Headache&FacialPainDiagnosisandmanagement
• TheInterna*onalClassifica*onofHeadacheDisorders3rd,edi*onbetaversion2013->280typesofheadachearedescribed• Interna*onalHeadacheSociety(hDp://www.ihs-headache.org/)• „Cephalalgia”(hDp://cep.sagepub.com/content/33/9/629.full).
HEADACHE:• 1/PRIMARY• 2/SECONDARY• 3/NEURALGIA
TENSION–TYPEHEADACHE• Tension-typeheadachepainiso\endescribedasaconstantpressure,asiftheheadwerebeingsqueezedinavise.Thepainisfrequentlypresentonbothsidesoftheheadatthesame*me.Tension-typeheadachepainistypicallymildtomoderate,butmaybesevere.• Episodicorchronic• Tensionheadachesaffectabout1.4billionpeople(20.8%ofthepopula*on)andaremorecommoninwomenthanmen(23%to18%respec*vely)
Variousprecipitatingfactorsmaycausetension-typeheadache:• Stress:usuallyoccursinthea\ernoona\erlongstressful
workhoursora\eranexam• Sleepdepriva*on• Uncomfortablestressfulposi*onand/orbadposture• Irregularmeal*me(hunger)• Eyestrain• Tension-typeheadachesmaybecausedbymuscletensionaroundtheheadandneck.Oneofthetheoriessaysthatthemaincausefortension-typeheadachesisteethclenchingwhichcausesachroniccontrac5onofthetemporalismuscle.
Headachediagnosis:1/Historytalking:localisa*onofthepain,character,howlong?,howo\en?,precipita*ngfactors;aura,characterofaura,nusea,vomi*ng,ifdependsonbodyposi*on,physicalac*vity,weather,menstrua*on,sleep,historyofheadacheinfamily,concomitantdisease,concomitanttreatment2/Physicalexamina*on,Neurologicalexamina*on3/Laboratory(morphology,Fe,Borreliaburgdorferi)4/Neuroimaging:MRofthehead,angioMR,angioCT5/ECG6/Ophthalmologistconsulta*on7/Laryngologistconsulta*on-sinusi*scanbeacauseofchronicheadache8/Stomatologistconsultac*on9/Psychologist10/Inprac*ceitisrecommendedtoprovidepa5ent’sdiary
Treatment:• preven*on• ibuprofen,paracetamol/acetaminophen,aspirin• relaxa*ontechniques
MIGRAINE:• Typically,theheadachesaffectsonehalfofthehead
(butinchildreno\enbilateral),arepulsa*nginnature,andlastsfromtwoto72hours,canbemoderateorsevere• Associatedsymptomsmayincludenausea,vomi*ng,andsensi*vitytolight,soundorsmell• Thepainisgenerallymadeworsebyphysicalac*vity.• Uptoone-thirdofpeoplehaveanAURA:typicallyashortperiodofvisualdisturbancewhichsignalsthattheheadachewillsoonoccur
MIGRAINE:• AURA-mechanismof“cor*calspreadingdepression”• Auraappearsgraduallyoveranumberofminutesandgenerallylastlessthan60minutes.• Symptomscanbevisual,sensoryormotorinnatureandmanypeopleexperiencemorethanone.• Visualeffectsoccurmostfrequently:scin*lla*ngscotoma(anareaofpar*alaltera*oninthefieldofvisionwhichflickersandmayinterferewithaperson'sabilitytoreadordrive)• Thesetypicallystartnearthecentreofvisionandthenspreadouttothesideswithzigzagginglineswhichhavebeendescribedaslookinglikefor*fica*onsorwallsofacastle.Usuallythelinesareinblackandwhitebutsomepeoplealsoseecolouredlines.Somepeopleloosepartoftheirfieldofvisionknownashemianopsiawhileothersexperienceblurring.
,,AliceinWonderlandSyndrom”
• Sensoryaura:O\enafeelingofpins-and-needlesbeginsononesideinthehandandarmandspreadstothenose–mouthareaonthesameside• Othersymptomsoftheauraphasecanincludespeechorlanguagedisturbances,worldspinning,andlesscommonlymotorproblems.• Motorsymptomsindicatethatthisisahemiplegicmigraine,andweaknesshemiplegia,hemiparesiso\enlastslongerthanonehourunlikeotherauras–5min-24hours-familialhemiplegicmigraine–type1(FHM1-genCACNA1A),type2(FHM2-genATP1A2),type3(FHM3-genSCN1A)
• Migrainesarebelievedtobeduetoamixtureofenvironmentalandgene*cfactors.Abouttwo-thirdsofcasesruninfamilies.Changinghormonelevelsmayalsoplayarole,asmigrainesaffectslightlymoreboysthangirlsbeforepubertyandtwotothree*mesmorewomenthanmen.• Mechanismsarenotfullyknown–probablyinvolvethenervesandbloodvesselsofthebrain• Migraineisbelievedtobeaneurovasculardisorderwithevidencesuppor*ngitsmechanismsstar*ngwithinthebrainandthenspreadingtothebloodvessels.Onetheoryisrelatedtoincreasedexcitabilityofthecerebralcortexandabnormalcontrolofpainneuronsinthetrigeminalnucleusofthebrainstem.HighlevelsoftheneurotransmiDerserotonin,alsoknownas5-hydroxytryptamine,arebelievedtobeinvolved.
Thediagnosisofmigrainewithoutaura,accordingtotheInterna5onalHeadacheSociety,canbemadeaccordingtothefollowingcriteria:• FiveormoreaDacks—formigrainewithaura,twoaDacksaresufficientfordiagnosis.
• Fourhourstothreedaysindura*on• Twoormoreofthefollowing:• Unilateral(affec*nghalfthehead);• Pulsa*ng;• Moderateorseverepainintensity;• Aggrava*onbyorcausingavoidanceofrou*nephysicalac*vity
• Oneormoreofthefollowing:• Nauseaand/orvomi*ng;• Sensi*vitytobothlight(photophobia)andsound(phonophobia)
Migrainesaredividedintosevensubclasses(someofwhichincludefurthersubdivisions):§ Migrainewithoutaura,or"commonmigraine",involvesmigraineheadachesthatarenotaccompaniedbyanaura.
§ Migrainewithaura,or"classicmigraine",usuallyinvolvesmigraineheadachesaccompaniedbyanaura
§ Childhoodperiodicsyndromesthatarecommonlyprecursorsofmigraineincludecyclicalvomi*ng(occasionalintenseperiodsofvomi*ng),abdominalmigraine(abdominalpain,usuallyaccompaniedbynausea),andbenignparoxysmalver*goofchildhood(occasionalaDacksofver*go).
• Re*nalmigraineinvolvesmigraineheadachesaccompaniedbyvisualdisturbancesoreventemporaryblindnessinoneeye.• Complica*onsofmigrainedescribemigraineheadachesand/oraurasthatareunusuallylongorunusuallyfrequent,orassociatedwithaseizureorbrainlesion.• Probablemigrainedescribescondi*onsthathavesomecharacteris*csofmigraines,butwherethereisnotenoughevidencetodiagnoseitasamigrainewithcertainty(inthepresenceofconcurrentmedica*onoveruse).• Chronicmigraineisacomplica*onofmigraines,andisaheadachethatfulfillsdiagnos*ccriteriaformigraineheadacheandoccursforagreater*meinterval.Specifically,greaterorequalto15days/monthforlongerthan3months.
MIGRAINE-MANAGEMENT1.ManagementoftheaDack:• -Analgesic:Paracetamol,Ibuprofen,Aspirin,Naproxen,• -Triptans• -Metoclopramid• -Ergotamine• Statusmigrainosus(whenmigrainelas*nglongerthan72hours)-Metoclopramid,Diazepam,Mannitol,steroids
2.Preven*vetreatment:• Propranolol,Flunaryzyna,amitryptylina,an*epilep*cdrugs(VPA,topiramat,gabapentyna)• Nonpharmacologicalmethods-useofstressreduc*ontechniquessuchascogni*vebehaviouraltherapyandrelaxa*ontechniques• elimina*onoftriggers,dietary
SECONDARYHEADACHE• Traumacapi*s,vasculardiseases,hypertension,infec*on,epilepsy,increasedintracranialpressure(tumourcerebri,idiopathicintracranialhypertension=pseudotumourcerebri),laryngologicaldisease(sinusi*s,o**s),ophatmologicdisease(visionloss,glaucoma)• Headacheinstomatology:odontogenicpain,non-odontogenicpain,temporomandibularjointdysfunc*onsyndrome• Headacheintumourcerebri:Duetoincreaseofintracranialpressure,bilateral,o\eninthemorningwithvomi*ng-neuroimagingcito!!!
• Bruns’syndrome:Characterizedbysuddenandsevereheadache,accompaniedbyvomi*ngandver*go,triggeredbyabruptmovementofthehead.Principalcausesarecystsandcys*cerosisofthefourthventricle,andtumoursofthemidlineofthecerebellumandthirdventricle
Trigeminalneuralgia=ticdouloureux• episodesofintensefacialpainalongthetrigeminalnerve
divisions.Thetrigeminalnerveisapairedcranialnervethathasthreemajorbranches:theophthalmicnerve(V1),themaxillarynerve(V2),andthemandibularnerve(V3).
TrigeminalneuralgiamostcommonlyinvolvesV2orV3.• EachindividualaDackusuallylastsfromafewsecondstoseveralminutesorhours,butthesecanrepeatforhourswithveryshortintervalsbetweeneachaDack.Inotherinstancesonly4-10aDacksareexperienceddaily.Theepisodesofintensepainmayoccurparoxysmally.
Trigeminalneuralgia• Todescribethepainsensa*on,pa*entso\endescribeatriggerareaonthefacesosensi*vethattouchingorevenaircurrentscantriggeranepisode;however,inmanypa*entsthepainisgeneratedspontaneouslywithoutanyapparents*mula*on.Itaffectslifestyleasitcanbetriggeredbycommonac*vi*essuchasea*ng,talking,shavingandbrushingteeth.Wind,chewingandtalkingcanaggravatethecondi*oninmanypa*ents.• TheaDacksaresaidbythoseaffectedtofeellikestabbingelectricshock,burning,sharp,pressing,crushing,explodingorshoo*ngpainthatbecomesintractable.
Trigeminalneuralgia
• Severaltheoriesexisttoexplainthepossiblecausesofneuralgia.• leadingresearchindicatesthatitisanenlargedorlengthenedbloodvessel–mostcommonlythesuperiorcerebellarartery–compressingorthrobbingagainstthemicrovasculatureofthetrigeminalnervenearitsconnec*onwiththepons.Suchacompressioncaninjurethenerve'sprotec*vemyelinsheathandcauseerra*candhyperac*vefunc*oningofthenerve.ThiscanleadtopainaDacksattheslightests*mula*onofanyareaservedbythenerveaswellashinderthenerve'sabilitytoshutoffthepainsignalsa\erthes*mula*onends.
• Thistypeofinjurymayrarelybecausedbyananeurysm;byanAVM(arteriovenousmalforma*on);byatumourinthecerebellopon*neangle.
• Othercauses:mul*plesclerosis,Herpessimplex(V1)
Trigeminalneuralgia
• Diagnosis:MR,angioMR• MANAGEMENT:• carbamazepin,gabapen*n,okskarbazepine,pregabalin,valproicacid,lamotrigine,phenytoin,clonazepam• Surgical–non-destruc*vemethod-microvasculardecompressionordestruc*vemethods
Glossopharyngealneuralgia(GN)• Affectstheglossopharyngealnerveandcauses
sharp,stabbingpulsesofpaininthebackofthethroatandtongue,thetonsils,andthemiddleear.• Paincanlastforafewsecondstoafewminutes,andmayreturnmul*ple*mesinadayoronceeveryfewweeks.• ManyindividualswithGNrelatetheaDacksofpaintospecifictriggerfactorssuchasswallowing,drinkingcoldliquids,sneezing,coughing,talking,clearingthethroat,andtouchingthegumsorinsidethemouth.• GNcanbecausedbycompressionoftheglossopharyngealnerve,butinsomecases,nocauseisevident.Itcanbeassociatedwithmul*plesclerosis.GNprimarilyaffectstheelderly.
STROKE
DEFINITIONOFSTROKE• Stroke,alsoknownascerebrovascularaccident(CVA)or"brainaDack",is
asyndromecausedbyadisrup*onintheflowofbloodtopartofthebrainduetoeitherocclusionofabloodvessel(ischemicstroke)orruptureofabloodvessel(hemorrhagicstroke).Theinterrup*oninbloodflowdeprivesthebrainofnutrientsandoxygen,resul*ngininjurytocellsintheaffectedvascularterritoryofthebrain.Ischemicstrokesaremorecommonthanhemorrhagicstrokes.
• Whenbraincellsdie,func*onofthebodypartstheycontrolisimpairedorlost,causingparalysis,speechandsensoryproblems,memoryandreasoningdeficits,coma,andpossiblydeath
TYPESOFSTROKE
• Ischemicstroke
(IS) 75-85%• Intracerebralhemorrhage
(ICH) 10-20%• Subarachnoidalhemorrhage(SAH)
ok.5%
BRAINISCHEMIA
• TransientischemicaDack,TIA(<24hours)• Reversibleischemicneurologicaldeficit,RIND(<21days)
• Minorstroke(non-disabling)• Majorstroke(disabling)
FACTORSASSOCIATEDWITHANINCREASEDRISKOFSTROKE
• Age(increasedwithage)• Gender(males>females)• Race(Blacks>AsiansandHispanics>Whites)• Geographicregion(EasternEurope>WesternEurope;Asia>EuropeorNorthAmerica)
• Familyhistory(strokeorheartdisease<age60)
POTENTIALLYMODIFABLERISKFACTORSFORSTROKE
• Hypertension• Diabetesmellitus• Hyperlipidemia• Smoking• Atrialfibrilla*on• Hyperhomocysteinemia• Physicalac*vity
OTHERPOTENTIALRISKFACTORS
• Migraine• Oralcontracep*ves• Obesity• Pregnancy• Alcoholabuse• Drugabuse• Sleepdisorders(sleepapnea)
TYPESOFIS
• ATHEROSCLEROTIC(Plaquesleadtostenosis,occlusion,distalembolisa*on(artery-to-arteryembolism)andstealphenomena
• CARDIOEMBOLIC
• LACUNAR
• OTHERS
• UNDETERMINED
CARDIACCAUSESOFIS• Atrialfibrilla*on• RecentMI• Ventricularaneurysm(postMI)• Akine*csegment(postMI)• Dilatedcardiomyopathy• Muralorintraven*cularthrombus• Valvularabnormali*es(mitralinsufficiency,mitralandaortalstenosis).
Alsocongenital• Infec*veendocardi*s• Atrialseptalaneurysm/defect• Patentforamenovale(PFO)• Myxoma• Mechanicalorbioprosthe*cvalve• CABG,PTCA,othercardiacsurgery
OTHERCAUSESOFIS
• Vasculopathies– Noninflamatory(dissec5on,vasospasm,others)– Inflamatory(PAN,SLE,vasculi5s,others)– Infec5ous(syphilis,HerpesZoster,AIDS,others)
OTHERCAUSESOFIS• Hematologicandcoagula5ondisorders– Polycythemia,thrombocytosis,trombocytopenia– An5thrombinIIIdeficiency– ProteinCorSdeficiency– DeficiencyoffactorsV,VII,XII,XIII– An5phospholipid/an5cardiolipinan5bodies– Malignancy– Pregnancy– Oralcontracep5ves
SYMPTOMSOFSTROKE
• Symptomsdependonlocaliza5onandsizeoflesion
• Lessone5ology/causeofstroke• Focalsymptoms• Globalsymptoms
SYMPTOMSOFSTROKE
Timecourseandevolu5on:• Suddenorrapidonsetofsymptoms– inthemorning,inday5me– onsleep,exercise
• Reachmaximalintensitywithin24hours• Gradualorstepwiseworseningcanoccur
SYMPTOMSOFSTROKE
Focalneurologicalsymptoms:• Cogni5veimpairments(aphasia,neglect,apraxia)
• Weaknessorincoordina5onoflimbs• Facialweakness• Numbnessoflimbsand/orface• Cranialnervepalsies
SYMPTOMSOFSTROKE
Globalsymptomsandsigns:• Headache• Nauseaandvomi5ng• Alteredmentalstatus– syncope– seizure– coma
• Hypertensionandabnormalvitalsigns• Nuchalrigidity
SYMPTOMSOFTIA/STROKE
• Caro5dcircula5on– Ipsilateralmonocularblindness– Contralateralweakness,numbness(hand,arm,face,leg)
– Aphasia
Lechemisphere(ie,dominant)
• Righthemiparesis,variableinvolvementoffaceandupperandlowerextremity
• Right-sidedsensoryloss,inasimilarpaeerntothemotordeficit;usuallyinvolvesallmodali5es,decreasedstereognosis,graphesthesia
• Righthomonymoushemianopia• Aphasia,fluentandnonfluent• Alexia• Agraphia• Acalculia• Apraxia
Righthemisphere(ie,nondominant)
• Lechemiparesis(samepaeernasonright)• Lec-sidedsensoryloss(similarpaeernasthemotor
deficit)• Lechomonymoushemianopia(samepaeernasonright)
• Neglectofthelecsideofenvironment• Anosognosia• Asomatognosia• Lossofprosodyofspeech• Flataffect
Posteriorcircula5on
PCAocclusion• Themostcommonfindingisoccipitallobeinfarc5onleadingto
contralateralhemianopiawithmacularsparing
• ClinicalsymptomsassociatedwithocclusionofthePCAvarydependingontheloca5onoftheocclusionandmayincludethethalamicsyndrome,thalamicperforatesyndrome,Webersyndrome,cor5calblindness,colorblindness,failuretoseeto-and-fromovements,verbaldyslexia,andhallucina5ons.
Basilararteryoclusion
• Abnormallevelofconsciousness
• Quadriparesis,whichusuallyisasymmetric
• Pupillaryabnormali5es
• Oculomotorsigns
Subarachnoidhaemorrhage(SAH)
• Bleedingintothesubarachnoidspace—theareabetweenthearachnoidmembraneandthepiamatersurroundingthebrain.• Thismayoccurspontaneously,usuallyfromarupturedcerebralaneurysm,ormayresultfromheadinjury
Cerebralaneurysm—aweaknessinthewallofoneofthearteriesinthebrainthatbecomesenlarged.TheytendtobelocatedinthecircleofWillisanditsbranches.
Subarachnoidhaemorrhage(SAH)
• Signsandsymptoms:asevereheadachewitharapidonset("thunderclapheadache"),aheadachedescribedas"likebeingkickedinthehead",orthe"worstever",developingoversecondstominutes.Thisheadacheo\enpulsatestowardstheocciput(thebackofthehead),meningism,vomi*ng,confusionoraloweredlevelofconsciousness,andsome*messeizures• Diagnosis:CTofthehead,MR,lumbarpuncture-mandatoryinpeoplewithsuspectedSAHifimagingisnega*ve(redbloodcells,xanthochromiaatleast>12hoursa\ertheheadache),ECG,angiography
Subarachnoidhaemorrhage(SAH)Management:• involvesgeneralmeasurestostabilizethepa*entwhilealsousingspecificinves*ga*onsandtreatments.• preven*onofrebleedingbyoblitera*ngthebleedingsource(neurosurgery),preven*onofaphenomenonknownasvasospasm(nimodipine-calciumchannelblocker),• andpreven*onandtreatmentofcomplica*ons(seizures-an*epilep*cdrugs,electrolytedisturbanceslikehyponatremia,hydrocephalus)
CEREBRALHAEMORRHAGE:
• spontaneousintracerebralhemorrhage(inptwithhypertension)• headtrauma• ruptureofananeurysmorarteriovenousmalforma*on(AVM)• bleedingwithinatumor• amyloidangiopathy• RiskfactorsforICHinclude:• hypertension(highbloodpressure)• Diabetesmellitus• CigareDesmoking• Excessivealcoholconsump*on• Severemigraine
Moyamoyasyndrome:• isadisease(congenitaloracquired)inwhichcertainarteriesinthebrainareconstricted.Acollatercircula*ondevelopsaroundtheblockedvesselstocompensatefortheblockage,butthecollateralvesselsaresmall,weak,andpronetohemorrhage,aneurysmandthrombosis.Onconven*onalX-rayangiography,thesecollateralvesselshavetheappearanceofa"puffofsmoke"(describedas"もやもや(moyamoya)"inJapanese).• Moyamoyadiseasetendstoaffectadultsinthethirdtofourthdecadeoflife.Inchildrenittendstocausestrokesorseizures.Inadultsittendstocausestrokesorbleeding.Theclinicalfeaturesarestrokes,recurrenttransientischemicaDacks(TIAs),sensorimotorparalysis(numbnessandparalysisoftheextremi*es),convulsionsand/ormigraine-likeheadache.• Treatment:aspirin,surgical
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