Headache, types, etiology, history taking and management

1. 01/03/15
1
HEADACHE, TYPES,
ETIOLOGY, HISTORY TAKING
AND MANAGEMENT
- Pabita Dhungel
B.Optometry
Institute of Medicine

2. References
01/03/15
2
Davidsons principles and practice of medicine 19th
edition
Neuro ophthalmology section 5 AAO series 2004-
2005
Oxford hand book of ophthalmology 2006
The wills eye manual
www.wikipedia.com

3. Presentation layout
01/03/15
3
Introduction
History
Epidemiology
Types of headache
Causes
Pathophysiology
Diagnostic approach
History taking
Management

4. Introduction
01/03/15
4
A headache or cephalagia
is pain anywhere in the
region of head or neck
Can be a symptom of a
number of different
conditions of head and
neck
 Ref: headache at Dorland’s Medical
Dictionary

5. Introduction
01/03/15
5
Headache in itself is not a disease but merely a
symptom of a disease.
 A symptom which may accompany many different
types of conditions.
 May be a manifestation of a syndrome such as
migraine.
 May be sight threatening or life threatening

6. Contd…
01/03/15
6
The frequency and severity of headache attacks
determine the extent to which the headache problem
will incapacitate the patient.
That’s why headache represents an item of extreme
economic and social importance
Headache is a frequent reason given for absenteeism
at work .
It is also a factor which will universally tend to lower
the individual’s efficiency while s/he is working.

7. Contd…
01/03/15
7
Since head is the most frequent site of pain and
discomfort almost everybody has a headache at one
time or other.
It is a warning signal to say something wrong within
the organism or enviroment.

8. History
01/03/15
8
Migraine , neuralgia ,shooting head pain have been
documented in medical literature of 1550 BC
Hippocrates in 460 BC described visual symptoms
associated with MIGRAINE
Aretacus in AD 80 described that the pain of
migraine is unilateral

9. 01/03/15
9
The first recorded classification system that
resembles the modern ones published by Thomas
Willis, in De Cephalagia in 1672
In 1787 Christian Baur divided headaches into
idiopathic (primary headache) and symptomatic
(secondary ones) and defined 84 catagories
Contd…

10. 01/03/15
An 1819 caricature by
George Cruikshank
depicting a headache
10
Contd…

11. Epidemiology
01/03/15
11
During a given year,90% of people suffer from
headaches
Of the ones seen in the ER , about 1% have a serious
underlying problem
Primary headache accounts for more than 90% of all
headache complaints and of these episodic tension
headache is the most common
 Ref: headache pathophysiology retrieved june 21-2010

12. Contd…
01/03/15
12
Annual cost through lost work and impaired
effectiveness may be £1.5 billion
Migraine appears to be exclusively experienced by
12% - 18% of the population
Cluster headache are thought to affect less than 0.5%
of the population
Cluster headache are more likely to occur in men
than women, tends to affect 5 to 8 times more men
Migraine headache more common in female(3:1)
 Ref: British research of headache 2007

13. Classification
01/03/15
13
Thoroughly classified by International Headache
Society’s International Classification of Headache
Disorders (ICHD) which published its second edition
in 2004
This classification is accepted by WHO

14. International classification of headache
disorders(ICHD)
01/03/15
14
Classification uses numeric codes
The top, one-digit diagnostic level includes 13 groups
First four group classified as primary headaches,
group 5-12 as secondary headache
Cranial neuralgia, central and primary facial pain
and other headaches for the last two groups
ICHD-2 classification defines migraine, tension-
types headaches, cluster headache and other
trigeminal autonomic cephalalgias as the main type
of primary headache

15. Contd…
01/03/15
15
Secondary headache are classified based on their
etiology not their symptoms
ICHD-2 includes secondary headaches due to head
and neck trauma such whiplash injury, intracranial
hematoma , post craniotomy and other head and
neck injury
Headache caused by ischemic stroke and transient
ischemic attack, non traumatic intracranial
hemorrhage, vascular malformation or arteritis are
also secondary headache

16. Contd…
01/03/15
16
Headache caused by epileptic seizure, HIV/AIDS,
intracranial infections and systemic infections are
also secondary headache
Headache caused by dialysis, HTN , hypothyroidism,
injury to jaws ,teeth or temporomandibular joints,
fasting and even psychotic disorders are also
classified as secondary headache

17. New classification
In 2007 the International Headache Society agreed
upon an updated classification system for headache.
the new classification system will allow health care
practitioners come to a specific diagnosis as to the
type of headache and to provide better and more
effective treatment.
1. primary headaches
2.secondary headaches
3. cranial neuralgias, facial pain, and other headaches
01/03/15
17

18. What are primary headaches?
Primary headaches include migraine, tension, and
cluster headaches, as well as a variety of other less
common types of headache.
Tension headaches are the most common type of
primary headache. Up to 90% of adults have had or
will have tension headaches. Tension headaches
occur more commonly among women than men.
01/03/15
18

19. Contd…
Migraine headaches are the second most
common type of primary headache. An estimated 28
million people in the United States (about 12% of the
population) will experience a migraine headache.
Migraine headaches affect children as well as adults.
 Before puberty, boys and girls are affected equally
by migraine headaches, but after puberty, more
women than men are affected.
It is estimated that 6% of men and up to 18% of
women will experience a migraine headache in their
lifetime.
01/03/15
19

20. Contd…
Cluster headaches are a rare type of primary
headache affecting 0.1% of the population (1 in a
1,000 people). It more commonly affects men in
their late 20s though women and children can also
suffer these types of headache.
01/03/15
20

21. What are secondary headaches?
Secondary headaches are those that are due to an
underlying structural problem in the head or neck.
There are numerous causes of this type of headache
ranging from bleeding in the brain, tumor, or
meningitis and encephalitis.
01/03/15
21

22. Pathophysiology
Different for various types
Headache of intracranial origin
Brain itself is not sensitive to any nociceptive stimuli
Venous sinuses , major arteries and large veins , spinal
nerves, head and neck muscles and meninges at base of
skull and sensory cranial nerves---- pain sensitive
Any sort of traction, distortion , irritation or inflammation
of these pain sensitive structure----- Headache
01/03/15
22

23. Ocular headache
Muscle contraction
Glaucoma is due to rise in IOP and involvement of
posterior cilliary Artery
Sinus headache
Common site – frontal and maxillary regions
i) congestion of mucosa
ii) ducts and ostial blocks
01/03/15
23

24. Nerve pathway for pain
Trigeminal nerve carries pain sensation from
-anterior 2/3 of head
-upper surface of tentorium
- supratentorial surface
Pain from these structure felt in the distribution of V
nerve( ant. Part of head)
01/03/15
24

25. Contd…
Pain from infratentorial region , post.fossa , and post. One
third of head (upper 3 cervical nerves)
posterior part of head and neck
Overlap between trigeminal and upper 3 cervical nerves
occurs –referred pain from anterior structure to posterior
and vice
01/03/15
25

26. Causes of headache
01/03/15
26
A) NON OCULAR
B) OCULAR

27. Non Ocular Causes Of Headache
01/03/15
27
1) Tension-type headache
2) Vascular headache
A) Migraine headache
Migraine with aura (classic migraine)
Migraine without aura (common migraine)
Complicated migraine
Hemiplegic migraine
Ophthalmoplegic migraine
Basilar artery migraine
B) Cluster headache
C) Systemic infection
D) Hypoxia
E) Systemic hypertension

28. 01/03/15
28
3) Head trauma
4) Headache due to disorders of head and neck
structures
a) Head and neck disorders
b) Ear and sinus disorders
c) Mouth and jaw disorders
5) Intracranial infections
a) Meningitis
b) Encephalitis
c) Brain abscess

29. 01/03/15
29
6)Traction headache
a) Brain tumor
b) Intracranial hemorrhage
c) Disorders of cerebrospinal fluid pressure
7)Psychogenic

30. Ocular causes of Headache
01/03/15
30
Three categories
a) headache due to refractory error and
eye muscle weakness
b) headache due to secondary
diseases of eye
c) those due to systemic disorders having
prominent ocular symptom

31. A) Refractory error and muscle
weakness
01/03/15
31
Mainly in afternoon or evening at the end of work
Hypermetropia and astigmatism
Low grade refractory error is main cause
Starts as heaviness in eye and continuous
use of eye leads to headache
Ocular muscle imbalance as latent squint and
convergence insufficiency cause headache
Accommodative insufficiency also causes headache
Lack of fusional capacity also causes headache

32. B) Secondary to eye diseases
01/03/15
32
Acute angle closure glaucoma
Acute iritis
Keratitis
Ocular ischemic syndrome

33. C) Systemic disorders with visual
symptoms
01/03/15
33
Raised intra cranial pressure
Migraine
Temporal arteritis
Psychogenic

34. Headache as dangerous sign
01/03/15
34
Medication overuse headache may occur in those
using excessive painkillers for headache ,
paradoxically causing worsening headaches
Life threatening headache are known as “red flag”
symptoms like thunderclap headache(develops
within minutes), inability to move a limb or
abnormalities on neurological examination, mental
confusion, headache that worsens with change in
posture, headache worsened by exertion or Valsalva
manoeuvre (coughing, straining)

35. Contd..
01/03/15
35
Headache associated with visual loss or jaw
claudication (jaw pain on chewing that resolves
afterwards), neck stiffness, fever and headaches in
people with HIV, cancer or risk factors for
thrombosis
Thunderclap headache may be the only symptom of
subarachnoid hemorrhage from brain aneurysm
Headache in fever may be due to meningitis and
confusion may be indicative of encephalitis

36. Contd…
01/03/15
36
Headache worsening with posture may be indicative
of brain tumors, idiopathic intercranial hypertension
and cerebral venous thrombosis
Headache associated with weakness is indicative of
stroke
Headache with visual loss and jaw claudication is
indicative of giant cell arteritis (GCA)
Headache in glaucoma(AACG) is due to rise in IOP
and involvement of posterior ciliary artery

37. History taking
01/03/15
37
A) Location-
frontal- sinusitis
temporal- temporal arteritis
occipital- tension, orthoptic problem
unilateral- migraine
frontal & parietal- refractive error
B) Intensity
mild- tension
very severe-raised ICP, papilledema

38. Contd…
01/03/15
38
C) Frequency- once and twice in a month
and mild type may not be significant
D) Nature-
throbbing- migraine
constricting- tension
E) Time of occurrence
afternoon and evening- ocular
worsening in morning- raised ICP
sinusitis

39. Contd…
01/03/15
39
F) Age of onset
childhood /teenage-refractory error
accommodative
convergence
fusional insuffiency
middle aged ----- hypertension
old age ------ GCA
intracranial
tumour

40. Contd…
01/03/15
40
G) Relieving factor
- improve with rest or mild NSAID
usually mild type
- not responding to pain killer which was
previously used to respond may be dangerous

41. Contd…
01/03/15
41
H) Other associated symptoms
according to suspected etiology
e.g. i) ENT problems
ii) dental problems
iii) anxiety or depressive symptom
iv) fever
v) feature of raised ICP
(diplopia ,vomiting)

42. Evaluation of eye in a patient with
headache
01/03/15
42
Importance
i) may harbour a life threatening disease e.g. intra
cranial neaoplasm
ii) ophthalmologist detects it by finding
papilloedema early
field defect cranial
nerve involvement
iii) early diagnosis may be life saving

43. Examination
- Detail OCULAR and SYSTEMIC examination
OCULAR EXAMINATION
A) Visual Acuity –decrease vision with
headache
i) refractory errors
ii) acute angle closure glaucoma
iii) anterior uveitis
iv) ocular ischemic syndrome
01/03/15
43

44. Contd…
Transient loss of vision (Amaurosis Fugax)
i) migraine
ii) severe hypertension
iii) papilledema
iv) GCA
B) Ocular motility
restricted in Ophthalmoplegic migraine
C) Cover test/uncover test – to rule out PHORIA
and TROPIA
01/03/15
44

45. Contd…
Conjunctiva –congestion( to R/O
glaucoma, uveitis
Cornea - edema
Anterior chamber- depth, cells and flares
Pupil - RAPD ( compressive neuropathy)
dilated ( cerebral aneurysm)
01/03/15
45

46. Intraocular pressure
Fundus examination - look for the signs of
i) papilledema
ii) glaucoma
iii) ocular ischemic syndrome
01/03/15
46

47. Contd…
Refraction – both with and without
cycloplegic
 Orthoptic - for evaluation of
convergence,accommodative and fusional
insufficiency and phorias
Visual field
 Gonioscopy
Detail neurological, ENT, dental, and
psychiatric evaluation will be needed according
to associated symptoms
01/03/15
47

48. Investigations
Should be done according to suspected cause and associated
symptoms
i) x ray PNS - to R/O sinusitis
ii) ESR /temporal artery biopsy
iii) CT or MRI - to R/O intra cranial pathology
iv) Carotid flow study - ocular ischemia
v) Lumbar puncture - meningitis
01/03/15
48

49. 01/03/15
49
Thank you!!!