Jaber Amin AL-Manasia5th year medical student

Presented to:

Dr. Amaal Al Nemry

HeadacheHeadache

Objectives:

1-defenition.2-epidemiology.

3-primary causes.4 -secondary causes.

5 -evaluation and diagnosis.6-mangment.

Headache is pain in any part of the head, including the scalp, face (including the orbitotemporal area), and interior of the head. Headache is one of the most common reasons patients seek medical attention.

Headache is common, with a lifetime prevalence of about 90% of

the general population. It accounts for 4.4% of consultations in

primary care and 30% neurology outpatient consultations.

The 8th most common outpatient diagnosis for family physicians

and the 13th for general internists.

As many as 4.5 million americans will experience recurrent

headaches.

5

Identify patients w/ treatable headache disorders,Diagnose the likely cause of the headaches,Prescribe appropriate interventions,Help patients changes in their lifestyle or environment to reduce the severity of headaches.

DIFFERENTIAL DIAGNOSIS

Primary Headache (90%) Secondary Headache (10%)

result from processes that manifest themselves primarily as head pain.

manifestations of another process.

No Organic Pathology:• Migraine• Cluster headache• Tension headache

Sinusitis caffeine withdrawal neck arthritis viral infections meningitisTemporal artritis Pseudotumer cerebriTrigeminal neuralgiaSubarachnoid hemorrhage

Chronic, genetically linked primary headache

Affects > 10% of adults (most common headache seen in primary care)

usually begin in late childhood or early adulthood (but the diagnosis may be delayed several years)

Women>>>men among adults ( ratio is equal in children ).

Migraine

The presentation of migraine is variable .

Because neurologic symptoms may either precede (“aura”) or accompany the headache, migraine can sometimes be confused with serious causes of headache, such as a transient ischemic stroketransient ischemic stroke. . (TIA).(TIA).

Because patients with migraine often report pain in the face or around (or behind) one eye, they are sometimes misdiagnosed as having sinus sinus headachesheadaches.

cont,,,

Diagnostic criteria for migraine:

International Headache Society ( IHS )Criteria for the Diagnosis of Migraine

The frequencyfrequency, severityseverity, and associated associated symptoms symptoms ofmigraine can vary between patients and within a given lifetime. Fluctuations in serum estrogen concentration inwomen (e.g., phase of the menstrual cycle, pregnancy) are often associated with onset, remission, or change in severity of migraine-related symptoms.

Other known “triggers” include certain foods, caffeine, sleep deprivation, psychosocial stressors,or changes in weather or barometric pressure .Daily pain diaries can help identify such triggers.

Tension–type headache

Tension-type headache is the most common cause of headache overall with a prevelance of ( 30 – 80 % ) in the general community

Tension-type headaches are usually mild or moderate in severity and are often self-treat

They are commonly episodic but can develop into daily or near-daily headaches.

Many patients with tension-type headaches describe bilateral symptoms or a “headband-like” pain.

Tension-type headache and migraine can occur concomitantly in the same patient

IHS diagnostic criteria IHS diagnostic criteria for tension-type headaches states that 2 of the following characteristics must be present :

Pressing or tightening (nonpulsatile quality)

Frontal-occipital location

Bilateral - Mild/moderate intensity

Not aggravated by physical activity

Tension-type headache history is: * Duration of 30 minutes to 7 days

*insomia* No nausea or vomiting (anorexia may occur)

*difficulty concentrating *Photophobia or phonophobia

*no prodrome*Minimum of 10 previous headache episodes;  fewer than 180 days per

year with headache to be considered "infrequent "

*May occur acutely under emotional distress or intense worryOften present upon rising or shortly thereafter

*Muscular tightness or stiffness in neck, occipital, and frontal regions*Duration of more than 5 years in 75% of patients with chronic

headaches*New headache onset in elderly patients should suggest etiologies

other than tension headache

MANAGEMENT

• Careful assessment followed by discussion of likely precipitants and explanation of the fact that the symptoms are not due to any sinister underlying pathology is more likely to be beneficial than analgesics.

• Excessive use of analgesics, particularly of codeine, may actually worsen the headache (analgesic headache).

• Physiotherapy (with muscle relaxation and stress management) is usually beneficial, and low-dose amitriptyline (10 mg nocte increased gradually to 30-50 mg) sometimes helps.

not common (0.3% to 0.4% ) are more prevalent in males classic presentation is described as a series of headaches occurring close together over 6 to 12 weeks and so named clustersevere, intense, unilateral pain lasting from several seconds to many minutes.Concurrent symptoms include ipsilateral lacrimation, rhinorrhea, and ptosis.The headache is also always on the same side,no matter how many months lapse between episodes.

Cluster headache

Cluster headache

A. At least 20 attacks fulfilling criteria B – D B. Severe or very severe unilateral orbital, supraorbital and/or Temporal pain lasting 15 – 180 min if untreated

C. Headache is accompanied by at least one of the following :

1 .Ipisilateral conjunctival injection and/or lacrimation 2 .Ipsilateral nasal congestion and/or rhinorrhoea

3 .Ipsilateral eyelid oedema 4 .Ipsilateral forehead and facial sweating

5 .Ipsilateral miosis and/or ptosis 6 .Sense of restlessness or agitation

D. Attacks have a frequency from one every other day to eight Per day

E. Not attributed to another disorder

MANAGEMENT

• Acute attacks can usually be halted by subcutaneous injections of sumatriptan or by inhalation of 100% oxygen.

• Preventative therapy with the agents used for migraine is often ineffective but attacks can be prevented in some patients by verapamil (80-120 mg 8-hourly), methysergide (4-10 mg daily, for a maximum of 3 months only) or short courses of oral corticosteroids.

• Patients with severe and debilitating clusters can be helped with lithium therapy, although the usual precautions concerning the use of this drug should be observed.

Comparison of key features distinguishing Comparison of key features distinguishing migrainemigraine, , tensiontension, and , and cluster cluster headachesheadaches

   MigraineMigraine TensionTension ClusterCluster

LateralLateralityity

Unilateral Unilateral (60%)(60%)

BilateralBilateral Unilateral (exclusive)Unilateral (exclusive)

IntensiIntensityty

Moderate or Moderate or severesevere

Mild or moderateMild or moderate SevereSevere

Pain Pain descriptodescriptor r (variable(variable))

Pulsating Pulsating (50%)(50%)

Pressing or Pressing or tighteningtightening Boring, piercingBoring, piercing

Physical Physical activityactivity

Aggravation Aggravation by physical by physical activityactivity

Does not worsen with Does not worsen with physical activityphysical activity

Restlessness or agitation during attackRestlessness or agitation during attack

AssociateAssociated d symptosymptomsms

Nausea and/or Nausea and/or photophobiaphotophobia//

phonophobiaphonophobia

No nausea, but may No nausea, but may rarely have rarely have photophobia or photophobia or phonophobiaphonophobia

Ipsilateral symptoms; conjunctival injection, Ipsilateral symptoms; conjunctival injection, lacrimation, nasal congestion, rhinorrhea, lacrimation, nasal congestion, rhinorrhea, forehead and facial sweating, miosis, ptosis, forehead and facial sweating, miosis, ptosis, eyelid edemaeyelid edema

DuratiDurationon

44––7272 hrhr Minutes to daysMinutes to days 1515 - -to 180-min cluster periodsto 180-min cluster periods

Sinusitis & “sinus headache Symptoms suggesting a nasal or sinus

etiology (rhinosinusitis) include: purulence in the nasal cavitynasal obstructionaltered smell (hyposmia or anosmia) and/or fever.

Patients who self-treat presumed sinus headaches with decongestants often report incomplete resolution of and present in the primary care office seeking antibiotics .

One their pain estimate is that 70% to 80% of patients presenting with “sinusitis causing a headache” may actually have migraine or could be classified as having probable migraine based on the presence of most but not all of the IHS criteria.

Cont…,

3% and 5% of adults worldwide experience headaches daily or nearly daily.

Paradoxically, the very medications commonly used to treat episodic headaches (including over-the-counter analgesics, especially acetaminophen, and migraine-specific medications such as triptans) are implicated in the transformation of episodic to chronic headaches, especially if consumed more often than 2 days per week over several months.

Family physicians should be aware that this is a common condition associated with a significant burden of suffering, and that effective treatment of migraine and tension-type headache without the overuse of medication may help prevent the development of this difficult to- treat condition.

Chronic daily headache

Raised intracranial pressure Raised intracranial pressure may be caused by mass

lesions (especially tumours), cerebral oedema, obstruction to CSF circulation (causing hydrocephalus) or impaired CSF absorption, as in idiopathic intracranial hypertension and cerebral venous obstruction, Characterized by : (secondary)Headache, Impairment of conscious level, Papilloedema, Vomiting, bradycardia, arterial hypertension.Headache:

• Worse in morning, improves through the day• Associated with morning vomiting• Worse bending forward• Worse with cough and straining• Relieved by analgesia• Dull ache, often mild

Pseudotumor cerebri

Pseudotumor cerebri occurs when the pressure inside your skull (intracranial pressure) increases for no obvious reason.

When no underlying cause for the increased intracranial pressure can be discovered, pseudotumor cerebri may also be called idiopathic intracranial hypertension.

Symptoms mimic those of a brain tumor, but no tumor is present.

Pseudotumor cerebri can occur in children and adults, but it's most common in obese women of childbearing age.

signs and symptoms:

1-Moderate to severe headaches that may originate behind your eyes, wake you from sleep and worsen with eye movement.

2-Ringing in the ears that pulses in time with your heartbeat

3-Nausea, vomiting or dizziness4-Blurred vision

5-Brief episodes of blindness, lasting only a few seconds and affecting one or both eyes (visual obscurations)

6-Difficulty seeing to the side7-Double vision (diplopia)

8-Seeing light flashes (photopsia)9-Neck, shoulder or back pain

RISK FACTORS:Obesity Obese women under the age of 44 are nearly 20 times more likely to develop the disorder.

MedicationsGrowth hormoneOral contraceptivesTetracyclineDiscontinuation of steroidsExcess vitamin AHealth problem:

Addison's disease Lyme diseaseMononucleosisPolycystic ovary syndromeSleep apnea Underactive parathyroid glands

Head injury Kidney diseaseLupus

Tests and diagnosis:Eye examsIf pseudotumor cerebri is suspected, we will look for a distinctive type of swelling — called papilledema — in the back of the eye. We will also undergo a visual fields test to see if there are any blind spots in patient vision besides normal blind spot in each eye where the optic nerve enters the retina.

Brain imagingCT or MRI scans can rule out other problems that can cause similar symptoms, such as brain tumors and blood clots.

Spinal tap (lumbar puncture)A lumbar puncture — which involves inserting a needle between two vertebrae in lower back — can determine how high the pressure is inside your skull.

Trigeminal neuralgia

Trigeminal neuralgia is a chronic pain condition that affects the trigeminal nerve, which carries sensation from your face to your brain.

Trigeminal neuralgia affects women more often than men, and it's more likely to occur in people who are older than 50.

.

Signs and symptoms:

1-Episodes of severe, shooting or jabbing pain that may feel like an electric shock.

2-Spontaneous attacks of pain or attacks triggered by things such as touching the face, chewing, speaking and brushing teeth

3 -Bouts of pain lasting from a few seconds to several seconds

4-Pain in areas supplied by the trigeminal nerve, including the cheek, jaw, teeth, gums, lips, or less often the eye and forehead.

5-Pain affecting one side of your face at a time

6-Attacks becoming more frequent and intense over time.

Trigeminal neuralgia can occur as a result of aging, or it can be related to multiple sclerosis or a similar disorder that damages the

myelin sheath protecting certain nerves .Less commonly, trigeminal neuralgia can be caused by a tumor

compressing the trigeminal nerve .Some people may experience trigeminal neuralgia due to a brain lesion or other abnormalities. In other cases, a cause can't be found.Triggers 

ShavingStroking your faceEatingDrinkingBrushing your teethTalkingPutting on makeupSmilingWashing your face

Tests and diagnosis Diagnosis of trigeminal neuralgia mainly based on description of the

pain, including:*Type. Pain related to trigeminal neuralgia is sudden, shock-like and

brief.*Location

*Triggers. Trigeminal neuralgia-related pain usually is brought on by light stimulation of your cheeks, such as from eating, talking or even encountering a cool breeze.

-A neurological examination. Touching examination,reflexes testing.-Magnetic resonance imaging (MRI).  to determine if multiple

sclerosis or a tumor is causing trigeminal neuralgia. Sometimes we may ask for MRA to view the arteries and veins and highlight blood flow (magnetic resonance angiogram).

Temporal arteritis

* Giant cell arteritis is an inflammation of the lining of

your arteries .

signs and symptoms:1-Persistent, severe head pain and tenderness,

usually in temple area2-Vision loss or double vision

3-Scalp tenderness — it may hurt to comb your hair or even to lay your head on a pillow, especially where the arteries are inflamed

4-Jaw pain (jaw claudication) when you chew or open your mouth wide

5-Fever6-Unexplained weight loss

Risk factors•The exact cause of giant cell arteritis isn't known.

•several factors can increase risk:

Age. Giant cell arteritis affects older adults almost exclusively — the average age at onset of the disease is 70, and it rarely occurs in people younger than 50.

Sex. Women are about two times more likely to develop giant cell arteritis.

Northern European — especially Scandinavian — .Although giant cell arteritis can affect anyone, people born in Northern European

countries appear to have higher rates of giant cell arteritis .

Polymyalgia rheumatica. People with polymyalgia rheumatica have stiffness and aching in the neck, shoulders and hips. About 15 percent of people with polymyalgia rheumatica also have giant cell arteritis.

Blindness. This is the most serious complication of giant cell arteritis,Sudden painless and perminant.

Aortic aneurysm.

Stroke.

complication

Tests and diagnosisTests and diagnosis::Giant cell arteritis can be difficult to diagnose because its early symptoms Giant cell arteritis can be difficult to diagnose because its early symptoms resemble those of many common conditions. For this reason, your will try to resemble those of many common conditions. For this reason, your will try to rule out other possible causes of the problemrule out other possible causes of the problem..ttestsests::

Physical examPhysical exam.. In addition to asking about symptoms and medical history,  In addition to asking about symptoms and medical history, paying particular attention to your temporal arteries. Often, one or both of these paying particular attention to your temporal arteries. Often, one or both of these arteries are tender with a reduced pulse and a hard, cord-like feel and arteries are tender with a reduced pulse and a hard, cord-like feel and appearanceappearance..

Blood testsBlood tests.1-.1- erythrocyte sedimentation rate. This test measures how quickly erythrocyte sedimentation rate. This test measures how quickly red blood cells fall to the bottom of a tube of blood. Red cells that drop rapidly red blood cells fall to the bottom of a tube of blood. Red cells that drop rapidly may indicate inflammation in the bodymay indicate inflammation in the body..

22 - -C-reactive protein (CRP)C-reactive protein (CRP)..Biopsy.Biopsy. The best way to confirm a diagnosis of giant cell arteritis is by taking a  The best way to confirm a diagnosis of giant cell arteritis is by taking a small sample (biopsy) of the temporal arterysmall sample (biopsy) of the temporal artery..

If you have giant cell arteritis, the artery will often show If you have giant cell arteritis, the artery will often show inflammation that inflammation that includes abnormally large cells, called giant cells, which give the disease its includes abnormally large cells, called giant cells, which give the disease its namename..

*imaging tests may also be used for diagnosing giant cell arteritis and for monitoring treatment. Possible tests include:Magnetic resonance angiography (MRA).Doppler ultrasound.Positron emission tomography (PET).

sudden and severe headache reaching maximal intensity within minutes and lasting an hour or more

may be accompanied by focal neurologic signs or other symptoms such as nausea, vomiting, photophobia, neck stiffness, seizures, or altered level of consciousness

worst headache of my life

It’s important not to miss SAH because early diagnosis and treatment is essential to improving outcomes.

Asking about headache severity in the context of previous headaches helps to ascertain the severity without suggestion or prompting of the patient with the words “worst headache of my life,” which is not very sensitive or specific as a screening question for SAH.

worst headache of my life

HISTORY

• Age at onset

• Presence or absence of aura and prodrome

• Frequency, intensity and duration of attack

• Number of headache days per month

• Time and mode of onset

• Quality, site, and radiation of pain

• Associated symptoms and abnormalities

• Family history of migraine

• Precipitating and relieving factors

• Effect of activity on pain

CONT…

• Relationship with food/alcohol

• Response to any previous treatment

• Any recent change in vision

• Association with recent trauma

• Any recent changes in sleep, exercise, weight, or diet

• State of general health

• Change in work or lifestyle (disability)

• Change in method of birth control (women)

• Possible association with environmental factors

• Effects of menstrual cycle and exogenous hormones (women)

PHYSICAL EXAMINATION:

1. Blood pressure measurement.

2. Neurological examination:

• Optic neuritis usually present as sudden, severe unilateral loss of vision suggests

• lesion in optic nerve pathway/ pituitary mass may present as unilateral field defect.

• Glaucoma present as holes around light

3. Fundoscopy: presence of papillodema might be sign of intracranial mass, psudotumorcerebri, encephalitis or meningitis

4. Examination of cerebellar system

5. Examine for neck brui/check for temporal and neck arteries.

RED FLAGS:• SUGGESTING SERIOUS PROGRESSIVE OR LIVE-THREATENING

DISEASE IN PATIENTS WITH HEADACHE

“Red Flags” Diagnosis

Headache that is sudden, explosive, (The worst headache of my life)

Intracranial hemorrhage

Headache with focal neurological signs or symptoms or papillodema

Tumor, subdural hematoma ,epidural bleeding

Headache of new in onset, that is constant, prevents sleep, and progressive over age of 50

Intracranial mass , temporal arteritis

local tenderness, absence of temporal pulse, or jaw claudication

Temporal arteritis (TA)

Headache in the elderly patient accompanied by focal neurological symptoms

Cerebro- Vascular Accident(CVA)

Headache accompanied by fever, stiff neck, photophobia or other systemic signs

Meningitis, encephalitis

Headache hours to weeks after trauma especially in elderly

Subdural hematoma

Headache first occurring with exertion Rupture aneurysm

attacks

References: 

1.Essentials of family medicine ( Sloane) 6th edition 20122.Clinical medicine (Kumar)7th edition 20093.Diagnosis and management of headache in adults; Scottish Intercollegiate Guidelines Network, 2008 4.Adult health clinical guidelines (HSS) 2006

5.www.migraine.ca