Dizzy Med Stud

8/3/2019 Dizzy Med Stud

1/48

Headache andDizziness/Vertigo

Surat Tanprawate, MD, MSc(Lond.), FRCPTDivision of NeurologyChaing Mai University

15/13/2011Thursday, December 15, 2011


2/48

Pain

Ren Descartes, French

Philosopher31 March 1596 11 February 1650

Thursday, December 15, 2011


3/48

Headache and Pain Sensitive Structure

Meninges

Venous sinus

Neural structure:-glossopharyngeal n.-trigeminal n.

-upper cervical n.

Artery:-dural a.-carotid a.-basilar a.



4/48

International Classification of

Headache Disorder-2004

International Classification

of

Headache Disorder 2004

http://ihs-classification.org

Part 1. The primary headaches

- Migraine, TTH, CH and other

TACs, and other primaryheadache disorder

Part II. The secondary

headaches

-Headache attributed to ....

Part III. Cranial neuralgias,

central and primary facial pain

and other headaches

http://ihs-classification.org/http://ihs-classification.org/http://ihs-classification.org/


5/48

Approach toHeadache disorder



6/48

Patient presents withcomplaint of a headache

Critical first step:Hx taking, physical exam

Red flag signs or alarmingsigns

Meets criteria for primaryheadache disorder?

Migraineheadache

Tension-typeheadache

Cluster

headache andother TACs

Chronic daily

headache (CDH)

Red flag signs

Investigation

Secondary

headache

disorder

Other (rare)

headache

disorder

(+)(-)

(+)



7/48

History taking



8/48

History taking



9/48

History taking



10/48

History taking



11/48





Migraineheadache


Cluster


Chronic daily

headache (CDH)

Red flag signs

Investigation

Secondary

headache

disorder

Other (rare)

headache

disorder

(+)(-)

(+)



12/48

Alarming signs and

symptoms

Alarming s/s suggest the possibility ofsecondary headache

The studies Headache sample (specific or non-

specific)

Pool analyzed data => guideline



13/48

Normal neurological

examination

Abnormal neurological

examination

Focal neurologic s/s

other than typical visual

or sensory aura

Papilledema

Temporalprofile

Concurrentevent

Provokingactivity

Age

Age> 50

Sudden onset-SAH, ICH, masslesion (posteriorfossa)

Worsening headache-Mass lesion, SDH,MOH

Pregnancy, postpartum-Cerebral veinthrombosis, carotiddissection, pituitaryapoplexy

Headache withcancer, HIV, systemicillness (fever,arteritis, collagenvascular disease)

Neck stiffness

Triggered by cough,exertion or Valsava-SAH, mass lesion

Worse in themorning-IICP

Worse on awakening-Low CSF pressure



14/48





Migraineheadache


Cluster


Chronic daily

headache (CDH)

Red flag signs

Investigation

Secondary

headache

disorder

Other (rare)

headache

disorder

(+)(-)

(+)



15/48

Description and Criteria


Description

Criteria

http://ihs-classification.org/http://ihs-classification.org/


16/48

Migraine Epidemiology and problematic

concern

Clinical andpathophysiological ground

Management strategies



17/48

Steewart WF. Am J Epidemiol.1991;134:1111-1120

Incidence of migraine by age and sex Adjusted prevalence of migraine by

geographic area and meta-analysis of

studies using IHS criteria

Prevalence of Migraine



18/48

Only migraine without auraOnly migraine with aura

Both types

Launer LJ et al. Neurology1999;53:537-42

Migraine without aura is more common

(previously called common migraine)

Population-based study



19/48

Triggerfactors

Genetic

Migraine attack

Environmentalfactors

Clinical Picture



20/48

"He seemed to see somethingshining before him like a light,

usually in part of theright eye; atthe end of a moment, a violent pain

supervened in theright temple,then in all the head and neck....

vomiting, when it becamepossible, was able to divert thepain and render it more moderate."

Migraine with aura =

Classic migraine



21/48

On a distinct form oftransient hemiopsia byDr. Hubert Airy in 1870.

Teichopsia

(Greek for townwall vision)



22/48

The Classic Migraine =

Migraine with aura



23/48

Migraine triggers

Diet

Hunger

Alcohol

Additives

Certain foods

Chronobiologic

Sleep (too much or toolittle)

Schedule change

Hormonal

change

Menstruation

Environmental

factors

Light glare Odors

Altitude

Weather change

Physical

exertion

Exercise

Sex

Stress and

anxiety

Head

trauma



24/48

Migraine Aura

Michael B. R. et al. Brain1996: 119, 355-361

n=163

99% 31%

6%

18%

Typical aura:

-Visual

-Sensory

-Speech



25/48

Mechanism of head painTrigeminovascular system



26/48

Migraine without aura

ICHD-II Cephalalgia.2004

Migraine with typical aura needs 2 attacksIn children, the attack may last 1-72 hours



27/48

Tension-type

headache Most common headache type

Featureless headache, uncertainpathophysiology (mental or muscular cause?)

HRQoL of Headache

ETTH > CTTH = EM > CM/TM

When migraine become chronic, theheadaches characters are similar to TTH



28/48

TTH diagnostic criteria



29/48

Trigeminal AutonomicCephalalgia

The most severe headache ever



30/48

TACs

A group of primary headache disorderscharacterized by strictlyunilateral head

pain that occurs in association with

ipsilateral cranial autonomic features

- Cluster headache (CH)

- Paroxysmal hemicrania (PH)

- Short-lasting unilateral neuralgiform headache

attacks with conjunctival injection and tearing/

cranial autonomic features (SUNCT/SUNA)Thursday, December 15, 2011


31/48

Cluster headache

Cluster headache

and others TACs

Short lasting,unilateral, severe

headache

accompanying with

autonomic symptoms

ICHD-II Cephalalgia.2004



32/48

International Classification of

Headache Disorder-2004

International Classification

of

Headache Disorder 2004


Part 1. The primary headaches

- Migraine, TTH, CH and other

TACs, and other primaryheadache disorder

Part II. The secondary

headaches

-Headache attributed to ....

Part III. Cranial neuralgias,

central and primary facial pain

and other headachesThursday, December 15, 2011
http://ihs-classification.org/http://ihs-classification.org/http://ihs-classification.org/


33/48

Cranial Neuralgias

The presence of sudden, sharp, aching,

lancinating, burning, and stabbing painlasting from only a few seconds to lessthan 2 min and recurring repeatedlywithin short periods of time, which is

often triggered by sensory ormechanical stimuli



34/48

ICHD-II, 2004



35/48

Trigeminal Neuralgia

70% of patients are older than 60 years atonset

Clinical hallmark: brief electric shock-like pains

abrupt in onset and termination

limited to the distributions of the trigeminalnerve

commonly stimuli: mechanical



36/48



37/48

Classical trigeminal neuralgia

Symptomatic trigeminal neuralgia

TN caused by a demonstrable structural lesion



38/48

Vertigo/Dizziness



39/48



40/48



41/48



42/48

Syndrome of vertigo: baseon connection

Major symptoms

Vertigenous sensation

Imbalance Nystagmus and

oscillopsia

Autonomic dysfunction

N/V

Palpitation

Fluctuation in BP

Psychiatric symptoms:

Fear

Anxiety Hyperventilation

syndrome

Phobia



43/48

S/S Peripheral Central

LatencyDurationFatiguability

Nystagmus direction

Intensity of S/S

reproducibility

0-40 sec


44/48

S/S Peripheral Central

LatencyDurationFatiguability

Nystagmus direction

Intensity of S/S

reproducibility

0-40 sec


45/48

Causes of vertigo

Peripheral vertigo

Infection/inflammation Peripheral vestibulopathy

Vestibular neuritis, acute neurolabyrinthitis

Localized: CN7+8 affected: Ramsay Huntsyndrome

Systemic: mump, measle, IM, URI

Trauma: post-traumatic vertigo

Local tumor

Vascular: rare

Metabolic/ toxic Aminoglycoside(rare)

Other: BPPV, Menieres disease

Central vertigo

Common is

Tumor: CP angle tumor

Demyelinating: MS Vascular: ischemia(VBI)

Posterior fossa lesion

Migraine

Vertigenous epilepsy



46/48

Systemic causes of vertigo and

dizziness

DrugsAED, hypnotic, alcohol, analgesic

Hypotension, presyncope Infectious disease

Syphilis, viral, systemic infection

Endocrine disease

Diabetes, hypothyroidism Vasculitis Others: hematological, granulomatous disease,

systemic toxin



47/48

Time course-onset



48/48

Thank You for Your

Kind Attention

Surat Tanprawate, MD, MSc(Lond.), FRCP(T)

CertHE(Hist Med)

Neurology staff,Division of Neurology, CMU

The Northern Neuroscience Center, CMU

Dizzy Med Stud

Documents

Transcript of Dizzy Med Stud