headache

Headache

Pain in head region has special consideration, etiology, presentation and management; it is important to exclude SECONDARY CAUSES OF HEADACHE.
Brain is painless organ.
The pain sensitive structure are:
the Falx cerebri. 2. The Dural blood vessels 3.Certain cranial nerves
4.Scalp, periosteum& muscles.

SECONDARY CAUSES OF HEADACHE

Referred pain( dental, sinus, orbit, TMJ)
CNS Infection (meningitis, encephalitis)
Intracranial Bleed
Raised Intracranial Pressure
Post Herpetic Neuralgia.

RED FLAGS FOR HEADACHES:

Loss of consciousness.
Convulsions
Focal neurological signs
Signs of meningeal irritation.
Fever & or association with systemic manifestations.


PRIMARY HEADACHE SYNDROMES:
Migraine
Tension Type Headache
Cluster headache

MIGRAINE

F>M.
Before age of 40yr.
Positive Family History.

Pathogenesis:

intracranial vasoconstriction leading to spreading reduction in blood flow from occipital cortex anteriorly responsible for aura.
Extracranial vasodilatation responsible for headache.

Clinical Presentation:

Aura: usaually visual only in 20% of cases Classical migraine)
TRIAD of ( headache, nausea +- vomiting, photophobia ) in 80% of cases Common Migraine
Headache usually throbbing, unilateral or sometimes bilateral Or occipital lasting hours to 3 days.

Precipitating Factors:

Fasting
Emotional & physical & bright light
Menses & hormonal E
Vasodilators
Certain foods


Treatment:
Abortive treatment: to the pain
NSAID
5HT agonist: sumatriptan
Anti emetics.
Prophylactic treatment:
Antidepressants to prevent pain: Amitryptiline, Venlafaxine
Antiepileptics: Valproate, Topiramate

TENSION TYPE HEADACHE

Most common headache syndrome, same age and gender distribution as migraine.
Underlying pathophysiology & mechanism unknown.
Tension unlikely to be primarily responsible .
Contraction is of scalp muscles is secondary phenomenon.

Clinical presentation:

Felt as Dull, Tight, or band like pressure around the head, usually bilateral,
Lasting hours to days.
There may be mild photophobia.
NO vomiting.


TREATMENT: Physiotherapy and explanation.
Psychotherapy
Relaxation.
Abortive for pain: NSAID
Prophylactic treatment: AMITRYPTYLINE

Cluster Headache

Chronic Headache disorder, more common in male than females.
Family history usually negative.
Later age of presentation usually after 25 years of age.

Pathophysiology:

Ipsilateral hypothalamic gray matter activation.

Clinical Presentation:

Clusters of brief, So severe, non throbbing, burning nose, lacrimation, horner syndrome, unilateral constant same side headaches.
Lasting minutes up to 2 hours. Same time at day and night for clusters of weeks to months.
Alcohol & vasodilator drugs usually precipitate attacks during cluster.
Treatment:
Abortive treatment:
Sumatriptan
100% oxygen (8-10) L/min for 10-15 minutes
Ergot
INDOETHACIN
Preventive Treatment:
Verapamil
Lithium Carbonate
Course of Prednisolone


IDEOPATHIC INTRACRANIAL HYPERTENSION (IIH)
PSUEDOTUMOR CEREBRI
Diffuse increase in the intracranial pressure without evident cause.
SECONDARY CAUSES: should be excluded
Cerebral venous thrombosis
Endocrine Dysfunction
Hypervitaminosis A, IDA
DRUGS (tetracycline, nalidixic acid)
Others HF

CLINICAL PRESENTATION:

Women: peak in third decade, obese. F>M
Headache usually is diffuse.
Tennitus is pulsatile.
Vision: Double Vision from abducent palsy
Blurred vision from Papilloedema
Transient visual obscurations.

INVESTIGATIONS:

MRI empty sella turcica in 70% of cases
Slit like lateral ventricles
Flattening of back of eye ball & dilatation of optic nerve sheath
CSF Study
High pressure with normal other parameters


TREATMENT:
SRERIAL LP DRAINAGE
ACETAZOLAMIDE 1-2 gm /day
FRUCEMIDE 40 mg twice daily .
POTASSIUM SUPPLEMENTATION.

Surgery:

Optic Nerve Sheath Fenestration
Lumboperitoneal Shunting