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    4 Headache PDF

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    John Ryan Paris
    The document provides information on different types of headaches including their signs, symptoms, and classification. It discusses primary headaches like migraines, tension headaches, and cluster headaches. It describes the mechanisms that cause headaches and the structures in the head that are sensitive or insensitive to pain. Diagnostic criteria for differentiating between migraine with and without aura are presented. Risk factors and management strategies for migraines are also summarized.

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    4 Headache PDF

    Uploaded by

    John Ryan Paris
    221 views39 pages
    The document provides information on different types of headaches including their signs, symptoms, and classification. It discusses primary headaches like migraines, tension headaches, and cluster headaches. It describes the mechanisms that cause headaches and the structures in the head that are sensitive or insensitive to pain. Diagnostic criteria for differentiating between migraine with and without aura are presented. Risk factors and management strategies for migraines are also summarized.

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    The document provides information on different types of headaches including their signs, symptoms, and classification. It discusses primary headaches like migraines, tension headaches, and cluster headaches. It describes the mechanisms that cause headaches and the structures in the head that are sensitive or insensitive to pain. Diagnostic criteria for differentiating between migraine with and without aura are presented. Risk factors and management strategies for migraines are also summarized.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    221 views39 pages

    4 Headache PDF

    Uploaded by

    John Ryan Paris
    The document provides information on different types of headaches including their signs, symptoms, and classification. It discusses primary headaches like migraines, tension headaches, and cluster headaches. It describes the mechanisms that cause headaches and the structures in the head that are sensitive or insensitive to pain. Diagnostic criteria for differentiating between migraine with and without aura are presented. Risk factors and management strategies for migraines are also summarized.

    Copyright:

    © All Rights Reserved
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    of 39

    HEADACHES

    Ma. Carmencita B. Gonzalez, M.D.

    Headaches
    At the end of the unit, the student will be able to:
    COGNITIVE
    Describe headache
    Classify the different types of headache and give its
    signs and symptoms
    Enumerate the different pain sensitive and insensitive
    structures of the brain
    Explain the different mechanisms that cause headache

    AFFECTIVE
    Realize that headaches could be a part of the signs and
    symptoms of an underlying brain pathology
    Realize that HA could be caused by other organ systems
    aside from the nervous system
    2

    Headaches
    Types of headache
    Primary headache
    Migraine headache
    Tension headache
    Cluster headache

    Secondary headache

    Different structures of head that may and


    may not cause pain
    Pain sensitive structures
    Pain insensitive structures

    Mechanisms causing headache


    3

    Pain Sensitive Structures


    Scalp and Aponeurosis
    Middle Meningeal Artery

    Dural Sinuses
    Falx Cerebri
    Proximal segments of the large pial
    arteries
    4

    Mechanisms of Pain Production


    Distention, traction or dilatation of
    intracranial and extracranial arteries
    Traction or displacement of large
    intracranial veins or their dural envelope
    Compression, traction, or inflammation of
    cranial and spinal nerves

    Mechanisms of Pain Production


    Spasm, inflammation and trauma to
    cranial and cervical muscles
    Meningeal irritation and raised
    intracranial pressure
    Perturbation of intracerebral
    serotonergic projections
    6

    Pain Insensitive Structures


    Ventricular ependyma
    Choroid plexus
    Pial veins
    Much of the brain parenchyma

    Nerves Subserving Pain


    Trigeminal nerve - supratentorial
    structures of the anterior and middle
    fossa
    First three cervical nerves - posterior fossa
    and infradural structures
    Glossopharyngeal and Vagus nerves posterior fossa, refers pain to the ear and
    throat
    8

    Evaluation of Headaches
    Headache attacks
    How it begins
    Precipitating event, illness, injury

    Headache attack descriptions


    Frequency and patterns
    Any significant changes

    Location
    Time to peak intensity
    Duration
    Quality and intensity
    Warning symptoms and aura
    Associated symptoms and level of disability
    Triggers and aggravating or relieving factors

    International Headache Society


    Classification of Primary Headaches
    2004
    1. Migraine
    a. Migraine without aura
    b. Migraine with aura
    2. Tension-type Headache
    3. Cluster Headache and Other Trigeminal
    Autonomic Cephalgias
    4. Other Primary Headaches
    10

    International Headache Society


    Classification of Primary Headaches
    2004
    5. Headache Attributed to Head and/or
    Neck Trauma
    6. Headache Attributed to Cranial or
    Cervical Vascular Disorder
    7. Headache Attributed to Non-vascular
    Intracranial Disorder
    8. Headache Attributed to a Substance or
    its Withdrawal
    11

    International Headache Society


    Classification of Primary Headaches
    2004
    9. Headache Attributed to Infection
    10. Headache Attributed to Disorder of
    Homoeostasis
    11. Headache or Facial Pain Attributed to
    Disorder of Cranium, Neck, Eyes, Ears,
    Nose, Sinuses, Teeth, Mouth, or Other
    Facial or Cranial Structures
    12

    International Headache Society


    Classification of Primary Headaches
    2004
    12.Headache Attributed to Psychiatric
    Disorder
    13.Cranial Neuralgias and Central Causes
    of Facial Pain
    14. Other Headache, Cranial Neuralgia,
    Central or Primary Facial Pain
    a. Trigeminal Neuralgia
    13

    MIGRAINE
    1.1 Migraine without Aura
    1.2 Migraine with aura

    1.3 Childhood Periodic Syndromes that are


    commonly Precursors of Migraine
    1.4 Retinal Migraine
    1.5 Complications of Migraine

    1.6 Probable Migraine


    14

    MIGRAINE
    Benign recurring headache with or without
    recurring neurologic dysfunction

    Pain free interludes


    Provoked by stereotyped stimuli

    More common among females


    With hereditary predisposition
    Onset usually in childhood, adolescent years
    or early adulthood
    15

    Symptoms of Migraine
    Unilateral headache = 62%
    Pulsating quality = 78%
    Moderate or severe intensity = 99%
    With nausea = 82%
    With photophobia & phonophobia = 83%/86%
    Aggravated by physical activity = 96%
    16

    Risk Factors for Migraine


    Family history
    Menstruation, Oral contraceptives,
    Menopause
    Stress, Fatigue
    Bright lights
    Meteorologic changes, high altitude
    Medicines - vasodilators
    Head trauma
    Hunger
    17

    Predisposing Factors & Triggers


    Family history
    h/o travel sickness
    h/o cyclical vomiting in
    childhood
    Stress
    Menstrual cycle
    Menopausal
    Head & neck trauma
    Strenuous exercise
    Meteorologic changes,
    high altitude

    Relaxation after stressweekend migraine


    Change of habit-missed
    meals /sleep
    Bright lights
    Loud noise
    Smells-perfume /petrol
    Dietary/Food
    Medications

    19

    Migraine without Aura


    Common Migraine; Hemicrania Simplex
    Recurrent headache disorder manifesting
    in attacks lasting 4-72 hours.
    Typical characteristics - unilateral,
    pulsating, moderate or severe,
    aggravation by routine physical activity
    and association with nausea and/or
    photophobia and phonophobia
    20

    Diagnostic Criteria
    Migraine without Aura
    DIAGNOSTIC CRITERIA:
    A. At least five attacks fulfilling criteria B-D
    B. Headache attack lasts 4-72 hours (untreated or
    unsuccessfully treated)
    C. Headaches with at least 2 of the following:
    1.
    2.
    3.
    4.

    Unilateral location
    Pulsating quality
    Moderate or severe intensity
    Aggravation by or causing avoidance of routine physical
    activity (eg. walking or climbing stairs )

    D. During headache, at least one of the following


    A. Nausea and/or vomiting
    B. Photophobia and phonophobia

    E. Not attributed to another disorder

    21

    Migraine with Aura


    Classic or classical migraine, Ophthalmic,
    Hemiparaesthetic, Hemiplegic or aphasic
    migraine, Migraine accompagnee, Complicated
    migraine
    Recurrent disorder of reversible focal
    neurological symptoms that develop gradually
    over 5-20 minutes and last for less than 60
    minutes
    Headache with the features of migraine without
    aura usually follows the aura symptoms
    Less commonly, headache lacks migrainous
    features or is completely absent
    22

    Diagnostic Criteria
    Migraine with Aura
    A. At least two attacks fulfilling criterion B
    B. Migraine aura fulfilling criteria B and C for one
    of the subforms 1.2.1-1.2.6
    C. Not attributed to another disorder
    1.2.1
    1.2.2
    1.2.3
    1.2.4
    1.2.5
    1.2.6

    Typical aura with migraine headache


    Typical aura with non-migraine headache
    Typical aura without headache
    Familial hemiplegic migraine
    Sporadic hemiplegic migraine
    Basilar-type migraine
    23

    B. Aura consisting of at least one of the following, but


    no motor weakness:
    1. Fully reversible visual symptoms including positive features
    (eg. Flickering lights, spots or lines) and/or negative
    symptoms (ie. Loss of vision)
    2. Fully reversible sensory symptoms including positive
    features (ie, pins and needles) and/or negative features (ie,
    numbness)
    3. Fully reversible dysphasic speech disturbance

    C. At least two of the following:


    1. Homonymous visual symptoms and/or unilateral sensory
    symptoms
    2. At least one aura symptom develops gradually over 5
    minutes and/or different aura symptoms occur in
    succession over 5 minutes
    3. Each symptom lasts 5 and 60 minutes

    24

    Basilar Migraine
    B. Aura consisting of at least one of the following, but no motor
    weakness:
    1.
    2.
    3.
    4.
    5.
    6.

    Dysarthria
    Vertigo
    Tinnitus
    Hypacusia
    Diplopia
    Visual symptoms simultaneously in both temporal and nasal fields
    of both eyes
    7. Ataxia
    8. Decreased level of consciousness
    9. Simultaneously bilateral paraesthesias

    C. At least two of the following:


    1. At least one aura symptom develops gradually over 5 minutes
    and/or different aura symptoms occur in succession over 5
    minutes
    2. Each aura symptom lasts 5 and 60 minutes
    25

    Pathogenesis of Migraine
    Vascular theory
    Spreading Depression Theory
    Present Concept:
    1. Brain stem generation
    2. Vasomotor activation
    3. Activation of the cells of the trigeminal
    nucleus caudalis and release of
    vasoactive neuropeptides at the
    terminations of the trigeminal nerve on
    blood vessels
    26

    27

    Management of Migraine

    Medications
    Lifestyle modifications
    Regular sleep
    Regular meals
    Moderate amount of exercise
    Drink plenty of water
    Limit caffeine, alcohol and other drugs
    Reduce stress

    Tension-Type Headache
    Tension, Muscle contraction, Psychomyogenic,
    Stress, Ordinary, Essential, Idiopathic, Psychogenic
    Headache
    Most common type of Primary headache; 3078%

    2.1
    2.2
    2.3
    2.4

    Infrequent episodic tension-type headache


    Frequent episodic tension-type headache
    Chronic tension-type headache
    Probable tension-type headache
    29

    Tension-Type Headache
    At least two of the following pain
    characteristics

    - Bilateral location
    Pressing/tightening (non-pulsating) quality
    Mild to moderate intensity
    No aggravation by walking stairs or similar
    routine physical activity

    Both of the following

    No nausea or vomiting (anorexia may occur)


    No more than one of photophobia or
    phonophobia

    30

    Cluster Headache and Other


    Trigeminal Autonomic Cephalalgias
    3.1 Cluster headache
    3.2 Paroxysmal hemicrania

    3.3 Short-lasting Unilateral Neuralgiform


    Headache Attacks with Conjunctival
    Injection and Tearing (SUNCT)
    3.4 Probable Trigeminal Autonomic
    Cephalalgia
    31

    Cluster Headache
    Ciliary neuralgia, Erythro-melalgia of
    the head, Erythroprosopalgia of Bing,
    Hemicrania angioparalytica, Hemicrania
    Neuralgiformis Chronica, Histaminic
    Cephalalgia, Hortons headache, HarrisHortons disease, Migrainous Neuralgia
    (of Harris), Petrosal Neuralgia (of
    Gardner)
    32

    Diagnostic Criteria
    Cluster Headache
    A. At least 5 attacks fulfilling criteria B-D
    B. Severe or very severe unilateral orbital, supraorbital and/or
    temporal pain lasting 15-180 minutes if untreated
    C. Headache is accompanied by at least one of the following:

    Ipsilateral conjuctival injection and/or lacrimation


    Ipsilateral nasal congestion and/or rhinorrhea
    Ipsilateral eyelid edema
    Ipsilateral forehead and facial sweating
    Ipsilateral miosis and/or ptosis
    A sense of restlessness or agitation

    D. Attack have a frequency from one every other day to eight


    per day
    E. Not attributed to another disorder

    33

    Other Types of Headache

    Cough Headache
    Coital Headache
    Post concussion Headache
    Giant Cell Arteritis
    Lumbar Puncture Headache
    Brain Tumor Headache
    34

    Diseases Which Present


    with Headaches

    Head and/or Neck Trauma


    Cranial or Cervical Vascular Disorder
    Non-vascular Intracranial Disorder
    Substance Use or its Withdrawal
    Infections
    Disorder of Homoeostasis
    Disorders of Cranium, Neck, Eyes, Ears, Nose,
    Sinuses, Teeth, Mouth or other Facial or Cranial
    Structures
    Psychiatric disorders
    Cranial Neuralgias and Central Causes of Facial Pain
    35

    Red Flags of Headaches


    Headaches only felt in one particular area of
    the head
    Headache which peaks in an instant
    thunder-clap
    Sleep deprivation
    Headaches accentuated by eye movement
    Headache accentuated by bending, lifting,
    coughing
    36

    Diagnosis of Secondary Headaches


    Red flag symptoms which should prompt referral for further investigation

    New onset or change in headache in patients over 50..remember ESR


    Thunderclap headache
    Focal neurological symptoms e.g. limb weakness/ aura lasting >1 hr
    Non-focal neurological symptoms e.g. impaired cognitive function
    Change in headache frequency/characteristics
    Abnormal neurological examination
    Headache that change with posture
    Headache wakening patient up
    Headache precipitated by physical exertion eg cough,/straining valaslva/
    Neck stiffness/fever
    New onset headache in patient with cancer
    Sleep deprivation
    Headaches felt persistently on the same area

    Trigeminal Neuralgia
    Tic doloureux
    Management: Carbamazepine, surgery

    38

    Diagnostic Criteria
    Trigeminal Neuralgia
    A. Paroxysmal attacks of pain lasting from a fraction
    of a second to 2 minutes, affecting one or more
    divisions of the trigeminal nerve and fulfilling
    criteria B and C
    B. Pain has at least one of the following
    characteristics
    1. intense, sharp, superficial or stabbing
    2. Precipitated from trigger areas or by trigger factors

    C. Attacks are stereotyped in the individual patient


    D. There is no clinically evident neurological deficit
    E. Not attributed to another disorder

    39

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