1. HEADACHEHEADACHE Dr. Estabrak Alyouzbaki

2. 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

3. 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

4. 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

5. 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. - 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

7. 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

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

9. 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

10. 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

11. 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

12. 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

13. 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

14. ‘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

15. 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

16. 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

17. Clinical types of Migraine

18. 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

19. 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

20. 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

21. Treatment: Acute attacks: 1-Simple analgesics; aspirin 600-1200mg,Naproxen 500mg Ibuprofen 400-800mg,Paracetamol 500-1000 mg. Dr. Estabrak Alyouzbaki

22. 2- 5-HT agonist: Sumatriptan; NS 5-20mg/spray, 40mg/24hrs; PO 50-100mg, 200mg/24hrs. SC 6mg, 12mg/ 24hrs. Others;Zolmatriptan, Rizatriptan, Naratriptan,Almotriptan Contraindications Dr. Estabrak Alyouzbaki

23. 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

24. 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

25. 5-Calicium channel antagonists: Verapamil,nicardepine. 6-Cyproheptadine. 7-Others:prochlorperazine, phenelzine 8- 5 HT antagonist : Methysergide, Pizotifen Dr. Estabrak Alyouzbaki

26. 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

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

28. Treatment 1-Drugs Therapy: Anticonvulsant drugs; carbamazepine 400- 1200mg ;phenytoin 200-400mg sod. Valproate; gabapentin lamotrigine Antidepressant drugs: amitriptyline, fluoxetine. Dr. Estabrak Alyouzbaki

29. 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

30. 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

31. Cluster headache A.At least 5 attacks fulfilling criteria B-D B.Severe or very severe unilateral orbital, supraorbital and/or temporal pain lasting 15-180 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

33. ACUTE ATTACK: sumatriptan 100% oxygen 8-10L/min. for 10-15 min. Dihydroergotamine SC. Ergotamine PO. Or suppository Prednisolone 40-80 mg/ day for wk. then tapering and discontinue next wk.  Dr. Estabrak Alyouzbaki

34. Prophylaxis: Dr. Estabrak Alyouzbaki Verapamil 80-120mg 8 hourly Methysergide 4-10 mg /day max. three months. Corticosteroid for short courses Lithium carbonate or citrate Indomethacine

35. 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

36. ERS almost high with mean of 100mm/hr Prednisolone 40-60 mg /day decrease after three months Maintenance 1-2years Dr. Estabrak Alyouzbaki

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

38. 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

39. 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