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Headache

Zheng Dongming

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The most common symptom in clinic the causes are myriad.

1.intracranial disease

2.extracranial disease

3.functional or psychological disease

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Pathophysiology of headache

Pain-sensitive structure: periosteum of the skull,skin,subcutaneous tissues muscles,blood vessels venous sinuses,dural arteries,arteries at the base

of the skull. The trigeminal,glossopharyngeal,vagus,the

second and third cervical nerves

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Principle :

1.history is very important in the diagnosis of headache.

2.physical examinatin 3.CT ,MRI,lumbar puncture.

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Migraine

Migraine is characterized by an episodic unilateral throbbing headache . It is a common idiopathic headache seen in clinic.

2/3~3/4 women onset early. 55% 20 years of age 90% 40 family histry

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Etiology Genetics:approximately three-quarters of patients

who suffer from migraine have close relatives similarly affected.

Endocrine and metabolic factors:menstruation. Cheese, chocolate, sherry and red wine are common precipitants.

Others:bright lights ,loud noise ,exercise ,hunger,emotional stress and anxiety

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Pathogenesis vascular theory:some studies e.g. PET scans of

migraineurs, suggest that the aura is due to an spreading area of vascoconstriction over the brain .there is some evidence that the headache in migraine is due to subsequent vasodilatation of blood vessels .the association of stroke with migraine supports a vascular aetiology.

neuronal theory: aura are associated with spreading neuronal inhibition which does not respect vascular territories .neuronal dysfunction could be the cause of the spreading vasoconstriction

5-HT.etc

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Clinical features A.migraine with Aura(classic Migraine) prodrome : a vague change in mood or appetite,sensitivity to

light and sound aura : visual disturbance: Scintillating scotoma, the visual

symptoms usually occupying one visual field, described as zig-zag patterns, flashing lights, crescents, motor or sensory disturbance.mins~1 hour

headache : the headache is often pulsatile and over one side , nausea and vomiting ,4~72 hours.

Resolution:weekness

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Clinical features B.migraine without Aura(commonic Migraine) most common one headache : the headache is often pulsatile and over one

side , nausea and vomiting ,4~72 hours.

C.special type basilar artery migraine hemiplegic migraine ophthalmoplegic migraine late onset migraine migraine equivalents

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ophthalmoplegic migraine

With ophthalmoplegic migraine syndrome, the headache localises around one eye and it is followed hours later by a IIIrd or VIth nerve palsy on that side. The nerve palsy gradually improves over several days or weeks.

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basilar artery migraine Basilar artery migraine is a variety of classical

migraine seen most commonly in young women and has an aura that is believed to be due to vertebro-basilar ischaemia.

Features of the aura may include:vertigo,dysarthria ,ataxia,diplopia ,bilateral visual impairment or sensory symptoms.

The proceeding headache is usually occipital.

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hemiplegic migraine

Hemiplegic migraine is a term used to describe the migraine syndrome that is associated with a weakness or sensory loss of the limbs on one side of the body. The headache usually precedes the weakness by a day or more. The limbs gradually return to normal over several days.Often there is a family history of this type of migraine, usually with an autosomal dominant inheritance.

It is a rare form of migraine.

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Diagnosis 1. Migraine is characterized by periodic headaches

which are typically unilateral and are often associated with visual disturbance and there is usually freedom of symptoms between attacks.

2. There is often a family history of migraine. 3. The nervous system examination is normal.

CT,MRI,MRA:normal. 4. Ergotamine is probably effective.

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Diagnostic criteria of common migraine

Migraine are episodes of headache lasting 4-72 hours with the following features:

two of the following: unilateral pain throbbing quality aggravated by movement moderate/severe pain one of the following: nausea/vomiting photo- or phonophobia

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differential diagnosisThe differential diagnosis of migraine is large, but includes: cluster headache carotidynia painful ophthalmoplegia hypertention,hypotention ,arteriovenous malformations dental caries ,sinusitis in the elderly, transient ischaemic attacks epilepsy tumours

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Treatment Mild:Aspirin,ibuprophen severe:Ergotamine,dihydroergotamine,codei

ne,clorpromazine. prophylactic

treatment:propranolo,flunarizine, Ergotamine,etc.precipitating factors.