1. بسم الله الرحمن الرحيم كل عام وانتم بخير Headache and facial pain Dr.Hayder Kadhum H. FICM NEUR. /Fellow Ship-Luvan university KUFA COLLEGE OF MEDICINE

2. HEADACHE  H. means pain in the head and we include facial pain with it.  it is very common symptom and it’s 7th common cause of medical office visits.it is commonest N. symptom in O.P neurological clinic  it is usually of benign cause but it may be the earliest and principle manifestation of serious systemic or intracranial disease. The diagnosis of H. cause is depending upon understanding of path - physiology of H. pain as well as good history, examination and formulating DD. PATHOPHYSIOLOGY H. is caused by traction,displacement, inflammation or distention of pain sensitive structure? These are : Intracranial Extra cranial

3. Radiation of pain Lesions above tentorium Lesion in posterior fossa  Approach to patient with H. HISTORY ------- ask about:  Onset and duration: 1.acute ------sudden or over days. 2.sub acute-----H. occur over weeks to months 3.chronic------H over years as in migraine and tension H.  Location:  Characteristic (nature, type): Throbbing------ Tightness or pressure steady sensation ----- Dull and steady------- Sharp lancinating ----- Ice pick like -----  Temporal pattern : In mass lesion------increase in severity with time maximum on awakening seen also in sinus H.) In cluster ------repeated attack at same time each day for weeks to return back again in next year while in migraine the attacks are episodic may be worse in menses and patient have pain free period between the attacks (not more 2-3 attack /week). Tension-----steady come when there is stressful situation max. at the end of the day.

4. Prodromal features; Scintillating scotoma-----in migraine and some times after seizure which followed by headache.  Associated features:  Recent wt. loss -----  Fever and chills -----  Visual disturbance -----  Nausea and vomiting ---- .Diarrhea -------  Photophobia -----  Ipsilateral lacrimation and nasal congestion -- -  Transient loss of Con ---  Precipitating factors:  Can provide hint to diagnosis like  -emotional stress,menses,hunger, ice cream foods containing nitrite hot dogs, and most sausage), phenyl ethylamine (chocolates) or tyramine(cheese) and bright light one or more of these may ppt. attack of M. H. as well as contraceptive pills.  -dental surgery ----  -chewing and eating ---  -alcohol intake ---

5. Aggravating and relieving factors:  Darkness and sleep, vomiting and pressure on ipsilateral T. artery ----------.  Post LP H. -----  Coughing and sneezing aggravate ------  Anger excitement ppt and worsen -----  Stooping,bending forward---  age, sex and job.History of trauma,drug abuse, family history are important.

6. G. PHYSICAL EXAM.  WEIGHT LOSS  SKIN  SCALP AND FACE  NECK INCLUDING MENINGEAL SIGNS  HEART AND LUNG  NEUROLOGICAL EXAM.  MENTAL STATE EXAMINATION  CRANIAL N. EXAMINATION  MOTOR EXAM.  SENSORY EXAM.  DD:

7. INVESTIGATIONS: WORK-UP FOR RECURRENT HEADACHES  CBC with ESR Chemistries Na, K, Ca++, glucose, BUN/Cr Urine analysis VDRL/FTA X-rays:  CT-scan of Sinus if sinus disease expected. Cervical Spine Film For occipital headache  Brain CT Scan: If any part of the history is worrisome for a bleed, or if any part of the neurological examination is abnormal.  CT is especially good if you suspect blood. MR Scan--Most Headaches More sensitive- Look at brain, and soft tissue CSF examination if SAH, infection, or increased intracranial pressure is suspected

8. REASONS FOR FURTHER EVALUATION OF HEADACHES  Unexplainable and abnormal worsening of previously existing migraines.  Dramatic or unusual change in character of the prodrome or the headache previously present.  Headaches awakening the patient in the middle of the night (provided it is not a cluster headache).  Headaches much worse when recumbent or with coughing, sneezing, Valsalva.  Unusually severe headache of sudden onset ("worst headache of my life").  Focal deficits which do not disappear after the headache is over.  Any abnormal neurologic finding.  Beginning of headaches at an older age without a previous history nor a positive family history