APPROACH TO HEADACHE powerpoint presentation

Approach to headache

1. APPROACH TO HEADACHE Dr. V. V. RAGHA SOWMYA.(1 ST YR PG)

2. INTRODUCTION Headache is one of the most common of human complaints. Its causes ranges from a mild head injury to a serious brain tumour . A specific classification system-’The Classification & Diagnostic criteria for headache disorders, Cranial neuralgias and facial pain’ was proposed by International Headache Society in 1988 and the same was revised in the year 2004. All headache disorders have been organized into 14 major groups & divided into 257 different subtypes Group 1 to 4 – Primary headaches Group 5 to 14 – Secondary headaches

3. ANATOMY S – SKIN C – CONNECTIVE TISSUE A – APONEUROSIS L – LOOSE AREOLAR TISSUE P - PERIOSTEUM

4. PHYSIOLOGY PAIN PRODUCING STRUCTURES: Skin Subcutaneous tissue Muscles Extracranial arteries Periosteum of skull Meningeal arteries( middle meningeal & superficial temporal) Dural sinuses Falx cerebri Proximal segments of large pial arteries NERVES INVOLVED: Optic Oculomotor Trigeminal Glossopharyngeal Vagus 1 st 3 Cervical nerves

5. NON PAIN PRODUCING STRUCTURES: Ventricular ependyma Choroid plexus Pial veins Much of brain parenchyma INTENSE REPEATED PROLONGED STIMULI APPLIED TO DAMAGED TISSUE THRESHOLD FOR ACTIVATING PAN IS LOWERED FREQUENCY OF FIRING IS HIGHER FOR ALL STIMULUS INTENSITIES SENSITIZATION I inflammatory mediators like BK,Nerve Growth factor, PGs & leukotrienes

6. TYPES OF HEADACHE

7. CAUSES OF HEADACHE INTRACRANIAL & LOCAL EXTRACRANIAL: Trauma Intracranial inflammation Vascular headaches Traction headache Post LP headache Cough headache CRANIAL NEURITIS & NEURALGIAS: Orbital neuralgia Auriculotemporal Posterior auricular Greater Occipital Herpes of Gasserian ganglion GENERAL OR SYSTEMIC CAUSES: Anoxaemia Toxic( fevers,uraemia,metallic poison,drugs ) Metabolic factors Haemopoietic factors REFERRED PAIN: Eyes Ears Teeth Paranasal sinuses Neck OTHERS: Psychogenic Tension(muscle contraction) Exertional Hypnic Exploding head syndrome

8. APPROACH HISTORY – Pattern recognition is most important for headache diagnosis. -Some patients can have more than 1 type of headache . INCIDENCE- Anxiety headaches, Migraine & those due to fevers, sinusitis and eyes are m/c. AGE CHILDREN(3-16 YRS) ADULTS(17-65 YRS) ELDERLY(>65 YRS) MIGRAINE TENSION CERVICOGENIC FATIGUE/PSYCHOGENIC MIGRAINE CHRONIC TENSION POST TRAUMATIC CLUSTER CRANIAL ARTERITIS POSTERIOR FOSSA TUMOURS POST TRAUMATIC/SUBDURAL HEMATOMA TUMOUR/SUBDURAL HEMATOMA/GLAUCOMA/CLUSTER/MIGRAINE TUMOURS PAGETS DISEASE OS SKULL

9. ONSET & DURATION Acute- trauma,spont ICH,hydrocephalus,SAH,meningitis,Migraine . Chronic recurrent-Migraine, TTH, Daily continuous headache. PROGRESSION Progressively worsening headache- raising ICP/uncontrolled Systemic disease. Same time everyday in some pts - CLUSTER HEADACHE Increasing towards evening- TTH Headaches that may occur 1 st thing in the morning&awaken the pt from sleep- MIGRAINE Short lasting occurring several times a day a/w autonomic features- TAC ( CLUSTER HEADACHES & ITS VARIANTS ).

10. CHARACTER Pulsating/throbbing – Migraine , fever , Arterial HTN. Sense of tightness/external pressure- Brain tumor, Meningitis. Band/Cap like pressure – TTH . Thunderclap headache- SAH. Bursting,wakes up pt & relieves soon after rising- TRACTION HEADACHE. Worse in morning,worse on bending/coughing- RAISED ICT Deep excruciating with specific periodicity- CLUSTER HEADACHE Dull,wakes up pt from sleep lasting few min to hrs -Intracranial tumors Paroxysmal – NEURALGIAS .

11. LOCATION & TYPE OF HEADACHE U/L pulsating /throbbing headaches – VASCULAR ( B/L- MIGRAINE ) U/L ,in same location during each episode rarely shifts sides- CH Diffuse, dull aching & generally B/L – TTH First in neck & occiput- PSYCHOGENIC HEADACHE ACCOMPAINMENTS Absence of history of recurrent headaches/ ppt by triggers – Consider Organic causes A/w fever, arthralgias & malaise – SYSTEMIC DISEASE A/w neurological deficits/aura such as transient visual symp / hemisensory deficits – MIGRAINE WITH AURA Any other neuro accomp - need to r/o b/w Complic migraine & TIA/Vascular anomalies/ Seizure disorder Visual disturbances- MIGRAINE Depression/Anxiety- PSYCHIC HEADACHE Facial pain-TTH, raised ICT, Trigeminal neuralgia,post herpetic neuralgia

12. TIMING OF HEADACHE Regularly just before /during menstrual periods- MENSTRUAL MIGRAINE. M/c in morning – HTN HEADACHE Worse on bending- SINUSITIS HEADACHE More towards evening- EYESTRAIN HEADACHE More intense after a period of inactivity- CERVICAL ARTHRITIS PROVOKING & RELIEVING FACTORS M/c in migraine which is frequently provoked by missing meals/ going out in hot sun. Sudden change in position or head jolt aggravate pain- IC TUMOUR Aggravated by emotional stress & mental fatigue- PSYCHOGENIC Lying down 1 st worsens gradually it subsides- SINUSITIS .

13. MEDICAL HISTORY Any malignancy anywhere in the body – CEREBRAL METS Vascular headaches in a pt with h/o spontaneous abortions/TE events- APLA SYNDROME SLEEP- Meningeal headaches produce loss of sleep. FAMILY HISTORY – Imp in MIGRAINE EXAMINATION Routine examination to exclude HTN/MENINGITIS/SYSTEMIC FEBRILE ILLNESS. Palpation of skull- engorged & pulsatile artery of scalp/localized erythema of temporal or other cranial arteries. Palpation over the head and neck – to detect trigger points Auscultation over the skull,carotid & vertebral vessels- for bruits. Palpation of TMJ & cervical spine- for tenderness & movement limitations. Tempoaral artery tenderness Mental status, Cranial nerve examination , Asymmetry in power & reflexes. Fundus examination- for papilloedema Examination of sinuses- Sinus tenderness. PSYCHIATRIC EVALUATION

14. INVESTIGATIONS X rays- a)PNS b)Skull-for evidence of raised ICT/Pineal shift. c)C Spine- for Cervical spondylosis . CSF- Meningitis/Cerebral abscess/SAH CSF PRESSURE MANOMETRY) – esp in IIH. CBC- Leucocytosis in meningitis,sinusitis,cerebral abscess. To look for anemia,dyscrasias,leukemias . Serology – for neurosyphilis . Urine-Chronic UTI FBS- hypoglycemia Serum Creatinine- Uraemia ESR- raised in Tempoaral arteritis & infections EEG- high incidence of abn in pts with vascular headache NEUROIMAGING – Must in all pts with danger signs CT SCAN- for intracranial lesions CEREBRAL ANGIOGRAPHY- for tumour,berry aneurysmor A-V malformations MRI & MRV BIOPSY OF AFFECTED ARTERY- in GCA

15. WHEN TO AVOID? WHEN THERE IS A H/O SIMILAR HEADACHES IN THE PAST EXAMINATION IS NORMAL HEADACHE IMPROVING WITH TREATMENT

16. CASE SCENARIOS

17. CASE 1 A 20 yr old female came with acute onset severe headache since 2-3 days with low grade fever and neck pain.Pt complains that pain increasing with eye movement.O /e pt was unable to flex neck and terminal neck stiffness present. MENINGITIS

18. CASE 2 A 35 yr old male pt presented with acute onset severe headache reaching maximal intensity in <5 min,pain lasted for only 5 mins with neck pain and neck stiffness.No h/o fever. SAH Other possibilities: Ruptured aneurysm A-V Malformation Intraparenchymal hemorrhage

19. CASE 3 A 32 yr old female pt came with c/o vomitings since 3 wks ; headache since 4 days which is intermittent deep dull aching of moderate intensity which worsens on exertion or change in position.Pt also complains that there is sleep disturbance because of the pain POSTERIOR FOSSA TUMORS

20. CASE 4 A 26 yr old female came with c/o headache since 3 months which is dull aching, intermittent type.Pt had h/o amenorrhea since 4 months.Her UPT was negative.She is married and had no children yet. PROLACTIN SECRETING PITUITARY ADENOMA

21. CASE 5 A 65 yr old male pt came with c/o headache since 4 months which is dull aching type present almost throughtout the day associated with occasional vomitings.He is a chronic smoker and complains of chronic cough with blood in the sputum since 1 year.His CT chest is given below CEREBRAL METASTASIS/ CARCINOMATOUS MENINGITIS

22. CASE 6 A 65 yr old male presented with headache,pain on movement of jaw,fever since 10 days.H /o wt loss,loss of appetite since 3 months.H /o generalized body pains & stiffness of neck and shoulder since 1 wk.Headache is more in b/l temporal region,gradual in onset over few hrs ocassionally explosive,pt felt something superficially external to the skull.he has difficulty in brushing hair & resting head on pillow.Pain is worse at night ,aggravated by exposure to cold.O /E reddened,tender nodules / redstreaking of skin over temporal region with tenderness over temporal & occipital regions +.ESR is raised. TEMPORAL ARTERITIS/GCA

23. GCA Inflammation of medium& large sized arteries M/c artery is Superficial temporal artery. F>M, Elderly. Throbbing/Stabbing headache with scalp tenderness + . JAW CLAUDICATION- specific symptom.Pain increases on movement. Irreversible blindness-d/t involvement of POSTERIOR CILIARY ARTERY. Pain +stiffness of neck,back,shoulder – POLYMYALGIA RHEUMATICA. Inv - ESR,Temporal artery biopsy(3-5 cms ) DOC- Steroids(Prednisolone 80 mg daily for 1 st 4-6 wks )-taper acc to ESR Aspirin – in chronic ischemic complications Toclizumab (IL-6 inhib ) IN HIGH SUSPICION ALWAYS START STEROIDS FIRST & LATER GO FOR BIOPSY FOR CONFIRMATION.

24. CASE 7 A 48 yr old male patient came with sudden onset severe u/l eye pain since 5 hrs a/w severe headache, nausea and vomiting.O /e Eye is red with a fixed ,moderately dilated pupil. ACUTE ANGLE CLOSURE GLAUCOMA

25. CASE 8 A 26 yr old female pt came with c/o headache since 1 yr which is chronic dull aching.She is using several OTC painkillers for the same since 1 yr on daily basis.Initially pain is sudden in onset lasting 30min to 1 hr daily,now it is dull,diffuse type persistent throughtout the day. MEDICATION OVERUSE HEADACHE/DRUG REBOUND HEADACHE

26. MEDICATION OVERUSE HEADACHE OP BASIS: Stop all analgesics Reduce dose by 10% every 1-2 wks. T.NAPROXEN 500MG BiD for residual pain. IP BASIS: For detoxification. 1 st day- stop all analgesics. Antiemetics & fluids given . Clonidine – for opiod withdrawl . Acute intolerable pain during waking hrs - ASPIRIN 1g IV IM CHLORPROMAZINE is helpful at night with good hydration. 3 to 5 days after admission-IV DHE every 8 hrs for 5 days along with ondansetron .

27. CASE 9 A 30 yr old female presented with headache since 2 yrs a/w dizziness,reeling sensation and decreasing memory .H/o head trauma 3 yrs back for which she is not hospitalized and no disabling features present then.Her imaging was normal . POST TRAUMATIC HEADACHE(PTH)

28. PTH D/d- Chronic Subdural hematoma. It is also seen after Carotid dissection/ SAH/ After intracranial surgery. T/t- TCAs- AMITRYPTYLINE Anticonvulsants- Topiramate /Valproate/Candesartan/Gabapentin MAO Inhib - Phenelzine . Usually resolves in 3-5 yrs.

29. CASE 10 A 58 yr old male pt came with mild headache since 4-5 days, paresthesias of rt UL & LL since 2 days f/b weakness of both rt UL & LL since morning a/w deviation of angle of mouth to left side & slurring of speech.Pt was a known hypertensive and was not taking any medication.His BP at presentation was 190/100.O/e rt UL & LL power was 2/5, rt plantar was extensor. ACUTE ISCHEMIC STROKE

30. CASE 11 A 24 yr obese female came with c/o headache & vomitings since 1 wk.H /o blurring of vision since 4 days during the headache episodes.Headache is generalized that is present on waking and improves as the day goes on,worsens on recumbency.She is on OCPs.O /e fundus showed Papilledema.LP showed evidence of raised Opening pressure. IIH/PSEUDOTUMOUR CEREBRI

31. IIH Idiopathic is m/c. Other causes-Obstruction of SSS/Drug induced/Metabolic. MRI with MR venogram - intial study. CSF pressure measured by LP when pt is symptomatic. Removal of 20-30 ml of CSF- Immediate symptomatic relief seen. Raised opening pressure seen. T/t- ACETAZOLAMIDE 250-500 MG BiD , pt improves within wks Next choice is TOPIRAMATE. In severely disabled pts - Shunting procedure is done.

32. CHRONIC DAILY HEADACHE(CDH) Headache occurring on a daily or near daily basis for >15days/month. T/t- TCA- AMITRYPTYLINE/NORTRYPTILINE 1Mg/kg usually started in low doses of 10-25 mg daily-12 hrs before expected time of awakening.

33. NEW DAILY PERSISTENT HEADACHE(NDPH) Headache begins abruptly,onset may be more gradual,evolution over 3 days is upperlimit for this syndrome.

34. CASE 12 A 28 yr old male presented with headache which is sudden in onset,begins when pt sits/stands upright and resolves upon reclining.Pain is occipitofrontal dull aching type, ocassionally throbbing,not present on waking but worsens during the day.Recumbency improves headache within minutes. LOW CSF VOLUME HEADACHE(M/c/c-CSF leak following LP) Other index events-Epidural injection/ Vigourous valsalva manevours /POTS(Postural Orthostatic Tachycardia Syndrme ).

35. LOW VOLUME CSF HEADACHE To identify source of leak- MRI with Gd is study of choice(Diffuse meningeal enhancement). T/t- Bed rest IV CAFFEINE 500 Mg in 500ml NS over 2hrs-Very effective in persistent pain( Atleast 2 infusions must be given). Abdominal binder. Autologous blood patch(also for post LP headache). Oral THEOPHYLLINE- for intractable headache.

36. CASE 13 A 32 yr old female patient came with c/o headache rt side > lt ,moderate to severe in intensity ,pulsating type.A /w blurring of vision, nausea & vomitings preceding headache episodes.Headache lasts for 4-5 hrs continuously ,relieved only after medication and taking rest.Bright light aggravates pain. MIGRAINE

37. PROPHYLAXIS: If no. of attacks >/= 4 /month. Given for 5-6 mnths . DRUGS: BETA BLOCKERS- Propanolol / Metaprolol / Timolol AED- Valproate/ Topiramate . CCB- FLUNARIZINE( Cerebroselective ). TCA- Amitryptyline .

38. CASE 14 A 40 yr old male came with c/o headache that occurs around 10-12 times/day since last 2 months.H /o similar episode 1 yr back,resolved with medication within 3 months.Pain usually starts as retroorbital more on lt side, awakens him from sleep,a /w lacrimation & rhinorrhea.Pain increases on taking alcohol. CLUSTER HEADACHE.

39. CLUSTER HEADACHE 1-8 attacks/day for 1-8 wks - daily Asymptomatic period of 1 yr & then reoccur. Lesion at hypothalamus T/t –O2 inhalation @10-12L/min for 10-15 min- for Acute attack. SUMATRIPTAN Prophylaxis- VERAPAMIL- Doc for lifelong. Steroids Lithium