HEADACHEHEADACHE Dr. Estabrak Alyouzbaki

Pain Sensitive Structures Intracranial: 1-Blood vessels:v. sinuses; meningeal, cerebral and internal carotid arteries. 2-Dura at the base of the skull. 3-Cranial somatic nerves (v, ix, x). 4-Brain stem periaqueduct,grey matter. 5-Sensory thalamic nuclei. Dr. Estabrak Alyouzbaki

Extra cranial: 1-Periosteum. 2-Skin,subcutaneous tissue,muscles and arteries. 3-Second and third cervical roots. 4-Eyes,ears,teeth,sinuses,nasal mucosa. Dr. Estabrak Alyouzbaki

Mechanism Of Headache 1-Displacement : S.O.L., raised intracranial pressure, decrease CSF pressure. 2-Irritation : of meningeal nerves and vessels ;e.g. meningitis and SAH; somatic cranial nerves. 3-Vascular : throbbing through afferent nerve fibers to thalamus then to cortex. 4-Muscle spasm. Dr. Estabrak Alyouzbaki

1-Onset:Acute,subacute,chronic headache 2-Precipitating factors: food, tension or emotional stress, menses, drugs, position, systemic or local illness … 3-Prodromal symptoms or aura 4-Characteristics of pain: throbbing, dull and steady, tightness or pressure, sharp Lancinating pain… 5-Location:unilat. Ocular, paranasal, focal Occipital, frontal, bandlike… Dr. Estabrak Alyouzbaki

- 6-Associated symptoms: fever,wt. loss, visual disturbances, nausea and vomiting, photophobia, rhinorrhea, lacremiation loss of consciousness 7-Timing and pattern : morning, on awakening, During sleep, episodic max.at evening, clustering 8-Relieving factors: sleep, vomiting, pressure Position, darkness… 9-Exacerbating factors: change in head position coughing,sneezing, anger… 10-History and frequency of the headache. Dr. Estabrak Alyouzbaki

Classification Part 1: Primary headache disorders Part 2: Secondary headache disorders Part 3: Cranial neuralgias, central and primary facial pain and other headaches Dr. Estabrak Alyouzbaki

Primary or secondary headache? Primary: no other causative disorder Dr. Estabrak Alyouzbaki

Primary or secondary headache? Secondary (ie, caused by another disorder): new headache occurring in close temporal relation to another disorder that is a known cause of headache Dr. Estabrak Alyouzbaki

Classification Part 1: The primary headaches 1. Migraine 2. Tension-type headache 3. Cluster headache and other trigeminal autonomic cephalalgias 4. Other primary headaches Dr. Estabrak Alyouzbaki

Classification Part 2: The secondary headaches 1. Headache attributed to head and/or 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 Dr. Estabrak Alyouzbaki

Classification Part 2: The secondary headaches 6.Headache attributed to disorder of hamoeostasis 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 Dr. Estabrak Alyouzbaki

Classification Part 3: Cranial neuralgias, central and primary facial pain and other headaches 1. Cranial neuralgias and central causes of facial pain 2. Other headache, central or primary facial pain Dr. Estabrak Alyouzbaki

‘Chronic’ Notes In pain terminology, chronic denotes persistence over a period of more than 3 months In headache terminology, it retains this meaning for secondary headache disorders For primary headache disorders that are more usually episodic (eg, migraine), chronic is used whenever headache occurs on more days than not (>15 days)over more than 3 months – the trigeminal autonomic cephalalgias (qv) are an exception Dr. Estabrak Alyouzbaki

Definition: It is an episodic paroxysmal headache usually unilateral and frequently pulsatile in quality. It is often associated with nausea, vomiting, photophobia, phonophobia and lassitude. Visual or other neurological auras occur in about 10% of patients. Dr. Estabrak Alyouzbaki

Migraine occurs in: ( prevalence) 4% of children. 4% of children. 6% of male. 6% of male. 18% of females. 18% of females. Two third to three fourth of cases Two third to three fourth of cases occur in women. occur in women. Onset: is early in live; 25% begin in first decade 25% begin in first decade 55% by 20 years of age 55% by 20 years of age >90% before age of 40 >90% before age of 40 Family history of migraine is present in most cases. Dr. Estabrak Alyouzbaki

Clinical types of Migraine

A.At least 5 attacks fulfilling criteria B-D B.Headache attacks lasting 4-72 h (untreated or unsuccessfully treated) C.Headache has  2 of the following characteristics: 1.unilateral location 2.pulsating quality 3.moderate or severe pain intensity 4.aggravation by or causing avoidance of routine physical activity ( eg, walking, climbing stairs) D.During headache  1 of the following: 1.nausea and/or vomiting 2.photophobia and phonophobia E.Not attributed to another disorder Dr. Estabrak Alyouzbaki

2- Migraine with aura ( classical migraine): (at least 2 attacks) The headache preceded by transient neurological symptoms,, lasting from 5-60 min. most common auras are visual alteration; hemianopic field defects and scotomas; sensory symptoms; no motor weakness. 3-Basilar type migraine. Dr. Estabrak Alyouzbaki

4-Migraine equivalent; typical aura without headache. 5-Hemiplegic migraine: familial or sporadic. 6-Abdominal migraine. Precipitating Factors: Certain foods(tyramine-containing cheese; meat with nitrite preservatives; banana; Chocolate containing phenyl ethylamine), drugs, stress, menses. Dr. Estabrak Alyouzbaki

Treatment: Acute attacks: 1-Simple analgesics; aspirin mg,Naproxen 500mg Ibuprofen mg,Paracetamol mg. Dr. Estabrak Alyouzbaki

2- 5-HT agonist: Sumatriptan; NS 5-20mg/spray, 40mg/24hrs; PO mg, 200mg/24hrs. SC 6mg, 12mg/ 24hrs. Others;Zolmatriptan, Rizatriptan, Naratriptan,Almotriptan Contraindications Dr. Estabrak Alyouzbaki

3-Ergot prepareations;ergotamine 1-2mg tab. 2-6 tab./ day, max. 10/ wk. or Suppository. dihydroergotamine IM,SC,IV,NS 1-2mg. It causes dependance. Contraindications:  4-Others :Neuroleptic and antiemetic Dr. Estabrak Alyouzbaki

Prophylaxis. 1. Anticonvulsants: Topiramate. sod. Valproate, phenytoin. 2. Anti-inflammatory agents: aspirin Naproxen. 3. Tricyclic antidepressant: amitriptyline, nortriptyline. SSRI: fluoxtine 4. B- blockers: propranolol, nadolo, atenolol, metaprolol. Dr. Estabrak Alyouzbaki

5-Calicium channel antagonists: Verapamil,nicardepine. 6-Cyproheptadine. 7-Others:prochlorperazine, phenelzine 8- 5 HT antagonist : Methysergide, Pizotifen Dr. Estabrak Alyouzbaki

T RIGEMINAL N EURALGIA Paroxysmal intense very sharp severe brief but repetitive pain, strictly confined to the distribution of the 5 th cranial nerve usually unilateral but some times bilat. (M.S.). Age: middle-aged or elderly patient (>50 years) Precipitated by; eating, shaving, exposure to cold, touching trigger zones Dr. Estabrak Alyouzbaki

Etiology 1-Microcompression by aberrant loops of cerebellar arteries. 2-Vascular disease. 3-M.S. 4-Tumor. Dr. Estabrak Alyouzbaki

Treatment 1-Drugs Therapy: Anticonvulsant drugs; carbamazepine mg ;phenytoin mg sod. Valproate; gabapentin lamotrigine Antidepressant drugs: amitriptyline, fluoxetine. Dr. Estabrak Alyouzbaki

2-Alcohol or phenol injection into peripheral branches of the 5 th nerve. 3-Percutaneous placing of radiofrequency lesion in the N. near Gasserian ganglion. 4-Microsurgical decompression. Dr. Estabrak Alyouzbaki

Very sever recurrent unilateral constant non throbbing headache. Male >female Age: 25 yrs and more. Last from 10 min.-2hrs Recurs on the same side Commonly at night at same time Cluster last weeks to months Dr. Estabrak Alyouzbaki

Cluster headache A.At least 5 attacks fulfilling criteria B-D B.Severe or very severe unilateral orbital, supraorbital and/or temporal pain lasting min if untreated C.Headache is accompanied by  1 of the following: 1.ipsilateral conjunctival injection and/or lacrimation 2.ipsilateral nasal congestion and/or rhinorrhoea 3.ipsilateral eyelid oedema 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 1/2 d to 8/d E. Not attributed to another disorder Dr. Estabrak Alyouzbaki

ACUTE ATTACK: sumatriptan 100% oxygen 8-10L/min. for min. Dihydroergotamine SC. Ergotamine PO. Or suppository Prednisolone mg/ day for wk. then tapering and discontinue next wk.  Dr. Estabrak Alyouzbaki

Prophylaxis: Dr. Estabrak Alyouzbaki Verapamil mg 8 hourly Methysergide 4-10 mg /day max. three months. Corticosteroid for short courses Lithium carbonate or citrate Indomethacine

Giant Cell Arteritis ( Temporal Arteritis) Sub acute granulomatus inflammation of extra cranial a. (sup. Temporal and vertebral arteries) Unknown etiology Age > 50 years Male 2: 1 female Unilat. Headache, visual problem, VBI Polymyelgia rheumatica Dr. Estabrak Alyouzbaki

ERS almost high with mean of 100mm/hr Prednisolone mg /day decrease after three months Maintenance 1-2years Dr. Estabrak Alyouzbaki

Tension-type headache 1-Episodic tension-type headache (infrequent and frequent) 2-Chronic tension-type headache Dr. Estabrak Alyouzbaki

C HRONIC TTH.Headache occurring on  15 d/mo (  180 d/y) for >3 mo. Headache lasts hours or may be continuous The distinguishing pain features of chronic tension- type headache are bilateral location, nonpulsating quality, mild to moderate intensity, and lack of aggravation by routine physical activity. The pain is unaccompanied by nausea and vomiting, although just one of the symptoms of photophobia, phonophobia or mild nausea does not exclude the diagnosis. Not attributed to another disorder Dr. Estabrak Alyouzbaki

Treatment For patients with chronic daily headache, a combination of: Pharmacological. Nonpharmacological; behavioral, physical interventions, is usually necessary for a favorable outcome. Dr. Estabrak Alyouzbaki