Headache approach and managemnetptt .pptx

ww

1. Case presentation (Headache “more than just pain”) By Hamada Abdeltawab Salama Assistant lecturer of neurology&neurointervention F aculty of medicine /AL-Azhar university

2. Case scenario : An overweight,asthmatic 30 year-old woman presents with 3 to 4 severe ,debilitating headaches per month for the last 2 years . ,The headaches last 12 to 24 hours .They are sometimes localized bifrontally, but more often localized to right temple,right frontal region,and behind the right eye , there is often rinorrhea congestion and red eye associated with her headaches . ,The pain is usually throbbing and associated with nausea but no vomiting But , in the last 2 months headache became persistent , dull aching and associated with blurred vision and pulsatile tinitus What is the most likely diagnosis ?

3. “Formulation of the case and options ” An obese,asthmatic 30 year-old woman P resented with recurrent attacks of headache : - site : retro-orbital and fronto-temporal - character : dull acheand , throbbing - Radiation : Localized - Duration : 12 to 24 hours - increasment : by physical activity - Decreasment : partially by simple analgesics - Association :Nausea and autonomic features The last 2 months : -New headache (parsistent, dull aching) -New association ( blurred vision , tinitus)

4. Examination and Investigations Examination : -Neurological examination : free -Fundus exam : Grade-3-papilledema Laboratory tests: normal finding Visual field test S how abnormal finding with MD -15 bilaterally MRI brain and MRV :

5. Brain imaging MRI finding : 1- Normal brain parenchyma 2-Empty sella 3-flattening of post.globe 4-Dilatation of perioptic subarachnoid space

6. MRV MRV finding : 1-Left Transverse sinus S tenosis 2- No CVT

7. The best diagnosis is : 1- Episodic migraine with autonomic symp. 2-IIH (idiopathic intracranial hypertension) 3-Cerebral venous stenosis 4-All of the above

8. Explanation and discussion The patient fullfill criteria of migrain without aura (over 2 years): -More than 5 attacks . -Duration : 12 :24 hours (Typical from 4 hours to 3 days ). 4 clinical from 4 (Throbbing,severe, unilaterally localized ,interfere with physical activity ). -1 association from 2 (nausea) . Autonomic features ?? : ( frequently coexist with migrain because of trigeminal nerve cross-activation of parasympathetics via stimulation of superior salivatory nucleus of the facial nerve .

9. Explanation and discussion The patient fullfill ICHD criteria of IIH ( the last 2 months) : 1- clinically : new headache(change in character of pre-existing headache).(1 from 1) 2-Association : pulsatile tinitus and papilledema (2 from 2 ) 3- CSF pressure = 35 “ first measurment”

10. M edical therapy The best medical therapy for this patient is : 1- Na valporoate 2-Propranolole 3-Acetazolamide 4- Rivaroxiban 5-Topiramate

11. The best answer is : Topiramate

12. Interventional therapy Venous stenting was done F or stenosed transverse sinus

13. Outcome Patient markedly improved as regard headache ( both migranous attack and headache attributed to IIH) within few days both stenting +150 mg topiramate in 2 divided doses Follow up fundus exam resolved from papilledema after 5 months F ollow up perimetry ach ie ve MD -1 bilaterally after 4 months P atient now free from headache , controlled on topiramate 5 mg BID

14. Home message Migain sometimes accompained by autonomic features V enous stenting is promising ttt in patient with IIH & underying significant venous stenosis - Risk factors and patient condition play important role in determination of optimal therapy