HEADACHE - WordPress.com

HEADACHE - WordPress.com

HEADACHE HEADACHE HEADACHES INCIDENCE/PREVALENCE: 7095% of population experience headache/year 18% women/ 15% men will consult MD

COSTS: $50 billion/yr in missed workdays and medical benefits Headache: A Common Problem One of the commonest symptoms that clinicians evaluate.

General practice 4.4 consultations/100 registered patients annually Neurology 30% of referrals

Population of 100,000 adults each year: 10 brain tumours 220,000 headaches 4,000 GP consultation for headache 200 secondary care consultations Current Presenting Illness When did your headaches first start? Have they changed in character or frequency?

Do you headaches ever alter your ability to work, study, play? How many headaches total /month, disabling headaches/month? Current Presenting Illness What triggers your attacks? How do they start (gradually, suddenly, other)? Recent trauma, medical or dental procedure? Family history of headache?

for chronic H/As also ask about mood, sleep disturbance, hormonal changes For women, relationship to menses, experience with pregnancy Past Medical History Headache History Head trauma HIV Current or past history of

Allergic Rhinitis Recent Lumbar Puncture Cancer Medications Overuse of analgesics frequently cause rebound headaches. HA is listed as a side effect of treatment or withdrawal in more than a 1000 medications.

Steroids, Accutane, Tamoxifen, and Cimetidine are known to cause increased intracranial pressure. Substance Abuse- ETOH, opiates, caffeine Red Flags Headaches begin after age 50 Very sudden onset of Headache Change in frequency or severity Fever, stiff neck, rash, trauma

Focal neurologic symptoms or signs Papilledema Physical Exam General appearance and vital head (including palpation) signs pupil reaction, visual field testing fundiscopic exam ( normal exam

does not mean normal intracranial pressure ears, sinuses, teeth, oropharynx neck and neuro exam SNOOP-T Red flags for secondary headache Flag Systemic symptom or Secondary risk factors

Neurological symptoms or abnormal signs Onset Older Previous headache history Triggered headache Description/example Fever/weight loss or known cancer,

HIV,immunosuppression or thrombotic risk Confusion ,drowsiness or persistent focal signs>1hr First and worst headache , sudden or abrupt from sleep, or progressively worsening. New and progressive >50 Consider TA First headache or

fundamental change in characteristics of h/a By valsalva /exertion or sexual intercourse Classification of headaches Primary Secondary

headaches OR Idiopathic headaches headaches OR Symptomatic headaches THE HEADACHE IS ITSELF THE DISEASE


Headache classification Primary headaches -Migraine -tension type -cluster headache -Others

Headache classification Secondary headaches Trauma

Cranial/ cervical vascular disorder Substance or its withdrawl Infection Homeostasis related Neck , sinuses,eyes,nose, teeth Anxiety/somatisation Primary Headache Disorders Benign,

usually recurrent headaches with no organic cause Rarely have physical findings and account for greater than 90% of all headaches Migraines, tension-type and cluster are most common Secondary Headache Disorders Headaches

with organic etiology Underlying disease may range from mild viral infections to metastatic cancer SECONDARY, SYMPTOMATIC HEADACHES THE HEADACHE IS A SYMPTOM OF AN


Hypertension Sinusitis Glaucoma Eye strain Fever Cervical spondylosis Anaemia Temporal arteriitis Meningitis, encephalitis

Brain tumor, meningeal carcinomatosis Haemorrhagic stroke Secondary headache disorders Headache attributed to ... 5. head and/or neck trauma 6. cranial or cervical vascular disorder 7. non-vascular intracranial disorder 8. a substance or its withdrawal 9. infection 10. disorder of homoeostasis

11. disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cranial structures 12. psychiatric disorder 13. cranial neuralgias and central causes of facial pain Vascular Causes SUBARACHNOID HEMORRAGE an abrupt onset headache that is often severe, but may be

subtle. Patient may have transient LOC or meningeal symptoms. Noncontrast CT will dx 90% of SAH, but LP is required to rule out this treatable condition. Vascular Causes SUBDURAL HEMATOMA Lateralizing features may be subtle or absent. Besides trauma, risk factors include

cerebral atrophy, bleeding diathesis, alcoholism, old age and dialysis. Vascular Causes TEMPORAL ARTERITIS rapidly leads to permanent loss of vision if not treated. Patients >50 years old present with new headache May have temporal artery tenderness, decreased vision, or

abnormal fundiscopic exam, symptoms of jaw claudication, or consititutional symptoms such as weight loss, anemia, elevated LFTS, or polymyalgia rheumatica. Nonvascular Causes INTRACRANIAL TUMORS About one-third of patients with brain tumors present with a primary complaint of

headache. Pain is usually intermittent, dull, bi-frontal, with nausea (50% of the time) Pseudotumor Cerebri Idiopathic intracranial hypertension presents with headache and transient visual symptoms

Young overweight woman with a normal neuro exam except for papilledema LP is diagnostic with CSF pressure >250mm Hg and normal CSF composition Treatment includes weight loss, acetazolamide and furosemide in idiopathic cases Decreased Intracranial Pressure

CSF pressure below 50-90 mm Hg Dull, throbbing headache, worse with sitting or standing Usually after LP, Trauma, Surgery, can happen spontaneously Treatments include fluids, steroids, tetracycline, IV caffeine, or blood patch. Migraine

MIGRAINE - DEFINITION Migraine is a familial disorder characterized by recurrent attacks of headache widely variable in intensity, frequency and duration. Attacks are commonly unilateral and are usually associated with anorexia, nausea and vomiting -World Federation of Neurology

Migraines Epidemiology: 18% of woman, 6% of men. Migraineurs suffer a median of 12 attacks/ year. Onset usually before age 50. Terminology: Migraine with aura, was Classic migraine

Migraine without aura , was Common migraine PHASES OF ACUTE MIGRAINE Prodrome Aura Headache Postdrome AURA

Aura is a warning or signal before onset of headache Symptoms Flashing of lights Zigzag lines Difficulty in focusing Duration : 15-30 min POSTDROME

Following headache, patient complains of Fatigue Depression Severe exhaustion Some patients feel unusually fresh Duration: Few hours or up to 2 days PHASES Attack Initiation

Vulnerability Prodrome Aura Time Headache Postdrome MIGRAINEPATHOPHYSIOLOGY

MIGRAINEPATHOPHYSIOLOGY Migraine is not completely understood yet, but there are some theories to explain migraine. Some of which are VASCULAR THEORY SEROTONIN THEORY CENTRAL NERVOUS SYSTEM THEORY CENTRAL NERVOUS SYSTEM SENSITIVITY THEORY Diagnostic Criteria for Migraine Without Aura

Migraine is defined as episodic attacks of headache lasting 4-72 hours With two of the following symptoms:

Unilateral Pain (60%) Throbbing (70%) pulsating, Aggravation on movement Pain of moderate or severe intensity And one of the following symptoms:

Nausea or Vomiting Photophobia or phonophobia MIGRAINE AURA Usually, the aura precedes the headache, The most common auras are: flashing, brightly colored lights in a

zigzag pattern (referred to as fortification spectra), usually starting in the middle of the visual field and progressing outward; and a hole (scotoma) in the visual field, Migraine with aura IHS criteria: (3 out of 4) One or more fully reversible aura symptoms indicates focal cerebral cortical or brainstem dysfunction.

At least one aura symptom develops gradually over more than 4 minutes. No aura symptom lasts more than one hour. HA follows aura w/free interval of less than one hour and may begin before or w/aura. Hemiplegic migraine Unilateral motor and sensory symptoms that may persist after the headache.

Complete recover Familial hemiplegic migraine Precipitating factors stress head and neck infection head trauma/surgery aged cheese dairy red wine nuts

shellfish caffeine withdrawal vasodilators perfumes/strong odors irregular diet/sleep light Treatment of Migraines Triptans are more effective than NSAIDs and combination analgesics

NSAIDS seem to act synergistically with the Triptans Consider non-oral meds for patients whose headaches start with nausea & vomiting. Sleep often abolishes the headache. Prophylaxis of Migraines Consider

prophylaxis if acute medications are used more than two times a week, when rescue medications are necessary more than once a month, or if headaches are functionally limiting Prophylaxis should be started at low doses and titrated up over 2-3 months

Triptans Highly Highly Selective Specific Rapid Onset of Action Multiple routes of administration Migraine and Hormonal Cycles

Can increase during or only occur with menses (falling estradiol) 70% of migraineurs improve during pregnancy rebound post-partum with falling estrogen levels Usually resolves, or markedly improves with menopause

Tension-type Headache Tension-type Headache Lifetime prevalence of 69% in men and 88% in women Pain is typically bilateral (90% of the time), pressure or band-like Lasts hours to days Precipitants include anxiety, depression and situational stress

Treatment of Tension-type Headache NSAIDs for occasional headaches, and combination analgesics for recurrent headaches. Both sedating antihistamines and antiemetics can potentiate analgesics Consider prophylactic therapy if meds are used more than 2 times a week. Amitriptyline has been shown

most effective. Limited studies have shown biofeedback, relaxation training, spinal manipulation and physical therapy as helpful therapy Cluster Headache Affects men 6x>women. Onset in 3rd through 6th

decades. Prevalence .4 2%. Pain is severe, recurrent unilateral, orbital, supraorbital or temporal, accompanied by ipsilateral autonomic signs. Lasts 15 minutes to 3 hours and occurs qod to 8 times a day Cluster Headache Because

pain is so severe, most patients will present to their physician Episodes cluster over weeks to months separated by months to years of remission Nitrates or alcohol may trigger attack during the cluster period but have no effect during remission

Treatment of Cluster Headache Oxygen inhalation (100%) at 8 L/minute for 15 minutes via a loose fitting mask is a safe option and works within 10 minutes if patient is going to respond Sublingual ergotamine or DHE, SubQ sumitriptan (6mg), and nasal lidocaine are effective acute therapies Prophylactic Measurers include

Verapamil, lithium, and methylsergide

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