Dr sadik al ghazawi Associated professer Neurologist Mrcp,frcp uk Headache Dr sadik al ghazawi Associated professer Neurologist Mrcp,frcp uk

Accounts for 1% to 2% of emergency department evaluations and up to 4% of medical office visits Headache is caused by traction, displacement, inflammation, or distention of the pain-sensitive structures in the head or neck

Intracranial Pain-Sensitive Structures Venous sinuses Anterior and middle meningeal arteries Dura at the base of the skull Trigeminal (V), glossopharyngeal (IX), and vagus (X) nerves Proximal portions of the internal carotid artery and its branches near the circle of Willis Brainstem periaqueductal gray matter Sensory nuclei of the thalamus

Venous sinuses

periaqueductal gray matter

Causes of headache Primary Migraine Tension-type Cluster Paroxysmal hemicrania Trigeminal neuralgia Chronic daily headache Secondary Medication overuse (rebound) head/neck trauma Vascular disorder – SAH, AVM, vasculitis, CSVT High ICP / Low ICP Tumor Infection CNS Other infections

Red Flags in Hx

Red Flags in Hx “Worst HA of my life” New onset HA Change in character of headache Awakens him from sleep Associated with focal symptoms or fever Worsening with bending, laying down, coughing or sneezing Immunocompromised h/o cancer

Migraine Prevalence 12% More than 90% before age 40 begins with visual or other neurologic symptoms in approximately 15% to 20% of patients (migraine with aura, or classic migraine) In most cases no aura occurs (migraine without aura, or common migraine

Diagnostic Criteria: A. At least 5 attacks fulfilling criteria B through D B. Headache attacks lasting 4 to 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 or causing avoidance of routine physical activity (eg, walking or climbing stairs) D. During headache at least one of the following: 1. Nausea and/or vomiting 2. Photophobia and phonophobia E. Not attributed to another disorder

Management Prophylactic propranolol(inderal) Abortive, analgesia Triptans

Tension headache A. At least 10 episodes Fulfilling criteria B through D listed below B. Headache lasting from 30 minutes to 7 days C. Headache has at least two of the following pain characteristics: 1. Bilateral location 2. Mild or moderate intensity (may inhibit but does not prohibit activity) 3. Pressing/tightening (non-pulsating) quality 4. No aggravation while climbing stairs or similar routine physical activity

D. Both of the following: 1 D. Both of the following: 1. No nausea or vomiting (anorexia may still occur) 2. No more than one of photophobia and phonophobia E. Not attributed to another disorder

Cluster HA A. At least five attacks fulfilling criteria B through D B. Severe or very severe unilateral orbital, supraorbital, and/or temporal pain lasting 15 to 180 minutes if untreated C. Headache is accompanied by at least one of the following: 1. Ipsilateral conjunctival injection and/or lacrimation 2. Ipsilateral nasal congestion and/or rhinorrhea 3. Ipsilateral eyelid edema 4. Ipsilateral forehead and facial sweating 5. Ipsilateral miosis and/or ptosis 6. A sense of restlessness or agitation

D. Attacks have a frequency from one every other day to eight per day E. Not attributed to another disorder

Trigeminal neuralgia (tic douloureux) In many instances, the trigeminal (V) nerve roots are close to a vascular structure, and microvascular compression followed by demyelination of the nerve is believed to cause the disorder. Second (V2) and third (V3) divisions of the trigeminal (V) nerve Lightning-like momentary (>1 second to approximately 2 minutes) Trigger zones about the cheek, nose, or mouth by touch, cold, wind, talking, or chewing can precipitate the pain. Young pts, bilateral symptoms or abn exam r/o MS and brainstem tumors

Medication-overuse HA A. Headache > or = 15 d/mo B. Regular overuse for >3 months of > or = 1 acute/symptomatic treatment drugs: 1. Ergotamine, triptans, opioids, or combination analgesic medications on > or = 10 d/mo on a regular basis for >3 months 2. Simple analgesics or any combination of ergotamine, triptans, or analgesics opioids on > or = 15 d/mo on a regular basis for >3 months without overuse of any single class alone C. Headache developed or markedly worsened during medication overuse