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Approach To Headache

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Rasha Dabbagh
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14 views37 pages

Approach To Headache

Uploaded by

Rasha Dabbagh
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
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APPROACH TO

HEADACHE
Dr. Rasha Aldabbagh
PGY1 Neurology

Consultant: Dr. Jamal Sajid


Headache affects virtually everyone at some time in their life
NO pain receptors in brain parenchyma.
Pain receptors ARE present in:
Blood vessels
Meninges
Scalp
Skull
HEADACHE CLASSIFICATION - IHS 2018

Primary Headaches
1. Migraine
2. Tension-type headache
3. Trigeminal autonomic cephalalgias
4. Other primary headache disorders
HEADACHE CLASSIFICATION - IHS 2018
Secondary:
 Trauma to head/neck. • Disorder of homoeostasis
 Cranial/cervical vascular • Disorder of the cranium, neck,
disorder. eyes, ears, nose, sinuses, teeth,
 Non-vascular intracranial
mouth or other facial or cervical
disorder. structure.
• Psychiatric disorder.
 Substance or its withdrawal.
 Infection.
Painful Cranial Neuropathies, Other Facial Pain/Headaches
HISTORY

Age of Onset:
Primary: any age, childhood or 20-50 years.
Older patients: 2nry types (eg, giant cell
arteritis, trigeminal neuralgia, subdural
hematoma, herpes zoster and postherpetic
neuralgia, brain tumors)
Gender:
Female: Migraine, Tension, Pseudotumor
cerebri.
Males: Cluster.
LOCATION
LOCATION
 Unilateral: Cluster, migraine.
 Generalized, Bandlike or bi-occipital: Tension
 Ocular/retroorbital pain: eye disease, migraine, cluster headache.
 Paranasal pain with tenderness: Sinusitis
 Occipital: meningeal irritation, disorders of joints/muscles/ligaments of
upper cervical spine.
 Focal headache may result from intracranial mass lesions, evolves to
bioccipital and bifrontal pain when ICP becomes elevated.
ONSET
Acute- sudden onset (minutes to hours):
 SAH, AVM, Expanding aneurysm, Carotid/vertebral
dissection, CVA, posterior fossa mass lesions.
 Phaeochromocytoma, Glaucoma, Migraine.
Acute gradual onset (hours to days):
 Meningitis, Encephalitis, Systemic infection, Acute obstructive
hydrocephalus.
ONSET
Sub-acute (over several days):
 Expanding brain lesions, Progressive hydrocephalus,
Temporal arteritis, GCA, Subacute meningitis (TB,
Cryptococcus), BIH, Sinusitis, Glaucoma.
Recurrent & Chronic:
 Primary headaches, medication overuse, sinusitis, dental
disease.
QUALITY & SEVERITY
 Tension: Pressing, Squeezing, Tightness or Heaviness, mild-
moderate.
 Intracranial lesion: Relatively Mild, dull and steady.
 Migraine: Throbbing, pulsating or Pounding.
 Cluster: Sharp, penetrating, stabbing, excruciating.
 Trigeminal neuralgia: Sharp, lancinating (stabbing) pain.
 Acute SAH: explosive & intense.

 Quality is Not reliable.


DURATION & FREQUENCY
DURATION & FREQUENCY
Migraine: 4 hours to 3 days.
Cluster: 15 min to 3 hours, 1-2/day for 8-10 wk/year.
Tension: variable, 30 min to 7 days.
Fluctuations in intensity and duration with fluctuation
in LOC : Subdural hematoma.
DIURNAL VARIATION
On awakening: Mass lesions, Sinus.
At the end of day: Tension, low CSF pressure.
Cluster headaches: awaken patients from sleep;
recur at same time each day.
EXACERBATING FACTORS
 Migraine: Menses, ovulation, change in head position, stress,
exercise, Valsalva, cough, foods, hunger, change in sleep,
dehydration.
 Increased ICP: Coughing, Valsalva maneuver, change in head
position.
 Sinusitis: bending forward, sneezing, nose blowing.
 Low CSF pressure: (maximal when upright, nearly absent when
lying down).

 Alcohol: cluster, migraine.


RELIEVING FACTORS
Migraine: darkness, sleep, vomiting, pressing
on ipsilateral temporal artery, pregnancy.
Low CSF pressure: recumbency
Intracranial mass lesions: Standing.
ASSOCIATED SYMPTOMS
Fever: Local or systemic infection, SAH, GCA.
Weight loss: cancer, GCA, depression.
Dyspnea or heart symptoms: SIE and resultant brain abscess.
Aura: visual or sensory disturbances.
Visual disturbances: ocular or visual pathway disorder (eg,
glaucoma), migraine, BIH, GCA.
Nausea&vomiting: migraine, mass lesions, post-traumatic.
ASSOCIATED SYMPTOMS
 Photophobia: migraine, acute meningitis, SAH.
 Myalgias: Tension, systemic viral infections, GCA.
 Neck pain: Tension, carotid/vertebral dissection.
 Ipsilateral rhinorrhea, sweating, lacrimation during
attacks: cluster.
 Focal Neurological deficits, altered consciousness.
Recent Trauma or Procedures:
Postconcussive disorder, ICH, dissection.
Migraine and cluster headaches may be triggered by
head trauma.
LP, rhinoscopy, dental procedures (e.g., tooth
extraction); endoscopic surgery.
MEDICATION HISTORY
 Medication overuse headache.
 Caffeine containing drugs.
 Long term use of PPI.
 Oral contraceptive agents and nitrates : Migraine
Pregnancy: Pre-eclampsia, cerebral venous
thrombosis. Change of headache suggests migraine or
another primary headache.

Past medical Hx: HTN, Cancer,


immunocompromised, OSA, IV drug use.

Family History: Migraine, Cluster.


PHYSICAL EXAMINATION:
VITALS
Fever: infectious (meningioencephalitis, brain abscess)
BP & pulse:
Paroxysmal headache with tachycardia and perspiration is
characteristic of pheochromocytoma.
Hypertension.
SAH.
Stroke.
Hypoxia/Hypercapnia from respiratory insufficiency.
PHYSICAL EXAMINATION:
Weight loss: Cancer, chronic infections.
Skin:
Cellulitis.
Rash: vasculitis, meningococcemia, endocarditis, cancer.
Neurofibromas or café-au-lait spots.
Cutaneous angiomas: AVMs.
Herpes zoster.
PHYSICAL EXAMINATION:
Scalp:
Scalp tenderness: Migraine, SDH, GCA, postherpetic
neuralgia.
Localized area of tenderness in recent head trauma or a mass
lesion.
Warm tender skull in Paget disease.
Nodularity, erythema, or tenderness over the temporal
artery: GCA
PHYSICAL EXAMINATION:

 Eyes, ears, nose or teeth.


 Ipsilateral conjunctival injection, lacrimation, Horner
syndrome, rhinorrhea: cluster headache.
 Sinus tenderness.
 Bruit over orbit or skull: intracranial AVM, carotid artery–
cavernous sinus fistula, aneurysm, or meningioma.
 Temporomandibular joint disease is accompanied by local
tenderness and crepitus over the joint.
PHYSICAL EXAMINATION:
 Carotid bruits: cerebrovascular disease.
 Cervical muscle spasm: Tension, migraine, cervical spine
injuries, cervical arthritis, or meningitis.
 Meningeal irritation e,g, nuchal (neck) rigidity, Brudzinski sign.
 Fundoscopy: Papilledema, Retinal hemorrhages, ischemic
retinopathy.
 CN palsies, Motor/Sensory deficit.
 No Neurological abnormality: Tension.
LOW-RISK FEATURES:
 Age ≤50 years
 Features typical of primary headaches.
 History of similar headache
 No concerning change in usual headache pattern
 No abnormal neurologic findings
 No high-risk comorbid conditions
 No new or concerning findings on history or examination
Do not require imaging.
RED FLAG SYMPTOMS
 Sudden-onset headache  Pain that disturbs sleep or presents
 First severe headache immediately upon awakening
 Known systemic illness
 “Worst” headache ever
 Onset after age 55
 Vomiting that precedes headache
 Fever or unexplained systemic signs
 Subacute worsening over days or
weeks  Abnormal neurologic examination
 Pain induced by bending, lifting,  Pain associated with local
cough tenderness, e.g., region o temporal
artery
INVESTIGATIONS
 CBC, ESR
 X-Ray Skull/Sinuses/Cervical Spine.
 MRI/CT:
 Brain, vessels, orbits, ear, face, sinuses, TMJ.
 Primary or metastatic neoplasm, abscess, hematoma, hydrocephalus,
cerebral edema from ischemia or infarction.
 LP:
 CSF pressure, SAH, infectious, inflammatory, or neoplastic.
Thank You

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