Cet 27 July 2012 Kipioti
Cet 27 July 2012 Kipioti
Cet 27 July 2012 Kipioti
Dispensing Opticians
disability. They affect all ages, including children, and there is frequently a positive family history. They can be unilateral or bilateral, pulsating, moderate or severe and can last from a few hours to three days. The pain is often localised to the periocular region, or there may be associated visual aura in the form of zigzag lines (fortification spectrum). Occasionally, patients report diplopia. Migraine without associated aura often has a strict menstrual relationship. The aura is fully reversible and consists of positive features (eg flickering lights, (eg loss of vision, scotoma). It may be accompanied by fully reversible sensory symptoms, including positive features reversible (pins and needles) speech. and/or Apart negative features (numbness) and fully dysphasic from the visual aura, other premonitory symptoms include photophobia and phonophobia and (aversion in to noise), fatigue, neck stiffness, blurred vision difficulty concentrating.
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Classification
In the broad sense, headache is any pain or ache located in the head, but in practice, only the ones located in the cranial vault are referred to as headaches. Headaches have such diverse aetiology that it is has been a significant challenge to classify the different types and their diagnostic criteria. In 1988, after three years of congresses and combined effort, the International Headache Society with a headache classification sub-committee produced the first edition of
When optometrists are faced with a patient complaining of headaches, an attempt at classifying the disorder as a primary headache (eg migraine, tension headache) or secondary headache (eg tumour, stroke) should be made. In general, primary headaches are far more common and are not related to significant underlying pathology, whereas secondary headaches are rarer, but may be a warning sign of a sinister underlying cause. The key to aiding this differentiation is in the history and symptoms reported by the patient.
With or without peri-cranial tenderness, TTH is the least studied of the primary headache disorders and yet it is, by far, the commonest. Lifetime prevalence in the general population is estimated to be 30-78%4 and is believed to have the highest socio-economic impact. It was previously considered to be primarily psychogenic. bilateral, The pain or is typically in pressing tightening
quality and of mild to moderate intensity. Cluster headache and trigeminal autonomic cephalalgias (TAC) Cluster headache is of particular interest to ophthalmologists and optometrists because of their frequent localisation around the eyes. One of the commonest examples is the short-lasting unilateral neuralgiform conjunctival headache injection attacks and with tearing
The
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(SUNCT).
Cluster
headaches
are
attacks of severe, strictly unilateral pain, which can be orbital, supraorbital or temporal, lasting 15-180 minutes and with a typical regular recurrence, from once every other day to eight
Headache attributed to head and neck trauma Headache attributed to cranial or cervical vascular disorder Headache attributed to non-vascular intracranial disorder Headache attributed to a substance or its withdrawal Headache attributed to infection Headache attributed to disturbance of homoeostasis Headache or facial pain attributed to disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cranial structures Headache attributed to psychiatric disorders
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times a day. It is often associated with conjunctival injection, lacrimation, nasal congestion, rhinorrhoea, forehead and facial sweating, miosis, ptosis and eyelid oedema. The patients are typically restless or agitated during an attack (in contrast to the migraine patient, who wants to lie down in a quiet room).
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jaw claudication, proximal myalgia, weight loss, malaise, and more rarely, eye or orbital pain (indicating ocular ischaemic syndrome). The headache may worsen on standing up and be associated with transient blurred vision (amaurosis
Figure 1 Papilloedema
fugax), transient diplopia or even cranial nerve palsies. AION (anterior ischaemic optic neuropathy) with optic nerve swelling and visual loss is a common first presentation of GCA and, again, the diagnosis of AION in a patient over 50
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years of age with a headache should raise a strong suspicion of temporal arteritis. Acute visual loss in one or both eyes may ensue if not urgently treated with high dose steroids, and it can be fatal. The commonest clinical scenario of GCA is that of an elderly patient with loss of vision in one eye and pain (headache). The temporal arteries may be prominent, inflamed and non-pulsatile, and upon examination the clinician confirms an optic nerve swelling and a visual field defect, usually altitudinal. Such a patient needs urgent admission to A&E and intravenous steroids followed by systemic steroid treatment for a year.
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Raised intracranial pressure (ICP) ICP can cause papilloedema. The optic nerve sheaths are an extension of dura around the brain and the sub-arachnoid space of the sheath contains CSF (cerebrospinal fluid), which is in direct communication with the CSF flowing around the brain. When there is high pressure of the CSF, the pressure extends around the optic nerve and results in obstruction of the axoplasmic flow in the optic nerve axons. A build-up of blocked axoplasm in the optic nerve head becomes visible as a swelling, causing the appearance of papilloedema (Figure 1). If pressure is unrelieved, the consequences are optic nerve axon dysfunction and eventually death (optic atrophy). Raised ICP may be caused by a number of reasons, the commonest being an intracranial space-occupying lesion (eg a brain tumour or abscess), intracranial haemorrhage hydrocephalus, (stroke, meningitis, trauma), dural
previous name of benign intracranial hypertension is now abandoned as it can be very aggressive and refractory to treatment and many patients lose their vision (complete bilateral blindness is possible) or have severe disabling headaches. It is associated with obesity (except in children, who may have normal body weight) and patients are usually overweight women, who present with swollen discs, headaches and often visual obscurations. Diagnosis is based on the clinical image, a normal appearance of the brain on neuroimaging and high opening pressure on lumbar puncture
venous sinus thrombosis or idiopathic (pseudotumour cerebri). Symptoms that patients may report include blurred vision from optic nerve dysfunction or from induced hypermetropia (the eyeball is shortened by pressure from the dilated optic nerve sheath), transient
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Headaches
Symptoms Examination Consider
and diplopia from cranial nerve palsies. Subarachnoid haemorrhage This is a medical emergency and requires an urgent referral to neurology as it is fatal for over 50% of patients within 24 hours of onset. The great majority of cases are
Primary headaches (migraine - TTH)
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Aura
Chronic headache
due to leakage of blood from an arterial wall defect of the middle cerebral artery, a terminal branch of the internal carotid artery. The blood then spreads between two of the meninges (the membranes that
Daily recurrence
Conjunctival signs
cover the brain), the pia and arachnoid mater, causing headache and raised ICP. Other causes include venous bleeds, clotting disorders and haemorrhages due
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presents with a thunderclap headache, which has an onset within a split second and is frequently described as the worst ever that the patient has experienced. Often, it is occipital (back of the head) in site and may be associated with neck
Jaw claudication
Malaise
Transient
diplopia
nausea and vomiting (blood is a very good irritant of the meninges, so it resembles an acute onset of meningitis). Confusion and altered consciousness are poor prognostic indicators, as are focal neurological signs
Visual Obscurations
Horners syndrome
include the features of raised intracranial pressure such as papilloedema and sixth nerve palsies. Infrequently, sub-hyaloid (pre-retinal) haemorrhage with or without vitreous haemorrhage may occur, which
Papilloedema
Subhyaloid Haemorrhage
Dural venous sinus thrombosis Thrombosis of cerebral veins (or venous sinuses) is an uncommon condition (although a lot more prevalent than
Unpleasant sensations
Anisocoria
Trigeminal Neuralgia
previously
thought),
which
often
presents a diagnostic challenge, with a non-specific and, occasionally, dramatic presentation which the optometrist may be the first to see. In this condition, one of the cerebral veins (usually the superior sagittal or one of the transverse sinuses)
becomes obstructed by a clot and ceases to drain CSF from the sub-arachnoid space, thus resulting in raised ICP, headaches and papilloedema, with or without visual symptoms. The patient may be otherwise well initially, but as the drainage of cerebral veins remains obstructed, the slow flow and backpressure may eventually lead to stroke, with focal neurological signs, seizures and coma. Imaging is paramount for the diagnosis of this condition, but the findings may be subtle and the clinician must have a high index of clinical suspicion to order the correct examination (MRI with venography is the investigation of choice; CT scan alone will miss a significant number of cases) and instigate appropriate treatment.
with presbyopia). Confirmation of the diagnosis is based on the rapid response to appropriate glasses. Similarly, a heterophoria or heterotopia may also cause recurrent, non-pulsatile, mild to moderate frontal headaches, usually absent upon awakening, but worsening throughout the day. Headache-inducing heterophoria tends to be either significant (close to or at limit of the fusion range) or intermittent (controlling a large-angle divergent squint). Other symptoms include intermittent blurred vision or diplopia and difficulty adjusting visual focus from distance to near and vice versa.
refractive correction) Ocular motility and cover test revealing the presence of heterotropia and muscle under-actions following IIIrd, IVth and VIth nerve palsies Visual field defects, eg those related to papilloedema (enlarged blind spot) or AION (altitudinal) Anisocoria, and/or fixed dilated pupils Eyelid ptosis (as seen in Horners syndrome) Slit lamp examination of ocular redness and the anterior chamber angle (looking for the presence of papilloedema) Palpate temporal arteries Figure 3 provides a quick reference guide practitioners can use to aid differential diagnosis. Binocular indirect fundoscopy
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Diagnostic approach
When faced with a patient complaining of headaches, one has to remember that the vast majority of headaches are primary or innocuous, but it is important not to miss the few that are caused by a more sinister underlying cause. To this effect, the eye care practitioner should pay attention to some important symptoms and signs that may point to a secondary cause: Symptoms History where, when, triggers of the headache, any change in the pattern of pain Other neurological symptoms (nausea, vomiting, tinnitus) or migraineous aura Headache upon waking or deteriorating with postural changes Neck or arm pain Fever or seizures or change in personality and mental status Diplopia, blurred vision or visual obscuration Redness or swelling of the eye(s) If the patient is over 50 years of age, it is important to specifically enquire about other GCA symptoms such as scalp tenderness Signs Reduced visual acuity (with best
Conclusion
There is no doubt that, in the course of their career, optometrists are highly likely to be presented with headache cases, most of which will be benign but others which may be life-threatening. Their skill lies in identifying these few sinister cases and making a difference to the patients life or vision. In case of uncertainty, a telephone call to emergency eye services for advice may avoid a referral or and indeed expedite an admission appropriate management.
or facial pain attributed to herpes Tolosa-Hunt syndrome. Trigeminal neuralgias may be idiopathic or secondary due to compression of the nerve by a tumour or aneurysm, or secondary to multiple sclerosis. It may be persistent or recurrent, unilateral or periocular and can occasionally have an electric shock-like quality, or unpleasant sensations of pins and needles or ants crawling under the skin. Associated decreased corneal or facial sensation or the presence of anisocoria, increases the risk of a tumour. Ophthalmic causes of headache include angle-closure glaucoma, herpes zoster ophthalmicus, uncorrected refractive error and heterophoria or heterotropia. Headaches due to refractive error tend to be recurrent, mild, frontal and/or ocular, are normally absent on awakening and are typically precipitated or aggravated by prolonged visual tasks (eg reading
References
See on www.optometry.co.uk/clinical. references to download. Click on the article title and then
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2. Which of the following signs is NOT associated with dry eyes? a) Congestion of conjunctival vessels b) Filamentary keratitis c) Superficial punctate corneal erosions d) Cells in the anterior chamber 3. Which of the following tests may be used in the diagnosis of dry eyes? a) Schirmers Type 1 and 2 b) Tear osmolarity c) Fluorescein and lissamine dye staining d) All of the above
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