Headache

‘secondary’ headaches:

with a defined pathophysiological basis

Primary headache syndromes:

of uncertain pathogenesis

Increased intracranial pressure

Idiopathic intracranial hypertension

Meningeal irritation

Giant cell arteritis (cranial arteritis, temporal arteritis)

stroke, haemorrhage, intracranial venous sinus thrombosis or arterial dissection ,, Metabolic disturbances, e.g. hypoxia, hypercapnia and hypoglycaemia, vasoactive drugs, alcohol, monosodium glutamate, nitrites and nitrates

Due to raised ICP either tumor “ usually has a short history days to weeks the pain start suddenly and persist, daily, nausea and vomiting, “Effortless vomiting” or SOL.

Other focal neurological signs are more definitive of raised ICP than headache

Wake the patient from sleep or at morning with headache

Exacerbated by coughing, sneezing, bending and lying down.

Headaches of low ICP characterized by

relieving on lying down.

Usually follow LP

“Spontaneous low pressure headache”

Young and obese women

Raised ICP with no mass, pathophysiology is incompletely known but may due to “impaired CSF absorbtion”

Patients present with morning headache, vomiting and sometimes visual disturbance –typically diplopia and visual obscurations, + tinnitus

O/E Bilateral papilloedema

6th nerve palsy. No othe FNS.

Ventricles are small

High ICP with normal CSF content

Resolve by weight reduction or LP.

TRT.

- Acetazolamaide CA inhibitor

- Chlorothalidone

- Corticosteroid

- Surgical:*Lumboperitoneal shunt*Optic nerve fenestration

intracranial venous sinus thrombosis

hypervitaminosis A,

disturbances of calcium metabolism,

systemic lupus erythematosus,

drugs, including tetracyclines and

corticosteroids

Meningism or irritation of the meninges due to inflammation or blood accumulation

characteristically produces severe global or occipitalheadache with vomiting, exacerbation of symptoms by bright lights (photophobia) and neck stiffness (nuchal rigidity).

In SA haemorrhage, the pain is very sudden (within seconds) and severe, and the patient may lose consciousness

In bacterial meningitis, the headache is also acute in onset, but usually worsening over minutes or hours.

Kernig’s signch.

Over 50

Granulomatous inflammatory changes (with giant cells) are present in branches of the external carotid artery.

narrowing of the lumen, then thrombotic occlusion

Viral infection ,, autoimmunity ??

Scalp tenderness on coping hair.

intermittent claudication of the jaw, difficulty of chewing

The temporal arteries may become swollen and non-pulsatile

Amaurosis fugax

low-grade fever, night sweats, shoulder

and/or pelvic girdle pains, malaise,

anorexia and weight loss.

Important investigations:

-ESR > 100, CRP high

-CBC normocytic normochromic anemia

- LFT abnormal

-temporal artery biopsy. skip lesions

IV hydrocortisone. 40–60 mg daily of

prednisolone become better in 24-48 hrs

treatment may be needed for 18 months- 2

yrs

polymyalgia rheumatica

7.5–15 mg daily of prednisolone

Migraine is a periodic disorder

characterized by unilateral (or

sometimes bilateral) headache, which

may be associated with vomiting and

visual disturbance.

-common, 10% of the general population

experience at least one attach

-any age ,typically teens and twenties

-Female >male

-family history in the majority

-travel sickness and cyclical vomiting in

childhood

-relate to hypertension and head injury

-obscure

-Neurologic symptoms ,aura

(intercerebral vasoconstriction

-Headache phase ,subsequent

vasodilation of extracerebral vessel in

scalp and dura

-Serotoninergic pathway

-Genetic >> calcium channels

● stress, particularly after the stress is over, e.g. at weekends and holidays;

● physical exercise;

● diet – alcohol; occasionally specific dietary triggers can be identified, e.g. cheese, chocolate, red wine;

● hormones – the onset of migraine may follow

the menarche, and symptoms may also increase

in severity around the menopause. Attacks may be

related to menstruation.

-Migraine with aura(classical migraine)

-Migraine without aura(common migraine)

-Basilar migraine (Bickerstaff variant)

-Hemiplegic and ophthalmoplegic

migraine

-experience vague prodromal symptoms for hours preceding an attack, including drowsiness, mood changes, hunger or anorexia

-classical attack begins with the aura- Visual symptoms

-Expanding scotoma ,teichopsia,fortificationspectra

-homonymous hemianopia,or complete blindness- Sensory symptoms- Dysphasia and limb weakness

The aura generally resolves after 15–20 minutes (it may last as long as an hour ).

The headache of migraine is typically

unilateral and periorbital,. Pain is throbbing

in quality and may be exacerbated by

coughing, straining or bending (jolt

phenomenon). It lasts several hours

(generally between 4 and 72 hours).

Patients prefer to lie in a darkened room

and may gain relief from sleep. Associated

symptoms include photophobia, nausea,

vomiting, pallor and diuresis.

Migraine without aura (common migraine)

In this case, the aura is absent but patients

may experience vague prodromal

symptoms. Headache may be present

on waking but is otherwise similar to that

of classical migraine.

Basilar migraine (Bickerstaff variant)

This syndrome, which particularly affects

teenage female patients, is

characterized by prominent features

suggestive of vertebrobasilar ischaemia

during the aura, including vertigo,

diplopia, dysarthria, ataxia and syncope

Hemiplegic and ophthalmoplegic

migraine

These rare syndromes, in which migrainous

headaches are accompanied by

hemiplegia or ophthalmoplegia, with

focal neurological signs persisting for

days or weeks, should be diagnosed only

after structural causes, e.g. aneurysm,

have been excluded.

- History (periodicity)

- Status migrainosus

- neurological examination is normal

(except during an attack of hemiplegic

or ophthalmoplegic migraine, or unless

migrainous cerebral infarction has

occurred)

- a cranial bruit >vascular malformation

the differential diagnosis of transient focal

neurological symptoms is:

● migraine,

● transient cerebral ischaemia,

● epilepsy.

Acute attach -dark room and sleep-analgesic and antiemetic-ergotamine(vasoconstrictor) OR triptans( sumatriptan,5-HT1 receptor agonist)

Prophylaxis-avoid dietary triggers-oestrogen containing preparation;OC,hormone replacement therapy-drugs (frequent attachs) propranolol and other beta blockers,pizotifen,sodiumvalproate,verapamil,topiramate,methysergide

Despite also being characterized by

unilateral headache, this syndrome is

distinct from migraine, though the two

conditions may coexist. Histaminergic

and other humoral mechanisms are

thought to underlie the autonomic

accompaniments of the headache.

-Male>female

-age onset 20-60

- Severe attacks of pain around one eye (always the same side) characteristically last 20–120 minutes and may recur several times a day, often waking the patient more than once at night. Alcohol may precipitate an attack. This pattern continues for days, weeks or months, and the patient may then be symptom-free for many weeks, months or even years, hence the disorder’s name.

Unlike migraine, patients with cluster headache are often restless during an attack and may appear red rather than pale. More pronounced autonomic accompaniments of the pain include conjunctivalinjection, lacrimation and nasal discharge or congestion

-high flow 100% O2

-ergotamine ( bedtime ,best with caffine)

-Sumatriptan

-corticosteroid

*long term treatment

(methysergide,verapamil,pizotifen)

*chronic cluster headache (Lithium)

*trigeminal autonomic

syndromes>>indometacin

The most common headache of unknown

cause though abnormal contraction of

muscles of the head and neck has been

invoked as one putative mechanism.

Muscle contraction may be triggered by

-psychogenic factors, i.e. anxiety or

depression, -local disease of the head

and neck, e.g. cervical spondylosis or

dental malocclusion.

- headache vary from dull pain at various

sites, to a global pressure sensation, to

the feeling of a tight band around the

head

- are no associated symptoms

- neurological examination is normal

* Migraine and tension-type headache

frequently coexist.

Treatment :

- no sinister underlying cause

- 3–6-month course of a tricyclic or

related compound, e.g. amitriptyline or

dosulepin, may be helpful if tension-type

headache is frequent or persistent

-physiotherapist ( relaxation exercise)

-psychotherapy( stress management)

>15 days/month

causes:

-secondary headache syndrome

-chronic tension type headache

-transformed migraine

-medication overuse

Trigeminal neuralgia

Post-herpetic neuralgia

Atypical facial pain

->50 years

-compression of the trigeminal sensory root

-idiopathic and symptomatic(tumor of the

cerebellopontine angle ,younger MS)

-unilateral facial pain within the distribution

of one or more divisions of the trigeminal

nerve(mandibular and maxillary are

most common )

-The pain is lancinating in quality-brief,severe,sharp,stabbing,electric shock-like jolts of pain.

-trigger areas (fear of provoking an attach by washing face or shaving)

-speaking, cold breeze , chewing produce pain

-Glossopharyngeal neuralgia>pain in throat or deep inside the ear

-normal trigeminal nerve examination ,abnormal neurologic signs indicate tumor (MRI)

-Tic douloureux:anxiety about trigger areas may lead to involuntary facial spasm

-analgesic unuseful,Carbamazepine ,other drugs,surgically.

Patients who have suffered shingles in one of the

branches of the trigeminal nerve (often the first –zoster ophthalmicus) may experience persistent facial pain after the rash has healed. The pain may be very severe and intractable, lasting 2–3years after the eruption, but sometimes responds

to tricyclic antidepressants, carbamazepine or topical application of capsaicin

Atypical facial neuralgiaSome patients present with constant facial pain in

a non-anatomical distribution, and for which no

local cause is found. Treatment is unsatisfactory

but coexistent anxiety and/or depression may indicatepotential benefit from tricyclic and related

drugs, e.g. dosulepin.

-local causes of pain :eyes,ears,nose,paranasal sinuses,throator teeth

- cough,exertion,and sexual intercourse headache (benign ) *exclude cerebellar ectopia

- Coital headache (benign)*exclude subarachnoid hemorrhage

- Ice-pick headache (benign) :sharp jabs felt anywhere in head