headache headache

headache headache

 Headache is one of the commonest Headache is one of the commonest

neurological complain reported at neurology neurological complain reported at neurology

clinic clinic



path physiology path physiology

Intracranial pain sensitive structures include

Intracranial pain sensitive structures include: the : the arteries of the circules of willis &the first few arteries of the circules of willis &the first few

centimeters of their median sized branches centimeters of their median sized branches Meningeal arteries

Meningeal arteries

Large veins &dural venous sinuses Large veins &dural venous sinuses

Extra cranial sensitive structures:

Extra cranial sensitive structures:

external carotid arteires, scalp ,neck muscle ,skin external carotid arteires, scalp ,neck muscle ,skin

& cutaneous nerves, cervical nerve &nerve roots,

& cutaneous nerves, cervical nerve &nerve roots, mucosa of the sinus &teeth ..

mucosa of the sinus &teeth ..

Case history Case history

 25 y old f with h/o : ER h/o sever headache ,diffuse 25 y old f with h/o : ER h/o sever headache ,diffuse ,dull in nature ,not relived by analgesia,aggrevated ,dull in nature ,not relived by analgesia,aggrevated by by cough ,sneezing.cough ,sneezing.

 Assosiated with vomitingAssosiated with vomiting

 No other neurological symptoms.No other neurological symptoms.

 She gave h/o of chronic infrequent She gave h/o of chronic infrequent

headache ,which tension type and less sever, headache ,which tension type and less sever,

relieved by analgesia relieved by analgesia

 She is singleShe is single

 Recently She was following with dermatology Recently She was following with dermatology

O/E O/E

 Neurological exam :Neurological exam :

 HF:NHF:N

 Speech :normalSpeech :normal

 Cranial nerves: Cranial nerves: fundoscopic fundoscopic exam:papilledema

exam:papilledema

 Motor, sensory, coordination :normal Motor, sensory, coordination :normal

 Is this headache serious? Is this headache serious?

headache headache

 Primary (benign)Primary (benign) secondary secondary

 e.g(Migraine,tension,cluster) e.g(Migraine,tension,cluster)

 brain systemic referred brain systemic referred

 HPT ear,teethHPT ear,teeth

 anemia eye,sinusanemia eye,sinus

serious

serious meninges meninges parenchyma parenchyma vacsular vacsular

Secondary causes (serious) Secondary causes (serious)

 Structural causesStructural causes

 MeningesMeninges: meningitis: meningitis

 parenchyma parenchyma : encephalitis ,abscess, tumor: encephalitis ,abscess, tumor

 VascularVascular: hemorrhage, venous thrombosis, : hemorrhage, venous thrombosis, giant cell arterities

giant cell arterities

 CsfCsf: increase CSF pressure : increase CSF pressure (hydrocephalus ,pseudotumor (hydrocephalus ,pseudotumor

cerebri) ,decrease CSF pressure…leak cerebri) ,decrease CSF pressure…leak

 Careful history and examination should be Careful history and examination should be done to differentiate between benign and done to differentiate between benign and

serious headache serious headache

Age Age

 Migraine headacheMigraine headache: child hood or early : child hood or early adulthood

adulthood

 Giant cell arteritis:Giant cell arteritis: >50 y >50 y

 New onset headache in elderly should be New onset headache in elderly should be always a concern

always a concern

Onset Onset

 Headache of many years duration &with Headache of many years duration &with little changes is almost always of benign little changes is almost always of benign

origin origin

 New onset headache in old age or New onset headache in old age or increasingly sever headache ….

increasingly sever headache ….seriousserious headache..

headache..

 Hyperacute : SAHHyperacute : SAH

periodicity:

periodicity:

 episodic headache is benignepisodic headache is benign

 Migraine ,Cluster headache Migraine ,Cluster headache

 a daily constant headache ..tension typea daily constant headache ..tension type

duration duration

 Migraine: 4-72 hMigraine: 4-72 h

 Cluster:1/2-2hCluster:1/2-2h

 Tension headache :build up over hours lasts Tension headache :build up over hours lasts days to years

days to years

Location Location

 unilateral headache:migraine,cluster,temporal unilateral headache:migraine,cluster,temporal arterities .

arterities .

 TensionTension headache : generalized ,frontal or headache : generalized ,frontal or posterior cervical region

posterior cervical region

 Carotid dissection commonly present with Carotid dissection commonly present with

neck,face,and head pain usually ipsilateral to the neck,face,and head pain usually ipsilateral to the

dissection dissection

Nature Nature

 Nature: Nature:

 throbbing: vascular throbbing: vascular

 Tension :fullness, tightness, pressure like Tension :fullness, tightness, pressure like

aura,& associated symptoms aura,& associated symptoms

 migrainemigraine: : aura;aura; focal cerebral symptoms focal cerebral symptoms

associated with lasts from 20-30 min, precedes the associated with lasts from 20-30 min, precedes the

headache headache

 Sensory, motor,autonomic,..Sensory, motor,autonomic,..

 ClusterCluster headache: ptosis,lacrimation, conjuctival , headache: ptosis,lacrimation, conjuctival , nasal congestion

nasal congestion

 Headcahe +fever …..infectionHeadcahe +fever …..infection

 Transient visual obscuration, diplopia,tinnitus …Transient visual obscuration, diplopia,tinnitus …

aura,& associated symptoms aura,& associated symptoms

 Jaw clawdication: temporal arteritisJaw clawdication: temporal arteritis

 Headache: progressive+ central nervous Headache: progressive+ central nervous symptoms is suggestive …structural brain symptoms is suggestive …structural brain

lesion lesion

Aggravating & relieving Aggravating & relieving

 AggravatingAggravating

 Cough, straining……intracranial pressure Cough, straining……intracranial pressure

 Activity., stress…..migraine, tension typeActivity., stress…..migraine, tension type

 Sitting: CSF hypotensionSitting: CSF hypotension

 Relieving:Relieving:

 Rest…….migraine,tension Rest…….migraine,tension

Drug history Drug history

 Oral contraceptive… Cerebral vein Oral contraceptive… Cerebral vein thrombosis, migraine

thrombosis, migraine

 Steroid withdrawal pseudotumor cerebriSteroid withdrawal pseudotumor cerebri

 Retin A tablets Retin A tablets

 Warfarin : HgeWarfarin : Hge

 Postpartum : cerebral venous thrombosisPostpartum : cerebral venous thrombosis

 Recurrent abortionRecurrent abortion

FH FH

 migrainemigraine

exam exam

 v/s: v/s: fever ,BPfever ,BP

 General: General: sinus tendernesssinus tenderness

 Eye ,throat ,ear examEye ,throat ,ear exam

exam exam

 Normal examNormal exam: benign headache: benign headache

 PapilledemaPapilledema: increased intracranial pressure: increased intracranial pressure

 Focal neurological findingFocal neurological finding……serious……serious

 Complicated migraineComplicated migraine….neurological signs….neurological signs

 Horner syndromeHorner syndrome: cluster headache: cluster headache

 Scalp tenderness,Scalp tenderness, pulslesspulsless: temporal arteritis: temporal arteritis

Is this headache serious?

Is this headache serious?

 Characteristics of headache with serious underlying pathology Characteristics of headache with serious underlying pathology

 History :History :

 Explosive onset and severe at onsetExplosive onset and severe at onset

 No similar headaches in the pastNo similar headaches in the past

 you have a constant headache, which is gradually getting worse;you have a constant headache, which is gradually getting worse;

 Altered mental statusAltered mental status

 Age over 50Age over 50

 ImmunosuppressionImmunosuppression

 Physical examination :Physical examination :

 Neurologic abnormalities Neurologic abnormalities

 Decreased level of consciousnessDecreased level of consciousness

 MeningismusMeningismus

Work up Work up

 If history and exam is suggestive of serious If history and exam is suggestive of serious headache

headache

 Brain image: CT brain, mri brainBrain image: CT brain, mri brain

 If suspect cerebral vein throbosis..CT If suspect cerebral vein throbosis..CT venogram ,MRV

venogram ,MRV



 if fever or ? SAH …LPif fever or ? SAH …LP

Go back to the case

Go back to the case

Case history Case history

 25 y old f with h/o : ER h/o sever headache ,diffuse 25 y old f with h/o : ER h/o sever headache ,diffuse ,dull in nature ,not relived by analgesia,aggrevated ,dull in nature ,not relived by analgesia,aggrevated by by cough ,sneezing.cough ,sneezing.

 Assosiated with vomitingAssosiated with vomiting

 No other neurological symptoms.No other neurological symptoms.

 She gave h/o of chronic infrequent She gave h/o of chronic infrequent

headache ,which tension type and less sever, headache ,which tension type and less sever,

relieved by analgesia relieved by analgesia

 She is singleShe is single

 Recently She was following with dermatology Recently She was following with dermatology doctor and he gave her tablets for facial peeling doctor and he gave her tablets for facial peeling

O/E O/E

 Neurological exam :Neurological exam :

 HF:NHF:N

 Speech :normalSpeech :normal

 Cranial nerves: Cranial nerves: fundoscopic fundoscopic exam:papilledema

exam:papilledema

 Motor, sensory, coordination :normal Motor, sensory, coordination :normal

Work up Work up

 CT brain : normalCT brain : normal

 MRI brain:NMRI brain:N

 MRV: NMRV: N

 LP: increased CSF pressure, protein, LP: increased CSF pressure, protein, glu,cell count were normal

glu,cell count were normal

 Pseudo tumor cerebriPseudo tumor cerebri

 ( Idiopathic Intracranial Hypertension )( Idiopathic Intracranial Hypertension )

Home message Home message

Careful history and exam including Careful history and exam including (opthalmoscopic) exam is the key to

(opthalmoscopic) exam is the key to

differentiate benign from serious headache.

differentiate benign from serious headache.