Headache medical ppt for medical College students

Headache medical ppt

1. HEADACHE in Primary Care Ayşe Arzu Akalın MD Family Medicine 1

2. In the end of this lecture the students will be able to; d ifferentiate primary and secondary headache list the characteristics of most common headache types in primary care explain the warning features in history and physical exam list the common headache triggers 2

3. Definition Headache or cephalalgia is pain or discomfort perceived in the head, neck or both. Primary headache disorders are recurrent benign headaches. Secondary headaches result from an underlying pathology caused by a distinct condition. ( eg ., aneurysm, infection, inflammation, or neoplasm) 3

4. Epidemiology Annual prevalence may be as high as 90%, with a minority of those sufferers pursuing medical evaluation. Headache is the second most common pain syndrome in primary care ambulatory practice. 4

5. E pidemiology In children the rate of the patients who seek care for headache has a negative correlation with the age. The prevalance increases with age significantly and the pain is less in severity and duration compared with adults . Incidence is between 20%-54% in the pre-adolescence period based to the epidemiologic studies. 5

6. Pain Insensitive S tructures in Brain Brain parenchyma Dura over convexity of skull (Dura around vascular sinuses and vessels is sensitive to pain) Ependyma Choroid plexus Arachnoid Pia matter 6

7. Pain Sensitive S tructures in Head INTRACRANIAL Cranial venous sinuses with afferent veins Arteries at base of brain and arteries of dura including middle meningeal artery Dura around venous sinuses and vessels Falx cerebri 7

8. Pain S ensitive S tructures in H ead EXTRACRAN I A L & NERVES Skin Scalp appendages Periosteum Muscles Arteries Mucosa Trigeminal ( V. CN ) Facial ( VII. CN ) Vagal ( X. CN ) Glossopharyngeal ( IX. CN ) Optic and oculomotor CNs (II & III: CN) 8

9. Causes of H eadaches . 1 . Traction or dilatation of intracranial or extracranial arteries . 2. Traction of large extracranial veins 3. Compression, traction or inflammation of pain sensitive intra cranial structures 4. Spasm and trauma to cranial and cervical muscles . 5. Meningeal irritation and raised intracranial pressure 6. Eye , ear , nose and throat pathologies 9

10. Classification of International Headache Society A- Primary Headaches (90%) 1. Migraine including : 1.1 Migraine without aura 1.2 Migraine with aura 2. Tension-type headache, including: 2.1 Infrequent episodic tension-type headache 2.2 F requent episodic tension-type headache 2.3 Chronic tension-type headache 2.4 Probable tension-type headache 3. Cluster headache and other trigeminal autonomic cephalalgias , including: 3.1 Cluster headache 3.2 Other primary headaches 10

11. Classification of International Headache Society A- Primary Headaches (90%) 4. Other primary headaches 4.1. Primary stabbing headache 4.2. Primary cough headache 4.3. Primary exertional headache 4.4. Primary headache associated with sexual activity 4.4.1. Preorgasmic headache 4.4.2. Orgasmic headache 4.5. Hypnic headache 4.6. Primary thunderclap headache 4.7. Hemicrania continua 4.8. New daily persistent headache (NDPH) 11

12. Primary H eadache Definition None of the primary headaches is associated with demonstrable organic disease or structural neurologic abnormality. Laboratory and imaging test results are generally normal. The physical and neurologic examinations are also usually normal 12

13. Primary H eadache Definition Should an abnormality be found on testing, by definition, it most likely is not the cause of the headache. During the headache attack however, patients might have some abnormal clinical findings 13

14. B- Secondary Headaches (10%) 5 . Headache attributed to head and/or neck trauma, including: 5.2 Chronic post-traumatic headache 6. Headache attributed to cranial or cervical vascular disorder, including: 6.2.2 Headache attributed to subarachnoid hemorrhage 6.4.1 Headache attributed to giant cell arteritis 7. Headache attributed to non-vascular intracranial disorder, including: 7.1.1 Headache attributed to idiopathic intracranial hypertension 7.4 Headache attributed to intracranial neoplasm 14

15. B- Secondary Headaches 8. Headache attributed to a substance or its withdrawal, including: 8.1.3 Carbon monoxide-induced headache 8.1.4 Alcohol-induced headache 8.2 Medication-overuse headache 8.2.1 Ergotamine-overuse headache 8.2.2 Triptan -overuse headache 8.2.3 Analgesic-overuse headache 9. Headache attributed to infection, including: 9.1 Headache attributed to intracranial infection 15

16. B- Secondary Headaches 10. Headache attributed to disorder of homoeostasi s 10.1. Headache attributed to hypoxia and/or hypercapnia 10.2. Dialysis headache 10.3. Headache attributed to arterial hypertension 10.4. Headache attributed to hypothyroidism 10.5. Headache attributed to fasting 10.6. Cardiac cephalalgia 10.7. Headache attributed to other disorder of homoeostasi s 16

17. B- Secondary Headaches 11. Headache or facial pain attributed to disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth or other facial or cranial structures, including: 11.2.1 Cervicogenic headache 11.3.1 Headache attributed to acute glaucoma 12. Headache attributed to psychiatric disorder 17

18. Secondary H eadache Definition Secondary headaches are usually of recent onset and associated with abnormalities found on clinical examination. Laboratory testing or imaging studies confirm the diagnosis. 18

19. Secondary Headache Definition Recognizing headaches related to an underlying condition or disease is critical : because treatment of the underlying problem usually eliminates the headache the condition causing the headache may be life-threatening. 19

20. C- Cranial Neuralgias, Central and Primary Facial Pain and Other Headaches 13. Trigeminal neuralgia 14. Other headache, cranial neuralgia, central or primary facial pain 20

21. Headache in Primary Care 21

22. Taking a Diagnostic History The history is all-important in the diagnosis of the primary headache disorders and of medication-overuse headache There are no useful diagnostic tests. The history should elicit any warning features of a serious secondary headache disorder . 22

23. Warning F eatures in H istory Any new headache in an individual patient, or a significant change in headache characteristics, should be treated with caution. " I have never had a headache like this before " " This is the worst headache I have ever had" 23

24. Specific W arning F eatures in History (1/5) Thunderclap headache ( intense headache with “explosive” or abrupt onset ) ͢→ subarachnoid hemorrhage) Estimated prevalence of subarachnoid hemorrhage in the setting of thunderclap headache is 43% 24

25. Specific W arning F eatures in History (2/5) Headache with atypical aura ( duration >1 hour, or including motor weakness ) ͢→ symptoms of transient ischemic attack (TIA) or stroke Aura without headache in the absence of a prior history of migraine with aura ͢→ symptom s of TIA or stroke Aura occurring for the first time in a patient during use of combined oral contraceptives ͢→ r isk of stroke 25

26. Aura is a subjective sensation or motor phenomenon that precedes and marks the onset of a neurological condition, particularly an epileptic seizure or m igraine 26

27. Specific W arning F eatures in H istory (3/5) New headache ; in a patient older than 50 years → symptom ͢of temporal arteritis or intracranial tumour , in a pre-pubertal child ͢→ requires specialist referral and diagnosis in a patient with a history of cancer, HIV infection or immunodeficiency ͢→ secondary headache 27

28. Specific W arning F eatures in History (4/5) Progressive headache , worsening over weeks or longer ͢→ intracranial space-occupying lesion Headache aggravated by postures or maneuvers that raise intracranial pressure ͢→ intracranial tumour , CNS infection 28

29. Specific W arning F eatures in H istory (5/5) Headache first occuring with exercise ͢→ ruptured aneurysm Headache hours to weeks after a history of trauma , especially in an older person ͢→ subdural hematoma Similar new onset of headaches in an acquaintance or family member ͢→ environment exposure such as carbon monoxide 29

30. Questions to A sk in the H istory (1/7) How many different headache types does the patient have? A separate history is needed for each. Any change in character or intensity? Is this your first or worst headache ? Is this headache like the ones you usually have ? 30

31. Questions to A sk in the H istory (2/7) Time questions Why consulting now? How recent in onset? When did this headache begin ? How did it start ( gradually , suddenly , other )? How frequent, and what temporal pattern (episodic or daily and/or unremitting)? Do you have headaches on a regular basis ? How long lasting? 31

32. Questions to A sk in the H istory (3/7) Character questions Intensity of pain ? How bad is your pain on a scale of 1 to 10? N ature and quality of pain ? What kind of pain do you have ( throbbing , stubbing , dull , other )? Site and spread of pain ? Where is your pain ? Does the pain seem to spread to any other area ? If so , where ? 32

33. Questions to A sk in the H istory (4/7) Character questions Associated symptoms? What symptoms do you have before the headache starts ? What symptoms do you have during the headache ? What symptoms do you have right now ? 33

34. Questions to A sk in the H istory (5/7) Cause questions Predisposing and/or trigger factors? Aggravating and/or relieving factors? Family history of similar headache? 34

35. Common Headache Triggers Alcohol Caffeine Food additives ( MSG , aspartame, tyramine (found in aged cheeses , some red wines, smoked fish, etc .), sodium nitrite (found in processed meats ). 35

36. Common Headache Triggers Foods ( Chocolate, fruits, dairy, onions, beans, nuts ) Environmental changes ( Light, odors (perfume, paint, etc.), travel, abrupt changes in weather or altitude ) 36

37. Common Headache Triggers Lifestyle factors ( Insufficient, excessive, disrupted, or irregular sleep; tobacco or alcohol use; fasting; physical activity; head injury; schedule changes; stress or release from stress; anger; or exhilaration ) Hormone changes, or addition of estrogen- containing medication ( Timing of headache with menses or change/ addition of hormones ) 37

38. Questions to A sk in the H istory (6/7) Response questions What does the patient do during the headache? How much is activity (function) limited or p revented ? What medication has been and is used, in what manner and with what effect? Do you take any medicines ? If so , what ? 38

39. Questions to A sk in the H istory (7/7) State of health Completely well, or residual or persisting between attacks symptoms? Concerns, anxieties, fears of recurrent attacks and/or their cause? Do you have other medical problems ? If so , what ? Have you recently hurt your head or had a medical or dental procedure ? 39

40. Diagnostic D iary Once serious causes have been ruled out, a headache diary kept over a few weeks clarifies the pattern of headaches and associated symptoms as well as medication use or overuse. 40

41. Physical E xamination Physical examination is mandatory when the history is suggestive of secondary headache. General appearance , Does s/he look unwell? V ital signs , Measure BP Head and neck exam including palpation Neurological exam incl uding fundoscopy ENT exam , Ophtalmologic exam (astigmatism, glocoma) 41

42. Warning F eatures on E xamination P yrexia  Blood Pressure ( sist >200 mmHg / diast >120 mm Hg )  hypertensive encephalopathy , A palpable tender temporal artery  Temporal arteritis Papilledema  increased intracranial pressure 42

43. Warning F eatures on E xamination F ocal neurological signs Stiff neck , rush , fever , photophobia , vomiting and other systemic signs  meningitis , encephalitis H eadache aggravated by postures or maneuvers rais ing intracranial pressure  intracranial tumour , subdural hematoma , epidural bleeding 43

44. Investigations Investigations, including neuroimaging, are indicated when the history or examination suggest headache may be secondary to another condition. 44

45. Primary H eadaches The most common primary headaches in primary care are: Migraine (with aura / without aura) Tension-type headache Cluster headache Medicine-associated headache 45

46. M igraine E pisodic attacks with specific features of which nausea is the most characteristic. Attack frequency between once a year and once a week (most commonly once a month). I n children, attacks tend to be of shorter duration and abdominal symptoms more prominent. 46

47. Migraine without aura : IHS criteria 5 attacks of Headache lasting 4-72 hours. Must be associated with nausea or vomiting or photophobia and phonophobia Must have 2 of the following Unilateral Pulsating Moderately / severe . Aggravated by physical activity 47

48. Migraine P rimary headache disorder with genetic basis . Activation of a mechanism deep in the brain causes release of pain-producing inflammatory substances around the nerves and blood vessels of the head. Why this happens periodically, and what brings the process to an end in spontaneous resolution of attacks, are to a large extent uncertain. 48

49. M igraine Starting at late childhood or puberty, Affects those aged between 35 and 45 years but also younger people, including children. Prevalence in Europe and America: 6-8% in men and 15-18% in women Prevalence in Turkey: 10% in men and 22% in women. 49

50. Migraine In children : attacks may be shorter-lasting headache is more commonly bilateral and less usually pulsating gastrointestinal disturbance is more prominent. 50

51. Migraine with typical aura Migraine with aura affects one third of people with migraine and accounts for 10% of migraine attacks overall. Aura is a subjective sensation or motor phenomenon that precedes and marks the onset of a neurological condition, particularly an epileptic seizure or m igraine 51

52. Migraine with typical aura Characterized by aura preceding headache, one or more neurological symptoms that develop gradually over >5 minutes and resolve within 60 minutes : • hemianop t ic visual disturbances, or a spreading scintillating scotoma (patients may draw a jagged crescent if asked) and/or unilateral paresthesia of hand, arm and/or face and/or (rarely) dysphasia. 52

53. Migraine with typical aura Diagnostic Criteria Aura consisting of at least one of the following, but no motor weakness: Fully reversible visual symptoms including positive features (e.g., flickering lights, spots, or lines) and/or negative features (i.e., loss of vision) Fully reversible sensory symptoms including positive features (e.g., pins and needles) and/or negative features (i.e., numbness) Fully reversible dysphasic speech disturbance _______________________________________________________________________________________________ Headache begins during the aura or follow the aura within 60 minutes _______________________________________________________________________________________________ Diagnostic Criterion: Must have at least 2 attacks fulfilling the above criteria and no signs of Secondary headache disorder 53

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56. Scintillating scotoma 56

57. Tension-type headache Pericranial tenderness Headache usually generalized most intense about neck or back of the head No focal neurologic symptoms Nonspesific symptoms No family history 57

58. Tension-type headache Most common headache 25-35% Most misdiagnosed headache Age: ≥ 20 Gender : F / M = 3 / 1 Mild to moderate in severity, often self-treated 58

59. Tension-type headache Triggering factors Physical and / or psychological stress Noise Glare Changes in sleep or nutrition Menstruation Bad posture Oromandibulary disturbances 59

60. Tension-type headache Associating symptoms Sensitivity in head and neck muscles Sleep disturbances Balance disturbances Limitation in conjugated eye movements Psychiatric disorders 60

61. Tension-type headache Inf requent episodic tension-type headache F requent episodic tension-type headache C hronic tension-type headache Probable tension-type headache 61

62. Cluster headache occurs in two subtypes, Episodic cluster headache occurs in bouts (clusters), typically of 6-12 weeks’ duration, once a year or two years, and then remits until the next cluster. Chronic cluster headache , which persists without remissions (>12 months or remission <14 days), is less common. It may develop from and/or revert to episodic cluster headache. 62

63. Cluster headache mostly affects men manifests as strictly unilateral, excruciating pain around the eye recurs frequently, typically once or more daily, commonly at night is short-lasting, for 15-180 minutes ( typically 30-60 minutes ) 63

64. Cluster headache has highly characteristic and strictly ipsilateral autonomic features including any of: - red and watering eye - running or blocked nostril - ptosis c auses marked agitation (the patient, unable to stay in bed, paces the room, even going outdoors) 64

65. Triggering factors Alcohol intake Medication (sublingual nitroglycerine) Hunger Stress Climate change Allergies Hormonal changes 65

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67. Medication-overuse headache a chronic daily headache syndrome, is an aggravation of a prior headache (usually migraine or tension-type headache) by chronic overuse of medication taken to treat headache or other pain. All acute headache medications may have this effect . 67

68. M edication -overuse headache Frequency, regularity and duration of intake are important determinants of risk. A history can be elicited of increasingly frequent headache episodes, with increasing medication use, over months to many years. 68

69. Medication-overuse headache is associated with: regular use of simple analgesics on ≥15 days a month and/or - regular use of opioids, ergots or triptans , or any combination of these, on ≥10 days a month occurs daily or near-daily is present – and often at its worst – on awakening in the morning 69

70. M edication -overuse headache is initially aggravated by attempts to withdraw the medication. Diagnosis of medication-overuse headache is confirmed if symptoms improve within 2 months after overused medication is withdrawn. 70

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72. Acute O nset H eadache Sufficient evidence from retrospective and prospective studies to support the association of an acute sudden onset headache with a vascular event. Sudden onset headache is a red flag Critical issues in the evaluation and management of patients presenting to the emergency department with acute headache: Annals of Emerg Med 2002 (1):39. 72

73. Life Threatening C auses of A cute H eadaches Vascular events Intracranial hemorrhage Subdural hemorrhage Subarachnoid h emorrhage Thrombosis, Vasculitis, Malignant hypertension Arterial dissection Aneurysm 73

74. Life Threatening C auses of A cute H eadaches Infections Abscess Encephalitis Meningitis 74

75. Life Threatening C auses of A cute H eadaches Intracranial masses Preeclampsia Carbon monoxide poisoning 75