headache

1. headache • Headache is one of the commonest neurological complain reported at neurology clinic

2. path physiology Intracranial pain sensitive structures include: the arteries of the circules of willis &the first few centimeters of their median sized branches Meningeal arteries Large veins &dural venous sinuses Extra cranial sensitive structures: external carotid arteires, scalp ,neck muscle ,skin & cutaneous nerves, cervical nerve &nerve roots, mucosa of the sinus &teeth ..

3. Case history • 25 y old f with h/o : ER h/o sever headache ,diffuse ,dull in nature ,not relived by analgesia,aggrevated by cough ,sneezing. • Assosiated with vomiting • No other neurological symptoms. • She gave h/o of chronic infrequent headache ,which tension type and less sever, relieved by analgesia • She is single • Recently She was following with dermatology doctor and he gave her tablets for facial peeling

4. O/E • Neurological exam : • HF:N • Speech :normal • Cranial nerves: fundoscopic exam:papilledema • Motor, sensory, coordination :normal

5. ?

6. Is this headache serious?

7. headache • Primary (benign)secondary • e.g(Migraine,tension,cluster) • brain systemic referred • HPT ear,teeth • anemia eye,sinus serious meningesparenchyma vacsular CSF

8. Secondary causes (serious) • Structural causes • Meninges: meningitis • parenchyma : encephalitis ,abscess, tumor • Vascular: hemorrhage, venous thrombosis, giant cell arterities • Csf: increase CSF pressure (hydrocephalus ,pseudotumor cerebri) ,decrease CSF pressure…leak

9. Careful history and examination should be done to differentiate between benign and serious headache

10. history

11. Age • Migraine headache: child hood or early adulthood • Giant cell arteritis: >50 y • New onset headache in elderly should be always a concern

12. Onset • Headache of many years duration &with little changes is almost always of benign origin • New onset headache in old age or increasingly sever headache ….seriousheadache.. • Hyperacute : SAH

13. periodicity: • episodic headache is benign • Migraine ,Cluster headache • a daily constant headache ..tension type

14. duration • Migraine: 4-72 h • Cluster:1/2-2h • Tension headache :build up over hours lasts days to years

15. Location • unilateral headache:migraine,cluster,temporal arterities . • Tension headache : generalized ,frontal or posterior cervical region • Carotid dissection commonly present with neck,face,and head pain usually ipsilateral to the dissection • Local pain :superfacial structures

16. Nature • Nature: • throbbing: vascular • Tension :fullness, tightness, pressure like

17. aura,& associated symptoms • migraine: aura; focal cerebral symptoms associated with lasts from 20-30 min, precedes the headache • Sensory, motor,autonomic,.. • Cluster headache: ptosis,lacrimation, conjuctival , nasal congestion • Headcahe +fever …..infection • Transient visual obscuration, diplopia,tinnitus …increase intracranial pressure

18. aura,& associated symptoms • Jaw clawdication: temporal arteritis • Headache: progressive+ central nervous symptoms is suggestive …structural brain lesion

19. Aggravating & relieving • Aggravating • Cough, straining……intracranial pressure • Activity., stress…..migraine, tension type • Sitting: CSF hypotension • Relieving: • Rest…….migraine,tension

20. Drug history • Oral contraceptive… Cerebral vein thrombosis, migraine • Steroid withdrawal pseudotumor cerebri • Retin A tablets • Warfarin : Hge

21. Postpartum : cerebral venous thrombosis • Recurrent abortion

22. FH • migraine

23. exam • v/s: fever ,BP • General: sinus tenderness • Eye ,throat ,ear exam

24. exam • Normal exam: benign headache • Papilledema: increased intracranial pressure • Focal neurological finding……serious • Complicated migraine….neurological signs • Horner syndrome: cluster headache • Scalp tenderness,pulsless: temporal arteritis

25. Is this headache serious? • Characteristics of headache with serious underlying pathology • History : • Explosive onset and severe at onset • No similar headaches in the past • you have a constant headache, which is gradually getting worse; • Altered mental status • Age over 50 • Immunosuppression • Physical examination : • Neurologic abnormalities • Decreased level of consciousness • Meningismus • Papilledema

26. Work up • If history and exam is suggestive of serious headache • Brain image: CT brain, mri brain • If suspect cerebral vein throbosis..CT venogram ,MRV • if fever or ? SAH …LP

27. Go back to the case

28. Case history • 25 y old f with h/o : ER h/o sever headache ,diffuse ,dull in nature ,not relived by analgesia,aggrevated by cough ,sneezing. • Assosiated with vomiting • No other neurological symptoms. • She gave h/o of chronic infrequent headache ,which tension type and less sever, relieved by analgesia • She is single • Recently She was following with dermatology doctor and he gave her tablets for facial peeling

29. O/E • Neurological exam : • HF:N • Speech :normal • Cranial nerves: fundoscopic exam:papilledema • Motor, sensory, coordination :normal

30. Work up • CT brain : normal • MRI brain:N • MRV: N • LP: increased CSF pressure, protein, glu,cell count were normal

31. Pseudo tumor cerebri • ( Idiopathic Intracranial Hypertension )

32. Home message Careful history and exam including (opthalmoscopic) exam is the key to differentiate benign from serious headache.

33. thanks