Headache
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Transcript of Headache
Daniel EshetuDaniel Eshetu
one of the most important symptoms in clinical medicine
As many as 90% of individuals have at least one headache per year
Severe, disabling headache is reported to occur at least annually by 40% of individuals worldwide
Headache is usually a benign symptom, but occasionally it is the manifestation of a serious illness:
- Brain tumor, subarachnoid hemorrhage, meningitis, or giant cell arteritis
In emergency settings, approximately 5% of patients with headache are found to have a serious underlying neurologic disorder
IHS 2004:
- primary- Secondary
Primary: headache and the associated symptoms are the disorder in itself
Secondary: caused by exogenous disorders
only certain cranial structures are sensitive to pain:
1. Skin, subcutaneous tissue, muscles, extra cranial arteries, periosteum of the skull
2. delicate structures of the eye, ear, nasal cavities, and para-nasal sinuses
3. Intracranial venous sinuses and their tributaries
4. Parts of the dura at the base of the brain and the arteries with in the dura and pia-arachnoid
5. The middle meningeal and superficial temporal arteries
6. The optic, oculomotor, trigeminal, glossopharyngeal, vagus and the first three cervical nerves
Structures which lack sensitivity:
- The bony skull
- much of the pia-arachnoid over the convexity of the brain
- the parenchyma of the brain
- the ependyma and choroid plexus
Distention, traction, or dilation of intracranial or extracranial arteries
Traction or displacement of large intracranial veins or their dural envelope
Compression, traction, or inflammation of cranial and spinal nerves
spasm, inflammation, or trauma to cranial and cervical muscles
Meningeal irritation and raised intracranial pressure
Other possible mechanisms such as activation of brainstem structures.
In dealing with any painful state determine:qualityseveritylocationdurationtime courseconditions that produce, exacerbate, or relieve it.
occasionally helpful for diagnosis
Most tension-type headaches are described as tight “bandlike” pain or as dull, deeply located, and aching pain
A throbbing quality and tight muscles about the head, neck, and shoulder girdle are common nonspecific accompaniments of migraine headaches.
rarely has diagnostic value
patient's perspective, it is the single aspect of pain that is most important
most patients entering emergency departments with the most severe headache of their lives usually have migraine
The headache produced by a brain tumor is not usually distinctive or severe.
may be informative
If the source is an extracranial structure, as in giant cell arteritis, the correspondence with the site of pain is fairly precise
Inflammation of an extracranial artery- causes pain and tenderness at the site of the vessel
CTD
Lesions of paranasal sinuses, teeth, eyes, and upper cervical vertebrae- localized pain
Intracranial lesions in the posterior fossa- cause occipitonuchal pain
supratentorial lesions most often induce frontotemporal pain
are diagnostically useful
A ruptured aneurysm results in head pain that peaks in an instant, thunderclap-like
Cluster headache attacks reach their peak over 3 to 5 min, remain at maximal levels for about 45 min, and then taper off
Migraine attacks build up over hours, are maintained for several hours to days, and are characteristically relieved by sleep
Sleep disruption and early morning headaches brain tumors or other disorders that produce increased intracranial pressure.
must be distinguished from headache
Trigeminal and, less commonly, glossopharyngeal neuralgia are frequent causes of facial pain
Neuralgias are painful disorders characterized by paroxysmal, fleeting, often electric shock–like episodes
frequently caused by demyelinating lesions of nerves
the trigeminal or glossopharyngeal nerves in cranial neuralgias
Certain maneuvers characteristically trigger paroxysms of pain
- However, the most common cause of facial pain by far is dental
- The effect of eating on facial pain may provide insight into its cause
- Is it the chewing, swallowing, or taste of the food that elicits pain?
- Chewing suggests trigeminal neuralgia, temporomandibular joint dysfunction, or giant cell arteritis (“jaw claudication”)
- Whereas swallowing and taste provocation suggest glossopharyngeal neuralgia
Patients who present with their first severe headache raise entirely different diagnostic possibilities than those with recurrent headaches over many years.
In new-onset and severe headaches- a potentially serious cause is considerably greater than in recurrent headache
an acute, new-onset headache- consider: - meningitis - subarachnoid hemorrhage, - epidural or subdural hematoma- glaucoma - purulent sinusitis
Clinical features of acute, new-onset headache caused by serious underlying conditions(Red Flags):“Worst” headache everFirst severe headacheSubacute worsening over days or weeksAbnormal neurologic examinationFever or unexplained systemic signsVomiting precedes headacheInduced by bending, lifting, coughDisturbs sleep or presents immediately upon awakeningKnown systemic illnessOnset after age 55
A complete neurologic examination is an essential first step in the evaluation
an abnormal examination should be followed by a computed tomography (CT) or a magnetic resonance imaging (MRI) study
As a screening procedure for intracranial pathology in this setting, CT and MRI methods appear to be equally sensitive
Cardiovascular and renal status by blood pressure monitoring and urine examination
Eyes by fundoscopy, intraocular pressure measurement, and refraction
Cranial arteries by palpation
And cervical spine by the effect of passive movement of the head and imaging
The psychological state of the patient should also be evaluated
Head pain and depression
Many patients in chronic daily pain cycles become depressed
Greater-than-chance coincidence of migraine with both bipolar and major depressive disorders
Meningitis: - Nuchal rigidity - headache - photophobia- prostration- may not be febrile. - Lumbar puncture is diagnostic.
Intracranial hemorrhage (SAH or IPH):
- Nuchal rigidity and headache
- may not have clouded consciousness or seizures.
- Hemorrhage may not be seen on CT scan.
- Lumbar puncture shows “bloody tap” that does not clear by the last tube.
- A fresh hemorrhage may not be xanthochromic.
Brain tumor:
- prostrating pounding headaches
- associated with nausea and vomiting
- suspected in progressively severe new “migraine” that is invariably unilateral
Temporal arteritis:
- unilateral pounding headache
- Onset - older patients (>50 years)
- frequently associated with visual changes
- The erythrocyte sedimentation rate is the best screening test and is usually markedly elevated (i.e., >50)
- Definitive diagnosis can be made by arterial biopsy.
Glaucoma:
- consists of severe eye pain
- May have nausea and vomiting
- The eye is usually painful and red
- The pupil may be partially dilated.
systemic illnesses
idiopathic intracranial hypertension
Cough
Lumbar puncture
Post - concussion
Coital headache
CLINICAL VARIETIES OF RECURRENT HEADACHES
TENSION-TYPE HEADACHE:
- A chronic head pain syndrome characterized by bilateral tight, bandlike discomfort
- Head feels as if it is in a vise or that the posterior neck muscles are tight
- The pain typically builds slowly, fluctuates in severity, and may persist more or less continuously for many days
- Exertion does not usually worsen the headache
- The headache may be episodic or chronic (i.e., present >15 days per month).
- Tension-type headache is common in all age groups, and females tend to predominate
- In some patients, anxiety or depression coexist with tension headache
The 2nd most common cause of headache in clinical practice
afflicts approximately 15% of women and 6% of men- In Ethiopia: 4.2% Vs 1.7%
a benign and recurring syndrome of headache, nausea, vomiting, and/or other symptoms of neurologic dysfunction in varying admixtures
Migraine can often be recognized by its
- Activators: red wine, menses, hunger, lack of sleep, glare, estrogen, worry, perfumes, let-down periods
- Deactivators: sleep, pregnancy, exhilaration, triptans
- Migraine without aura
- Migraine with aura
- ‘Ophthalmoplegic migraine’
- Retinal migraine
- Childhood periodic syndromes that may be precursors to or associated with migraine – eg cyclical vomiting
- Migrainous disorder not fulfilling above criteria
Migraine with Aura (Classic Migraine)A. At least two attacks that fulfill criterion B
B. At least three of the four characteristics:1)one or more reversible aura symptoms indicating focal cerebral or brainstem dysfunction
2) at least one aura develops gradually over more than 4 minutes and no single aura lasts longer than 60 minutes.
CTD3)headache begins during aura or follows with a symptom-free interval of less than 60 minutes
C. An appropriate history, physical, and diagnostic tests that exclude related organic disease
A distinctive and treatable vascular headache syndrome
The episodic type:
- most common
- characterized by one to three short-lived attacks of periorbital pain per day over a 4- to 8-week period, followed by a pain-free interval that averages 1 year
The chronic form:
- is characterized by the absence of sustained periods of remission
- may begin de novo or several years after an episodic pattern has become established
Each type may transform into the other
Men are affected seven to eight times more often than women
Hereditary factors are usually absent
Onset is generally between ages 20 and 50
Clinical Features :
- Periorbital or, less commonly, temporal pain begins without warning and reaches a crescendo within 5 min
- It is often excruciating in intensity and is deep, nonfluctuating, and explosive in quality
Only rarely is it pulsatile
Pain is strictly unilateral and usually affects the same side in subsequent months
Attacks last from 30 min to 2 h
There are often associated symptoms of homolateral lacrimation, reddening of the eye, nasal stuffiness, lid ptosis, and nausea
Alcohol provokes attacks in about 70% of patients but ceases to be provocative when the bout remits
This on-off vulnerability to alcohol is pathognomonic of cluster headache
Only rarely do foods or emotional factors precipitate pain, in contrast to migraine.
There is a striking periodicity of attacks in at least 85% of patients
At least one of the daily attacks of pain recurs at about the same hour each day for the duration of a cluster bout
Onset is nocturnal in about 50% of the cases, and then the pain usually awakens the patient within 2hrs of falling asleep.
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