HEADACHE
Nov 30, 2014
HEADACHE
PRIMARY HEADACHE SYNDROMES
• Tension type headache
• Migraine• Trigeminal Neuralgia• Atypical facial pain• Cluster headache• Benign paroxysmal
headaches
TENSION TYPE
•Most common-69%•Episodic or chronic•Gradual onset , radiate forward from
occiput•Bilateral, dull, tight, band like pain•Less in morning, pain increase as day
goes on •No accompanying N,V, throbbing,
sensitivity to light, sound or movement
Pathophysiology
• Primary disorder of CNS pain modulation• Precipitating factorsStress: usually occurs in the afternoon after long
stressful work hours or after an exam Sleep deprivation Uncomfortable stressful position and/or bad
posture Irregular meal time (hunger) Eyestrain Caffeine withdrawal Dehydration
2 Theories
Muscle tension around head and neckMalfunctioning pain filter located in brain
stem, brain misinterprets information and interprets this signal as pain. One of the main neurotransmitters which is probably involved is serotonin
Management
•Paracetamol,Aspirin,NSAIDs•Behavioral approach-relaxation•Chronic-amitriptyline
MIGRAINE
•2nd most common-16%•15% women and 6% men•Severe, episodic, unilateral,throbbing
pain• Nausea,Vomiting• Sensitivity to light ,sound, movement• Genetic predisposition
Classical Migraine or Migraine with AURA
Symptom TriadParoxysmal headachenausea &/or vomitingaura of focal neurological events(visual) 20-25%
AURA
• flashing lights, silvery zigzag lines moving across visual field over a period of 20 minutes sometimes leaving a trail of temporary visual field loss• Sometimes-Auditory ,Olfactory, gustatory
hallucinations• Sensory aura-spreading front of tingling
and numbness, from one body part to another
Rare aura:• Vertigo• Aphasia• Hemiparesis• DeliriumMigraine with limb weakness-
Hemiplegic migraineSymptoms of aura do not resolve leaving
permanent neurological damage-Complicated migraine
Common Migraine or Migraine without AURA
•Paroxysmal headache•Vomiting +/-•NO AURA
Simplified Diagnostic Criteria for MIGRAINE
At least 2 of the following:
+ At least 1 of the following:
• Unilateral pain• Throbbing pain• Aggravation by
movement• Moderate or severe
intensity
• Nausea/vomitting• Photophobia and
phonophobia
Clinical phases of a migraine attack
Vulnerability
Prodrome
Aura
Pain
Postdrome
Attack Initiation
Triggers
• Flashing lights• Loud sounds• Strong odors• Stress• Hunger• Fatigue• Alcohol• Smoking
• Menstruation• Pregnancy• Menopause• Oral Contraceptives• Sleep changes• Caffeine• Chocolate• Tyramine• MSG
Pathophysiology of Migraine
•Cortical spreading depression
•Vascular• Low Serotonin • Melanopsin receptor
Cortical spreading depression of LEAO•Dysfunction of ion channels-Quick
depolarization(activation) followed by long-lasting depression over an area of cortex
•Release of inflammatory mediators
•Irritation of cranial nerve roots-trigeminal
Vascular
Vasoconstriction of blood vessels in brain-Aura
(begins in occipital lobe)
Vasodilatation of scalp blood vessels
Inflammation
Pain
Migraine Pain-Trigeminovascular•Key pathway for pain is trigeminovascular
input from meningeal vessels
•Modulation of trigeminovascular input comes from dorsal raphe nucleus, locus coeruleus and nucleus raphe magnus
Management
•Acute attack-aspirin/paracetamol+metoclopromide/ domperidone
•Severe attack-Sumatriptan•Frequent attacks-
Propranolol,Amitriptyline,Sodium valproate or Topiramate
Trigeminal Neuralgia
• Lancinating pain in 2nd and 3rd divisions of trigeminal nerve
• >50yrs• Severe,
brief ,repetitive pain causing patient to flinch
• Precipitated by touching trigger zones—washing, shaving, eating, cold wind
Pathophysiology
•Compression of trigeminal N by aberrant loop of cerebellar arteries as nerve enters brainstem
•Other benign compressive lesions
•Multiple sclerosis- TN occurs due to plaque of demyelination in trigeminal root entry zone
Management
•Carbamazepine-DOC•Intolerant-Gabapentin/Pregabalin•Injection of alcohol into peripheral branch
of nerve•Posterior craniotomy to relieve vascular
compression of trigeminal nerve
Atypical facial pain
•Persistent idiopathic facial pain•Continuous,
burning/crushing,unremittent, centred over maxilla usually left side
•Middle aged women•Early form of trigeminal neuralgia•Rx-Amitriptyline, Gabapentin
Other causes of facial pain
Sinusitis • Frontal-pain more in morning, decreases
as day progresses, stooping and blowing nose increase pain• Ethmoid and Sphenoid-pain over vertex,
less in morning and increase gradually
Post herpetic neuralgia-continuous, burning pain sensitive to light touch, shingles
THANK YOU