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HEADACHE

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Episodic, lasting 4-72 h, associated with nausea and/or vomiting, photophobia ... and include mood changes eg elation, food cravings, thirst and excessive yawning. ... – PowerPoint PPT presentation

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Title: HEADACHE


1
HEADACHE
  • Southern Neurology

2
MIGRAINE
  • Migraine is derived from the word hemicrania or
    half-a-head
  • Episodic, lasting 4-72 h, associated with nausea
    and/or vomiting, photophobia and phonophobia and
    interferes with day-to-day functioning.
  • Headache has a throbbing or pulsatile quality and
    is often unilateral (2/3rds of patients) although
    may become generalised

3
IHS diagnostic criteria for migraine without aura
  • A. At least 5 attacks fulfilling B-D in the
    absence of another alternative disorder (eg
    metabolic, vascular, substance abuse)
  • Headache lasting 4-72 h (untreated or
    unsuccessfully treated)
  • Headache with at least 2 of following-
    unilateral, pulsating, moderate or severe
    intensity (inhibits daily activities) or
    aggravation by walking stairs or similar
    activity)
  • During headache at least one of (i) nausea and/or
    vomiting, or (ii) photophobia and phonophobia

4
Migraine epidemiology
  • Approximately 5 of men and 10-15 of women.
  • First attack occurs in majority during
    adolescence and early 20s. Uncommon to occur for
    first time after age 40 years. Remission common
    after menopause or in fifth and sixth decades.
  • 50-70 report a family history

5
Migraine other symptoms
  • Prodromal symptoms occur in 25-40 in the 24 h
    prior to a headache and include mood changes eg
    elation, food cravings, thirst and excessive
    yawning. Presumably of hypothalamic origin.
  • Hypersensitivity of scalp, hypersensitivity to
    smell
  • Auras blurring of vision or spots more common
    than fortification spectra which are experienced
    in 10-15. Paraesthesia is next commonest.
    Dysphasia and hemiparesis less common. Auras
    usually occur 1 hour prior to a migraine and last
    less than 1 hour.

6
IHS diagnostic criteria for migraine with aura
  • At lease 2 attacks fulfilling B
  • At least 3 of the following characteristics
  • One or more fully reversible aura symptoms
    indicating focal cerebral cortical and/or
    brainstem dysfunction.
  • At least one aura symptom develops gradually over
    more than 4 minutes, or 2 or more symptoms occur
    in succession.
  • No aura symptom lasts more than 60 minutes. If
    more than one aura symptom is present, accepted
    duration is proportionally increased.
  • Headache follows aura with a free interval of
    less than 60 minutes (but it may also begin
    before or simultaneously with aura).

7
Factors associated with an attack
  • Increased incidence on weekends and holidays
  • Menstrual pattern
  • Reduced frequency in first trimester of pregnancy
  • Stress (often as crisis is resolving)
  • Fasting or missing a meal
  • Certain foods eg chocolate, alcohol, cheese
  • Extreme changes in weather

8
Drug therapy
  • Acute attacks analgesics, NSAIDS, dopamine
    antagonists, ergotamines and triptans
  • Preventive therapy propranolol, tricyclic
    antidepressants, pizotifen, methysergide,
    valproate, natural therapies eg feverfew, high
    dose riboflavin ? Newer AEDs gabapentin and
    topiramate
  • ? Role of acupuncture etc

9
Unusual migraine manifestations
  • Migraine with prolonged aura aura lasts gt 60
    minutes and lt 7 days with normal neuroimaging.
  • Migrainous infarction (prev called complicated
    migraine) auras not fully reversible within 7
    days and/or neuroimaging confirmation of
    ischaemic infarction.
  • Status migrainosus attack lasts gt 72 h whether
    treated or not.
  • Childhood periodic syndromes abdominal migraine
    and cyclical vomiting, benign paroxysmal vertigo
    of childhood, alternating hemiplegia of childhood
    (typical age onset lt 18 months).
  • Familial hemiplegic migraine migraine with aura
    including hemiparesis with at least one affected
    first degree relative.

10
Other headaches Normal headaches
  • Excessive stimulation of scalp nerves eg wearing
    tight goggles, diving into cold water
  • Ice-cream headache holding very cold ice-cream
    in mouth or swallowing cold ice-cream.
    Increased frequency in migraineurs
  • Hot dog headache eating cured meats ? Nitrites
  • MSG
  • Hangover secondary to acetaldehyde/acetate
  • Fasting
  • Exertion

11
Tension headaches
  • Two to three times more common in women
  • Bilateral in 90
  • Dull and pressure-like some patients experience
    jabs of pain
  • 10 may also suffer from migraine
  • In up to 50 of patients, the headache is daily
  • If associated with regular analgesic usage
    consider diagnosis of headache induced by chronic
    substance use or exposure

12
IHS diagnostic criteria for episodic tension-type
headache
  • A. At least 10 previous headache episodes
    fulfilling B-D. Less than 180 attacks/yr
  • Headache lasts 30 minutes to 7 days
  • At least 2 of the following pressing or
    tightening quality (no-pulsating), mild to
    moderate intensity (may inhibit but does not
    prohibit activities), bilateral, no aggravation
    by walking stairs or similar routine activity
  • Both of the following (i) no nausea or vomiting
    (may have anorexia) (ii) photophobia and
    phonophobia are both absent (or one but not the
    other is present).
  • Chronic tension headache has same features but
    headache is present for at least 15 days a month
    during at least 6 months.

13
Headache induced by chronic substance use or
exposure
  • Occurs after daily doses of substance for gt 3
    months. Headache is chronic (15 days or more per
    month) and headache disappears within 1 month
    after withdrawal of substance.
  • Ergotamine induced headache preceded by daily
    ergotamine ingestion (oral ? 2mg, rectal ? 1mg).
  • Analgesic abuse headache (gt 100 tablets a month
    or aspirin or equivalent of other mild
    analgesics).
  • Caffeine withdrawal headache patient consumes
    caffeine daily and gt 15 g/month. Occurs witin 24
    h of last caffeine and is relieved within 1 hour
    by 100 mg caffeine.

14
Cluster headache
  • Severe, unilateral pain, orbitally,
    supraorbitally and/or temporally, lasting 15-180
    minutes, occurring from once every other day to 8
    times a day.
  • Bouts may last weeks or months (or so-called
    cluster periods) and then remit for months or
    years (average 1/year)
  • 80-90 are episodic (as above), 10-20 are
    chronic. 85 with episodic cluster headaches are
    males vs FgtM for chronic

15
IHS diagnostic criteria for episodic cluster
headache
  • At least 5 attacks fulfilling B-D
  • Severe unilateral orbital, supra-orbital and/or
    temporal pain lasting 15-180 minutes untreated.
  • Headache associated with at least one of the
    following signs conjunctival injection
    lacrimation nasal congestion rhinorrhea
    forehead and facial sweating miosis, ptosis,
    eyelid oedema.
  • Frequency once every other day to 8 per day.
  • Chronic refers to similar attacks but occurring
    for gt 1 year without remission or with remission
    lasting lt 14 days.

16
Cluster headache (continued)
  • Associated features Horners syndrome, nasal
    blockage and rhinorrhoea, conjunctival injection
  • Alcohol and vasodilators may trigger pain during
    an attack
  • Treatment acute 100 oxygen, ergotamines and
    triptans preventive ergotamines, methysergide,
    corticosteroids, verapamil, lithium

17
Chronic paroxysmal hemicrania
  • Attacks with same characteristics of pain and
    associated symptoms and signs as cluster headache
    but short lasting (2-45 minutes), more frequent
    (attack frequency 5 a day or more for more than
    half of the time), occur mostly in females and
    there is absolute effectiveness of indomethacin
    (150 mg or less).

18
Trigeminal neuralgia
  • FM 21
  • Most commonly after age 40 years
  • Pain affecting gums, cheek or chin as single or
    repeated stabs although in less than 5 forehead
    (CNV division 1) may also be affected
  • Important characteristics are pain intensity,
    brevity and tendency to recur in cycles
  • Pain never crosses to opposite side but may be
    bilateral in 3-5.
  • Majority are idiopathic although compression of
    trigeminal nerve by blood vessel in brainstem
    most likely cause (gt85). Tumour or angioma can
    be seen in up to 6 and lt5 of patients may have
    MS. Hence, MRI is diagnostic test of choice.

19
Other non-serious headaches
  • Post-herpetic neuralgia
  • Occipital neuralgia
  • Cervicogenic headaches
  • Analgesia rebound headaches
  • TMJ dysfunction
  • Sinusitis
  • Low pressure headache post lumbar puncture
  • BIH

20
Serious causes of headache
  • Raised ICP secondary to structural lesion eg
    haemorrhage or tumour
  • Subarachnoid haemorrhage
  • Meningo-encephalitis
  • Temporal arteritis
  • Cerebrovascular disease

21
Case history 1
  • 25 y.o.female
  • Previously well. No past medical history.
  • 1 day history of gradual onset generalised
    headache, throbbing quality
  • Vomited x 1, photophobia, phonophobia
  • ? Diagnosis
  • ? Investigation
  • ? Treatment

22
Case history 2
  • 80 year old female
  • 3 week history of intermittent but daily
    bifronto-temporal headache
  • Non-specific visual disturbances with episodic
    blurring
  • Associated myalgias
  • ? Diagnosis
  • ? Investigations

23
Case history 3
  • 35 year old male
  • Sudden onset of severe generalised headache
    whilst lifting weights at gym
  • Resolved within 10 minutes of ceasing activity
    but recurred at same level of activity if
    repeated
  • ? Diagnosis
  • ? Investigations
  • ? Treatment

24
Case history 4
  • 15 year old female
  • Non-specific generalised headache of gradual
    onset with visual obscurations and diplopia on
    lateral gaze
  • Past medical history acne treated with
    vibramycin
  • Clinical examination papilloedema
  • ? Diagnosis and investigations
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