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  1. 1. Sahar yusuf Alkadi Prepared by:
  2. 2. Lecture Outline • Headaches Introduction • Sensitive structures in the skull • Headache ‘red flags’Diagnosis • Patho-physiology • Etiology • Classification of headaches • History : Profile of HA • Home care for headaches • Material to read later-Case StudyMaterial to read later-Case Study
  3. 3. Definition: Pain or discomfort from the level of the brows to the suboccipital region
  4. 4. WhyWhy????
  5. 5. Sensitive structures in the skull 1. All the tissue covering the bone except the hair 2. Cerebral arteries 3. Venous sinuses 4. Cranial nerves: 5,9,10 & upper 3 cervical nerves 5. Meninges: especially the basal N.B: the Brain itself is insensitive
  6. 6. Origins of Pain in the Head Extra-cranial pain sensitive structures: Intra-cranial pain sensitive structures:  Sinuses  Eyes/orbits  Ears  Teeth  TMJ  Blood vessels  Arteries  Veins  Meninges  Dura
  7. 7. Headache ‘red flags’ New onset headache in middle age or later ;and progressive headache, especially in middle- age >50 (giant cell arteritis) New or progressive headache that lasts for days Headache with neurologic symptoms Systemic symptoms (neck stiffness, fever, nausea, Vomiting, weight loss ,blurry or double vision ) or Secondary risk factors (HIV, systemic cancer)
  8. 8. Nerve involved : - Trigeminal nerve - First 3 cervical nerve - Facial nerve - Glosso-pharyngeal & vagus nerve
  9. 9. Etiology 1) Vascular headache : (V.D.) Migraine Hypertension & Hypoxia & Hypoglycemia Arteritis & Aneurysm Toxic: Caffeine withdrawal & Alcohol  renal and hepatic failure 2) Traction Headache: (Space occupying lesion ) due to stretch of Meninges as in brain tumors
  10. 10. 3) Tension Headache: (Psychogenic headache ) Cap-like constriction (Ache pain) Not localized & Not throbbing & Don’t increase with Straining Usually associated with depression, neurosis & stress 4) Meningeal irritation: Meningitis Subarachnoid hemorrhage 5) Muscle contraction headache: Prolonged contraction of the muscles of the head and neck e.g: prolonged driving
  11. 11. 6) Neuritis and neuralgia: Of the sensory nerves of the scalp e.g.: trigeminal neuralgia 7) Referred headache: may be very sever Eye: iritis, glaucoma Ear: middle ear diseases Nasal sinuses diseases Teeth diseases and Tongue diseases
  12. 12. Classification of headaches Primary headaches OR Idiopathic headaches THE HEADACHE IS ITSELF THE DISEASE NO ORGANIC LESION IN THE BEACKGROUND TREAT THE HEADACHE! Secondary headaches OR Symptomatic headaches THE HEADACHE IS ONLY A SYMPTOM OF AN OTHER UNDERLYING DISEASE TREAT THE UNDERLYING DISEASE! The differentiation between 1° and 2° is critical as it dictates diagostic approach and guides treatment and prognosis.
  13. 13. *Migraine *Thunderclap headache (TCH)- sudden onset Exertional headache Cough headache *Tension type of headache *Cluster headache Other, rare types of primary headaches *Sexual headache (Coital Cephalgia) deBruijn, SF, et al. Lancet. 1996; Lancet. 1998.
  14. 14. Episodic headache disorder characterised by combinations of changes: Neurological, Gastrointestinal, Autonomic Definition A neurologic disorder characterised by idiopathic, paroxysmal, recurrent attacks of headache lasting from 2-72 hours Typical characteristics:  Unilateral (sometimes bilateral)  pulsating quality  mod or severe intensity  may be accompanied by either nausea & vomiting or photophobia & phonophobia  aggravated by physical activity  may be preceded by an aura Definition of Migraine headache
  15. 15. .The Most common type of 1ry headache, TTH accounts for nearly 90% of all headaches. Approximately 3% of the population has chronic tension-type headaches. .lasting 30 min to 7 days. .The pain not only occurs in the head and neck, but also radiates around the face and scalp muscles. .This is a type of muscle contraction pain. .It is more in females than males.
  16. 16. - The exact cause of tension headache is unknown. - it’s thought to occur due to stress, tension, depression, bad posture, staying in one position for long time, or caffeine.
  17. 17. . Adult or tightness pain around the head , band like . Pain radiates down to the neck. . The pain is bilateral, vary in intensity. . Not associated with aura, nausea, vomiting, or light or sound sensitivity. .sever in early part of the day and less as day goes. .continue for weeks or months without interruption
  18. 18. ..Tension headache is usually treated with the help of over-the counter medications(pain- killers) as: aspirin ,acetaminophen or naproxen . ..If these fail , other supportive ttt are available as: massage & stress management. ..If recurrent headache , should seek for medical help.
  19. 19. Prophylactic treatment of the chronic tension type of headache Tricyclic antidepressants Guidelines: • Start with low dose (10-25 mg) and increase the dose if no beneficial effect after 1-2 weeks • Maximal dose should not be more than 75 mg/day • Change to other tricyclic antidepressant only after 6-8 weeks • Ask the patient to use headache diary • Use the tricyclic antidepressant for 6-9 months • Decrease the dose gradually
  20. 20. Prophylactic treatment of the chronic tension type of headache First choice of drug: Amitryptiline or Mirtazapine 1st week: 25 mg in the evening 2nd week: 50 mg in the evening 3rd week: 75 mg in the evening continuously Change to other drug (e.g. clomipramine) if no beneficial effect within 6 weeks
  21. 21. is one of the most painful types of headache.. - Is avascular headache that causes extreme pain. - Occur for several days or weeks at the same time of the day. - It’s more common in men, especially smokers. - It begins in adolescence but can extend to middle age. - There are 2 types of cluster headache: . Episodic . Chronic
  22. 22. Causes of cluster headache: . the cause of cluster headache is unknown. .it’s brought to occur due to: 1- dilation of blood vessels. 2- inflammation of the nerves present behind eyes. 3- bright sunlight, smoking, drinking alcohol and some foods as: chocolate or foods high in nitrites like smoked meats may trigger cluster headache. 4- tend to run in families& this suggest that there may be areole for genetics. 5- may be due to changes in sleep patterns. 6- may be triggered by medication as: nitroglycerin which used for heart disease.
  23. 23. Symptoms of cluster headache: 1- sever unilateral per orbital pain accompanied by: unilateral lacrimation , nasal congestion.. (dull, steady pain ,some pt. describe the pain as feeling like a hot poker in the eye, the affected eye may become red, inflamed and watery ,also the nose of the affected side may become congested and runny). 2- attack occur at the same time every day , lasting for 30 to 90 min , often awaken the pt. at night from a sleep. 3- once or twice daily or more than twice followed by respite for months before another cluster occur — known as cluster periods . 4- tend to be restless which make the pt. to pace the floor or bang their head against a wall. 5- nausea and vomiting rarely occur. 6-symptoms develop in early hours of morning
  24. 24. - There’s no specific ttt for cluster headache. -- However ttt help in reliving the symptoms as well as help prevent more attacks. Some of these ttt include: 1. Inhalation of high concentration oxygen: the pt. is required to wear an oxygen mask that help increase the amount of oxygen in blood , thus relaxing the blood vessels and providing pain relief.
  25. 25. 2. Injection of triptan medication as, sumatriptan which is common migraine medication. 3. Injection of lidocaine ,local anasthetic into the nostril. 4. caffine.
  26. 26. Prevention of the next cluster headache include the following: 1- calcium channel blocker as verapamil. 2- prednisolone. 3- antidepressant medication. 4- lithium. 5- antiseziure medication as valproic acid. .also life style changes may help to minimize the risk of cluster headache as stop smoking and alcohol.
  27. 27. Prophylactic treatment of the episodic form of cluster headache Episodic form: prednisolone Treatment: 1-5. days 40 mg 6-10. days daily 30 mg 10-15. days daily 20 mg 16-20. days daily 15 mg 21-25. days daily 10 mg 26-30. days daily 5 mg Nothing Intravenous magnesium sulfate relieves cluster headaches in about 40% of patients with low serum ionized magnesium levels. Melatonin has also been demonstrated to bring significant improvement in approximately half of episodic patients
  28. 28. Prophylactic treatment of the chronic form of cluster headache Lithium carbonate Daily 600-700 mg Can be decreased after 2 weeks remission Control of serum level is necessary (0,4 - 0,8 mmol/l) Methysergide (synthetic ergot alkaloid), and the anticonvulsant topiramate are alternative treatments.
  29. 29. DuboseDubose et alet al (1995); Goadsby (1999); Marks and Rapoport (1997)(1995); Goadsby (1999); Marks and Rapoport (1997) Family historyFamily history YesYes SexSex More femalesMore females OnsetOnset VariableVariable LocationLocation Usually unilateralUsually unilateral in adultsin adults Character/severityCharacter/severity PulsatilePulsatile ThrobbingThrobbing Frequency/Frequency/ 2–72 h/attack2–72 h/attack durationduration 1 attack/year to1 attack/year to >8 per month>8 per month AssociatedAssociated Visual auraVisual aura symptomssymptoms PhonophobiaPhonophobia PhotophobiaPhotophobia PallorPallor Nausea/vomitingNausea/vomiting Clinical featureClinical feature MigraineMigraine NoNo More malesMore males During sleepDuring sleep Behind/aroundBehind/around one eyeone eye Excruciating/Excruciating/ sharpsharp SteadySteady 15–90 min/attack15–90 min/attack 1–8 attacks/day1–8 attacks/day for 3–16 weeksfor 3–16 weeks 1–2 bouts/year1–2 bouts/year SweatingSweating Facial flushingFacial flushing Nasal congestionNasal congestion PtosisPtosis LacrimationLacrimation Conjunctival injectionConjunctival injection Pupillary changesPupillary changes Cluster headacheCluster headache YesYes More femalesMore females Under stressUnder stress Bilateral in bandBilateral in band around headaround head DullDull Persistent Tightening/pressingPersistent Tightening/pressing 30 min to 7 days30 min to 7 days 3–4 attacks/week3–4 attacks/week to 1–2 attacks/yearto 1–2 attacks/year Mild photophobiaMild photophobia Mild phonophobiaMild phonophobia AnorexiaAnorexia Tension headacheTension headache
  30. 30. refers to a severe headache of sudden onset. Its explosive and unexpected nature is likened to a "clap of thunder.”
  31. 31. - are headaches brought on by sexual activity. - You may notice a dull ache in your head and neck that builds up as sexual excitement increases - you may experience a sudden, severe headache just before or during orgasm.( Obviously, sex raises the blood pressure. This in turn raises the pressure in the head. Also, sex causes muscle tightening and tension.) Sex headaches are a combination of the blood pressure and muscle tension, for most people.
  32. 32. Trigeminal neuralgia Lancinating pain in 2nd ,3rd division of trigeminal nerve Usually in pt. over the 50 yrs.
  33. 33. Clinical features Sever, very brief but repetitive Precipitated by touching trigger zones within the trigeminal territory by cold wind blowing on the face or by eating
  34. 34. Management 1-Carbamazepine more than 1200mg/daily 2-Gabapentin or pregabalin
  35. 35. Hypnic headaches Tend to occur in the elderly, women>men. Occur particularly at night, waking patient during REM stages of sleep. Characterized by throbbing, without autonomic features, may last upto 1 hr and reoccur through the night.
  36. 36.  Cluster headache  Short, excruciating (15 min-3 hrs)  Usually occur in the middle of the night  unilateral pain behind eye  occur daily for 2-3mths then remit for months-years  Red, watering eyes, blocked nose  Tension headache  diffuse pain in tight head-band pattern  bilateral, non-pulsating  no prodrome/aura  No nausea and vomiting  10 attacks lasting 30 min–7 days  2 of the following 4  Bilateral  Not pulsating  Mild or moderate intensity  Not aggravated by routine physical activity  No nausea or vomiting  One or neither photophobia or phonophobia  Not attributable to another disorder  Sinus headache  Evidence of purulent discharge from the nose  constant dull ache in cheek area accompanied by sinusitis  worsens with bending over or blowing nose Differential diagnosis of primary headaches
  37. 37. SECONDARY – (structural or metabolic abnormality): • Extra-cranial: sinusitis, otitis media, glaucoma, TMJ ds • Intra-cranial: SAH, vasculitis, dissection, central vein thrombosis, tumor, abscess, meningitis • Metabolic disorders: CO2 retention, CO poisoing
  38. 38. History : Profile of HA time from onset to peak usual time of onset (week , month, season, hour of day) frequency & duration change over lifetime description : pulsating, pressing, sharp location : unilateral or bilateral or changing severity precipitating factors Aggravating factors factors that relieve the headache effectiveness of pharmacological or non- pharmacological treatments Aura
  39. 39. Giant cell arteritis syn Arteriitis temporalis syn temporal arteritis • Giant cell arteritis (GCA or temporal arteritis) is an autoimmune disease, granulomatose inflammation of branches of External Carotid Artery that supply the head eyes, and optic nerves . It is a form of vasculitis. • The name (giant cell arteritis) reflects the type of inflammatory cell that is involved (as seen on biopsy). • The terms "giant cell arteritis" and "temporal arteritis" are sometimes used interchangeably, because of the frequent involvement of the temporal artery.
  40. 40. Epidemiology: It is more common in females than males by a ratio of 3:1. The mean age of onset is about 70 years, and it is rare in those less than 50 years of age. The incidence is 24.2 per 100,000 women over 50 and 8.2 per 100,000 men over 50
  41. 41. Clinical Presentation: •Unilateral headache, pulsating pain more sever at night •Fever •Tenderness and sensitivity on the scalp •Jaw claudication (pain in jaw when chewing)  inflammation of internal maxillary artery •Tongue claudication (pain in tongue when chewing) and necrosis •Reduced visual acuity (blurred vision) •Acute visual loss (sudden blindness) •Diplopia (double vision) •Acute tinnitus (ringing in the ears) •Approximately 50% of GCA patients also have polymyalgia rhematica (PMR), which is characterized by muscle pain and stiffness. •The inflammation may affect blood supply to the eye and blurred vision or sudden blindness may occur. In 76% of cases involving the eye, the ophthalmic artery is involved causing anterior ischemic optic neuropathy. Loss of vision in both eyes may occur very abruptly and this disease is therefore a medical emergency. Amaurosis fugax may precede the blindness
  42. 42. Treatment Corticosteroids, typically high-dose prednisone (40–60 mg bd), must be started as soon as the diagnosis is suspected (even before the diagnosis is confirmed by biopsy) to prevent irreversible blindness secondary to ophthalmic artery occlusion. The dose of prednisone is lowered after a 2–4 weeks, and slowly tapered over the course of 9–12 months. Oral steroids are at least as effective as iv steroids, except in the treatment of acute visual loss where iv steroids appear to offer significant benefit over oral steroids
  43. 43. Home care for headaches : Headaches make life difficult , those who suffer from regular headaches ,will agree with this statement . .. When a headache strikes , one should follow some simple home care tips that help relieve the symptoms to some extent . These include : - First and foremost , if possible , rest , it is very important that you leave all works aside & rest in a quiet dark room . - At times , a light sleep helps relieve the stress that causes headaches . - You can place a light , cool cloth over the head as it helps you relax . - Use painkiller .
  44. 44. Material to read later-Case Study  17 yr old female  L-sided pulsatile headache recurring 3-4x monthly  headache preceded by loss of visual fields  headache is accompanied by nausea, vomiting and photophobia  headache lasts all day unless able to lie in a dark room & sleep  affects ability to work/study  past medical history unremarkable - no other medical problems  general physical & neurologic exam -normal
  45. 45. Thank you