BYDR. SUBHASISH DEB

B U R D W A N M E D I C A L C O L L E G E A N D H O S P I T A L( D E P A R T M E N T O F I N T E R N A L M E D I C I N E )

APPROACH TO HEADACHE

10/14/2014Dr Subhasish Deb

HEADACHE= CEPHALALGIA

Definition:

“Diffuse pain in various parts of the head, not confined to the distribution of any nerve”

(source: Steadman’s Pocket Medical Dictionary)

10/14/2014Dr Subhasish Deb

WHAT ACHES?

PAIN SENSITIVE STRUCTURES:

1. Scalp

2. Middle meningeal artery

3. Dural sinuses

4. Falx cerebri

5. Proximal segment of large pial arteries

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WHAT DOESN’T ACHE?

Pain insensitive structures:

1. Ventricular ependyma

2. Choroid plexus

3. Pial veins

AND

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WHAT ABOUT BRAIN PARENCHYMA?

Most of the brain parenchyma is INSENSITIVE to pain

HOWEVER, the region of the dorsal raphe in the MID BRAIN is sensitive to pain.

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TRANSMISSION OF PAIN

Sensory stimuli from head CNS

Supratentoralstructures in anterior

and middle cranial fossa

Posterior cranial fossaand infratentorial

structures

TRIGEMINAL NERVE C1, C2, C3

Cervical spinal n

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What happens?

MECHANISM OF HEADACHES

1. Distention/traction/dilatation of intracranial or extracranial arteries

2. Traction/displacement of large i.c. veins/ their dural envelopes

3. Compression/traction/inflammation of cranial and spinal nerves

4. Spasm/inflammation/trauma to cranial and cerivalmuscles

5. Meningial irritation and raised icp

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CLASSIFICATION

Primary headache

Secondary headache

• Symptom based•No organic causes

•Etiology based

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PRIMARY HEADACHES

1. Migraine

2. Tension-type headache

3. Trigeminal autonomic cephalalgias (including cluster headaches)

4. Other primary headache disorders Cough

Exertional

Headache associated with sexual activity

Hypnic

Primary thunderclap

Hemicranial continua

New daily-persistent headache

-ISH Cefalalgia 2013

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PRIMARY HEADACHE TYPES

MIGRAINE TENSION CLUSTER

Pain Description

Throbbing, Moderate to severe,Worse with exersion

Pressure,Tightness,Waxes and wanes

Abrupt onset, deep, continuous, excruciating, explosive.

Associated Symptoms

Photo/phonophobia,Nausea/vomiting,Aura

NONE Tearing, congestion, rhinorrhea, pallor, sweating

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PRIMARY HEADACHE TYPES

MIGRAINE TENSION CLUSTER

Location 60-70% Unilateral Bilateral Unilateral

Duration 4-72 hrs Variable 0.5 -3 hrs, many per day

Patient Appearance

Resting in quiet dark room,

Young female

Remains active or prefers to rest

Male, smoker,

Remains active, prefers hot showers.

10/14/2014Dr Subhasish Deb

10/14/2014Dr Subhasish Deb

10/14/2014Dr Subhasish Deb

MIGRAINE

It is the second most common cause of headaches (m/c is tension type headache)1

Often can be recognized by its activators= TRIGGERS

-light, sound, stress, hunger, menstruation, stormy weather, lack or

excess of sleep, barometric pressure change, alcohol

basis of life style adjustments

A headache diary is often useful in making diagnosis, assessing disability and frequency of treatment for acute attacks

1 Harrison’s Principles of Internal Medicine 18thed

10/14/2014Dr Subhasish Deb

10/14/2014Dr Subhasish Deb

Types of Migraine

1. Without Aura (Common migraine) = 80%

2. With Aura (Classic migraine) =20%

3. Migraine varients Basilar migraine

Retinal migraine

Ophthalmoplegic migraine

Migraine with complicated aura

Migrainous stroke

Migraine aura without migraine (Acephalalgic migraine)

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Classic Migraine

Potential phases of migraine attack

1. Prodrome – occurs hours to days before headache, change in

mood, behaviour, appetite, cognition

2. Aura- occurs within 1 hour of headache, most commonly visual

or sensory

Visual aura

Most common

Consists of photopsias, bright flashing lights, scintilating scotomas, field cuts and fortification spectra(zig zag lines/ Teichopsia)

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Sensory aura

Numbness and paresthesiae in a limb

Motor weakness and aphasia are less common

3. Headache

4. Recovery

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10/14/2014Dr Subhasish Deb

10/14/2014Dr Subhasish Deb

Common Migraine

Symptoms similar to classical migraine but without aura

Precipitating factors:

Foods rich in tyramine ( cheese, redwine)

Foods containing monosodium glutamate (Chinese and Mexican food)

Foods containing nitrates ( salami, smoked meat)

Caffeinated beverages (soft drinks, tea and coffee)

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MIGRAINE VARIENTS

Basilar migraine a/k bickerstaff syndrome, brainstem migraine, basilar artery

migraine, vertebrobasilar migraine

This disorder is now called Migraine with Brain stem Aura(MBA)

rare form of migraine with aura wherein the primary signs and symptoms seem to originate from the brainstem, without evidence of weakness. (d/d- FHM)

Originally described by Bickerstaff in 1961 as a distinct clinical entity

Brain stem aura: Dysarthria, vertigo, hyperacusis, diplopia, visual symptoms in both temopral and nasal fields, decreased level of conciousness.

10/14/2014Dr Subhasish Deb

Retinal migraine:

a/k ocular migraine

Characterized by retinal or optic nerve ischemia

Other migraines affect eyesight in both eyes but here typically single eye is affected.

Mono ocular blindness, disc edema occurs and vision recovers only partially after several months

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Ophthalmoplegic migraine:

Characterized by recurrent unilateral headaches associated with weakness of extra ocular muscles.

Transient 3rd nerve palsy with ptosis with/without involvement of the pupil is the usual picture.

6th nerve is early effected common in children

Paresis may persist even after headache for days to weeks

Occasionally opthalmoperesis may remain permanent

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Complicated migraine

a/k migranous infarction

Here, the temporary neurologic symptom of migraine headache may remain permanent.

Ex: a homonymous visual field defect

In children with mitochondrial disease MELAS (Mitochondrial myopathy, Encephalopathy, Lactic Acidosis and Stroke like symptoms)

And in adults with very rare vasculopathy :

CADASIL (Cerebral Autosomal Dominant Arteriopathy with Subcortical infarcts and Leukoencephalopathy

10/14/2014Dr Subhasish Deb

Tension type headache

Describes a chronic head-pain syndrome characterized by bilateral, tight, band like discomfort

Pain builds up slowly, persists more or less continuously for days

When present > 15days/month- chronic TTH

Featureless

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<180/year (<15/month)

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Trigeminal Autonomic Cephalalgias

Characterized by relatively short lasting attacks of head pains associated with autonomic symptoms-lacrimation, conjunctival injection or nasal congestion

Includes:

1. Cluster headache

2. Paroxysmal hemicrania

3. SUNCT/SUNA

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Cluster headache

A rare form of headache with a population freq 0.1%

Pain is:

Deep, usually retroorbital

Excruciating in intensity

Non fluctuating

Explosive in quality

CORE feature = PERIODICITY

At least one of the daily attacks of pain recurs in the same hour each day for the duration of cluster bout

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Typically pts has daily bouts of 1-2 attacks of short duration, unilateral pain for 8-10 weeks a year

Followed by pain free interval that lasts less than a year

Associated with ipsilateral symptoms of cranial parasympathetic autonomic activation

10/14/2014Dr Subhasish Deb

10/14/2014Dr Subhasish Deb

Paroxsymal Hemicrania

Frequent unilateral, sever short lasting episodes of headache

Like cluster, pain tends to be retroorbital, autonomic symptoms

A characteristic feature is its EXCELLENT response to INDOMETHACIN. (cluster headaches respond to 100% O2 therapy)

In contrast to cluster headaches, here the male : female ratio is 1:1

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SUNCT/SUNA

Short lasting Unilateral Neuralgiform headache attacks with Conjunctival injection and Tearing

Diagnosis requires: At least 20 attacks, lasting 5-240sec

Ipsilateral conjunctival injection and lacrimation should be present

Characteristics are: Lack of response to INDOMETHACIN

A lack of refractory period to triggering between attacks

Presence of cutaneous triggers of attacks

d/d- trigeminal neuralgia

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SECONDARY HEADACHE TYPES

10/14/2014Dr Subhasish Deb

CLINICAL APPROACH TO THE PATIENT

History, history, history (Headache diary)

Site

Onset

Character

Radiation

Associated symptoms

Timing

Exacerbating and relieving factors

Severity

Sate of health between attacks

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HISTORY

SITE

Extra Cranial

Intra Cranial

vascular

Giant cell arteritis – precise location

PNS. Ocular, Dental, Uppercervical verebrae

Less sharply localized but still regionally distributed

Anterior and mid cranial fossa

Fronto-temporal pain

Posterior cranial fossa

Occipitonuchal pain

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hrs-days

ONSET

Ruptured aneurysm

Migraine Cluster Headache

Thunderclap headache

hrs3-5 mins

45mins taper

Relieved by sleep

Brain tumours / raised ICP: headaches that disturb sleep/ early morning headaches

10/14/2014Dr Subhasish Deb

ONSET

Early morning headache on waking up and again at the end of day is dues to Maxillary sinusitis (diurnal variation)

Office headache: due to Frontal sinusitis

[patient wakes up mostly without pain due to overnight drainage, develops pain after a few hours that lasts throughout the day]

Vacuum headache: the headache on waking up that may occur in Frontal sinusitis due to over night drainage

10/14/2014Dr Subhasish Deb

Dull aching pain: sinusitis related

Tension type: tight ‘band like’ pain

Migraine: throbbing with tight muscles around head, neck and shoulder girdle. Aslo w/w.o aura.

CHARACTER

10/14/2014Dr Subhasish Deb

Most important aspect of pain from patients point of view.

But it rarely has any diagnostic importance!

Can often be misleading since even a brain tumourneed NOT present with severe/distinctive pain.

INTENSITY

10/14/2014Dr Subhasish Deb

Chronic daily headache without migranous or autonomic features- tension type

Migrane- peakes within 1-2 hrs of onset and lasts typically 4-72 hrs

Cluster headache- peaks at onset or within minutes, lasts for 15-180 mins

Chronic paroxysmal hemicrania- similar to cluster but last 2-30 mins with several episodes in a day

TEMPORAL PROFILE

10/14/2014Dr Subhasish Deb

Cluster- Almost have a clock like periodicity and awakes the patient from sleep

Hypnic headaches- also awaken pts from sleep but are more diffuse and there are no associated autonomic symptoms

Migraine- any time of the day

Chronic tension type- present during day and is most severe in the latter part of the day

TIME OF DAY

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Worsening of headache on coughing or physical jolt indicated an intra cranial component

Worsening in upright position suggests intracranial hypotension

Worsening on routine physical activity, light, sound – migraine attacks

AGGRAVATING FACTORS

10/14/2014Dr Subhasish Deb

PHYSICAL EXAMINATION

Vital sign along with body temperature

General appearance- whether restless or calm in a dark room (cluster vs migraine)

Palpation of ipsilateral temporal artery for tenderness, tm joint for crepitance while pt closes or opens jaw

Area over infected sinus may be tender

Pseudotumor cerebri- often seen in young obese females

Eye and periorbital area- lacrimation, conjuctivalinjection, flushing (TACs vs glaucoma)

10/14/2014Dr Subhasish Deb

Pupillary size and light responses, extra ocular muscles, visual acuity

Fundus- papilledema and retinal pulsations

Neck for rigidity, kernig, brudzinski signs

Cervical spine palpated for tenderness

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INVESTIGATIONS

Most patients can be diagnosed without testing, however some serious disorders may require urgent testing

CT and MRI should be done in pts with the following findings: Thunderclap headache

Altered mental status

Meningismus

Palliledema

Signs of sepsis

Acute focal neurological deficit

Sever hypertenstion (SBP>220, DBP>120)

-API Medicine Update 2013 Chap 113

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If meningitis, SAH, or encephalitis is being considered- CSF study if not contraindicated

For acute angle closure glaucoma: tonometry, slit lamp shows shallow ant. Chnaber, h/0- nausea, visual hallows.

ESR- in patients with visual symptoms, jaw or tongue claudications- giant cell arteritis

10/14/2014Dr Subhasish Deb

RED FLAGS

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Sinusitis vs Migraine

SUMMIT STUDY:

Prospective multi center observational study of 2,991 patients with self diagnosed or physician diagnosed sinus headache. Using the HIS migraine criteria, 80% of them had migraine

-Schreiber CP, et al. Archives of Internal Medicine

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SUMMARY

Headache is one symptom that may be a manifestation of a simple, benign problem like a tension headache or one of the life threatening fatal diseases like a Berry aneurysm

Acute and new onset headaches have a more serious prognosis than other types of onsets

So careful evaluation of the etiology is very essential.

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THANK YOU

10/14/2014Dr Subhasish Deb