Headache : Causes and management

Headache : Causes and management

1. Anees Kurikkal 2008 MBBS MES Medical College

2. Definition Headache is defined as a pain or discomfort between the orbit and the occipital region arising from extracranial and/ or intracranial pain sensitive structures.

3. Classification Headaches can be classified broadly into Primary headaches Secondary headaches

4. Primary headaches are those in which headache and its associated features are the disorder in itself, whereas secondary headaches are those caused by exogenous disorders( like headache due to RTI) Primary headache often results in considerable disability and a decrease in the patient's quality of life

5. Classification

6. Pathophysiology of Headache Pain usually occurs when peripheral nociceptors are stimulated in response to tissue injury, visceral distension, or other factors .Pain can also result when pain-producing pathways of the peripheral or central nervous system (CNS) are damaged or activated inappropriately. Headache may originate from either or both mechanisms .

7. Relatively few cranial structures are pain-producing; these include the scalp, middle meningeal artery, dural sinuses, falx cerebri , and proximal segments of the large pial arteries. The ventricular ependyma , choroid plexus, pial veins, and much of the brain parenchyma are not pain-producing.

8. Intracranial pain sensitive structures Dura near vessels Cranial nerves 5,7,9,10 Circle of Willis and proximal continuations Meningeal arteries Large veins in the brain and dura

9. Extra cranial pain sensitive structures Mucous membrane of nose and Para nasal sinuses, Middle ear cleft . Skin of Ext Auditory Canal Scalp and neck muscles Scalp vessels Orbital contents Teeth and gums

10. ETIOLOGY Naso -sinus causes Sinusitis Vacuum headache Sinonasal tumors Trauma Contact Neuralgia ( Sluder’s neuralgia) Ear causes Complications of otitis media Malignant otitis externa Herpes zoster oticus Ophthalmic Refractive error Eye strain Retrobulbar neuritis Dacryocystitis Orbital tumors Glaucoma Vascular Migraine Cluster headache Temporal arteritis

11. ETIOLOGY Contnd . Neuralgias Trigeminal neuralgia Glossopharyngeal neuralgia Cervical neuralgia Sluder’s syndrome Dental Malocclusion TMJ dysfunction Caries teeth Apical abscess Drugs Vasodilators OCPs Caffeine Tension head ache Muscle contraction headache Head injury psychological Intracranial Tumors Meningitis/encephalitis Brain abscess SOL Benign intracranial HT Systemic causes HTN Hypoglycemia Hypoxia Post alcohol hangover

12. MIGRAINE Most common type of headache Headache – throbbing type along the arteries, which could be unilateral or bilateral Headache comes in paroxysms. Frequency and duration of each attack is variable. Aura usually present in classical migraine

13. Nausea, vomiting Photophobia, phonophobia Precipitating factors : mental stress Diet like chocolate,cheese etc Relieving factors Rest/sleep Staying in silent and dark room

14. Treatment Analgesics and anti emetics given in acute attacks (Metoclopramide 5-10mg/day with paracetamol / aceclofenac ) If not responding, vasoconstrictors (ergot alkaloids) are given Sumatriptan ( 50–100 mg tablet at onset; may repeat after 2 h (max 200 mg/d ) ) Prophylaxis – topiramate , flunarizine , propranalol

15. CLUSTER HEADACHE Horton’s cephalgia or histamine cephalgia Less common, but more severe than migraine No aura Headache comes in clusters of 1 to 7 episodes each day for a week or more followed by symptom free interval for weeks or months. Males are commonly affected than females Severe unilateral pain around the eye assoc. with conjunctival injection, rhinorrhea, transient Horner’s syndrome occasionally.

16. Treatment Mechanism serum histamine level raised during attack, hence called histamine cephalgia Treatment Ergotamine, methisergide Inhalation of 100% oxygen Sumatriptan Prednisolone 30mg daily for 10 days (refractory cases)

17. Tension headache A common form of headache experienced by everyone. Diffuse dull aching band like headache worse on touching scalp aggravated by noise assoc with tension but not with other physical symptoms. Last from few hours to few days. Worse towards the end of the day. Headache is due to persistent contraction of scalp and posterior neck muscles. Bilateral and frequently localizes to occipital nuchal area.

18. Treatment NSAIDs Short course of diazepam Reassurance Antidepressants are used rarely

19. TEMPORAL ARTERITIS Common in elderly Severe throbbing type of headache Usually involving superficial temporal artery Pain while chewing or talking due to ischemia of masseter muscle following jaw claudication Assoc. blindness and diplopia Weight loss, lassitude, polymyalgia rheumatica ( genzd . muscle aches)

20. Treatment Investigation ESR raised CRP, alkaline phosphatase may be elevated Biopsy - diagnostic Treatment Prednisolone 60mg daily and gradually reduced to 5mg daily

21. POST TRAUMATIC HEADACHE Follows head injury More similar to migraine or tension type of headache Light headedness, irritability, difficulty in concentration Underlying neurological defects looked for and appropriate treatment given

22. FACIAL NEURALGIA Neuralgias are extremely painful conditions distributed along the course of the cutaneous supply . Trigeminal neuralgia Glossopharyngeal neuralgia Sluder’s neuralgia(contact neuralgia) Cervical neuralgia Raeder’s neuralgia Ramsay Hunt syndrome TMJ dysfunction

23. TRIGEMINAL NEURALGIA Synonyms – Tic Douloureux , Suicide disease Episodes of intense, stabbing, electric shock like pain in the areas of the face where the branches of trigeminal nerve are distributed. Most often affect on one side of face. Exact cause not known, probably due to abnormal loop of vessels over the nerve intracranially .

24. The three major sensory divisions of the trigeminal nerve consist of the ophthalmic, maxillary, and mandibular nerves

25. Clinical features Most often after 50yrs Pain along distribution of nerve, sharp shooting type Pain triggered by casual activities like brushing,putting makeup etc. Treatment Usually treated by anticonvulsants like Tegretol or neurontin Antidepressant drugs Neurosurgical procedures (to reduce the sensitivity )

26. GLOSSOPHARYNGEAL NEURALGIA Triggering zone is often in the tonsillar area and extends to the ipsilateral area. Pain is also felt in the back of tongue or posterior pharyngeal wall. Precipitated by swallowing, eating, or irritation of tonsillar region. Xylocaine test may be helpful in reducing pain. Stylalgia – glossopharyngeal neuralgia due to elongated styloid process. Anticonvulsants , intracranial section of IX nerve

27. RAMSAY HUNT NEURALGIA Rare Due to invovement of geniculate ganglion by herpes zoster virus

28. TMJ DYSFUNCTION Malocclusion, improper positioning of mandibular condyle within glenoid fossa Due to contraction of masticatory muscles unequal bite may cause spasm Treatment NSAIDs Massage Joint rest Muscle relaxant exercise Condylectomy for joint ankylosis

29. PARA-TRIGEMINAL NEURALGIA (RAEDER’S SYNDROME) Retro-ocular pain May be associated with dilated pupil Occur due to encroachment of vessel into para -trigeminal region Treatment Neuroendoscopic surgical decompression

30. SINUSITIS Sinusitis refers to inflammation of the mucosa of one or more Para nasal sinuses where the mucociliary clearance function is affected due to anatomical or pathological abnormalities leading to blockage of the sinus ostium

31. types ACUTE Frontal sinusitis Maxillary sinusitis Ethmoiditis Sphenoidal sinusitis CHRONIC SINUSITIS

32. Acute frontal sinusitis Severe headache, periodic in nature, confined to frontal region. Starts in the morning, subsides in the afternoon – office headache Precipitated on bending, straining, coughing. unilateral or bilateral Usually affects the medial canthus region and root of nose. Investigations X-ray of PNS Diagnostic nasal endoscopy CT scan of ostiomeatal complex

33. Medical Broad spectrum antibiotic - amoxycillin + clavulanate . Anaerobic infection – metronidazole Observation for complications Systemic decongestants – pseudoephedrine hydrochloride combined with mucolytic promotes drainage. Local decongestants – oxymetazoline or xylometazoline . Analgesics – aceclofenac .

34. Surgical Frontal sinus trephination Endoscopic sinus surgery Endoscopic frontal recess clearance

35. Acute maxillary sinusitis Pain over the cheek following upper respiratory infection may radiate to the teeth or the frontal region. Aggravated on straining or bending forwards. Investigations X-ray PNS Diagnostic nasal endoscopy CT

36. Medical Infection of dental origin – antibiotic coverage for anaerobic infection. Surgical Middle meatal maxillary sinusostomy Irrigation of maxillary sinus with isotonic saline by antral puncture Infected tooth if any should be extracted.

37. Acute sphenoidal sinusitis Headache may be vertical, frontal, occipital or central May radiate to temporal region Postnasal drip and hawking

38. Investigations CT scan Nasal endoscopy Treatment Medical Broad-spectrum antibiotics Nasal decongestants Anti inflammatory Anti histamines Nasal irrigation with saline Mucolytics Steam inhalation surgical endoscopic sphenoidotomy

39. Acute ethmoiditis Most common sinus involved in children Pain between the eyes associated with frontal headache. Nasal discharge, usually purulent Post nasal drip assoc with nocturnal cough Constitutional symptoms – fever, bodyache

40. Investigations CT scan of osteomeatal complex Treatment Amoxycillin + clavulanic acid for 3wks Nasal decongestants Analgesics, anti- inflammatory

41. references 1. Textbook of ENT and head and neck surgery, HAZARIKA 2. Harrison's Principles of Internal Medicine 17 th edition 3.Handbook of headache, Evans and Mathew