Post on 27-Dec-2015
A&E(VMH)
Introduction
• It is usually a benign symptoms but occasionally it is manifestation of a serious illness such as brain tumour, SAH, meningitis or giant cell arteritis
A&E(VMH)
Pain……
• Pain occurs when peripheral nociceptors are stimulated in response to tissue injury, visceral dilatation or other factors
• Occurs when pain sensitive pathways are activated or damaged
A&E(VMH)
Pain sensitive structures of head
• Scalp,middle meningeal artery,dural sinuses,falx cereberi,proximal segments of large pial arteries
A&E(VMH)
Pain insensitive structures
• Ventricular ependyma, choroid plexus, pial veins & most of brain parenchyma
A&E(VMH)
• Sensory stimuli from head conjugated to CNS via trigeminal nerves for structures above the tentorium in the anterior & middle fossa of the skull
• Via first three cranial nerves for those in post fossa & inferior surface of tentorium
A&E(VMH)
Head ache occur…..
• Distension, traction/ dilatation of intracranial or extra cranial arteries
• Traction or displacement of large intracranial veins or their dural envelope
• Compression, traction or inflammation of cranial & spinal nerves
A&E(VMH)
• Spasm , inflammation or trauma to cranial & cervical muscles
• Meningeal irritation & raised ICP
• Activation of brain stem structure
A&E(VMH)
Approach to patient with head ache
History – head ache
• Pattern
• Onset
• Location
• Associated symptoms
• Other history
• Family history
A&E(VMH)
scenario
• A 30 yr old female presented to ER
• B/Lhead ache after heavy exercise ,
• head ache more over the base of the skull
• not associated with any other symptoms
A&E(VMH)
Tension head ache
• Most frequently occuring type
• Physical & emotional stress
• Contraction of muscles that cover the skull
A&E(VMH)
Clinical features
• Pain at back of head & upper neck
• Band like tightness / pressure
• Mild & bilateral
• Not associated with aura & other symptoms
A&E(VMH)
treatment
• OTC
• Aspirin, ibuprofen, acetaminopen
Recurrent head ache
• Massage
• Stress management
A&E(VMH)
scenario
• A 35 yr old male presents with
• a daily head ache
• two attacks per day over last three wks.each lasts about an hour
• awakens the pt from sleep.asso with tearing & redness of lt eye
• .pain is deep,excrutiating &limited to lt side of head
A&E(VMH)
• Episodic type characterised by one to three short lived attacks of periorbital pain/day over a 4-8 wks period fallowed by pain free interval
A&E(VMH)
features
• Men> women
• Age 20-50 yrs
• Periorbital/temporal pain
• Starts with out aura & peaks in 5 min
• Excrutiating & explosive in quality
A&E(VMH)
• Rarely pulsatile
• Strictly unilateral
Accompained –
• homolateral lacrimation,
• redening of eye
• nasal stiffness,
• lid ptosis
• nausea
A&E(VMH)
pathogenesis
• Hypothalamus is the site of activation
• Anterior – circadian pace maker
• Posterior – regulate autonomic functions
A&E(VMH)
Prophylactic
• Verapamil
• Prednisolone 60 mg x 10 days
• Lithium 600 – 900 mg daily
• Ergotamine
• methysergide
A&E(VMH)
scenario
• A 25 yr old female who is having first day of her menstruation
• severe throbbing head ache on rt side
• pulsatile in nature
• prior to attack pt had one episode of vomiting & flashing lights
A&E(VMH)
Migraine
• It is a benign & recurring syndrome of head ache, nausea,vomiting & other symptoms of neurologic dysfunction in varying admixtures
• Common in younger age
• Female predominance
A&E(VMH)
Pathogenesis
• Genetic basis of migraine
• Vascular thoery
• Trigemino vascular system
• 5-hydroxytryptamine
• Dopamine in migraine
A&E(VMH)
Clinical features
Common migraine:
• No FND precedes the attack
• Mod – severe head ache
• Pulsatile
• Unilateral
• Aggravated by routine activity,nausea,vomiting
Photophobia
A&E(VMH)
Classic migraine:
• Accompanied by sensory,motor or visual symptoms
• FND common during the attacks
• Migraine equivalents – FND with out headache,vomiting
• Complicated migraine- persisting residual neurological deficit
A&E(VMH)
Basilar migraine
• Symptoms referable to brain stem dysfunction(vertigo,dysarthria,diplopia)
• Bickerstaffs migraine : total blindness fallowed by vertigo tinnitus dysarthria parasthesia
• Throbbing head ache
• Full recovery
A&E(VMH)
Diagnostic criteria for migraine
• Repeated headache lasting for 4- 72h with normal physical examination &
A&E(VMH)
TREATMENT
Non pharmacological
• Avoidance of head ache triggers
• Regulated life style
• Yoga
• Meditation
• hypnosis
A&E(VMH)
Prophylactic treatment
• Beta blockers – propanalol 80-320 mg qd
timolol 20-60 mg qd
• Anticonvulsant- sodium valproate 250 mg bd
• TCA – amitriptyline 10-50 mg q hs
nortriptyline 25-75 mg qhs
• MOI – phenelzine 15 mg tds
A&E(VMH)
• Serotonergic drugs – methysergide 4-8 mg qd
cyproheptadine 4-16 mg qd
• Verapamil – 80 – 480 mg qd
A&E(VMH)
Secondary head ache
• It is due to underlying structural problem in head or neck.
• There are numerous causes & some are life threatening and deadly
A&E(VMH)
scenario
• A 45 yr old gentleman
• hypertensive on irregular treatment presented with sudden onset of severe throbbing headache more over the occipital region
• pain radiates to the cervical spine
A&E(VMH)
SAH
• Severe headache , sudden onset
• Common location – occipitonuchal
• Pain radiates down along the cervical spine
• CT brain
A&E(VMH)
Cont…..
• LP mandatory following negative CT scan
• Presence of xanthochromia in the CSF supernatant – gold standard
A&E(VMH)
Cont…
• Neurologic consultation
• Nimodipine 60 mg po q 6 h
• Prophylactic phenytoin to avoid seizures
A&E(VMH)
scenario
• A 35 yr old gentleman presented to er
• complaints of fever and head ache since one weak ,
• altered sensorium for one day & one episode of GTCS 15 min back
• O/E pt was in post ictal state. HR – 58/mt, BP – 160/100 mmhg RR – 32/mt irregular pattern of breathing
A&E(VMH)
Meningitis
• Acute onset of fever, headache, neck stiffness
• LP
• CT brain
• Early empirical antibiotic therapy
A&E(VMH)
• Intraparenchymal hge & cerebral ischemia
• Brain tumour :
head ache :worse in morning
asso with position, nausea, vomiting
A&E(VMH)
scenarioA 65 yr old gentle man presented
to er
• head ache over the rt parietotemporal region
• associated with fever , stiffness & pain in the muscles of shoulder girdle & blurring of vision.
• On examination he has tachycardia
• bld investigations shows raised ESR
A&E(VMH)
Temporal arteritis
• It is an inflammation of medium & large sized arteries
• Common age > 50 yrs
• Characterised –
fever,head ache, anaemia& high ESR
• Head ache – pulsatile early & occluded later
A&E(VMH)
• Scalp pain, jaw claudication
• Polymyalgia rheumatica
• Complication – optic neuropathy - blindness
A&E(VMH)
management
• History & examination
• Biopsy of temporal artery
• USG of temporal artery
Treatment:
• Prednisolone 40-60 mg/day x 1 mon
• Combine with aspirin
A&E(VMH)
glaucoma
• Slowly progressive, insidious optic atrophy usually associated with chronic elevation of IOP
• Axons entering inferotemporal & supero temporal aspect of optic disc damages first
A&E(VMH)
• As fibres destroyed, neural rim of optic disc shrinks & physiologic cup with in optic enlarges – pathological cupping
Normal fundus
A&E(VMH)
Treatment
• Topical adrenergic agonist
• Topical cholinergic agonist
• Topical beta blockers
• Topical prostaglandin analogue
A&E(VMH)
hypertension
• Higher diastolic pressure – severe head ache
• Hypertensive emergency / urgency excluded
• Rule out other secondary causes
A&E(VMH)
Drug related & toxic& metabolic
• Drugs – nitrates, MAOI, chronically analgesic
• Metabolic – hypoxia , hypercapnia , hypoglycemia
• Toxins – monosodium glutamate, carbon monoxide
A&E(VMH)
Post lumbar puncture
• Develop headache after LP with in 24 – 48 hrs due to persistent CSF leak from dura
• Treated with analgesic,IV fluids , IV caffeine
• Blood patch may be required
A&E(VMH)
Pseudo tumor cereberi
• Young ,obese pts
• Assoc – OCP,tetracycline,vit A, thyroid disorder
• Normal level of cons,normal CT, papilledema,
• Elevated CSF pressure on LP
• COMPLICATION – visual loss
• TRMT – acetazolamide, repeated LP to drain CSF
A&E(VMH)
summary
• To select patient for emergency intervention & treatment
• To diagnose & treat early
• To provide appropriate disposition and fallow up for all discharged patients