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Headache

Headache. Dr.Padmashini. Introduction. It is usually a benign symptoms but occasionally it is manifestation of a serious illness such as brain tumour, SAH, meningitis or giant cell arteritis. Pain…….

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Headache

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  1. Headache Dr.Padmashini

  2. Introduction • It is usually a benign symptoms but occasionally it is manifestation of a serious illness such as brain tumour, SAH, meningitis or giant cell arteritis

  3. Pain…… • Pain occurs when peripheral nociceptors are stimulated in response to tissue injury, visceral dilatation or other factors • Occurs when pain sensitive pathways are activated or damaged

  4. Pain sensitive structures of head • Scalp,middle meningeal artery,dural sinuses,falx cereberi,proximal segments of large pial arteries

  5. Pain insensitive structures • Ventricular ependyma, choroid plexus, pial veins & most of brain parenchyma

  6. Sensory stimuli from head conjugated to CNS via trigeminal nerves for structures above the tentorium in the anterior & middle fossa of the skull • Via first three cranial nerves for those in post fossa & inferior surface of tentorium

  7. Head ache occur….. • Distension, traction/ dilatation of intracranial or extra cranial arteries • Traction or displacement of large intracranial veins or their dural envelope • Compression, traction or inflammation of cranial & spinal nerves

  8. Spasm , inflammation or trauma to cranial & cervical muscles • Meningeal irritation & raised ICP • Activation of brain stem structure

  9. Classification of head ache • International Headache Society

  10. Approach to patient with head ache History – head ache • Pattern • Onset • Location • Associated symptoms • Other history • Family history

  11. General physical examination

  12. scenario • A 30 yr old female presented to ER • B/Lhead ache after heavy exercise , • head ache more over the base of the skull • not associated with any other symptoms

  13. Most frequently occuring type Physical & emotional stress Contraction of muscles that cover the skull Tension head ache

  14. Pain at back of head & upper neck Band like tightness / pressure Mild & bilateral Not associated with aura & other symptoms Clinical features

  15. OTC Aspirin, ibuprofen, acetaminopen Recurrent head ache Massage Stress management treatment

  16. scenario • A 35 yr old male presents with • a daily head ache • two attacks per day over last three wks.each lasts about an hour • awakens the pt from sleep.asso with tearing & redness of lt eye • .pain is deep,excrutiating &limited to lt side of head

  17. Cluster head ache • Readers syndrome • Histamine cephalgia • Spheno palatine neuralgia

  18. Episodic type characterised by one to three short lived attacks of periorbital pain/day over a 4-8 wks period fallowed by pain free interval

  19. Men> women Age 20-50 yrs Periorbital/temporal pain Starts with out aura & peaks in 5 min Excrutiating & explosive in quality features

  20. Rarely pulsatile Strictly unilateral Accompained – homolateral lacrimation, redening of eye nasal stiffness, lid ptosis nausea

  21. pathogenesis • Hypothalamus is the site of activation • Anterior – circadian pace maker • Posterior – regulate autonomic functions

  22. treatment Initial : • Inhalation of high conc of O2 • Inj sumatriptan 6 mg s/c • NSAID

  23. Prophylactic • Verapamil • Prednisolone 60 mg x 10 days • Lithium 600 – 900 mg daily • Ergotamine • methysergide

  24. scenario • A 25 yr old female who is having first day of her menstruation • severe throbbing head ache on rt side • pulsatile in nature • prior to attack pt had one episode of vomiting & flashing lights

  25. Migraine • It is a benign & recurring syndrome of head ache, nausea,vomiting & other symptoms of neurologic dysfunction in varying admixtures • Common in younger age • Female predominance

  26. Pathogenesis • Genetic basis of migraine • Vascular thoery • Trigemino vascular system • 5-hydroxytryptamine • Dopamine in migraine

  27. Common migraine: NoFNDprecedes the attack Mod – severe head ache Pulsatile Unilateral Aggravated by routine activity,nausea,vomiting Photophobia Clinical features

  28. Classic migraine: • Accompanied by sensory,motor or visual symptoms • FND common during the attacks • Migraineequivalents– FND with out headache,vomiting • Complicatedmigraine- persisting residual neurological deficit

  29. Symptoms referable to brain stem dysfunction(vertigo,dysarthria,diplopia) Bickerstaffsmigraine : total blindness fallowed by vertigo tinnitus dysarthria parasthesia Throbbing head ache Full recovery Basilarmigraine

  30. Diagnostic criteria for migraine • Repeated headache lasting for 4- 72h with normal physical examination &

  31. TREATMENT Non pharmacological • Avoidance of head ache triggers • Regulated life style • Yoga • Meditation • hypnosis

  32. Prophylactictreatment • Betablockers– propanalol 80-320 mg qd timolol 20-60 mg qd • Anticonvulsant- sodium valproate 250 mg bd • TCA– amitriptyline 10-50 mg q hs nortriptyline 25-75 mg qhs • MOI– phenelzine 15 mg tds

  33. Serotonergicdrugs– methysergide 4-8 mg qd cyproheptadine 4-16 mg qd • Verapamil– 80 – 480 mg qd

  34. Secondary head ache • It is due to underlying structural problem in head or neck. • There are numerous causes & some are life threatening and deadly

  35. scenario • A 45 yr old gentleman • hypertensive on irregular treatment presented with sudden onset of severe throbbing headache more over the occipital region • pain radiates to the cervical spine

  36. SAH • It is bleeding in the area between the brain & thin tissues that covers the brain

  37. Severe headache , sudden onset Common location –occipitonuchal Pain radiates down along the cervical spine CT brain SAH

  38. Cont….. • LP mandatory following negative CT scan • Presence of xanthochromia in the CSF supernatant – gold standard

  39. Cont… • Neurologic consultation • Nimodipine 60 mg po q 6 h • Prophylactic phenytoin to avoid seizures

  40. scenario • A 35 yr old gentleman presented to er • complaints of fever and head ache since one weak , • altered sensorium for one day & one episode of GTCS 15 min back • O/E pt was in post ictal state. HR – 58/mt, BP – 160/100 mmhg RR – 32/mt irregular pattern of breathing

  41. Meningitis • Acute onset of fever, headache, neck stiffness • LP • CT brain • Early empirical antibiotic therapy

  42. Intraparenchymal hge & cerebral ischemia • Brain tumour : head ache :worse in morning asso with position, nausea, vomiting

  43. A 65 yr old gentle man presented to er head ache over the rt parietotemporal region associated with fever , stiffness & pain in the muscles of shoulder girdle & blurring of vision. On examination he has tachycardia bld investigations shows raised ESR scenario

  44. It is an inflammation of medium & large sized arteries Common age > 50 yrs Characterised – fever,head ache, anaemia& high ESR Head ache –pulsatileearly&occludedlater Temporal arteritis

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