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  • 1. Headache Jaber Amin AL-Manasia 5th year medical student Presented to:Dr. Amaal Al Nemry

2. :Objectives .defenition-1 .epidemiology-2 .primary causes-3 .secondary causes- 4 .evaluation and diagnosis- 5 .mangment-6 3. 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. 4. 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.5 6. 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 headacheSinusitis caffeine withdrawal neck arthritis viral infections meningitis Temporal artritis Pseudotumer cerebri Trigeminal neuralgia Subarachnoid hemorrhage 7. Migraine 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 ). 8. ,,,cont . 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 stroke. (TIA). Because patients with migraine often report pain in the face or around (or behind) one eye, they are sometimes misdiagnosed as having sinus headaches. 9. :Diagnostic criteria for migraine International Headache Society ( IHS )Criteria for the Diagnosis of Migraine 10. The frequency, severity, and associated symptoms of frequency severity migraine can vary between patients and within a given lifetime. Fluctuations in serum estrogen concentration in women (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 11. Tensiontype 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 12. 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 13. :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 worry* Often 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 14. M N G EM T A A EN 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. 15. Cluster headache 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 cluster severe, 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. 16. Cluster headache 17. A. At least 20 attacks fullling 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 Ipisilateral conjunctival injection and/or lacrimation . 1 Ipsilateral nasal congestion and/or rhinorrhoea. 2 Ipsilateral eyelid oedema. 3 Ipsilateral forehead and facial sweating. 4 Ipsilateral miosis and/or ptosis. 5 Sense of restlessness or agitation. 6 D. Attacks have a frequency from one every other day to eight Per day E. Not attributed to another disorder 18. M N G EM T A A EN 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. 19. Comparison of key features distinguishing migraine , tension , and cluster headaches MigraineTensionClusterLaterali tyUnilateral )(60%Bilateral)Unilateral (exclusiveIntensit yModerate or severeMild or moderateSeverePain descriptor ) (variablePulsating )(50%Pressing or tighteningBoring, piercingPhysica l activityAggravation by physical activityDoes not worsen with physical activityRestlessness or agitation during attackAssociatedNausea and/or / photophobia phonophobiaNo nausea, but may rarely have photophobia or phonophobiaIpsilateral symptoms; conjunctival injection, lacrimation, nasal congestion, rhinorrhea, forehead and facial sweating, miosis, ptosis, eyelid edemaDuratio nhr 724Minutes to daysto 180-min cluster periods- 15symptom s 20. Sinusitis & sinus headache Symptoms suggesting a nasal or sinus :etiology (rhinosinusitis) include purulence in the nasal cavity nasal obstruction altered smell (hyposmia or anosmia) and/or fever. 21. ,Cont 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 22. Chronic daily headache 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. 23. Raised intracranial pressure may be caused by masslesions (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 24. Pseudotumor cerebri 25. 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. 26. :signs and symptoms Moderate to severe headaches that may originate behind-1 your eyes, wake you from sleep and worsen with eye .movement Ringing in the ears that pulses in time with your heartbeat-2 Nausea, vomiting or dizziness-3 Blurred vision-4 Brief episodes of blindness, lasting only a few seconds and-5 (affecting one or both eyes (visual obscurations Difficulty seeing to the side-6 (Double vision (diplopia-7 (Seeing light flashes (photopsia-8 Neck, sho