Headache

Headache

Dr jignesh vora

What is a headache?

• a pain arising from the head or upper neck of the body. • pain originates from the tissues and structures that surround the

brain because the brain itself has no nerves that give rise to the sensation of pain

• The periosteum that surrounds bones• muscles that encase the skull• sinuses• eyes, and ears• meninges that cover the surface of the brain• spinal cord, arteries, veins, and nerves, all can become inflamed or

irritated to cause headache• pain may be a dull ache, sharp, throbbing, constant, mild, or intense

What u feel during attack

• Nausea• Vomiting• Diarrhea• Sweating• Cold hands• Light sensitivity• Dizziness• Neck pain

• Sensitivity to sound• Scalp tenderness• Pale complexion• Pulsating temple• Pressure pain• Vertigo• Difficulty thinking

Causes of headaches.

1. Traction or dilatation of intracranial or extracranial arteries.

2. Traction of large extracranial veins3. Compression, traction or inflammation of cranial and

spinal nerves4. Spasm and trauma to cranial and cervical muscles.5. Meningeal irritation and raised intracranial pressure6. Disturbance of intracerebral serotonergic projections

Life Threatening causes of acute headaches.

• Intracranial hemorrhage– Subdural hemorrhage– Subarachnoid

hemorrhage.

• Meningitis• Hypertensive

encephalopathy.

Hypertensive Encephalopathy

• Associated with high blood pressure, nausea, vomiting and blurred vision

• Usually associated with blood pressures of 200/130.

• Headache diffuse and worse in the morning and subsides during the day.

Meningitis:useful signs and symptoms.

• The absence of fever, neck stiffness and altered mental status in a patient with a headache virtually eliminates the diagnosis of meningitis.

• In multiple studies the presence of neck stiffness on examination has a pooled sensitivity of 70%.

types

1. Primary2. Secondary3. Cranial neuralgias4. Facial pain5. Other

Primary headache

1. Migraine headache2. Tension headache3. Cluster headache

Tension headaches• most common type of primary headache• women >men• Due to contraction of the muscles that cover the skull. • When the muscles covering the skull are stressed, they may

become inflamed, go into spasm, and cause pain. • Common sites include the base of the skull where the trapezius

muscles of the neck insert, the temples where muscles that move the jaw are located, and the forehead.

• because of physical or emotional stress• difficult and prolonged manual labor• sitting at a desk or computer for long periods of time

concentrating.

Causes of TTH( tension type headache)

• Some evidence that like migraine caused by serotonin imbalance but to a lesser extent than migraine.

• This would indicate that similar treatments would work.

Symptoms of tension h’ache

• Pain that begins in the back of the head and upper neck and is described as a band-like tightness or pressure. It may spread to encircle the head.

• The most intense pressure may be felt at the temples or over the eyebrows.

• usually is bilateral• not associated with an aura , nausea, vomiting, or sensitivity to

light and sound. • sporadically (infrequently and without a pattern) but can occur

frequently and even daily in some people. • allows most people to function normally, despite the headache.

Episodic Tension Type Headache.

IHS Criteria• Tension type headaches < 15 per month.• Lasts 30 mins to 7 days• No nausea or vomiting• No photophobia and phonophobia (1 ok)• Headache has at least 2 of the following criteria:

a. pressing/tighteningb. Bilateralc. Mild-moderated. Not aggravated by physical activity.

Chronic Daily Headache

• Affects 4-5% of the population.• Definiton: head pain for at least 4 hours for more

than 15 days/month.• Often develops from an episodic headache disorder

either migraine or episodic tension type headache• Includes chronic tension type headache(CTTH) and

chronic daily migraine

Prevention of CTTH

• Tricyclic antidepressants.• Stress management• Tizanidine• SSRIs:prozac• Anticonvulsants:gabapentin and topiramate.• Acupuncture

Dx of tension h’ache

• History• pain is mild-to-moderate• Bilateral• described as a tightness that is not throbbing• not made worse with activity• no associated symptoms like nausea,

vomiting, or light sensitivity.

Rx for tension h’ache

• NSAIDs• Stress management• Anxiolytics

Cluster h’ache

intro• occur daily for periods of a week or more • with long periods of time, months to

years, with no headache symptoms.• occur at the same time of day, often

waking the patient in the middle of the night.

• due to a sudden release of the chemicals histamine and serotonin in the brain

• The hypothalamus, an area located at the base of the brain, is responsible for the body's biologic clock and may be the location that is the source for this type of headache.

causes• tend to run in

families • triggered by changes

in sleep patterns• By Rx - NTG for heart

disease• smoking, alcohol,

chocolate and foods high in nitrites like smoked meat are responsible

Symptoms of cluster h’ache• headaches that come in groups (clusters) separated by pain-free periods of months

or years.• A patient may experience a headache on a daily basis for weeks or months and

then be pain free for years.• begins in adolescence but can extend to those in middle age.• pain typically occurs once or twice daily• Each episode of pain lasts from 30 to 90 minutes. • occur at the same time every day• awaken the patient at night from a sound sleep.• around or behind one eye. • patients describe the pain as feeling like a hot poker in the eye• The affected eye may become red, inflamed, and watery. • The nose on the affected side may become congested and runny. • patients with cluster headaches tend to be restless• They often pace the floor, bang their heads against a wall, can do suicide

Dx of cluster h’ache

• History• description of the pain• clock-like recurrence • If examined in the midst of an attack, the patient

usually is in a painful crisis and may have the eye and nose watering as described previously.

• If the patient is seen when the pain is not present, the physical examination is normal and the diagnosis will depends upon the history.

Rx of cluster h’ache• very difficult to treat• headache recurs daily, there are two treatment needs. The pain of the

first episode needs to be controlled, and the following headaches need to be prevented.

• Initial treatment options may include one or more of the following:• inhalation of high concentrations of oxygen• injection of triptan medications, like, sumatriptan (Imitrex), zolmitriptan

(Zomig), and rizatriptan (Maxalt) which are common migraine medications;

• injection of lidocaine into the nostril;• dihydroergotamine (DHE, Migranal), a medication that causes blood

vessels to constrict; and• caffeine.

Prevention of the next cluster h’ache

• CCBs – verapamil , diltiazem• prednisone• antidepressant medications - lithium• antiseizure rx - valproic acid, topiramate• Life style modification• Avoid smoking /alcohol

Migraine headaches

• are the second most common type of primary headache.

• affect children as well as adults.• Before puberty - boys and girls are affected

equally • after puberty - women > men

Cluster headaches

• are a rare type of primary headache. • It more commonly affects men in their late 20s • though women and children can also suffer

secondary headaches

• due to an underlying structural problem in the head or neck.

• broad group of medical conditions ranging from dental pain from infected teeth to pain from an infected sinus, to life-threatening conditions like bleeding in the brain or infections like encephalitis or meningitis

• Traumatic headaches fall into this category including post-concussion headaches.

• also includes headaches associated with substance abuse and excess use of medications used for headache

Secondary headache

1. Head and neck trauma• Subdural hemorrhage• Epidural hemorrhage• Subarachnoid hemorrhage• Concussions

2. Bl vessel problem in Head and neck • Stroke, TIA, temporal arteritis, arteriovenous

malformation-AVM

Sec h’ache

3. Non bl vessel problem in brain• Tumor• Seizure• > ICT

4. Drugs discontinuing analgesics

5. Infections meningitis, encephalitis, HIV, influenza, pneumonia

Sec headache

6. Change in body enviornment HTN, DM, renal dialysis, dehydration

7. Psychiatric diseases

8. ENT diseases

9. Ophthalmic disease

10. Teeth disease

• CBC• ESR• CT • MRI• Lumbar puncture

cranial neuralgias, facial pain, and other headaches?

• Neuralgia -neur= nerve + algia =pain • Cranial neuralgia describes inflammation of

one of the 12 nerves that supply the motor and sensation function of the head and neck

• eg. trigeminal neuralgia which affects cranial nerve V (the trigeminal nerve) and can cause intense facial pain.