Headache Flashcards
Headache is caused by ….
Pathophys
traction, displacement, inflammation, vascular spasm, or distention of
the pain sensitive structures in the head or neck.
Chronic headaches tend to be ……. while new-onset headaches are usually …….
Primary … secondary
Headaches from………. are commonly maximal on awakening
Mass lesion
headaches frequently awaken patients from sleep; they often recur at the same time each day or night. And this headache headache (peak over ….. min while migraine over …. To …….
Cluster …. Over 3-5 min while of migraine over minutes to hours
Unilateral headache is an invariable feature of
cluster headache and occurs in the majority of migraine attacks; many patients with tension headache report unilateral pain.
Ocular or retroocular pain suggests a
primary ophthalmologic disorder such as acute iritis or glaucoma, optic (II) nerve disease (eg, optic neuritis). It is also common in migraine or cluster headache.
Headache from intracranial mass lesions may be
focal, but even in such cases it is replaced by bioccipital and bifrontal pain when the intracranial pressure becomes elevated.
Bandlike or occipital discomfort is commonly associated with
tension headaches. Occipital localization can also occur with meningeal irritation from infection or hemorrhage and with disorders of the upper cervical spine.
Pulsating, throbbing pain support the diagnosis of
migraine, but it doesn’t exclude tension headache.
steady sensation of tightness or pressure is also commonly seen with
tension headache.
pain produced by intracranial mass lesions is typically
dull and steady.
Prodromal symptoms such
Recent weight loss ……..
Fever………
Visual disturbances……….
Photophobia……….
Nausea and vomiting………….
Myalgias………
Ipsilateral rhinorrhea and lacrimation ……….
Painful transient monocular visual loss …….
cancer, giant cell arteritis, or depression.
CNS infection.
ocular disorder and migraine.
migraine and acute meningitis or subarachnoid hemorrhage.
migraine and posttraumatic headache syndromes and can be seen in the course of mass lesions.
tension headaches, viral infections, and giant cell arteritis.
cluster headache.
giant cell arteritis.
Precipitation of headache by alcohol is especially typical
use of oral contraceptive agents or other drugs such as nitrates may precipitate or exacerbate
rapid changes in head position or by events that transiently raise intracranial pressure, such as coughing and sneezing, is often associated with an
Anger, excitement, or irritation
Chewing and eating
Cluster hd
Migraine
Intracranial mass or migraine
Tension or migraine jaw claudication of giant cell arteritis
Headache symptoms that suggest serous underlying disease
Worst headache ever
Subacute worsening over days or weeks
Abnormal Neuro exam
Fever or systemic signs
Vomiting preceded headach
Pain induced by binding , lifting, cough
Pin disturb sleep
Onset after age of 55 local tenderness associated pain
Hypertension per se rarely causes headache unless
the blood pressure elevation is acute, paroxysmal as with pheochromocytoma, or very high, as with early hypertensive encephalopathy.
pheochromocytoma headache
brief. They last less than 15 minutes in one half of patients and are characteristically associated with perspiration and tachycardia.
mental status examination, patients with acute headache may demonstrate disturbance of consciousness, as is commonly seen with
subarachnoid hemorrhage and meningitis.
Physical examination of headach steps are …
- Vital signs:
- Complete systemic physical examination
- Neck
- Mental status examination
- Cranial nerve examination
- Complete the neurological examination to reveal any focal neurological signs
History of headach steps
- Temporal pattern of headache
- Location
- The pain character
- Prodromal symptoms associated phenomena and the chronological evolution.
- Precipitating and exacerbating factors.
- Relieving factors.
- History of headache.
- Past medical history.
- Drugs history.
- Family history (migraine and seizures).
Strong indications for imaging in headache include:
- Abnormal neurologic examination. 2. When the neurologic examination is normal, the indications include:
a) An element of the history suggests a specific diagnosis (e.g., epilepsy or brain tumor).
b) The headaches have developed a new quality, are more severe, or have become
Headaches according to the temporal profile
Headaches of sudden onset Sudden onset of new headache may be a symptom of serious intracranial or systemic disease. 1. Subarachnoid hemorrhage 2. intracerebral hemorrhage
Headaches of subacute onset Subacute headaches occur over a period of weeks to months.
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intractable to treatment. c) History of systemic disease (e.g. malignancy or endocrine dysfunction). d) Headaches of sudden onset. e) Persistent or increased vomiting. f) Headache triggered by maneuvers that increase intracranial pressure, such as
coughing, sneezing, and straining at stool. g) The headache is maximal on awakening from sleep.
Headaches of sudden onset
Headaches of sudden onset
Headaches of acute onset
- Meningitis or encephalitis 2. Seizures 3. Hypertensive encephalopathy 4. Drugs and alcohol induce headache 5. Headache secondary to systemic illnesses
Headaches of subacute onset
- Intracranial mass 2. Pseudotumor cerebri 3. Giant cell arteritis
Chronic headaches
- Tension type headache 2. Migraine 3. Analgesic withdrawal headache 4. Cluster headache 5. Referred pain from upper cervical spines
The secondary headaches:
- Headache attributed to head and neck trauma 2. Headache attributed to cranial or cervical vascular disorder 3. Headache attributed to non-vascular intracranial disorder 4. Headache attributed to a substance or its withdrawal 5. Headache attributed to infection 6. Headache attributed to disturbance of homoeostasis 7. Headache or facial pain attributed to disorder of cranium, neck, eyes, ears, nose, sinuses,
teeth, mouth or other facial or cranial structures 8. Headache attributed to psychiatric disorder
Diagnostic criteria for secondary headaches:
- Disorder known to be able to cause headache has been demonstrated 2. Headache occurs in close temporal relation to the other disorder and/or there is other
evidence of a causal relationship 3. Headache is greatly reduced or resolves within 3 months (this may be shorter for some
disorders) after successful treatment or spontaneous remission of the causative disorder
temporal arteritis, is characterized by
subacute granulomatous inflammation that affects the medium and large-sized arteries, usually involving one or more branches of the carotid artery, may accompany polymyalgia rheumatica.
Inflammation of the pain sensitive arterial wall produces the headache.
Diagnosis and Therapy of temporal arteries
Diagnosis is made by biopsy of affected temporal arteries, the erythrocyte sedimentation rate (ESR) is almost invariably elevated. Therapy for giant cell arteritis is prednisone, 40–60 mg/d orally, with decreasing dosage usually after about 1-2 months, depending upon the response. Therapy generally has to be continued for 1–2 years. Although dramatic improvement in headache occurs within 2–3 days after institution of therapy, the blindness is usually irreversible.
The main feature of a low CSF pressure headache
bitemporal pressure or heaviness that is completely or near-completely relieved by lying flat. Aural symptoms such as muted hearing or non-pulsatile tinnitus commonly accompany the low pressure state
Pseudotumor cerebri is
syndrome characterized by a diffuse increase in intracranial pressure causing headache, and papilledema. Diplopia may also occur as a result of abducens nerve palsy. Pulse synchronous tinnitus can occur.
Treatment of Pseudotumor cerebri
Treatment: The main goals of treatment are alleviation of symptoms, including headache, and preservation of vision. All overweight patients should reduce weight, along with a low- salt diet. Acetazolamide is the treatment of choice. In other instances, topiramate and repeated lumbar punctures may be necessary. Surgical intervention is required when other treatments have failed to prevent progressive vision loss or when the disease onset is fulminant.
Medication overuse and medication withdrawal headache
triptans (1 to 2 years), longer for ergots (3 years), and longest for analgesics (5 years).
When medication overuse is present (abortive anti-migraine drugs or opioids or combination analgesics taken on >10 days/month and simple analgesics on >15 days/month), it is likely cause of chronic headache. Treated by slow tapering with or without steroid
Cervical spine disease
Injury or degenerative disease processes involving the upper neck can produce pain in the occiput and may referred to the orbital regions due to irritation of the second cervical nerve root. In the lower cervical spine pain refer to the ipsilateral arm or shoulder, not to the head.
Acute pain of cervical origin is treated with immobilization of the neck (eg, using a soft collar) and analgesics or anti-inflammatory drugs.
The main pain features of tension headache
begins after age 20. Women are more commonly bilateral location, squeezing non- pulsating quality, mild to moderate intensity, and lack of aggravation by routine physical activity.
bilateral occipital head pain that is not associated with vomiting or prodromal visual disturbance.
There are three subtypes of tension headache
- Infrequent episodic tension headache (headache episodes on <1 day per month) 2. Frequent episodic tension headache (headache episodes on 1 to 14 days per month) 3. Chronic tension headache (headache on >15 days per month, perhaps without
recognizable episodes).
treatment tension headache:
Acute attacks may respond to acetaminophen, or nonsteroidal anti-inflammatory drugs. For prophylactic treatment, amitriptyline is the only proven treatment.
Migraine
episodic recurrent disabling headache disorder manifesting in attacks lasting 4–72 hours which can be classified into common and classic migraine. Intracranial vasoconstriction and extracranial vasodilatation have long been held to be the respective causes of the aura and headache phases of migraine.
Migraine attacks can be precipitated by
certain foods (chocolate and cheese). Fasting, emotion, menses, drugs (especially oral contraceptive agents and vasodilators such as nitroglycerin), and bright lights may also trigger attacks.
The most common cause of transient binocular visual loss
the visual aura that occurs with migraine.
Migraine without aura (common migraine).
usually bilateral and periorbital, and is seen more frequently in clinical practice
Vomiting may occasionally terminate the headache.
Migraine with aura (classic migraine):
auras are visual alterations, particularly scotomas and scintillations that enlarge and spread peripherally last for about 20 minutes followed by throbbing unilateral headache.
no more than one attack per week.
Migraine Remissions are common during
second and third trimesters of pregnancy and after menopause.
During the migraine headache, prominent associated symptoms include ……. And released by
nausea, vomiting, photophobia, phonophobia, irritability and lassitude.
Migraine headaches are frequently relieved by darkness, sleep, vomiting, or pressing on the ipsilateral temporal artery.
Treatment of migraine
Acute migraine attacks may respond to simple analgesics (acetaminophen, or NSAIDs). If not, they usually respond to triptans or narcotic analgesics or ergot preparations.
Prophylactic treatment is indicated for:
Four or more headache episodes per month Acute medications ineffective, contraindicated, or overused Adverse effects from acute medications
Classes of Migraine Preventives:
Antiepileptic drugs Antidepressants Beta-adrenergic blockers Calcium channel antagonists Nonsteroidal anti-inflammatory drugs
Migraine during pregnancy should be treated only with
opiates as all other pharmacologic agents raise concerns regarding teratogenicity or complications of pregnancy.
Cluster headache:
Cluster headache is much more frequently in men than in women. Cluster headaches characteristically the mean age at onset of 25 years.
The Cluster headache: syndrome presents as
brief, very severe, unilateral, constant nonthrobbing headaches that last from a few minutes to less than 2 hours.
Unlike migraine headaches, cluster headaches are always unilateral, and usually recur on the same side in any given patient.
are commonly associated with the attack of clustered headache
Ipsilateral conjunctival injection, lacrimation, nasal stuffiness, and Horner’s syndrome
Acute relief of pain in cluster headach within minutes may be achieved by
triptan and 100% oxygen. Dramatic improvement is typically seen with administration of prednisone, 40–80 mg/d orally for 1 week, discontinued by tapering the dose over the following week. Pain may resolve within hours, and most patients who respond do so within 2 days.
Prophylactic drugs for cluster headach are
Verapamil , lithium
