance
resolves in 10-30 min of stimulus withdrawl
TRPM 8 –transient receptor potential cation subfamily M member 8
cold temperature sensor
this mediate this syndrome

62. External pressure headache
 Headache stimulus Due to external pressure like helmets, swimming
goggles or very long ponytails
 Treatment : recognise and remove the problem

63. Primary stabbing headache
 Ice pick pains / jabs & jolts
 Last for 1 to many seconds
occurs as a single stab or series of stabs
Absent
cranial autonomic feature
cutaneous triggering
Reccurent type at irregular interval (hours to days)
Treatment : indomethacine 25-50 mg BD/ TID is excellent

64. Nummular headache
 Continuous/ intermittent type
in a fixed place of 1-6 cm size elliptical discomfort
associated with allodynia / hypesthesia
Treatment : tricyclics like amitriptyline
anticonvulsants like topiramate / valproate

65. Hypnic headache
 After 6o years age mostly female
Begins few hrs after sleep
2 * Due to poor control of HTN so 24hr BP monitoring is required
Headache for 15-30 min can be throbbing unilateral ..upto 3 times/night
Migraine features are not seen
Treatment lithium carbonate 200-600 mg HS
or verapamil 160mg Hs
1 / 2 cups coffe or 6omg caffeine po is effective
others like flunarizine 5mg HS / indomethacine 25-75 mg HS

66. References
 Harrison principles of medicine 22nd edition
 International headache society guideliness 2018

67. Thank you…