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HEADACHE, TYPES, ETIOLOGY, HISTORY TAKING AND MANAGEMENT

- Pabita Dhungel

B.Optometry

Institute of Medicine

References

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Davidsons principles and practice of medicine 19th edition

Neuro ophthalmology section 5 AAO series 2004-2005

Oxford hand book of ophthalmology 2006The wills eye manualwww.wikipedia.com

Presentation layout

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IntroductionHistoryEpidemiologyTypes of headacheCauses PathophysiologyDiagnostic approachHistory takingManagement

Introduction

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A headache or cephalagia is pain anywhere in the region of head or neck

Can be a symptom of a number of different conditions of head and neck

Ref: headache at Dorland’s Medical Dictionary

Introduction

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Headache in itself is not a disease but merely a symptom of a disease.

A symptom which may accompany many different types of conditions.

May be a manifestation of a syndrome such as migraine.

May be sight threatening or life threatening

Contd…

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The frequency and severity of headache attacks determine the extent to which the headache problem will incapacitate the patient.

That’s why headache represents an item of extreme economic and social importance

Headache is a frequent reason given for absenteeism at work .

It is also a factor which will universally tend to lower the individual’s efficiency while s/he is working.

Contd…

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Since head is the most frequent site of pain and discomfort almost everybody has a headache at one time or other.

It is a warning signal to say something wrong within the organism or enviroment.

History

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Migraine , neuralgia ,shooting head pain have been documented in medical literature of 1550 BC

Hippocrates in 460 BC described visual symptoms associated with MIGRAINE

Aretacus in AD 80 described that the pain of migraine is unilateral

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The first recorded classification system that resembles the modern ones published by Thomas Willis, in De Cephalagia in 1672

In 1787 Christian Baur divided headaches into idiopathic (primary headache) and symptomatic (secondary ones) and defined 84 catagories

Contd…

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An 1819 caricature by George Cruikshank depicting a headache

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Contd…

Epidemiology

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During a given year,90% of people suffer from headaches

Of the ones seen in the ER , about 1% have a serious underlying problem

Primary headache accounts for more than 90% of all headache complaints and of these episodic tension headache is the most common

Ref: headache pathophysiology retrieved june 21-2010

Contd…

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Annual cost through lost work and impaired effectiveness may be £1.5 billion

Migraine appears to be exclusively experienced by 12% - 18% of the population

Cluster headache are thought to affect less than 0.5% of the population

Cluster headache are more likely to occur in men than women, tends to affect 5 to 8 times more men

Migraine headache more common in female(3:1)

Ref: British research of headache 2007

Classification

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Thoroughly classified by International Headache Society’s International Classification of Headache Disorders (ICHD) which published its second edition in 2004

This classification is accepted by WHO

International classification of headache disorders(ICHD)

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Classification uses numeric codesThe top, one-digit diagnostic level includes 13 groupsFirst four group classified as primary headaches,

group 5-12 as secondary headacheCranial neuralgia, central and primary facial pain

and other headaches for the last two groupsICHD-2 classification defines migraine, tension-

types headaches, cluster headache and other trigeminal autonomic cephalalgias as the main type of primary headache

Contd…

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Secondary headache are classified based on their etiology not their symptoms

ICHD-2 includes secondary headaches due to head and neck trauma such whiplash injury, intracranial hematoma , post craniotomy and other head and neck injury

Headache caused by ischemic stroke and transient ischemic attack, non traumatic intracranial hemorrhage, vascular malformation or arteritis are also secondary headache

Contd…

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Headache caused by epileptic seizure, HIV/AIDS, intracranial infections and systemic infections are also secondary headache

Headache caused by dialysis, HTN , hypothyroidism, injury to jaws ,teeth or temporomandibular joints, fasting and even psychotic disorders are also classified as secondary headache

New classification

In 2007 the International Headache Society agreed upon an updated classification system for headache.

the new classification system will allow health care practitioners come to a specific diagnosis as to the type of headache and to provide better and more effective treatment.

1. primary headaches

2.secondary headaches

3. cranial neuralgias, facial pain, and other headaches

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What are primary headaches?

Primary headaches include migraine, tension, and cluster headaches, as well as a variety of other less common types of headache.

Tension headaches are the most common type of primary headache. Up to 90% of adults have had or will have tension headaches. Tension headaches occur more commonly among women than men.

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Contd…

Migraine headaches are the second most common type of primary headache. An estimated 28 million people in the United States (about 12% of the population) will experience a migraine headache. Migraine headaches affect children as well as adults.

Before puberty, boys and girls are affected equally by migraine headaches, but after puberty, more women than men are affected.

It is estimated that 6% of men and up to 18% of women will experience a migraine headache in their lifetime.

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Contd…

Cluster headaches are a rare type of primary headache affecting 0.1% of the population (1 in a 1,000 people). It more commonly affects men in their late 20s though women and children can also suffer these types of headache.

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What are secondary headaches?

Secondary headaches are those that are due to an underlying structural problem in the head or neck. There are numerous causes of this type of headache ranging from bleeding in the brain, tumor, or meningitis and encephalitis.

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Pathophysiology

Different for various types Headache of intracranial origin

Brain itself is not sensitive to any nociceptive stimuliVenous sinuses , major arteries and large veins , spinal

nerves, head and neck muscles and meninges at base of skull and sensory cranial nerves---- pain sensitive

Any sort of traction, distortion , irritation or inflammation of these pain sensitive structure----- Headache

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Ocular headacheMuscle contraction Glaucoma is due to rise in IOP and involvement of

posterior cilliary Artery Sinus headacheCommon site – frontal and maxillary regions

i) congestion of mucosa ii) ducts and ostial blocks

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Nerve pathway for pain

Trigeminal nerve carries pain sensation from

-anterior 2/3 of head

-upper surface of tentorium

- supratentorial surface

Pain from these structure felt in the distribution of V nerve( ant. Part of head)

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Contd…

Pain from infratentorial region , post.fossa , and post. One third of head (upper 3 cervical nerves)

posterior part of head and neck

Overlap between trigeminal and upper 3 cervical nerves occurs –referred pain from anterior structure to posterior and vice

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Causes of headache

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A) NON OCULAR

B) OCULAR

Non Ocular Causes Of Headache

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1) Tension-type headache 2) Vascular headache

A) Migraine headache Migraine with aura (classic migraine) Migraine without aura (common migraine) Complicated migraine

Hemiplegic migraine Ophthalmoplegic migraine Basilar artery migraine

B) Cluster headache C) Systemic infection D) Hypoxia E) Systemic hypertension

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3) Head trauma 4) Headache due to disorders of head and neck

structures a) Head and neck disorders b) Ear and sinus disorders c) Mouth and jaw disorders5) Intracranial infections a) Meningitis b) Encephalitis c) Brain abscess

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6)Traction headache a) Brain tumor b) Intracranial hemorrhage c) Disorders of cerebrospinal fluid pressure7)Psychogenic

Ocular causes of Headache

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Three categories

a) headache due to refractory error and eye muscle weakness

b) headache due to secondary diseases of eye

c) those due to systemic disorders having prominent ocular symptom

A) Refractory error and muscle weakness

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Mainly in afternoon or evening at the end of workHypermetropia and astigmatismLow grade refractory error is main causeStarts as heaviness in eye and continuous

use of eye leads to headacheOcular muscle imbalance as latent squint and

convergence insufficiency cause headacheAccommodative insufficiency also causes headacheLack of fusional capacity also causes headache

B) Secondary to eye diseases

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Acute angle closure glaucomaAcute iritisKeratitisOcular ischemic syndrome

C) Systemic disorders with visual symptoms

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Raised intra cranial pressureMigraine Temporal arteritisPsychogenic

Headache as dangerous sign

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Medication overuse headache may occur in those using excessive painkillers for headache , paradoxically causing worsening headaches

Life threatening headache are known as “red flag” symptoms like thunderclap headache(develops within minutes), inability to move a limb or abnormalities on neurological examination, mental confusion, headache that worsens with change in posture, headache worsened by exertion or Valsalva manoeuvre (coughing, straining)

Contd..

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Headache associated with visual loss or jaw claudication (jaw pain on chewing that resolves afterwards), neck stiffness, fever and headaches in people with HIV, cancer or risk factors for thrombosis

Thunderclap headache may be the only symptom of subarachnoid hemorrhage from brain aneurysm

Headache in fever may be due to meningitis and confusion may be indicative of encephalitis

Contd…

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Headache worsening with posture may be indicative of brain tumors, idiopathic intercranial hypertension and cerebral venous thrombosis

Headache associated with weakness is indicative of stroke

Headache with visual loss and jaw claudication is indicative of giant cell arteritis (GCA)

Headache in glaucoma(AACG) is due to rise in IOP and involvement of posterior ciliary artery

History taking

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A) Location- frontal- sinusitis temporal- temporal arteritis occipital- tension, orthoptic problem unilateral- migraine frontal & parietal- refractive errorB) Intensity mild- tension very severe-raised ICP, papilledema

Contd…

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C) Frequency- once and twice in a month and mild type may not be significant

D) Nature- throbbing- migraine constricting- tensionE) Time of occurrence afternoon and evening- ocular worsening in morning- raised ICP sinusitis

Contd…

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F) Age of onset childhood /teenage-refractory error accommodative convergence fusional insuffiency middle aged ----- hypertension old age ------ GCA intracranial

tumour

Contd…

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G) Relieving factor

- improve with rest or mild NSAID usually mild type

- not responding to pain killer which was previously used to respond may be dangerous

Contd…

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H) Other associated symptoms

according to suspected etiology

e.g. i) ENT problems

ii) dental problems

iii) anxiety or depressive symptom

iv) fever

v) feature of raised ICP (diplopia ,vomiting)

Evaluation of eye in a patient with headache

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Importance i) may harbour a life threatening disease e.g. intra

cranial neaoplasmii) ophthalmologist detects it by finding

papilloedema early field defect cranial nerve involvement

iii) early diagnosis may be life saving

Examination

- Detail OCULAR and SYSTEMIC examination

OCULAR EXAMINATION

A) Visual Acuity –decrease vision with headache

i) refractory errors

ii) acute angle closure glaucoma

iii) anterior uveitis

iv) ocular ischemic syndrome

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Contd…

Transient loss of vision (Amaurosis Fugax) i) migraine ii) severe hypertension iii) papilledema iv) GCAB) Ocular motility restricted in Ophthalmoplegic migraineC) Cover test/uncover test – to rule out PHORIA

and TROPIA

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Contd…

Conjunctiva –congestion( to R/O glaucoma, uveitis

Cornea - edemaAnterior chamber- depth, cells and flaresPupil - RAPD ( compressive neuropathy)

dilated ( cerebral aneurysm)

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Intraocular pressure

Fundus examination - look for the signs of

i) papilledema

ii) glaucoma

iii) ocular ischemic syndrome

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Contd…

Refraction – both with and without cycloplegic

Orthoptic - for evaluation of convergence,accommodative and fusional insufficiency and phorias

Visual field Gonioscopy Detail neurological, ENT, dental, and

psychiatric evaluation will be needed according to associated symptoms

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Investigations

Should be done according to suspected cause and associated symptoms

i) x ray PNS - to R/O sinusitis

ii) ESR /temporal artery biopsy

iii) CT or MRI - to R/O intra cranial pathology

iv) Carotid flow study - ocular ischemia

v) Lumbar puncture - meningitis

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49Thank you!!!