Headache, Back and Neck Pain Flashcards
HEADACHE
• Most common reasons to seek medical attention
• Globally responsible for more disability than other
neurologic problem
• Can be primary or secondary
PRIMARY - headache
o Caused by overactivity of or problems with
pain-sensitive structures in your head
(Mayo Clinic)
o Isn’t a symptom of any underlying disease
o often results in considerable disability and
a decrease in patient’s quality of life
SECONDARY - headaches
o a symptom of a disease that can activate the pain-sensitive nerves of the head o mild secondary headaches are seen in association with upper respiratory tract infections
Stimulus (peripheral nociceptors)
Tissue injury, visceral distention, etc.
o Damaged or inappropriate activation of
PNS or CNS
Cranial structures that are pain-producing:
o Scalp o Middle meningeal artery o Dural sinuses o Falx cerebri o Proximal segments of large pial arteries
KEY STRUCTURES INVOLVED IN PRIMARY HEADACHE
• Large intracranial vessels and dura mater
• Peripheral terminals of the trigeminal nerve that
innervate these structures
• Caudal portion of the trigeminal nucleus, which
extends into the dorsal horns of the upper cervical
spinal cord and receives input from the 1st and
2nd cervical nerve roots (trigeminocervical
complex)
• Rostral pain processing region
• Pain modulatory system in the brain that receives
input from trigeminal nociceptor
ACUTE NEW ONSET HEADACHE
• Potentially serious cause is considerably greater
than recurrent headache
• Signs and symptoms pertain to potentially serious
etiology, wherein there is presence of worrisome
symptoms (being sudden & severe)
• Need prompt evaluation and management
• Complete neurologic examination (1st step)
• Dx/Labs: CT, MRI, lumbar puncture (LP)
• Serious causes include:
o Meningitis
o Subarachnoid hemorrhage
o Epidural or subdural hematoma
o Glaucoma
o Tumor
o Purulent sinusitis
FINDINGS OF POTENTIALLY SERIOUS OR WORRISOME
HEADACHES
• Worst headache ever • First severe headache • Subacute worsening over days or weeks • Abnormal neurologic examination • Fever or unexplained systemic signs • Vomiting preceding headache • Pain induced by bending, lifting, coughing • Pain that awakens patients or is present upon awakening • Known systemic illness • Onset after age 55 • Pain associated with local tenderness
GENERAL EVALUATION OF ACUTE HEADACHE
• Investigation of cardiovascular and renal status
o Blood pressure monitoring and urine
examination
• Fundoscopy (presence of papilledema suggests
increased intracranial pressure), intraocular
pressure measurement, and refraction
• Cranial arteries by palpation
• Cervical spine by the effect of passive movement of
the head and by imaging
• Psychological state (comorbidity rather than cause)
o There is a relationship between head pain
and depression.
SECONDARY HEADACHE
63% - systemic infection (most common) o 4% - head injury o 1% - vascular disorders o <1% - subarachnoid hemorrhage o 0.1% - brain tumor
MENINGITIS
• Acute (<5 min.), severe (>5 min.) headache
• Fever and stiff neck (suggestive symptoms)
• Accentuation of pain with eye movement
• Pounding headache, photophobia, nausea and
vomiting (easily mistaken for migrain)
• Dx test: LP is mandatory
• Treatment: antibiotics
INTRACRANIAL HEMORRHAGE
• Acute and severe
• Stiff neck WITHOUT fever
• Secondary to ruptured aneurysm, AV
malformations, or intraparenchymal hemorrhage
• Dx: CT scan and LP may be used for diagnosis
o head CT is normal, if hemorrhage is small
or below the foramen magnum, you can
do a lumbar tap
LUMBAR PUNCTURE CONTRAINDICATIONS
Increased intracranial pressure is a relative LP
contraindication
• Absolute contraindications
o The presence of infected skin over the needle
entry site and the presence of unequal pressures
between the supratentorial and infratentorial
compartments
Characteristic findings on CT of
the brain of LP
• Midline shift • Loss of suprachiasmatic and basilar cisterns • Posterior fossa mass • Loss of superior cerebellar cistern • Loss of quadrigeminal plate cistern
BRAIN TUMOR
• Chief complaint in 30% of patients: HEADACHE
• Intermittent, deep, dull aching pain of moderate
intensity
• Aggravated by exertion or change in position maybe
associated with nausea/vomiting (more in migraine)
• In 10% of cases, headache disturbs sleep
• Vomiting precedes headache by weeks (posterior
fossa brain tumors)
• History of amenorrhea or galactorrhea (prolactinsecreting pituitary adenoma or the polycystic ovary
syndrome)
• Headache arising from a known malignancy (cerebral
metastases or carcinomatous meningitis, or both)
• HA appearing abruptly after bending, lifting or
coughing may indicate presence of posterior fossa
mass, a Chiari malformation, or low CSF volume
TEMPORAL ARTERITIS (Giant Cell)
• aka Horton’s or giant cell arteritis; Inflammatory
disorder of arteries; Extracranial carotid circulation
• Commonly seen in females age 50 and older
o average age of onset is 70 years, and
women account for 65% of cases
• If left untreated, may lead to blindness due to the
development of ischemic optic neuropathy
• Presents with headache, PMR (polymyalgia
rheumatica), jaw claudication, fever, weight loss
and tenderness with scalp
TEMPORAL ARTERITIS (Giant Cell) headache
Head pain may be unilateral or bilateral, temporally
located in 50% of cases. Associated with malaise
and muscle aches
• Pain usually appears gradually over few hours
before peak, occasionally explosive and seldom
throbbing
• Almost invariably described as dull and boring and
usually worse at night and often aggravated by
exposure to cold
• Head pain is superficial, external to the skull, rather
than originating deep within the cranium
• Marked degree of scalp tenderness
o brushing of hair or resting the head on a
pillow may be impossible
• Reddened, tender nodules or red streaking of the
skin overlying the temporal arteries, less common
tenderness on occipital arteries
TEMPORAL ARTERITIS (Giant Cell) headache Diagnosis
Dx: Elevated ESR
• Gold standard Tx: temporal artery biopsy
• Mx: steroids (Prednisone 80mg daily fir the first 4-6
weeks); initiated when clinical suspicion is high
GLAUCOMA
Usually secondary to acute angular closure glaucoma (a medical emergency) • Prostating headache • Nausea and vomiting • Severe eye pain • Red, fixed, moderately dilated pupil • Tx: medication and surgery
PRIMARY HEADACHE SYNDROME
• Headaches and associated symptoms occur in the
absence of an exogenous cause
PHS common causes
o 69% - Tension type o 16% - Migraine o 2% - Idiopathic stabbing o 1% - Cluster (trigeminal autonomic cephalgias) o 1% - Exertional
MIGRAINE
• 2nd most common cause of headache
• Benign and recurring syndrome of headache
associated with other symptoms of neurologic
dysfunction
Episodic headache
associated with sensitivity to
light, sound, or movement
• Usually accompanied with nausea and vomiting
• Most common headache-related disability in the
world, afflicts 15% of women and 6% of men over a
year
• Have triggers prior to the onset of an attack
• Stimulus could be environmental or sensory
• Sensitivity is amplified in female during menses
Triggers for Migrane
o Glare, bright lights, sounds, or other afferent stimulation o Hunger o Excess stress o Physical exertion o Stormy weather or barometric pressure changes o Hormonal fluctuations during menses o Lack of or excess sleep o Alcohol or other chemical stimulation
PATHOGENESIS of Migrane
o Activation of vasoactive neuropeptides § Calcitonin gene related peptide o 5-hydroxytryptamine (5-HT) or serotonin § Methysergide can stimulate 5- HT1B/1D o Dopamine o Dopamine receptor hypersensitivity § as demonstrated by the induction of yawning, nausea, vomiting, hypotension, and other symptoms of a migraine attack by dopaminergic agonists at doses that do not affect non-migraineurs
Familial Hemiplegic Migraine (FHM)
Mutation of voltage-gated calcium channel CACNA1A gene (FHM1) o Na+K+ATPase ATP1A2 gene (FHM2) - 20% of FHM cases o Neuronal voltage-gated sodium channel SCN1A
Associated symptoms of migraine
o Nausea o Photophobia o Lightheadedness o Scalp tenderness o Vomiting o Visual disturbance § Photophobia § Fortification spectra o Paresthesia o Vertigo o Alteration of consciousness § Syncope § Seizure § Confusional state o Diarrhea
Diagnostic Criteria for Migraine
o Repeated attack of headache lasting 4-72h in patient with normal PE, no other reasonable cause for the headache and o At least 2 of the following § Unilateral pain § Throbbing pain § Aggravation by movement § Moderate or severe intensity o Plus at least 1 of the following features § Nausea/vomiting § Photophobia/phonophobia o A high index of suspicion is required to diagnose migraine § The migraine aura, consisting of visual disturbances with flashing lights or zigzag lines moving across the visual field or of other neurologic symptoms (20-25% of patients) § Headache diary • Helpful in making the diagnosis • Helpful in assessing disability and the frequency of treatment for acute attacks
Migraine must be differentiated from
tension-type headache
§ Migraine headache is headache
with associated features
§ Whereas tension-type headache
that is featureless
One third of patient referred for vertigo or
dizziness have a
primary diagnosis of
migraine known as acephalgic migraine
wherein there is typical aura but without
headache.
non-pharma Management/ Treatment of migrane
§ Avoidance of triggers § Regulated lifestyle • Healthy diet • Exercise • Regular sleep patterns • Avoid excess caffeine and alcohol • Avoid acute changes in stress levels
PHARMACOLOGICAL migrane
§ NSAID’s § 5-HT1 agonist § Ergotamine and dihydroxyergotamine • These are non-selective receptor agonist • Comes in oral, nasal, and IV preparation • Can induce nausea • Dosage is 2 mg § Triptans (e.g. sumatriptan, zolmitriptan, almotriptan etc) • Selective 5-HT1B/1D agonist • Not effective in migraine with aura • Contraindicate in patient with cardiovascular and cerebrovascular disease § Dopamine antagonist • Oral metoclopramide 10mg • Parenteral (e.g. chlorpromazine, prchlorperazine, and metoclopramide) • It enhances gastric absorption • It decreases nausea vomiting • Restores normal gastric motility § Others • Narcotics • B-blockers (propranolol and timolol) • Topiramate • Sodium valproate or gabapentin • Methysergide o Migraine can be modified and controlled but cannot be eradicated o Migraine is commonly not associated with serious or life-threatening illness
Preventive Treatments in Migraine
The probability of success with any one of the
antimigraine drugs is only 50-75%
§ Many patients are managed adequately with
low-dose amitriptyline, propranolol, topiramate,
gabapentin, or valproate but if it fails or lead to
unacceptable side effects, second-line agents
such as methysergide or phenelzine can be
used.
§ Once effective stabilization is achieved, the
drug is continued for 5-6 months and then
slowly tapered to assess the continued need
TENSION TYPE HEADACHE
• Chronic head type pain syndrome
• Bilateral tight band-like discomfort
• Episodic or chronic (>15 days per month)
• No accompanying symptoms
• Management is usually by acetaminophen,
analgesics, or NSAIDs
• Amitriptyline for chronic TTH
TRIGEMINAL AUTONOMIC CEPHALAGIAS
• Include cluster headache, paroxysmal
hemicrania, and SUNCT (short lasting unicranial
neuralgiform headache attacks with conjunctival
injection & tearing)
• Relatively, this has short attacks of head pain
• Associated with cranial autonomic symptoms
such as lacrimation, conjunctival injection, or
nasal congestion
• Usually the pain is severe and may recur more
than once a day
• It may be a manifestation of a pituitary tumor related headache
CLUSTER HEADACHE
• It is a rare form 0.1% of cases
• Deep pain, usually retro-orbital, excruciating in
intensity, non-fluctuating and explosive in quality
• Periodicity: 1-2 bouts for a period of 8-10 weeks
in a year (core feature) recurring at about the
same hour each day
• Patients are generally well between episodes of
attacks
• Male affected 3x more than women
• Nocturnal in onset 50% of the time
Associated symptoms of Cluster headache
o Conjunctival injection or lacrimation
o Rhinorrhea
o Ptosis
o Unilateral photophobia phonophobia
Acute attacks
§ O2 inhalation (100% at 10- 12L/min for 15-20 mins.) § Sumatriptan SQ (subcutaneously) or nasal spray (oral not effective for acute attacks) § Zolmitriptan nasal spray
Preventive
§ Corticosteroids § Ergotamine § Lithium § Verapamil (up to 960mg with caution) o Neurostimulation in the region of the posterior hypothalamic gray matter (when medical therapy fails) § The risk of benefit ratio make it inappropriate
PAROXYSMAL HEMICRANIA
• Unilateral, severe short-lasting episodes (2 to 45 mins)
• Frequent attacks (>5x a day)
• Rapid course (<72 h)
• May be retro-orbital, with marked autonomic
features ipsilateral to the pain
• Equal distribution between male and female
• Excellent responds to indomethacin (25-75mg tid)
