overview headache

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Headache overview Suroto Dept of Neurology, Fac of Medicine Sebelas Maret University [email protected]

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Overview Headache

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Headache overview

SurotoDept of Neurology, Fac of Medicine

Sebelas Maret University

[email protected]

Of all the painful states, Headache is the most frequent reason for seeking medical help.

95% of young women and 91% of young men experienced headache during a 12-month period;

18% of these women and 15% of these men consulted a physician because of their headache.

Headache is usually a benign symptom but occasionally it is the manifestation of a serious illness.

INTRODUCTION

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Defferentiating headache and vertigo

Headache or Cephalalgia: A pain in the head with the pain being above the eyes or the ears, behind the head (occipital), or in the back of the upper neck.

The word “cephalal” : head and “algesia”: ache

Vertigo: is a feeling that you are dizzily turning around or that things are dizzily turning about you.

The word "vertigo" comes from the Latin "vertere", to turn + the suffix "-igo", a condition = a condition of turning about).4/18/2014 3

Headache can occur as a result of:

1. Distension, traction or dilatation of intra-cranial or extra-cranial arteries,

E.g. - After taking nitrates. -After eating monosodium glutamate. - Extreme rise of BP. - After ingestion of alcohol.

2. Traction or displacement of large intracranial veins or their dural envelope.

3. Compression, traction or inflammation cranial or spinal nerves.

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Contd..

4. Spasm, inflammation or trauma to cranial & cervical muscles & apophyseal joints in the upper part of spine.

5. Meningeal irritation & raised ICP.

6. Headache of ocular origin:

eg. sustained contraction of extra ocular muscles, acute glaucoma, and iridocyclitis.

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CLASSIFICATION OF HEADACHE

Primary headaches OR Idiopathic headaches

THE HEADACHE IS ITSELF THE DISEASE

NO ORGANIC LESION IN THE BEACKGROUND

TREAT THE HEADACHE!

Secondary headaches OR Symptomatic

headaches

THE HEADACHE IS ON LY A SYMPTOM OF AN OTHER UNDERLYING DISEASE

TREAT THE UNDERLYING DISEASE!

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Primary, Idiopathic Headache

1.Tension type headache

2. Migraine

3. Cluster headache

4. Miscellaneous primary headache:

Idiopathic stabbing headache.

Cold stimulus headache .

Headache associated with sexual activity .

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Secondary, Symptomatic Headache

5.Headache associated with head and/neck trauma.

6.Headache associated with vascular disorder.

7.Headache associated with non vascular intracranial disorder.

8.Headache associated with substances or its withdrawal

9.Headache associated with infection.

10. Headache associated with homeostasis disorder.

11.Headache or facial pain associated with disorders of cranial or facial structures.

12.Headache attributed to psychiatric disorder

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HISTORY AND EXAMINATIONS SHOULD CLARIFY:

THE PATIENT HAS PRIMARY OR SECONDARY

HEADACHE

IS THERE ANY URGENCY

IN CASE OF PRIMARY HEADACHE ONLY THE

HEADACHE ATTACKS SHOULD BE TREATED

(„ATTACK THERAPY”), OR PROPHYLACTIC THERAPY

IS ALSO NECESSARY („PREVENTIVE THERAPY,

INTERVAL THERAPY”)

DIAGNOSTIC APPROACH OF HEADACHE

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History Taking:

1.Age, sex: Migraine headache – more frequent in teenagers & young adults, higher occurrence in female. Cluster headache – almost exclusively in males.Cranial arteritis – more frequently in late middle age & in elderly.

2.Quality of pain: Tension headache – pressing, squeezing, tight or heavy. Migraine headache – throbbing or pounding. Headache due to intracranial lesion – relatively mild. Acute SAH- pain tends to be explosive & intense.

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History Taking: Contd

3. Location of headache:As a general rule localized headache is of greater significance than diffuse

headache.

Tension headache – typically generalized, band like or bioccipital.

Migraine with aura – often unilateral & frequently more prominent

interiorly.

Migraine without aura – frequently bilateral.

Cluster headache – invariably limited to the same side of the head in any

given attacks & usually periorbital.

Sinusitis – fontal/ethmoidal, head position

Cranial arteritis – manifested by localized temporal headache.

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History Taking: Contd

4. Associated symptoms: Tension headache – often associated with other psycho-physiologic disturbances.Cluster headache – typically associated with ipsilateral

lacrimation, conjuctival injection, rhinorrhoea, & facial flushing.

Intracranial mass lesion – associated symptoms are more prominent than headache. Some intra-cerebral lesion may exhibit seizure or vomiting.Cranial arteritis – systemic symptoms as fever, anorexia &

rheumatic symptoms.

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History Taking: Contd

5. Precipitating & aggravating factors:

Tension headache & vascular headache – induced or

aggravated by emotional factors.

Intraventricular & posterior fossa tumour – may be

accentuated by change in the head position, coughing &

Valsalva maneuver.

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History Taking: Contd

6. Frequency, duration & diurnal variation:

Tension headache – long duration -- often persist & may worsen as the day progress.

Migraine headache – the frequency is variable & unpredictable. Although usual variation is from 4 - 72 hrs, they may persist for days.

Cluster headache – occur repetitively over a period of weeks or months. Often there are 1 or 2 attacks daily. The headache typically nocturnal & of brief duration (30 min to a few hours).

Headache due to meningeal cause – acute in onset.

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PHYSICAL EXAMINATION:

1. General physical examination:

Flushed face, lacrimation, and unilateral rhinorrhoea –

cluster headache.

Systemic sign (fever, weight loss, anaemia) – infectious

disease, specific infection of CNS, metastatic disease of brain

&/or meninges.

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PHYSICAL EXAMINATION:

2. Neurological examination: No neurological abnormality – tension headache.

Evidence of cerebral ischaemia – small percentage of

migraine (permanent residual damage).

Horner’s syndrome – sometimes during migraine headache

(rarely permanent).

Localizing sign – expanding IC-SOL.

Papilledema - ICP due to IC-SOL.

Bruits over the eyes/cranium – vascular malformation.

Sign of meningeal irritation – lesion affecting the meninges.4/18/2014 16

Investigations

Blood Examination. Skull & Cervical Spine Imaging. CT Scan of the head. MRI & MRA of the brain. Eye & ENT evaluation. Cardiologic & renal evaluation.

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When to scan a patient with headache

First or worst headache, particularly if of sudden onset.

Headache of increasing frequency or severity.

Increased frequency of vomiting and headache.

Headache triggered by coughing, straining or postural

changes.

Persistent physical symptoms or signs after attack.

Meningism, confusion, impairment of consciousness or

seizures.

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Tx of Primary Headache

Pharmacologic Treatment

NonPharmacologic Treatment

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Acute Medical Treatment of Migraine Headaches

Ergot Preparations oral, sublingual and rectal formulations most effective if taken early in an attack may need adjunctive antiemetic potent vasoconstrictors contraindicated in patients with PVD, CAD,

thrombophlebitis, marked HTN, pregnant or breast-feeding women or very elderly patients

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Triptans

Contraindications: ischemic heart disease (angina, hx of MI,

documented silent ischemia or Prinzmetal’s angina),

uncontrolled HTN concomitant use of ergotamine preparations pregnancy

decreased dose of triptans recommended if a MAO inhibitor is being taken

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Prophylactic Treatment of Migraine Headaches

Beta Blockers: propanolol, atenolol

Calcium Channel Blockers: diltiazem

Antidepressants: amitryptiline, fluoxetine

Serotonin Antagonist: methysergide

Anticonvulsants: valproic acid, topiramat

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Treatment of Cluster Headache

Acute treatment: 100% Oxygen via face mask at 8liters/min

given in a seated position SL ergotamine at onset of HA and repeated

once if needed Triptans shown effective in two RCTs Intranasal administration of a local

anesthetic (4% lidocaine) may be helpful

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Treatment of Cluster Headache

Preventive Treatment Verapamil 80 mg qid Lithium 300 - 900 mg per day Prednisone 40 mg per day in divided

doses, tapered over 3 weeks Ergotamine 2 mg 2 hrs before bedtime to

prevent nocturnal attacks Divalproex sodium 600 - 2000 mg per day

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Red flag for secondary headache - Silberstein SD et al

Flag Descriptions/exampleSystemic symptoms or secondary risk factors

Fever,W-loss,or known cancer,HIV, immunosupression or thrombotic risks

Neurological symptoms or signs Confusion,impaired alertness/drowsy, persistent focal signs >1h

Onset First and worst headache,sudden abrupt from sleep, or progressively worsening

Older New onset at age and progressive (Giant cell arteritis)

Previous headache history Significant change in features, freq. or severity

Triggered headache By valsalva, exertion,

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HEADACHE OF SOME SERIOUS ILLNESS:

Meningitis:Acute severe headache – rapid evolution, minutes to hours.Site - generalized or bi-occipital or bi-frontal.Associated with fever, photophobia, nausea and vomiting.Neck stiff on forward bending, Kernig and Brudzinski signs. LP- diagnostic.

SAH: Acute severe headache – rapid evolution, minutes to hours. Site – generalized. Not associated with fever. Neck stiffness – on forward bending. LP – diagnostic.

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Brain tumor:

Site – unilateral or generalized headache.

Worse in the early morning & improves during day.

Worsen with exertion, change in position, bending, lifting

or coughing.

Associated with nausea, vomiting.

Impaired mentation, focal sign, seizures, and

papilloedema – present.

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Temporal arteritis/giant cell arteritis:

Age – older patients (>50 yrs). Site – uni/bilateral & is located temporally in 50% patients.· Character – dull & boring with superimposed lancinating Appears gradually over a few hours before peak intensity Worse at night & is often aggravated by exposure to cold.Associated with polymyalgia rheumatica, jaw claudication, fever & weight loss. · Scalp tenderness . Temporal artery & less commonly

occipital artery may be tender. ESR - . Temporal artery biopsy – diagnostic. Treatment – prednisolone 80 mg daily for 4-6 wks.

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Summary Headache is usually a benign symptom but occasionally

it is the manifestation of a serious illness. Primary headache: tension headache, migraine, cluster

headache Secondary headache: the headache is only a symptom

of an other underlying disease Accurate history taking is fundamental in making

diagnosis Need for further investigation: determined by red flag

symptoms Acute Tx vs Preventive Tx

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