Headache: Neuroophthalmic Aspects for Med Students


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A review of the primary causes of headaches, which have a neuro-ophthalmic significance and are vision-threatening. Med Students are expected to recognize and refer these cases appropriately after completing this presentataion.

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Headache: Neuroophthalmic Aspects for Med Students

  1. 1. Raed Behbehani , MD FRCSC
  2. 2. •Periocular pain due to diseases of the face, orbit, sinuses , andintracranial cavity.•Trigeminal innervation (V1-V3).
  3. 3. •Any headache can cause eye pain (and vice versa).•Take good history ( loss of vision, diplopia, transient visualobscurrations, redness, photophobia, jaw claudication, systemicsymptoms).• Examination : check vision at least grossly, look forredness, ptosis, corneal edema, check pupil reactions, palpate the eyesand orbits, check sensation v1-v3 and other cranial nerves.•FUNDOSCOPY !
  4. 4. • Migraine (with / without aura)•Cluster Headache .•Tension Headache.•Chronic Daily Headache.•Medication overuse.
  5. 5. • Ocular disease ( dry eye, uveitis, acute glaucoma).• Orbital disease (Thyroid eye disease, idiopathic orbitalinflammatory disease).• Vasculitis ( Giant cell arteritis)• High intracranial pressure (Pseuotumor cerebri , cerebral venoussinus thrombosis)
  6. 6. • Inadequate tear production.• Primary / Secondary to rheumatological conditions.• Slit lamp examination : Flourescin stain/ Rose bengal• Artificial tears/ punctal occlusion is the treatment.
  7. 7. • Anterior/Posterior Uveitis.• Pain and Photophobia.• Cells in the anterior chamber/ Ciliary injection/ Posteriorsynechiae.• Idiopathic/ associated with rheumatologic conditions/ infectious(post-operative).
  8. 8. • Severe periocular pain +- headache.• Blurred vision , nausea , and vomiting.•Cilliary injection/ corneal edema/ fixed mid-dilated pupil.• Previous history of transient visual disturbances .
  9. 9. • New onset of headache (temporal) , acute or transient loss ofvision, jaw claudication, weight loss, fever, and myalgias.• Age usually over 60.• Occult GCA ( No systemic symptoms).
  10. 10. Arteritic ischmeic opic neuropathy.
  11. 11. Central retinal artery occlusion/ Branch retinal artery occlusion
  12. 12. Ophthalmoplegia
  13. 13. Stat ESR , CRP and CBC (platelets).ESR can be normal in 15-20% of cases.CRP is more sensitive and specific.CRP and CBC have 97% sensitivity and specifity.Start high dose systemic steroids (IV or Oral ) immediately uponsuspicioun !Arrange for temporal artery biopsy within 2 weeks , while patient ison steroids.
  14. 14. • Treatment is long term high dose systemic steroids (1-2 years)• Rheumatological consultation to rule out systemic involvement (aortic aneurysm or dissection)• Follow up clinically and with CRP and ESR to titrate steroid dose• Protention against steroid complications ( diabetes, osteoporosis)
  15. 15. • Optic neuritis.• Orbital inflammtory disease.
  16. 16. • Dull , aching pain worse with eye movements.• Loss of vision.• Pupil testing : relative afferent pupillary defect (RAPD).• Loss of color vision (Dyschromatopsia).• Fundus : optic disc normal in 70% (retrobulbar optic neuritis).
  17. 17. • Sudden onset.• Pain, proptosis, limited eye movement, chemosis.• Idiopathic or due to Wegener’s granulmatosis, Grave s’ disease,sarcoidosis)
  18. 18. • Headache, pain in the neck and shoulders and upper back.• Worse with coughing/straining.• Pulsatile tinnitis.•Transient visual obscurations.• Diplopia ( Abducens nerve palsy )
  19. 19. 1) Symptoms of raised intracranial pressure (headache, nausea, vomiting, transient visual obscurations, or papilledema)2) No localizing signs with the exception of abducens (sixth) nerve palsy3) The patient is awake and alert4) Normal CT/MRI findings without evidence of thrombosis5) LP opening pressure of >25 cmH2O and normal biochemical and cytological composition of CSF 6 No other explanation for the raised intracranial pressure
  20. 20. •Medical ( Diuretics): Acetazolmide , Freusomide• Surgical :visual loss  Optic nerve sheath fenstration.headache and vision loss  ventriculoperitoneal orlumboperitoneal shunt.• Cerebral venous sinus thrombosis : Anti-coauglants (warfarin) , ?venous stenting.
  21. 21. • Take good history ( try to distinguish primary from secondaryheadache syndrome).• Look for abnormal neuro-ophthalmic signs (Ptosis, ophthalmoplegia, abnormal facial sensation, check visualacuity, and pupils, and look for papilledema).• Giant cell arteritis is vision-threatening.•Papilledemaican be life threatening.