Post on 03-Jun-2015
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_Headache is one of the most common neurological problems, in which the careful analysis of the details of history is particularly important.
_Duration of the headache may give clear idea of the seriousness of the und-
erlying disease.
_sudden headache for the first time may be due to meningitis, intracranial
hemorrhage, subarachnoid hemorrhage.
_Headache for years usually is psychogenic.
_Headache for weeks or months may suggest a progressive or an expanding
intracranial lesion& require careful investigation.
_Pain sensitive structures both inside and outside the head receive their
sensory innervation from the tigeminal, glossopharangeal and vagus
nerves or from the upper three cervical nerves
_If the headache is due to a lesion above tentorium pain is felt at
the distribution of ophthalmic division of trigeminal nerve.
_If the lesion is below tentorium the pain is referred to distribution
of upper three cervical nerves or ninth or tenth cranial nerves
_the duration and frequency are important when the headache is
periodic or recurrent, migraine may occur at regular intervals or
confined to certain times, at premenstrual period and may be absent during pregnancy.
_Aggravating factors are important, headache of increased intracra-
nial pressure is aggravated by change in posture or sudden movement also in vascular and post-concussional headache
_Certain food, cheese , chocolate and hypoglycemia may bring on
migraine, while rest will generally relieve vascular headache.
_ The quality of pain also helpful, in migraine is throbbing, but in
migrainous neuralgia may take the form of severe boring pain, while
in tension headache is dull, pressing and band-like.
Migraine.
Tension.
Cluster.
BENIGN PAROXYSMAL HEADACHES
Character of pain Duration Location
Comment
Ice pick Stabbing Very brief (split-second)
Variable, usually temporal or parietal
Benign, more common in migraine
Ice cream Sharp, severe 30-120 seconds Bitemporal/occipital
Obvious trigger by cold stimuli
Exertional/coital Bursting, thunderclap
Severe for minutes then less severe for hours
Generalised Subarachnoid haemorrhage needs exclusion
Cough Bursting Seconds to minutes
Occipital or generalised
Intracranial pathology needs exclusion (especially cranio-cervical junction)
Cluster headache
(migrainous neuralgia)
Severe unilateral, with ptosis, tearing, conjunctival injection, unilateral nasal congestion
30-90 minutes 1-3 times per day
Periorbital Usually men, occurring in clusters over weeks/months
Chronic paroxysmal hemicrania
Severe unilateral with cluster headache-like autonomic features (above)
5-20 minutes, frequently through day
Periorbital/temporal
Usually women, responds to indometacin
SUNCT* Severe, sharp, triggered by touch or neck movements
15-120 seconds, repetitive through day
Periorbital May respond to carbamazepine
SUNCT :Short-lasting, Unilateral, Neuralgiform headache with Conjunctival injection
Subarachoid hemorrhage.
Meningitis.
Intracranial tumors.
Temporal artritis.
Subdural hematoma.
“Red Flags” for headache evaluation
HIGH RISK HISTORICAL HIGH RISK HISTORICAL FEATURES FEATURES
Sudden Onset Sudden Onset New onset > 50yrsNew onset > 50yrs Headache with exertion Headache with exertion Visual disturbancesVisual disturbances LocationLocation Medication Medication HIV , ImmunocompromisedHIV , Immunocompromised
Sudden onset Sudden onset
Subarachnoid hemorrhage (SAH) often Subarachnoid hemorrhage (SAH) often presents with the abrupt onset of presents with the abrupt onset of excruciating pain.excruciating pain.
Other serious etiologies include carotid Other serious etiologies include carotid and vertebral artery dissections, venous and vertebral artery dissections, venous sinus thrombosis, pituitary apoplexy, sinus thrombosis, pituitary apoplexy, and hypertensive emergenciesand hypertensive emergencies
New Onset > 50 yrs of New Onset > 50 yrs of ageage
The "first" or "worst headache of The "first" or "worst headache of my life“my life“
Intracranial mass lesion and Intracranial mass lesion and temporal arteritistemporal arteritis
Headache with exertionHeadache with exertion
Cough, Valsalva, intercourse, Cough, Valsalva, intercourse, exercise.exercise.
Possibility of carotid artery Possibility of carotid artery dissection or intracranial dissection or intracranial hemorrhage.hemorrhage.
Headache associated Headache associated with visual with visual
disturbancesdisturbances May indicate conditions such as May indicate conditions such as
glaucoma or optic neuritisglaucoma or optic neuritis
Location of painLocation of pain
Unilateral temple headache in Unilateral temple headache in adult life (may indicate cranial adult life (may indicate cranial arteritis)arteritis)
Head pain that spreads into the Head pain that spreads into the lower neck and between the lower neck and between the shoulders may indicate meningeal shoulders may indicate meningeal infection.infection.
HIV and HIV and immunosuppression immunosuppression
Significant risk for intracranial Significant risk for intracranial disease, including toxoplasmosis, disease, including toxoplasmosis, brain abscess, meningitis and brain abscess, meningitis and tumours.tumours.
MedicationsMedications
Use of anticoagulants or Use of anticoagulants or nonsteroidal antiinflammatory nonsteroidal antiinflammatory drugs eg, aspirin increases the risk drugs eg, aspirin increases the risk of intracranial bleeding.of intracranial bleeding.
Analgesics can mask severe Analgesics can mask severe symptoms or exacerbate migraine symptoms or exacerbate migraine headache headache
HIGH RISK EXAMINATION HIGH RISK EXAMINATION FINDINGSFINDINGS
Neurological abnormalitiesNeurological abnormalities MeningismMeningism Ophthalmologic findingsOphthalmologic findings Abnormal vital signsAbnormal vital signs
Neurological Neurological Abnormalities Abnormalities
Best clinical predictor of intracranial Best clinical predictor of intracranial pathology.pathology.
Unilateral vision loss, ataxia, or seizure.Unilateral vision loss, ataxia, or seizure. Pupillary asymmetry, unilateral pronator Pupillary asymmetry, unilateral pronator
drift, or extensor plantar response drift, or extensor plantar response
Decreased level of Decreased level of consciousness consciousness
Atypical of benign headachesAtypical of benign headaches
Increases the likelihood of meningitis, Increases the likelihood of meningitis, encephalitis, subarachnoid hemorrhage encephalitis, subarachnoid hemorrhage (SAH), or other space occupying lesion.(SAH), or other space occupying lesion.
MeningismMeningism
Nuchal rigidity Nuchal rigidity Photophobia Photophobia Kernig’s signKernig’s sign Brudzinski’s signBrudzinski’s sign
Ophthalmologic findingsOphthalmologic findings
PapilloedemaPapilloedema Raises the suspicion of raised intracranial Raises the suspicion of raised intracranial
pressurepressure Mass lesion or benign intracranial Mass lesion or benign intracranial
hypertension.hypertension.
Abnormal Vital SignsAbnormal Vital Signs
FebrileFebrile Increased BPIncreased BP BradycardiaBradycardia
_Its common, usually described as severe, continuous as sense of
pressure or tightness rather than pain, usually on the vault or less
frequently occipito-frontal and usually bilateral
_ migraine is very common and a wide variety of atypical and
partial forms are seen.
_usually start at adolescence as recurrent headache lasting 2 hs
to 2 days.
_the pain is usually unilateral associated with photophobia, nausea
and vomiting.
_Many patients experience an aura before the pain usually visual
disturbance as flashing lights, scotomata, or even hemianopia,
paraesthesiae may occur around the angle of the mouth or in the
hand.
Chronic migraine: headache (not attributable to another disorder) on ≥ 15 days/month for > 3 months fulfilling the following criteria for migraine:
At least 2 of the following: 1) unilateral location, 2) pulsating quality, 3) moderate/severe pain intensity, 4) aggravation by routine physical activityAt least 1 of the following: 1) nausea and/or vomiting, 2) photophobia and phonophobia.
A.At least 10 previous headache episodes meeting criteria B to DB.Lasting from 30 minutes to 7 daysC. At least 2 of the following pain characteristics
1. Pressing/tightening (nonpulsating) quality2. Mild or moderate intensity3. Bilateral location4. No aggravation by walking stairs
D. Absence of both of the following1. Nausea and vomiting2. Photophobia and phonophobia
Occasional TTH is seldom disabling (unlike chronic TTH) Both TTH and migraine are aggravated by stress (so can be hard to differentiate) Headache more often than once a week may be a mixture of TTH and migraine Successful management is dependent on recognition and management of each separate headache type
Formerly known as migrainous neuralgiaGenerally affects men (ratio 6:1), often smokers, in their 20s or olderTypically occurs in bouts for 6-12 weeks every one or two yearsAttacks typically occur at night, waking the patient 1 to 2 hours after falling asleep, lasting 30 to 60 minutesPain is intense, probably as severe as renal colic, and strictly unilateral
_Its much less common than migraine and more in males, onset
usually at third decade.
_Characterized by severe periodic unilateral periorbital pain with
conjunctival injection, unilateral lacrimation, nasal congestion
and partial horner`s syndrome
_The pain is brief last 30-90 minutes.
_usually occur at early morning for weeks disappear for months
followed by another cluster.
_Usually due to space occupying lesions, brain tumor, abscess, or
haematoma.
_Other causes of raised intracranial pressure, viral encephalitis,
lead encephalopathy and malignant hypertension.
_Severe headache occurs in meningeal irritation as in meningitis and
subarachnoid haemorrhage which are associated with vomiting and
neck rigidity.
_Usually middle-aged men develop sudden, severe headache at
the climax of sexual intercourse last for 10-15 minutes, a milder
headache may persist for few hours.
_A similar headache may occur after unaccustommed exertion in
unfit person.
_Most patients with persisting facial pain have, trigeminal neuralgia,
atypical facial pain or post-herpetic neuralgia.
_Trigeminal neuralgia causes very sharp lancinating pains in one
division of trigeminal nerve in middle-aged and elderly patients the
pain is severe, brief and repetitive make the patient to flinch.
_Atypical facial pain is continuous and unremitting, centered over
the maxilla most frequently on left side in middle-aged women.
_Post-herpetic neuralgia is continuous, felt as burning at affected
territory which is sensitive to light touch and there is history of
Herpes zoster.
Prevalence: less common in those aged over 60 years than in younger people. Common causes: trigeminal neuralgia, temporal arteritis and post-herpetic neuralgia, which occur rarely in younger patients. Migraine and tension headache: less common than in younger people. Raised intracranial pressure: not always associated with headache, vomiting or papilloedema because intracranial mass lesions can reach larger sizes before presentation, as the involutional process that occurs in ageing brains allows the accommodation of an expanding lesion more easily than in younger patients.