Headache Headache is a pain in the head. It results from disorders that affect pain-sensitive...

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Pain-Sensitive Structures: - the venous sinuses (eg, sagittal sinus); a) Within the Cranial Vault - the venous sinuses (eg, sagittal sinus); - the anterior and middle meningeal arteries; - the dura at the base of the skull; - the trigeminal (V), glossopharyngeal (IX), and vagus (X) nerves; - the proximal portions of the internal carotid artery and its branches near the circle of Willis; - the brainstem periaqueductal gray matter; - the sensory nuclei of the thalamus.

Transcript of Headache Headache is a pain in the head. It results from disorders that affect pain-sensitive...

Headache Headache is a pain in the head. It resultsfrom disorders that affect pain-sensitivestructures of the head and neck. Pain-Sensitive Structures: - the venous sinuses (eg, sagittal sinus);
a) Within the Cranial Vault - the venous sinuses (eg, sagittal sinus); - the anterior and middle meningeal arteries; - the dura at the base of the skull; - the trigeminal (V), glossopharyngeal (IX), andvagus (X) nerves; - the proximal portions of the internal carotidartery and its branches near the circle of Willis; - the brainstem periaqueductal gray matter; - the sensory nuclei of the thalamus. b) Extracranial Pain-Sensitive Structures
- the periosteum of the skull; - the skin; the subcutaneous tissues of skull; - muscles, and arteries of skull; - the neck muscles; - the second and third cervical nerves; - the eyes, ears, teeth, paranasal sinuses, - oropharynx; and the mucous membranes of thenasal cavity. Causes of Headache and Facial Pain according to the mode of onset:
Acute onset (over minutes, hours, days): Common: Subarachnoid hemorrhage, Other cerebrovasculardiseases,Meningitis or encephalitis,Ocular disorders (glaucoma,acute iritis) Less common: Seizures,Lumbar puncture,Hypertensiveencephalopathy,Coitus Subacute onset (over weeks, months):Giant cell (temporal)arteritis,Intracranial mass (tumor, subdural hematoma,abscess),Pseudotumor cerebri (benign intracranialhypertension),Trigeminal neuralgia,Glossopharyngealneuralgia,Posttherpetic neuralgia,Hypertension (includingpheochromocytoma and the use of monoamine oxidase inhibitorsplus tyramine),Atypical facial pain Chronic (over years):Migraine,Cluster headache,Tensionheadache,Cervical spine disease,Sinusitis,Dental disease Tension Headache It is chronic headache ofunapparent cause that lackenough features characteristic ofmigraine or cluster headache. The underlying pathophysiologicmechanism is unknown, and tension isunlikely to be primarily responsible.Contraction of neck and scalp muscles,which has also been proposed as thecause, is probably a secondaryphenomenon. It is either episodic or chronic (i.e: present > 15days per month). The chronic disorder beginsafter age 20. It is characterized by frequent(often daily) attacks of nonthrobbing, bilateraloccipital head pain that is not associated withnausea, vomiting, or prodromal visualdisturbance. The pain is sometimes likened to atight band around the head or pressure over thevertex. Women are more commonly affectedthan men. It is more at evening than morning.Relieved by preoccupation & exaggerated byisolation & stress. It does not interfere with dailyliving activities or awake patient from sleep. Although tension headache and migraine havebeen traditionally considered two distinctdisorders, many patients have headaches thatexhibit features of both. Thus, some patientswho are classified as having tension headachesexperience throbbing headaches, unilateralhead pain, or vomiting with attacks. Inconsequence, it may be more accurate to viewtension headache and migraine as representing2 opposite poles of a single clinical spectrum. Treatment of Tension Headache:
a) Acute phase therapy (during the attack) : aspirin, other non-steroidal anti-inflammatory drugs,acetaminophen (2 tab x 3 per day, tab 325 mg), ergotamine, ordihydroergotamine. b) prophylactic treatment only in chronic form (after end of acuteattack to prevent new attacks) Amitriptyline (Tryptizol) a tricyclic antidepressant ( mgat bed time, tab 10, 25, 50, 75, 100, 150) or imipramine(Tofranil)are often effective, and propranolol is useful insome cases. Although many patients respond tobenzodiazepines such as diazepam, 530 mg/d orally, orchlordiazepoxide (Librium), 1075 mg/d orally, these drugsshould be used sparingly because of their addictive potential. Migraine Migraine, the most common cause ofheadache, afflicts approximately 15% ofwomen and 6% of men. A useful definitionof migraine is a benign and recurringsyndrome of headache, nausea, vomiting,and/or other symptoms of neurologicdysfunction in varying admixtures. Triggering factors: red wine menses (so ask about the effect ofmenstrual cycle on headache) hunger (so avoid fasting) lack of sleep glare estrogen worry perfumes Relieving factors: sleep (the patient have a desire to sleepwhen attack come) pregnancy exhilaration triptans Pathogenesis: It is multifactorial
a) Genetic factors: It is of polygenic + strong environmental factors. The aggregation of migraine within families has long been recognized (+vefamily history). Consistent mendelian patterns of inheritance have not been found Concordance rates in monozygotic twins of only 2852% A rare subtype of migraine with aura, familial hemiplegic migraine, has astraightforward autosomal dominant mode of inheritance. b) Vascular theory: Intracranial vasoconstriction and extracranial vasodilatation have longbeen held to be the respective causes of the aura and headache phasesof migraine. This theory applied only for classic migraine & even here it isweak theory. c) Neuronal theory: Increase in activation of dorsal raphe (serotonergic cells) & locus cereulus(adrenergic cells) lead to 2 results: a. increase in blood flow in mid-brain& pons causing headache, b. activation in lateral geniculate body, visualcortex, superior colliculus, retina causing aura. Clinical Features: MIGRAINE WITHOUT AURA (COMMON MIGRAINE) In this syndrome no focal neurologic disturbanceprecedes the recurrent headaches. Migraine without aura is by far the more frequenttype of vascular headache. The International Headache Society criteria formigraine include moderate to severe head pain,pulsating quality, unilateral location, aggravationby walking stairs or similar routine activity, attendant nausea and/or vomiting, photophobiaand phonophobia, and multiple attacks, eachlasting 2 hr, up to 72 h, (10 hr as average) Migraine with Aura (Classic Migraine)
In classic migraine headache is preceded by transient neurologicalsymptomsthe aura. The most common auras are scintillationscotomas (fortification spectra) that occurs in 10 % of patients startas small paracentral scotomas then slowly enlarge and spreadperipherally into C-shape with illuminating zigzag borders lasting minutes. A throbbing unilateral headache ensues with or followingthese prodromal features. The frequency of headache varies, but 50% of patients experience no more than one attack per week. Theduration of episodes is 2 hours and less than 1 day in mostpatients. Remissions are common during the second and thirdtrimesters of pregnancy and after menopause. Between yearsespecially in the elderly, prodromal symptoms may occur withoutheadache (migraine equivalents). Although hemicranial pain is ahallmark of classic migraine, headaches can also be bilateral.Bilateral headache, therefore, does not exclude the diagnosis ofmigraine, nor does an occipital locationa characteristic commonlyattributed to tension headaches. During the headache, prominentassociated symptoms include nausea, vomiting, photophobia,phonophobia, irritability, and lassitude. Uncommonly, migraines areassociated with frank neurologic deficits that accompany, or persistbeyond resolution of the pain phase. These may includehemiparesis, hemisensory loss, speech dysfunction, or visualdisturbance. Treatment: a) During the acute attack: 1st start with simple analgesia + anti-emetic Simple analgesia like: Aspirin mg/d or Paracetamol (Emidol) mg/d Diclofenac potassium (Voltfast) powder Anti-emetic like: Metoclopramide (Plasil) ampoule 10 mg I.V orS.C injection or Prochlorperazine (Stemetil) mg I.M or I.V If no response so ADD to the above one of the following: 1. Ergot preparations: they act by causing vasospasm & are of 2 types: a. non-selective 5 HT agonists like: Dihydroergotamine ampoule (1 mg/cc) 1-2 mg I.M or S.C or mg I.V injction. Nasal spray (4 mg/cc) (2 mg/spray=0.5cc) 1 spray to each nostrilrepeated in 15 minutes Ergotamine/caffeine (Migrail) or (Cafergot) tab or suppositories(1/100 mg), (2/100 mg) 2-6 tab / w max. 10 tab / w or -2 supp. /w max. 5 supp. / w Side effect: nausea, vomiting Contraindicated in pregnancy, coronary or peripheral vascular diseases& HT b.Triptan (selective 5 HT agonist) like:
Sumatriptantab (25,50,100 mg/tab) 200 mg/d orally nasal spray (5,20 mg/spray) 40 mg/d ampoule (6 mg/ampoule) 12 mg/d S.C Side effect & contraindications are the same for previousgroup. In addition they must never use in combinationwith them. 2. Narcotics like: Mepredine (50,100 mg tab or ampoule) mg orally orI.M injection. Paracetamol/Codeine (Cetapar) : mg Codeine /day For mild attack use oral preparations, while nasal sprayfor moderate one & injectable forms in sever cases. These drugs to be of maximum effect theyshould be used as early as possible beforethe onset of headache phase in classicmigraine & as early as possible when thesymptom start in common migraine. b) Prophylactic treatment (to prevent new attacks): It is indicated if the patienthave 3 or more attacks per months or if there is C.I to acute phase therapy. We use one of the following agents: a.Anticonvulsants like Na valiprait (Depakine) tab mg bid orTopiramate (Topamax) mg/d2 or Gabapentin (Neurontin) tab mg/d3 b.B blockers like Propranolol tab mg bid SRP mg qd or bid we use them preferably for patients with prominent visual aura. Side effects: symptomatic bradycardia, bronchospasm, hypotension, exerciseintolerance, impotence, sedation, depression. c.Tricyclic antidepressants like Amitriptyline (Tryptizol) (10,25,50,75,100,150mg/tab) mg at bed time. Side effects: dry mouth, urinary retention, dilated pupils ; so they arecontraindicated in B.P.H & glaucoma. we use them preferably for patients with anxiety, insomnia or depression. d.Calcium channel blockers Verapamil (Isoptine) (40, 80, 120 mg/tab) mg tid 240 mg qd or bid SRP. They are not for use with B blockers. They cause constipation & not used inhy