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Approach to headaches

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Published on October 14, 2014

Author: subhasish_deb

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Approach to headache
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1. APPROACH TO HEADACHE BY DR. SUBHASISH DEB BURDWAN MEDICAL COL LEGE AND HOS P I TAL (DEPARTMENT OF INTERNAL MEDIC INE) Dr Subhasish Deb 10/14/2014

2. HEADACHE= CEPHALALGIA Definition: “Diffuse pain in various parts of the head, not confined to the distribution of any nerve” (source: Steadman’s Pocket Medical Dictionary) Dr Subhasish Deb 10/14/2014

3. WHAT ACHES? PAIN SENSITIVE STRUCTURES: 1. Scalp 2. Middle meningeal artery 3. Dural sinuses 4. Falx cerebri 5. Proximal segment of large pial arteries Dr Subhasish Deb 10/14/2014

4. WHAT DOESN’T ACHE? Pain insensitive structures: 1. Ventricular ependyma 2. Choroid plexus 3. Pial veins AND Dr Subhasish Deb 10/14/2014

5. WHAT ABOUT BRAIN PARENCHYMA? Most of the brain parenchyma is INSENSITIVE to pain HOWEVER, the region of the dorsal raphe in the MID BRAIN is sensitive to pain. Dr Subhasish Deb 10/14/2014

6. TRANSMISSION OF PAIN Sensory stimuli from head CNS Supratentoral structures in anterior and middle cranial fossa Posterior cranial fossa and infratentorial structures TRIGEMINAL NERVE C1, C2, C3 Cervical spinal n Dr Subhasish Deb 10/14/2014

7. What happens? MECHANISM OF HEADACHES 1. Distention/traction/dilatation of intracranial or extracranial arteries 2. Traction/displacement of large i.c. veins/ their dural envelopes 3. Compression/traction/inflammation of cranial and spinal nerves 4. Spasm/inflammation/trauma to cranial and cerival muscles 5. Meningial irritation and raised icp Dr Subhasish Deb 10/14/2014

8. CLASSIFICATION Primary headache Secondary headache • Symptom based •No organic causes •Etiology based Dr Subhasish Deb 10/14/2014

9. PRIMARY HEADACHES 1. Migraine 2. Tension-type headache 3. Trigeminal autonomic cephalalgias (including cluster headaches) 4. Other primary headache disorders  Cough  Exertional  Headache associated with sexual activity  Hypnic  Primary thunderclap  Hemicranial continua  New daily-persistent headache -ISH Cefalalgia 2013 Dr Subhasish Deb 10/14/2014

10. PRIMARY HEADACHE TYPES MIGRAINE TENSION CLUSTER Pain Description Throbbing, Moderate to severe, Worse with exersion Pressure, Tightness, Waxes and wanes Abrupt onset, deep, continuous, excruciating, explosive. Associated Symptoms Photo/phono phobia, Nausea/vomiting, Aura NONE Tearing, congestion, rhinorrhea, pallor, sweating Dr Subhasish Deb 10/14/2014

11. PRIMARY HEADACHE TYPES MIGRAINE TENSION CLUSTER Location 60-70% Unilateral Bilateral Unilateral Duration 4-72 hrs Variable 0.5 -3 hrs, many per day Patient Appearance Resting in quiet dark room, Young female Remains active or prefers to rest Male, smoker, Remains active, prefers hot showers. Dr Subhasish Deb 10/14/2014

12. Dr Subhasish Deb 10/14/2014

13. Dr Subhasish Deb 10/14/2014

14. MIGRAINE  It is the second most common cause of headaches (m/c is tension type headache)1  Often can be recognized by its activators= TRIGGERS -light, sound, stress, hunger, menstruation, stormy weather, lack or excess of sleep, barometric pressure change, alcohol basis of life style adjustments  A headache diary is often useful in making diagnosis, assessing disability and frequency of treatment for acute attacks 1 Harrison’s Principles of Internal Medicine 18thed Dr Subhasish Deb 10/14/2014

15. Dr Subhasish Deb 10/14/2014

16. Types of Migraine 1. Without Aura (Common migraine) = 80% 2. With Aura (Classic migraine) =20% 3. Migraine varients  Basilar migraine  Retinal migraine  Ophthalmoplegic migraine  Migraine with complicated aura  Migrainous stroke  Migraine aura without migraine (Acephalalgic migraine) Dr Subhasish Deb 10/14/2014

17. Classic Migraine Potential phases of migraine attack 1. Prodrome – occurs hours to days before headache, change in mood, behaviour, appetite, cognition 2. Aura- occurs within 1 hour of headache, most commonly visual or sensory  Visual aura  Most common  Consists of photopsias, bright flashing lights, scintilating scotomas, field cuts and fortification spectra(zig zag lines/ Teichopsia) Dr Subhasish Deb 10/14/2014

18.  Sensory aura  Numbness and paresthesiae in a limb Motor weakness and aphasia are less common 3. Headache 4. Recovery Dr Subhasish Deb 10/14/2014

19. Dr Subhasish Deb 10/14/2014

20. Dr Subhasish Deb 10/14/2014

21. Common Migraine Symptoms similar to classical migraine but without aura Precipitating factors:  Foods rich in tyramine ( cheese, redwine)  Foods containing monosodium glutamate (Chinese and Mexican food)  Foods containing nitrates ( salami, smoked meat)  Caffeinated beverages (soft drinks, tea and coffee) Dr Subhasish Deb 10/14/2014

22. MIGRAINE VARIENTS  Basilar migraine  a/k bickerstaff syndrome, brainstem migraine, basilar artery migraine, vertebrobasilar migraine  This disorder is now called Migraine with Brain stem Aura(MBA)  rare form of migraine with aura wherein the primary signs and symptoms seem to originate from the brainstem, without evidence of weakness. (d/d- FHM)  Originally described by Bickerstaff in 1961 as a distinct clinical entity  Brain stem aura: Dysarthria, vertigo, hyperacusis, diplopia, visual symptoms in both temopral and nasal fields, decreased level of conciousness. Dr Subhasish Deb 10/14/2014

23.  Retinal migraine:  a/k ocular migraine  Characterized by retinal or optic nerve ischemia  Other migraines affect eyesight in both eyes but here typically single eye is affected.  Mono ocular blindness, disc edema occurs and vision recovers only partially after several months Dr Subhasish Deb 10/14/2014

24.  Ophthalmoplegic migraine:  Characterized by recurrent unilateral headaches associated with weakness of extra ocular muscles.  Transient 3rd nerve palsy with ptosis with/without involvement of the pupil is the usual picture.  6th nerve is early effected common in children  Paresis may persist even after headache for days to weeks  Occasionally opthalmoperesis may remain permanent Dr Subhasish Deb 10/14/2014

25.  Complicated migraine  a/k migranous infarction  Here, the temporary neurologic symptom of migraine headache may remain permanent.  Ex: a homonymous visual field defect  In children with mitochondrial disease MELAS (Mitochondrial myopathy, Encephalopathy, Lactic Acidosis and Stroke like symptoms)  And in adults with very rare vasculopathy : CADASIL (Cerebral Autosomal Dominant Arteriopathy with Subcortical infarcts and Leukoencephalopathy Dr Subhasish Deb 10/14/2014

26. Tension type headache  Describes a chronic head-pain syndrome characterized by bilateral, tight, band like discomfort  Pain builds up slowly, persists more or less continuously for days  When present > 15days/month- chronic TTH  Featureless Dr Subhasish Deb 10/14/2014

27. <180/year (<15/month) Dr Subhasish Deb 10/14/2014

28. Trigeminal Autonomic Cephalalgias  Characterized by relatively short lasting attacks of head pains associated with autonomic symptoms-lacrimation, conjunctival injection or nasal congestion  Includes: 1. Cluster headache 2. Paroxysmal hemicrania 3. SUNCT/SUNA Dr Subhasish Deb 10/14/2014

29. Cluster headache  A rare form of headache with a population freq 0.1%  Pain is:  Deep, usually retroorbital  Excruciating in intensity  Non fluctuating  Explosive in quality  CORE feature = PERIODICITY At least one of the daily attacks of pain recurs in the same hour each day for the duration of cluster bout Dr Subhasish Deb 10/14/2014

30.  Typically pts has daily bouts of 1-2 attacks of short duration, unilateral pain for 8-10 weeks a year Followed by pain free interval that lasts less than a year Associated with ipsilateral symptoms of cranial parasympathetic autonomic activation Dr Subhasish Deb 10/14/2014

31. Dr Subhasish Deb 10/14/2014

32. Paroxsymal Hemicrania  Frequent unilateral, sever short lasting episodes of headache  Like cluster, pain tends to be retroorbital, autonomic symptoms  A characteristic feature is its EXCELLENT response to INDOMETHACIN. (cluster headaches respond to 100% O2 therapy)  In contrast to cluster headaches, here the male : female ratio is 1:1 Dr Subhasish Deb 10/14/2014

33. SUNCT/SUNA  Short lasting Unilateral Neuralgiform headache attacks with Conjunctival injection and Tearing  Diagnosis requires:  At least 20 attacks, lasting 5-240sec  Ipsilateral conjunctival injection and lacrimation should be present  Characteristics are:  Lack of response to INDOMETHACIN  A lack of refractory period to triggering between attacks  Presence of cutaneous triggers of attacks  d/d- trigeminal neuralgia Dr Subhasish Deb 10/14/2014

34. SECONDARY HEADACHE TYPES Dr Subhasish Deb 10/14/2014

35. CLINICAL APPROACH TO THE PATIENT History, history, history (Headache diary) Site Onset Character Radiation Associated symptoms Timing Exacerbating and relieving factors Severity Sate of health between attacks Dr Subhasish Deb 10/14/2014

36. HISTORY SITE Extra Cranial Intra Cranial vascular Giant cell arteritis – precise location PNS. Ocular, Dental, Uppercervical verebrae Less sharply localized but still regionally distributed Anterior and mid cranial fossa Fronto-temporal pain Posterior cranial fossa Occipitonuchal pain Dr Subhasish Deb 10/14/2014

37. ONSET hrs-days Ruptured aneurysm Migraine Cluster Headache Thunderclap headache hrs 45mins taper 3-5 mins Relieved by sleep Brain tumours / raised ICP: headaches that disturb sleep/ early morning headaches Dr Subhasish Deb 10/14/2014

38. ONSET  Early morning headache on waking up and again at the end of day is dues to Maxillary sinusitis (diurnal variation)  Office headache: due to Frontal sinusitis [patient wakes up mostly without pain due to overnight drainage, develops pain after a few hours that lasts throughout the day]  Vacuum headache: the headache on waking up that may occur in Frontal sinusitis due to over night drainage Dr Subhasish Deb 10/14/2014

39. CHARACTER  Dull aching pain: sinusitis related  Tension type: tight ‘band like’ pain  Migraine: throbbing with tight muscles around head, neck and shoulder girdle. Aslo w/w.o aura. Dr Subhasish Deb 10/14/2014

40. INTENSITY  Most important aspect of pain from patients point of view.  But it rarely has any diagnostic importance! Can often be misleading since even a brain tumour need NOT present with severe/distinctive pain. Dr Subhasish Deb 10/14/2014

41. TEMPORAL PROFILE  Chronic daily headache without migranous or autonomic features- tension type  Migrane- peakes within 1-2 hrs of onset and lasts typically 4-72 hrs  Cluster headache- peaks at onset or within minutes, lasts for 15-180 mins  Chronic paroxysmal hemicrania- similar to cluster but last 2-30 mins with several episodes in a day Dr Subhasish Deb 10/14/2014

42. TIME OF DAY  Cluster- Almost have a clock like periodicity and awakes the patient from sleep  Hypnic headaches- also awaken pts from sleep but are more diffuse and there are no associated autonomic symptoms  Migraine- any time of the day  Chronic tension type- present during day and is most severe in the latter part of the day Dr Subhasish Deb 10/14/2014

43. AGGRAVATING FACTORS  Worsening of headache on coughing or physical jolt indicated an intra cranial component  Worsening in upright position suggests intracranial hypotension  Worsening on routine physical activity, light, sound – migraine attacks Dr Subhasish Deb 10/14/2014

44. PHYSICAL EXAMINATION  Vital sign along with body temperature  General appearance- whether restless or calm in a dark room (cluster vs migraine)  Palpation of ipsilateral temporal artery for tenderness, tm joint for crepitance while pt closes or opens jaw  Area over infected sinus may be tender  Pseudotumor cerebri- often seen in young obese females  Eye and periorbital area- lacrimation, conjuctival injection, flushing (TACs vs glaucoma) Dr Subhasish Deb 10/14/2014

45.  Pupillary size and light responses, extra ocular muscles, visual acuity  Fundus- papilledema and retinal pulsations  Neck for rigidity, kernig, brudzinski signs  Cervical spine palpated for tenderness Dr Subhasish Deb 10/14/2014

46. INVESTIGATIONS  Most patients can be diagnosed without testing, however some serious disorders may require urgent testing  CT and MRI should be done in pts with the following findings:  Thunderclap headache  Altered mental status  Meningismus  Palliledema  Signs of sepsis  Acute focal neurological deficit  Sever hypertenstion (SBP>220, DBP>120) -API Medicine Update 2013 Chap 113 Dr Subhasish Deb 10/14/2014

47.  If meningitis, SAH, or encephalitis is being considered- CSF study if not contraindicated  For acute angle closure glaucoma: tonometry, slit lamp shows shallow ant. Chnaber, h/0- nausea, visual hallows.  ESR- in patients with visual symptoms, jaw or tongue claudications- giant cell arteritis Dr Subhasish Deb 10/14/2014

48. RED FLAGS Dr Subhasish Deb 10/14/2014

49. Sinusitis vs Migraine SUMMIT STUDY: Prospective multi center observational study of 2,991 patients with self diagnosed or physician diagnosed sinus headache. Using the HIS migraine criteria, 80% of them had migraine -Schreiber CP, et al. Archives of Internal Medicine Dr Subhasish Deb 10/14/2014

50. SUMMARY  Headache is one symptom that may be a manifestation of a simple, benign problem like a tension headache or one of the life threatening fatal diseases like a Berry aneurysm  Acute and new onset headaches have a more serious prognosis than other types of onsets  So careful evaluation of the etiology is very essential. Dr Subhasish Deb 10/14/2014

51. THANK YOU Dr Subhasish Deb 10/14/2014

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