mellss med yr3 headache
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Nur Amalina Aminuddin Baki082012100067
Headache
Introduction
1) Tension- type Headache2) Trigeminal Autonomic Cephalgias
a) Cluster headacheb) Paroxysmal hemicraniac) SUNCT/SUNA
3) Chronic Daily Headache4) Other Primary Headache
1) Tension type Headache Chronic head-pain
syndrome Diagnosis:
No nausea, vomiting, photophobia, phonophobia,
No throbbing sensation No aggravation with
movement Differential
diagnosis : MIGRAINE
Certain patient may have TTH with migraine
CharacteristicSite : Bilateral
Onset: Builds slowly
Character: Tight, bandlike discomfort
Timing: continuously for many days or episodic or chronic (>15 days/m).
Severity Flunctuates
1) Tension type Headache Pathophysiology :incompletely
understood. Due to a primary disorder of CNS pain
modulation or genetic .Treatment
Simple analgesics (acetaminophen, aspirin, or NSAIDs)
Relaxation Triptans in TTH with migraine. Chronic TTH :amitriptyline
2) Trigeminal Autonomic Cephalgias
Group of primary headaches Cluster headache Paroxysmal hemicrania Sunct /suna
Differential diagnosis: Sinus headache, trigeminal neuralgia, primary stabbing headache, and
hypnic headache Increased TACs presentation may be due to pituitary tumor.
CharactAssociation:
lacrimation, conjunctival injection,nasal congestion
Timing:
Short , occur > 1/d
Severity
Severe
a) Cluster Headache
Rare (0.1%.) M>F
Patients tend to move during attacks (pacing/ rocking/ rubbing their head for relief)
Unilateral photophobia/ phonophobia on the same side of the pain
S •Unilateral,retroorbital,
O •50% nocturnal , explosive
C •deep , stabbingA •ipsilateral conjunctival injection/
lacrimation /rhinorrhea /nasal congestion / ptosis
T •recurs at same hour for same duration•daily 1-2 short attacks X 8 - 10 w/y followed by a pain-free interval (<1y)•Chronic ( no period of sustained remission)
S •excruciating ,nonfluctuating,
Treatment :Cluster Headache
Acute attack 100% oxygen
at 10-12L/min for 15-20min
Sumatriptan 6mg SC
Nasal sprays▪ Sumatriptan
(20 mg) ▪ zolmitriptan (5
mg)
Short –term prevention
Long-term prevention
Episodic cluster headache
Episodic & prolonged chronic cluster headache
Prednisone 1 mg/kg up to
Verapamil 160–960 mg/d
60 mg qd, tapering
Lithium 400–800 mg/d
over 21 days Methysergide 3–12 mg/d Topiramate 100–400 mg/d
Methysergide 3–12 mg/d
Gabapentin 1200–3600 mg/d
Verapamil 160–960 mg/d
Melatonin 9–12 mg/d
Ergotamine 1-2mg
Deep brain stimulation of posterior hypothalamus
b) Paroxysmal Hemicrania Male:female ratio is 1:1. Treatment
Indomethacin (25–75 mg tid), Topiramate Piroxicam
Secondary PH If patient requires high doses
indomethacin (>200 mg/d) Sella turcica lesions
(arteriovenous malformation, cavernous sinus meningioma, epidermoid tumors.)
Bilateral PH Raised CSF pressure
Charact.Site : Unilateral , retroorbital
Association:
lacrimation and nasal congestion
Timing:
Frequent(>5/d) , short ( 2-45min) and rapid course(<72h)
Severity
excruciating
c) SUNCT/SUNASUNCT (short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing)SUNA (short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms)
Basic patterns short-lived single stab groups of stabs a longer attack ("saw-tooth" )
Differential diagnosis trigeminal neuralgia (TN)
Secondary (Symptomatic) SUNCT Posterior fossa or pituitary lesions. Pituitary function tests ,brain MRI
Charac.Site : unilateral orbital
or temporalCharacter:
stabbing or throbbing
Association:
ipsilateral conjunctival injection and lacrimation
Timing: >20 attacks, lasting for 5–240s , no refractory period
Exacerbating factors:
Cutaneous triggers
Severity severe
TREATMENT: SUNCT/SUNA Abortive Therapy
IV lidocaine(hospitalized patients.) to arrest symptoms
Preventive Therapy Goal:minimize disability
and hospitalization Medical approaches▪ Lamotrigine, 200–400 mg/d. ▪ Topiramate and gabapentin.▪ Carbamazepine, 400–500
mg/d
Surgical approaches ▪ Microvascular
decompression or destructive trigeminal procedures
▪ Greater occipital nerve injection
▪ Occipital nerve stimulation ▪ deep-brain stimulation of
the posterior hypothalamic region
Short-term prevention (intractable cases) ▪ IV lidocaine ▪ occipital nerve stimulation.
Cluster Headache
Paroxysmal Hemicrania
SUNCT
Gender M > F F = M F ≈MType Stabbing, boring Throbbing, boring,
stabbingBurning, stabbing, sharp
Severity Excruciating Excruciating Severe to excruciating
Site Orbit, temple Orbit, temple PeriorbitalAttack frequency
1/alternate day–8/d
1–40/d (>5/d for more than half the time)
3–200/d
Duration 15–180 min 2–30 min 5–240 sAlcohol trigger
Yes No No
Cutaneous triggers
No No Yes
Abortivetreatment
Sumatriptan injection or nasal sprayOxygen
No effective treatment
Lidocaine (IV)
Prophylactictreatment
Verapamil MethysergideLithium
Indomethacin Lamotrigine TopiramateGabapentin
3) Chronic Daily Headache >15days/month
Primary Secondary<4 h Daily >4 h Daily Posttraumatic
• Head injury• Iatrogenic• Postinfectious
Chronic cluster headache
Chronic migraine
Chronic paroxysmal hemicrania
Chronic tension-type headache
Inflammatory• Giant cell arteritis• Sarcoidosis• Behçet's syndrome
SUNCT/SUNA Hemicrania continua Chronic CNS infectionHypnic headache New daily persistent
headacheMedication-overuse headache
If it is a medically intractable disabling CDH Occipital nerve
stimulation
a) Primary CDH <4h daily : Hypnic Headache
Most are female Onset >60 years. Differential diagnosis:
Poorly controlled hypertension. Treatment:
Lithium carbonate (200–600 mg) at bedtime
Verapamil (160 mg) Methysergide (1–4 mg at
bedtime) One to two cups of coffee
/caffeine, 60 mg orally, at bedtime
Flunarizine, 5 mg nightly.
Charac.
Site :
Uni/bilateral
Onset:
a few hours after sleep
Character:
generalized /throbbing
Timing:
15 – 30 min , <3 repetitions/ night
Severity
moderately severe
b) Primary CDH >4h daily : Hemicrania Continua
Essential features : Moderate , continuous unilateral pain with fluctuations of severe
pain Complete resolution of pain with indomethacin Associated with conjunctival injection, lacrimation, and
photophobia on same side Age of onset :11 to 58 years. Woman: man = 2:1
Treatment IM injection of 100 mg indomethacin Oral indomethacin (initial,25 mg tid, then 50 mg tid,75 mg Topiramate Patients unable to tolerate indomethacin ▪ Occipital nerve stimulation
c) Primary CDH >4h daily : New Daily Persistent Headache
Abrupt onset / gradual
Primary NDPH Migrainous type
unilateral headache,throbbing pain, nausea, photophobia, phonophobia
Treatment :preventive therapies of migraine
Featureless type refractory to treatment
86% headache-free after 2 years
Primary NDPH
Secondary NDPH
Migrainous-type
Subarachnoid hemorrhage
Featureless (tension-type)
Low CSF volume headache
Raised CSF pressure headachePosttraumatic headacheChronic meningitis
Secondary NDPHi. Low CSF Volume
Headache Dull, throbbing
occipitofrontal headache that not present on waking up , worsen as day progress and relieved by recumbency position
Cause : CSF leak after lumbar puncture
(within 48 h -12 d) index events (epidural injection
or vigorous Valsalva maneuver)
Differential diagnosis: Postural orthostatic tachycardia
syndrome [POTS ]
Investigations: Brain MRI -diffuse
meningeal enhancement, chiari malformation
Spinal MRI, CT Treatment
Bed rest IV caffeine (500 mg in 500
ml saline administered over 2 h)
Abdominal binder Autologous blood patch Oral
theophylline(intractable pain)
Secondary NDPHii. Raised CSF Volume Headache Generalized headache present on waking and improves as the
day goes on, worse with recumbency.
Investigations Funduscopy-papilledema MRI, including an MR venogram Lumbar puncture
Differential diagnosis: Obstructive sleep apnea Poorly controlled hypertension Idiopathic intracranial hypertension without visual problems
Treatment Acetazolamide (250–500 mg bid) Topiramate Severe disabled patient that do not respond to medication -intracranial pressure
monitoring ,shunting
Secondary NDPHiii. Post-traumatic HeadacheHeadache that remit after several weeks or persist after the
trauma associated with dizziness, vertigo and impaired memory Injury to the head Carotid dissection and subarachnoid hemorrhage,and following intracranial surgery Infection (viral meningitis / parasitic infection)
Differential diagnosis: Chronic subdural hematoma Iatrogenic low CSF volume headache
Treatment Tricyclic antidepressants (amitriptyline) Anticonvulsants (topiramate, valproate, and gabapentin) MAOI (phenelzine) Resolves within 3–5 years
d) Secondary CDH: Medication – Overuse Headache
Increased headache frequency and induce - refractory daily headache due to overuse of analgesic for headache
Management : Outpatients Reduce and stop analgesic
(reduce dose by 10% every 1–2 w)
A small dose NSAID Naproxen, 500 mg bid
( overuse problems with more frequent dosing )
Preventive medication (when analgesic is stopped)
Management : InpatientsFailed at outpatient withdrawal/ significant medical condition
Withdrawn analgesics Antiemetics and fluids Clonidine (opiate withdrawal
) Aspirin 1 g IV (acute
intolerable pain during day) IM chlorpromazine (night) After effect of withdrawn
substance settles (3-5d) IV dihydroergotamine (DHE)
every 8 h for 5 days + 5-HT3 antagonists (ondansetron/ granisetron) or domperidone oral/ suppository
4) Other Primary Headachea) PRIMARY STABBING HEADACHE Features:
Stabbing pain Lasting from 1 to many seconds or minutes Occurring as a single or series of stab No associated cranial autonomic features No cutaneous triggering of attacks Recurrence at irregular intervals (hours to days). "Ice-pick pains" or "jabs and jolts." More common in patients with other primary headaches
(migraine, TACs, and hemicrania continua)
Treatment: Indomethacin (25–50 mg two to three times daily
4) Other Primary Headacheb) PRIMARY COUGH HEADACHE
Generalized headache that begins suddenly Lasts for several minutes Precipitated by coughing, preventable by avoiding coughing
Exclude serious etiology : Chiari malformation /any lesion causing obstruction of CSF
pathways /displacing cerebral structures. Cerebral aneurysm, carotid stenosis, and vertebrobasilar disease.
Can resemble benign exertional headache (patients is typically younger)
Treatment: Indomethacin 25–50 mg two to three times daily Lumbar puncture
4) Other Primary Headachec) PRIMARY EXERTIONAL
HEADACHE Features resembling both
cough headache and migraine Precipitated by any form of exercise Pulsatile 5 min - 24 h, Bilateral and throbbing at onset Migrainous features Prevented by avoiding excessive
exertion, Mechanism :unclear. ??? Possible etiologies:
Cardiac cephalgia Pheochromocytoma Intracranial lesions and stenosis of
the carotid arteries
Treatment: Modest and progressive
exercise regimens Indomethacin 25 to 150
mg daily Prophylactic
measures. Indomethacin (50 mg) Ergotamine (1 mg orally) Dihydroergotamine (2 mg
by nasal spray) Methysergide (1–2 mg
orally given 30–45 min before exercise)
4) Other Primary Headached) PRIMARY SEX HEADACHE
Dull bilateral headache that intensify at orgasm.
Prevented by ceasing sexual activity before orgasm.
Types : Dull ache in head and neck Sudden, severe, explosive
headache Postural headache after coitus
5–12% are caused by subarachnoid hemorrhage
Occur more in men than women Subside within 5min -2 h. ( In
patient who stop sexual activity when notice headache)
Subside within 6 months.
More common in patients with exertional headache and migraine
Treatment: Recur irregularly and
infrequently Reassurance and advice about
ceasing sexual activity Recurs regularly or
frequently Propranolol 40 to 200 mg/d Diltiazem, 60 mg tid. Ergotamine (1 mg) or Indomethacin (25–50 mg) 30–45
min prior to sexual activity
4) Other Primary Headachee) PRIMARY THUNDERCLAP
HEADACHE Differential diagnosis
Subarachnoid hemorrhage Cervicocephalic arterial
dissection Cerebral venous
thrombosis. Ingestion of tyramine-
containing foods in a patient taking MAOIs
Pheochromocytoma. If posterior
leukoencephalopathy present, ▪ Cerebral angiitis, ▪ Drug toxicity
(cyclosporine,methotrexate or cocaine)
▪ Postpartum angiopathy.
Excluding subarachnoid hemorrhage Patients do very well over
the long term. Some developed migraine
or tension-type headache. Investigations :
Neuroimaging (CT or, when possible, MRI with MR angiography)
CSF examination Cerebral angiography
Treatment with nimodipine
Conclusion
1) Tension- type Headache
2) Trigeminal Autonomic Cephalgias
a) Cluster headacheb) Paroxysmal hemicraniac) SUNCT/SUNA
3) Chronic Daily Headache
a) Primary (<4h/day and >4h/day)
b) Secondary
4) Other Primary Headache
a) Stabbing Headache
b) Exertional Headache
c) Cough Headached) Sex Headachee) Thunderclap
Headache
References Harrison’s Principle of Internal
Medicine, 18th Edition, Volume 1
Davidson’s Principles and Practice of Medicine, 22nd Edition
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