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Headache
1
2
Pain and Headache
3
Pain Sensitive Structures
Intracranial Structures
● cranial sinuses and veins
● arteries of the dura mater
● arteries of the base of the brain and their major branches
● parts of the dura mater near the large vessels
Extracranial Structures
● skin, scalp, fascia
● mucosa
● arteries
Nerves
● trigeminal, facial, glossopharyngeal and vagus nerves
● upper three cervical nerves
4
Neurologic Examination
New onset and Severe Headaches
● Meningitis
● Subarachnoid hemorrhage
● Epidural or Subdural hematoma
● Glaucoma
● Tumor
● Purulent sinusitis
Recurrent Headaches
● Otologic problem
● Dental problem
● Trauma
Diagnostic Tests:
● CT scan or MRI
● Lumbar puncture
● Fundoscopy
5
Migraine
● Unilateral, throbbing or
pulsatile quality felt over the
fronto-parietal or retro-orbital
area
● Lasts few hours to days
● Generally Infrequent
● Severe intensity
● Associated with visual
disturbances, vomiting
● Aggravated by certain foods,
stress, hormones
● (+) Family history
Timing: Occur any time of day
Freq: 1 to 10 per month
(average 1.5)
Onset: Gradual onset, peak, then
subsidence
Duration 4 to 72 hours (adults)
2 to 48 hours
(children)
Location: Unilateral 60%
Pain: Moderate to severe
50% pulsating, 50%
tight,
pressure
Aggravated by movement
6
7
Migraine Triggers:
● Diet
● Sleep deprivation or
excess
● Hormonal changes
● Environmental factors
● Physical exertion
● Stress and anxiety
● Head trauma
Migraine without aura
Migraine with aura
Acephalgic migraine
8
9
10
Tension Headaches
● Bilateral, bandlike , more posterior
in origin
● Constricting, compressing quality
● Lasts minutes to hours, can occur
daily
● Aggravated by fatigue, poor posture
and emotional burdens
● Present in type A personalities
● Normal neurologic examination
● With identifiable “stressor”
Treatment:
● Acetaminophen, aspirin, or NSAIDs
11
Cluster Headaches
● Similar to migraine in quality
● Common among males
● Attacks are nocturnal, within 1-2
hours of falling asleep
● Accompanied by lacrimation
and conjunctival and nasal
congestion
● Occurs in “clusters” lasting for
weeks separated by months or
years of headache freedom
● Normal neurologic examination
Treatments:
Sumatriptan (20 mg) and zolmitriptan (5 mg)
nasal sprays
12
13
Trigeminal neuralgia
● Involves one side of the face
● Short jabs/lightning like stabs of
pain along the cheek and corner
or the mouth repeated
throughout the day; mistaken as
dental pain
● Worse with yawning, laughing,
chewing and brushing of teeth
● Does not respond well to
common analgesics
● Common among elderly
● Normal neurologic examination
Treatments:
Sumatriptan (20 mg) and zolmitriptan (5 mg)
nasal sprays
14
Vascular-Related Headaches
● Throbbing, maybe uni- or
bilateral
● Maybe associated with
dizziness and vomiting
● Worsens with coughing and
exertion, bearing down or
doing a Valsalva maneuver
● With coexisting vascular
disease like hypertension,
vasodilatation with nitrate use
Treatments:
Relieved with control of BP or
discontinuation of medications
15
Headache from Subarachnoid Hemorrhage
● Thunderclap onset
● Throbbing, bilateral
● “worst headache of my life”
● Maybe associated with dizziness and
vomiting, seizures, loss of
consciousness
● Worsens with coughing and exertion,
bearing down or doing a Valsalva
maneuver
● Associated papilledema and
hemorrhages on fundoscopy; neck
rigidity on meningeal testing; may have
focal neurologic deficits referable to the
site of ruptured artery
16
Headache from CNS Infection
● Generalized, bilateral,
progressive intensity
● Maybe associated with
vomiting, FEVER at onset,
sensorial change, seizures,
delirium
● May have (+) neck rigidity
17
Headache from CNS Tumor
● May start focal and in weeks
and months become
generalized
● Progressive intensity and
frequency over weeks and
months
● Worse in the middle of the night
or upon waking up
● (+) papilledema in 50% of cases
● May have associated vomiting,
blurring of vision and neurologic
signs related to the site of the
tumor
18
Headache Danger Signs
● Sudden onset of new severe
headache
● first headache in adulthood
● progressively worsening
headache
● onset with exertion, coughing,
straining and/or sexual activity
● with drowsiness, malaise,
confusion, memory loss,fever,
weakness, blurring, clumsiness or
loss of balance
● Abnormal vital signs-BP/T
● altered sensorium
● unequal poorly reactive pupils
● papilledema/retinal hge
● meningeal irritation
● focal weakness or sensory loss
● asymmetrical reflexes/ (+)babinski
19
Thank You!
References:
Headache Peter J. Goadsby Chapter 13.
Harrison's Principles of Internal Medicine, 20e J. Larry Jameson, Anthony S. Fauci, Dennis L.
Kasper, Stephen L. Hauser, Dan L. Longo, Joseph Loscalzo
20
21
22

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Headache Harrison's Hour.pptx

  • 2. 2
  • 4. Pain Sensitive Structures Intracranial Structures ● cranial sinuses and veins ● arteries of the dura mater ● arteries of the base of the brain and their major branches ● parts of the dura mater near the large vessels Extracranial Structures ● skin, scalp, fascia ● mucosa ● arteries Nerves ● trigeminal, facial, glossopharyngeal and vagus nerves ● upper three cervical nerves 4
  • 5. Neurologic Examination New onset and Severe Headaches ● Meningitis ● Subarachnoid hemorrhage ● Epidural or Subdural hematoma ● Glaucoma ● Tumor ● Purulent sinusitis Recurrent Headaches ● Otologic problem ● Dental problem ● Trauma Diagnostic Tests: ● CT scan or MRI ● Lumbar puncture ● Fundoscopy 5
  • 6. Migraine ● Unilateral, throbbing or pulsatile quality felt over the fronto-parietal or retro-orbital area ● Lasts few hours to days ● Generally Infrequent ● Severe intensity ● Associated with visual disturbances, vomiting ● Aggravated by certain foods, stress, hormones ● (+) Family history Timing: Occur any time of day Freq: 1 to 10 per month (average 1.5) Onset: Gradual onset, peak, then subsidence Duration 4 to 72 hours (adults) 2 to 48 hours (children) Location: Unilateral 60% Pain: Moderate to severe 50% pulsating, 50% tight, pressure Aggravated by movement 6
  • 7. 7
  • 8. Migraine Triggers: ● Diet ● Sleep deprivation or excess ● Hormonal changes ● Environmental factors ● Physical exertion ● Stress and anxiety ● Head trauma Migraine without aura Migraine with aura Acephalgic migraine 8
  • 9. 9
  • 10. 10
  • 11. Tension Headaches ● Bilateral, bandlike , more posterior in origin ● Constricting, compressing quality ● Lasts minutes to hours, can occur daily ● Aggravated by fatigue, poor posture and emotional burdens ● Present in type A personalities ● Normal neurologic examination ● With identifiable “stressor” Treatment: ● Acetaminophen, aspirin, or NSAIDs 11
  • 12. Cluster Headaches ● Similar to migraine in quality ● Common among males ● Attacks are nocturnal, within 1-2 hours of falling asleep ● Accompanied by lacrimation and conjunctival and nasal congestion ● Occurs in “clusters” lasting for weeks separated by months or years of headache freedom ● Normal neurologic examination Treatments: Sumatriptan (20 mg) and zolmitriptan (5 mg) nasal sprays 12
  • 13. 13
  • 14. Trigeminal neuralgia ● Involves one side of the face ● Short jabs/lightning like stabs of pain along the cheek and corner or the mouth repeated throughout the day; mistaken as dental pain ● Worse with yawning, laughing, chewing and brushing of teeth ● Does not respond well to common analgesics ● Common among elderly ● Normal neurologic examination Treatments: Sumatriptan (20 mg) and zolmitriptan (5 mg) nasal sprays 14
  • 15. Vascular-Related Headaches ● Throbbing, maybe uni- or bilateral ● Maybe associated with dizziness and vomiting ● Worsens with coughing and exertion, bearing down or doing a Valsalva maneuver ● With coexisting vascular disease like hypertension, vasodilatation with nitrate use Treatments: Relieved with control of BP or discontinuation of medications 15
  • 16. Headache from Subarachnoid Hemorrhage ● Thunderclap onset ● Throbbing, bilateral ● “worst headache of my life” ● Maybe associated with dizziness and vomiting, seizures, loss of consciousness ● Worsens with coughing and exertion, bearing down or doing a Valsalva maneuver ● Associated papilledema and hemorrhages on fundoscopy; neck rigidity on meningeal testing; may have focal neurologic deficits referable to the site of ruptured artery 16
  • 17. Headache from CNS Infection ● Generalized, bilateral, progressive intensity ● Maybe associated with vomiting, FEVER at onset, sensorial change, seizures, delirium ● May have (+) neck rigidity 17
  • 18. Headache from CNS Tumor ● May start focal and in weeks and months become generalized ● Progressive intensity and frequency over weeks and months ● Worse in the middle of the night or upon waking up ● (+) papilledema in 50% of cases ● May have associated vomiting, blurring of vision and neurologic signs related to the site of the tumor 18
  • 19. Headache Danger Signs ● Sudden onset of new severe headache ● first headache in adulthood ● progressively worsening headache ● onset with exertion, coughing, straining and/or sexual activity ● with drowsiness, malaise, confusion, memory loss,fever, weakness, blurring, clumsiness or loss of balance ● Abnormal vital signs-BP/T ● altered sensorium ● unequal poorly reactive pupils ● papilledema/retinal hge ● meningeal irritation ● focal weakness or sensory loss ● asymmetrical reflexes/ (+)babinski 19
  • 20. Thank You! References: Headache Peter J. Goadsby Chapter 13. Harrison's Principles of Internal Medicine, 20e J. Larry Jameson, Anthony S. Fauci, Dennis L. Kasper, Stephen L. Hauser, Dan L. Longo, Joseph Loscalzo 20
  • 21. 21
  • 22. 22