headacheheadache

Headache is one of the commonest Headache is one of the commonest neurological complain reported at neurology neurological complain reported at neurology clinicclinic

path physiologypath physiology

Intracranial pain sensitive structures includeIntracranial 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 branchescentimeters of their median sized branches

Meningeal arteriesMeningeal arteries

Large veins &dural venous sinusesLarge veins &dural venous sinuses

Extra cranial sensitive structures: Extra cranial sensitive structures: external carotid arteires, scalp ,neck external carotid arteires, scalp ,neck muscle ,skin & cutaneous nerves, cervical nerve muscle ,skin & cutaneous nerves, cervical nerve &nerve roots, mucosa of the sinus &teeth ..&nerve roots, mucosa of the sinus &teeth ..

Case historyCase history

25 y old f with h/o : ER h/o sever 25 y old f with h/o : ER h/o sever headache ,diffuse ,dull in nature ,not relived by headache ,diffuse ,dull in nature ,not relived by analgesia,aggrevated by analgesia,aggrevated 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 analgesiarelieved 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 peelingdoctor and he gave her tablets for facial peeling

O/EO/E

Neurological exam :Neurological exam : HF:NHF:N Speech :normalSpeech :normal Cranial nerves: Cranial nerves: fundoscopic fundoscopic

exam:papilledemaexam:papilledema Motor, sensory, coordination :normal Motor, sensory, coordination :normal

Is this headache serious?Is this headache serious?

headacheheadache

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

meningesmeninges parenchyma parenchyma vacsular vacsular CSFCSF

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 arteritiesgiant 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 headacheserious headache

Age Age

Migraine headacheMigraine headache: child hood or early : child hood or early adulthoodadulthood

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 concernalways 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

durationduration

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 yearsdays 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 regionposterior 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

Local pain :superfacial structuresLocal pain :superfacial structures

Nature Nature

Nature: Nature: throbbing: vascular throbbing: vascular Tension :fullness, tightness, pressure like Tension :fullness, tightness, pressure like

aura,& associated symptomsaura,& associated symptoms

migrainemigraine: : aura;aura; focal cerebral symptoms focal cerebral symptoms associated with lasts from 20-30 min, precedes associated with lasts from 20-30 min, precedes the headachethe headache

Sensory, motor,autonomic,..Sensory, motor,autonomic,.. ClusterCluster headache: ptosis,lacrimation, conjuctival , headache: ptosis,lacrimation, conjuctival ,

nasal congestionnasal congestion Headcahe +fever …..infectionHeadcahe +fever …..infection Transient visual obscuration, diplopia,tinnitus …Transient visual obscuration, diplopia,tinnitus …

increase intracranial pressureincrease intracranial pressure

aura,& associated symptomsaura,& 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 & relievingAggravating & 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 historyDrug 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

FHFH

migrainemigraine

examexam

v/s: v/s: fever ,BPfever ,BP General: General: sinus tendernesssinus tenderness Eye ,throat ,ear examEye ,throat ,ear exam

examexam

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 PapilledemaPapilledema

Work upWork up

If history and exam is suggestive of serious If history and exam is suggestive of serious headacheheadache

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

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

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

Go back to the caseGo back to the case

Case historyCase history

25 y old f with h/o : ER h/o sever 25 y old f with h/o : ER h/o sever headache ,diffuse ,dull in nature ,not relived by headache ,diffuse ,dull in nature ,not relived by analgesia,aggrevated by analgesia,aggrevated 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 analgesiarelieved 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 peelingdoctor and he gave her tablets for facial peeling

O/EO/E

Neurological exam :Neurological exam : HF:NHF:N Speech :normalSpeech :normal Cranial nerves: Cranial nerves: fundoscopic fundoscopic

exam:papilledemaexam:papilledema Motor, sensory, coordination :normal Motor, sensory, coordination :normal

Work upWork 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 normalglu,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.