headache  Headache is one of the commonest neurological complain reported at neurology clinic 

path physiology Intracranial pain sensitive structures include: the arteries of the circules of willis &the first few centimeters of their median sized branches Meningeal arteries Large veins &dural venous sinuses Extra cranial sensitive structures: external carotid arteires, scalp,neck muscle,skin & cutaneous nerves, cervical nerve &nerve roots, mucosa of the sinus &teeth..

Case history  25 y old f with h/o : ER h/o sever headache,diffuse,dull in nature,not relived by analgesia,aggrevated by cough,sneezing.  Assosiated with vomiting  No other neurological symptoms.  She gave h/o of chronic infrequent headache,which tension type and less sever, relieved by analgesia  She is single  Recently She was following with dermatology doctor and he gave her tablets for facial peeling

O/E  Neurological exam :  HF:N  Speech :normal  Cranial nerves: fundoscopic exam:papilledema  Motor, sensory, coordination :normal

 Is this headache serious?

headache headache  Primary (benign) secondary  e.g(Migraine,tension,cluster)  brain systemic referred  HPT ear,teeth  anemia eye,sinus serious serious meninges parenchyma vacsular CSF

Secondary causes (serious)  Structural causes  Meninges: meningitis  parenchyma : encephalitis,abscess, tumor  Vascular: hemorrhage, venous thrombosis, giant cell arterities  Csf: increase CSF pressure (hydrocephalus,pseudotumor cerebri),decrease CSF pressure…leak

 Careful history and examination should be done to differentiate between benign and serious headache

Age  Migraine headache: child hood or early adulthood  Giant cell arteritis: >50 y  New onset headache in elderly should be always a concern

Onset  Headache of many years duration &with little changes is almost always of benign origin  New onset headache in old age or increasingly sever headache ….serious headache..  Hyperacute : SAH

periodicity:  episodic headache is benign  Migraine,Cluster headache  a daily constant headache..tension type

duration  Migraine: 4-72 h  Cluster:1/2-2h  Tension headache :build up over hours lasts days to years

Location  unilateral headache:migraine,cluster,temporal arterities.  Tension headache : generalized,frontal or posterior cervical region  Carotid dissection commonly present with neck,face,and head pain usually ipsilateral to the dissection  Local pain :superfacial structures

Nature  Nature:  throbbing: vascular  Tension :fullness, tightness, pressure like

aura,& associated symptoms  migraine: aura; focal cerebral symptoms associated with lasts from min, precedes the headache  Sensory, motor,autonomic,..  Cluster headache: ptosis,lacrimation, conjuctival, nasal congestion  Headcahe +fever …..infection  Transient visual obscuration, diplopia,tinnitus …increase intracranial pressure

aura,& associated symptoms  Jaw clawdication: temporal arteritis  Headache: progressive+ central nervous symptoms is suggestive …structural brain lesion

Aggravating & relieving  Aggravating  Cough, straining……intracranial pressure  Activity., stress…..migraine, tension type  Sitting: CSF hypotension  Relieving:  Rest…….migraine,tension

Drug history  Oral contraceptive… Cerebral vein thrombosis, migraine  Steroid withdrawal pseudotumor cerebri  Retin A tablets  Warfarin : Hge

 Postpartum : cerebral venous thrombosis  Recurrent abortion

FH  migraine

exam  v/s: fever,BP  General: sinus tenderness  Eye,throat,ear exam

exam  Normal exam: benign headache  Papilledema: increased intracranial pressure  Focal neurological finding……serious  Complicated migraine….neurological signs  Horner syndrome: cluster headache  Scalp tenderness, pulsless: temporal arteritis

Is this headache serious?  Characteristics of headache with serious underlying pathology  History :  Explosive onset and severe at onset  No similar headaches in the past  you have a constant headache, which is gradually getting worse;  Altered mental status  Age over 50  Immunosuppression  Physical examination :  Neurologic abnormalities  Decreased level of consciousness  Meningismus  Papilledema

Work up  If history and exam is suggestive of serious headache  Brain image: CT brain, mri brain  If suspect cerebral vein throbosis..CT venogram,MRV   if fever or ? SAH …LP

Go back to the case

Case history  25 y old f with h/o : ER h/o sever headache,diffuse,dull in nature,not relived by analgesia,aggrevated by cough,sneezing.  Assosiated with vomiting  No other neurological symptoms.  She gave h/o of chronic infrequent headache,which tension type and less sever, relieved by analgesia  She is single  Recently She was following with dermatology doctor and he gave her tablets for facial peeling

O/E  Neurological exam :  HF:N  Speech :normal  Cranial nerves: fundoscopic exam:papilledema  Motor, sensory, coordination :normal

Work up  CT brain : normal  MRI brain:N  MRV: N  LP: increased CSF pressure, protein, glu,cell count were normal

 Pseudo tumor cerebri  ( Idiopathic Intracranial Hypertension )

Home message Home message Careful history and exam including (opthalmoscopic) exam is the key to differentiate benign from serious headache. Careful history and exam including (opthalmoscopic) exam is the key to differentiate benign from serious headache.