approach to headaches
DESCRIPTION
Approach to headacheTRANSCRIPT
BYDR. SUBHASISH DEB
B U R D W A N M E D I C A L C O L L E G E A N D H O S P I T A L( D E P A R T M E N T O F I N T E R N A L M E D I C I N E )
APPROACH TO HEADACHE
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HEADACHE= CEPHALALGIA
Definition:
“Diffuse pain in various parts of the head, not confined to the distribution of any nerve”
(source: Steadman’s Pocket Medical Dictionary)
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WHAT ACHES?
PAIN SENSITIVE STRUCTURES:
1. Scalp
2. Middle meningeal artery
3. Dural sinuses
4. Falx cerebri
5. Proximal segment of large pial arteries
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WHAT DOESN’T ACHE?
Pain insensitive structures:
1. Ventricular ependyma
2. Choroid plexus
3. Pial veins
AND
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WHAT ABOUT BRAIN PARENCHYMA?
Most of the brain parenchyma is INSENSITIVE to pain
HOWEVER, the region of the dorsal raphe in the MID BRAIN is sensitive to pain.
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TRANSMISSION OF PAIN
Sensory stimuli from head CNS
Supratentoralstructures in anterior
and middle cranial fossa
Posterior cranial fossaand infratentorial
structures
TRIGEMINAL NERVE C1, C2, C3
Cervical spinal n
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What happens?
MECHANISM OF HEADACHES
1. Distention/traction/dilatation of intracranial or extracranial arteries
2. Traction/displacement of large i.c. veins/ their dural envelopes
3. Compression/traction/inflammation of cranial and spinal nerves
4. Spasm/inflammation/trauma to cranial and cerivalmuscles
5. Meningial irritation and raised icp
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CLASSIFICATION
Primary headache
Secondary headache
• Symptom based•No organic causes
•Etiology based
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PRIMARY HEADACHES
1. Migraine
2. Tension-type headache
3. Trigeminal autonomic cephalalgias (including cluster headaches)
4. Other primary headache disorders Cough
Exertional
Headache associated with sexual activity
Hypnic
Primary thunderclap
Hemicranial continua
New daily-persistent headache
-ISH Cefalalgia 2013
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PRIMARY HEADACHE TYPES
MIGRAINE TENSION CLUSTER
Pain Description
Throbbing, Moderate to severe,Worse with exersion
Pressure,Tightness,Waxes and wanes
Abrupt onset, deep, continuous, excruciating, explosive.
Associated Symptoms
Photo/phonophobia,Nausea/vomiting,Aura
NONE Tearing, congestion, rhinorrhea, pallor, sweating
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PRIMARY HEADACHE TYPES
MIGRAINE TENSION CLUSTER
Location 60-70% Unilateral Bilateral Unilateral
Duration 4-72 hrs Variable 0.5 -3 hrs, many per day
Patient Appearance
Resting in quiet dark room,
Young female
Remains active or prefers to rest
Male, smoker,
Remains active, prefers hot showers.
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10/14/2014Dr Subhasish Deb
10/14/2014Dr Subhasish Deb
MIGRAINE
It is the second most common cause of headaches (m/c is tension type headache)1
Often can be recognized by its activators= TRIGGERS
-light, sound, stress, hunger, menstruation, stormy weather, lack or
excess of sleep, barometric pressure change, alcohol
basis of life style adjustments
A headache diary is often useful in making diagnosis, assessing disability and frequency of treatment for acute attacks
1 Harrison’s Principles of Internal Medicine 18thed
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10/14/2014Dr Subhasish Deb
Types of Migraine
1. Without Aura (Common migraine) = 80%
2. With Aura (Classic migraine) =20%
3. Migraine varients Basilar migraine
Retinal migraine
Ophthalmoplegic migraine
Migraine with complicated aura
Migrainous stroke
Migraine aura without migraine (Acephalalgic migraine)
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Classic Migraine
Potential phases of migraine attack
1. Prodrome – occurs hours to days before headache, change in
mood, behaviour, appetite, cognition
2. Aura- occurs within 1 hour of headache, most commonly visual
or sensory
Visual aura
Most common
Consists of photopsias, bright flashing lights, scintilating scotomas, field cuts and fortification spectra(zig zag lines/ Teichopsia)
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Sensory aura
Numbness and paresthesiae in a limb
Motor weakness and aphasia are less common
3. Headache
4. Recovery
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10/14/2014Dr Subhasish Deb
10/14/2014Dr Subhasish Deb
Common Migraine
Symptoms similar to classical migraine but without aura
Precipitating factors:
Foods rich in tyramine ( cheese, redwine)
Foods containing monosodium glutamate (Chinese and Mexican food)
Foods containing nitrates ( salami, smoked meat)
Caffeinated beverages (soft drinks, tea and coffee)
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MIGRAINE VARIENTS
Basilar migraine a/k bickerstaff syndrome, brainstem migraine, basilar artery
migraine, vertebrobasilar migraine
This disorder is now called Migraine with Brain stem Aura(MBA)
rare form of migraine with aura wherein the primary signs and symptoms seem to originate from the brainstem, without evidence of weakness. (d/d- FHM)
Originally described by Bickerstaff in 1961 as a distinct clinical entity
Brain stem aura: Dysarthria, vertigo, hyperacusis, diplopia, visual symptoms in both temopral and nasal fields, decreased level of conciousness.
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Retinal migraine:
a/k ocular migraine
Characterized by retinal or optic nerve ischemia
Other migraines affect eyesight in both eyes but here typically single eye is affected.
Mono ocular blindness, disc edema occurs and vision recovers only partially after several months
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Ophthalmoplegic migraine:
Characterized by recurrent unilateral headaches associated with weakness of extra ocular muscles.
Transient 3rd nerve palsy with ptosis with/without involvement of the pupil is the usual picture.
6th nerve is early effected common in children
Paresis may persist even after headache for days to weeks
Occasionally opthalmoperesis may remain permanent
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Complicated migraine
a/k migranous infarction
Here, the temporary neurologic symptom of migraine headache may remain permanent.
Ex: a homonymous visual field defect
In children with mitochondrial disease MELAS (Mitochondrial myopathy, Encephalopathy, Lactic Acidosis and Stroke like symptoms)
And in adults with very rare vasculopathy :
CADASIL (Cerebral Autosomal Dominant Arteriopathy with Subcortical infarcts and Leukoencephalopathy
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Tension type headache
Describes a chronic head-pain syndrome characterized by bilateral, tight, band like discomfort
Pain builds up slowly, persists more or less continuously for days
When present > 15days/month- chronic TTH
Featureless
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<180/year (<15/month)
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Trigeminal Autonomic Cephalalgias
Characterized by relatively short lasting attacks of head pains associated with autonomic symptoms-lacrimation, conjunctival injection or nasal congestion
Includes:
1. Cluster headache
2. Paroxysmal hemicrania
3. SUNCT/SUNA
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Cluster headache
A rare form of headache with a population freq 0.1%
Pain is:
Deep, usually retroorbital
Excruciating in intensity
Non fluctuating
Explosive in quality
CORE feature = PERIODICITY
At least one of the daily attacks of pain recurs in the same hour each day for the duration of cluster bout
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Typically pts has daily bouts of 1-2 attacks of short duration, unilateral pain for 8-10 weeks a year
Followed by pain free interval that lasts less than a year
Associated with ipsilateral symptoms of cranial parasympathetic autonomic activation
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10/14/2014Dr Subhasish Deb
Paroxsymal Hemicrania
Frequent unilateral, sever short lasting episodes of headache
Like cluster, pain tends to be retroorbital, autonomic symptoms
A characteristic feature is its EXCELLENT response to INDOMETHACIN. (cluster headaches respond to 100% O2 therapy)
In contrast to cluster headaches, here the male : female ratio is 1:1
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SUNCT/SUNA
Short lasting Unilateral Neuralgiform headache attacks with Conjunctival injection and Tearing
Diagnosis requires: At least 20 attacks, lasting 5-240sec
Ipsilateral conjunctival injection and lacrimation should be present
Characteristics are: Lack of response to INDOMETHACIN
A lack of refractory period to triggering between attacks
Presence of cutaneous triggers of attacks
d/d- trigeminal neuralgia
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SECONDARY HEADACHE TYPES
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CLINICAL APPROACH TO THE PATIENT
History, history, history (Headache diary)
Site
Onset
Character
Radiation
Associated symptoms
Timing
Exacerbating and relieving factors
Severity
Sate of health between attacks
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HISTORY
SITE
Extra Cranial
Intra Cranial
vascular
Giant cell arteritis – precise location
PNS. Ocular, Dental, Uppercervical verebrae
Less sharply localized but still regionally distributed
Anterior and mid cranial fossa
Fronto-temporal pain
Posterior cranial fossa
Occipitonuchal pain
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hrs-days
ONSET
Ruptured aneurysm
Migraine Cluster Headache
Thunderclap headache
hrs3-5 mins
45mins taper
Relieved by sleep
Brain tumours / raised ICP: headaches that disturb sleep/ early morning headaches
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ONSET
Early morning headache on waking up and again at the end of day is dues to Maxillary sinusitis (diurnal variation)
Office headache: due to Frontal sinusitis
[patient wakes up mostly without pain due to overnight drainage, develops pain after a few hours that lasts throughout the day]
Vacuum headache: the headache on waking up that may occur in Frontal sinusitis due to over night drainage
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Dull aching pain: sinusitis related
Tension type: tight ‘band like’ pain
Migraine: throbbing with tight muscles around head, neck and shoulder girdle. Aslo w/w.o aura.
CHARACTER
10/14/2014Dr Subhasish Deb
Most important aspect of pain from patients point of view.
But it rarely has any diagnostic importance!
Can often be misleading since even a brain tumourneed NOT present with severe/distinctive pain.
INTENSITY
10/14/2014Dr Subhasish Deb
Chronic daily headache without migranous or autonomic features- tension type
Migrane- peakes within 1-2 hrs of onset and lasts typically 4-72 hrs
Cluster headache- peaks at onset or within minutes, lasts for 15-180 mins
Chronic paroxysmal hemicrania- similar to cluster but last 2-30 mins with several episodes in a day
TEMPORAL PROFILE
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Cluster- Almost have a clock like periodicity and awakes the patient from sleep
Hypnic headaches- also awaken pts from sleep but are more diffuse and there are no associated autonomic symptoms
Migraine- any time of the day
Chronic tension type- present during day and is most severe in the latter part of the day
TIME OF DAY
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Worsening of headache on coughing or physical jolt indicated an intra cranial component
Worsening in upright position suggests intracranial hypotension
Worsening on routine physical activity, light, sound – migraine attacks
AGGRAVATING FACTORS
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PHYSICAL EXAMINATION
Vital sign along with body temperature
General appearance- whether restless or calm in a dark room (cluster vs migraine)
Palpation of ipsilateral temporal artery for tenderness, tm joint for crepitance while pt closes or opens jaw
Area over infected sinus may be tender
Pseudotumor cerebri- often seen in young obese females
Eye and periorbital area- lacrimation, conjuctivalinjection, flushing (TACs vs glaucoma)
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Pupillary size and light responses, extra ocular muscles, visual acuity
Fundus- papilledema and retinal pulsations
Neck for rigidity, kernig, brudzinski signs
Cervical spine palpated for tenderness
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INVESTIGATIONS
Most patients can be diagnosed without testing, however some serious disorders may require urgent testing
CT and MRI should be done in pts with the following findings: Thunderclap headache
Altered mental status
Meningismus
Palliledema
Signs of sepsis
Acute focal neurological deficit
Sever hypertenstion (SBP>220, DBP>120)
-API Medicine Update 2013 Chap 113
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If meningitis, SAH, or encephalitis is being considered- CSF study if not contraindicated
For acute angle closure glaucoma: tonometry, slit lamp shows shallow ant. Chnaber, h/0- nausea, visual hallows.
ESR- in patients with visual symptoms, jaw or tongue claudications- giant cell arteritis
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RED FLAGS
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Sinusitis vs Migraine
SUMMIT STUDY:
Prospective multi center observational study of 2,991 patients with self diagnosed or physician diagnosed sinus headache. Using the HIS migraine criteria, 80% of them had migraine
-Schreiber CP, et al. Archives of Internal Medicine
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SUMMARY
Headache is one symptom that may be a manifestation of a simple, benign problem like a tension headache or one of the life threatening fatal diseases like a Berry aneurysm
Acute and new onset headaches have a more serious prognosis than other types of onsets
So careful evaluation of the etiology is very essential.
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THANK YOU
10/14/2014Dr Subhasish Deb