A&E(VMH)

Headache

Dr.Padmashini

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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

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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

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Pain sensitive structures of head

• Scalp,middle meningeal artery,dural sinuses,falx cereberi,proximal segments of large pial arteries

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Pain insensitive structures

• Ventricular ependyma, choroid plexus, pial veins & most of brain parenchyma

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• 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

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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

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• Spasm , inflammation or trauma to cranial & cervical muscles

• Meningeal irritation & raised ICP

• Activation of brain stem structure

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Classification of head ache• International Headache Society

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Approach to patient with head ache

History – head ache

• Pattern

• Onset

• Location

• Associated symptoms

• Other history

• Family history

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General physical examination

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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

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Tension head ache

• Most frequently occuring type

• Physical & emotional stress

• Contraction of muscles that cover the skull

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Clinical features

• Pain at back of head & upper neck

• Band like tightness / pressure

• Mild & bilateral

• Not associated with aura & other symptoms

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treatment

• OTC

• Aspirin, ibuprofen, acetaminopen

Recurrent head ache

• Massage

• Stress management

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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

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Cluster head ache

• Readers syndrome

• Histamine cephalgia

• Spheno palatine neuralgia

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• 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

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features

• Men> women

• Age 20-50 yrs

• Periorbital/temporal pain

• Starts with out aura & peaks in 5 min

• Excrutiating & explosive in quality

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• Rarely pulsatile

• Strictly unilateral

Accompained –

• homolateral lacrimation,

• redening of eye

• nasal stiffness,

• lid ptosis

• nausea

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pathogenesis

• Hypothalamus is the site of activation

• Anterior – circadian pace maker

• Posterior – regulate autonomic functions

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treatment

Initial :

• Inhalation of high conc of O2

• Inj sumatriptan 6 mg s/c

• NSAID

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Prophylactic

• Verapamil

• Prednisolone 60 mg x 10 days

• Lithium 600 – 900 mg daily

• Ergotamine

• methysergide

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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

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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

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Pathogenesis

• Genetic basis of migraine

• Vascular thoery

• Trigemino vascular system

• 5-hydroxytryptamine

• Dopamine in migraine

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Clinical features

Common migraine:

• No FND precedes the attack

• Mod – severe head ache

• Pulsatile

• Unilateral

• Aggravated by routine activity,nausea,vomiting

Photophobia

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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

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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

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Diagnostic criteria for migraine

• Repeated headache lasting for 4- 72h with normal physical examination &

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TREATMENT

Non pharmacological

• Avoidance of head ache triggers

• Regulated life style

• Yoga

• Meditation

• hypnosis

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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

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• Serotonergic drugs – methysergide 4-8 mg qd

cyproheptadine 4-16 mg qd

• Verapamil – 80 – 480 mg qd

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Secondary head ache

• It is due to underlying structural problem in head or neck.

• There are numerous causes & some are life threatening and deadly

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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

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SAH

• It is bleeding in the area between the brain & thin tissues that covers the brain

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SAH

• Severe headache , sudden onset

• Common location – occipitonuchal

• Pain radiates down along the cervical spine

• CT brain

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Cont…..

• LP mandatory following negative CT scan

• Presence of xanthochromia in the CSF supernatant – gold standard

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Cont…

• Neurologic consultation

• Nimodipine 60 mg po q 6 h

• Prophylactic phenytoin to avoid seizures

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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

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Meningitis

• Acute onset of fever, headache, neck stiffness

• LP

• CT brain

• Early empirical antibiotic therapy

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• Intraparenchymal hge & cerebral ischemia

• Brain tumour :

head ache :worse in morning

asso with position, nausea, vomiting

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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

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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

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• Scalp pain, jaw claudication

• Polymyalgia rheumatica

• Complication – optic neuropathy - blindness

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management

• History & examination

• Biopsy of temporal artery

• USG of temporal artery

Treatment:

• Prednisolone 40-60 mg/day x 1 mon

• Combine with aspirin

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glaucoma

• Slowly progressive, insidious optic atrophy usually associated with chronic elevation of IOP

• Axons entering inferotemporal & supero temporal aspect of optic disc damages first

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• As fibres destroyed, neural rim of optic disc shrinks & physiologic cup with in optic enlarges – pathological cupping

Normal fundus

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features

• Painful red eye

• Severe head ache

• Nausea, vomiting

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Diagnosis

• IOP measurement – tonometry

• Exam of optic nerve

• Visual field test

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Treatment

• Topical adrenergic agonist

• Topical cholinergic agonist

• Topical beta blockers

• Topical prostaglandin analogue

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cont

• In ant chamber Topical / oral CAI

• Laser treatment of trabecular meshwork

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• REVERSIBLE SEC CAUSES…..

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hypertension

• Higher diastolic pressure – severe head ache

• Hypertensive emergency / urgency excluded

• Rule out other secondary causes

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Drug related & toxic& metabolic

• Drugs – nitrates, MAOI, chronically analgesic

• Metabolic – hypoxia , hypercapnia , hypoglycemia

• Toxins – monosodium glutamate, carbon monoxide

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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

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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

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summary

• To select patient for emergency intervention & treatment

• To diagnose & treat early

• To provide appropriate disposition and fallow up for all discharged patients

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