4 headache.pdf

8/18/2019 4 Headache.pdf

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HEADACHES

Ma. Carmencita B. Gonzalez, M.D.

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Headaches•

At the end of the unit, the student will be able to:• COGNITIVE

– Describe headache

– Classify the different types of headache and give itssigns and symptoms

– Enumerate the different pain sensitive and insensitivestructures of the brain

– Explain the different mechanisms that cause headache

• AFFECTIVE –

Realize that headaches could be a part of the signs andsymptoms of an underlying brain pathology

– Realize that HA could be caused by other organ systemsaside from the nervous system

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Headaches

•Types of headache – Primary headache

• Migraine headache

• Tension headache

• Cluster headache

– Secondary headache

• Different structures of head that may and

may not cause pain – Pain sensitive structures

– Pain insensitive structures

• Mechanisms causing headache3


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Pain Sensitive Structures

• Scalp and Aponeurosis

• Middle Meningeal Artery

• Dural Sinuses

• Falx Cerebri

• Proximal segments of the large pial

arteries

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Mechanisms of Pain Production

• Distention, traction or dilatation ofintracranial and extracranial arteries

• Traction or displacement of largeintracranial veins or their dural envelope

• Compression, traction, or inflammation of

cranial and spinal nerves

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Mechanisms of Pain Production

• Spasm, inflammation and trauma to

cranial and cervical muscles

• Meningeal irritation and raised

intracranial pressure

• Perturbation of intracerebralserotonergic projections

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Pain Insensitive Structures

• Ventricular ependyma

• Choroid plexus

• Pial veins

•

Much of the brain parenchyma

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Nerves Subserving Pain

• Trigeminal nerve - supratentorial

structures of the anterior and middle

fossa

• First three cervical nerves - posterior fossa

and infradural structures

• Glossopharyngeal and Vagus nerves -

posterior fossa, refers pain to the ear and

throat8


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Evaluation of Headaches

• Headache attacks – How it begins

• Precipitating event, illness, injury

• Headache attack descriptions – Frequency and patterns

•

Any significant changes – Location

– Time to peak intensity

– Duration

– Quality and intensity

– Warning symptoms and aura – Associated symptoms and level of disability

– Triggers and aggravating or relieving factors


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International Headache Society

Classification of Primary Headaches

20041. Migraine

a. Migraine without aura

b. Migraine with aura

2. Tension-type Headache

3. Cluster Headache and Other Trigeminal

Autonomic Cephalgias4. Other Primary Headaches

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Classification of Primary Headaches20045. Headache Attributed to Head and/or

Neck Trauma

6. Headache Attributed to Cranial orCervical Vascular Disorder

7. Headache Attributed to Non-vascular

Intracranial Disorder8. Headache Attributed to a Substance orits Withdrawal

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Classification of Primary Headaches2004

9. Headache Attributed to Infection

10. Headache Attributed to Disorder ofHomoeostasis

11. Headache or Facial Pain Attributed to

Disorder of Cranium, Neck, Eyes, Ears,Nose, Sinuses, Teeth, Mouth, or OtherFacial or Cranial Structures

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Classification of Primary Headaches2004

12.Headache Attributed to Psychiatric

Disorder13.Cranial Neuralgias and Central Causes

of Facial Pain

14. Other Headache, Cranial Neuralgia,Central or Primary Facial Pain

a. Trigeminal Neuralgia

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MIGRAINE

1.1 Migraine without Aura

1.2 Migraine with aura

1.3 Childhood Periodic Syndromes that arecommonly Precursors of Migraine

1.4 Retinal Migraine

1.5 Complications of Migraine

1.6 Probable Migraine

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MIGRAINE

• Benign recurring headache with or withoutrecurring neurologic dysfunction

• Pain free interludes

• Provoked by stereotyped stimuli

• More common among females

• With hereditary predisposition

• Onset usually in childhood, adolescent yearsor early adulthood

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Symptoms of Migraine

• Unilateral headache = 62%

• Pulsating quality = 78%

• Moderate or severe intensity = 99%

• With nausea = 82%

• With photophobia & phonophobia = 83%/86%

• Aggravated by physical activity = 96%

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Risk Factors for Migraine

• Family history

• Menstruation, Oral contraceptives,Menopause

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Stress, Fatigue• Bright lights

• Meteorologic changes, high altitude

• Medicines - vasodilators

• Head trauma• Hunger

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Predisposing Factors & Triggers

• Family history

• h/o travel sickness

• h/o cyclical vomiting inchildhood

• Stress

• Menstrual cycle

• Menopausal

• Head & neck trauma

• Strenuous exercise• Meteorologic changes,

high altitude

• Relaxation after stress-”weekend migraine”

• Change of habit-missedmeals /sleep

• Bright lights

• Loud noise

• Smells-perfume /petrol

•Dietary/Food

• Medications


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Migraine without Aura

• Common Migraine; Hemicrania Simplex

• Recurrent headache disorder manifesting

in attacks lasting 4-72 hours.

• Typical characteristics - unilateral,

pulsating, moderate or severe,

aggravation by routine physical activityand association with nausea and/or

photophobia and phonophobia

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Diagnostic Criteria

Migraine without Aura

DIAGNOSTIC CRITERIA:

A. At least five attacks fulfilling criteria B-D

B. Headache attack lasts 4-72 hours (untreated orunsuccessfully treated)

C. Headaches with at least 2 of the following:1. Unilateral location2. Pulsating quality3. Moderate or severe intensity4. Aggravation by or causing avoidance of routine physical

activity (eg. walking or climbing stairs )

D. During headache, at least one of the followingA. Nausea and/or vomitingB. Photophobia and phonophobia

E. Not attributed to another disorder

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Migraine with Aura

•Classic or classical migraine, Ophthalmic,Hemiparaesthetic, Hemiplegic or aphasicmigraine, Migraine accompagnee, Complicatedmigraine

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Recurrent disorder of reversible focalneurological symptoms that develop graduallyover 5-20 minutes and last for less than 60minutes

•

Headache with the features of migraine withoutaura usually follows the aura symptoms

• Less commonly, headache lacks migrainousfeatures or is completely absent

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Diagnostic Criteria

Migraine with Aura

A. At least two attacks fulfilling criterion B

B. Migraine aura fulfilling criteria B and C for oneof the subforms 1.2.1-1.2.6

C. Not attributed to another disorder

1.2.1 Typical aura with migraine headache

1.2.2 Typical aura with non-migraine headache

1.2.3 Typical aura without headache1.2.4 Familial hemiplegic migraine

1.2.5 Sporadic hemiplegic migraine

1.2.6 Basilar-type migraine23


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B. Aura consisting of at least one of the following, but

no motor weakness:

1. Fully reversible visual symptoms including positive features(eg. Flickering lights, spots or lines) and/or negative

symptoms (ie. Loss of vision)

2. Fully reversible sensory symptoms including positive

features (ie, pins and needles) and/or negative features (ie,numbness)

3. Fully reversible dysphasic speech disturbance

C. At least two of the following:

1. Homonymous visual symptoms and/or unilateral sensory

symptoms

2. At least one aura symptom develops gradually over ≥ 5

minutes and/or different aura symptoms occur in

succession over ≥ 5 minutes

3. Each symptom lasts ≥ 5 and ≤ 60 minutes 24


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Basilar Migraine

B. Aura consisting of at least one of the following, but no motor

weakness:1. Dysarthria

2. Vertigo

3. Tinnitus

4. Hypacusia

5. Diplopia6. Visual symptoms simultaneously in both temporal and nasal fields

of both eyes

7. Ataxia

8. Decreased level of consciousness

9. Simultaneously bilateral paraesthesias

C. At least two of the following:1. At least one aura symptom develops gradually over ≥ 5 minutes

and/or different aura symptoms occur in succession over ≥ 5

minutes

2. Each aura symptom lasts ≥ 5 and ≤ 60 minutes

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Pathogenesis of Migraine

• Vascular theory

• Spreading Depression Theory

• Present Concept:

1. Brain stem generation

2. Vasomotor activation

3. Activation of the cells of the trigeminal

nucleus caudalis and release ofvasoactive neuropeptides at the

terminations of the trigeminal nerve on

blood vessels26


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Management of Migraine

• Medications

• Lifestyle modifications

• Regular sleep

• Regular meals

• Moderate amount of exercise

• Drink plenty of water

• Limit caffeine, alcohol and other drugs

• Reduce stress


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Tension-Type Headache

• Tension, Muscle contraction, Psychomyogenic,Stress, Ordinary, Essential, Idiopathic, PsychogenicHeadache

• Most common type of Primary headache; 30-78%

2.1 Infrequent episodic tension-type headache2.2 Frequent episodic tension-type headache

2.3 Chronic tension-type headache

2.4 Probable tension-type headache29


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Tension-Type Headache

• At least two of the following paincharacteristics

- Bilateral location – Pressing/tightening (non-pulsating) quality – Mild to moderate intensity – No aggravation by walking stairs or similarroutine physical activity

• Both of the following – No nausea or vomiting (anorexia may occur) – No more than one of photophobia orphonophobia

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Cluster Headache and Other

Trigeminal Autonomic Cephalalgias

3.1 Cluster headache

3.2 Paroxysmal hemicrania

3.3 Short-lasting Unilateral Neuralgiform

Headache Attacks with Conjunctival

Injection and Tearing (SUNCT)

3.4 Probable Trigeminal Autonomic

Cephalalgia31


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Cluster Headache

• Ciliary neuralgia, Erythro-melalgia of

the head, Erythroprosopalgia of Bing,

Hemicrania angioparalytica, Hemicrania

Neuralgiformis Chronica, Histaminic

Cephalalgia, Horton’s headache, Harris-

Horton’s disease, Migrainous Neuralgia

(of Harris), Petrosal Neuralgia (ofGardner)

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Diagnostic Criteria

Cluster HeadacheA. At least 5 attacks fulfilling criteria B-D

B. Severe or very severe unilateral orbital, supraorbital and/ortemporal pain lasting 15-180 minutes if untreated

C. Headache is accompanied by at least one of the following:

– Ipsilateral conjuctival injection and/or lacrimation

– Ipsilateral nasal congestion and/or rhinorrhea

– Ipsilateral eyelid edema

– Ipsilateral forehead and facial sweating

– Ipsilateral miosis and/or ptosis

– A sense of restlessness or agitation

D. Attack have a frequency from one every other day to eightper day

E. Not attributed to another disorder

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Other Types of Headache

• Cough Headache

• Coital Headache

• Post concussion Headache

• Giant Cell Arteritis

•

Lumbar Puncture Headache• Brain Tumor Headache

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Diseases Which Present

with Headaches

• Head and/or Neck Trauma

• Cranial or Cervical Vascular Disorder

• Non-vascular Intracranial Disorder

•

Substance Use or its Withdrawal• Infections

• Disorder of Homoeostasis

• Disorders of Cranium, Neck, Eyes, Ears, Nose,Sinuses, Teeth, Mouth or other Facial or CranialStructures

• Psychiatric disorders

• Cranial Neuralgias and Central Causes of Facial Pain

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Red Flags of Headaches

• Headaches only felt in one particular area of

the head

• Headache which peaks in an instant

“thunder-clap”

• Sleep deprivation

• Headaches accentuated by eye movement

• Headache accentuated by bending, lifting,

coughing

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Diagnosis of Secondary Headaches

Red flag symptoms which should prompt referral for further investigation

New onset or change in headache in patients over 50…..remember ESR

Thunderclap headache

Focal neurological symptoms e.g. limb weakness/ aura lasting >1 hr

Non-focal neurological symptoms e.g. impaired cognitive functionChange in headache frequency/characteristics

Abnormal neurological examination

Headache that change with posture

Headache wakening patient up

Headache precipitated by physical exertion eg cough,/straining valaslva/

Neck stiffness/feverNew onset headache in patient with cancer

Sleep deprivation

Headaches felt persistently on the same area


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Trigeminal Neuralgia

• Tic doloureux

• Management: Carbamazepine, surgery

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Diagnostic Criteria

Trigeminal NeuralgiaA. Paroxysmal attacks of pain lasting from a fraction

of a second to 2 minutes, affecting one or moredivisions of the trigeminal nerve and fulfillingcriteria B and C

B. Pain has at least one of the followingcharacteristics1. intense, sharp, superficial or stabbing

2. Precipitated from trigger areas or by trigger factors

C. Attacks are stereotyped in the individual patient

D. There is no clinically evident neurological deficitE. Not attributed to another disorder

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