HeadacheHeadacheBy Dr. Osman Sadig By Dr. Osman Sadig

BukhariBukhari

- - HA is defined as feeling of pain, aches HA is defined as feeling of pain, aches or discomfort in za cranium, face or or discomfort in za cranium, face or upper neck.upper neck. - - Headache is za most common Headache is za most common neurological symptom neurological symptom

- - Almost every one have had itAlmost every one have had it

- - Not all HA have an intra cranial causeNot all HA have an intra cranial cause

or due to brain tumoursor due to brain tumours

- - Not all pts wz HA require brain scanNot all pts wz HA require brain scan

> - > - 75%75% of HA can be diagnosed by of HA can be diagnosed by historyhistory

- - Hypotension causes HA > HTHypotension causes HA > HT

- -Cause vary from trivial nuisance to Cause vary from trivial nuisance to serious intra cranial disease serious intra cranial disease

- - HA may be due to disease of nearby HA may be due to disease of nearby structures: sinuses, T/M joint, structures: sinuses, T/M joint, teeth , gums, tonsils, ears, eyes, teeth , gums, tonsils, ears, eyes, neck, etcneck, etc..

classification of HAclassification of HA

11 - -Non life threatening HANon life threatening HA e.g. e.g. migraine, tension HA, cluster migraine, tension HA, cluster HA, facial pain, cervicogenic HA, facial pain, cervicogenic

HAHA

22 - -Life threatening HA:Life threatening HA: infections infections (meningitis, encephalitis), intra (meningitis, encephalitis), intra cranial bleeding, SOL, temporal cranial bleeding, SOL, temporal arteritisarteritis

HA may be acute ( migraine, SAH, HA may be acute ( migraine, SAH, meningitis) or chronic (tension meningitis) or chronic (tension HA, ICP )HA, ICP )

HA how to diagnoseHA how to diagnose?? HistoryHistory::

- -Age, sex, occupation, etcAge, sex, occupation, etc..

- - Onset , site, duration, nature, Onset , site, duration, nature, severity, frequency, change wz severity, frequency, change wz cough, bending & straining, cough, bending & straining, relation to menses, precipt or relation to menses, precipt or aggravating or relieving factors, aggravating or relieving factors,

response to TR, etc response to TR, etc . .

ExaminationExamination::

- -temp, BP, gen ex including teeth, temp, BP, gen ex including teeth, gums, neck stiffness, temporal gums, neck stiffness, temporal

tendernesstenderness

- - Full neurological ex including Full neurological ex including fundoscopyfundoscopy..

InvestigationsInvestigations::

- -not all HA require investigationsnot all HA require investigations

- - simple investigations may give a simple investigations may give a diagnosis: FBC ( anaemia & high diagnosis: FBC ( anaemia & high ESR in temp arteritis, leucocytosis ESR in temp arteritis, leucocytosis in infections, polycythemia), BUN in infections, polycythemia), BUN and E, LFT, CXRand E, LFT, CXR

- -Only 5-10% of pts wz HA need brain Only 5-10% of pts wz HA need brain scanscan

- - Brain scan ifBrain scan if : : - SOL - focal N signs - SOL - focal N signs - if suspect intra cranial infection - if suspect intra cranial infection - disc margin is not clear - disc margin is not clear - change in HA pattern - change in HA pattern - if suspect BIH - if suspect BIH . .

- -Lumber puncture if: Lumber puncture if: - acute & chronic CNS - acute & chronic CNS infections - BIH infections - BIH - if - if Ca meningitis is Ca meningitis is suspected - normal suspected - normal

pressure hydrocephaluspressure hydrocephalus

Alarming signsAlarming signs:: - -sudden onset severe HA - fever > 39 sudden onset severe HA - fever > 39

CC

- - decreased alertness - traumadecreased alertness - trauma

- - HA wz seizures - persistent HA wz seizures - persistent HAHA

- - HA interfering wz normal life or that HA interfering wz normal life or that causecause

sleep disturbancesleep disturbance

- - change in sleep patternchange in sleep pattern

Mechanism of headacheMechanism of headache - - Brain substance is devoid of pain receptorsBrain substance is devoid of pain receptors

- - Pain receptors are present in za meningesPain receptors are present in za meninges,,

blood vessels in za base of za brain, extrablood vessels in za base of za brain, extra

cranial vessels & face. Nerve impulses cranial vessels & face. Nerve impulses travel centrally via za 5travel centrally via za 5thth, 9, 9thth and upper and upper cervicalcervical

sensory rootssensory roots . .

- - Sensory receptors are stimulated Sensory receptors are stimulated mechanicallymechanically

by stretch & distension or chemically byby stretch & distension or chemically by

5HT & histamine5HT & histamine..

HA, D.DHA, D.D:: 11 - -AAccording to ageccording to age: migr in teenagers: migr in teenagers

22 - -AAccording to genderccording to gender:- migr > in females:- migr > in females,,

cluster HA > in males, temp arteritis > incluster HA > in males, temp arteritis > in

femalesfemales

33 - -AAccording to siteccording to site:-frontal in sinusitis, temporal:-frontal in sinusitis, temporal

in migr & temp arteritis, occipital in SAHin migr & temp arteritis, occipital in SAH

44 - -AAccording to timingccording to timing:- new early morning HA in:- new early morning HA in

SOL, acute HA during activity in SAH, eveningSOL, acute HA during activity in SAH, evening

HA in tension HAHA in tension HA

55 - -AAccording to severityccording to severity:- very severe :- very severe and acute inand acute in severe & recurrent in severe & recurrent in cluster HA, moderately severe cluster HA, moderately severe SAH, severe & temp in temp SAH, severe & temp in temp arteritis, very severe arteritis, very severe & dull in SOL. & dull in SOL. 6- 6- According to associated symptomsAccording to associated symptoms:- :- fever and photophobia in fever and photophobia in meningitis, HA increased by meningitis, HA increased by cough & sneezing in SOL; visual cough & sneezing in SOL; visual symptoms in SOL, BIH, migr symptoms in SOL, BIH, migr and TIAand TIA

Causes of headacheCauses of headache 11 - -Referred headacheReferred headache

22 - -Vascular headacheVascular headache

- - migraine - temporal arteritismigraine - temporal arteritis

- - A/V malformation & aneurysmsA/V malformation & aneurysms

- - Severe HT - Vasodilt. from alcohol & Severe HT - Vasodilt. from alcohol & CO2CO2

33 - -Tension headache Tension headache 4 - meningeal irritation 4 - meningeal irritation

55 - -Neuralgic headacheNeuralgic headache

66 - -ICPICP

77 - -Systemic causesSystemic causes..

Referred headacheReferred headache - - EyesEyes: glucoma, irirtis, refractory errors: glucoma, irirtis, refractory errors....

- - Para nasal sinusesPara nasal sinuses: sinusitis: sinusitis

- - EarsEars: otitis media & externa: otitis media & externa

- - ThroatThroat: tonsillitis: tonsillitis

- - Cervical sponylosisCervical sponylosis

- - TeethTeeth

- - Tempro mandibular arthritisTempro mandibular arthritis..

** ** Treatment is by analgesics & that of theTreatment is by analgesics & that of the

underlying causeunderlying cause..

Tension headacheTension headache - - Commonest chronic headacheCommonest chronic headache

- - Nuchal or generalized, constant or dull or tightNuchal or generalized, constant or dull or tight

pressure pain wz local tenderness & pressure pain wz local tenderness & associatedassociated

with anxiety or depressionwith anxiety or depression..

- - Variable in duration & intensityVariable in duration & intensity

- - Often ppted by stress, depression, noises andOften ppted by stress, depression, noises and

fumesfumes..

- - No vomiting or photophobiaNo vomiting or photophobia

- - Careful history & exam clarify za diagnosisCareful history & exam clarify za diagnosis

and reassures za patand reassures za pat..

- - Immaging to exclude intra cranial diseaseImmaging to exclude intra cranial disease

and to allay za anxiety of za patand to allay za anxiety of za pat

- - Management includesManagement includes::

- - ReassuranceReassurance

- - Avoidance of ppting causesAvoidance of ppting causes..

- - Massage & ice bagsMassage & ice bags

- - AnalgesicsAnalgesics

- - Treatment of za underlying anxiety Treatment of za underlying anxiety andand

depressiondepression..

MigraineMigraine - - Migraine is a recurrent episodic, throbbingMigraine is a recurrent episodic, throbbing

headache, associated wz prostration, headache, associated wz prostration, nauseanausea,,

vomiting & photophobia +/_ focal vomiting & photophobia +/_ focal neurologicalneurological

symptoms & signs ( usually visual in classicsymptoms & signs ( usually visual in classic migrainemigraine.).)

- - 20%20% of females & 6% of males will have anof females & 6% of males will have an attack in their life timeattack in their life time..

- - Genetic predisposition ( 50% have FH)Genetic predisposition ( 50% have FH) - - 11stst episode before puberty is rare episode before puberty is rare..

- - Interval between attacks varies & episodesInterval between attacks varies & episodes last hours to dayslast hours to days..

Mechanism of migraineMechanism of migraine - - Intra cerebral vasoconstriction at za Intra cerebral vasoconstriction at za

onsetonset

due to 5HT release causes transient focal due to 5HT release causes transient focal neurological S & S, prodrome or neurological S & S, prodrome or

aura lasting 15-60 minaura lasting 15-60 min . .

- - Headache is due to vasodilt. of meningeal Headache is due to vasodilt. of meningeal andand

extra cranial arteries with stimulation of extra cranial arteries with stimulation of nervenerve

endings. This is due to release of endings. This is due to release of vasoactive subst. like NO2. 5HT falls vasoactive subst. like NO2. 5HT falls

during headacheduring headache . .

Clinical features of migraineClinical features of migraine 11 - -Classic migraineClassic migraine-:-:

- - Aura precedes or accompany za headacheAura precedes or accompany za headache..

- - Headache is throbbing & associated with Headache is throbbing & associated with nausea, vomiting, irritability, photophobia. nausea, vomiting, irritability, photophobia. Superficial temporal may be engorged & Superficial temporal may be engorged & pulsating. Sleep may follow an attack pulsating. Sleep may follow an attack..

22 - -Common migraineCommon migraine: migraine without aura: migraine without aura..

33 - -Hemiplegic migraineHemiplegic migraine: This is classic migraine: This is classic migraine

followed by hemiparesis recovering withinfollowed by hemiparesis recovering within

2424 hourshours

44 - -Basilar migraineBasilar migraine:- The headache is :- The headache is precededpreceded

by brain stem S & Sby brain stem S & S..

55 - -Ophthalmoplegic migraineOphthalmoplegic migraine:- There is:- There is

ophthalmoplegia during za attack- rareophthalmoplegia during za attack- rare..

66 - -Facioplegic migraineFacioplegic migraine..

Precipitating factorsPrecipitating factors 11 - -Dietary:- alcohol, cheese, chocolateDietary:- alcohol, cheese, chocolate..

22 - -Contraceptive pills, pre & post Contraceptive pills, pre & post menstrual andmenstrual and

pregnancy ( hormonal influences)pregnancy ( hormonal influences)..

33 - -StressStress

44 - -Rarely follows head injuryRarely follows head injury

55 - -Rarely follows development of HTRarely follows development of HT

66 - -No triggering cause in 50%No triggering cause in 50%..

Differential diagnosis of migraineDifferential diagnosis of migraine 11 - -Meningitis & SAHMeningitis & SAH (acute onset) (acute onset)

22 - -Thromboembolic TIAThromboembolic TIA ( headache is rare) ( headache is rare)

33 - -Sensory epilepsy wz unilateral Sensory epilepsy wz unilateral numbnessnumbness

( ( headache unusualheadache unusual))

44 - -Tension headacheTension headache

55 - -Cluster headacheCluster headache ( usually wz watery ( usually wz watery eyes)eyes)

66 - -Referred headacheReferred headache

Management of migraineManagement of migraine - - Avoid ppting factors e.g. dietary, pillsAvoid ppting factors e.g. dietary, pills

- - Start treatment early in za attackStart treatment early in za attack.. - - Simple analgesicsSimple analgesics +/- anti emetics will +/- anti emetics will

abortabort most attacks except za severe onesmost attacks except za severe ones..

- -Premenstrual migraine may respond to Premenstrual migraine may respond to diureticsdiuretics

- - TriptansTriptans ( 5HT1 agonist) in severe ( 5HT1 agonist) in severe migraine e.g. sumatriptan, zolmitriptan. Thymigraine e.g. sumatriptan, zolmitriptan. Thy are potent extra cranial vasoconstrictor. 1are potent extra cranial vasoconstrictor. 1stst

dose is followed by za 2dose is followed by za 2ndnd dose 2h later if dose 2h later if there is no response. Avoided in vascular there is no response. Avoided in vascular

disdis . .

- - Ergotamine tartarateErgotamine tartarate is now rarely used is now rarely used.. Over dose is serious. Also avoided in vascularOver dose is serious. Also avoided in vascular

dis. & pregnancydis. & pregnancy..

ProphylaxisProphylaxis It is used in frequent attacks disturbing workIt is used in frequent attacks disturbing work

and social life ( 2 attacks or more / month)and social life ( 2 attacks or more / month).. - - B-blockersB-blockers e.g. propranolol 10mgX3– 40- e.g. propranolol 10mgX3– 40-

80mg80mg X3X3..

- - PizotifenPizotifen (antihistamine & 5HT antagonist) (antihistamine & 5HT antagonist):: 0.5mg noct increasing to 1.5mg0.5mg noct increasing to 1.5mg

- - Tricyclic antidepressantsTricyclic antidepressants e.g. amitrypt 10- e.g. amitrypt 10-50mg50mg

- - Sodium valporateSodium valporate 300mg bid 300mg bid..

- - MethysergideMethysergide ( 5HT antagonist) may ( 5HT antagonist) may causecause

retroperitoneal fibrosis. Therefore used inretroperitoneal fibrosis. Therefore used in

resistant cases for short periods (3/12)resistant cases for short periods (3/12)..

Cluster headachesCluster headaches - Excoriating recurrent headaches clustered

around one eye & awakening the patient - Less common than migraine & little genetic

predisposition. - Male affected more than female & attacks

are brief. More common in heavy smokers and

alcohol may ppt it. - Excessive lacrimation, conjunctival & nasal

congestion may occur, rarely transient Horners.

- Triptans abort za attack & O2 inhalation is useful. Lithium & verapamil for prophylaxis.

Cluster HACluster HA MigraineMigraine - - sex: male femalesex: male female

- - age: 20-40 15-20age: 20-40 15-20

- - frequency: several/day frequency: several/day 1-4/month1-4/month

- - unilaterality: unilateral unilat/ unilaterality: unilateral unilat/ bilateralbilateral

- - nausea & V: rare commonnausea & V: rare common

- - during attack: sitting rest/ during attack: sitting rest/ quietquiet

Pressure headaches ( ICP)Pressure headaches ( ICP) - - Due to intracranial mass lesion displacing andDue to intracranial mass lesion displacing and

stretching meninges & basal blood vesselsstretching meninges & basal blood vessels

either directly or due to ICPeither directly or due to ICP..

- - Headache increases wz cough, straining andHeadache increases wz cough, straining and

after lying down due to increased pressure andafter lying down due to increased pressure and

cerebral oedemacerebral oedema..

- - There is associated evidence of ICP e.g. vomitThere is associated evidence of ICP e.g. vomit

blurring of vision, focal signs, disturbed conscioblurring of vision, focal signs, disturbed conscio

usnes, false localizing signs, seizures, papilloedusnes, false localizing signs, seizures, papilloed

Benign intracranial hypertensionBenign intracranial hypertension ( ( Pseudo tumor cerebriPseudo tumor cerebri -) -)BIHBIH..

- - Increased ICP without SOL, ventricular Increased ICP without SOL, ventricular dilatation or CSF obstruction or impairment dilatation or CSF obstruction or impairment

of consciousnessof consciousness . .- - - Occur usually in obese females wz Occur usually in obese females wz

menstrual disturbances, usually during menstrual disturbances, usually during child bearing age - Tetracyclines, vit A, pills child bearing age - Tetracyclines, vit A, pills and steroid, may be other causes. and steroid, may be other causes. - Headache and - Headache and papilloedema wz threat to vision +/- false papilloedema wz threat to vision +/- false localizing signs, but no focallocalizing signs, but no focal

- neurological deficitneurological deficit..- - - CSF is under pressure, but CT brain is CSF is under pressure, but CT brain is

normal normal . .

- - Spontaneous remission may occur over Spontaneous remission may occur over Ms & yrMs & yr

but there is always threat to vision whichbut there is always threat to vision which

should be monitoredshould be monitored..

- - Dietary advice & stopping offending the Dietary advice & stopping offending the drugs - Management by: drugs - Management by: - repeated LP & diuretics - repeated LP & diuretics . .

- - Shunt insertion Shunt insertion - Avoid steroids because of recurrence - Avoid steroids because of recurrence

on withdrawalon withdrawal . .

Temporal arteritis (giant cellTemporal arteritis (giant cell arteritisarteritis))

- - There is granulomatous arteritis of unknownThere is granulomatous arteritis of unknown cause ( ? AI) occurring over the age of 60cause ( ? AI) occurring over the age of 60

affecting extradural arteries & closely relatedaffecting extradural arteries & closely related to polymyalgia rheumatica which may co to polymyalgia rheumatica which may co

existexist.. - - F:M=2:1. Age= >55 yearsF:M=2:1. Age= >55 years

- - There is severe headache over za inflammedThere is severe headache over za inflammed superficial temp arteries which is thickenedsuperficial temp arteries which is thickened,,

tortuous, non pulsatile & tender. The tortuous, non pulsatile & tender. The overlyingoverlying

skin is red & gangrenous patches over scalpskin is red & gangrenous patches over scalp may be foundmay be found..

- -Visual symptoms include blurring of vision, Visual symptoms include blurring of vision, amaurosis fugax, diplopia, amaurosis fugax, diplopia, ophthalmoplegia and may proceed to ophthalmoplegia and may proceed to ipsilateral blindness within an hour in ipsilateral blindness within an hour in 25%25%..

- - Facial pain & claudication of za mandible Facial pain & claudication of za mandible maymay

also occuralso occur.. - - Constitutional symptoms wz fever, night Constitutional symptoms wz fever, night

sweats, muscle pain , malaise, anorexia & sweats, muscle pain , malaise, anorexia & Wt loss may occur Wt loss may occur - Ischemic lesions may occur in other - Ischemic lesions may occur in other organsorgans . .

- - ESR, CRP & alpha2 globulins with ESR, CRP & alpha2 globulins with normocytic normochromic anaemianormocytic normochromic anaemia

- - history, clinical ex, FBC & ESR, CRP history, clinical ex, FBC & ESR, CRP suggestsuggest

diagnosis and superficial temp artery diagnosis and superficial temp artery biopsy shows typical pathologybiopsy shows typical pathology

- - Prednisolone 60-100mg given early Prednisolone 60-100mg given early taperedtapered

as symptoms resolve(2/12) or ESR comes as symptoms resolve(2/12) or ESR comes down. Response within hours and down. Response within hours and histology of sup temp artery normalize histology of sup temp artery normalize within 48h. TR may cont. for Ms or within 48h. TR may cont. for Ms or yearsyears..

ProblemProblem 3636 year old lady, mother of 2, smoker & onyear old lady, mother of 2, smoker & on

contraceptive pillscontraceptive pills.. - - C/o headache for 9/12, associated with C/o headache for 9/12, associated with

blurringblurring of vision. Headache is severe & generalizedof vision. Headache is severe & generalized.. - - Ex: she is slightly overweight, Bp 140/80, noEx: she is slightly overweight, Bp 140/80, no

neck stiffness. There is bilateral papilloedema. neck stiffness. There is bilateral papilloedema. CNS Ex CNS Ex

intact. No pyramidal or cerebellar signs. intact. No pyramidal or cerebellar signs. NormalNormal

systemic Ex. What is the diff diagnosissystemic Ex. What is the diff diagnosis?? - - Investigation: CBC= normal, ESR= normalInvestigation: CBC= normal, ESR= normal..

Blood urea, electrolytes & LFT= normalBlood urea, electrolytes & LFT= normal

CXR & CT brain are normalCXR & CT brain are normal..

What is the diagnosisWhat is the diagnosis??

What is next stepWhat is next step??

What is the managementWhat is the management??