APPROACH TO HEADACHE

1. APPROACH TO HEADACHE Done by: Hani Abdeljawad.

2. INTRODUCTION This is the first time we discuss headache (or Cephalalgia) as a separated subject. Definition:Headache is pain in any part of the head, including the scalp, face (including the orbitotemporal area), and interior of the head. Headache is one of the top ten most common complaints patients seek medical attention for. Headache occurs due to activation of pain-sensitive structures in or around the brain, skull, face, sinuses, or teeth. Headache may occur as a primary disorder or be secondary to another disorder.

3. Most headaches don’t represent a serious medical condition, however; has one of the longest lists of differential diagnoses in all of medicine. The most important diagnostic tool is a detailed history.

4. Pathophysiology The brain tissue itself is not sensitive to pain because it lacks pain receptors. Rather, the pain is caused by disturbance of the pain-sensitive structures around the brain. Several areas of the head and neck have these pain-sensitive structures, which are divided in two categories: within the cranium (blood vessels, meninges, and the cranial nerves) and outside the cranium (the periosteum of the skull, muscles, nerves, arteries and veins, subcutaneous tissues, eyes, ears, sinuses and mucous membranes). Headache often results from traction to or irritation of the meninges and blood vessels. The nociceptors* may also be stimulated by other factors than head trauma or tumors and cause headaches. Some of these include stress, dilated blood vessels and muscular tension. Once stimulated, a nociceptor sends a message up the length of the nerve fiber to the nerve cells in the brain, signaling that a part of the body hurts. Endorphins rule. (A nociceptor is a sensory receptor that responds to potentially damaging stimuli by sending nerve signals to the spinal cord and brain. This process, called nociception, usually causes the perception of pain.)

5. Pain sensitive structures include: * Skin and its blood supply * Muscles of the head and neck * Great venous sinuses and tributaries * Portions of the meninges including the dura mater at the * base of the skull * Dural arteries * Intracerebral arteries * Cervical nerves * Select cranial nerves * Pain sensitive structures are affected by tension,traction, distension, dilatation, and inflammation.

6. Within the skull, the dura and the proximal large pial blood vissels are the main structures sensitive to the pain. The pain sensitive structures are mainly innerveted by the trigeminal nerve.

7.  Headache may occur as a primary disorder or be secondary to another disorder.

8. Classification of headaches Primary headaches OR Idiopathic headaches THE HEADACHE IS ITSELF THE DISEASE NO ORGANIC LESION IN THE BEACKGROUND TREAT THE HEADACHE.

9. The t basic categories of primary headache are: - Tension, - Migraine, - Cluster, - and less commonly; Hemicrania continua.

10. Secondary headaches OR Symptomatic headaches THE HEADACHE IS ONLY A SYMPTOM OF AN OTHER UNDERLYING DISEASE TREAT THE UNDERLYING DISEASE!

11. THE HEADACHE IS A SYMPTOM OF AN UNDERLYING DISEASE, LIKE Sinusitis Glaucoma Eye strain Fever Cervical spondylosis Anaemia Temporal arteriitis Meningitis, encephalitis Brain tumor, meningeal carcinomatosis Haemorrhagic stroke

12. To summarize "MM...IT ACHES" - this phrase gives us our mnemonic for the majority of differential diagnoses for a headache..M - MigraineM - MeningitisI - Increased Intracranial PressureT - Tension Headache + Temporal ArteritisA - AV MalformationsC - Cluster HeadacheH - HypertensionE - Eye Disorders (Refractory Errors + Glaucoma)S - Sinusitis + Sub-Arachnoid Hemorrhage + most Systemic illnesses

13. Does hypertension cause headache ? Currently, there is no concrete evidence to establish a firm causal link between hypertension and headache. There is, however, an evidence that hypertension does not cause headaches and in fact may be protective against the development of headache. Despite conflicting data in the medical literature, many of the large trials that have examined this relationship have found no association between hypertension and the development of headache. Hypertension increases risk of brain hemorrhage, so may cause headache.

14. Red flags for headache complaint;

15. Cont’d

16. History of headache chief complaint. History: History of present illness includes questions about headache location, duration, severity, onset (eg, sudden, gradual), and quality (eg, throbbing, constant, intermittent, pressure-like). Exacerbating and remitting factors (eg, head position, time of day, sleep, light, sounds, physical activity, odors, chewing) are noted. If the patient has had previous or recurrent headaches, the previous diagnosis (if any) needs to be identified, and whether the current headache is similar or different needs to be determined. For recurrent headaches, age at onset, frequency of episodes, temporal pattern (including any relationship to phase of menstrual cycle), and response to treatments (including OTC treatments) are noted.

17. Review of systems should seek symptoms suggesting a cause, including Vomiting: Migraine, increased intracranial pressure Fever: Infection (eg, encephalitis, meningitis, sinusitis) Red eye, visual symptoms (halos, blurring): Acute narrow-angle glaucoma Visual field deficits, diplopia, or blurring vision: Ocular migraine, brain mass lesion, idiopathic intracranial hypertension Lacrimation and facial flushing: Cluster headache Rhinorrhea: Sinusitis Pulsatile tinnitus: Idiopathic intracranial hypertension Preceding aura: Migraine Focal neurologic deficit: Encephalitis, meningitis, intracerebral hemorrhage, subdural hematoma, tumor or other mass lesion Seizures: Encephalitis, tumor or other mass lesion Syncope at headache onset: Subarachnoid hemorrhage Myalgias, vision changes (people > 55 yr): Giant cell arteritis

18. Past medical history should identify risk factors for headache, including exposure to drugs (methapred), substances ( caffeine), and toxins, recent lumbar puncture, immunosuppressive disorders or IV drug use (risk of infection); hypertension (risk of brain hemorrhage); cancer (risk of brain metastases); and dementia, trauma, coagulopathy, or use of anticoagulants or ethanol (risk of subdural hematoma). Family and social history should include any family history of headaches, particularly because migraine headache may be undiagnosed in family members.

19. PRIMARY (IDIOPATHIC) HEADACHE; Tension headache (the most common type of primary headache.) Migraine Cluster headache Other, rare types of primary headaches

20. BY HISTORY

21. Tension headache ( tension-type headache) Tension-type headaches account for nearly 90% of all headaches. ension-type headache pain is often described as a constant pressure, as if the head were being squeezed.

22. Frequency and duration: - Tension-type headaches can be episodic or chronic. -  Episodic tension-type headaches are defined as tension-type headaches occurring fewer than 15 days a month, whereas chronic tension headaches occur 15 days or more a month for at least 6 months.

23. Causes. Various precipitating factors may cause TTH in susceptible individuals: - Stress: usually occurs in the afternoon after long stressful work hours or after an exam - Sleep deprivation - Uncomfortable stressful position. - Irregular meal time (hunger) - Eyestrain - Caffeine withdrawal - Dehydration One half of patients with TTH identify stress or hunger as a precipitating factor. Tension headaches may be caused by muscle tension around the head and neck.

24. TTH  that occur 15 or more days a month for at least three months, they're considered chronic. TTH that occur fewer than 15 times in a month, your headaches are considered episodic. Tension headaches can sometimes be difficult to distinguish from migraines, but unlike some forms of migraine, tension headache usually isn't associated with visual disturbances (blind spots or flashing lights), nausea, vomiting, abdominal pain, weakness or numbness on one side of the body, or slurred speech.

25. CRITERIA A. At least 10 episodes occurring on <1 day/month on average and fulfilling criteria B-D B. Headache lasting from 30 minutes to 7 days C. Headache has at least 2 of the following characteristics: Bilateral location Pressing/tightening (non-pulsating) quality Mild or moderate intensity Not aggravated by routine physical activity such as walking or climbing stairs D. Both of the following: No nausea or vomiting (anorexia may occur) No more than one of photophobia or phonophobia E. Not attributed to another disorder

26. Treatment of tension type of headache Episodic form: NSAID drugs. Chronic, Tricyclic antidepressants.

27. MIGRAINE Migraine is derived from the word ‘hemicrania’ or ‘half-a-head’ Episodic, lasting 4-72 h, associated with nausea and/or vomiting, photophobia and phonophobia . Headache has a throbbing or pulsatile quality and is often unilateral (2/3rds of patients) although may become generalised We have Migraine without aura (more common) , and, Migraine with aura. Aura:  precedes the migraine with some sort of visual disturbance known as an aura. Aura symptoms typically last from 10 to 25 minutes. Visual changes can occur in one or both eyes. They can include one or more of the following: Zigzag lines Flashing lights auditory hallucinations  numbness or tingling on one side of the face or body Weakness, unsteadiness.. etc

28. Migraine without aura (MO) diagnostic criteria A. At least five headache attacks lasting 4 - 72 hours (untreated or unsuccessfully treated), which has at least two of the four following characteristics: 1. Unilateral location 2. Pulsating quality 3. Moderate or severe intensity (inhibits or prohibits daily activities) 4. Aggravated by walking stairs or similar routine physical activity B. During headache at least one of the two following symptoms occur: 1. Phonophobia and photophobia 2. Nausea and/or vomiting

29. Migraine with aura (MA) diagnostic criteria A. At least two attacks fulfilling with at least three of the following: 1. One or more fully reversible aura symptoms indicating focal cerebral cortical and/or brain stem functions 2. At least one aura symptom develops gradually over more than four minutes, or two or more symptoms occur in succession 3. No aura symptom lasts more than 60 minutes; if more than one aura symptom is present, accepted duration is proportionally increased 4. Headache follows aura with free interval of at least 60 minutes (it may also simultaneously begin with the aura B. At least one of the following aura features establishes a diagnosis of migraine with typical aura: 1. visual disturbance 2. Unilateral paresthesias and/or numbness 3. Unilateral weakness 4. Aphasia or unclassifiable speech difficulty

30. IMPORTANT TO KNOW! MIGRAINE WITH AURA IS A RISK FACTOR FOR ISCHAEMIC STROKE THEREFORE PATIENTS SUFFERING FROM MIGRAINE WITH AURA SHOULD NOT SMOKE!!! SHOULD NOT USE ORAL CONTRACEPTIVE DRUGS!!!

31. Drug therapy Acute attacks – analgesics, NSAIDS, dopamine antagonists, ergotamines( by inhibiting trigeminal neurotransmission). Preventive therapy – propranolol, tricyclic antidepressants.

32. Cluster headache Severe, unilateral pain, orbitally, supraorbitally and/or temporally, lasting 15-180 minutes, occurring from once every other day to 8 times a day. Bouts may last weeks or months (scince the name clusture) and then remit for months or years (average 1/year) 80-90% are episodic (as above), 10-20% are chronic

33. Cluster Headache criteria A. At least five attacks of severe unilateral orbital, supraorbital and/or temporal pain lasting 15 to 180 minutes untreated, with one or more of the following signs occurring on the same side as the pain 1. Conjunctival injection 2. Lacrimation 3. Nasal congestion 4. Rhinorrhoea 5. Forehead and facial sweating 6. Miosis 7. Ptosis 8. Eyelid oedema B . Frequency of attacks from one every other day to eight per day

34. Treatment – acute: 100% oxygen, ergotamines and triptans, preventive: ergotamines, corticosteroids, verapamil.

35. Hemicrania continua Hemicrania continua (HC) is a persistent unilateral headache that responds to indomethacin (NSAID) it's considered "diagnostic" if they respond completely to indomethacin because the cause and etiology are not known.

36. Diagnostic criteria * The following diagnostic criteria are given for hemicrania continua[1]: Headache for more than 3 months fulfilling other 3 criteria: All of the following characteristics: Unilateral pain without side-shift Daily and continuous, without pain-free periods Moderate intensity, but with exacerbations of severe pain At least one of the following autonomic features occurs during exacerbations and ipsilateral to the side of pain: Conjunctival injection and/or lacrimation Nasal congestion and/or rhinorrhea Ptosis and/or miosis Complete response to therapeutic doses of indomethacin

37. Secondary headache Thunderclap headache subarachnoid hemorrhage Sinus Headaches Arteriitis temporalis Idiopathic intracranial hypertension Meningitis ,,,, etc

38. Thunderclap headache Is a headache that is acute and severe at onset Originally used to describe the headache associated with subarachnoid hemorrhage(SAH). If the work-up for SAH is negative, however, there is a list of alternate possibilities for etiology. Diagnosis is made via a process of exclusion with accompanying negative CT and lumbar puncture results.

39. Thunderclap headaches can be caused by a number of different conditions including: Subarachnoid hemorrhage Cerebral venous thrombosis Cervical artery dissection Ischemic stroke Meningitis Primary thunderclap headache Complicated sinusitis

40. Subarachnoid hemorrhage Most common cause of secondary thunderclap headache and should be the focus of the initial investigations 25% of patients presenting with thunderclap headache have SAH Etiology of SAH: - Ruptured aneurysm 85% - Non aneurysmal perimesencephalic bleed 10% - Other causes 5%

41. Need to have maximal headache within a few minutes Typically the headache lasts at least a few days 10-43% of patients with aneurysmal SAH have a history of a sentinel headache days to weeks before. CT head: Sensitivity with new scanners nears 100% within the first 12 hours. Sensitivity falls to 50% by 1 week.

43. Sinus Headaches Sinus headaches are headaches that may accompany sinusitis, a condition in which the membranes lining the sinuses become swollen and inflamed. patient may feel pressure around his eyes, and forehead. There are numerous factors that may predispose to sinusitis and sinus headaches. If a patient suffers from frequent colds and upper respiratory infections, he may find that your sinuses are easily and often inflamed. Some structural problems such as a deviated septum in the nose can put you at a higher risk of sinus headaches. Asthmatics may find that they experience frequent sinus headaches due to a greater sensitivity to allergens. So this headache is treated by mostly antibacterial and decongestants drugs.

44. Consult doctor if: symptoms last longer than 10 days have a severe headache, and over-the-counter pain medicine doesn't help have a fever greater than (38 C).

45. Arteriitis temporalis  is an inflammatory disease of blood vessels (most commonly large and medium arteries of the head). It is a form of vasculitis. The terms "giant cell arteritis" and "temporal arteritis" are sometimes used interchangeably, because of the frequent involvement of thetemporal artery. However, it can involve other large vessels. It is more common in females than males by a ratio of 3:1 with age>50y. Corticosteroids, typically high-dose prednisone (40–60 mg ), must be started as soon as the diagnosis is suspected.

46. Patients present with: 1- fever 2-headache[4] 3 tenderness and sensitivity on the scalp 4- jaw claudication (pain in jaw when chewing) 5- tongue claudication (pain in tongue when chewing). 6- reduced visual acuity (blurred vision) 7- acute visual loss (sudden blindness) 8- diplopia. 9- acute tinnitus (ringing in the ears)

47. To summerize

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