Headaches

1
Headaches Facial Pain

• Refer to Chapter 2 of Clinical Neurology Textbook

2
Headaches and Facial Pain

• You should know
• Pathophysiology of HA
• Diagnostic exam procedures
• Differentiate Acute, Subacute, and Chronic types
  of HA onset
• 4 Categorizations of HA and example of each
• Characterize/Localize different types of HA

3
Headaches and Facial Pain

• Pathophysiology of HA
• 7th leading reason to seek medical care
• HA caused by any of the following
• Traction or distension of neuro-vascular tissue
• Displacement by SOL or blood (hemorrhage)
• Inflammation secondary to biochemical changes,
  infection, trauma, or disease (MS)
• Vascular Spasm secondary to hypertension,
  neurogenic source, vascular occlusion

4
Headaches and Facial Pain

• Pathophysiology of HA
• Ultimately most HAs are a result of the
  vaso-dilation and vaso-constrictive events.
• Diagnostic Exam Procedures
• Case History very important
• Physical Exams
• Special Imaging

5
Headaches and Facial Pain

• Three Types of HA Onsets
• Acute
• Time onset w/I 2-3 dys max
• Intensity severe
• Examples
• Subacute
• Time onset wks-mnths, may be an acute
  presentation
• Intensity not as severe
• Examples

6
Headaches and Facial Pain

• Three Types of HA Onsets
• Chronic/Recurrent
• Time onset usually years
• Intensity varied
• Examples

7
Headaches and Facial Pain

• Four Categories of HA
• Neurovascular Events
• Tension Cervical Spine Disease
• Metabolic
• Miscellaneous

8
Headaches and Facial Pain

• Localization Characterization of HA
• Location Unilateral or Bilateral
• Characteristics
• Pulsating, Tightness, Dull Steady,
  Sharp/Lancinating, Ice Pick
• Associated Symptoms
• Weight Loss
• Fever/Chills
• Dyspnea
• Visual Disturbances
• Nausea/Vomiting
• Photophobia

9
Specific Headaches
10
Headaches of Acute Onset

• Subarachnoid Hemorrhage (SAH)
• Background
• Aneurysms AVMs
• Pathology
• Pathophysiology
• Inc ICP distorts pain sensitive structures
• Sagittal Sinus
• Ant Middle Meningeal Arteries
• Dura _at_ base of Skull
• CN V, IX, X
• ICA
• Sensory Nuclei of the Thalamus

11
Headaches of Acute Onset

• Subarachnoid Hemorrhage (SAH)
• Clinical Presentation
• Signs Symptoms
• NEW, Sudden onset, LOC frequent, Vomiting stiff
  neck
• Lab Findings
• CT Lumbar Puncture
• Complications
• Reoccurnance doubles mortality rate
• Prognosis
• 20 DOA
• 25 die from initial bleed 20 from reoccurance
• Survival

12
Headaches of Acute Onset

• Infectious Headaches
• Background
• Meningitis and Encephalitis
• Pathology
• Pathophysiology

13
Headaches of Acute Onset

• Infectious Headaches
• Clinical Presentation
• Classic HA, Fever, Stiff Neck, Altered Level
  of Consciousness
• S/S can vary depending on age
• Neonate, Children Adults, Adults, Older
  generation
• Headache Presentation
• Diagnosis Management
• CSF analysis
• Referral to the ER

14
Headaches of Acute Onset

• Headaches Following Lumbar Puncture
• Background
• AKA Low Pressure Headache
• MC is lumbar puncture
• Pathophysiology
• Headache Presentation
• Clinical Pearl
• the more severe the HA, the more frequent it is
  assoc. w/ vertigo, nausea/vomiting, tinnitus
• The longer the pt is upright, the longer it takes
  for the HA to subside

15
Headaches of Acute Onset

• Coital Headaches
• Three Types Types I, II, III
• Clinical Presentation
• Type I
• Occurs as sexual excitement inc
• Dull ache, Occipital or Diffuse, Sever _at_ orgasm
• Type II AKA Vascular or Explosive
• Occurs _at_ orgasm
• Severe, throbbing, frontal or occipital, min-hrs
• Clinical Pearl
• Type III
• Occurs after coitus resembling a low pressure HA

16
Headaches of Subacute Onset

• Temporal Arteritis
• AKA Giant Cell Arteritis
• Pathophysiology
• T-cell mediated vasculitis
• Clinical Presentation
• Classic presentation is a 50 plus year old female
  with unilateral HA that is causing unilateral
  visual disturbance. Intensity is moderate to
  severe and will be insidious in onset.
• Other findings
• Jaw claudication
• NP or BP
• Bruits over temporal artery
• Blindness
• May be accompanied by polymyalgia rheumatica.

17
Headaches of Subacute Onset

• Temporal Arteritis
• Key exam procedures
• Note historical characteristics
• Temporal artery will be palpably enlarged and
  abnormally pulsating. May be able to hear a bruit
  upon auscultation
• Extremely elevated ESR (highly indicative)
• Temporal Artery Biopsy is conclusive study

18
Headaches of Subacute Onset

• Trigeminal Neuralgia
• AKA Tic Douloureux
• Facial Pain syndrome that effects the CN V
• Pathophysiology
• Demyelination of CN V or the ganglia
• Clinical Presentation
• WgtM
• Spares V1
• Unilateral w/ no HA
• Intense burning
• Face may distort tic

19
Headaches of Subacute Onset

• Postherpetic Neuralgia
• Neuralgia of the trigeminal nerve following
  herpes infection.
• Most commonly affects V1 as well as V2 V3
• This is the KEY difference between post-herpetic
  and trigeminal neuralgia.

20
Chronic Headaches

• Migraine Headaches
• Two types of migraines
• Classic
• Common
• Background
• 66-75 in females
• 90 start before age 40
• Pathophysiology
• Unknown

21
Chronic Headaches

• Migraine Headaches
• Clinical Presentation
• Common Findings of Common Classic
• Signs Symptoms
• Nausea/Vomiting
• Irritability
• Photo, Phono, Osmophobic
• Lassitude
• Four Phases
• Prodrome Days Hrs before
• Aura immediately precedes HA
• Headache
• Postdrome follows HA

22
Chronic Headaches

• Migraine Headaches
• Classic Type Clinical Presentation
• Characterization and Localization
• MC Unilateral, Frontal/Orbital-Temporal/Parietal
• Prodomal events Auras
• Scintillating scotomas
• Nausea disorientation/vertigo
• Photobia
• Frequency 1-2/wk
• Duration 2-4 hrs up to 12-24hrs
• Provoking Events physical or emotional stress

23
Chronic Headaches

• Migraine Headaches
• Common Type Clinical Presentation
• NO prodome events
• Common migraines are precipitated by certain
  dietary agents such as foods containing
  tyramines, MSG, nitrates, and caffiene. Foods
  high in artificial flavors and preservatives are
  most likely triggers.

24
Chronic Headaches

• Analgesic/Caffeine Withdrawal Headaches
• Associated with intake of high doses of caffeine
  and/or analgesics
• Pathophysiology
• Serum level drop
• Clinical Presentation
• Constant
• Atypical
• Afternoon
• Hx key

25
Chronic Headaches

• Cluster Headache
• Background
• 61 Male predilection
• MC begins late 20s
• Clinical Presentation
• Time Frequency
• Character
• Location
• Provoking Events
• Associated S/S

26
Chronic Headaches

• Tension-Type Headaches
• Background
• Diagnostic Requirements
• 10 previous HA lasting 30 min 7 days
• 2 of the following
• Pressure
• Mild-Mod severity
• Activity doesnt inc
• No gastrointestinal s/s
• No comb of photo or phonophobia
• Episodic vs Chronic
• Clinical Presentation
• Onset, Quality, Radiation, Location, Time

27
Chronic Headaches

• Cervicogenic Headaches
• Background
• Causes VCS, DDD, DJD, Whiplash
• Upper C-spine
• Must have postural distortions or degeneration
• Clinical Presentation
• Unilateral pain pattern
• Palpation

28
Chronic Headaches

• Cervicogenic Headaches
• Chiropractic care is preferred method of
  treatment.
• Management should include
• Spinal adjustments to improve segmental function
  of upper cervical spine and
• Postural rehab to correct for anterior head
  carriage.
• Myofacial release or other muscle therapy should
  be utilized to reduce myo-tension and spasms.

29
Miscellaneous HAs

• Headaches can occur due to dysfunction of the
  TMJ. This HA is associated with TMJ pain and
  limited jaw motion that may or may not have
  clicking/locking of TMJ.
• Dental infections, sinus infections and sinus
  masses such as nasal polyps will produce frontal
  pressure HAs.