These are slides of headache ,mainly primary headaches ,which is a topic of neurology and neurosurgery for medical students

1. Primary
Headache
By: Komal Fatima
Smbbmcl

2. Defination
HEADACHE , is one of the common medical
complaints,arising from psychological ,
ototlogical, opthalmological, neurological or
systemic .
Primary Headache
Secondary Headache
Headache is broadly classified into 2
types:
Here, We will discuss the primary
Headache .

3. Venous sinuses &tributaries
Dural & meningeal arteries, arteries
at the base of the brain.
Portions of the meninges
Upper cervical roots
Scalp muscles & aponeurosis.
Pain sensitive strucures of the head:
Brain parenchyma
Ventricular ependyma
Most of the dura
Pia mater
Structures largely insensitive to pain:

4. Primary Headache
Migraine
Cluster Headache
Tension type
( most common)
common
causes
Migraine
Tension-type
Cluster headache
Trigeminal neuralgia
Primary cough headache
Chronic Paroxysmal Hemicrania (CPH)
Short-lasting Unilateral Neuralgiform
Attacks with Conjunctival Injection and
Tearing (SUNCT)
Primary stabbing headache
Hypnic headache
Primary headache with sexual activity

5. Migraine

6. It affects about 20% of females and 6% of males,
usually appear before middle age (40 years).
Not completely understood.
Cortical Spreading Depression ( CSD) Theory of
leo:
The headache Phase is associated with
extracranial vasodilatation.
*dysfunction of ion channels causing a spreading
cortical deporilastion ( excitation) followed by
hyperpolarization ( depression of activity).
This is for Migraine with aura.
Pathophysiology

7. Migraine with Aura
Classic Migraine
20% of cases
Visual symptoms: positive features ( flickering lights, spots,
or lines ) or negative symptoms ( blind spots, loss of
vision), or both.
Sensory symptoms , including positive symptoms (pins and
needles )or negative features ( numbness) or both .
Dysphasic speech disturbance.
Symptoms of aura that develop over 5 mins.& last less than
1 hr & headache if present that follows within hour.
Types

8. Types
Migraine without Aura
Common Migraine
80% of cases
At least 5 attacks
Headache attacks lasting 4-72hrs
At least 2 of the following pain characteristics:
Unilateral location
Pulsating quality
moderate to severe intensity
Aggravated by or causes avoidance of routine physical activity
During a headache at least 1 of the following
NV
Photophobia & Phonophobia.

9. Moderate to Severe
Throbbing ( pulsatile)
with photophobia
phonophobia
vomiting
Movement makes the pain worse
patient prefers to lie in a quiet and dark
room.
last 7 to 24 hours.
Trigger by: Oral contraceptives,
Menstruation, Cheese, Chocolate, Red wine
types.
Clinical Features

10. Acephalic: just aura occurs
Basilar migraine: dysarthria, vertigo, diplopia,
confusion, BL
Child periodic symptoms: paroxysmal vertigo,
abd. Pain, and vomiting
Chronic migraine without aura for half of the
day, about 2 months familial sporadic cases
with a reversible aura of hemiplegia.
Retinal: recurrent attacks of monocular vision
disturbance ( scotoma, blindness) with a
headache.
Status migrainous: Migraine attacks lasting
more than 72 hours
Vestibular: Migraines with vertigo
Variants

11. Avoidance of trigging factors and exacerbating factors.
Prevention: Regular sleep and eating habits should be
regular.
Minimize caffeine intake.
Acute attack: Simple analgesia like aspirin, paracetamol
and nsaids.
Severe attacks: Triptans ( serotonin agonists), Alternate
Ergotamine.
Preventive Therapy: ( If >3-4 attacks per month). Beta-
blockers, calcium channel blockers, Antiepileptics, and
Tricyclic antidepressants.
Inj ketorolac can be given in case of status migrainosus
Managment

12. Tension type
headache

13. Pathophysiology
A milder version of migraine.
The exact cause of TTH is not fully understood. However, there are links
to various factors, including nutritional, muscular, environmental, and
genetic.
Environmental and muscular factors are also possible etiology of tension
headaches. Stress and posture appear to be the two significant factors.

14. Clinical Features
Dull, tight, and band-like.
generalized ( bilateral)
Episodic and persistent but the severity may vary.
no associated photophobia or vomiting.
no aura
Triggers: Stress, sleep deprivation, dehydration, fatigue, missed meals.

15. Criteria
At least 10 episodes occurring fewer than 15 days per month on average
for at least three months.
Headache lasting from 30 mins-7 days
At least two of the following:
1) Bilateral location ( band like)
2) Pressing/ tightening (non-pulsating) quality
3) Mild to moderate intensity
4) Not aggravated by routine physical activity

16. Management
Physiotherapy ( Muscle relaxation and stress management) and
mindfulness.
Analgesics: Ibuprofen/Naproxen
Chronic: Tricyclic antidepressants, Venlafaxine
Muscle relaxants.
Supraorbital and occipital nerve blocks

17. Cluster
headache

18. Pathophysiology
Migrainous Neuralgia
Male dominance (5:1 ratio)
onset is the third decade.
Cause unclear
Little evidence for a genetic predisposition.
Imaging studies have suggested abnormal neuronal activity
in the hypothalamus.
patients are heavy smokers with higher alcohol
consumption.

19. Clinical Features
Sudden onset severe unilateral headache, lasting 30- 90
minutes.
Attacks tend to cluster over time, daily headaches for
weeks to months then long periods of remission
one or several attacks within a 24-hour period and awoken
from sleep ( alarm clock headache).
Ipsilateral periorbital pain with autonomic features such as
Ipsilateral lacrimation, nasal congestion, and conjunctival
injection. Features of Horner syndrome ( ptosis, Anhidrosis,
miosis).
Triggers : Alcohol
Pain is boring and Knife like

20. Criteria
Multiple attacks of severe unilateral orbital, supraorbital, and
temporal pain lasting 15-180 mins.
At least one of the following :
unilateral conjunctival injection, lacrimation or both
Ipsilateral nasal congestion, rhinorrhea or both
Ipsilateral eyelid edema
Ipsilateral forehead and facial sweating
Ipsilateral miosis, ptosis or both
A sense of restlessness or agitation
Attack frequency ranging from 1 every other day to 8 per day

21. Managemnet
Acute: high flow 100% oxygen (8-12 liters per min) until the attack
is resolved.
Injection sumatriptan.
Prevention : corticosteroids , Verapamil(high dose)

22. Trigeminal
Neuralgia

23. Tic douloureux
Lancinating pain in 2nd and 3rd divisons of trigeminal nerve .
Around 50 years old patients.
Pathopyiology
Not clear
vascular compression, loops of cerebellar arteries compressing trigeminal
nerves.

24. Clinical features
A severe, repetitive, knife-like pain in the face.
Triggers: Touching face, cold wind, eating, pronouncing
certain words.

25. Drug of choice: Carbamazepine
Gabapentine if cant take carbamazepine
surgical procedure: Alcohol or phenol injection into peripheral
nerve
surgical decompression of the nerve through a posterior
craniotomy.
Management

26. Thank You