Approach to headaches

Approach to headache

1. BY Dr. subhasish deb Burdwan medical college and hospital (Department of internal medicine) APPROACH TO HEADACHE 10/14/2014 Dr Subhasish Deb

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) 10/14/2014 Dr Subhasish Deb

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

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

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. 10/14/2014 Dr Subhasish Deb

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 10/14/2014 Dr Subhasish Deb

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

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

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

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 10/14/2014 Dr Subhasish Deb

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. 10/14/2014 Dr Subhasish Deb

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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 10/14/2014 Dr Subhasish Deb

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

17. Classic Migraine Potential phases of migraine attack Prodrome – occurs hours to days before headache, change in mood, behaviour , appetite, cognition 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 ) 10/14/2014 Dr Subhasish Deb

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

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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) 10/14/2014 Dr Subhasish Deb

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 . 10/14/2014 Dr Subhasish Deb

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 10/14/2014 Dr Subhasish Deb

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

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 ( M itochondrial myopathy , E ncephalopathy, L actic A cidosis and S troke like symptoms) And in adults with very rare vasculopathy : CADASIL ( C erebral A utosomal D ominant A rteriopathy with S ubcortical infarcts and L eukoencephalopathy 10/14/2014 Dr Subhasish Deb

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 10/14/2014 Dr Subhasish Deb

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

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

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 10/14/2014 Dr Subhasish Deb

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 10/14/2014 Dr Subhasish Deb

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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 10/14/2014 Dr Subhasish Deb

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 10/14/2014 Dr Subhasish Deb

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

35. CLINICAL APPROACH TO THE PATIENT History, history, history (Headache diary) S ite O nset C haracter R adiation A ssociated symptoms T iming E xacerbating and relieving factors S everity Sate of health between attacks 10/14/2014 Dr Subhasish Deb

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 10/14/2014 Dr Subhasish Deb

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

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 10/14/2014 Dr Subhasish Deb

39. 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. CHARACTER 10/14/2014 Dr Subhasish Deb

40. 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. INTENSITY 10/14/2014 Dr Subhasish Deb

41. 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 TEMPORAL PROFILE 10/14/2014 Dr Subhasish Deb

42. 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 TIME OF DAY 10/14/2014 Dr Subhasish Deb

43. 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 AGGRAVATING FACTORS 10/14/2014 Dr Subhasish Deb

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) 10/14/2014 Dr Subhasish Deb

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 10/14/2014 Dr Subhasish Deb

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 10/14/2014 Dr Subhasish Deb

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 10/14/2014 Dr Subhasish Deb

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

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 10/14/2014 Dr Subhasish Deb

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. 10/14/2014 Dr Subhasish Deb

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