Headache

Headache
Headache is pain in any region of the
head Which may occur on one or both
sides of the head, be isolated to a
certain location, radiate across the head
from one point.

headache may be a sharp pain,

throbbing sensation or dull ache.
 Headaches may appear gradually or
suddenly and they may last less than a
hour to several days.

Headache is a common symptom in

neurologist practice.

Its pathogenesis is very complex.

Etiology
Intracranial disease:
SOL
Intracranial hypertension or low pressure.
Arterial inflammation
Intracranial inflammation
Cerebral vascular disease
Functional or mental disease:
Tension headache, headache neurosis
 ENT and eye disease :
Sinusitis
Refractive errors

Systemic disease:
Fever
HTN
Low blood sugar
classifications
According to the course:
Acute headache: if persists upto 2
weeks

Sub-acute headache: if persists upto 3

months

Chronic headache: more than 3 months

 According to the degree of pain:
Mild headache
Moderate headache
Severe headache
According to the cause

Primary headache: A primary

headache is caused by problems with or
over activity of pain-sensitive structures
in head. It is not symptoms of any
underlying disease.
Tension headache
Migraine
Cluster headache
 Secondary headache: A secondary
headache is a symptom of a disease
that can activate the pain-sensitive
nerves of the head.
Systemic infections
Head injury
Brain tumors
Diagnosis of headaches
Principles :
History : family history, sleep, emotions
Characteristics: time, property, location,
precipitating factors.
Aura symptoms
Medical examinations
Instrumental examinations: CT, MRI, LP
 Treatment principles:
Etiological treatment
Symptomatic treatment at the time of
acute attack.
Preventive treatment
Migraine
Migraine
Migraine is described as a recurrent
headache lasting 4-72 hours.
Often has unilateral pulsating pain,
moderate to severe intensity pain,
nausea and \or photophobia.
It is second most common cause of
headache.
15% women and 6% men over 1 year.
 In general there are 4 symptoms phase:
They may not all occur in every patient
Prodromal phase
Aura phase
Attack phase
Postdromal phase
 Prodromal phase:
Early warning sign
It occurs 2 hours to 2 day before
migraine.
May feel unusual sensations e.g
irritability, thirsty, sleepy with frequent
yawning, craving for food, unusually
energetic and excited or depressed,
frequent micturation etc.
 Aura phase:
Strange sensation arise.
It begins before or starts along
headache (appear over a number of min
and lasts <60 mins ).
About 1 in 5 people with migraine
develop aura.
It can include change in vision, skin
sensation and language problems.
 Attack phase:
Lasts from few hours to several days.
Pain usually begins above eyes.
Typically affects one side but it may strike entire
head.
May get worse with physical activity or lean
forward.
Unusual sensitivity to light, sound and smell.
Light headedness and fainting.
Nausea and vomiting.
 Postdromal phase:
Its a post migraine phase which lasts
upto some days.
Extreme tiredness
Confusion
sluggishness
Etiology
Certain types of foods such as MSG, caffeine,
red wine and chocolate.
Hormonal changes, especially for woman
during the menstrual cycle.
Changes in the weather.
Muscular tension.
Bright or fluorescent lights or sunlight, loud
noises strong odors.
Changes in serotonin levels in the brain.
Genetic predisposition (80% ).
 Other factors:
Emotional stress or excitement
Head trauma
Starvation
Sleep disorders
Climate change
Psycho-stress
 Pathogenesis
Activation of trigeminovascular
System: the key pathway for Pain is
trigeminovascular input from meningeal
Vessels.
Cortical spreading depression:
Linked to aura and headache.

Neuronal sensitization: play imp.

Role in somatic pain.
A. At least 5 attacks fulfilling criteria B-D below:
B.
Classification Criteria for Migraine
Headache attacks lasting 4-72 hours (untreated or
unsuccessfully treated) .
C. Headache has at least two of the following characteristics:
unilateral location
pulsating quality
moderate or severe pain intensity
aggravation by movement
D. During headache at least one of the following:
nausea and/or vomiting

photophobia and phonophobia

E. Not attributed to another disease.
Clinical manifestations
Typical migraine (with aura)
Common migraine (without aura)
Special type of migraine:
A. paralyzed ocular migraine
B. hemiplegia-type headache
C. basilar migraine
D. late-onset migraine
E. migraine equivalents
Typical migraine
Aura :
continuing a few minutes to a few hours.
Visual aura (dark points, light, amaurosis,
hemiscotosis, hallucinations).
Paresthesia (pharynx, lips, tongue or
partial body numbness).
Unilateral paresis or aphasia.
 Headache stage:
Location: from orbital or posterior temporal

half or whole head throbbing.

Accompanied symptoms: nausea, vomiting,
pale tiredness.
Duration a few hours to several hours.
Headache may be aggravated by shaking the head
and neck relieved post-sleep.

Post headache: fatigue, malaise, irritability,

Unpleasant symptoms as flu, after the headache
Common migraine
Most frequent type of migraine (approx
80%).
Premonitory symptoms are not obvious.
Mostly pulsatile headache and can
spread to contralateral or bilateral side.
Special type
Opthalmoplegic migraine:
Rare form of migraine that felt around eyes.
Symptoms:

Double vision
ptosis
eye paralysis
Lasts from several hours to weeks.
CN
 Hemiplegic migraine:
Symptoms often starts in childhood and
disappear in adulthood.
Rare type of headache
Its migraine with aura.
Numbness, weakness or paresis on one side of
body.
Aphasia
Basilar migraine
Also known as basilar artery migraine.
Incidence in children and adolescents, > in
women.
Lasts from 4 to 72 hours.
Migraine with aura.
Symptoms: dizziness, diplopia, nystagmus,
tinnitus,
dysarthria
B/L limbs numbness and weakness,
confusion
 Late life migraine
Incidence after age of 45.
Lasts from 1-72 hours.
Mild headache
Same neurological deficiency
TIA should always be excluded
Migraine equivalent
Abdominal migraine.
Most common in young children esp.
girls
No headache instead symptoms include
stomach cramp, nausea, vomiting,
fatigue and excessive yawning.
Diagnosis

Long term history of recurrent.

Family history
Physical and neurological examinations
Blood tests and urinalysis
Sinus X-ray
CT or MRI
LP
Differential diagnosis
Brain anuerysm
Brain tumor
Cluster headache
Meningitis
Sinusitis
Tension headache
Cluster headache
Accompanied by severe pain in the side
of the orbit around the onset of
headache.
Cluster headaches typically start before
the age of 30 .
They are more common in men.
A cluster headache typically awakens a
person from sleep one to two hours after
going to bed.
refers to a type of headache that recurs
over a period of time.
 Etiology :
Season is the most common trigger factor.
Smoking and drinking alcohol excessively.
Symptoms:
Type of pain: unilateral
Severity\intensity of pain: burning and piercing
quality.
Location of pain: behind one eye
Duration of pain: usually 15-180 mins
Frequency: 1-3 headache per day.
 Classification criteria
A. At least 5 attacks fulfilling criteria B-D
B. Severe or very severe unilateral orbital, supra-orbital
and/or temporal pain lasting 15-180 minutes if
untreated
C. Headache is accompanied by at least one of the
following
Ipsilateral conjunctival injection and/or lacrimation
Ipsilateral nasal congestion and/or rhinorrhea
Ipsilateral eyelid edema
Ipsilateral forehead and facial sweating
Ipsilateral miosis and/or ptosis
A sense of restlessness or agitation
D. Attacks have a frequency from one every other day to
8 per day
E. Not attributed to another disorder
Tension type headache
A tension headache is generally a diffuse,
mild to moderate pain in head.
Most common type of headache.
Tension type headache accounts approx
90% of headache.
Tension type headache is infrequent
episode of headache that lasts mins to
days.
Pain is usually B/L with pressing or
tightening quality.
Etiology
Stress
Sleep deprivation
Uncomfortable stressful position or bad
posture.
Irregular meal time
eyestrain
 Symptoms:
Dull aching headache.
Sensation of tightness or pressure
across forehead or on sides and back of
head.
Tenderness in scalp, neck and shoulder
muscle.
 Tension headache divided into 2 main
categories:
Episodic tension headache:
last 30 mins to week
headache <15 days a month for at least 3
months
Chronic tension headache:
Lasts for hours and may be continuous.
Headache >15 day for at least 3 months.
They are considered chronic.
Tolosa Hunt Syndrome
is a syndrome where the cavernous
sinus develops inflammation causing
severe pain in the eye as well as
damage or irritation of the nerves of the
face.
normally involves the 3rd, 4th, 5th and
6th cranial nerves
pain around the back and sides of the
eye along with paralysis and weakness
of certain eye muscles.
 Symptoms:
Affect only one side of the head
unilateral
Muscles around the eye paralysis
Intense sharp pain
Spontaneous remission
Ptosis, vertigo, arthralgia, diplopia,
exophthalmos
Chronic fatigue
Treatment
Pain relieving medications:
Aspirin
Nsaids
Triptans
Ergotamine
Anti-emetics
glucocorticoids
 Preventive medications:
Beta blockers e.g propanolol
Calcium channel blockers e.g verapamil
Anti-depressant e.g amitryptiline
Anti convulsants e.g sodium valproate
The end